Investigations Abortion

State Documents Reveal No Proof of Harm to Women in Texas Abortion Services

Sharona Coutts

The documents, which were requested by the House Committee on Energy and Commerce in May, show that the state already had one of the nation’s most proactive and aggressive systems to police abortion services and ensure that facilities were complying with those rules.

See other pieces from Rewire‘s State of Abortion series here.

Review the database of state documents collected and analyzed by Rewire here.

When Texas passed its controversial new abortion restrictions this July, proponents claimed the measures were justified both on religious grounds and because they were necessary to “protect women.”

“This legislation builds on the strong and unwavering commitment we have made to defend life and protect women’s health,” said Republican Gov. Rick Perry, before signing the bill into law.

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The requirements of the new law are so onerous that all but five of the state’s 42 clinics have said they will be unable to meet them, and are expected to close. For instance, clinics that perform abortions will now need to obtain a license as an ambulatory surgical facility, when in reality many clinics provide medical abortions, which involve taking a pill that leads to a miscarriage of a very early pregnancy, up to eight weeks maximum. In other words, there is no “surgery” involved, and no need for the stretchers, gurneys, and other surgical equipment required to obtain a license as an ambulatory surgical facility.

Given the radical effect of this law, the public might have expected proponents to provide evidence of the alleged threats to women’s health that the law was designed to address.

But despite multiple calls for that evidence, anti-choice campaigners and politicians relied instead on a mix of junk science about fetal pain, and the rhetorical ploy that has become their favored political device: constant references to Kermit B. Gosnell, the rogue abortion provider who was convicted of murder and involuntary manslaughter in Pennsylvania this June.

Now, Rewire is able to present what the evidence says about the safety of abortion services in Texas prior to the passage of the most recent restrictions.

We analyzed the response provided to the United States House Committee on Energy and Commerce by the Texas Health and Human Services Commission about abortion regulation and monitoring in the state. The request for information by the committee was made in May, before the new law was passed.

In answering the congressional committee, Texas gathered data from the state entities that play a primary role in regulating abortion services in that state: the Department of State Health Services, the Department of Family and Protective Services, the Texas Medical Board, and the Texas Board of Nursing.

Together, those agencies have extensive oversight of abortion services in Texas. Far from indicating that women were at risk of being harmed when seeking abortions, the documents show that the state already had one of the nation’s most proactive and aggressive systems to police abortion services and ensure that facilities were complying with those rules.

Take, for instance, the Texas Board of Nurses, which imposes roughly 2,500 disciplinary orders on nurses every year. It found only one disciplinary action that involved an abortion. In 2002, the board imposed a sanction on a nurse after a patient was diagnosed with a “septic abortion” and was treated at a hospital’s emergency room. The nurse was disciplined for failing to follow the “minimum standards of nursing,” according to the board, but those actions were “unrelated to an abortion procedure or clinic,” the board said.

Indeed, the nursing board concluded that there had been “no disciplinary action of a nurse that specifically occurred in an abortion facility” from 2008 until 2013.

The answers from the Texas Medical Board similarly showed an absence of risk to patients.

The board oversees physicians, disciplines scores of doctors every year, and took action against 58 physicians in June 2013 alone. It noted that it had taken disciplinary action for conduct related to abortion on only four occasions between 2008 and 2013, and none of those involved harm to women.

According to public records, in 2008 Dr. Robert E. Hanson Jr. paid a penalty of $1,000 for his failure to supervise adequately the practices at Whole Women’s Health in Austin. That facility was pinged in 2006 for administrative failures. None of those violations included actual harm to a patient.

A second doctor was disciplined in 2011 for allegedly failing to obtain informed consent for all abortion procedures. She was fined $5,000 and ordered to submit to monitoring from another physician, and to undergo further training.

And in 2012, the board again fined Hanson, this time for relying on a medical assistant to record a patient’s history and physical exam, instead of doing the entire assessment himself at the time that the procedure was scheduled. The board fined Hanson $3,000 and required him to undertake additional training.

Also in 2012, the board found that Dr. Alan Molson had violated state regulations by allowing his medical assistants to perform follow-up visits on patients. Like Hanson, Molson was fined $3,000 and ordered to do more training.

What of the problems identified at abortion facilities themselves, over the five-year period examined by the congressional committee?

Monitoring and inspection of health facilities is the responsibility of the Department of State Health Services, which conducts annual inspections of abortion clinics, and visits ambulatory surgical centers at least every three years, according to Carrie Williams, a spokesperson for the department.

“Our role is to make sure facilities are safe and that the state’s laws and rules are being followed to protect the health of patients,” said Williams. “We look at everything from policies and procedures to cleanliness and infection control. We review how medical instruments are cleaned and stored. We also review medical records and conduct interviews of staff and, in some cases, patients.”

The department conducted dozens of inspections every year, and it did identify several issues with abortion clinics. None involved actual harm to patients.

The most serious violations involved four Planned Parenthood clinics, which in 2009 were found to have been functioning as abortion clinics without the required licenses to do so. The clinics paid collective fines and penalties of $119,000.

Jeffrey Hons, president and CEO of Planned Parenthood Trust of South Texas, told Rewire that the reason those locations were working without a license is because they were not performing surgical abortions; rather, they were administering the abortion pill, Mifepristone.

Those facilities were opened in 2004, when Mifepristone was relatively new to the United States. Planned Parenthood was advised by the state that it did not need a license so long as it was not providing any surgical procedures at those locations, said Hons.

However, five years later, in 2009, Hons was reviewing new state regulations on Mifepristone, and realized that they now indicated that the clinics were required to have licenses.

“We made application for these new licenses, and that’s what sounded the alarm,” he said. “We were the ones telling the state that we needed licenses for these places.”

Hons called the experience “surreal,” and said he agreed to settle the dispute rather than fight a prolonged and expensive legal battle over the fines. He noted that Planned Parenthood continued to cooperate with authorities throughout the period of the dispute.

Another set of violations related to four clinics’ failure to post their unique state license number on their websites. For that, each facility paid a $350 fine.

The department also noted receiving complaints against abortion facilities in each of the five years under review. In 2011, it received 25 complaints, and in 2012, it received 19. In all other years, it received between three and seven complaints.

While the department is legally prevented from commenting on complaints, it did report that every complaint was investigated. Where an investigation results in formal action against a clinic or individual, that action usually becomes a public record, and would have been included in the department’s other answers.

In other words, nothing in all of the records produced to the congressional committees suggests any hint of systemic dangers to Texas women under the system that was already in place to regulate and monitor abortion services. On the contrary, the evidence shows that Texas already aggressively policed abortion facilities, and cracked down on even minor infractions of state regulations.

Of course, there is one name prominent in its absence from this list—Douglas Karpen, who is currently under investigation by the state department of health, after anti-choice activists published interviews with three women who claim to be former employees of the abortion provider.

In those interviews, the women describe gruesome practices and allege that Karpen performed abortions past the point of fetal viability, and that he killed certain fetuses that were delivered alive.

Anti-choice campaigners have branded Karpen the “Texas Gosnell,” and have used him as an example of why, they claim, Texas’s new restrictions on abortion are necessary.

Williams, the department’s spokesperson, told Rewire that Karpen’s clinics had been inspected in accordance with Texas law—Aaron Women’s Clinic was inspected on March 8, 2013, and Texas Ambulatory Surgical Center was inspected on November 5, 2010—and that the licenses for those facilities remain in good standing. Williams said the department has also conducted inspections more recently, in the wake of the new allegations against Karpen.

The Texas Medical Board also investigated Karpen earlier this year, when similar claims were made. The board concluded in February of this year that “Dr. Karpen did not violate the laws connected with the practice of medicine and there is no evidence of inappropriate behavior.”

It is impossible to say what the current investigations of Karpen will find. Nonetheless, he remains the sole example that anti-choice campaigners have pointed to as a provider who has allegedly posed risks to the public—and those allegations are yet to be proven.

Advocates for reproductive rights point out what they see as the irony of the new restrictions: that shuttering reputable clinics is likely to push women into the hands of rogue providers who are willing to break the laws.

“When it comes to abortion, people are not writing these laws because they want abortion care to happen, they’re writing them to stop it,” said Hons. “That’s why we have these laws that are so maladaptive and harmful.”

“A real review of the situation does not indicate that there is a current problem to be fixed,” he said. “The state has this solution that is desperately in search of a problem that doesn’t exist.”

News Abortion

Texas Pro-Choice Advocates Push Back Against State’s Anti-Choice Pamphlet

Teddy Wilson

The “A Woman’s Right to Know” pamphlet, published by the state, has not been updated since 2003. The pamphlet includes the medically dubious link between abortion care and breast cancer, among other medical inaccuracies common in anti-choice literature.

Reproductive rights advocates are calling for changes to information forced on pregnant people seeking abortion services, thanks to a Texas mandate.

Texas lawmakers passed the Texas Woman’s Right to Know Act in 2003, which requires abortion providers to inform pregnant people of the medical risks associated with abortion care, as well as the probable gestational age of the fetus and the medical risks of carrying a pregnancy to term.

The “A Woman’s Right to Know” pamphlet, published by the state, has not been updated or revised since it was first made public in 2003. The pamphlet includes the medically dubious link between abortion care and breast cancer, among other medical inaccuracies common in anti-choice literature. 

The Texas Department of State Health Services (DSHS) in June published a revised draft version of the pamphlet. The draft version of “A Woman’s Right to Know” was published online, and proposed revisions are available for public comment until Friday.

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John Seago, spokesperson for the anti-choice Texas Right to Life, told KUT that the pamphlet was created so pregnant people have accurate information before they consent to receiving abortion care.

“This is a booklet that’s not going to be put in the hands of experts, it’s not going to be put in the hands of OB-GYNs or scientists–it’s going to be put in the hands of women who will range in education, will range in background, and we want this booklet to be user-friendly enough that anyone can read this booklet and be informed,” he said.

Reproductive rights advocates charge that the information in the pamphlet presented an anti-abortion bias and includes factually incorrect information.

More than 34 percent of the information found in the previous version of the state’s “A Woman’s Right to Know” pamphlet was medically inaccurate, according to a study by a Rutgers University research team.

State lawmakers and activists held a press conference Wednesday outside the DSHS offices in Austin and delivered nearly 5,000 Texans’ comments to the agency.  

Kryston Skinner, an organizer with the Texas Equal Access Fund, spoke during the press conference about her experience having an abortion in Texas, and how the state-mandated pamphlet made her feel stigmatized.

Skinner told Rewire that the pamphlet “causes fear” in pregnant people who are unaware that the pamphlet is rife with misinformation. “It’s obviously a deterrent,” Skinner said. “There is no other reason for the state to force a medical professional to provide misinformation to their patients.”

State Rep. Donna Howard (D-Austin) said in a statement that the pamphlet is the “latest shameful example” of Texas lawmakers playing politics with reproductive health care. “As a former registered nurse, I find it outrageous that the state requires health professionals to provide misleading and coercive information to patients,” Howard said.

Howard, vice chair of the Texas House Women’s Health Caucus, vowed to propose legislation that would rid the booklet of its many inaccuracies if DSHS fails to take the thousands of comments into account, according to the Austin Chronicle

Lawmakers in several states have passed laws mandating that states provide written materials to pregnant people seeking abortion services. These so-called informed consent laws often require that the material include inaccurate or misleading information pushed by legislators and organizations that oppose legal abortion care. 

The American Congress of Obstetricians and Gynecologists (ACOG) sent a letter to DSHS that said the organization has “significant concerns with some of the material and how it is presented.”

Among the most controversial statements made in the pamphlet is the claim that “doctors and scientists are actively studying the complex biology of breast cancer to understand whether abortion may affect the risk of breast cancer.”

Texas Right to Life said in a statement that the organization wants the DSHS include “stronger language” about the supposed correlation between abortion and breast cancer. The organization wants the pamphlet to explicitly cite “the numerous studies that indicate undergoing an elective abortion contributes to the incidence of breast cancer in women.”

Rep. Sarah Davis (R-West University Place) said in a statement that the state should provide the “most accurate science available” to pregnant people seeking an abortion. “As a breast cancer survivor, I am disappointed that DSHS has published revisions to the ‘A Woman’s Right to Know’ booklet that remain scientifically and medically inaccurate,” Davis said.

The link between abortion and cancer has been repeatedly debunked by scientific research.

“Scientific research studies have not found a cause-and-effect relationship between abortion and breast cancer,” according to the American Cancer Society.

A report by the National Cancer Institute explains, “having an abortion or miscarriage does not increase a woman’s subsequent risk of developing breast cancer.”

DSHS spokesperson Carrie Williams told the Texas Tribune that the original booklet was written by a group of agency officials, legislators and public health and medical professionals.

“We carefully considered medical and scientific information when updating the draft booklet,” Williams said.

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.