Five Decades After Roe v. Wade, Doctors Train to Keep Abortion Out of the Shadows
Fred W. McDarrah
The procedure is nearly silent. The tools are portable, easy to fit into a large purse or small knapsack. The "no touch" technique, in which the doctor's hands never make contact with the portion of the instrument that enters the woman's body, is ideal for "low-resource settings," sans electricity or sterile facilities. Even the way my fellow students and I learned to hold the tenaculum (long metal pincers used to grip the cervix) ensured the procedure could be virtually undetectable once it was completed. These are abortions you can do in the dark, with a $20 plastic tube and the flashlight on your phone. Though we were encouraged to assist one another, instructor Brent Monseur assured us that "in real life, you can do this completely solo."
What he didn't say was, in a post-Roe future, we might have to.
While still technically legal in all fifty states, abortion has been slipping down the back alley for years. Between 2011 and 2014 alone, 17 percent of the country's dedicated abortion clinics disappeared, thanks in large part to waves of extremely restrictive state laws. Mike Pence, the vice president, is an anti-abortion hard-liner who signed an Indiana abortion law that the Washington Post called one of the strictest in the nation.
General clinics offering prescription terminations have surged in their wake, with the combination of mifepristone and misoprostol or similar drug cocktails now accounting for close to half of early abortions. But those drugs, too, are tightly restricted, leaving Etsy stores selling herbal abortifacients and Twitter accounts hawking misoprostol without a prescription to fill the gap. The Trump administration wants to leave abortion to the states, in practice making it disappear from much of the country.
Despite this — or because of it — interest in abortion rights is soaring. Since the election, organizations big and small have been inundated with medical students, volunteer clinic escorts, and hand-holders looking to put their bodies on the front lines of the battle for reproductive freedom.
Practicing first- trimester abortion skills at a Medical Students for Choice workshop
Courtesy Medical Students for Choice
"We've never had anywhere near that level of demand," said Lois Backus, executive director of Medical Students for Choice (MSFC), which runs the abortion training intensive program I attended last month. A kind of abortion boot camp for aspiring providers, the February training received close to 200 applications for just 30 spots. Students had traveled from across the country to attend the weekend-long conference in Philadelphia, and for many, the hands-on practicum was the highlight of their trip.
"Oh my God, this smells amazing," cried 22-year-old Lisa Lavelanet, an aspiring pediatrician with a wax-print headwrap and flawless winged eyeliner, as she set up to perform the country's most contested medical procedure. To her right were the tools of a first-trimester abortion: the thin metal tenaculum, two plastic cervical dilators, a long, pliable cannula, and a manual vacuum aspirator. To her left lay the patient, an insentient and overripe Hawaiian papaya.
Cheap, plentiful, and remarkably analogous to the female reproductive system, papayas have for years been the go-to model for early-term abortions. In the process, papaya workshops have become a kind of gateway drug to abortion training for American medical students, many of whom will neither see an elective termination nor even hear one discussed throughout their formal education.
"My course director for this next block is a man who is pro-life — that's our women's health course director," said Hytham Rashid, 27, of Nova Southeastern University, who recently taught his own papaya workshop in Jerusalem. "In South Florida, I don't even know where the Planned Parenthood is. That's a real issue for medical students — we don't even know where the resources are because it's not in our curriculum."
Given how difficult it is to learn about abortion, you'd expect the first-trimester procedure itself to be complicated. It is not. Among the greatest victories of the anti-abortion rights movement has been to convince Americans that abortion is as invasive and potentially life-threatening as liposuction, when the reality is closer to a breast biopsy.
"People really do think you're taking them into an OR and chopping up their uterus," said Clara Johnson, a 26-year-old student at the University of Oklahoma. "Really it's only a little more complicated than a Pap smear."
In fact, a manual vacuum aspirator looks uncannily like a LifeStraw, the personal water filter system survivalists keep in their go kits. It takes more upper body strength to inflate a soccer ball than to generate the 60 millimeters of mercury vacuum pressure needed to evacuate a uterus, and significantly less time to complete the procedure than to read this article from start to finish.
"The procedure itself was not traumatizing at all," said Queens artist Poppy Liu, 26, whose short film about her abortion, Names of Women, debuted the night after Trump's inauguration. "I was awake the whole time. It lasted under two minutes."
While the right to a surgical abortion of the kind taught in papaya workshops is a keystone battle of the pro-choice movement, the introduction of abortion drugs that can induce terminations has changed the landscape. In 2014 fully 45 percent of American abortions performed before nine weeks gestation were induced by a combination of pills, usually mifepristone and misoprostol.
Activists see these so-called medical abortions as a ray of sunshine in the otherwise stormy climate for reproductive rights. A few even consider early surgical abortion essentially obsolete.
"I don't understand why anyone would be teaching us in the U.S. to be using a vacuum aspirator when all you have to do is take a pill," argues public health researcher and medical abortion evangelist Francine Coeytaux. "Even if you go to Planned Parenthood or a clinic and you choose a medical abortion over a surgical abortion, you're pretty much doing it yourself."
Coeytaux says that in some countries, the proportion of abortions induced through medication is now close to 90 percent. "We're only at half because we have such a provider bias about it being done by doctors," she says.
Abortion pills, however, still have drawbacks. While many women see surgical intervention as more frightening than taking a pill, the medication-induced abortions are functionally chemical miscarriages, and tend to hurt a lot more. The prescription "works well for women who prefer what they think of as a 'more natural' method," Backus told me, but it costs roughly the same as a surgical procedure and takes an average of four to five hours at home.
Jessa Jordan, 25, a model and burlesque performer in Philadelphia, says her medication-induced abortion included "very intense cramps" that made it "very difficult to walk." Jordan says that she would have been more fearful going into a surgical procedure, but still recalls the drug-induced miscarriage as intensely painful. She compared the six-hour process to the discomfort she experienced having her back inked at a tattoo convention. "That's by far one of the most painful tattoos I've had, and if I had to scale the pain between that tattoo and having the abortion, I'd say the tattoo was about a seven and the abortion was about an eight and a half," says Jordan.
Planned Parenthood supporters gathered in Lower Manhattan in February to protest Republican plans to defund the pro-choice organization.
In addition to being painful, medication-induced abortions can be surprisingly difficult to get. Many states have created byzantine hurdles, turning what could at least be a home procedure into one that requires multiple trips to a doctor or hospital.
"It's just as hard to get one in Texas as it is to get a surgical abortion," says Leah Payne, 27, a commercial insurance manager for an oil and gas company in Fort Worth, Texas, and a Planned Parenthood volunteer who had her own medical abortion in 2008. "It's three appointments to take four pills in my mouth and a week of doxycycline," and that was almost ten years ago, before the state enacted its most restrictive laws.
Restrictions on medications like mifepristone and misoprostol have, ironically, sent some women back to illegal abortions with gray-market misoprostol alone. The prescription-free pills are an ad-hoc Plan C, and even the most cursory Google search suggests they are cheap and abundant where traditional abortion care is not. Rights activists, like Coeytaux, see medication as the future of legal abortions, and the gray market as an important stopgap in places where abortion is increasingly inaccessible. "It's going to be a while before we can make it officially over the counter, but I think we already have a lot of access," to cheap, safe, do-it-yourself abortion care via the internet.
The future of reproductive choice may well hinge largely on over-the-counter prescriptions. For the moment, however, the election has created a surge in support for clinics that even a decade of successively more egregious anti-choice legislation could not. In the months since November, Payne, the Texan, says the number of would-be volunteers looking to escort patients from their cars to the clinic or to simply help out with clerical work at her local Planned Parenthood have increased tenfold.
"There's a Planned Parenthood not far from my house, and we have gone from training five or six people to having fifty to sixty people in a room for a training," Payne told me. "I've been involved with politics from the time I was sixteen and I've never seen anything like this."
The change isn't limited to anti-choice states like Texas. New York City's Doula Project, whose "abortion doulas" support patients in local Planned Parenthood clinics, received triple the normal volume of applications for its spring 2017 training. "We're all in danger of losing our reproductive rights in the next four years, and it's pretty terrifying right now," says Doula Project spokeswoman Sarah McCarry. "I think that people are looking for very tangible forms of activism that can be a way to channel that fear."
While for some it might seem surprising that the Doula Project, known mainly for help with childbirth, would train "abortion doulas," those who have had abortions never fail to cite the volunteer who held their hand through the procedure as a source of enormous comfort and relief.
Planned Parenthood supporters gathered in Lower Manhattan in February to protest Republican plans to defund the pro-choice organization.
"You have this very intense connection with someone for a short period of time," McCarry told me of her experience as an abortion doula. "People will come in and say 'this is a terrible thing to be doing.' And I'm like, 'you're the tenth person I've seen today.' There are thousands of people who are going through this. I think that can be very comforting for people who have no idea how common abortions are."
Organizations like the 1 in 3 Campaign and Shout Your Abortion are working to erode the stigma surrounding elective terminations in the United States, but the continuing availability of reproductive choice still depends on a vanguard of young doctors. Just thirteen states allow abortions to be performed by physician assistants and some advanced nurses. While attacks on abortion care are overt, their impacts on medical education are more subtle — and in much of the country, far more insidious.
"A lot of places in the South or Midwest, there are no providers within the medical student's community," Backus explained. Medical students are likely to observe an appendectomy as part of their third-year clinical rotations. Not so with abortions — just six percent of which are done in teaching facilities — though they are more than twice as common.
"We have to actually ship them other places," Backus said of medical students and residents who seek abortion training, often sending them to hesitant providers at stand-alone clinics who may never have had an apprentice before. Now, even those slim ranks are being stretched to the limit, as clinic closures cripple care in the South and Midwest. In states like New Jersey, where the number of clinics offering elective terminations has actually increased, virtually all new providers offer medical abortions alone.
Even as activists press for over-the-counter access to medications, workshops like those from MSFC provide a crucial — and even increasingly important — link between future doctors and the basic tools of reproductive choice.
"We did the papaya workshop [at a student event] and that's what really got me interested," said medical student Jeremie Oliver, a onetime Mormon missionary and aspiring plastic surgeon whose square jaw and Midwestern good looks belie an upbringing on Oahu's impoverished North Shore. "I think if you talk to everyone in the room, the vast majority would say that they don't get formal training on these topics in their medical school curriculum. It just doesn't exist right now."
Close to 20 percent of medical school programs never mention abortion, either in lecture or clinical rotations, and while abortion training is technically mandated for residents in obstetrics and gynecology, at least 16 percent of programs don't teach it, and only about half make it a routine part of their curriculum. So even many OB-GYNs leave medical school unfamiliar with how to perform the procedure.
That's an omission that MSFC is trying to remedy by expanding the pool of providers beyond the traditional realm of women's health. For every aspiring OB-GYN I met at the abortion training intensive, I also met a future pediatrician, plastic surgeon, or family doctor. I even spoke with a Dallas-based neuroscience MD/Ph.D. student who parlayed her papaya workshop into an informal rotation volunteering at a local abortion clinic.
"I like to see things for myself," she told me matter-of-factly. "I wanted to seek it out, especially because there are all of these restrictions here in Texas."
In a way, letting future doctors in many specialties see for themselves is the goal. The purpose of the intensives isn't to churn out new abortion specialists, but to familiarize doctors across many medical fields with a treatment that one in three American women will undergo in their lifetimes.
"I think that incorporating abortion into general care is important for destigmatizing it," said Libby Wetterer, 24, an aspiring family physician and first-year medical student at Georgetown, whose associated hospitals are prohibited from performing elective terminations.
Wetterer is Catholic and only became pro-choice in college. She said she never imagined herself actually doing elective terminations until she began applying to medical schools and realized she might not have the opportunity to learn them.
"If Roe v. Wade gets overturned, having more physicians trained to perform abortions is really important," Wetterer told me. "I see it as a responsibility."
Correction: Because of an editing error, an earlier version of this story incorrectly referred to a "Plan B-induced miscarriage." The procedure that Jessa James underwent was a medical abortion, which is induced with misoprostol and mifepristone, not the Plan B emergency contraceptive pill.
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