Strategies for Staying Sexual After Menopause

Rebecca Chalker

Women's health advocates vigorously question unrealistic projections for sexuality and aging - bleak sexual desert or pharmaceutical Niagara - and have identified helpful strategies for maintaining and enhancing sexuality after menopause.

This article was first published in the Women’s Health Activist.

When was the last time you
heard a joke suggesting that sex invariably goes ever downhill or totally
crashes after menopause? Like yesterday? This concept was boldly reaffirmed – without
reference to reliable research – at a conference on menopause held by
the National Institutes of Health in 2005! So, if you ask your doctor
about sex after menopause, she or he will likely agree that the outlook
is gloomy. On the flip side, the golden-years myth is heavily promoted
by TV ads for erection drugs, which portray the "Cialis woman" always
blissfully ready for intercourse whenever her partner drops a pill. 

Fortunately, women’s health
advocates, sexologists, and researchers vigorously question these equally
unrealistic projections for sexuality and aging – of a bleak sexual
desert or a pharmaceutical Niagara – and have identified numerous helpful
strategies for maintaining and enhancing sexuality after menopause.
Here’s a survey of some of the most common problems and strategies
to help make sex during this life phase more comfortable and rewarding. 

Vaginal Dryness 

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By far the most common sexual
problem that women report in their post-reproductive years is dyspareunia – pain
or discomfort during or after intercourse or insertion of fingers or
sex toys into the vagina. After menopause, reduced levels of the hormones
estrogen and progesterone result in less natural lubrication that may
result in bleeding, tightening of the vaginal opening, and/or narrowing
and shortening of the vagina. All of these can make intercourse uncomfortable
or even intolerable. 

Solutions: Many women and sex
therapists report the reality of the use-it-or-lose-it factor: regular
sex, either with a partner, through masturbation, or a combination of
the two, definitely helps keep vaginal tissues more supple and moist.
Extended sex play before insertion is always helpful even if discomfort
isn’t severe. Liberal use of a water soluble lubricant is often enough
to make intercourse more comfortable. Having intercourse after a long
time without it can be painful or impossible, but don’t give up. You
may need to work up to it. Over a few weeks, the vaginal opening can
be comfortably stretched using lubricants and successively larger blunt
objects such as vibrators or dildos, or a set of vaginal dilators (available
without a prescription at medical supply stores). Alternatively, daily
use of nonprescription Replens (a nonhormonal lubricant) may provide
sufficient relief. Some women turn to medical treatment and use a small
amount of low dose estrogen cream applied at the opening and inside
of the vagina. Women who have a personal plastic speculum may find looking
inside the vagina helpful to assess the normal appearance of vaginal
tissues and to monitor response to self-help or medical remedies. You
can order a speculum from the Feminist
Women’s Health Centers

Low or Absent Sexual Desire 

Many older women also report
slower response to mental or physical sexual stimulation; a longer time
to become sufficiently aroused; or, in severe cases, a total lack of
interest in or revulsion to sex. Decreased interest in sex may be temporary
or long term, but surgical removal of the ovaries (due to cancer, endometriosis,
uterine prolapse, or other reasons) can cause these changes to be sudden
and sometimes devastating. Numerous drugs, especially selective serotonin
reuptake inhibitors (SSRIs), are known to cause reduced sexual interest.
On top of this, the lower systemic availability of testosterone, the
key promoter of desire in both women and men, can cause less interest
in sex. 

Solutions: First, ask your
doctor to review all of your medications and discontinue any that are
not essential. For certain medications, taking a "drug holiday"
on weekends, or for a few days during a vacation, can be helpful if
your doctor approves. The SSRI citalopram (Celexa) is reported to have
a lower negative impact on desire, so switching to it may be an option.
If you have a partner, it’s important to talk about lower sexual interest
so that he or she does not feel that sexual coolness is personal. In
addition, you can use any of the suggestions in Strategies for Staying
Sexual, below. 

Urinary Incontinence 

Involuntary loss of urine can
occur at any age but, after the age of sixty-five, 10 percent of the
population experiences mild to severe leakage. There are different types
of incontinence, but by far the most common in women is stress or "giggle"
incontinence, in which sudden movements or vigorous activity – such
as sex – can result in leaks. Urinary leaks can be disconcerting, and
the possibility of this happening during sex can cause some women to
avoid partner sex altogether. Primary causes of urinary incontinence
include changes in bladder position after vaginal childbirth, lax pelvic
muscle tone, involuntary bladder contractions (called "overactive
bladder"), the usage of some medications, and pelvic surgery (especially
hysterectomy). 

Solutions: The gold standard
of incontinence treatment is pelvic floor muscle exercises, commonly
called "Kegel exercises," after Dr. Arnold Kegel, who researched
and popularized them in the 1950s. Doing these exercises several times
a day may be all that is needed to check surprise leaks. A common myth
is that Kegels don’t work. They do, especially for mild to moderate
urine loss. And the huge plus of well toned genital muscles is the possibility
of having more intense orgasms! If doing Kegels on your own does not
improve continence, a biofeedback program can be very effective in strengthening
continence muscles and monitoring progress. (Sometimes biofeedback is
covered by insurance.) Biofeedback can be combined with bladder retraining,
which helps you hold urine comfortably for longer periods of time. In
addition, several medications are available to control overactive bladders. 

Pelvic Surgery 

Pelvic surgery can result in
a host of dramatic changes in sexuality. This is particularly true for
hysterectomy, especially if one or both of the ovaries are removed.
Cancer is the only absolute medical indication for surgical removal
of the uterus and/or ovaries, so if your doctor recommends hysterectomy
for any other reason, definitely seek a second opinion. Until recently,
hysterectomy was the recommended remedy for uterine fibroids, but newer
techniques are now available that preserve the uterus. (See the National Women’s
Health Network’s fibroids fact sheet
.)
Sexual changes associated with hysterectomy, as with menopause in general,
may include vaginal dryness, reduced or lost sexual desire, noticeable
changes in time to orgasm, less intense orgasms, and loss of ability
to have multiple orgasms. 

Solutions: See the suggestions
for alleviating vaginal dryness and loss of desire noted above and Strategies
for Staying Sexual, below. 

Strategies for Staying Sexual 

In addition to the techniques
suggested here, many women use a variety of self-help solutions to enhance
their interest in, and comfort during, sex. Heterosexual women and lesbians
certainly have the same problems, but lesbians may find it easier to
negotiate solutions because their partners may have similar issues.
If intercourse is painful and/or male partners don’t get erections
readily, consider taking the focus of sex off of intercourse and indulge
in the much heralded pleasures of outercourse, which includes every
sexual activity except penis-in-vagina sex. If orgasm isn’t as reliable
as before, why not make pleasure the goal of sex rather than orgasm?
Sex therapist JoAnn Loulan asserts that sex should begin with willingness
and end with pleasure, with or without orgasm in between. It’s the
brain, anyway, not the genitals, that’s the chief sex organ, so starting
there should be key to sexual enhancement. Rewarding sex can be as simple
as cuddling, trading sensual massages, sharing fantasies, genital stroking,
or watching or reading erotica alone or together. If the genitals respond
to such activities, whether or not they are touched, it’s still sex!

Many sex therapists recommend the use of filmed or written erotica to
encourage sexual interest, and erotic material is readily available
for every taste and interest. In addition, there is a wealth of sexuality
self-help material in books, magazines, and on the Internet. My personal
favorites are sexual techniques based on the ancient Asian traditions
of Tantra and Tao, which take the focus off of the genitals and use
ritual, extended sex play, and full body sexual stimulation to create
more intense sexual response. Books and workshops by Margot Anand are
particularly popular. For those with more serious disability issues,
there are several excellent books on sex and disability; you might start
with The
Ultimate Guide to Sex and Disability: For All of Us Who Live with Disabilities,
Chronic Pain, and Illness

Masturbation: Masturbation
isn’t just a crutch to use in place of partner sex. It is a self-affirming
sexual activity and is eminently useful in helping to discover different
routes to sexual pleasure. In national studies, up to 40 percent of
women report that they masturbate on a regular basis, but this incidence
may be lower for older women. Many older women may remember being discouraged
(or even punished) for masturbating as children, and may still be reluctant
to engage in this pleasurable sexual activity. Ultrasound images have
captured male and female fetuses masturbating in the uterus; these images
confirm that masturbation is an innate and entirely normal part of sex! 

Safer Sex: The explicit truth
is: regardless of age, in partner sex, we are all at some risk for contracting
a sexually transmitted infection (STI), including HIV/AIDS. In fact,
one in ten people diagnosed with AIDS in the United States are over
the age of fifty (although transmission rates are much lower among lesbians
than among gay men and heterosexuals). Discuss a new partner’s sexual
history, keep condoms handy, and don’t take any risks. Outercourse,
as described above, greatly reduces the risk of STIs, without reducing
pleasure. 

Websites: Countless websites
devoted to sex and aging provide information on every conceivable topic.
Long time NWHN member Betty Dodson, a very youthful eighty, is celebrating
forty years of helping women explore and enhance their sexuality. Recently,
Dodson teamed up with Carlin Ross to build a new interactive
website
that provides
resources on a wide array of topics. Dodson also appears in Still Doing It:
The Intimate Lives of Women Over Sixty
,
a film and book of the same title by Deirdre Fishel and Diana Holtzberg. 

Women-friendly Sexuality Boutiques:
Incorporating sex toys, especially vibrators, into masturbation or partner
sex can be extremely helpful in altering sexual routines. All sexuality
boutiques have extensive online and printed catalogs to enable shopping
in the privacy of one’s own home. For a start, Babeland, Good
Vibrations
, and Eve’s Garden have especially wide selections. 

Sex Therapy: If these strategies
aren’t sufficient, you might consider seeing a sex therapist. One
source for a trained therapist in your area is American Association
of Sexuality Educators, Counselors and Therapists
‘ website. Your therapist can help
you sort through feelings about sex and aging, issues with a partner,
or medical conditions that impact on sex, and she or he can make additional
suggestions about how to cope with other problems and can suggest additional
strategies for staying sexual. 

Life Changes that Impact
Sexuality
 

Clearly, there are many ways
to cushion or fix the physical changes that may occur after menopause.
But truth be told, changes in relationships, as well as complex life
situations caused by diminished income, divorce, illness, or death can
be vexing and more difficult to resolve. Such changes can deprive us
of the comforts and intimacy afforded by sex in a long term relationship,
or for many women, they might provide the opportunity to explore new
sexual possibilities where rewarding sex has been lacking. 

"Good sex" is different
for many people and in later years, many are happy to say goodbye to
the hormone driven sex of their youth and live with "good enough"
sex that focuses on emotional and quiet physical pleasures, which may
or may not include orgasm. The key here is to identify what is pleasurable
for you and then look at what is possible given your situation. 

Traditionally, "sex" has
been defined as heterosexual intercourse, but feminists and sex educators
have successfully redefined sex to include any activity that results
in sexual pleasure. With a partner, as noted above, we always have cuddling,
petting, kissing, sharing fantasies and stories, bathing together, dancing,
even dressing up and playing games! And don’t forget about adding
sex toys to your repertoire.  

For those who are single (I
like to think of it as "independent"), the possibilities for new
connections and friendships are there for the asking. Joining an interest
group is an easy way to slip into a new social current. Take a class.
If you can afford it, take a cruise. Volunteer! Visit a larger congregation.
Others in similar situations are seeking partnerships too! 

If fetuses can masturbate in
the uterus, and we know that they do, then, at the most basic level,
we are sexual throughout our lives. Sexuality is a part of our humanity;
it’s why we are here today. Menopause may reduce our reproductive
hormones, but it does not rob us of our sexuality. It’s still there
to be relished, enjoyed, and, perhaps, shared.

Commentary Politics

No, Republicans, Porn Is Still Not a Public Health Crisis

Martha Kempner

The news of the last few weeks has been full of public health crises—gun violence, Zika virus, and the rise of syphilis, to name a few—and yet, on Monday, Republicans focused on the perceived dangers of pornography.

The news of the last few weeks has been full of public health crises—gun violence, the Zika virus, and the rise of syphilis, to name a few—and yet, on Monday, Republicans focused on the perceived dangers of pornography. Without much debate, a subcommittee of Republican delegates agreed to add to a draft of the party’s 2016 platform an amendment declaring pornography is endangering our children and destroying lives. As Rewire argued when Utah passed a resolution with similar language, pornography is neither dangerous nor a public health crisis.

According to CNN, the amendment to the platform reads:

The internet must not become a safe haven for predators. Pornography, with its harmful effects, especially on children, has become a public health crisis that is destroying the life [sic] of millions. We encourage states to continue to fight this public menace and pledge our commitment to children’s safety and well-being. We applaud the social networking sites that bar sex offenders from participation. We urge energetic prosecution of child pornography which [is] closely linked to human trafficking.

Mary Frances Forrester, a delegate from North Carolina, told Yahoo News in an interview that she had worked with conservative Christian group Concerned Women for America (CWA) on the amendment’s language. On its website, CWA explains that its mission is “to protect and promote Biblical values among all citizens—first through prayer, then education, and finally by influencing our society—thereby reversing the decline in moral values in our nation.”

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The amendment does not elaborate on the ways in which this internet monster is supposedly harmful to children. Forrester, however, told Yahoo News that she worries that pornography is addictive: “It’s such an insidious epidemic and there are no rules for our children. It seems … [young people] do not have the discernment and so they become addicted before they have the maturity to understand the consequences.”

“Biological” porn addiction was one of the 18 “points of fact” that were included in a Utah Senate resolution that was ultimately signed by Gov. Gary Herbert (R) in April. As Rewire explained when the resolution first passed out of committee in February, none of these “facts” are supported by scientific research.

The myth of porn addiction typically suggests that young people who view pornography and enjoy it will be hard-wired to need more and more pornography, in much the same way that a drug addict needs their next fix. The myth goes on to allege that porn addicts will not just need more porn but will need more explicit or violent porn in order to get off. This will prevent them from having healthy sexual relationships in real life, and might even lead them to become sexually violent as well.

This is a scary story, for sure, but it is not supported by research. Yes, porn does activate the same pleasure centers in the brain that are activated by, for example, cocaine or heroin. But as Nicole Prause, a researcher at the University of California, Los Angeles, told Rewire back in February, so does looking at pictures of “chocolate, cheese, or puppies playing.” Prause went on to explain: “Sex film viewing does not lead to loss of control, erectile dysfunction, enhanced cue (sex image) reactivity, or withdrawal.” Without these symptoms, she said, we can assume “sex films are not addicting.”

Though the GOP’s draft platform amendment is far less explicit about why porn is harmful than Utah’s resolution, the Republicans on the subcommittee clearly want to evoke fears of child pornography, sexual predators, and trafficking. It is as though they want us to believe that pornography on the internet is the exclusive domain of those wishing to molest or exploit our children.

Child pornography is certainly an issue, as are sexual predators and human trafficking. But conflating all those problems and treating all porn as if it worsens them across the board does nothing to solve them, and diverts attention from actual potential solutions.

David Ley, a clinical psychologist, told Rewire in a recent email that the majority of porn on the internet depicts adults. Equating all internet porn with child pornography and molestation is dangerous, Ley wrote, not just because it vilifies a perfectly healthy sexual behavior but because it takes focus away from the real dangers to children: “The modern dialogue about child porn is just a version of the stranger danger stories of men in trenchcoats in alleys—it tells kids to fear the unknown, the stranger, when in fact, 90 percent of sexual abuse of children occurs at hands of people known to the victim—relatives, wrestling coaches, teachers, pastors, and priests.” He added: “By blaming porn, they put the problem external, when in fact, it is something internal which we need to address.”

The Republican platform amendment, by using words like “public health crisis,” “public menace” “predators” and “destroying the life,” seems designed to make us afraid, but it does nothing to actually make us safer.

If Republicans were truly interested in making us safer and healthier, they could focus on real public health crises like the rise of STIs; the imminent threat of antibiotic-resistant gonorrhea; the looming risk of the Zika virus; and, of course, the ever-present hazards of gun violence. But the GOP does not seem interested in solving real problems—it spearheaded the prohibition against research into gun violence that continues today, it has cut funding for the public health infrastructure to prevent and treat STIs, and it is working to cut Title X contraception funding despite the emergence of Zika, which can be sexually transmitted and causes birth defects that can only be prevented by preventing pregnancy.

This amendment is not about public health; it is about imposing conservative values on our sexual behavior, relationships, and gender expression. This is evident in other elements of the draft platform, which uphold that marriage is between a man and a women; ask the U.S. Supreme Court to overturn its ruling affirming the right to same-sex marriage; declare dangerous the Obama administration’s rule that schools allow transgender students to use the bathroom and locker room of their gender identity; and support conversion therapy, a highly criticized practice that attempts to change a person’s sexual orientation and has been deemed ineffective and harmful by the American Psychological Association.

Americans like porn. Happy, well-adjusted adults like porn. Republicans like porn. In 2015, there were 21.2 billion visits to the popular website PornHub. The site’s analytics suggest that visitors around the world spent a total of 4,392,486,580 hours watching the site’s adult entertainment. Remember, this is only one way that web users access internet porn—so it doesn’t capture all of the visits or hours spent on what may have trumped baseball as America’s favorite pastime.

As Rewire covered in February, porn is not a perfect art form for many reasons; it is not, however, an epidemic. And Concerned Women for America, Mary Frances Forrester, and the Republican subcommittee may not like how often Americans turn on their laptops and stick their hands down their pants, but that doesn’t make it a public health crisis.

Party platforms are often eclipsed by the rest of what happens at the convention, which will take place next week. Given the spectacle that a convention headlined by presumptive nominee (and seasoned reality television star) Donald Trump is bound to be, this amendment may not be discussed after next week. But that doesn’t mean that it is unimportant or will not have an effect on Republican lawmakers. Attempts to codify strict sexual mores are a dangerous part of our history—Anthony Comstock’s crusade against pornography ultimately extended to laws that made contraception illegal—that we cannot afford to repeat.

Commentary Abortion

It’s Time for an Abortion Renaissance

Charlotte Taft

We’ve been under attack and hanging by a thread for so long, it’s been almost impossible to create and carry out our highest vision of abortion care.

My life’s work has been to transform the conversation about abortion, so I am overcome with joy at the Supreme Court ruling in Whole Woman’s Health v. Hellerstedt. Abortion providers have been living under a very dark cloud since the 2010 elections, and this ruling represents a new day.

Abortion providers can finally begin to turn our attention from the idiocy and frustration of dealing with legislation whose only intention is to prevent all legal abortion. We can apply our energy and creativity fully to the work we love and the people we serve.

My work has been with independent providers who have always proudly delivered most of the abortion care in our country. It is thrilling that the Court recognized their unique contribution. In his opinion, after taking note of the $26 million facility that Planned Parenthood built in Houston, Justice Stephen Breyer wrote:

More fundamentally, in the face of no threat to women’s health, Texas seeks to force women to travel long distances to get abortions in crammed-to-capacity superfacilities. Patients seeking these services are less likely to get the kind of individualized attention, serious conversation, and emotional support that doctors at less taxed facilities may have offered.

This is a critical time to build on the burgeoning recognition that independent clinics are essential and, at their best, create a sanctuary for women. And it’s also a critical time for independent providers as a field to share, learn from, and adopt each other’s best practices while inventing bold new strategies to meet these new times. New generations expect and demand a more open and just society. Access to all kinds of health care for all people, including excellent, affordable, and state-of-the-art abortion care is an essential part of this.

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We’ve been under attack and hanging by a thread for so long—with our financial, emotional, and psychic energies drained by relentless, unconstitutional anti-abortion legislation—it’s been almost impossible to create and carry out our highest vision of abortion care.

Now that the Supreme Court has made it clear that abortion regulations must be supported by medical proof that they improve health, and that even with proof, the burdens can’t outweigh the benefits, it is time to say goodbye to the many politically motivated regulations that have been passed. These include waiting periods, medically inaccurate state-mandated counseling, bans on telemedicine, and mandated ultrasounds, along with the admitting privileges and ambulatory surgical center requirements declared unconstitutional by the Court.

Clearly 20-week bans don’t pass the undue burden test, imposed by the Court under Planned Parenthood v. Casey, because they take place before viability and abortion at 20 weeks is safer than childbirth. The federal Hyde Amendment, a restriction on Medicaid coverage of abortion, obviously represents an undue burden because it places additional risk on poor women who can’t access care as early as women with resources. Whatever the benefit was to late Rep. Henry Hyde (R-IL) it can’t possibly outweigh that burden.

Some of these have already been rejected by the Court and, in Alabama’s case, an attorney general, in the wake of the Whole Woman’s Health ruling. Others will require the kind of bold action already planned by the Center for Reproductive Rights and other organizations. The Renaissance involves raising an even more powerful voice against these regulations, and being firm in our unwillingness to spend taxpayer dollars harming women.

I’d like to entertain the idea that we simply ignore regulations like these that impose burdens and do not improve health and safety. Of course I know that this wouldn’t be possible in many places because abortion providers don’t have much political leverage. This may just be the part of me that wants reproductive rights to warrant the many risks of civil disobedience. In my mind is the man who stood in front of moving tanks in Tiananmen Square. I am yearning for all the ways to stand in front of those tanks, both legal and extralegal.

Early abortion is a community public health service, and a Renaissance goal could be to have early abortion care accessible within one hour of every woman in the country. There are more than 3,000 fake clinics in this country, many of them supported by tax dollars. Surely we can find a way to make actual services as widely available to people who need them. Of course many areas couldn’t support a clinic, but we can find ways to create satellite or even mobile clinics using telemedicine to serve women in rural areas. We can use technology to check in with patients during medication abortions, and we can provide ways to simplify after-care and empower women to be partners with us in their care. Later abortion would be available in larger cities, just as more complex medical procedures are.

In this brave new world, we can invent new ways to involve the families and partners of our patients in abortion care when it is appropriate. This is likely to improve health outcomes and also general satisfaction. And it can increase the number of people who are grateful for and support independent abortion care providers and who are able to talk openly about abortion.

We can tailor our services to learn which women may benefit from additional time or counseling and give them what they need. And we can provide abortion services for women who own their choices. When a woman tells us that she doesn’t believe in abortion, or that it is “murder” but she has to have one, we can see that as a need for deeper counseling. If the conflict is not resolved, we may decide that it doesn’t benefit the patient, the clinic, or our society to perform an abortion on a woman who is asking the clinic to do something she doesn’t believe in.

I am aware that this last idea may be controversial. But I have spent 40 years counseling with representatives of the very small, but real, percentage of women who are in emotional turmoil after their abortions. My experience with these women and reading online “testimonies” from women who say they regret their abortions and see themselves as victimized, including the ones cited by Justice Kennedy in the Casey decision, have reinforced my belief that when a woman doesn’t own her abortion decision she will suffer and find someone to blame for it.

We can transform the conversation about abortion. As an abortion counselor I know that love is at the base of women’s choices—love for the children they already have; love for their partners; love for the potential child; and even sometimes love for themselves. It is this that the anti-abortion movement will never understand because they believe women are essentially irresponsible whores. These are the accusations protesters scream at women day after day outside abortion clinics.

Of course there are obstacles to our brave new world.

The most obvious obstacles are political. As long as more than 20 states are run by Republican supermajorities, legislatures will continue to find new ways to undermine access to abortion. The Republican Party has become an arm of the militant anti-choice movement. As with any fundamentalist sect, they constantly attack women’s rights and dignity starting with the most intimate aspects of their lives. A society’s view of abortion is closely linked to and mirrors its regard for women, so it is time to boldly assert the full humanity of women.

Anti-choice LifeNews.com contends that there have been approximately 58,586,256 abortions in this country since 1973. That means that 58,586,256 men have been personally involved in abortion, and the friends and family members of at least 58,586,256 people having abortions have been too. So more than 180 million Americans have had a personal experience with abortion. There is no way a small cadre of bitter men with gory signs could stand up to all of them. So they have, very successfully so far, imposed and reinforced shame and stigma to keep many of that 180 million silent. Yet in the time leading up to the Whole Woman’s Health case we have seen a new opening of conversation—with thousands of women telling their personal stories—and the recognition that safe abortion is an essential and normal part of health care. If we can build on that and continue to talk openly and honestly about the most uncomfortable aspects of pregnancy and abortion, we can heal the shame and stigma that have been the most successful weapons of anti-abortion zealots.

A second obstacle is money. There are many extraordinary organizations dedicated to raising funds to assist poor women who have been betrayed by the Hyde Amendment. They can never raise enough to make up for the abandonment of the government, and that has to be fixed. However most people don’t realize that many clinics are themselves in financial distress. Most abortion providers have kept their fees ridiculously and perilously low in order to be within reach of their patients.

Consider this: In 1975 when I had my first job as an abortion counselor, an abortion within the first 12 weeks cost $150. Today an average price for the same abortion is around $550. That is an increase of less than $10 a year! Even in the 15 states that provide funding for abortion, the reimbursement to clinics is so low that providers could go out of business serving those in most need of care.

Over the years a higher percent of the women seeking abortion care are poor women, women of color, and immigrant and undocumented women largely due to the gap in sexual health education and resources. That means that a clinic can’t subsidize care through larger fees for those with more resources. While Hyde must be repealed, perhaps it is also time to invent some new approaches to funding abortion so that the fees can be sustainable.

Women are often very much on their own to find the funds needed for an abortion, and as the time goes by both the costs and the risk to them increases. Since patients bear 100 percent of the medical risk and physical experience of pregnancy, and the lioness’ share of the emotional experience, it makes sense to me that the partner involved be responsible for 100 percent of the cost of an abortion. And why not codify this into law, just as paternal responsibilities have been? Perhaps such laws, coupled with new technology to make DNA testing as quick and inexpensive as pregnancy testing, would shift the balance of responsibility so that men would be responsible for paying abortion fees, and exercise care as to when and where they release their sperm!

In spite of the millions of women who have chosen abortion through the ages, many women still feel alone. I wonder if it could make a difference if women having abortions, including those who received assistance from abortion funds, were asked to “pay it forward”—to give something in the future if they can, to help another woman? What if they also wrote a letter—not a bread-and-butter “thank you” note—but a letter of love and support to a woman connected to them by the web of this individual, intimate, yet universal experience? This certainly wouldn’t solve the economic crisis, but it could help transform some women’s experience of isolation and shame.

One in three women will have an abortion, yet many are still afraid to talk about it. Now that there is safe medication for abortion, more and more women will be accessing abortion through the internet in some DIY fashion. What if we could teach everyone how to be excellent abortion counselors—give them accurate information; teach them to listen with nonjudgmental compassion, and to help women look deeper into their own feelings and beliefs so that they can come to a sense of confidence and resolution about their decision before they have an abortion?

There are so many brilliant, caring, and amazing people who provide abortion care—and room for many more to establish new clinics where they are needed. When we turn our sights to what can be, there is no limit to what we can create.

Being frustrated and helpless is exhausting and can burn us out. So here’s a glass of champagne to being able to dream again, and to dreaming big. From my own past clinic work:

At this clinic we do sacred work
That honors women
And the circle of life and death.