When Donald Trump becomes the president later in January, some worry the days when women had to take dealing with unwanted pregnancies into their own hands will return. Throughout his campaign, Trump made several inflammatory comments about abortion, including the mischaracterization of abortion as a violent and brutal procedure that could be performed up until the "ninth month" and "last day" of pregnancy. In March, he said that if abortion were to become illegal in the US, anyone seeking the procedure should face "some form of punishment."
Trump later recanted those remarks, which were seen as too extreme even for anti-abortion conservatives. But women in the US are already being punished for ending unwanted pregnancies when they are unable to access safe, legal abortion. Experts warn that with further attacks on abortion access and contraceptive coverage likely to come, rates of self-induced abortion—and the criminalization of those who perform or facilitate it—will rise.
"We know of at least 17 people who have been arrested for self-inducing abortion [since Roe v. Wade], and some who have been convicted, but we suspect there are many more," said Jill E. Adams, executive director of the Center on Reproductive Rights and Justice at Berkeley Law. "Only a tiny handful of states have statutes that explicitly prohibit self abortion. In all the other cases, these brazen prosecutors are just picking and choosing and misapplying all manner of laws." Adams and her colleagues have identified 40 different kinds of laws that could be applied to criminalize self-induce abortion, as well as implicate the people who help the women who carry them out.
Women seek abortions at nearly the same rate whether it's illegal or not. According to a 2016 study published in the Lancet, the incidence of abortion in countries where it is completely illegal or permitted only to save a woman's life is about 37 per 1,000 women aged 15 to 44. In countries where abortion is generally legal, the incidence is 34 per 1,000 women—almost exactly the same rate. The difference is that virtually all of the abortions in countries where the procedure is illegal happen under circumstances defined as "unsafe" by the World Health Organization. The procedures are performed by people without proper training, or are performed in an inappropriate setting, or are self-induced by the woman herself.
In the United States, what we know about the effects of extreme abortion restrictions largely comes from Texas. A Texas law known as HB2, introduced in 2013, caused more than half of the state's abortion clinics to close. Researchers from the Texas Policy Evaluation Project (TxPEP) estimated that between 100,000 and 240,000 women in Texas have tried to end pregnancies on their own due to limited abortion access.
The most common method of self-induced abortion among those women was taking misoprostol, a drug used in legal medication abortions. Other methods included ineffective remedies like herbs, teas, and hormone pills, and occasionally violent means like being punched in the stomach. Dr. Daniel Grossman, a co-investigator in the TxPEP project and professor of obstetrics, gynecology, and reproductive sciences at the University of California, San Francisco, told me the Texas study did not find incidences of women using invasive means, like trying to insert an object into the vagina or uterus. But those cases do sometimes still happen in the US. Most notable in recent years was the case of Tennessee woman Anna Yocca, who was charged with three felonies for attempting to self-induce using a coat hanger.
"We have heard stories of women ordering [abortion drugs] online that don't turn out to be what they were supposed to be."—Daniel Grossman
The availability of misoprostol, sometimes known simply as "miso" and also sold under the brand name Cytotec, has transformed the process of self-induced abortion around the globe. It was originally brought to market in the 1970s as a drug to prevent stomach ulcers, but it was not long before doctors and people facing unwanted pregnancy discovered its off-label use. Misoprostol use is particularly widespread in Latin America, where few countries permit abortion. In legal medication abortions, misoprostol is usually used in conjunction with another drug, mifepristone, which is the most effective method. Misoprostol on its own, however, is still 75 to 85 percent effective in ending pregnancy in the first trimester. It can also be effective later in pregnancy, but more medical follow-up care is required.
"From a medical perspective, misoprostol used by itself is very safe and effective to induce early abortion," Grossman told me. "However, it's important that women know how far along in the pregnancy they are, and know the correct dosages for the medication. Another concern is whether medications they get are high quality medications. We have heard stories of women ordering things online that don't turn out to be what they were supposed to be."
Texas prohibits anyone other than a licensed physician from performing an abortion, and requires that the doctor be in the room for the procedure. That means doctors cannot provide medication via telemedicine, even though that approach is considered to be safe and effective. They're also prohibited from providing patients with harm reduction information, even if they know the patient is going to try and self-induce abortion.
"We saw a rise in women attempting their own abortions long before HB2, connected to a bill called HB15 that passed in 2011," said Amy Hagstrom Miller, founder and CEO of Whole Woman's Health, the lead plaintiff in the Supreme Court case that ultimately overturned HB2. "It requires a minimum of two visits in order to get an abortion and a waiting period of at least 24 hours between them. That became too big a barrier for many of our patients to deal with travel, childcare, or lost wages." Miller told me that people in Texas have historically crossed the border into Mexico to get cheaper medications and healthcare. Now, women cross the border to buy miso in pharmacies, where it is generally available without a prescription.
In Texas's Rio Grande Valley, which includes the state's poorest counties and where the population is over 86 percent Latinx, there is just one abortion clinic left: Whole Woman's Health in McAllen. That clinic closed briefly after the passage of HB2, but reopened during the ensuing court battle.
"Before the McAllen clinic reopened, there was effectively an abortion ban for the Rio Grande Valley. Even once the clinic reopened and we were better able to connect women with the care they needed, there were longer wait times because there were no other clinics to shoulder the burden," Jessica González-Rojas, executive director of the National Latina Institute for Reproductive Health, told me. Without access to a clinic, some women are forced to take matters into their own hands.
A miso-induced abortion is virtually indistinguishable from a spontaneous miscarriage, which may lead to the belief that women who seek follow-up care at a hospital or other medical practice would be safe from criminalization. But Adams said that of the 17 known cases of women being arrested for self-inducing abortion, several were reported to the authorities by medical staff. Most extreme is the case of Purvi Patel, who was sentenced to 20 years in prison for self-inducing abortion until an appellate court vacated her conviction. The doctor who reported her to the police was part of an association of anti-abortion physicians and even accompanied detectives to the scene where Patel admitted she disposed of fetal remains.
"We are perpetuating a culture of surveillance and repression of pregnant people," Adams told me. "People always want to know about the physical safety of self-induced abortion, but what about the safety of being arrested, of going to prison, of being deported? If people are truly concerned about safety as related to abortion, they ought to be considering how dangerous it can be for people's physical and emotional health to be ensnared in the legal system."
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