Commentary Abortion

An Abortion Provider Speaks Out: “Being Patient-Centered is Being Pro-Choice”

Dr. Linda Prine

I do love this work, and I learn new things every day from my residents and my patients. One of the comments a resident said to me a few years ago has especially stuck with me. She said, “being patient centered is being prochoice.” The more I thought about it since then, however, the more I think it is true.

Linda Prine, MD, gave a shortened version of this speech as she accepted the 2012 William K. Rashbaum, MD, Abortion Provider Award from Physicians for Reproductive Choice and Health earlier this week.

Published in partnership with Physicians for Reproductive Choice and Health (PRCH)

I feel very honored to be the recipient of the Rashbaum award. I was lucky enough to have had the opportunity to get some training from Dr. [William K.] Rashbaum up at the old Jacoby Hospital, back when I was a resident at Montefiore in the late eighties. Those sessions were very memorable for me. Because I had been an operating room nurse before I went to medical school, I had a sense of how an operating room setting was usually run. But these days with Dr. Rashbaum were nothing like that. He was basically by himself in this ancient OR suite. He would go to a waiting room and fetch the patient and walk through a maze of corridors to the OR and instruct her to position herself on the table and then do the procedure, talking her through it, and then walk her to another area where she would sit until she felt ready to leave. I suppose there must have been some staff checking these women in and out, but I rarely saw anyone else.

This was basically the same setup when I trained with Dr. G in that Women’s Pavilion at Montefiore, so I just came to understand that, if you were going to provide abortions, you were on your own. When I had been an OR nurse, in the seventies, there was a circulating nurse and a scrub nurse and an anesthesiologist for every procedure, including early abortions (and I was even working in a Catholic hospital!). In the intervening 10 years there had been a shift in the country and my training in abortion taught me in not-so-subtle ways that abortions were now separated from other surgeries.

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I understand that, in the beginning, feminists created abortion clinics in order to make sure that women got their abortions in a supportive and caring environment. Some of my friends got their first jobs in these feminist clinics as lay advocates — women who did the counseling and then accompanied the patient through every step of the abortion process. Ultimately, however, this separation allowed abortion to become a marginalized aspect of medical care, and made it possible to not teach the skills in medical schools and residencies because the procedures were performed outside of the institutions of mainstream medicine.

By the time I was doing my gyn rotation in medical school, there were no abortions on the OR schedule anymore. And by the time I became a resident, I had to seek out abortion training from brave physicians like Dr. Rashbaum and Dr. G who were doing them in deserted wings of medical buildings with virtually no staff.

Years later, when I became faculty in a residency program, I wanted to have abortion training for my residents. At first we were able to, through the Clinician Training Initiative at Planned Parenthood NYC. My residents would rotate during their gyn block through PPNYC to get abortion training and because we weren’t able to offer abortions in our health center, we’d refer our health center patients needing abortions to ourselves at PPNYC. But offering abortions at a place other than our health center didn’t always work for our patients.

What woke me up to this was my patient, Samantha. She was bringing her one year-old daughter to me for her check-ups. We had concerns about this child: she wasn’t gaining weight properly and she had a rash on her body that looked suspiciously like burns. I got more suspicious when I learned that Samantha’s two older children were not in her custody but were in foster care. Then, in the midst of this, Samantha tells me she’s pregnant. I offered her an abortion and she was relieved and admitted she truly could not cope with another child. I made her an appointment to come to PPNYC on the day I would be there. But she didn’t show.

Three months later, when she finally came back to see me, she was five months pregnant. I asked her what happened. She just couldn’t go to an abortion clinic, she tells me. It scared her. She was afraid there would be protestors. I asked her, if I had been able to do her abortion in my office, would she have had wanted it? She said, “Of course.” It made me realize that sometimes, abortions need to be really easy for women to access. Especially for women whose lives are so troubled, like Samantha.

I’ve seen how important ready access is many times since then, as we make every effort to accommodate women at our health center with medication abortions offered mornings, afternoons, evenings and weekends, fully integrated into our schedules of sore throats, check-ups, children, the elderly. I worked the Sunday of Memorial Day weekend and did three medical abortions. None of the women had scheduled appointments. One I had counseled a few weeks earlier at our student-run free clinic. She wasn’t sure what she wanted to do, she had to ask her abusive boyfriend. She wasn’t ready to leave him. She had met with our social workers and been offered shelters and all. I gave her my phone number and told her I’d be working over Memorial Day weekend. I think she had to find a way to get away from him.

Another woman that day was a new immigrant from Russia. We have a bit of a Russian underground at our health center because several of our nurses are Russian. She told me that, although abortion is very available in Russia, really easier to get than birth control, that she never expected to be treated nicely when she came for the abortion, so she’s very happy to be in the United States. I didn’t have the heart to tell her that walking into to a clinic on a Sunday and being treated nicely when you ask for an abortion isn’t really so common in the United States, either. But we’re working on that.

It’s not only the patients’ stories that motivate me to do this work, it’s also teaching the residents and helping them see how important it is, and how integral it needs to be to family medicine. Through my work with the Reproductive Health Access Project, I connect with residents and family physicians all across the country and we have created a community that started with a list serve and has grown to be an amazing network. De-stigmatizing abortion by making it part of mainstream medicine makes it easier on the women and on the physicians. I mean, what kind of message do we give to women if we say that we can take care of them if they are continuing their pregnancy but that they have to go somewhere else if they want an abortion? How can we pretend to be pro-choice and not offer them care?

If we are really all about creating healthy families, we need to help women make those families only when they are ready to. And in the process of coming to us for unintended pregnancies, we have to let women know that we respect and support their decisions. For example, one day I had a teen who was being seen by my chief resident, and one of our newer junior residents had sat in on the counseling. The teen had asked if her mom could come in for the MVA procedure, and of course we said, “yes.” This mom was really so wonderfully supportive — she sat with her daughter and held her hand during the procedure and kept her distracted. At the end of the procedure I complimented the mom for being so there for her daughter and told them what a contrast it was to what we sometimes see. (In fact, just a day earlier I had witnessed parents telling their 16-year-old daughter she could not return to their home when she told them she was pregnant.)

When the residents and I left the room after the procedure I explained to them that it’s really important for us, as physicians, to use our power by giving respect and support back to our patients, and to be sure to say something affirming when we saw good family interactions like we’d just witnessed with this mother and daughter. My junior resident, who had watched this very warm interaction and the very gentle abortion the more senior resident had done, said to us, “Yeah! I really want to do this work.”

I do love this work, and I learn new things every day from my residents and my patients. One of the comments a resident said to me a few years ago has especially stuck with me. She said, “being patient=centered is being pro-choice.” When she first said that, it took me by surprise and I had to think about it a bit. It seemed so radical, to say that doctors who were not pro-choice were actually not patient-centered. The more I thought about it since then, however, the more I think it is true.

How can we, as physicians, possibly presume to know what is best for our patients when it comes to their decision-making about when to have a child? How could we possibly, in good conscience, withhold information about their options for ending an unwanted pregnancy or tell them that they are making a bad decision?

We can’t.

There is one other thing I’ve started doing, that I would love to share with you. I have been asking my residents to write a short narrative about their thoughts as they begin their month-long rotation with me, and then another piece at the end. It’s been amazing to look at the pieces they have written, really — I should make a book. They are so moving. Most recently, for example, my resident had written a somewhat judgmental piece as she started the rotation, saying something along the lines of “why can’t women be more responsible…” Then, at the end, she wrote this short narrative that I really just have to read to you because it is so beautiful:

“One patient that made an impression on me during my during my gyn rotation was a young lady I saw with an unintended pregnancy. She was very scared and came in with a lot of pre-formed ideas about abortion and about what she ‘should’ be doing. It seemed like, to her, that her options were continuing the pregnancy vs. hoping and praying that she wasn’t in fact pregnant. She was pregnant, and as I started discussing her options it quickly became clear that none of it was registering. I decided I would probably be more help to her just listening at this point, and after about a minute of silence, she started unpacking: about her thoughts on abortion, about how she wasn’t sure if those were her thoughts or her mother’s, about how she really didn’t feel ready to be pregnant. She ended up choosing a medication abortion, and when I saw her back the next week she seemed like she was 100 pounds lighter, smiling and relaxed. I know this is a pretty romantic story, and not everyone’s experience is like this, but the special part for me was just being able to be with her through this. To be able to sit with someone while they find the path that’s right for them and then help them carry it out is such a privilege. ”

In conclusion, I want to thank PRCH for this brilliant idea of having awards for those of us who teach and provide abortion care. It’s not often in our lives that we get honored for this work, most of it is an incredible uphill battle and most of the time we’re described as being too uncompromising or strident or pushy. It does take a thick skin sometimes to do this work, so it’s really nice for a change to get an award!

News Politics

Clinton Campaign Announces Tim Kaine as Pick for Vice President

Ally Boguhn

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

The Clinton campaign announced Friday that Sen. Tim Kaine (R-VA) has been selected to join Hillary Clinton’s ticket as her vice presidential candidate.

“I’m thrilled to announce my running mate, @TimKaine, a man who’s devoted his life to fighting for others,” said Clinton in a tweet.

“.@TimKaine is a relentless optimist who believes no problem is unsolvable if you put in the work to solve it,” she added.

The prospect of Kaine’s selection has been criticized by some progressives due to his stances on issues including abortion as well as bank and trade regulation.

Kaine signed two letters this week calling for the regulations on banks to be eased, according to a Wednesday report published by the Huffington Post, thereby ”setting himself up as a figure willing to do battle with the progressive wing of the party.”

Charles Chamberlain, executive director of the progressive political action committee Democracy for America, told the New York Times that Kaine’s selection “could be disastrous for our efforts to defeat Donald Trump in the fall” given the senator’s apparent support of the Trans-Pacific Partnership (TPP). Just before Clinton’s campaign made the official announcement that Kaine had been selected, the senator praised the TPP during an interview with the Intercept, though he signaled he had ultimately not decided how he would vote on the matter.

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Kaine’s record on reproductive rights has also generated controversy as news began to circulate that he was being considered to join Clinton’s ticket. Though Kaine recently argued in favor of providing Planned Parenthood with access to funding to fight the Zika virus and signed on as a co-sponsor of the Women’s Health Protection Act—which would prohibit states and the federal government from enacting restrictions on abortion that aren’t applied to comparable medical services—he has also been vocal about his personal opposition to abortion.

In a June interview on NBC’s Meet the Press, Kaine told host Chuck Todd he was “personally” opposed to abortion. He went on, however, to affirm that he still believed “not just as a matter of politics, but even as a matter of morality, that matters about reproduction and intimacy and relationships and contraception are in the personal realm. They’re moral decisions for individuals to make for themselves. And the last thing we need is government intruding into those personal decisions.”

As Rewire has previously reported, though Kaine may have a 100 percent rating for his time in the Senate from Planned Parenthood Action Fund, the campaign website for his 2005 run for governor of Virginia promised he would “work in good faith to reduce abortions” by enforcing Virginia’s “restrictions on abortion and passing an enforceable ban on partial birth abortion that protects the life and health of the mother.”

As governor, Kaine did support some existing restrictions on abortion, including Virginia’s parental consent law and a so-called informed consent law. He also signed a 2009 measure that created “Choose Life” license plates in the state, and gave a percentage of the proceeds to a crisis pregnancy network.

Regardless of Clinton’s vice president pick, the “center of gravity in the Democratic Party has shifted in a bold, populist, progressive direction,” said Stephanie Taylor, co-founder of the Progressive Change Campaign Committee, in an emailed statement. “It’s now more important than ever that Hillary Clinton run an aggressive campaign on core economic ideas like expanding Social Security, debt-free college, Wall Street reform, and yes, stopping the TPP. It’s the best way to unite the Democratic Party, and stop Republicans from winning over swing voters on bread-and-butter issues.”

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.