“If we are going to debate abortion in every state, given how fractured and angry America is today, we need caution and epistemic humility to guide our approach.” — Peter Wehner in The Atlantic
I showed up for one of the many Bans Off Our Bodies rallies across the country on May 14. It was the least I could do. It wasn’t enough. I’m not sure what will be.
Some Black folks on Twitter were shaking their heads at the stupidity of people who officially signed up to go to these things, wore recognizable T-shirts, shared photos, and in general made themselves obvious. They knew from bitter experience that being identifiable at a protest can lead to unpleasant consequences. In Albuquerque, going to an event like this is a pretty mainstream thing to do, and my old white lady self had little to worry about, but that was a wake-up call. I know it’s not so easy everywhere or for everyone.
Why is it always framed only as a women’s issue?
The closest thing to a threat I noticed was a tall, heavyset guy, a rather imposing figure, wearing a shirt that bore a childishly offensive message intended to incense Democrats, yelling anti-abortion insults nonstop through a megaphone. He was the only visible representative of his side, and he certainly did nothing to help their cause. He was also failing to get the attention he apparently wanted. Everyone was ignoring him.
“It’s not what people want.”
The other day one of my patients, a lady in her late 60s, told me that her husband is extremely angry about Justice Samuel Alito’s draft that shows the court plans to overturn Roe v Wade and throw the country further into red/blue chaos. She is not angry herself, she said, because, as she stated with total confidence, “It’s not going to happen.” I asked her why she would say that. “It’s not what people want,” she replied.
Her pronouncement was like an incantation. It felt incontrovertibly true and immediately real. Perhaps, since about ¾ of Americans do think Roe should remain, she will be proven correct. After a lot of pain, death, and waste, I fear.
It must be stated firmly that no one is “pro-abortion.” That is not at all what people mean when they express the importance of keeping abortion available. This morning I read a local news story that referred to a pro-abortion student group. What terrible reporting, and worse messaging. It feeds into the false narrative that Democrats want to allow abortion up till the moment of birth. It intensifies polarization and makes rational communication all the harder.
Most Americans express middle-of-the-road, nuanced, pragmatic, compassionate views on abortion. They know it’s complicated and that every situation is unique. They want it to remain legal, but they are comfortable with a certain degree of restriction. That’s what poll after poll tells us. The ‘90s mantra of “safe, legal, and rare” seems to describe the mainstream attitude well.
No one wants to find themselves in the position of needing an abortion. No one hopes or plans that someday they will terminate a pregnancy. The very fact that someone is looking to do that means that something, somehow has gone wrong. Maybe horrifyingly wrong.
Even in a perfect world in which every pregnancy was wanted and celebrated, in which rape and incest did not exist, in which every family was confident that they could support every child who came along, there would still be cases in which abortion was needed for medical reasons. More of them than you might expect. That could happen, has happened, to people who desperately wanted that child to grow and be born. It could happen, has happened, to people who believed abortion was wrong and never in a million years expected to need one. Nature doesn’t care about our religious beliefs or political attitudes, or our desires or our convenience. Nature follows her own laws.
This is the point I want to drive home today, that abortion is medical care and that it must remain available to save lives and prevent great harm. It was over 10 years ago that I wrote the post I’ve copied below, “It’s Mainly Medical, Not Moral.” At the time, the big war was over coverage for contraception under the Affordable Care Act. Note this well: despite Justice Alito’s assurances that the Supremes are only talking about abortion, not contraception, LGBTQ rights, or anything else, the right wing has been fighting against access to contraception all this time. It absolutely is a target and they will come after it.
As an LGBTQ person, I’m very nervous about where this is going. As a woman, I’m anxious, even though I’ve been out of the reproductive game for decades. As a health care professional, I’m afraid for all the doctors and other providers who have to care for their patients while trying not to run afoul of laws that make no sense. And as a person who wants democracy to be a reality in the United States, I’m terrified.
A couple of days ago I was spinning down into a maelstrom of fear and depression. Then I realized what should have been obvious: They want me to be afraid. They want us all to be paralyzed by fear and unable to get ourselves together to oppose them. Let’s not give them that.
Catch-22s all over
One would think that since effective contraception leads to far fewer abortions, anti-abortion folk would be much in favor of it. And one would be wrong, at least in the case of the more extreme elements of their movement. This is what I find most incomprehensible of all. There is a clear path to reducing the number of abortions: reduce unwanted pregnancies. Yet the same states that want to outlaw abortion also refuse to expand Medicaid, and work in every other way they can to limit access to birth control. Under this regimen, people can’t prevent pregnancy, can’t terminate it, can’t afford to get prenatal care or give birth, can’t afford care for the baby while they go to work, and can’t afford to stay home to do child care themselves. Especially for the poor, it’s hard to see what the option is supposed to be. (Breed babies for the rich to adopt, perhaps? That’s what Justice Coney Barrett’s flippant and heartless rhetoric suggests.)
It’s been pointed out that if we as a country really cared about babies, we’d do more to provide health care, child care, decent wages, and so forth, and obviously we don’t do that. There are some fervently anti-choice organizations that do try to support pregnant women in distress and those with newborns. I personally know two families that have taken young, financially stressed pregnant women into their homes and literally supported them. However, these efforts are far from state policy and are not remotely adequate to handle the thousands of individuals and families in difficult situations as a result of pregnancies.
A world in which abortion is criminalized means that some women will be arrested and jailed after having miscarriages or stillbirths. That’s been going on in El Salvador for many years, and despite a push to free women who have been imprisoned under such circumstances, it has just happened again. A woman who had an obstetric emergency and sought care at a hospital, as any of us would have done, was convicted of homicide after losing the baby. She has already been in pretrial detention for two years.
But this is not just something that happens in faraway lands— it has already been happening here, for quite a while, even with Roe still in place. And not only do women risk arrest if their pregnancy goes awry, they may be unable to get medications that are commonly used to treat miscarriages, because those can be associated with abortion. https://www.npr.org/sections/health-shots/2022/05/10/1097734167/in-texas-abortion-laws-inhibit-care-for-miscarriages
A miscarriage is medically indistinguishable from a medication abortion, so anyone who has had one is potentially vulnerable to prosecution under such draconian laws. This means that the totally normal, sensible act of going to a hospital can put a person in grave danger. And of course when one is bleeding heavily, avoiding going to a hospital is not a very safe choice either.
This is not what most people want our country to be like. We know that a strong majority of Americans, including a majority of Republicans, want Roe v Wade to stand. We know that most Americans want to see, at the very least, exceptions for rape and incest, exceptions that the farthest-right state legislatures no longer wish to allow. It’s astonishing that a policy so widely opposed by people all across the political and social spectrum can even be considered as law.
Welcome to the age of minority rule.
Should we rage?
The forces arrayed against reproductive rights have had passion and long-term commitment on their side. Those wanting to keep abortion and contraception available have been more complacent— for so long, there seemed to be little reason to scream about rights that everyone, even certain Supreme Court nominees, recognized as “settled law.” (What patsies we were.)
So now we are beginning a “Summer of Rage,” in which protests will be loud and persistent. I don’t know whether this is the best course. We can’t be complacent anymore, and this is a genuine emergency that deserves every effort to hammer it into the public consciousness. Would we be better off with a more rational, conversational approach? That would be my way of doing things, but I can’t say that it’s worked particularly well so far, so maybe hot pink rage really is the ticket right now.
Medical hazards and crises
At any rate, in this post I would like to speak to the typical person and bypass extreme rhetoric. I want to again point out some of the dire medical reasons a pregnancy may need to be terminated, no matter what the ideology of the mother, the health care personnel, the state, or anyone else. There are many more that I won’t get around to here.
First, the likelihood, or should I say certainty, of young girls being impregnated by relatives or others. Incest is far more common than we like to think. All too often this happens to a child who is too young and small to safely carry a baby to term and give birth. Beyond the sheer cruelty of putting a child through this— how can anyone justify sacrificing one child to save another, especially another who was unlikely to survive to begin with? There have been famous cases like this in countries where abortion was totally banned. There are guaranteed to be more.
Even before the current era of extreme state laws, some states commanded that minors would have to have permission from their parents to get abortions. Right-wing forces tend to hold a rosy picture of caring parents in nurturing families in which a confused teenager might be lovingly guided to make good choices, but obviously that is not always the reality. What if, in fact, the parent is the perpetrator? Are we really going to require girls to give birth to their siblings? Does that make either medical or legal sense?
Pregnancy and birth are not only dangerous for the youngest girls, though; they’re hazardous for everyone with a uterus. You probably already know that the US has an embarrassing level of postpartum deaths, and that the rate is worst for Black women. (Poorer women get worse care in general, but even wealthy Black women face increased risks.) The people most impacted by draconian laws against abortion are also the ones who are less likely to get through pregnancy and birth safely.
In addition to the fundamental, “normal” risks of pregnancy and childbirth, there are the many unforeseen tragedies that can befall a fetus during gestation and that can threaten the mother’s health and/or life. Laws that purport to make exception for saving the life of the mother but are written without medical understanding, and without details about what is actually allowed, tie the hands of doctors in emergencies and lead to unnecessary deaths. When this happened to Savita Halappanavar in Ireland, the country responded to the outrageous situation by changing its laws. The same kind of deaths will no doubt occur here. It’s just a matter of time.
In fact, last week I read about a woman who had a similar problem to Ms. Halappanavar’s— her water broke, it was too early for the fetus to survive outside the womb, sepsis was likely. And she lived in Texas. Because the mother’s life wasn’t in danger at that very moment, even though it probably would have been in the very near future, the doctors felt unable to terminate the doomed pregnancy— as they would have before the new law kicked in. The mother ended up being driven about 8 hours by ambulance to a neighboring state, a stressful, dangerous, expensive, and totally unnecessary trip. This is craziness.
Don’t understand why doctors would be prevented by law from saving a woman in such circumstances? Let a real OB-GYN explain how incredibly fraught and confusing an emergency can become:
We have to remember that suicide is also a major risk to the life of a distressed pregnant person. Here is an anecdote from another OB-GYN:
“During medical school in Florida, my first experience with abortion was with a 19-year-old woman who had been gang raped and was now pregnant; she was suicidal and placed in the behavioral unit. Our team saw she was devastated; she did not want to continue the pregnancy. It was simple; this traumatic, unforgivable experience would ruin her life. I was disappointed to see the reluctance to offer the care she needed. Only one physician, a newly graduated physician who trained in LA, immediately offered her care. His care could change her future and offer her some peace of mind for her mental and physical turmoil. I wanted to become the physician that would not back down, would show up and would be present for a patient in her time of need. When I applied to residency, I knew I wanted a program that offers training in abortion care.”
It’s not my purpose here to try to list every kind of medical crisis that could occur during a pregnancy and make termination the best or only choice. There are so many heartbreaking things that can happen to either the mother or the fetus, and each one requires its own unique response. Things that go horribly wrong often do so late in pregnancy, well after the 6 weeks Texas allows and even after the or 15 or 20 some other states have wrangled over. (Savita Halappanavar developed sepsis at 17 weeks.) Pregnant people, their families, and their doctors need the flexibility to make the right decisions in the moment, often with very little time available. Legislators making rigid, blanket pronouncements cannot possibly cover all the contingencies that have to be dealt with in the complex reality of reproductive health care.
Ten Years Ago— Plus Ça Change
When I wrote “It’s Mainly Medical, Not Moral” on 2/20/12, the big battle was over the Affordable Care Act’s provision to cover birth control. We have only gone backwards since. Here is the text of that post.
It’s Mainly Medical, Not Moral
You’re probably sick of hearing about the war over insurance coverage for contraception under the Affordable Care Act, but I think I have a few useful points to make that haven’t been brought up elsewhere.
For those of you who live elsewhere, let me catch you up on this only-in-America craziness. The Affordable Care Act, otherwise known as the health care reform law, mandates that contraception must be covered by insurers without co-pays (direct costs at the time of service) to the patient, and that employee health plans must provide this coverage. While there is an exception for employees of churches and other places of worship, hospitals, universities, and other institutions owned by religious sects are included in this mandate. A number of right-wing forces have complained that this tramples upon religious freedom. After being thoroughly raked over the coals, the President and his advisors worked out a compromise: the religious groups would not have to pay for the coverage, and it would be provided directly by the insurance companies, so that those who object could keep their sense of purity. Insurers have agreed to this because providing contraception saves them money (and is expected to save money for the entire health-care system as well as for individual families). The war is still raging as I write this, with the self-styled guardians of freedom insisting that the government is still overstepping its bounds.
On the front lines of this trumped-up battle, we find none other than the Conference of Catholic Bishops, the same fine folks who protected us from the evil, dangerous practice of Reiki by banning it in all Catholic hospitals and other institutions. (See my post “Attack of the Bishops.”) Need I state the obvious? These ideas are being promulgated largely by partnerless elderly men. These are not people who have any need to prevent pregnancy or any understanding of what that issue is like for those who do, including the 98% of Catholic women who use birth control at some point in their lives. This outrage is compounded by the fact that Viagra is covered and the bishops have no problem with that.
A letter I wrote about this recently was published in the Albuquerque Journal on Sunday 2/12/12, before the President backpedaled, and before Rep. Darrell Issa convened a panel of ALL MALE religious leaders, Catholic and otherwise, to testify before Congress. Issa and his Religious Right cohorts have managed to make it crystal clear that their agenda has little or nothing to do with religious freedom, and is really about a) attacking the president and killing the Affordable Care Act any way they can, and b) controlling women. They’ve abundantly shown that they want to get rid of not only abortion but all forms of contraception. And while wailing about the government infringing upon their freedom, they’ve shown that they have no problem with curtailing the freedom of others– especially if those others happen to have pairs of X chromosomes.
Here’s my letter:
“In all the indignation-filled rants I’ve heard about the Obama administration requiring religious institutions to include contraception in employees’ health insurance coverage, there has been one glaring omission: No one has mentioned the fact that quite often, hormonal contraceptives (the Pill, patches, or implants) are used for medical reasons that have nothing to do with birth control. Many women take the Pill, etc. for conditions like polycystic ovary syndrome or severely painful periods. Many of those women are not even sexually active, or not sexually active with men. I’ve seen this quite a bit with my own patients. Whatever one thinks about contraception, it’s hard to imagine even the staunchest Catholic objecting to legitimate medical treatment for such conditions.
“I’d just as soon see women use natural alternatives, but in many cases hormonal birth control really changes their lives for the better. The costs of these medications can be quite substantial, however, and that can put them out of reach for students and low-paid workers. The costs of the conditions they treat can be substantial, too, as when a woman must miss work because of debilitating pain. We would not ask an employee to forgo painkillers for arthritis or inhalers for asthma. How is this different?
“The President may have lost some votes with this decision, but there are quite a few of us who are relieved to see him standing up for women and for what makes medical sense. Try as I might, I can’t see this as primarily an issue of religious freedom or of morality. Women who object to contraceptives are still free not to use them. Morality means doing the best we can for everyone in our society, and that includes medical care, which includes birth control.”
I didn’t want to get all confessional in the newspaper, and I wanted to focus on a single point for impact, without bringing in other aspects of the situation, but I have a personal story that I think sheds particular light on the complexity of this issue and the reasons a total ban by religious “authorities” is not only ludicrous but cruel.
When I was about 25, I developed severe cervical dysplasia, well on the way toward cancer. This was treated with cryosurgery to remove the diseased cells, which was a standard treatment back then; no one realized at the time that cryosurgery would only mask the problem, which would resurface later on. My primary care doctor told me I should have a hysterectomy, which showed a remarkable ignorance on his part, it seemed to me, as the precancerous cells were not invasive and might never be. I had not yet had a child, and was determined to be able to do so. After I healed from the cryosurgery, I did get pregnant, and my daughter was born when I was 27. Over the next couple of years I became allergic to or unable to tolerate most forms of birth control, and so, with my husband and my very small daughter in agreement (Lenore’s opinion was “We have enough babies around”), I had a tubal ligation. Which was covered by insurance, by the way, because my husband is one of those awful, greedy public employees, a teacher that is, and he gets all those totally undeserved benefits.
That was not the end of the medical story. I had a number of years of clear Pap smears, then skipped a year, because it didn’t seem critical to have one at that point. The next Pap showed carcinoma in situ. The tissue underneath the layer affected by the cryosurgery had been stealthily developing toward cancer the whole time, and it had simply taken that long to show up on the surface. By that time, most of my cervix consisted of abnormal cells, and I was noticeably ill. To deal with this, my OB-GYN did a cone biopsy to remove all that– they use the word “biopsy,” since it does have a diagnostic aspect, but it’s a far larger matter than the word suggests.
The hospital personnel wanted to do a pregnancy test. I explained that I’d had my tubes tied. They impressed on me repeatedly that after this procedure my cervix could not support a pregnancy, and that I needed to be OK with that. I reassured them again, and the surgery was done. The pathologist found that there were still diseased cells around the edges of the cone, so a few months later I went through the whole thing again, nearly bleeding to death afterward, and ending up with even less of a cervix. I emerged from the process weakened but cancer-free.
I often thought about what would happen if a woman in this condition did get pregnant. Surely it has happened many times. An embryo would start to grow, everything going fine, and at some point it would lose its moorings in its mother’s womb and essentially fall to its death. I wondered how far developed the poor creature would be when that happened. It seems horribly sad, doesn’t it? The child would be doomed from the start. The mother would suffer both mentally and physically for nothing. And all of that could be prevented with the use of reliable contraception, or with my chosen option, sterilization. If it could not be prevented for some reason, it seems very clear to me that abortion would be a far kinder choice than allowing the baby to keep growing until its inevitable demise, possibly till it could begin to feel something, and certainly exposing the mother to greater risks and discomforts.
I have always wondered how very observant Catholics would find their way through this dilemma, since there would be no way to avoid pain and tragedy, only to minimize it.* The Church’s official stance, I suppose, would be simply “Don’t have sex.” Ever again, or at least not until menopause, so that such a tragic pregnancy could never get started.
And of course there are also medical situations where pregnancy would be life-threatening or seriously health-threatening for the mother. These women need their contraception to be as effective as possible, and depriving them of it verges on criminality, I would say. Birth control advocates tend to mean hormonal drugs when they speak of “effective” contraception, and that has been the focus of much of the fighting. I certainly think women should have access to these medications, but I don’t want to come across as a wholehearted fan of the Pill and its cousins. The Pill, patch, and implant can be problematic for many women, and they can have dangerous side effects, especially as women age.
A friend of mine who cannot use these drugs was put in a ludicrous position by our local Presbyterian Health Plan, on purely ideological rather than medical grounds. Having been unable to tolerate the type of IUD that releases hormones into the body, she and her doctor decided that she should try the old-fashioned, non-hormonal IUD. Presbyterian refused to cover that, saying that it’s an abortifacient rather than a contraceptive, and therefore not morally acceptable.** They were happy to cover the hormonal IUD, which they insisted my friend should use despite the fact that it was already proven to be unsuitable and harmful for her. The patient’s medical needs meant absolutely nothing. Let me repeat that, because this is how our system works, and we need to be clear about it: The patient’s medical needs meant absolutely nothing. Her own beliefs and moral convictions also meant absolutely nothing. Fortunately, although she was a college student doing low-paid restaurant work, this young woman was able to get the money together to pay for the IUD herself.
And that is what we face when religion, and only some people’s religion at that, is allowed to determine our medical care. If the bills currently being proposed by certain members of Congress were to become law, any employer could refuse to cover any type of treatment for any reason. I don’t think that will come to pass, but stranger things have happened, and we need to stay on top of this situation. I can only hope that American women will continue to get more and more engaged and will work to hold the ground we’ve gained– and that men have gained along with us– over the past few decades.
I promise to get back to more spiritual matters in my next post.
*Despite 12 years of Catholic school and being good friends with a nun, I still can’t answer this. Odd situations like this never came up in the typical anti-abortion rhetoric. And by the way, I don’t remember Catholics railing against birth control back in the ’70s the way it’s happening now. Maybe I just didn’t notice.
**The common scientific view is that pregnancy begins with implantation, not with conception. The IUD prevents implantation.
For some other current perspectives:
A Few More Things to Consider
“I am not pro-abortion.
“Like nearly all pro-choice human beings, I never rejoice over or celebrate these decisions, because I know that they are ones reached after arduous deliberation and great pain; that they are often born out of emotional trauma, physical assault, or dire medical news.
“I know that abortions are not chosen impulsively or without careful or prayer wrestling.
I believe in education and in birth control and in doing everything possible not to create an unwanted pregnancy. All pro-choice people I know believe these things.
“…There is a sad irony at play when I realize that a pro-life woman arguing with a pro-choice man like myself, is essentially relinquishing control over her destiny to other men and I am saying she deserves better.” — Pastor John Pavlovitz
“[George H.W.] Bush would remain a staunch advocate of reproductive freedom for women until political considerations during the 1980 presidential elections, when he was on the ticket with Ronald Reagan, accounted for one of the most dramatic and cynical public policy reversals in modern American politics.”
“Reagan had supported California’s liberal policies on contraception and abortion as governor, and Bush as Richard Nixon’s Ambassador to the United Nations had helped shape the UN’s population programs. But Republican operatives in 1980 saw a potential fissure in the traditional New Deal coalition among Catholics uncomfortable with the new legitimacy given to abortion after Roe v. Wade and white southern Christians being lured away from the Democrats around the issue of affirmative action and other racial preferences. Opposition to abortion instantly became a GOP litmus test, and both presidential hopefuls officially changed stripes.”
Faced with the lowest and slimiest of Twitter trolls, one woman retorted, “I’ll ask my rapist nicely to wear a condom.”