Multipurpose Prevention Technologies for Sexual and Reproductive Health: Gaining Momentum and Promise

Contraception

Multipurpose prevention technologies were the focus of Advancing Prevention Technologies for Sexual and Reproductive Health, an international symposium held in Berkeley, CA, in March 2009. For 2 days, more than 150 participants from developing and industrialized countries discussed and debated the opportunities and challenges for advancing technologies that address multiple sexual and reproductive health (SRH) needs. The symposium proceedings draw from those presentations and the subsequent discussions.2 This editorial seeks to convey the key points of these discussions and engage health care professionals in the effort to fulfill the potential that these technologies might offer.

This editorial was originally published in the journal Contraception and was co-authored by Bethany Young Holt, Maggie Kilbourne-Brook, Alan Stone, Polly Harrison, and Wayne Shields.

Over the past four decades, the world has made substantial
gains in the effort to prevent unplanned pregnancies and reduce the risk of
sexually transmitted infections (STIs), including HIV, and other reproductive
tract infections (RTIs). Yet, STIs and RTIs still cause a heavy health burden,
especially in developing countries, and there is an equally urgent unmet need
for contraception.1,2,3,4,5,6

To date, prevention
strategies have focused largely on single indications, namely, the prevention
of unplanned pregnancy, prevention of STIs or prevention of RTIs. This approach
does not adequately recognize the intrinsic link between unplanned pregnancy
and STIs: a woman at risk of an unplanned pregnancy is often simultaneously at
risk for an STI, including HIV, or other RTI. Thus, there is a critical need
for multipurpose prevention technologies that will allow people to avoid more
than one adverse health outcome.

Multipurpose prevention
technologies were the focus of Advancing Prevention Technologies for Sexual and
Reproductive Health, an international symposium held in Berkeley, CA, in March
2009. For 2 days, more than 150 participants from developing and industrialized
countries discussed and debated the opportunities and challenges for advancing
technologies that address multiple sexual and reproductive health (SRH) needs.
The symposium proceedings draw from those presentations and the subsequent
discussions.2 This editorial seeks to convey the key points of these
discussions and engage health care professionals in the effort to fulfill the
potential that these technologies might offer.

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A
universal health need

Unplanned pregnancy and STIs
typically affect the most disadvantaged groups — especially young women,
adolescents and the poor — the hardest. But women from all socioeconomic groups
face challenges to their SRH.7,8,9,10,11

Each year:

  • More than 120 million couples have an unmet need for
    contraception.

  • An estimated 80 million women experience an unplanned
    pregnancy (45 million of which end in abortion).

  • More than half a million women die from complications
    associated with pregnancy, childbirth and the postpartum period.

  • Roughly 340 million people acquire new gonorrhea,
    syphilis, chlamydia or trichomonas infections.

 

In addition, untold numbers
of individuals acquire chronic infections with the herpes simplex virus (HSV)
and human papillomavirus (HPV), which is the primary cause of cervical cancer.12

Millions of women are
vulnerable to several of these adverse outcomes, yet many women are only able
to access or afford prevention for a single intervention, such as contraception
or treatment for an STI. At the same time, many providers struggle to ensure
that their clients have access to all prevention methods that meet their
multiple needs.

A
new approach

It is time to address SRH
prevention in a more holistic way and to develop prevention tools that address
multiple health risks; are acceptable, affordable, accessible and easy to use;
and can meet individuals’ varying health needs and reproductive intentions.
Such interventions could have a dramatic effect on the health and well-being of
millions of women and their families.

Multipurpose preventive
technologies for SRH could include vaccines, microbicides and devices [such as
intravaginal rings (IVRs), diaphragms and condoms] that provide protection from
unplanned pregnancy; STIs including HIV; and/or other common RTIs. As the
report from the Berkeley symposium explains, “Providing people with suitable
protection is a continuing challenge, especially in settings where access to
health services is limited, and the availability of technologies that address
more than one indication would be a significant improvement in terms of
efficiency and convenience. The provider would be able to stock, supply, and
advise on a more compact range of products, and the user would need to
purchase, understand, store, and use fewer products. A further advantage is
that users would be protected automatically against more than one indication
even if they had obtained the product with regard to a single perceived risk”.2
While such technologies will benefit both men and women, women will gain the
most, as they are more vulnerable to these risks for both physiological and
societal reasons.

Some multipurpose prevention
technologies already exist, but they are woefully underutilized. Male and
female condoms, for instance, prevent both unplanned pregnancy and STIs. Male
condoms are not always used consistently. While the launch of the UNFPA Global
Female Condom Initiative in 2005 has significantly increased access to female
condoms, this woman-controlled prevention method has nonetheless been slow to
achieve widespread distribution or user acceptance and more must be done to
increase its demand and access.13

Extensive experience with
existing prevention methods — condoms, diaphragms, IVRs, hormonal methods and
vaccines — and recent advances in the development of microbicides and oral
pre-exposure prophylaxis with antiretroviral drugs have laid a solid foundation
for the development of new prevention technologies for multiple SRH risks.
Several of these technologies, such as more user-friendly female condoms and
diaphragms, are in the late stages of clinical testing. The PATH Women’s
Condom, for example, has gone through several clinical studies and is entering
a regulatory study for its approval in China and the US. A new generation of
microbicides, including products based on antiretroviral drugs, continues to
hold promise despite the failure of some of the earlier products to protect,
including the polyanion PRO 2000 (http://www.mdp.mrc.ac.uk).

Momentum is building. The
National Institutes of Health, US Agency for International Development, the
Ministry of Health of China and other donors are currently supporting efforts
to advance multipurpose prevention strategies, including preclinical research,
effectiveness trials and pre- and postintroduction studies on a range of
potential multipurpose prevention products, both coitally dependent and long
acting.2

Collaborations between different organizations and research
disciplines, such as behavioral scientists, immunologists, engineers,
epidemiologists, drug developers, clinicians, and advocates, are evolving and
helping to advance some exciting novel SRH prevention approaches.14, 15,
16, 17

Research efforts include semisolid gels, gel capsules, films,
IVRs, sponges, compound-releasing intrauterine systems, diaphragms, and male
and female condoms with and without spermicidal or anti-infective agents.
Listed here are some of the various entities which are currently pursuing this
work: CONRAD, Family Health International, International Partnership for
Microbicides, Ministry of Health of China, PATH, the Population Council, Queens
University of Belfast, University of Witwatersrand, University of Alabama,
University of California Berkeley, University of California San Francisco,
University of Utah, biotech companies (e.g., ReProtect, Mapp Biopharmaceutical,
Inc., and Osel, Inc.) and others. The CONRAD program, for example, has
dedicated a major portion of its portfolio to combined approaches.2
The Population Council, PATH, International Partnership for Microbicides,
University of Utah and CONRAD are working on multipurpose IVRs and diaphragms
which would be impregnated with contraceptives and anti-STI microbicides.2,18

Other technologies in development include probiotics that prevent bacterial and
urinary infections and could be modified to serve as drug-delivery systems.19,20
Multipurpose vaccines are also in development and the discovery of
potentially suitable antigens for several STI pathogens is progressing,
including chlamydia, HIV, HSV, gonorrhea and trichomonas.

For each of the
technologies, the challenge will be to ensure that their production and
deployment can be sufficiently cost-effective for widespread use in developing
countries with minimal health care infrastructure. The Berkeley symposium gave
voice to many promising ideas and a shared belief that multipurpose
technologies can and should be developed. It is, of course, recognized that
these technologies will not by themselves achieve all the desired goals and
that they will need to be introduced with care, and their deployment preceded
and accompanied by well-designed educational programs.

The effort to develop
multipurpose prevention technologies and bring them to populations in need will
encounter many complex challenges. The work will require technical innovation,
scientific persistence, significant human and technical resources, and,
crucially, political will. Given the rapid evolution of relevant technologies
and an increasingly focused effort, these challenges can be overcome. With
sufficient funding, new tools such as these could become the building blocks
for cost-effective prevention efforts. When combined with more effective
programming of existing prevention technologies, women and communities will
benefit from improved health.

Recommended
actions

Multifaceted collaboration
will be required to bring multipurpose prevention technologies within reach.
Researchers, funders, product developers, engineers, microbiologists,
behavioral scientists, advocates and others must work together to maximize
their technical expertise, community involvement and political will. In
addition, these stakeholders must promote cross-disciplinary communication and
collaboration, ensuring that parallel development tracks interact at strategic
points.

Health professionals can
contribute their expertise and voice toward this effort in multiple ways. For
example, they can:

  • Educate clients about the intrinsic link between STIs
    and unplanned pregnancies and the need for simultaneous prevention.

  • Clinicians can educate
    their clients about the need to prevent STIs and unplanned pregnancy and
    encourage clients to use existing combined methods to increase their
    levels of protection, such as male or female condoms for STI/HIV
    prevention combined with hormonal methods and IUDs, since these are the
    most effective contraceptive options now available.

  • Seek opportunities to facilitate cross-disciplinary
    collaboration.
  • Researchers can explore
    opportunities to collaborate with researchers in different fields that
    can complement their work. They can also participate in conferences and
    learn about relevant work outside their particular research area. 
  • Clinicians can find
    ways to help researchers recruit participants into clinical trials of new
    prevention products and participate in product acceptability research.
    Data on these topics are needed in diverse geographic regions in the US
    and internationally as well as in communities with diverse social and
    demographic characteristics.
  • Advocate for increased support for multipurpose
    prevention technologies.
     

  • All health care
    professionals can educate donors and funders about the need for intensive,
    multidisciplinary research aimed at providing affordable and acceptable
    multipurpose prevention technologies.

  • Professionals can also
    educate legislators and policymakers about the importance of multipurpose
    prevention technologies.
     

  • They can inform other
    stakeholders — professional societies, organizations and coalitions;
    reproductive health and HIV organizations; and health advocacy groups —
    about the need for greater investment in multipurpose prevention
    technologies for SRH
  • All supporters can
    spread the word within their professional networks by presenting on this
    topic and submitting articles to these networks’ newsletters and related
    communication outlets.

Conclusion

This is a pivotal time for
reproductive health professionals. We have the opportunity to identify and
prioritize opportunities to achieve a significant health impact in
industrialized as well as in developing countries by accelerating the
development of multipurpose prevention technologies. Together, we can address
this need and improve the health and well-being of women and their families
around the world.

References

  1. Guttmacher Institute and United Nations Population Fund
    (UNFPA). Adding It Up: The Benefits of Investing in Sexual and Reproductive
    Health Care. New York: AGI. Available at: http://www.guttmacher.org/pubs/addingitup.pdf.
    2003.
  2. Stone A. Symposium Report: Advancing Prevention
    Technologies for Sexual and Reproductive Health. Available at: http://www.cami-health.com/APT2009/PDFs/report-aug09.pdf.
    2009.
  3. Cates W, Steiner MJ. Dual protection against unplanned
    pregnancy and sexually transmitted infections: what is the best
    contraceptive approach?. Sex Transm Dis. 2002;29:168–174.
  4. International Planned Parenthood Federation, University
    of California San Francisco, Joint United Nations Program on HIV/AIDS,
    UNFPA, World Health Organization. Sexual & reproductive health and
    HIV. Linkages: evidence review and recommendations. Available online at: http://data.unaids.org/pub/Agenda/2009/2009_linkages_evidence_review_en.pdf.
    2009.
  5. Wilcher R, Petruney T, Reynolds HW, Cates W. From
    effectiveness to impact: contraception as an HIV prevention intervention. Sex
    Transm Infect
    . 2008;84(Suppl 2):ii54–ii60.
  6. Feldblum PJ, Nasution MD, Hoke TH, et al. Pregnancy
    among sex workers participating in a condom intervention trial highlights
    the need for dural protection. Contraception. 2007;76:105–110.
  7. Allsworth JE, Lewis VA, Peipert JF. Viral sexually
    transmitted infections and bacterial vaginosis: 2001–2004 National Health
    and Nutrition Examination Survey data. Sex Transm Dis.
    2008;35:791–796.
  8. Frost JJ, Singh S, Finer LB. US women’s one-year
    contraceptive use patterns, 2004. Perspect Sex Reprod Health.
    2007;39:48–55.
  9. Glasier A, Gulmezoglu AM, Schmid GP, Moreno CG, Van
    Look PFA. Sexual and reproductive health: a matter of life and death. Lancet.
    2006;368:1550–1551.
  10. CDC. HIV/AIDS Surveillance Report 2003; (Vol. 15).
    Atlanta: US Department of Health and Human Services, CDC; 2005.
  11. The World Bank and International Monetary Fund. Global
    Monitoring Report 2009: A Development Emergency. 2009; Washington DC.
  12. Bosch FX, de Sanjosé S. The epidemiology of human
    papillomavirus infection and cervical cancer. Dis Markers.
    2007;23:213–227.
  13. UNFPA. Empowering women to protect themselves:
    promoting the female condom in Zimbabwe. Available at: http://www.unfpa.org/public/cache/offonce/News/pid/3913;jsessionid=4FBD9DA8AD4EFB9F069224AC0EEB0670.
    2009.
  14. Verguet S, Young Holt B, Szeri A. Reframing behavioral
    acceptability of microbicide gel vehicles in conjunction with biophysical
    constraints. Presented at the 2009 Advancing Prevention Technologies for
    Sexual and Reproductive Health Symposium, Berkeley California. Available
    at: http://www.cami-health.com/APT2009/posters.html2009.
  15. Morrow K, Fava J, Rosen R, Kiser P, Katz D. Linking
    biophysical functions to user perceptions and acceptability in preclinical
    product development. Presented at the 2009 Advancing Prevention
    Technologies for Sexual and Reproductive Health Symposium, Berkeley
    California. Available at: http://www.cami-health.com/APT2009/posters.html.
  16. Arntzen C, Herbst-Kralovetz M, Mason H, Tacket C,
    Khanna N, Zeitlin L, Whaley K The vaccine and microbicide alliance.
    Presented at the 2009 Advancing Prevention Technologies for Sexual and
    Reproductive Health Symposium, Berkeley California. Available at: http://www.cami-health.com/APT2009/posters.html.
  17. Alliance for Microbicide Development. HIV/STI
    Prevention Research and Development: October 2009 Pipeline Update of
    Microbicide and PrEP Candidates. Silver Spring, MD. Available at: http://www.microbicide.org/uploads/3/1/2/1/3121935/microbicide_pipeline_update_1_oct_2009.pdf.
  18. Nath A, Sitruk-Ware R. Novel non-oral hormonal
    contraceptive methods for women. Exp Rev Obstet Gynecol.
    2009;4:565–573.
  19. Bolton M, van der Straten A, Cohen CR. Probiotics:
    potential to prevent HIV and sexually transmitted infections in women. Sex
    Transm Dis
    . 2008;35:214–225.
  20. Liu X, Lagenaur LA, Simpson DA, et al. Engineered
    vaginal lactobacillus strain for mucosal delivery of the human
    immunodeficiency virus inhibitor cyanovirin-N. Antimicrob Agents
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Commentary Sexual Health

Parents, Educators Can Support Pediatricians in Providing Comprehensive Sexuality Education

Nicole Cushman

While medical systems will need to evolve to address the challenges preventing pediatricians from sharing medically accurate and age-appropriate information about sexuality with their patients, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Last week, the American Academy of Pediatrics (AAP) released a clinical report outlining guidance for pediatricians on providing sexuality education to the children and adolescents in their care. As one of the most influential medical associations in the country, AAP brings, with this report, added weight to longstanding calls for comprehensive sex education.

The report offers guidance for clinicians on incorporating conversations about sexual and reproductive health into routine medical visits and summarizes the research supporting comprehensive sexuality education. It acknowledges the crucial role pediatricians play in supporting their patients’ healthy development, making them key stakeholders in the promotion of young people’s sexual health. Ultimately, the report could bolster efforts by parents and educators to increase access to comprehensive sexuality education and better equip young people to grow into sexually healthy adults.

But, while the guidance provides persuasive, evidence-backed encouragement for pediatricians to speak with parents and children and normalize sexual development, the report does not acknowledge some of the practical challenges to implementing such recommendations—for pediatricians as well as parents and school staff. Articulating these real-world challenges (and strategies for overcoming them) is essential to ensuring the report does not wind up yet another publication collecting proverbial dust on bookshelves.

The AAP report does lay the groundwork for pediatricians to initiate conversations including medically accurate and age-appropriate information about sexuality, and there is plenty in the guidelines to be enthusiastic about. Specifically, the report acknowledges something sexuality educators have long known—that a simple anatomy lesson is not sufficient. According to the AAP, sexuality education should address interpersonal relationships, body image, sexual orientation, gender identity, and reproductive rights as part of a comprehensive conversation about sexual health.

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The report further acknowledges that young people with disabilities, chronic health conditions, and other special needs also need age- and developmentally appropriate sex education, and it suggests resources for providing care to LGBTQ young people. Importantly, the AAP rejects abstinence-only approaches as ineffective and endorses comprehensive sexuality education.

It is clear that such guidance is sorely needed. Previous studies have shown that pediatricians have not been successful at having conversations with their patients about sexuality. One study found that one in three adolescents did not receive any information about sexuality from their pediatrician during health maintenance visits, and those conversations that did occur lasted less than 40 seconds, on average. Another analysis showed that, among sexually experienced adolescents, only a quarter of girls and one-fifth of boys had received information from a health-care provider about sexually transmitted infections or HIV in the last year. 

There are a number of factors at play preventing pediatricians from having these conversations. Beyond parental pushback and anti-choice resistance to comprehensive sex education, which Martha Kempner has covered in depth for Rewire, doctor visits are often limited in time and are not usually scheduled to allow for the kind of discussion needed to build a doctor-patient relationship that would be conducive to providing sexuality education. Doctors also may not get needed in-depth training to initiate and sustain these important, ongoing conversations with patients and their families.

The report notes that children and adolescents prefer a pediatrician who is nonjudgmental and comfortable discussing sexuality, answering questions and addressing concerns, but these interpersonal skills must be developed and honed through clinical training and practice. In order to fully implement the AAP’s recommendations, medical school curricula and residency training programs would need to devote time to building new doctors’ comfort with issues surrounding sexuality, interpersonal skills for navigating tough conversations, and knowledge and skills necessary for providing LGBTQ-friendly care.

As AAP explains in the report, sex education should come from many sources—schools, communities, medical offices, and homes. It lays out what can be a powerful partnership between parents, doctors, and educators in providing the age-appropriate and truly comprehensive sexuality education that young people need and deserve. While medical systems will need to evolve to address the challenges outlined above, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Parents and Caregivers: 

  • When selecting a pediatrician for your child, ask potential doctors about their approach to sexuality education. Make sure your doctor knows that you want your child to receive comprehensive, medically accurate information about a range of issues pertaining to sexuality and sexual health.
  • Talk with your child at home about sex and sexuality. Before a doctor’s visit, help your child prepare by encouraging them to think about any questions they may have for the doctor about their body, sexual feelings, or personal safety. After the visit, check in with your child to make sure their questions were answered.
  • Find out how your child’s school approaches sexuality education. Make sure school administrators, teachers, and school board members know that you support age-appropriate, comprehensive sex education that will complement the information provided by you and your child’s pediatrician.

School Staff and Educators: 

  • Maintain a referral list of pediatricians for parents to consult. When screening doctors for inclusion on the list, ask them how they approach sexuality education with patients and their families.
  • Involve supportive pediatricians in sex education curriculum review committees. Medical professionals can provide important perspective on what constitutes medically accurate, age- and developmentally-appropriate content when selecting or adapting curriculum materials for sex education classes.
  • Adopt sex-education policies and curricula that are comprehensive and inclusive of all young people, regardless of sexual orientation or gender identity. Ensure that teachers receive the training and support they need to provide high-quality sex education to their students.

The AAP clinical report provides an important step toward ensuring that young people receive sexuality education that supports their healthy sexual development. If adopted widely by pediatricians—in partnership with parents and schools—the report’s recommendations could contribute to a sea change in providing young people with the care and support they need.

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.

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