Analysis Abortion

Working with Dr. Tiller: His Staff Recalls a Tradition of Compassionate Care at Women’s Health Care Services of Wichita

Carole Joffe

Dr. Tiller’s murder and the closing of his clinic brought renewed national attention to the problems facing women who need abortions late in pregnancy. While he was viciously attacked by anti-choicers, one of whom eventually killed him, he was beloved by his staff and his patients for compassionate care in extraordinary circumstances.

This article is cross-posted with permission from the forthcoming issue (September 2011) of Perspectives on Sexual and Reproductive Health.  We are grateful to the Guttmacher Institute for facilitating this exchange.

While attending Sunday church services in May 2009, Dr. George Tiller, an abortion provider in Wichita, Kansas, was assassinated by an antiabortion extremist. The doctor’s murder led shortly to the closing of his clinic, Women’s Health Care Services (WHCS), which had been the best known of the handful of U.S. facilities to openly provide abortions at 24 weeks of gestation or later for women with serious health conditions and those carrying fetuses with severe or lethal anomalies. One of the most polarizing symbols of the U.S. abortion conflict, Dr. Tiller was reviled by abortion opponents. Among abortion rights supporters, and especially among his colleagues in the close-knit abortion provider community, Dr. Tiller was a beloved hero, legendary for the kindness and compassion he extended to desperate women who came to him from all over the United States and abroad.

Dr. Tiller’s murder and the closing of his clinic brought renewed national attention to the problems facing women who need abortions late in pregnancy. Fewer than 2 percent of the 1.2 million abortions performed each year in the United States occur after 20 weeks of gestation.[1]  An unknown number occur after 24 weeks; in most states, such procedures are permitted only under highly restricted circumstances. At the time of Dr. Tiller’s death, only two or three other clinics were known to openly provide third-trimester procedures for qualifying women. Some hospitals provide these services on a case-by-case basis for patients of attending physicians, but the fact that WHCS served women from all over the country indicates that many women had difficulty finding the care they needed close to home.

WHCS’s closure raised important public health concerns; chief among these was what would become of women carrying wanted pregnancies that go horribly wrong late in pregnancy. For abortion providers wishing to offer similar specialized abortion care, and for scholars of the nation’s longstanding abortion conflict, the closure raises other important questions: What services were developed for this unique segment of abortion patients? How did staff cope with working in a facility that was continually under attack by antiabortion activists?

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This report draws on interviews the author conducted with seven former WHCS staff members to address these questions. Open-ended group interviews took place in Wichita in December 2009. The author made follow-up queries by e-mail and phone. The institutional review board of the University of California, San Francisco, approved the project.

The focus here is on the carefully choreographed experience of women who qualified for abortions after 24 weeks’ gestation because of fetal indication—that is, their fetuses had anomalies such as anencephaly (the absence of a large part of the brain and skull) or trisomy 13 (a genetic disorder characterized by multiple abnormalities, which typically leads to death within the first month of life). According to staff, Dr. Tiller devoted much thought to the particular care needed by fetal indication patients, and he refined his approach over many years. These patients made up about 15–20 percent of the WHCS caseload. (Of the remaining patients, about half sought first-trimester abortions, and half either sought second-trimester abortions or came for later abortions because of “maternal indications”—serious physical or mental health conditions, such as cancer or pregnancy resulting from incest.)

PATIENT EXPERIENCES
First Phone Contact

Some women learned about Dr. Tiller’s practice after finding out they were too advanced in pregnancy to obtain an abortion from a local provider. Others were referred by genetic counselors they had consulted after learning of a fetal anomaly. Some women, either in the care of physicians opposed to abortion or having no regular physician, found WHCS on their own after searching the Internet.

However women learned of WHCS, their first contact with the clinic was by phone. The clinic’s phone counselors were trained to carefully screen for those who would qualify under Kansas’s strict guidelines for third-trimester procedures, and prospective patients or their physicians were asked to fax documentation of the diagnosis. Those who were accepted as fetal indication patients were told to prepare for a 4 to 5-day visit, which typically began on a Tuesday. Interwoven with information on hotels and driving instructions were cautions about the protesters the patients could expect to encounter upon arrival.

Day 1: First Experiences at the Clinic

The events of the first day consisted of medical procedures and activities geared toward helping the patient psychologically prepare for the abortion. After checking in, patients, typically accompanied by spouses or other relatives, would watch a video made by Dr. Tiller describing what to anticipate during their several days’ stay in Wichita, including the details of the abortion procedure. (At WHCS, procedures performed late in pregnancy were done by induction, defined in a leading medical textbook as “the termination of pregnancy by stimulation of labor-like contractions that cause eventual expulsion of the fetus and placenta from the uterine cavity.”[2]) Notably, fetal indication patients watched the video as a group. As staff explained, having patients bond with each other throughout their clinic stay was a central component of Dr. Tiller’s approach.

“Doctor [as Dr. Tiller was invariably referred to by staff] felt that no one else could understand them as well as others in the same situation,” said one staff member.

Once the video was over, Dr. Tiller met with the group, which typically consisted of six to 12 people. He prepared for this meeting, as a staff member said, by doing his “homework”: Over the weekend preceding the arrival of a new cohort of fetal indication patients, he read the women’s files carefully, learning their names, the names of those accompanying them and their hometowns.

In a blog post, the husband of one patient said of that first encounter:

“Dr. Tiller had an understanding of [our] pain, perhaps better than anyone who has never gone through it personally. As a doctor he was up-front about everything he was about to do and everything we needed to do to make things go well. When we arrived, he sat all four couples down and told us everything that was going to happen. He showed us the instruments he was going to use. He told us how the drugs would make the women feel. He told them fl at out that it was going to hurt and she needed to be ready.… He also asked about us. He wanted to know who we were, what we did, and how we lived as couples and families.”[3]

After this group meeting, Dr. Tiller met privately with each woman, couple or family to answer questions. The first day then proceeded with lab work and a meeting with a second physician, who, as required by Kansas law, would affirm patients’ eligibility for a post–24-week abortion. Then patients underwent what staff considered one of the most emotionally difficult experiences of their stay at WHCS: an ultrasound followed by an injection of digoxin, a heart medicine, administered in a dose that causes fetal demise without affecting the mother. At this time, patients were sedated with Versed, a drug that relieves anxiety and causes some memory loss, and Dr. Tiller inserted laminaria to gradually dilate the cervix in preparation for the induced labor that would follow in the next 48 hours or so.

The fetal indication patients then had lunch together in the clinic. Dr. Tiller often joined them if he was available. “For Doctor, having a meal together was a connection,” one staff member explained. After lunch, Dr. Tiller and the staff chaplain convened a “support and healing group,” at which participants were urged to share their stories. The bonding among patients intensified during this meeting, according to staff. As a nurse who was often present at these meetings put it, “A patient would begin to talk, and you could just see that all the other patients would be thinking, ‘Wow! Her story is almost like mine.’” A Latina staff member hired as a Spanish translator told a moving story of a patient who spoke no English and listened quietly to the others: “She sensed the empathy that was occurring among the others in the room and whispered to me that she wanted to tell her story…and proceeded to do so in Spanish.”

At this meeting, Dr. Tiller asked patients what kind of support they had back home and what they had told others about their trip to Kansas. Such concerns were especially pertinent to patients who had children, whom they had had to leave with relatives or friends. Staff told of a handout that Dr. Tiller had prepared to help patients navigate difficult conversations, colloquially referred to as the “nosey people paper.” A staff member summarized Dr. Tiller’s recommended response to those inquiring why someone who had been visibly pregnant no longer was: “The baby was sick. We went for testing. The baby didn’t make it. It’s hard for me to talk about it right now.”

Patients at this meeting were also given written information on “baby plans” (For fetal indication patients, staff used the term “baby,” rather than “fetus,” reflecting these patients’ preferences. The word “baby” was not typically used with other abortion patients at WHCS; among other women, the most common term was “pregnancy.”)—the options available to them after their abortion. They were asked to consider, for example, whether they wished to see and hold their baby after delivery and whether they wanted pictures, blankets and footprints as keepsakes. They were also asked to contemplate whether they wanted a baptism or other religious ceremony, and whether they wished to have their baby’s ashes shipped to them after cremation at WHCS.

WHCS offered patients an array of options for religious services. Dr. Tiller was a deeply spiritual person, and his clinic pioneered the incorporation of religious elements into abortion care. The chaplain on staff, a Protestant minister, was available to tailor services for Christian and non-affiliated patients. The clinic also forged relationships with local rabbis and an imam in a neighboring county. One staff member recalled:

“When we had a Muslim patient, I’d call Mr. S, and he’d come over and talk to the patients, and make sure that I’d wrap the baby’s body in linen for the funeral service he’d conduct.”

As patients left the clinic on the first day, they were instructed to go to a pharmacy to pick up various medications. Typically, they then drove to their hotels. Many, according to staff, made dinner plans with other patients they had met that day.

Day 2: Further Preparations
The second day of fetal indication patients’ stay (typically a Wednesday) continued with a similar mixture of medical procedures and emotional support activities. The women had laminaria removed and new ones inserted, and received another ultrasound. Medical personnel checked to ensure that the digoxin injection had caused fetal demise. At another group meeting, Dr. Tiller and the head nurse went over the mechanics of the day of delivery. The patients then had another private meeting with Dr. Tiller and the chaplain, at which point they filled out a form declaring their preferences for the “baby plan.”

Days 3 and 4: Delivery

Most fetal indication patients were expected to deliver on Thursday, day three of their stay, or Friday, day four. They were instructed to fast as of midnight on Thursday. Upon a patient’s arrival at the clinic on Thursday morning, a nurse would check her cervix and insert new laminaria. The long-time head nurse was very adept at predicting the time of delivery; women who were expected to deliver within the next several hours were started on intravenous antibiotics and sedation, and were given misoprostol, which started contractions. Then, as this nurse said, “We just waited.”

While waiting for labor to begin, patients were supported by partners and relatives, and Dr. Tiller and other staff periodically stopped by to check on their progress and offer encouragement. “He [Dr. Tiller] would spend as much time as he could [with the fetal indication patients], rubbing their backs, chitchatting about different things,” said one nurse. Staff reported that Dr. Tiller firmly believed that “a woman’s body knows best,” and patients were not given additional medication to hasten delivery. While they waited in the labor suite, women expressed support to each other. As the nurse remarked, “It was always amazing to me how much they cared about the other person … how fast people bond when they’re going through a crisis together.”

If it looked likely that a woman was going to deliver during the night, arrangements were made for her to stay overnight at the clinic, where a staff member was in attendance.

Day 4 or 5: Viewing the Baby and Saying Good-Bye

Because patients were sedated during the induction, Dr. Tiller’s custom was to show the baby to parents who wished a viewing (and most did) the next day. This typically occurred after the woman’s final post-delivery checkup, in the clinic’s Quiet Room. According to staff, “The room, we set it up before they went in there…. We’d light candles and have soft lighting.” Dr. Tiller, accompanied by the chaplain and often by the head nurse, would tell the parents what to expect (such as babies with organs outside their bodies, misshapen heads and other potentially disturbing sights) and ask them if they wanted to see and hold the baby. If they did, the baby would be brought in wrapped in a blanket. “Sometimes we would hold hands and say a prayer with the parents,” recalled one nurse. Parents were then offered time alone with their baby and were encouraged to take as long as they wished.

Typically, the patients and those accompanying them would leave for the airport immediately after seeing their baby, stopping only for a quick, and often tearful, goodbye to staff. Staff acknowledged that some patients had a difficult time leaving the supportive environment of the clinic for the impersonal atmosphere of the airport. Staff expressed particular compassion for childless women and couples. “The ones without kids, those are the ones that hit me the most…. Often, they had their nursery all set up,” said one.

PROTESTERS

WHCS was one of the most targeted abortion clinics in the country. Indeed, the militant antiabortion group Operation Rescue moved its headquarters to Wichita from California in 2002 expressly to force the clinic’s closure. Protesters—who included statewide organizations such as Kansas Citizens for Life, smaller church groups and individuals—made their presence felt in three ways: by protesting at the clinic itself, gathering at the homes of Dr. Tiller and his staff, and pressuring local merchants to boycott the clinic.

Patients arriving at the clinic typically encountered noisy protesters, many of whom had bullhorns or waved huge placards with grotesque pictures that purportedly depicted aborted fetuses. Protesters were at the clinic virtually every day, in groups that generally ranged in size from a half-dozen to more than 10 times that. Several hundred would arrive on special occasions, such as the January 22 anniversary of Roe v. Wade. The protesters sometimes threw themselves in front of arriving cars. They would take pictures of patients’ license plates and, when possible, of patients themselves. In response, some patients wore wigs and sunglasses, while others pulled coats over their heads before walking to the clinic doors. When patients left the clinic, according to staff, protesters again shouted at them and attempted to take photographs. When staff were asked what they thought was the most challenging part of the experience at WHCS for patients, they immediately responded “the protesters.”

Employing a common tactic, antiabortion forces purchased a property adjacent to WHCS and opened a so-called crisis pregnancy center. This center attempted to lure confused abortion patients to its doors to counsel them against the procedure. “They would zero in on the Asian and Spanish-speaking patients,” one staff member recalled. Observing this through the window, staff would dispatch the WHCS security guard to bring the rattled patients to their intended destination.

Periodically, WHCS experienced serious vandalism and violence. Such incidents included a firebombing in 1986; the Summer of Mercy in 1991—a months-long siege of the clinic and Dr. Tiller’s home led by Operation Rescue, which was attended by  antiabortion protesters from all over the country and resulted in hundreds of arrests;[4] and, in 1993, the shooting of Dr. Tiller in both arms by a member of the extremist Army of God. (Dr. Tiller was not seriously wounded in that shooting, and he returned to the clinic the next day.)

Dr. Tiller was also subject to repeated legal actions by various political opponents. Notably, the former attorney general of Kansas, Phill Kline, made it a personal crusade to shut down WHCS.* Operation Rescue leaders also filed numerous legal complaints against Dr. Tiller, taking advantage of an 1887 law, unique to Kansas, that allowed grand juries to be impaneled on the basis of citizen petitions. Dr. Tiller won all these court battles. In his last trial, in March 2009, the jury acquitted Dr. Tiller in less than 45 minutes, dismissing accusations that he had violated the second physician requirement for post–24-week abortions.[5] Nevertheless, the clinic manager reported, these frequent legal battles imposed a considerable emotional strain on both Dr. Tiller and his staff.

On a day-to-day basis, one of the most difficult things for staff to manage was the boycott of the clinic by local businesses, an action engineered by Operation Rescue and other groups. Protesters photographed the license plates of all vehicles that entered the premises and maintained a list on the Operation Rescue Web site of local establishments that did business with the clinic. In many cases, this intimidation worked. Staff reported that numerous local establishments abruptly ended long-standing business relationships with WHCS.

As a result, many services to which medical providers normally would not give a second thought became problems for the resourceful staff to solve. For example, the pizza restaurant that for years had delivered the lunch served to patients suddenly refused to continue driving onto clinic grounds. Similarly, the hotel chain to which WHCS had long sent its fetal indication patients in return for reduced rates canceled this arrangement because of pressures brought on the chain’s national office. (The termination of this arrangement may also have been due to protesters’ periodically showing up in the hotel and putting antiabortion material under other guests’ doors.) Furthermore, of the three cab companies in Wichita, only one agreed to provide services for WHCS patients, and even with this company, there were sometimes problems. One of the company’s part-time drivers was a Catholic priest, who staff said harangued the patients. “So we had to call the company and say, ‘You have to provide a driver that will not hassle our patients.’” Even then, problems with cab drivers’ behavior did not end: Some drivers—whether out of fear of the protesters or in sympathy with them—would not follow instructions to take patients into the clinic’s back private parking lot, instead leaving them in the street, where they would have to make their way past screaming protesters to reach the clinic doors.

Arguably the most worrisome outcome of the boycott occurred when the company that had long provided trash hauling for the clinic called to say, as the clinic manager put it, “they were no longer interested in doing business with us.” She frantically called other local companies and finally found one willing to provide this service, “but with a ‘but’”: The new company would come to the clinic only in the middle of the night, which necessitated additional security arrangements to enable the truck to enter the secured parking lot. The clinic manager explained, “They drove an unmarked truck and had an unmarked bin, so nobody would know who they were.”

WHCS STAFF: STAYING THE COURSE

The WHCS staff had to deal with daily threats to the personal safety of their patients and themselves, repeated politically inspired lawsuits that put clinic operations at risk and elaborate negotiations with businesses fearful of being associated with the clinic—in addition to attending to fetal indication patients at a time of immense grief and caring for the other patients who came to WHCS. Despite these challenges, some staff had worked at WHCS for many years—the head nurse for more than 30 years, and the clinic manager for 14. And all staff made it clear that they were not only devastated by Dr. Tiller’s death, but deeply saddened to have lost work they loved. How did the WHCS employees cope with such a turbulent workplace?

In simplest terms, the staff’s commitment to this challenging work cannot be separated from their evident devotion to Dr. Tiller and their belief in the importance of what he had created at WHCS. Tiller often referred to the mission of the clinic as “saving women’s lives,”[6] and the staff clearly accepted this framing of their work. One recalled, “Doctor used to say, ‘We could all be working somewhere else, and if we are working here, it is for a reason.’”

By all accounts, Dr. Tiller was a beloved employer, who made clear to his staff how much he valued their work. One physician described how, when she started at the clinic, Dr. Tiller would observe her while she performed abortions for fetal indication patients: “He would see what was good about your technique, and he would encourage it.” She went on to recount how her new boss told her he modified his own practice after noting her skill at getting patients to relax.

Dr. Tiller also made it clear that he recognized the unusual sacrifices that working at WHCS entailed. For example, staff received additional “combat pay,” as the doctor called it, when they were targeted at home by protesters. Moreover, Dr. Tiller frequently sought opportunities to celebrate his employees and their work. On one memorable occasion, Dr. Tiller organized a party in honor of an elderly employee who worked as a “hand-holder” for patients. Recognizing that the woman had never before worked outside the home, he presented her with a blownup version of her first paycheck. Occasionally, in a political gesture that was especially meaningful to the staff, the clinic offered abortions at no cost to celebrate the anniversary of Roe v. Wade.

Working at WHCS led staff to identify strongly with the national abortion rights movement and, in particular, with their abortion provider colleagues. Abortion facilities across the country were regularly in touch with the clinic, where they periodically sent diffi cult cases. Staff who sometimes accompanied Dr. Tiller to national conferences of abortion providers reported feeling particularly appreciated by this community because of the special efforts WHCS made to accommodate hardship cases, such as by caring for incest victims (some as young as nine years old) and performing abortions at reduced or no cost.

Similarly, the very intensity of the opposition in Wichita led staff to feel especially gratified by demonstrations of local support. After the 1991 Summer of Mercy siege, for example, staff reported being deeply touched that community groups raised money to build a fence around the clinic. The dismay staff felt about the boycotts only strengthened their appreciation of the mainly family-owned local businesses that stood by them. The show of support by neighbors, even self-identified “pro-lifers,” after protesters came to staff homes, was particularly reassuring. One staff member recounted, “I don’t think any of us had problems with the neighbors after that…. I got a bouquet of flowers and a bunch of nice cards.”

As noted earlier, Dr. Tiller was a highly spiritual person, and he periodically referred to the clinic’s work as a “ministry.” Similarly, several staff—particularly those with the most emotionally challenging work—pointed to their own strong religious beliefs as having guided their work. “I felt I was doing the Lord’s work,” said the staff member charged with readying the stillborn babies to be seen by their parents. In almost identical terms, the woman who prepared the babies’ bodies for cremation said, “God put me here to do this work.” And the clinic chaplain, referring to the comfort she tried to give to grieving parents, recounted, “This was holy work we were doing here. We gave the parents the gift of not having to make their babies suffer.”

Gratitude from patients, particularly fetal indication patients, was also was a major factor in sustaining staff morale. One staff member said, “I have never worked for any physician where there was that kind of love and appreciation [from patients]…. They really felt like they had their lives back, that this was a place of healing for them.” The walls of the clinic were papered with thank-you letters from former patients. The staff were also aware of a Web site, Kansas Stories, which posted former patients’ descriptions of their experiences.[7] Expressing sentiments typical of the site’s contributors, one posting read, “We are forever grateful to the Women’s Health Center, the amazing doctor and all the staff for being our heaven when we were living in hell.”

Finally, a sense of pride and professionalism sustained the staff’s commitment to their highly demanding jobs. The clinic manager, recounting the ways she and her colleagues surmounted the obstacles put forward by their opponents, said, “We were survivors. We had to be.”

CONCLUSION

The history of WHCS is unique in several respects. No other clinic in the United States has been such a powerful symbol for both abortion opponents and supporters. Nor has any other facility been subject to such a sustained level of protest.6 And although the majority of abortion facilities experience some form of harassment, none have received the volume of violent threats that WHCS did. In April 2011, nearly two years after Dr. Tiller’s murder, the FBI released documents that revealed that the agency had  investigated “numerous death threats” against the doctor since the 1990s.[8] But, paradoxically, the very intensity of this opposition contributed to both Dr. Tiller’s and his staff’s resolve to continue with their work.

Given that Republican gains in the 2010 elections have led to an explosion of laws, at both the federal and the state levels, seeking to further restrict abortion at all stages, 9[9] it is difficult to be optimistic about the availability of abortions for those who need them late in pregnancy. Nevertheless, in response to the closing of WHCS, a number of facilities across the country have extended their services to include abortions after 24 weeks’ gestation under legally permitted circumstances. Most notably, a clinic in New Mexico, Southwestern Women’s Options, hired two former WHCS physicians and has begun to offer post–24-week abortions on a “case-by-case basis,” incorporating a modified version of the group experience for fetal indication patients pioneered in Wichita. It remains to be seen whether this clinic can avoid the polarization that characterized WHCS.


[1] Guttmacher Institute, Facts on induced abortion in the United States, In Brief, 2011, <http://www.guttmacher.org/pubs/fb_induced_abortion.html>, accessed Apr. 15, 2011.

[2] Paul M et al., Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care, West Sussex, UK: Blackwell Publishing, 2009, p. 178.

[3] Young D, Eulogy for Dr. George Tiller, Rabbi Young’s Blog, 2009, <http://rabbiyoung.blogspot.com/2009/06/eulogy-for-dr-george-tiller.html>, accessed Jan. 10, 2011.

[4] Risen J and Thomas JL, Wrath of Angels: The American Abortion War, New York: Basic Books, 1998, pp. 324–333.

[5] Stumpe J, Jurors acquit Kansas doctor in a late-term abortion case, New York Times, Mar. 27, 2009, <http://www.nytimes.com/2009/03/28/us/28abortion.html>, accessed Mar. 1, 2011.

[6] Barstow D, An abortion battle, fought to the death, New York Times, July 26, 2009, <http://www.nytimes.com/2009/07/26/us/26tiller.html?ref=georgertiller>, accessed June 27, 2011.

[7] A heartbreaking choice, Kansas Stories, 2010, <www.aheartbreakingchoice.com/kansasstories>, accessed Mar. 7, 2011.

[8] Hegeman R, Pages detail FBI probes into Tiller death threats, Wichita Eagle, Apr. 6, 2011, <http://www.kansas.com/2011/04/06/1795675/pages-detail-fbi-probes-into-tiller.html>, accessed Apr. 15, 2011.

[9] Guttmacher Institute, State legislative trends: hostility to abortion rights increases, 2001, news release, Apr. 12, 2011, <http://www.guttmacher.org/media/inthenews/2011/04/12/index.html>, accessed

May 9, 2011.

Analysis Law and Policy

After ‘Whole Woman’s Health’ Decision, Advocates Should Fight Ultrasound Laws With Science

Imani Gandy

A return to data should aid in dismantling other laws ungrounded in any real facts, such as Texas’s onerous "informed consent” law—HB 15—which forces women to get an ultrasound that they may neither need nor afford, and which imposes a 24-hour waiting period.

Whole Woman’s Health v. Hellerstedt, the landmark U.S. Supreme Court ruling striking down two provisions of Texas’ omnibus anti-abortion law, has changed the reproductive rights landscape in ways that will reverberate in courts around the country for years to come. It is no longer acceptable—at least in theory—for a state to announce that a particular restriction advances an interest in women’s health and to expect courts and the public to take them at their word.

In an opinion driven by science and data, Justice Stephen Breyer, writing for the majority in Whole Woman’s Health, weighed the costs and benefits of the two provisions of HB 2 at issue—the admitting privileges and ambulatory surgical center (ASC) requirements—and found them wanting. Texas had breezed through the Fifth Circuit without facing any real pushback on its manufactured claims that the two provisions advanced women’s health. Finally, Justice Breyer whipped out his figurative calculator and determined that those claims didn’t add up. For starters, Texas admitted that it didn’t know of a single instance where the admitting privileges requirement would have helped a woman get better treatment. And as for Texas’ claim that abortion should be performed in an ASC, Breyer pointed out that the state did not require the same of its midwifery clinics, and that childbirth is 14 times more likely to result in death.

So now, as Justice Ruth Bader Ginsburg pointed out in the case’s concurring opinion, laws that “‘do little or nothing for health, but rather strew impediments to abortion’ cannot survive judicial inspection.” In other words, if a state says a restriction promotes women’s health and safety, that state will now have to prove it to the courts.

With this success under our belts, a similar return to science and data should aid in dismantling other laws ungrounded in any real facts, such as Texas’s onerous “informed consent” law—HB 15—which forces women to get an ultrasound that they may neither need nor afford, and which imposes a 24-hour waiting period.

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In Planned Parenthood v. Casey, the U.S. Supreme Court upheld parts of Pennsylvania’s “informed consent” law requiring abortion patients to receive a pamphlet developed by the state department of health, finding that it did not constitute an “undue burden” on the constitutional right to abortion. The basis? Protecting women’s mental health: “[I]n an attempt to ensure that a woman apprehends the full consequences of her decision, the State furthers the legitimate purpose of reducing the risk that a woman may elect an abortion, only to discover later, with devastating psychological consequences, that her decision was not fully informed.”

Texas took up Casey’s informed consent mantle and ran with it. In 2011, the legislature passed a law that forces patients to undergo a medical exam, whether or not their doctor thinks they need it, and that forces them to listen to information that the state wants them to hear, whether or not their doctor thinks that they need to hear it. The purpose of this law—at least in theory—is, again, to protect patients’ “mental health” by dissuading those who may be unsure about procedure.

The ultra-conservative Fifth Circuit Court of Appeals upheld the law in 2012, in Texas Medical Providers v. Lakey.

And make no mistake: The exam the law requires is invasive, and in some cases, cruelly so. As Beverly McPhail pointed out in the Houston Chronicle in 2011, transvaginal probes will often be necessary to comply with the law up to 10 to 12 weeks of pregnancy—which is when, according to the Guttmacher Institute, 91 percent of abortions take place. “Because the fetus is so small at this stage, traditional ultrasounds performed through the abdominal wall, ‘jelly on the belly,’ often cannot produce a clear image,” McPhail noted.

Instead, a “probe is inserted into the vagina, sending sound waves to reflect off body structures to produce an image of the fetus. Under this new law, a woman’s vagina will be penetrated without an opportunity for her to refuse due to coercion from the so-called ‘public servants’ who passed and signed this bill into law,” McPhail concluded.

There’s a reason why abortion advocates began decrying these laws as “rape by the state.”

If Texas legislators are concerned about the mental health of their citizens, particularly those who may have been the victims of sexual assault—or any woman who does not want a wand forcibly shoved into her body for no medical reason—they have a funny way of showing it.

They don’t seem terribly concerned about the well-being of the woman who wants desperately to be a mother but who decides to terminate a pregnancy that doctors tell her is not viable. Certainly, forcing that woman to undergo the painful experience of having an ultrasound image described to her—which the law mandates for the vast majority of patients—could be psychologically devastating.

But maybe Texas legislators don’t care that forcing a foreign object into a person’s body is the ultimate undue burden.

After all, if foisting ultrasounds onto women who have decided to terminate a pregnancy saves even one woman from a lifetime of “devastating psychologically damaging consequences,” then it will all have been worth it, right? Liberty and bodily autonomy be damned.

But what if there’s very little risk that a woman who gets an abortion experiences those “devastating psychological consequences”?

What if the information often provided by states in connection with their “informed consent” protocol does not actually lead to consent that is more informed, either because the information offered is outdated, biased, false, or flatly unnecessary given a particular pregnant person’s circumstance? Texas’ latest edition of its “Woman’s Right to Know” pamphlet, for example, contains even more false information than prior versions, including the medically disproven claim that fetuses can feel pain at 20 weeks gestation.

What if studies show—as they have since the American Psychological Association first conducted one to that effect in 1989—that abortion doesn’t increase the risk of mental health issues?

If the purpose of informed consent laws is to weed out women who have been coerced or who haven’t thought it through, then that purpose collapses if women who get abortions are, by and large, perfectly happy with their decision.

And that’s exactly what research has shown.

Scientific studies indicate that the vast majority of women don’t regret their abortions, and therefore are not devastated psychologically. They don’t fall into drug and alcohol addiction or attempt to kill themselves. But that hasn’t kept anti-choice activists from claiming otherwise.

It’s simply not true that abortion sends mentally healthy patients over the edge. In a study report released in 2008, the APA found that the strongest predictor of post-abortion mental health was prior mental health. In other words, if you’re already suffering from mental health issues before getting an abortion, you’re likely to suffer mental health issues afterward. But the studies most frequently cited in courts around the country prove, at best, an association between mental illness and abortion. When the studies controlled for “prior mental health and violence experience,” “no significant relation was found between abortion history and anxiety disorders.”

But what about forced ultrasound laws, specifically?

Science has its part to play in dismantling those, too.

If Whole Woman’s Health requires the weighing of costs and benefits to ensure that there’s a connection between the claimed purpose of an abortion restriction and the law’s effect, then laws that require a woman to get an ultrasound and to hear a description of it certainly fail that cost-benefit analysis. Science tells us forcing patients to view ultrasound images (as opposed to simply offering the opportunity for a woman to view ultrasound images) in order to give them “information” doesn’t dissuade them from having abortions.

Dr. Jen Gunter made this point in a blog post years ago: One 2009 study found that when given the option to view an ultrasound, nearly 73 percent of women chose to view the ultrasound image, and of those who chose to view it, 85 percent of women felt that it was a positive experience. And here’s the kicker: Not a single woman changed her mind about having an abortion.

Again, if women who choose to see ultrasounds don’t change their minds about getting an abortion, a law mandating that ultrasound in order to dissuade at least some women is, at best, useless. At worst, it’s yet another hurdle patients must leap to get care.

And what of the mandatory waiting period? Texas law requires a 24-hour waiting period—and the Court in Casey upheld a 24-hour waiting period—but states like Louisiana and Florida are increasing the waiting period to 72 hours.

There’s no evidence that forcing women into longer waiting periods has a measurable effect on a woman’s decision to get an abortion. One study conducted in Utah found that 86 percent of women had chosen to get the abortion after the waiting period was over. Eight percent of women chose not to get the abortion, but the most common reason given was that they were already conflicted about abortion in the first place. The author of that study recommended that clinics explore options with women seeking abortion and offer additional counseling to the small percentage of women who are conflicted about it, rather than states imposing a burdensome waiting period.

The bottom line is that the majority of women who choose abortion make up their minds and go through with it, irrespective of the many roadblocks placed in their way by overzealous state governments. And we know that those who cannot overcome those roadblocks—for financial or other reasons—are the ones who experience actual negative effects. As we saw in Whole Woman’s Health, those kinds of studies, when admitted as evidence in the court record, can be critical in striking restrictions down.

Of course, the Supreme Court has not always expressed an affinity for scientific data, as Justice Anthony Kennedy demonstrated in Gonzales v. Carhart, when he announced that “some women come to regret their choice to abort the infant life they once created and sustained,” even though he admitted there was “no reliable data to measure the phenomenon.” It was under Gonzales that so many legislators felt equipped to pass laws backed up by no legitimate scientific evidence in the first place.

Whole Woman’s Health offers reproductive rights advocates an opportunity to revisit a host of anti-choice restrictions that states claim are intended to advance one interest or another—whether it’s the state’s interest in fetal life or the state’s purported interest in the psychological well-being of its citizens. But if the laws don’t have their intended effects, and if they simply throw up obstacles in front of people seeking abortion, then perhaps, Whole Woman’s Health and its focus on scientific data will be the death knell of these laws too.

News Law and Policy

Texas Lawmaker’s ‘Coerced Abortion’ Campaign ‘Wildly Divorced From Reality’

Teddy Wilson

Anti-choice groups and lawmakers in Texas are charging that coerced abortion has reached epidemic levels, citing bogus research published by researchers who oppose legal abortion care.

A Texas GOP lawmaker has teamed up with an anti-choice organization to raise awareness about the supposed prevalence of forced or coerced abortion, which critics say is “wildly divorced from reality.”

Rep. Molly White (R-Belton) during a press conference at the state capitol on July 13 announced an effort to raise awareness among public officials and law enforcement that forced abortion is illegal in Texas.

White said in a statement that she is proud to work alongside The Justice Foundation (TJF), an anti-choice group, in its efforts to tell law enforcement officers about their role in intervening when a pregnant person is being forced to terminate a pregnancy. 

“Because the law against forced abortions in Texas is not well known, The Justice Foundation is offering free training to police departments and child protective service offices throughout the State on the subject of forced abortion,” White said.

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White was joined at the press conference by Allan Parker, the president of The Justice Foundation, a “Christian faith-based organization” that represents clients in lawsuits related to conservative political causes.

Parker told Rewire that by partnering with White and anti-choice crisis pregnancy centers (CPCs), TJF hopes to reach a wider audience.

“We will partner with anyone interested in stopping forced abortions,” Parker said. “That’s why we’re expanding it to police, social workers, and in the fall we’re going to do school counselors.”

White only has a few months remaining in office, after being defeated in a closely contested Republican primary election in March. She leaves office after serving one term in the state GOP-dominated legislature, but her short time there was marked by controversy.

During the Texas Muslim Capitol Day, she directed her staff to “ask representatives from the Muslim community to renounce Islamic terrorist groups and publicly announce allegiance to America and our laws.”

Heather Busby, executive director of NARAL Pro-Choice Texas, said in an email to Rewire that White’s education initiative overstates the prevalence of coerced abortion. “Molly White’s so-called ‘forced abortion’ campaign is yet another example that shows she is wildly divorced from reality,” Busby said.

There is limited data on the how often people are forced or coerced to end a pregnancy, but Parker alleges that the majority of those who have abortions may be forced or coerced.

‘Extremely common but hidden’

“I would say that they are extremely common but hidden,” Parker said. “I would would say coerced or forced abortion range from 25 percent to 60 percent. But, it’s a little hard be to accurate at this point with our data.”

Parker said that if “a very conservative 10 percent” of the about 60,000 abortions that occur per year in Texas were due to coercion, that would mean there are about 6,000 women per year in the state that are forced to have an abortion. Parker believes that percentage is much higher.

“I believe the number is closer to 50 percent, in my opinion,” Parker said. 

There were 54,902 abortions in Texas in 2014, according to recently released statistics from the Texas Department of State Health Services (DSHS). The state does not collect data on the reasons people seek abortion care. 

White and Parker referenced an oft cited study on coerced abortion pushed by the anti-choice movement.

“According to one published study, sixty-four percent of American women who had abortions felt forced or unduly pressured by someone else to have an unwanted abortion,” White said in a statement.

This statistic is found in a 2004 study about abortion and traumatic stress that was co-authored by David Reardon, Vincent Rue, and Priscilla Coleman, all of whom are among the handful of doctors and scientists whose research is often promoted by anti-choice activists.

The study was cited in a report by the Elliot Institute for Social Sciences Research, an anti-choice organization founded by Reardon. 

Other research suggests far fewer pregnant people are coerced into having an abortion.

Less than 2 percent of women surveyed in 1987 and 2004 reported that a partner or parent wanting them to abort was the most important reason they sought the abortion, according to a report by the Guttmacher Institute.

That same report found that 24 percent of women surveyed in 1987 and 14 percent surveyed in 2004 listed “husband or partner wants me to have an abortion” as one of the reasons that “contributed to their decision to have an abortion.” Eight percent in 1987 and 6 percent in 2004 listed “parents want me to have an abortion” as a contributing factor.

‘Flawed research’ and ‘misinformation’  

Busby said that White used “flawed research” to lobby for legislation aimed at preventing coerced abortions in Texas.

“Since she filed her bogus coerced abortion bill—which did not pass—last year, she has repeatedly cited flawed research and now is partnering with the Justice Foundation, an organization known to disseminate misinformation and shameful materials to crisis pregnancy centers,” Busby said.  

White sponsored or co-sponsored dozens of bills during the 2015 legislative session, including several anti-choice bills. The bills she sponsored included proposals to increase requirements for abortion clinics, restrict minors’ access to abortion care, and ban health insurance coverage of abortion services.

White also sponsored HB 1648, which would have required a law enforcement officer to notify the Department of Family and Protective Services if they received information indicating that a person has coerced, forced, or attempted to coerce a pregnant minor to have or seek abortion care.

The bill was met by skepticism by both Republican lawmakers and anti-choice activists.

State affairs committee chairman Rep. Byron Cook (R-Corsicana) told White during a committee hearing the bill needed to be revised, reported the Texas Tribune.

“This committee has passed out a number of landmark pieces of legislation in this area, and the one thing I think we’ve learned is they have to be extremely well-crafted,” Cook said. “My suggestion is that you get some real legal folks to help engage on this, so if you can keep this moving forward you can potentially have the success others have had.”

‘Very small piece of the puzzle of a much larger problem’

White testified before the state affairs committee that there is a connection between women who are victims of domestic or sexual violence and women who are coerced to have an abortion. “Pregnant women are most frequently victims of domestic violence,” White said. “Their partners often threaten violence and abuse if the woman continues her pregnancy.”

There is research that suggests a connection between coerced abortion and domestic and sexual violence.

Dr. Elizabeth Miller, associate professor of pediatrics at the University of Pittsburgh, told the American Independent that coerced abortion cannot be removed from the discussion of reproductive coercion.

“Coerced abortion is a very small piece of the puzzle of a much larger problem, which is violence against women and the impact it has on her health,” Miller said. “To focus on the minutia of coerced abortion really takes away from the really broad problem of domestic violence.”

A 2010 study co-authored by Miller surveyed about 1,300 men and found that 33 percent reported having been involved in a pregnancy that ended in abortion; 8 percent reported having at one point sought to prevent a female partner from seeking abortion care; and 4 percent reported having “sought to compel” a female partner to seek an abortion.

Another study co-authored by Miller in 2010 found that among the 1,300 young women surveyed at reproductive health clinics in Northern California, about one in five said they had experienced pregnancy coercion; 15 percent of the survey respondents said they had experienced birth control sabotage.

‘Tactic to intimidate and coerce women into not choosing to have an abortion’

TJF’s so-called Center Against Forced Abortions claims to provide legal resources to pregnant people who are being forced or coerced into terminating a pregnancy. The website includes several documents available as “resources.”

One of the documents, a letter addressed to “father of your child in the womb,” states that that “you may not force, coerce, or unduly pressure the mother of your child in the womb to have an abortion,” and that you could face “criminal charge of fetal homicide.”

The letter states that any attempt to “force, unduly pressure, or coerce” a women to have an abortion could be subject to civil and criminal charges, including prosecution under the Federal Unborn Victims of Violence Act.

The document cites the 2007 case Lawrence v. State as an example of how one could be prosecuted under Texas law.

“What anti-choice activists are doing here is really egregious,” said Jessica Mason Pieklo, Rewire’s vice president of Law and the Courts. “They are using a case where a man intentionally shot his pregnant girlfriend and was charged with murder for both her death and the death of the fetus as an example of reproductive coercion. That’s not reproductive coercion. That is extreme domestic violence.”

“To use a horrific case of domestic violence that resulted in a woman’s murder as cover for yet another anti-abortion restriction is the very definition of callousness,” Mason Pieklo added.

Among the other resources that TJF provides is a document produced by Life Dynamics, a prominent anti-choice organization based in Denton, Texas.

Parker said a patient might go to a “pregnancy resource center,” fill out the document, and staff will “send that to all the abortionists in the area that they can find out about. Often that will stop an abortion. That’s about 98 percent successful, I would say.”

Reproductive rights advocates contend that the document is intended to mislead pregnant people into believing they have signed away their legal rights to abortion care.

Abortion providers around the country who are familiar with the document said it has been used for years to deceive and intimidate patients and providers by threatening them with legal action should they go through with obtaining or providing an abortion.

Vicki Saporta, president and CEO of the National Abortion Federation, previously told Rewire that abortion providers from across the country have reported receiving the forms.

“It’s just another tactic to intimidate and coerce women into not choosing to have an abortion—tricking women into thinking they have signed this and discouraging them from going through with their initial decision and inclination,” Saporta said.

Busby said that the types of tactics used by TFJ and other anti-choice organizations are a form of coercion.

“Everyone deserves to make decisions about abortion free of coercion, including not being coerced by crisis pregnancy centers,” Busby said. “Anyone’s decision to have an abortion should be free of shame and stigma, which crisis pregnancy centers and groups like the Justice Foundation perpetuate.”

“Law enforcement would be well advised to seek their own legal advice, rather than rely on this so-called ‘training,” Busby said.