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Weekly Link Roundup: November 3

The Social Status of Abortion Providers: ‘Doctors of Conscience’ Revisited

By Carole Joffe.

Note: This post is a lightly edited version of remarks given by Carole Joffee upon accepting the 2013 Lifetime Achievement Award from the Society of Family Planning in Seattle on October 7. It previously appeared on the RH Reality Check.

My journey as a researcher of abortion provision started in the late 1970s. I had just moved to the Philadelphia area for my first academic job, and I began an ethnography of a Planned Parenthood clinic in that city that was in the midst of incorporating abortion services. My interests at that time were in observing how a social movement issue becomes translated into a health-care “service.” But after immersing myself in that clinic for over a year, I became deeply interested in all categories of abortion providers, broadly speaking—counselors, nurses, physicians, clinic directors—and I have been studying providers ever since.

2101What I would like to do today is revisit some of the main points of my book, Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe v. Wade. What I attempted in that book was to apply a sociological lens to the work of providers, including an investigation of the “social status” of providers, which is sociological jargon for asking, more simply, how did involvement in abortion work affect both the personal and professional relationships of that first generation of providers whose work spanned the years immediately before and after legalization?

I argued, based on the interviews I conducted with those physicians, that abortion provision early on suffered from a marginality from the rest of medicine. As I put it, “mainstream medicine supported legal abortion but not the abortion provider.” Very briefly, I claimed that within medical circles the legacy of the “back alley butcher” of the pre-Roe era carried over and stigmatized all those who had performed abortions before Roe and went on to do so afterwards—even the “doctors of conscience” I interviewed who had provided, at great personal risk, safe and ethical care before legalization. I also wrote of the personal isolation many felt as a result of engaging in this work.

Today I would like to revisit and somewhat modify those arguments, because, as I will argue, some things in the field of abortion care have changed for the better. But before I proceed, let me be very clear! I am deeply aware that our field is in very serious trouble! This talk is not intended as a “don’t worry, be happy” motivational speech. Of course, as you all know, we are facing an unprecedented assault from state legislatures. Numerous clinics have closed in the last three years, and abortion provision in red states—and even in some not so red—has gotten extraordinarily difficult. And let me give a special shout out to those of you here who work in Texas, North Carolina, Ohio, Wisconsin, Pennsylvania, Virginia, Mississippi, and a list of other states that goes on too depressingly long.

Nevertheless, some things in the world of abortion provision are different—even arguably better as I have said—and I think these things will be very consequential in the years ahead as our field pushes back against this assault.

Let me start this story with the late Dr. Jane Hodgson, an obstetrician/gynecologist in Minnesota. Dr. Hodgson was one of the first physicians I interviewed for the study that became Doctors of Conscience, and someone from whom I learned so much. I interviewed her several times, and she is the subject of the first chapter of that book. Her historical importance is that she was the first and only U.S. doctor ever convicted of performing an abortion in a hospital. She did this openly in 1970, on a patient with rubella, hoping to become the test case that would come before the Supreme Court. As a result of this act, Dr. Hodgson was tried and convicted, and lost her Minnesota medical license; her license was not returned until the Roe decision in 1973. She went on to open several clinics in her state, wrote widely about abortion, including one of the first textbooks on the subject, and in the following decades was involved in several other key legal abortion cases.

But I will not talk today about the historical role Jane Hodgson played in abortion provision in the United States. Rather, I will reflect on what my interviews with her revealed about the impact of involvement with abortion on one’s social and professional identity.

To be sure, Jane Hodgson was not a complainer! On the contrary, as she said to me, reflecting on her decades-long involvement with abortion (in a statement which was repeated in her New York Times obituary), “I think in many ways I’ve been lucky to have been part of this. If I hadn’t gotten involved, I would have gone through life probably being perfectly satisfied to go to the medical society parties and it would have been very, very dull. I would have been bored silly.”

Upbeat as this statement is, nevertheless Jane Hodgson’s involvement with abortion was costly in numerous ways, both personally and professionally. In personal terms, one of the most painful costs of abortion involvement came when Hodgson attended her fiftieth reunion at Carleton College. As she told me, “They were giving me an alumni award at that reunion. I learned later from the committee that it was a very hot discussion whether they should give it to me or not but they finally did. But it was very painful.… I hadn’t been to one [reunion] and some of these people I hadn’t seen since college, and I’d rush forward to greet them and they’d turn away. It was kind of a low blow and I think that bothered me maybe as much as anything.”

Professionally, there were costs as well. As news of her arrest and trial spread, her favorite nurse, who had worked for years in Hodgson’s private practice, abruptly left; the strongly anti-abortion chair of the OB-GYN department at the University of Minnesota, where Hodgson had an appointment, was a key witness for the state and brought his residents to observe her trial—“I guess he wanted them to see what happens if you take the wrong path”; she was shunned at a meeting of the Minnesota Obstetrical Society, an organization of which she had formerly served as president.

In spite of the strong support Hodgson received from many influential individuals within medicine, she was particularly disappointed by the lack of any support from organized medicine, especially the American College of Obstetricians and Gynecologists. In one of the few moments of bitterness that Hodgson allowed herself in the course of many hours of interviews, she said, in response to my question of what the ACOG had done to help her case. “Nothing, not a thing. They never did anything.” (By coincidence, ACOG was holding a regional meeting in Minneapolis at the time of Dr. Hodgson’s trial, and she asked that someone come to testify on behalf of the need for safe abortion, and the public health consequences of unsafe abortion, but her request was refused).

I wish to argue to you today that since I interviewed Dr. Hodgson in 1987 and 1988, two significant changes have occurred, changes that would have greatly heartened her. Today, much of the medical community—beyond ACOG itself—is speaking up on behalf of abortion providers, and a quite extraordinary support community is in place within the abortion providing world itself.

One of most forceful of these recent statements on behalf of abortion providers, in response to the current wave of restrictions in state legislatures, has come from two professors at Harvard Medical School: Dr. Marcia Angell (former editor of the New England Journal of Medicine) and Dr. Michael Greene. In an op-ed published in USA Today, the authors decried the silence of organized medicine in the face of these legislative assaults, stating:

The profession as a whole, as represented by its professional organizations, needs to become involved, so that physicians are not left to fend for themselves. It is time for the American Medical Association and, particularly, the American College of Obstetricians and Gynecologists, to take a public position on behalf of the patients they are pledged to serve, and to support their members in doing so.

And ACOG, at both the national level and in state chapters, has been speaking out—to an unprecedented degree in that organization’s history. In the campaign season of 2012, for example, the national office of ACOG issued strong rejoinders to the notorious misstatements of extremist Republican candidates: for example, in response to Missouri senate candidate Todd Akin’s ludicrous claim about “legitimate rape,” the college declared that “Recent remarks by a member of the US House of Representatives suggesting that women who are victims of ‘legitimate rape’ rarely get pregnant’ are medically inaccurate, offensive, and dangerous,” and the statement went on to cite the “10-15,000 abortions that occur each year in the U.S. due to pregnancies resulting from rape or incest.”

Similarly, ACOG chapters at the state level have been very vocal about their opposition to the wave of restrictions passed by state legislatures. Texas OB-GYNs, for example, published a statement in the Austin American-Statesman decrying the “insidious legislation” passed by politicians in that state, and pointing to the fact “that these bills will not help protect the health of any woman in Texas. Instead, these bills will harm women’s health in very clear ways.” Physician groups in North Carolina, Wisconsin, Arizona, Georgia, and elsewhere have similarly spoken out against legislative interference with medical practice.

When Philip Darney and Uta Landy, both in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California, San Francisco, recently attempted to replicate (and update) a 1972 campaign that had obtained the signatures of 100 leading academic OB-GYNs on a “statement on abortion” urging their colleagues to accept and prepare for the imminent legalization of abortion, the 2012 effort also collected 100 signatures, a striking number of them from department chairs and professors in “red” states. The 2012 statement, which called on their fellow OB-GYNs to take action in light of the legislative assaults on abortion, was published in the leading journal in the field.

It is not only obstetricians who have been protesting the attacks on abortion. The American College of Medical Genetics and Genomics, for example, issued a statement expressing its concern about the recent wave of restrictions saying “The ACMG believes strongly that a balanced discussion of options, including termination of pregnancy, should be available to pregnant couples where their fetus has been diagnosed with a genetic disorder or congenital anomaly.” But perhaps the most encouraging expression of support for abortion providers came in a recent article in the New England Journal of Medicine, in which the executive director of ACOG was joined by leaders of four other medical organizations, including those in pediatrics and family medicine. The statement of these leaders is especially noteworthy to me precisely because it is not just about abortion providers, but medical practitioners more generally. I take this group effort as one indication that leaders in other fields in medicine are finally willing to move beyond the historic marginality of abortion provision. As the authors state in this article, “Some recent laws and proposed legislation inappropriately infringe on clinical practice and patient–physician relationships, crossing traditional boundaries and intruding into the realm of medical professionalism. … We believe that legislators should abide by principles that put patients’ best interests first.”

To be sure, when evaluating the impact of these various examples of support for abortion providers (and correspondingly, criticism of legislators), some might say that these efforts are “too little, too late.” With the exception of the 1972 statement mentioned above, one can ask where were OB-GYNs and others in medicine earlier—for example, when providers like Jane Hodgson very much needed their support? Certainly, the relative silence, up ’til now, of colleagues not engaged in abortion provision, has contributed to the marginal status of the latter. Moreover, one might question how significant are these statements of support, given the arguable decline of medical authority generally at the present moment. These are fair questions, and I regret that in this talk, I don’t have the time to engage with them. I will say, however, as one who has closely observed the abortion providing community for many years, that this level of solidarity with providers that is coming from elsewhere in medicine is truly unprecedented, and has to be seen as a positive development.

But in my view, unquestionably the most important change that has occurred in the world of abortion providers since the time I interviewed Dr. Hodgson is the emergence of a very strong and multi-faceted community within this world. Until the early 1990s, though there were a few national pro-choice political groups, such as NARAL and the National Organization for Women (NOW), the only group that was specifically concerned with meeting the logistical—and collegial—needs of providers was the National Abortion Federation (NAF), which was founded in 1977. NAF, then (as now) provided an important source of affirmation for providers, particularly at its annual meetings. But for many years, NAF was nearly the only game in town for most providers and its membership was largely confined to clinicians.

Starting in the early 1990s, a quite astonishing number of groups sprang up, all of which, in different ways, spoke directly to issues of abortion provision. To cite just some of these, a Fellowship in Family Planning (1991) and the Ryan Residency Training Program (1999) were established to expand training and clinical research in this field among mainly young OB-GYNs while the Reproductive Health Access Program and the RHEDI program (Reproductive Health Education In Family Medicine), both of which originated in the mid-1990s, served the same function in family medicine and primary care; the Center for Reproductive Rights (1992) became, along with the previously existing Reproductive Freedom Project of the American Civil Liberties Union (ACLU), a leader in the legal defense of abortion; Medical Students for Choice (1993), along with Clinicians for Choice (1996), Law Students for Reproductive Justice (2003), and Nursing Students for Choice (2007), brought people at early stages of their professional careers into this world; the founding of the Bixby Center for Global Reproductive Health at UCSF (1999) as well as Advancing New Standards in Reproductive Health (2003), a program within the Bixby Center, and Ibis Reproductive Health (2003) dramatically expanded the opportunities for social science research about abortion, and the formation of the Society of Family Planning (2004-2005) established a forum where clinical and social science researchers could meet; Physicians for Reproductive Health (1992) is of particular interest because it is an organization of both abortion providers and non-providers, with the latter committed to promoting the interests of the former.

It is not surprising to me that there was this explosion of new organizations starting in the early 1990s. The late 1980s and early 1990s saw the dramatic escalation of anti-abortion activity: the first large-scale blockades by Operation Rescue and other aggressive actions at the site of abortion providing facilities, and of course, in 1993, the tragic murder of David Gunn in Florida by an anti-abortion fanatic, the first of what was to eventually become eight murders of individuals within the provider world. Moreover, the early 1990s also marked a growing awareness of those in the field of an abortion provider shortage—a shortage caused not only by the rising aggression of protestors, but of the failure of mainstream medicine to normalize abortion training and services in reproductive health care.

Some groups, particularly Medical Students for Choice (MSFC) very deliberately pointed to the activities of their opponents as the core rationale for their founding: the group was founded in the aftermath of the murder of Dr. Gunn, and also shortly after an anti-abortion group sent a deeply offensive mailing to numerous medical students across the country, which demonized abortion providers. Others of the groups mentioned above focused on the need to have more providers in the pipeline as the first generation of legal abortion providers were nearing retirement age.

But the unquestionable fact is that the emergence of these various new organizations—many of which have overlapping memberships—has helped create a new sense of community within the abortion providing world. It is a broad multi-faceted community not only of providers, but of lawyers, advocates, artists, clergy, film makers, social scientists, and others—and what I have seen in my many years of observing this world, is that this is a community, most of all, that has each other’s back. To give just a few examples, busy academic doctors fly across country to testify on behalf of colleagues in malpractice trials that can only be described as political witch hunts; clinic directors who are part of the Abortion Care Network, an organization of independent clinics, rush from various parts of the country on short notice to Texas to support their colleague, Amy Hagstrom Miller, and meet with her patients and staff, as the legislature was in the midst of attempting to destroy abortion care in that state; when medical students involved with MSFC are threatened with reprisals by anti-abortion faculty, this community steps in to help with finding appropriate residencies; when beleaguered clinic directors in states with only one clinic remaining find it difficult to remain open, Willie Parker and other providers go through contortions to manage their schedules so they can travel regularly to Mississippi and elsewhere; our community’s lawyers, from the ACLU, the CRR, and several firms doing pro bono service, work literally around the clock to fight restrictions; the numerous listservs that have sprung up not only provide a forum to discuss interesting and challenging cases but also serve as an online community, especially to those providers in isolated areas such as the deep South; last, but hardly least to me and to many of us here, this is also a community that includes enlightened funders that makes possible research on abortion—research that, given the extreme politicization of abortion, would not otherwise be possible.

And we have persuasive evidence that this community matters. For example, the evaluation forms of those who have completed the two-year Fellowship in Family Planning frequently make reference to what is gained beyond technical skills. As one participant said, “I got so much out of the past 2 years. I feel like I blossomed in my skills, not just clinically but also in research, policy, advocacy, and teaching. So great to be part of this community.” Another said, “Great opportunity to network with a great group of people who share similar goals and missions. FFP community so much greater than expected.”

Researchers have also noted the importance of a sense of community in enabling people to remain in this often challenging work. As Dr. Lisa Harris and her colleagues found, in evaluating the “Provider Workshops” that Harris initiated, “[M]ost participants … referred to deeper emotional bonds forged through sharing experiences and feelings (including potentially dangerous ones), laughing together, and a stronger sense of collective team identity…’I could do what I do for the next thirty years as long as I had the chance to have this kind of sustaining group.’”

Similarly, the social scientists Jenny O’Donnell, Tracy Weitz, and Lori Freedman, in their study of providers, report this from one of their interviewees: “I think the most sustaining thing is probably the other people I work with. Because working in abortion, it draws really good people” and go on to conclude that “having a professional community that normalizes abortion care seems to make work more attractive and sustainable for those engaged in abortion care provision.”

It is a sociological truism that social movements lead to the creation of other “counter-movements.” The modern anti-abortion movement emerged as a result of Roe; the excess and extremism of that movement in turn led to many of the organizations I mentioned earlier. And let me point you to this paradox: our opposition, which has taken such an unacceptable toll on us, in so many ways, at the same time has contributed to the creation of not just a counter-movement that is fighting back politically, but also a community with deep emotional bonds among its members—bonds of a kind that one rarely, if ever, finds elsewhere in medicine.

So I will conclude by pointing to the dual nature of the field of abortion provision, as I have come to understand it. Thanks in large part to the Ryan Program and the Fellowship in Family Planning, and of course the Society of Family Planning, abortion provision has made a huge leap forward in taking its place as a legitimate and reputable part of U.S. medicine. Look around this room and think of the numerous medical schools represented here—and those of you who, like me, were around 25 years ago, think about what the situation was like then, and how much has changed. But the unique history of abortion in the United States also makes abortion provision a mission-driven enterprise, and I will argue to you that this is why we will ultimately triumph over those attempting to shut us down.

In conclusion, it has been a privilege to devote my career to studying this field and I thank you all for the trust you have shown in me. And I, of course, am deeply grateful to the Society of Family Planning for this award.


JoffeDr. Carole Joffe is a professor at the Bixby Center for Global Reproductive Health at the University of California, San Francisco. She is the author of four books: Friendly Intruders: Childcare Professionals and Family Life (1977); The Regulation of Sexuality: Experiences of Family Planning Workers (1986); Doctors of Conscience: The Struggle to Provide Abortion before and after Roe v Wade (1996); and Dispatches from the Abortion Wars: The Costs of Fanaticism to Doctors, Patients and the Rest of Us (2009). She is also the author of numerous articles on various aspects of reproductive health services and politics.