Abortion clinics nationwide face significant threats of harassment, intimidation, and violence, according to a new report showing that threats of violence against abortion providers have doubled since 2010.

The survey of 242 abortion providers in the United States found that there has been significantly higher levels of threats and targeted intimidation of doctors and staff in recent years. The report comes as widespread intimidation tactics were deployed against clinics during the anniversary of Roe v. Wade, the Supreme Court’s 1973 decision affirming a woman’s right to choose an abortion.

More than 500 plastic handcuffs placed inside “care packages” were reportedly delivered to abortion clinics throughout the country last week, according to The Christian Post. The packages were sent by the anti-choice organization Pro-Life Action League.

The packages included a postcard mentioning the recent arrest of Naresh Patel, an Oklahoma physician, and the ominous handwritten message: “Could you be next?”

Patel was arrested in December and charged with racketeering and three counts of obtaining money by false pretenses, according to reporting by the Oklahoman. An undercover investigation found that Patel was providing abortion-inducing drugs to patients without verifying that they were pregnant.

The message was written by Eric Scheidler, executive director of the Pro-Life Action League. “I thought this could really be a strong message to abortionists who really think seriously about the business that they’re involved in,” Scheidler told The Christian Post.

Pro-Life Action League received assistance in mailing the packages from the radical anti-choice organization Operation Rescue, whose members identified the clinics across the country that received the packages.

The use of similar intimidation techniques is on the rise, according to the National Clinic Violence Survey, conducted by the Feminist Majority Foundation. The report is the first comprehensive nationwide survey of violence at women’s health clinics since 2010.

The survey found that nearly one in five clinics experienced severe violence. Severe types of anti-choice violence affected 19.7 percent of clinics nationwide, down from the 23.5 percent of clinics nationwide that reported experiencing severe violence in 2010.

Incidents of wanted-style posters of abortion providers, pamphlets targeting doctors and clinic staff, and harmful information and pictures of doctors posted on the Internet have all significantly increased over the past four years, according to the report. The posters and flyers often include phrases like “Killers Among Us,” “Wanted For Killing,” and “Stop This Abortionist Now.”

The rate of clinics reporting stalking of physicians has also increased, from 6.4 percent of clinics in 2010 to 8.7 percent in 2014.

“The most stunning result in the survey, really, is this surge in serious threats that are being carried out against providers nationwide,” duVergne Gaines, the director of the National Clinic Access Project and one of the authors of the report, told ThinkProgress. “Those threats have almost doubled since 2010.”

The survey findings mirror reports by clinic staff and escorts from around the country who said they have seen an increase in clinic harassment. Other examples of anti-choice harassment, intimidation, and even acts of vandalism against abortion clinics have been reported around the country over the past year.

Abortion clinic physicians, staff, and escorts in Louisiana faced a barrage of harassment from anti-choice activists during July. Hundreds of activists with Operation Save America (OSA) descended on New Orleans to stage a week of protests throughout the city.

The activists targeted reproductive health-care clinics, personal residences, and even houses of worship in the hopes of intimidating abortion providers and reproductive rights supporters.

OSA activists were at the headquarters of the Jackson, Mississippi, police department a week after the protest in New Orleans, while fellow activists were facing criminal charges associated with protest activities outside the Jackson Women’s Health Organization. Three of the four activists were found guilty of charges including obstructing the sidewalk entrance to the clinic.

All Families Healthcare, a family medicine and reproductive health-care facility in Kalispell, Montana, was broken into and severely vandalized in March. The man who allegedly vandalized the facility is the son of a former board member of the local anti-choice crisis pregnancy center.

Susan Cahill, a physician assistant who manages the Kalispell office, told Rewire at the time that she believed the break-in was part of a coordinated effort to intimidate the facility into no longer providing abortion care. Cahill has been forced to close the facility indefinitely, while the suspect stands charged with four felonies, including burglary, criminal mischief, theft, and attempted burglary.

Increases in the incidents of harassment of abortion clinics appear to coincide with the increasing amount of legislation passed to restrict access to reproductive health care. Lawmakers across the country have returned to state houses this month and have renewed their legislative assault on women’s rights.

Elected leaders in Oakland, California, want to crack down on crisis pregnancy centers (CPCs) with a truth-in-advertising ordinance.

A panel of some members of the city council on Tuesday took up the proposed measure during a Life Enrichment Committee meeting, arguing that many of these religiously run centers target pregnant people with deceptive billboards, websites, and search engine results for “abortion.”

California already requires CPCs to post information about free or low-cost abortion care or contraception in their facilities. The proposed ordinance would penalize licensed and unlicensed “limited service pregnancy centers” for making untrue or misleading statements in ads, online, and in publications. The ordinance also applies to statements of omission, meaning the withholding of information. Violators would be given ten days to take corrective action by the city attorney, and could face civil fines from $50 to $500. Penalties also include running new ads to correct deceptive ones.

“Crisis pregnancy centers put their ideological agenda ahead of women’s health,” Oakland Vice Mayor Annie Campbell Washington told those gathered in chambers. “They target what they call ‘abortion-minded women’ with deceptive advertising, implying they offer abortion services or referrals.”

Campbell Washington said the new “consumer protection measure” was necessary because individuals who go to CPCs are “being lied to.”

Baltimore, Maryland, was the first city in the nation to enact a similar truth-in-advertising ordinance, which has been blocked amid a court challenge. In 2011, San Francisco passed a similar ordinance. It prevailed after a protracted court battle, when a district judge said the First Amendment does not protect false and misleading commercial speech.

During public comments, Christina Malin, director of family health services for Alameda County Public Health Department, expressed support for the ordinance, noting that CPCs inflict harm by targeting low-income communities of color in particular. She described receiving a voicemail message from a CPC worker asking for help with an undocumented client with a high-risk pregnancy. Malin never learned what happened to the patient.

Malin also noted that county prenatal clinics had observed a tendency by CPCs to refer their clients to county facilities for medical care once the client reached about 24 weeks of pregnancy, when the individual “can no longer terminate easily” and abortion care, while lawful, is more expensive. These former CPC clients, Malin added, arrive without records of appropriate prenatal medical care, such as lab work.

Campbell Washington noted that CPCs are difficult for clients to vet on their own because a facility will frequently change its name.

Rewire found, for example, the state has licensed the CPC Third Box Pregnancy Clinic to operate at 400 30th Street #401 in Oakland under the legal name First Resort. But online and in Yelp reviews the facility at 400 30th Street #401 is called Support Circle Pregnancy Clinic.

First Resort, as it turns out, is the same religiously run nonprofit that challenged the San Francisco ordinance, as the San Francisco Chronicle reported. In its print and online ads in San Francisco, First Resort claimed to offer “abortion information, resources and compassionate support for women facing the crucial decisions that surround unintended pregnancies and are considering abortion,” although it did not refer clients to abortion providers or provide abortion care.

On Tuesday, Amy Everitt, state director of the advocacy group NARAL Pro-Choice California, showed those gathered in chambers how a Google search for “Oakland” and “abortion” produced results with three clinics, two of which were CPCs. She noted that a 2015 NARAL investigation found that 91 percent of CPCs in the report dispensed false information.

Google has said it would correct its inaccurate search results.

The measure now heads to the full Oakland City Council after unanimously clearing the Life Enrichment Committee.

The ordinance comes amid reports in Sacramento and Los Angeles of CPCs flouting the new state law requiring pregnancy-related centers, including CPCs, to post a brief notice about access to free and low-cost abortion care and contraception.

The Los Angeles City Attorney recently announced that his office would begin cracking down on violators of the Reproductive Freedom, Accountability, Comprehensive Care, and Transparency (FACT) Act, as Rewire reported. But some jurisdictions have chosen not to enforce the law while five lawsuits against the FACT Act are pending.

Officials running CPCs contend they’d rather close than comply, and say in court filings the law violates their First Amendment rights.

Alliance Defending Freedom Senior Counsel Matt Bowman, who is representing the National Institute of Family and Life Advocates in challenging the FACT Act, said in a statement earlier this month that “forcing [the centers] to promote abortion and recite the government’s messages is a clear violation of their constitutionally protected First Amendment freedoms.”

Thirteen years before I was born, the Supreme Court declared abortion a fundamental right in Roe v. Wade. Despite this, for all 29 years of my life, the right to abortion has been under attack.

In the past six years alone, states have enacted 288 provisions restricting access to abortion care. Three years ago, the Texas state legislature enacted HB 2, an omnibus anti-abortion bill. And on Monday, the Supreme Court ruled two provisions of that law are unconstitutional.

I am a Texas native, a Latina, a lawyer, and a reproductive justice advocate, so this case, Whole Woman’s Health v. Hellerstedt, naturally hits close to home.

In the years since HB 2 has passed, I have heard from friends who have waited weeks and been forced to drive hours just to get an appointment at a clinic. And, as my colleagues and I wrote in an amicus brief the National Latina Institute for Reproductive Health filed with the Supreme Court, women of color in Texas, particularly the 2.5 million Latinas of reproductive age, have been disproportionately affected by the clinic closings resulting from the expensive, onerous, and medically unnecessary standards HB 2 imposed. For example, if the law had been allowed to go into full effect, residents of my birthplace, El Paso, Texas, where 81 percent of the population is Latinx, would have to drive over 500 miles to San Antonio in order to get an abortion in the state.

In early March, I slept at the Court overnight, waiting for oral arguments. In the 24 hours I spent outside the Court, I had time to reflect on the experiences that have made me an advocate.

***

I am 12, with my mother and her dear friend at the dinner table. As the three of us sit together, I regale them with stories of a teacher I deeply admire. She’s been telling us about how she prays the rosary and speaks to women entering abortion clinics, urging them to “choose life.” I believe this is a good act, something I want to be part of, and I’m proud of my righteousness. My mother’s friend says to me simply, “There are a lot of reasons women have abortions.” Almost 20 years later I will learn that this friend had an abortion, which makes sense statistically speaking, since one in three women do.

I am 14 and sitting in high school religion class. The male instructor tells us that pre-marital sex and contraception are forbidden by our Catholic faith. He says the risk especially isn’t worth it for women: It is, according to him, physically impossible for women to orgasm. At the time, and still, I despair for this man’s wife, and for him. Shortly after this lesson the class watches a 45-minute “documentary” about “partial-birth abortion.” This concludes my sexual health education.

I am 18 and counting 180 seconds, waiting to see whether one or two lines appear on a white stick. In a few weeks I am moving to New York to begin college. In those 180 seconds I decide with little fanfare that, regardless of the number of lines, I will not be pregnant when I go. One line appears and I move, able to begin the education I’ve dreamed of and worked for.

I am 19 and talking with a friend. We get to a question that often comes up among women: What would you do if you got pregnant? She tells me calmly and candidly that she would have an abortion. She is the first person I’ve heard say this aloud. Her certitude resonates with me. I know that I would too, and that though I always felt I should be sorry, I would not be. I feel the weight of the shame I’ve been carrying and I stop apologizing for what I know.

I am 20 and teaching sexual education classes to high school students. More than one young woman tells me that she believes she can prevent pregnancy by spraying Coca-Cola into her vagina after intercourse. We talk about safe and effective methods of contraception. Years later, I still think about the damage and danger inflicted upon young women out of fear of our sexuality and power.

I am 21 and lying naked in bed next to a man I’ve been seeing. We’re discussing monogamy. I’m on the pill and he’d like to stop using condoms. He wants me to know, though, that if I become pregnant he won’t let me have an abortion. Because I am desperate to be loved and because I don’t yet understand that love doesn’t mean conceding your autonomy, it will take another year before I leave him.

I am 22 and my friend—the first I know of—tells me she is having an abortion. After the procedure I do not know the right thing to do or say or how to comfort and support her. We will lose touch. Like 95 percent of women who have abortions, she will not regret her choice. When we reconnect years later, we will talk about her happiness and success and about how far we’ve both come.

I am 24 and reading about Congress making a budget deal contingent on “defunding” Planned Parenthood. I understand that though I now refuse to date men who believe they have a say in my reproductive choices, I’m stuck with hundreds of representatives and senators who think they do and who will use my body and health as a bargaining chip.

I am 26 and in my home state of Texas, Wendy Davis is filibustering an anti-abortion bill with two pink tennis shoes on her feet. I watch her all night, my heart swollen with pride at hundreds of women screaming in the rotunda, refusing to be ignored. Despite their efforts, Texas HB 2 will pass. Within three years, over half the abortion clinics in Texas will close.

Today I am 29 and five justices of the Supreme Court have declared the burden imposed by two provisions of HB 2 undue. Limiting abortion and lying about the effects of these laws hurts women’s health, and now the highest court in this nation has declared these actions and these laws unacceptable and unconstitutional. I am in Washington, D.C., 1,362 miles from the home where I grew up, the day the decision is announced, but it is not just about me and it’s not just about Texas. It is about the recognition and vindication of our worth and rights as human beings. All 162 million of us.