Analysis Abortion

Evidence-Based Advocacy: How Do Abortion Providers Experience Stigma?

Steph Herold

Many highly trained physicians provide abortion care, so why do abortion providers continue to be stereotyped as substandard doctors?

Evidence-Based Advocacy is a monthly column seeking to bridge the gap between the research and activist communities by profiling provocative new abortion research that activists may not otherwise be able to access.

Ask anyone to tell you who’s doing the most innovative research on abortion provider stigma and they’ll tell you it’s Dr. Lisa Harris and her interdisciplinary team at the University of Michigan. Together they pioneered the Provider Share Workshop, a pilot project testing the possibility that a support group for abortion providers could help reduce the negative impact of stigma. She writes about topics that others in even the most pro-choice communities shy away from—the need to have open and honest conversations about second trimester abortion provision, how stigma affects abortion complications, and, recently, the need to recognize conscience as a motivating factor in abortion provision. Now, Dr. Harris and her team, which includes social worker Jane Hassinger, and public health PhDs Michelle Debbink and Lisa Martin, have gone a step further and actually mapped out how abortion providers experience abortion stigma, coining a new term: the legitimacy paradox

Based on their interviews with abortion clinic staff who participated in the Provider Share Workshop, Dr. Harris and her team theorize that the combination of stigma and silence perpetuate a vicious cycle:

“When abortion providers do not disclose their work in everyday encounters, their silence perpetuates a stereotype that abortion work is unusual or deviant, or that legitimate, mainstream doctors do not perform abortions. This contributes to marginalization of abortion providers within medicine and the ongoing targeting of providers for harassment and violence. This reinforces the reluctance to disclose abortion work, and the cycle continues.”        

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A visualization of the legitimacy paradox, by Dr. Lisa Harris et al.

A visualization of the legitimacy paradox, by Dr. Lisa Harris et al.

The marginalization of abortion providers within medicine and society at large is not a new issue. In fact, as Dr. Harris and others have written, negative portrayals of abortion providers go back at least two centuries in the United States. In the nineteenth century, the American Medical Association opposed abortion in part because non-physicians (such as midwives, osteopathic doctors, and others) were the majority of abortion providers at that time and took away valuable business from physicians. The AMA sought to criminalize abortion to push these competing practitioners out of business, and thus began the association of abortion provision with “deviance” from mainstream medicine.

As the women’s liberation movement made the case for safe and legal abortion in the mid-twentieth century, abortion providers were depicted as “back alley butchers.” This portrayal and the grotesque images associated with it communicated the very real dangers of illegal and unsafe abortion, but neglected that many thousands of safe illegal abortions that were provided by both clinicians and lay-people during this time. While the use of the “back alley butcher” imagery certainly helped to legalize abortion in the United States, Dr. Harris argues that it did so while further stigmatizing abortion providers.

To track how abortion providers experience stigma today, Dr. Harris’ team conducted a focus group with abortion clinic staff in a Midwestern abortion clinic. She documented that all abortion clinic staff, including clinicians, counselors, front desk workers, and others, feel the negative impacts of doing stigmatized work. Providers commented on encountering stigma in public discourse, such as in political rhetoric, from institutions, such as hospitals and churches, as well as in their every day relationships with family, friends, and even their patients. As a result of this stigma, providers often have to choose if and how to disclose their involvement in abortion provision, weighing the possibilities of relationship conflict and threats to their safety if they decide to disclose, or isolation and disconnection if they keep their work a secret.

What are the consequences of this stigma? One possibility is that it may contribute to violence and harassment of abortion providers. Dr. Harris and her team explain:

“Stigma dehumanizes its subjects, and dehumanization is a step on the path to violent acts…When underlying prejudices, attitudes, or mental health conditions intersect with degrading rhetoric…some individuals may be incited to acts of violence.”

It shouldn’t come as a surprise to anyone that stigma can lead to violence, and that as a result, abortion providers decide not to routinely disclose the nature of their work in everyday situations. And that’s where the legitimacy paradox comes in: this (understandable) silence from abortion providers allows others to define abortion provider’s work and character for them. Many highly trained physicians provide abortion care, but abortion providers continue to be stereotyped as substandard doctors.

Why should we care about abortion provider stigma and the legitimacy paradox? Dr. Harris explains that it most likely affects the availability and accessibility of abortion services in several ways. The prevalent negative images and stereotypes of abortion providers may deter medical students from seeking abortion training and may discourage clinicians already in practice from providing abortions. For clinicians who already provide abortion care, being stereotyped as a “substandard” provider may cause them to provide abortion for only a short time in their careers. Additionally, the legitimacy paradox may impact people seeking abortion services—that is, patients may assume that doctors at an abortion clinic are “low-quality” physicians because they provide abortion services.

What can we do to address abortion provider stigma and the legitimacy paradox? The solution isn’t to push abortion providers out of the closet—considering the safety risks of publicly identifying as an abortion provider, this would be an irresponsible and perhaps even dangerous solution. Dr. Harris suggests that advocacy and medical organizations as well as institutions and clinics implement structural interventions to address abortion stigma and provider stereotypes. We must demonstrate that we value the work of abortion providers by challenging the harmful assumption, from anti-abortion legislators as well as some in the medical community, that abortion providers are sub-par clinicians.  Understanding and addressing the legitimacy paradox will enable us to better support abortion providers and people who seek abortion services.

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.

News Health Systems

Illinois Bill: Catholic Hospitals Must Inform Patients Where They Can Obtain Denied Care

Nicole Knight Shine

The legislation amends the state Health Care Right of Conscience Act to require religiously affiliated facilities to inform patients in writing about health-care providers "who they reasonably believe" offer procedures that the institutions will not perform.

Religiously affiliated hospitals in Illinois must advise patients where they can find treatments that the institutions won’t offer on religious grounds, under new legislation sitting on the governor’s desk.

The patient information measure, SB 1564, comes at a time when almost about 30 percent of hospital beds in the state—and one in six in the nation—are in Catholic institutions that bar certain reproductive health and end-of-life treatments, according to recent figures from the advocacy group MergerWatch.

The legislation amends the state Health Care Right of Conscience Act to require religiously affiliated facilities to inform patients in writing about health-care providers “who they reasonably believe” offer procedures that the institutions will not perform, or to refer or transfer patients to those alternate providers. Hospitals must do this in response to patient requests for such procedures. The legislation cleared the state house on a 61-54 vote and the senate on a 34-19 vote. Democrats control both chambers.

The office of Illinois Gov. Bruce Rauner (R) did not respond to request for comment on whether he would sign the bill.

Catholic facilities often follow U.S. Conference of Catholic Bishops religious directives  that generally bar treatments such as sterilization, in vitro fertilization, and abortion care. The federal Church Amendment and some state laws protect these faith-based objections.

Even so, growing concerns over facilities that deny treatment that patients want—and that doctors advise—has recently prompted lawmakers in Illinois, Michigan, and Washington state to advance patient information measures.

A Michigan lawsuit now on appeal alleges a Catholic facility caused unnecessary trauma by denying a patient treatment. In 2010, then-18-weeks pregnant Tamesha Means arrived at a Catholic hospital, Mercy Health Partners in Muskegon, Michigan, bleeding and miscarrying. On two occasions, the hospital turned away Means, as Rewire reported. It wasn’t until Means started delivering on her third hospital visit that she received treatment.

The Illinois legislation represents a compromise among the Illinois Catholic Health Association, the Illinois State Medical Society, and the Illinois affiliate of the American Civil Liberties Union (ACLU), representatives from the groups told Rewire.

Lorie Chaiten, director of the ACLU of Illinois’ Reproductive Rights Project, said in an online statement that the legislation “protects patients when health care providers exercise religious refusals.”

Research indicates that patients aren’t always aware that religiously affiliated facilities don’t provide a full spectrum of reproductive health services, according to a 2014 paper published in Contraception.

Patrick Cacchione, executive director of the Illinois Catholic Health Association, said the organization, which represents the state’s 43 Catholic hospitals, opposed an early version of the bill requiring religious health-care facilities to give patients a written list of known medical providers that perform the treatments that the religious institutions oppose.

Cacchione said such a direct referral would have made Catholic hospitals “complicit.”

“We will provide all the information you need, but we will not make a direct referral,” he told Rewire in a phone interview Monday. The new version of the legislation does not require hospitals to confirm that providers perform the treatments; the facilities must only have a “reasonable belief” that they do.

He said Illinois hospitals are already doing what the legislation now requires.

Approximately one in five doctors surveyed at religiously affiliated institutions “had experienced conflict with the institution over religiously based patient care policies,” according to the 2010 paper, “Religious Hospitals and Primary Care Physicians: Conflicts Over Policies for Patient Care,” published in the Journal of General Internal Medicine.

In an emailed statement, Dr. Thomas M. Anderson, a Chicago radiologist and president of the Illinois State Medical Society, told Rewire, “The Society strongly believes physicians should be able to exercise their right of conscience and changes made to SB 1564 protect that right.”