There is no area of medicine except for abortion in which
secrecy, constant politicization of a medical procedure, and even fear and
shame about medical work is par for the course. While many women seeking
abortions find their access to this legal procedure diminishing, abortion
providers also face onerous obstacles to providing care, and increasing danger
in doing so.
In Carole Joffe’s new book Dispatches
from the Abortion Wars: The Costs of Fanaticism to Doctors, Patients, and the
Rest of Us, she often uses pseudonyms to protect the privacy of
doctors and clinic workers she interviewed. As she details, many physicians are
actively discouraged from incorporating abortion into other forms of medical
practice, and the choice to perform abortions in some areas may make practicing
any other type of medicine virtually impossible.
Similarly, the risks and
complications of performing abortions in isolation prevent many doctors from
ever doing them. Knowing that they will not be backed by a supportive community
and may be targeted by fanatic activists, they may simply choose to opt out of
providing care they believe to be necessary and ethically unquestionable. In
these and many other ways, Joffe’s comprehensive overview and history of the
past 35 years details the very real and often urgent implications for women
when health care providers-doctors, nurses, pharmacists-are targeted by violent
Throughout the book, Joffe explores such divergent but
related topics as advances in fetal medicine and widespread use of ultrasounds,
which became popular in the 1980s and have affected many peoples’ relationship
with the fetus; how anti-abortion activists’ tactics play on other people’s
guilt of possessing sexual freedom, and how abortion practitioners who feared
the police pre-Roe now fear protestors instead. She details the specific issues
facing teens and the double standard that is applied when young people can be
judged as too immature to make the decision to choose to terminate a pregnancy
without parental consent, yet are judged fit to have a child nonetheless. Joffe
also investigates the relationship between economic hardship, childbirth, and
reproductive justice and writes passionately about how strictly pro-abortion
advocates must make space for the reproductive justice movement to flourish if
it is going to promote the health and rights of all women.
It is telling that the most extreme violence against
abortion providers takes place during pro-choice presidencies, and perhaps most
salient for many readers looking ahead, Joffe pays respectful homage to Dr.
George Tiller, who provided essential care in the most extreme circumstances of
incest, rape, and complications late in pregnancy when so many others could or
would not. Joffe ends her detailed account by looking at a future in which new
leaders must come forward to take up Tiller’s-and our collective-cause.
Joffe, also an RH Reality Check contributor, recently spoke
to me about her timely, if controversial, book.
Q: In Dispatches
from the Abortion Wars, you explain the importance of the role
of the deputy assistant secretary for population affairs (DAPSA) in the
Department of Health and Human Services, who is in charge of federal family
planning programs and oversees Title X of the Public Health Service Act.
However, former DAPSA appointees have lacked substantial professional experience
in family planning and have been appointed based more on their moral stances
than credentials. Why is such an important role so frequently overlooked in the
debates about federal laws regarding reproductive freedom?
Well, this role is overlooked by most Americans, but
carefully looked at by advocates on both sides of the abortion debate. In
general, it is fair to say that most Americans are apolitical, not especially
interested in government, and know relatively little about the workings of the
Q: You write about how
many ob-gyn practitioners lack basic abortion training. Do you think the
medical community’s larger lack of understanding of abortion procedures
trickles down the population at large? How do you think this affects women’s general
knowledge of abortion technology and options?
Even though most ob-gyns don’t perform abortions, I do not
believe that they don’t understand what abortion involves — many ob-gyns, for
example, perform procedures (e.g. d and c’s) that are similar to abortions. I
believe the American public’s misunderstandings of abortion procedures stem
directly from the very effective propaganda campaigns waged for years by the
anti-abortion movement. In particular, the so-called "partial-birth abortion"
campaign led many people to believe that most abortions took place very late in
pregnancy and involved near-term fetuses. In fact, only 1 percent of all
abortions take place after 21 weeks.
Q: You explain some of
the ways primary care physicians have incorporated abortion into their
practices. Can you talk about some of the hurdles these doctors face?
They face the problem of obtaining malpractice coverage.
They face the problem of having supportive colleagues, who share their
commitments to abortion care, and who will provide coverage for them if they
have to be out of town. In spite of these obstacles, some primary care
doctors-and where it is legally permitted, nurse practitioners, midwives and
physician assistants-have successfully incorporated abortion care into their
Q: Why isn’t the general
public more aware of the everyday threat of violence and dangers abortion
providers can face?
I think the general public is aware of the violence that
providers face. I think the public is less aware of the other obstacles — such as
targeted regulations against abortion providers ("trap laws"), lack of
collegial support, malpractice problems, etc — that face abortion providers. I am
quite convinced that the overwhelming majority of the public is very much
against the violence faced by providers, especially when it results in murder,
as we saw recently with the assassination of Dr. Tiller in Kansas. But though
this violence brings sympathy for the providers (and disgust with the
extremists), I also think the legacy of this violence is to mark abortion as
something that is always controversial, and that many people therefore simply
wish to avoid thinking about (until/unless they need one!).
Q: With the enormous
costs in terms of time and resources spent on security, police backup, cleanup
and HAZMAT for clinics under the threat and reality of violent
actions-including anthrax threats, acid attacks, and arson — why are
anti-abortion activists not considered domestic terrorists?
Excellent question! Certainly by the abortion rights
community, they are thought of in this way — when the violence first started to
pick up in the late 1980s, I recall advocates going to the administrations of
Ronald Reagan and the first President Bush and saying exactly that — these are
domestic terrorists… but not until the Clinton administration, and the first
killings of providers in the 1990s, was the problem taken seriously. Clinton
signed the "face act" — "freedom of access to clinic entrances" — which made it a
federal crime to interfere with someone trying to enter a clinic. This did
reduce the then quite common blockades and sieges of clinics. And after Dr.
Bart Slepian of Buffalo was killed in 1998, then-Attorney General Janet Reno
convened a task force within the Justice Department on clinic violence. I do
believe that the Dept. of Justice, especially under this administration, takes
violence against providers seriously. The problem of course is with
implementation of laws at the local levels. For whatever reasons, the local FBI
and the local police in Kansas did not respond to reports of Scott Roeder (the
murderer of Dr. Tiller) having vandalized a Kansas clinic the day before the Tiller murder, even
though Roeder’s license plate number was reported to these authorities.
Q: What effect do you
think the recession is having on women’s access to abortions? How much more
limited are poor women now than they were previously?
There are widespread reports of more women needing
reproductive health services — both contraception and abortions — and not being
able to afford them. The various funds that help poor women pay for abortions
(35 states do not allow use of Medicaid funds for this purpose) report that
they are running out of money, because the requests have escalated. Our access to data on how many abortions are
taking place is always lagging by a few years — but I suspect that this period of
recession will ultimately be revealed to be one in which the number of both
unintended pregnancies and abortions rose.
Q: How will a
significantly restricted universal healthcare bill affect low-income women who
Well at this moment, it is not clear there will be any
kind of healthcare bill, and it almost certainly will not be universal, to my
great disappointment. From the start, it was clear that the best the abortion
rights movement could hope for was the status quo — that is, as the Capps
Amendment (named for Rep. Lois Capps of California) put it, the bill would be
abortion neutral, leaving in place the Hyde Amendment, which prohibits the use
of public funding for poor women. But both the Stupak Amendment in the House,
and the Nelson "compromise" in the Senate, would make the abortion situation
worse-ultimately resulting, as health policy scholars from George Washington
University concluded, in a situation in which insurance plans which now offer
abortion coverage, would cease to do so — making it harder to obtain such
insurance, even with private funds.