Restricted access to abortions may have increased the risk of suicide among women of reproductive age for more than four decades, new research from the University of Pennsylvania suggests.

Though suicide deaths are rare, they are the second leading cause of death among women ages 20-24 in the United States, and the third leading cause among women ages 25-34.

A study published Wednesday in JAMA Psychiatry found that abortion restrictions may have played a role in some suicide deaths among younger women from 1974 to 2016.

During that period, 21 states enforced at least one Targeted Regulation of Abortion Providers (TRAP) law, which impose mandates on abortion providers or facilities, such as requiring facilities to be located near a hospital or requiring providers to be affiliated with a local hospital. From 1974 to 2016, the average annual suicide rate among women of reproductive age in those states was nearly 6% higher than in prior years when the laws weren’t enforced.

The study is the first of its kind to show an association between abortion restrictions and suicide rates among younger women, said Dr. Ran Barzilay, one of the authors.

The researchers did not find the same association for older women, he said, suggesting that the increased suicide risk was specific to women directly affected by TRAP laws. The researchers also ruled out other factors, such as the economy or a state’s political climate, on suicide rates.

“To begin with, the numbers are small. We looked at the ultimate adverse, worst outcome,” said Barzilay, an assistant professor of psychiatry at the University of Pennsylvania’s Perelman School of Medicine and a psychiatrist at Children’s Hospital of Philadelphia.

In an accompanying editorial published Wednesday, Tyler VanderWeele, an epidemiology professor at the Harvard T.H. Chan School of Public Health, estimated that TRAP laws may have been associated with around 127 suicides among women of reproductive age in 2016. Elevated suicide rates in states with more restrictive abortion laws “is cause for clinical concern,” he wrote.

Regardless of what’s causing these suicides, he added, the data “indicate the need for support and for mental health care” beyond what is currently offered in the U.S.

Unlike abortion restrictions that are geared toward patients, such as a parental consent requirement for minors, TRAP laws impose restrictions on providers or facilities that go beyond what’s medically necessary, said Nichole Austin, an assistant epidemiology professor at Dalhousie University in Nova Scotia, Canada.

The laws may stipulate the size of procedure rooms or the width of corridors in an abortion facility.

“Certain laws will impose certain requirements on the nature of the facilities themselves — you have to have a certain temperature, certain signage. It really gets a little bit ridiculous,” she said.

Austin said TRAP laws can increase travel time to abortion facilities or cause facilities to be shut down, which creates barriers to women seeking abortions.

“Instead of being able to go 5 miles down the road to an abortion provider, maybe your state passed some TRAP law and your nearest provider closed. So then, as a consequence, you’re finding yourself traveling 50 miles,” she said.

The UPenn researchers theorized that TRAP laws could amplify stress and anxiety among women of reproductive age.

“Stress is associated with increased mental health burden, and in turn is associated with increased suicide risk,” Barzilay said.

A five-year research project called The Turnaway Study found that women who had recently been denied an abortion had elevated levels of anxiety and stress, along with lower levels of self-esteem. But the study also found no difference in suicidal thoughts among women who were denied abortions versus those who had abortions.

That research ended in 2016, though, so it’s unclear how newer abortion restrictions — such as the Supreme Court decision to overturn Roe v. Wade — have affected suicide rates among younger women. More than a dozen states banned abortions since the Dobbs decision was issued in June.

“I would expect, from a purely speculative point of view, that the recent Supreme Court decision would have a real individual-level impact on a lot of women in a way that these TRAP laws would not,” Austin said.

One study showed that average travel times to abortion facilities increased from 30 minutes in 2021, before the Dobbs decision, to 100 minutes in September. The share of women of reproductive age who lived more than an hour away from an abortion facility also rose from 15% to 33% during that time.

Barzilay said the Dobbs decision could potentially exacerbate stress levels among younger women, though he cautioned that more research is needed to demonstrate that effect.

“What causes a person in need of an abortion to be stressed? It’s the loss of this option to do it,” he said.

If you or someone you know is in crisis, call 988 to reach the Suicide and Crisis Lifeline. You can also call the network, previously known as the National Suicide Prevention Lifeline, at 800-273-8255, text HOME to 741741 or visit SpeakingOfSuicide.com/resources for additional resources.