Commentary Abortion

What We Are Missing in the Trans-vaginal Ultrasound Debate

Tracy Weitz

In the heated debate around trans-vaginal ultrasounds, there is too little focus on what is really wrong with these laws.

Everyone please step away from the ledge. The public discourse about mandated trans-vaginal ultrasounds for abortion patients is completely out of control—among both abortion rights opponents and abortion rights supporters. The facts are slim and distorted on all sides. It is time for a more thoughtful discussion on the issue.

Let’s start with reviewing what these new laws usually require. The laws are often based on model legislation developed by American’s United for Life (AUL), a law and policy advocacy organization that seeks “legal protection for human life from conception to natural death.”  The laws mandate that abortion providers must let women view a real-time ultrasound image of their fetus prior to consenting to an abortion. That image must be as good as technology will allow and the doctor, who is the same doctor who will subsequently perform the abortion, must perform the ultrasound, describe the image to the woman in detail, and let her listen to the fetal heart. All this must occur at least 24 hours prior to the abortion. Because trans-vaginal ultrasounds provide higher quality images at earlier gestational stages, these laws by definition require abortion providers to perform trans-vaginal ultrasounds. Generally, women are not allowed to opt out of these requirements, although there are now a few very limited exceptions in some state laws.

Because the idea of sticking a probe in a woman’s vagina against her will is appalling to the general listener, abortion rights supporters have focused on this single aspect of the laws as a way to generate public outrage. Advocates refer to the required ultrasounds with phrases such as “medical rape.” The problem is that the indignation generated is almost exclusively focused on the mandatory nature of the probe—not on what is actually wrong with the law.

To step back, the stated purpose of the ultrasound laws is to give a woman information about her pregnancy that might persuade her to opt against having an abortion. AUL explains the logic: “Medical evidence indicates that women feel bonded to their children after seeing them on the ultrasound screen. Once that bond is established, researchers argue, a woman no longer feels ambivalent toward her pregnancy and actually begins to feel invested in her unborn child.” In all the high-pitched hype about “medical rape,” no one is critiquing this stated justification for the laws. And there is much to critique.

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First, the purported medical evidence is speculative. In the above excerpt from AUL’s argument, each sentence includes a footnote to a 1983 editorial in the New England Journal of Medicine that hypothesized that ultrasound viewing could dissuade women from having an abortion. However, the authors of the editorial based their conjecture on experiences with two—yes, only two—pregnant women who viewed their ultrasounds. This hardly counts as medical evidence.

Second, to date, no peer-reviewed empirical data has supported this proposition that viewing an ultrasound image discourages women from abortion. In fact, what limited information does exist suggests that women seeking abortions have a range of experiences associated with viewing their ultrasound and any mind-changing occurs in a complex context that may or may not include ultrasound viewing along with other factors.

In work my colleagues and I conducted at the UCSF ANSIRH program, we discovered that many women who voluntarily choose to view their ultrasound image find viewing helpful—and sometimes it even confirms their decision to have an abortion. Those who oppose abortion rights might be shocked to find that their efforts to ensure viewing actually help women choose abortion and resolve conflict over their decisions. This is true for women at all stages of gestation.

Both supporters and opponents of abortion rights get another thing wrong: they misunderstand standard abortion practice. The use of trans-vaginal ultrasounds is routine among abortion providers. When I started this work three decades ago, pregnant women often had to wait until they were seven or eight weeks pregnant before providers felt comfortable performing an abortion—they needed to wait that long to confirm a pregnancy and its placement. With advances in ultrasound technology—specifically the ability to conduct trans-vaginal ultrasounds—providers can now verify an intrauterine pregnancy as early as 4 weeks. Women no longer have to wait through weeks of pregnancy symptoms and distress before having a desired abortion. Trans-vaginal ultrasound is a useful tool and shouldn’t be maligned by abortion rights supporters seeking to make a quick exaggerated political point.

Please don’t get me wrong. Mandated ultrasound viewing regulations are bad laws—just not for the reasons that make the nightly news. Rather, it is the minutiae of the requirements, ones activists may feel are too hard to explain, that lead them and the media to focus on the elevated hype about probe penetration.

Let’s consider the minutiae of these laws and the significant problems they pose. To start, the policy requires that a physician perform the ultrasound at least one day in advance of the procedure and that this physician is the same physician who performs the abortion. There are several problems with this requirement. One, this type of mandate is contrary to the way health care is generally provided. The truth is that ultrasounds are routinely performed by competent non-physician staff in the abortion setting. There is no evidence that this way of providing care is unsafe or unsatisfactory.

Two, these mandates increase the costs of abortion. Requiring the physician to be present in the clinic on two consecutive days drives up the cost of abortion for the women seeking them. In most states, low-income women have to come up with between $500 and $1000 in cash to pay for an abortion. For a woman living at or below the poverty level this is equivalent to a month’s income.  Our research finds women take this money from other expenses like rent, utilities and food. In all other aspects of health care, the trend is to use less expensive personnel to perform some patient procedures to both drive down health care costs and save higher-skilled personnel for more complicated activities. The reverse trend in abortion care is deliberate and is meant to make women opt out of abortion, not because of some information the ultrasound gives them, but because abortion is no longer affordable. It is disappointing that state medical associations that vigorously fight efforts by state legislators to tell them how practice medicine have been virtually silent on these ultrasound requirements.

The next aspect I’ll consider here is the inability of women to opt out of aspects of ultrasound viewing; patients have to view and listen to a description of their ultrasound image. This is an intrusion into patient’s rights to control the course of her health care. Research from other health care services finds that patients’ sense of control has implications for long-term outcomes. It is not about whether women can refuse a probe (which may be medically necessary) but whether they can refuse to watch and listen—mandates that serves no medical purpose.

In contesting these mandates, however, abortion rights supporters need to be very careful about claiming that women will be traumatized by being forced to view their fetal ultrasounds.  We have no data that these outcomes occur. Yes, it is likely that some women will have negative reactions when they view an image they do not want to, but it may not be because of the content of those images. It is probable that the negative emotions are caused by the lack of agency they are allowed over what happens in their clinical encounters. Ultrasound is ubiquitous in American culture, so the images are neither foreign nor shocking for most women. We know, however, that women resent not being allowed to decide how they are treated by their health care providers. Indeed, objections to this kind of paternalism are what sparked the beginning of the women’s health movement in the first place.

We must also consider the unintended consequences of current pro-choice framing of these laws. Women who enter an abortion clinic prepped to think about trans-vaginal ultrasound as medical rape may well experience more negative outcomes than they would otherwise when they are informed by their health care provider that this procedure is necessary. It won’t matter that the trans-vaginal ultrasounds is called for not because the law mandates it but because the provider believes this ultrasound method is the correct medical choice.

We can see the second unintended consequence of this political approach in the experience in Virginia last year. After a very high profile “medical rape” fight over mandatory trans-vaginal ultrasound, the law was modified to remove the vaginal ultrasound requirement. An abdominal ultrasound is now acceptable.  All other aspects of the law were implemented. Despite a “political win” in Virginia, women receiving abortions are no better off. Instead, the real harms of the law—increased costs, loss of agency in health care decision-making—are obscured and ignored.

Rather than focus on the forced nature of the probe and the potential trauma to the woman of viewing her fetus, abortion rights supporters need to engage in a more honest conversation about what is wrong with the laws. These conversations are likely to be harder, more nuanced and not so easy to turn into sound bites. Mandatory ultrasound laws are wrong because they are provided in a way that drives up costs, because they make it harder to provide abortion care, and most importantly, because they do not improve health outcomes. They eliminate patient autonomy in how health care information is delivered and received. This is a truly egregious harm about which everyone, no matter their position on legal abortion, should be concerned. Trans-vaginal ultrasounds are not medical rape. They are often the preferred course of care. But in those circumstances where it is not medically necessary, ultrasounds should be provided using the clinician’s best judgment, just like any other health care interventions.

Unfortunately, this analysis will probably not lead the TV news tonight and that is part of what is wrong with the public discourse about abortion today.

Analysis Human Rights

El Salvador Bill Would Put Those Found Guilty of Abortion Behind Bars for 30 to 50 Years

Kathy Bougher

Under El Salvador’s current law, when women are accused of abortion, prosecutors can—but do not always—increase the charges to aggravated homicide, thereby increasing their prison sentence. This new bill, advocates say, would heighten the likelihood that those charged with abortion will spend decades behind bars.

Abortion has been illegal under all circumstances in El Salvador since 1997, with a penalty of two to eight years in prison. Now, the right-wing ARENA Party has introduced a bill that would increase that penalty to a prison sentence of 30 to 50 years—the same as aggravated homicide.

The bill also lengthens the prison time for physicians who perform abortions to 30 to 50 years and establishes jail terms—of one to three years and six months to two years, respectively—for persons who sell or publicize abortion-causing substances.

The bill’s major sponsor, Rep. Ricardo Andrés Velásquez Parker, explained in a television interview on July 11 that this was simply an administrative matter and “shouldn’t need any further discussion.”

Since the Salvadoran Constitution recognizes “the human being from the moment of conception,” he said, it “is necessary to align the Criminal Code with this principle, and substitute the current penalty for abortion, which is two to eight years in prison, with that of aggravated homicide.”

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The bill has yet to be discussed in the Salvadoran legislature; if it were to pass, it would still have to go to the president for his signature. It could also be referred to committee, and potentially left to die.

Under El Salvador’s current law, when women are accused of abortion, prosecutors can—but do not always—increase the charges to aggravated homicide, thereby increasing their prison sentence. This new bill, advocates say, would worsen the criminalization of women, continue to take away options, and heighten the likelihood that those charged with abortion will spend decades behind bars.

In recent years, local feminist groups have drawn attention to “Las 17 and More,” a group of Salvadoran women who have been incarcerated with prison terms of up to 40 years after obstetrical emergencies. In 2014, the Agrupación Ciudadana por la Despenalización del Aborto (Citizen Group for the Decriminalization of Abortion) submitted requests for pardons for 17 of the women. Each case wound its way through the legislature and other branches of government; in the end, only one woman received a pardon. Earlier this year, however, a May 2016 court decision overturned the conviction of another one of the women, Maria Teresa Rivera, vacating her 40-year sentence.

Velásquez Parker noted in his July 11 interview that he had not reviewed any of those cases. To do so was not “within his purview” and those cases have been “subjective and philosophical,” he claimed. “I am dealing with Salvadoran constitutional law.”

During a protest outside of the legislature last Thursday, Morena Herrera, president of the Agrupación, addressed Velásquez Parker directly, saying that his bill demonstrated an ignorance of the realities faced by women and girls in El Salvador and demanding its revocation.

“How is it possible that you do not know that last week the United Nations presented a report that shows that in our country a girl or an adolescent gives birth every 20 minutes? You should be obligated to know this. You get paid to know about this,” Herrera told him. Herrera was referring to the United Nations Population Fund and the Salvadoran Ministry of Health’s report, “Map of Pregnancies Among Girls and Adolescents in El Salvador 2015,” which also revealed that 30 percent of all births in the country were by girls ages 10 to 19.

“You say that you know nothing about women unjustly incarcerated, yet we presented to this legislature a group of requests for pardons. With what you earn, you as legislators were obligated to read and know about those,” Herrera continued, speaking about Las 17. “We are not going to discuss this proposal that you have. It is undiscussable. We demand that the ARENA party withdraw this proposed legislation.”

As part of its campaign of resistance to the proposed law, the Agrupación produced and distributed numerous videos with messages such as “They Don’t Represent Me,” which shows the names and faces of the 21 legislators who signed on to the ARENA proposal. Another video, subtitled in English, asks, “30 to 50 Years in Prison?

International groups have also joined in resisting the bill. In a pronouncement shared with legislators, the Agrupación, and the public, the Latin American and Caribbean Committee for the Defense of the Rights of Women (CLADEM) reminded the Salvadoran government of it international commitments and obligations:

[The] United Nations has recognized on repeated occasions that the total criminalization of abortion is a form of torture, that abortion is a human right when carried out with certain assumptions, and it also recommends completely decriminalizing abortion in our region.

The United Nations Committee on Economic, Social, and Cultural Rights reiterated to the Salvadoran government its concern about the persistence of the total prohibition on abortion … [and] expressly requested that it revise its legislation.

The Committee established in March 2016 that the criminalization of abortion and any obstacles to access to abortion are discriminatory and constitute violations of women’s right to health. Given that El Salvador has ratified [the International Covenant on Economic, Social and Cultural Rights], the country has an obligation to comply with its provisions.

Amnesty International, meanwhile, described the proposal as “scandalous.” Erika Guevara-Rosas, Amnesty International’s Americas director, emphasized in a statement on the organization’s website, “Parliamentarians in El Salvador are playing a very dangerous game with the lives of millions of women. Banning life-saving abortions in all circumstances is atrocious but seeking to raise jail terms for women who seek an abortion or those who provide support is simply despicable.”

“Instead of continuing to criminalize women, authorities in El Salvador must repeal the outdated anti-abortion law once and for all,” Guevara-Rosas continued.

In the United States, Rep. Norma J. Torres (D-CA) and Rep. Debbie Wasserman Schultz (D-FL) issued a press release on July 19 condemning the proposal in El Salvador. Rep. Torres wrote, “It is terrifying to consider that, if this law passed, a Salvadoran woman who has a miscarriage could go to prison for decades or a woman who is raped and decides to undergo an abortion could be jailed for longer than the man who raped her.”

ARENA’s bill follows a campaign from May orchestrated by the right-wing Fundación Sí a la Vida (Right to Life Foundation) of El Salvador, “El Derecho a la Vida No Se Debate,” or “The Right to Life Is Not Up for Debate,” featuring misleading photos of fetuses and promoting adoption as an alternative to abortion.

The Agrupacion countered with a series of ads and vignettes that have also been applied to the fight against the bill, “The Health and Life of Women Are Well Worth a Debate.”

bien vale un debate-la salud de las mujeres

Mariana Moisa, media coordinator for the Agrupación, told Rewire that the widespread reaction to Velásquez Parker’s proposal indicates some shift in public perception around reproductive rights in the country.

“The public image around abortion is changing. These kinds of ideas and proposals don’t go through the system as easily as they once did. It used to be that a person in power made a couple of phone calls and poof—it was taken care of. Now, people see that Velásquez Parker’s insistence that his proposal doesn’t need any debate is undemocratic. People know that women are in prison because of these laws, and the public is asking more questions,” Moisa said.

At this point, it’s not certain whether ARENA, in coalition with other parties, has the votes to pass the bill, but it is clearly within the realm of possibility. As Sara Garcia, coordinator of the Agrupación, told Rewire, “We know this misogynist proposal has generated serious anger and indignation, and we are working with other groups to pressure the legislature. More and more groups are participating with declarations, images, and videos and a clear call to withdraw the proposal. Stopping this proposed law is what is most important at this point. Then we also have to expose what happens in El Salvador with the criminalization of women.”

Even though there has been extensive exposure of what activists see as the grave problems with such a law, Garcia said, “The risk is still very real that it could pass.”

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 (D-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.”

CORRECTION: A previous version of this article included a typo that misidentified Sen. Tim Kaine as a Republican. We regret this error.