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It Was Very Oppressive for Women: Sexism in Medicine It Was Very Oppressive for Women: Sexism in Medicine
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The Making of Roe v. Wade The Making of Roe v. Wade
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Writing the History of Legal Abortion Writing the History of Legal Abortion
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Abstract
The introduction briefly chronicles women’s reproductive experiences prior to the legalization of abortion and situates the legalization of abortion into the context of the emerging women’s health movement. It offers a brief overview of the state-by-state legalization of abortion and of the US Supreme Court decisions that followed the 1973 Roe v Wade decision. It concludes with a discussion of the challenges of writing the history of a medical procedure as stigmatized and politicized as legal abortion.
In the early 1970s, Heather, an eighteen-year-old student at the University of North Carolina (unc), went to see Takey Crist, an assistant professor of obstetrics and gynecology (ob-gyn), known on campus as “the sex man.” Heather was pregnant and told Crist about her attempt earlier that year to get a prescription for the birth control pill at the student infirmary. The physician she saw told her that
he didn’t give contraceptives, and that the infirmary itself didn’t give contraceptives out to unmarried people. And then he said, did I want to talk about it [her decision to become sexually active], or had I already made up my mind? And I said that I had pretty much made up my mind. And he said, “Well, you know, I like sex just as much as any other normal person.” And then he said, “It’s like a glass of wine, you don’t guzzle it, in the same way you don’t use sex to excess.” And I just listened to him for a few more minutes, or rather, I didn’t listen to him for a few more minutes. And then I left.1Close
Humiliated and frustrated, Heather gave up on her attempts to seek birth control. After several months of unprotected sex, she became pregnant and ended up in Takey Crist’s office.
Young single women who sought contraceptive advice and sex education during the late 1960s and early 1970s tended to find all doors closed. Lacking training in this area, most physicians felt uncomfortable with issues of sexuality and considered prescribing contraceptives to single women immoral. A 1970 survey by the American College Health Association found that of 531 institutions of higher education, half prescribed contraceptives to their students but less than 10 percent did so for unmarried minors.2Close In many states, North Carolina included, the age of majority was 21. High school and college students who sought medical care thus needed parental consent even for their most intimate health care needs.3Close Most college-age women at unc came from small North Carolina towns and had grown up steeped in religious values critical of premarital sex. As a result, they frequently felt they could not discuss their sexual activity with their parents. Susan Hill, who attended Meredith College in Raleigh, North Carolina, in the late 1960s, remembers that a lot of girls worried about their lack of access to birth control. “There weren’t health clinics where you could walk in and get birth control. There was no Planned Parenthood in town. Your private doctors, you couldn’t trust them. … You were afraid they would tell your parents. So we were aware of [birth control] and virtually unable to get it.”4Close
In the late 1960s and early 1970s, young college students who discovered that they were pregnant worried about their parents’ reaction and understood that an unwanted pregnancy could jeopardize their educational future. One young man described in an anguished letter to Crist how he and his pregnant girlfriend had approached his girlfriend’s mother to ask for her consent to an abortion—by 1971, after a recent reform of the state’s abortion laws, available to young women with parental consent.5Close But rather than help the couple obtain an abortion, the mother forced her daughter to return home and, after the young man tried repeatedly to reason with her, moved herself and her daughter without leaving a forwarding address. “I cannot even write to her anymore,” he deplored, and concluded: “My girlfriend could still be in school today if we could have gotten an abortion.”6Close Women students feared that parents would kick them out of the house or force them to return home before they could finish their college education. Many had witnessed the shocked reactions of parents when a sister or a brother’s girlfriend got pregnant. “It was like hell in the family,” one student recalled as she explained to Takey Crist why she could not tell her parents about her own unwanted pregnancy after her brother’s girlfriend had gotten pregnant.7Close Children worried about the loss of financial or other support from their parents and concluded, as one girl noted, that their parents “would probably hate me for the rest of my life” if they found out about their unintended pregnancy.8Close Others feared their parents might become violent. After one father repeatedly told his daughter that if she ever got pregnant, she “wouldn’t be able to marry the guy—because he would have killed him,” the daughter was in despair when she did get pregnant. “My father is generally very levelheaded,” she explained to Dr. Crist, “and it takes a lot to make him mad, but I know that would push him right past the limit.”9Close Even students who did not fear their parents’ scorn felt that knowledge of a pregnancy outside marriage would cause their parents unnecessary anguish and disappointment.10Close “The fear of telling our parents was worse than the fear of the abortionist,” Hill remembered. “Being pregnant back then was worse.”11Close
Young women who saw their friends kicked out of school as a result of an unwanted pregnancy often remembered the circumstances of their friends’ expulsion for years after. Susan Hill recalled a Meredith College student who had gone to Cheraw, South Carolina, for an illegal abortion. She returned in the middle of the night with a severe infection. Her friends took the sick girl, who was barely able to walk, to the Meredith College infirmary from where she was quickly expelled. “We never saw her again,” Susan Hill remembered. “They treated her and she left and we never saw her again. And for weeks, no one would tell us what had happened to her. Finally we heard she’d been packed up and sent home. … She just disappeared once they knew what she’d done. It’s like she never existed.”12Close It did not take many stories like these for women students to understand that an unwanted pregnancy during their college years posed a serious threat to their future.
Of course, unwanted pregnancy was not an experience limited to young college-age women. Women of all backgrounds experienced unwanted pregnancies, and many of them sought an abortion even when the procedure was illegal. In the mid-1950s, estimates of the number of illegal abortions ranged anywhere from 200,000 to 1.2 million a year. Among urban, white, educated women, Alfred Kinsey found in his 1958 study of women’s sexual behavior that one-fifth to one-fourth of all pregnancies ended in abortion. The abortion rate climbed to 28 percent of all pregnancies among young wives between sixteen and twenty years old and to 79 percent among separated, divorced, and widowed women of all ages. Journalist Lawrence Lader noted in the mid-1960s that only about 8,000 abortions annually took place inside a hospital, constituting a fraction of the number of abortions performed each year.13Close Some women seeking illegal abortions were fortunate to find a skilled abortion provider. Across the country, physicians, nurses, and midwives, among others, practiced in secrecy, offering thousands of illegal abortions. In his 1966 book, Abortion, Lader lists twenty-nine states in which he was able to locate at least one skilled abortionist. Women also traveled abroad to seek abortions in Mexico, Puerto Rico, and England or as far away as Japan. But in most places the practice of skilled illegal providers was shrouded in secrecy, and not all women seeking illegal abortions were able to afford their fees, let alone travel to foreign locations.14Close Those without resources, poor white women as well as African American, Hispanic, and immigrant women, were forced to enter a world of underground abortions where care was frequently humiliating and the procedures dangerous. “Its practitioners,” Lader cautioned, “preying mainly on poor and ignorant women, rarely have a medical degree. In an analysis of 111 consecutive convictions [of underground abortionists] in New York County, less than a third were physicians. The remaining two-thirds boasted such non-medical occupations as clerks, barbers, and salesmen.”15Close Before the mid-1960s, the estimated mortality rate from illegal abortion stood at 1,000 to 8,000 deaths per year. Almost 80 percent of all abortion deaths occurred among non-white women.16Close
With eye-catching headlines and photos, often on the front page of newspapers, journalists described an underground world that connected illegal abortion to organized crime syndicates. Such press coverage not only thrilled the public, historian Leslie J. Reagan notes, but also threatened women, physicians, and others engaged in illegal abortion with arrest and exposure.17Close Other more serious investigations into illegal abortion drew attention to the devastating impact that criminal abortion laws had on women’s health and lives and argued for reform. Lader charged that criminal abortion laws contributed to a system in which minority groups, the poor, and the unsuspecting were punished doubly. “No study,” Lader noted, “could begin to measure the physical and psychological injury inflicted on women by quack abortionists, often virtual butchers. Nor could it encompass the damage women inflict on themselves in attempts at self-abortion.”18Close
Despite these grim statistics, countless women concluded that seeking an illegal abortion was preferable to carrying an unwanted pregnancy to term. “The search for a skilled abortionist,” Lader noted, “may be the most desperate period in a woman’s life.”19Close Women were often resourceful and asked around to locate an underground abortion provider. Many asked friends or any close medical contacts they might have or turned to their family physician or obstetrician for help. Susan Hill remembered that students at Meredith College had a map directing them to a doctor in Cheraw, South Carolina, who charged $600 cash for an illegal abortion.20Close Others, however, searched for weeks without success, losing valuable time, which made the abortion procedure more difficult—and thus riskier—as pregnancy progressed.
It Was Very Oppressive for Women: Sexism in Medicine
Women’s frustration with the medical profession was not limited to worries about access to contraception and abortion. Women of all age groups found their physicians unresponsive to their health care needs and unwilling to address their concerns. Their frustration with the medical profession stood out most clearly in women’s relationships with their ob-gyns, most of whom were male. Since they were the specialists responsible for women’s most intimate health care needs, the personal demeanor and attitude of obstetricians and gynecologists toward women and sexuality were crucial to women’s comfort. “A physician’s personal outlook and even his sexual bias can change a routine pelvic examination from a mildly embarrassing or uncomfortable experience into one that is demeaning and humiliating,” an article in Modern Medicine warned.21Close One prominent female ob-gyn noted about women patients’ comments concerning their (mostly male) physicians: “One often sees such comments as: ‘He doesn’t explain anything to me.’ ‘He treats me like an ignorant and somewhat stupid child.’ ‘He can’t seem to understand or relate to any of my emotional needs and problems.’”22Close Medical education contributed to this state of affairs. Into the 1970s, many ob-gyn textbooks taught medical students that most of women’s complaints were the result of neuroses rather than symptoms of disease. Couched in a Freudian framework, the 1971 edition of Obstetrics and Gynecology, for instance, advised medical students that many symptoms of illness in pregnancy, such as excessive nausea or headache, are really a result of her “fear that the rewards [of pregnancy] will be denied because of past sins.”23Close
Matters improved little once medical students left their textbooks behind and entered residency programs. Teaching practices frequently reinforced the notion that physicians need not listen to their patients. To teach residents at large teaching institutions how to conduct pelvic exams, for instance, instructors hid the woman’s upper body behind a screen or curtain or put a bag over her head so that the resident did not have to learn a patient’s identity or interact with her.24Close Indeed, medical students into the 1980s recalled learning how to perform pelvic exams at major university hospitals on patients who had been anesthetized for unrelated procedures.25Close As a result, many physicians were at best uncomfortable with their patients, at worst paternalistic and patriarchal. “It was very oppressive to women,” a member of Iowa City’s feminist health collective, the Emma Goldman Clinic (egc), remembered.26Close
Starting in the late 1960s, women across the country began to challenge the patriarchal attitude of medical professionals. They complained to more sympathetic physicians about the demeaning behavior of their colleagues and came together to discuss their health care providers and search for answers to their medical questions. A group of women in Boston began to discuss childbirth, sexuality, and their doctors, whom they found “condescending, paternalistic, judgmental, and non-informative.”27Close Group members researched and educated one another on a number of topics relating to women’s health and in December of 1970 published the results under the title Women and Their Bodies, which three years later became better known as Our Bodies, Ourselves.28Close Women in Chicago formed Jane, an underground abortion referral service. Frustrated with the cost of abortion and their inability to ensure that women were not exploited by underground abortionists, Jane members quickly moved from counseling and referral to performing the abortions themselves. Between 1969 and 1973, almost 11,000 women received abortions through Jane. This, Jane members concluded, is how the procedure ought to be done: by women, for women, as acts of liberation and empowerment.29Close Women in San Francisco passed out a leaflet with the names of physicians in Mexico and Japan who performed abortions. As demand for the list soared, feminists in California established the Association to Repeal Abortion Laws and created mechanisms for regulating illegal abortion practices so as to ensure that they were sending women to safe practitioners.30Close In Los Angeles, Carol Downer, a housewife turned health activist, began to teach women how to perform cervical self-exams. In the fall of 1971, Downer and Lorraine Rothman, who had developed a menstrual extraction kit, the Del-Em. em-barked on a twenty-three-city tour across the United States to demonstrate cervical self-exams and menstrual extraction and encourage women to start their own clinics.31Close They traveled to Iowa City, Iowa, for instance, where they taught a group of young feminists about cervical self-exams and discussed the establishment of women’s health clinics. Cervical self-exams and the idea of starting a women’s health clinic spread like wild-fire. As one Iowa City activist recalls, “We were everywhere with self-help, educating women about their bodies. And I think that part of what we did, and countless other women in this country, Our Bodies, Ourselves, has helped young women to not feel as uptight about their bodies.”32Close
Men, too, participated in the burgeoning reform movement surrounding sexual and reproductive health. After New York journalist Lawrence Lader found a number of reliable underground abortion providers when he researched Abortion, he shared the information with women who wrote to him asking for referrals.33Close Several prominent clergymen decided to establish a referral service to provide women with the names of trustworthy abortion providers. Within a year, clergy across the country, led by Reverend Howard Moody of Judson Memorial Church in New York City’s Greenwich Village, began to organize Clergy Consultation Service chapters across the country. Clergy members trained in “problem pregnancy” counseling and, like California feminists, conducted extensive interviews and reviews of underground abortion providers to select those who were safe and trustworthy.34Close In the late 1960s, William R. Baird, a thirty-four-year-old medical school dropout and contraceptive salesman, emerged as a crusader for sexual and birth control information on college campuses around the country. In the spring of 1967, students at Boston University invited Baird to speak about sexuality and contraception. After Baird displayed various contraceptives before an audience of more than 2,500 people and gave an unmarried female student a can of Emko contraceptive foam, the Boston vice squad arrested him and charged him with crimes against chastity. Baird used his arrest to draw attention to the repressive attitudes that not only stifled people’s intimate lives but also jeopardized women’s health. Following his arrest and subsequent court battle, students across the country rallied in support of Baird, holding public demonstrations and demanding reproductive rights for women.35Close Male students offered lectures on birth control to classmates and wrote advice manuals on sexuality and reproduction. They relied on the assistance of physicians, psychologists, and educators who began to participate in the establishment of student health services that offered information about sexuality and contraception.36Close
They were joined by progressive physicians who worked to improve their patients’ health care experiences. In the late 1960s and early 1970s, for instance, student health services at Brown, Stanford, Harvard, Yale, and the Universities of Illinois, Minnesota, Massachusetts, and Chicago began to offer contraceptive advice. Bolstered not only by growing demands from college students but also by increased funding for adolescent medicine under the War on Poverty, leaders in adolescent medicine lobbied for a change in state laws permitting minors to consent to treatment of sensitive health issues. By the late 1970s, adolescents had obtained the right to obtain contraceptives without parental consent.37Close unc stood at the center of this change. After the North Carolina legislature passed an abortion reform bill in 1967 that legalized therapeutic abortion if a woman could obtain the support of three physicians, Takey Crist and the Department of Obstetrics and Gynecology at unc’s Memorial Hospital opened access to abortions and institutionalized sex and contraceptive education and health services on campus.38Close As word spread that physicians were increasingly willing to honor women’s abortion requests, many physicians were confronted with patients who would have sought an underground abortion earlier. Students able to access these services expressed their immeasurable sense of relief. As one student wrote to Takey Crist after her abortion, “I have been given a beautiful chance at life again.”39Close
By the end of 1972, students received more than contraceptive advice at Student Health. unc freshmen learned about the availability of these services during freshman orientation. At the Student Stores, they could purchase a copy of the sex education booklet Elephants and Butterflies, written by three medical students under the direction of Takey Crist, which provided detailed information on sexuality, reproduction, and contraception and informed students where to turn for birth control and abortion. Students were able to write to the student newspaper, the Daily Tar Heel, which published a weekly column, “Questions to the Elephants and Butterflies,” in which Crist and student Lana Starnes answered questions about sex. They could seek help from a peer counselor at the Human Sexuality Information and Counseling Service, which held daily office hours at the Student Union, offering advice on any sexual issue imaginable. For a more academic approach, students could enroll in heed 33, an undergraduate course on human sexuality developed by Takey Crist, or invite Crist to present an evening education program at their dorm, sorority, or fraternity. Finally, they could seek contraceptive advice and therapeutic abortions at the Health Education Clinic established by Crist or call the Clergy Consultation Service (all phone numbers were listed in the back of Elephants and Butterflies) for a referral to abortion services in Washington, D.C., or New York State.40Close
This literal explosion of sex education services was part of a small but growing trend on campuses across the country. If, in the 1960s, state laws outlawing the distribution of contraceptives to unwed minors had significantly limited access to birth control information and devices, the 1972 Supreme Court decision Eisenstadt v. Baird greatly aided efforts to establish reproductive health services on college campuses. “If the right of privacy means anything,” the decision read, “it is the right of the individual, married or single, to be free from unwarranted governmental intrusion into matters so fundamentally affecting a person as the decision whether to bear or beget a child.”41Close In response to student interest, Planned Parenthood–World Population initiated a program of student community action to acquaint college students with the latest contraceptive techniques and devices and provide them with a vehicle for establishing contraceptive services on college campuses.42Close Whereas a 1966 survey conducted by the American College Health Association had found that physicians at only thirteen U.S. colleges and universities prescribed oral contraceptives to unmarried students, and most of these did so only for women over the age of twenty-one, by 1970 the association counted 118 institutions offering contraceptive services. Still, as historian Heather Prescott has pointed out, this was a small percentage of the more than 2,500 U.S. colleges and universities at the time.43Close
The Making of Roe v. Wade
A number of factors converged by the 1960s to set the stage for abortion reform. Responding to medical complaints about the lack of clear legal guidelines, the American Law Institute, made up of attorneys, judges, and law professors, proposed a model abortion law in 1959 that would clarify the legal exception for therapeutic abortion and enshrine it in law along more liberal lines. During the following decade, legal and medical organizations promoted the law institute’s model in state legislatures and in the media. Women’s rising labor force participation and college attendance contributed to falling birthrates and climbing abortion rates. Their growing need for access to safe abortion services became painfully evident to the medical professionals who were staffing the nation’s emergency rooms and taking care of women who had obtained illegal abortions. The specter of women dying as a result of illegal abortions propelled activists who hoped to protect the lives of women by making therapeutic abortion more accessible.44Close
In 1962, the Sherri Finkbine case raised public awareness of the dangers of thalidomide, a tranquilizer that could cause fetal defects, and inaugurated a nationwide debate about the use of abortion to avoid birth defects. Finkbine, the host of a popular children’s tv show, feared for her pregnancy after taking thalidomide and planned to have a therapeutic abortion performed by her physician. But her plan was thwarted when her situation became news and the hospital backed away. Finkbine, whose case became national and international news, subsequently traveled abroad for an abortion. Fears about the dangers of thalidomide were closely followed by a German measles epidemic that hit the United States in 1963. The ensuing debate not only altered national consciousness concerning abortion but also played a crucial role in emerging reform efforts.45Close In 1964 a group of prominent physicians, lawyers, clergy, and others established the Association for the Study of Abortion, which used the influence of its many experts to educate the public about abortion reform.46Close By the end of the decade, feminists began to organize to put pressure on the medical profession and state legislatures to repeal abortion laws.47Close
By the mid-1960s, state legislators across the country were debating abortion reform based on the American Law Institute’s model law, and in 1967 Colorado, North Carolina, and California were the first states in the nation to pass reform legislation, closely followed by Alaska, Hawaii, and New York.48Close On April 11, 1970, New York governor Nelson Rocke-feller signed a bill legalizing abortion in New York. The bill did not limit access to abortion to residents of New York, and on July 1, 1970, the day the law took effect, over 350 women called the Family Planning Information Service to ask for appointments. Although fewer than 100 of the 2,000 women who registered in New York that first day received legal abortions, over the coming 21⁄2 years thousands of women traveled to New York for a legal abortion.49Close And New York was not the only state to legalize abortion. Two court decisions in the fall of 1969 led to abortion reform in California and Washington, D.C. On September 5, 1969, the California Supreme Court, in People v. Belous, declared California’s abortion law unconstitutional and exonerated physician Dr. Leon Belous, who had been indicted for performing illegal abortions. Following this decision, California hospitals relaxed their abortion policies, and California’s physicians increased the number of abortions they performed. By 1972, the state’s abortion rate had climbed to 135,000 legal abortions per year, the second highest total behind New York. People v. Belous served as a precedent for a score of other challenges to similar state laws. When, two months later, Judge Arnold Gesell declared the District of Columbia abortion law unconstitutional in United States v. Vuitch and exonerated Dr. Milan Vuitch for performing illegal abortions, he cited the California decision. Following Gesell’s decision, Vuitch established an outpatient abortion clinic a few blocks from the White House with four treatment rooms, a laboratory, and a recovery room. Soon, the clinic was taking 100 abortion cases a week. In 1971, Vuitch—with the help of the National Abortion Rights Action League (naral)—opened a model outpatient clinic called Preterm. Preterm was quickly followed by two other outpatient clinics in Washington, D.C., and by the end of 1971, 20,000 women had received legal abortions in Washington, D.C.50Close Developments in California, New York, and Washington, D.C., were followed by a repeal of abortion laws in Hawaii and Alaska shortly thereafter.51Close
On January 22, 1973, the U.S. Supreme Court legalized abortion with its Roe v. Wade and Doe v. Bolton decisions. The decisions overturned nearly all state abortion regulations existing at the time and expanded the fundamental right of privacy established in 1965 in Griswold v. Connecticut—a decision which held that intimate marital decisions around family planning were protected by a right of privacy—to include abortion.52Close Women, however, did not gain a right to legal abortion. Rather, Roe v. Wade permitted women, in consultation with their physicians, to decide in the privacy of a physician’s office whether or not they wanted to end a pregnancy. Women’s and physicians’ ability to choose an abortion was not entirely unregulated. The decision set up a trimester framework during which a woman was free of state constraints on her decision if she was in the first twelve weeks of pregnancy. If she was in her second trimester, thirteen to twenty-four weeks, the state could restrict access to abortion only when necessary to protect the woman’s health. The court established the twenty-fifth week of pregnancy as a threshold after which it considered the fetus viable and permitted the state to invoke an interest in protecting the fetus and to restrict abortion. However, a state could not restrict abortion when the procedure was deemed necessary to preserve a woman’s life or health. In Doe v. Bolton, the Supreme Court further removed any requirements that women be a resident of the state in which they sought access to abortion and struck down requirements that abortions be performed in a hospital setting and that women obtain permission from a hospital abortion committee or that two other doctors endorse her physician’s recommendation of an abortion.
Since women had no right to an abortion procedure, it was their own responsibility to find an abortion provider and pay for the procedure. As a result, women’s actual access to abortion procedures emerged as a significant issue. Indeed, the Roe v. Wade decision signified the beginning, rather than the end, of a protracted political, legislative, and legal battle over access to abortion. As the antiabortion movement gained strength in the 1970s, antiabortion activists set out to overturn the Roe v. Wade decision by introducing a Human Life Amendment and eliminated public funding for any aspect of abortion care with passage of the 1976 Hyde Amendment. Still, throughout the 1970s and 1980s, the U.S. Supreme Court protected abortion as a private choice. The justices pondered two questions: First, what limitations on abortion are permissible under Roe? And second, did the right to an abortion require states to support access to the procedure for women who found it difficult to actually obtain an abortion? Initially, as states began to draft laws that would restrict women’s access to abortion, the U.S. Supreme Court, in three key decisions, struck down attempts to limit access to abortion. In the first case, Planned Parenthood of Central Missouri v. Danforth (1976), the Supreme Court struck down a Missouri law requiring parental consent to a minor’s abortion, a husband’s written consent to his wife’s abortion, a woman’s written and informed consent, and a ban on second trimester saline procedures. Seven years later, in Akron v. Akron Center for Reproductive Health, Inc. (1983), the court struck down a twenty-four-hour waiting period, a hospitalization requirement for abortions after the first trimester, parental consent to abortions for girls aged fifteen or younger, a doctor-only counseling provision, a requirement that women receive specific information during the counseling session, and strict instructions about the disposal of fetal waste. In the 1986 Thornburgh v. American College of Obstetricians and Gynecologists decision—a case that challenged Pennsylvania’s 1982 Abortion Control Act—the court rejected a state-mandated counseling script read by doctors to patients, a requirement that doctors attempt to save fetuses in postviability abortions, a requirement that two doctors attend postviability abortions, and a reporting requirement that allowed public access to abortion records.53Close
But because a central premise of the Roe ruling holds that a woman lacks a fundamental right to abortion per se, questions of public funding fared less well before the Supreme Court. In two cases, Maher v. Roe (1977) and Harris v. McRae (1980), the court determined that neither states nor the federal government was obligated to provide abortion funding for the poor. These decisions created an obvious class distinction. All women could choose abortion, but only those able to pay for the procedure could actually realize their choice and obtain an abortion. The cases also signaled the advent of a theory of negative rights that emboldened the pro-life movement. The majority of justices agreed that a woman’s access to abortion could be denied through state omission—a lack of financial assistance to poor women—although not through active state-imposed hurdles. The state or federal government could thus legitimately assert its preference for birth over abortion by denying support for abortion.54Close
In 1989, the U.S. Supreme Court also began to shift away from its refusal to allow state-imposed restrictions to abortion. In its Webster v. Reproductive Health Services decision, the justices for the first time questioned the trimester framework that had established a protected zone for abortion and had limited states’ ability to favor birth over abortion until the third trimester, when the Roe decision had considered the fetus to be viable. Now the court argued that, owing to the advancement of medical technology, viability changed over time and place. A fetus not considered viable in 1973 might, with advances in medical technology, be considered viable by the late 1980s. One not viable in a rural community hospital might be considered viable in a sophisticated neonatal unit in an urban hospital. Unwilling to leave the judgment over fetal viability in the hands of physicians, Webster asserted that states could express interest in fetal life prior to viability and could withhold state resources to assert this preference. In practice this meant that the state of Missouri was permitted to bar public facilities from offering abortion services. While Roe had protected abortion until viability, Webster embraced a new vision in which states could now express an interest in fetal life. The Supreme Court now allowed states to second-guess physicians by imposing specific directions and restrictions on abortion services. (Webster, for instance, upheld a Missouri provision that required physicians to perform viability tests before performing an abortion.)55Close
The shift away from physician authority to a stronger role of state legislatures in the performance of abortion was further strengthened in the 1992 decision in Planned Parenthood of Southeastern Pennsylvania v. Casey. Indeed, states wishing to impose abortion restrictions now simply had to demonstrate that the burden imposed on women’s access to abortion was not “undue”—that is, placed no “substantial obstacle in the path of a woman seeking an abortion of a nonviable fetus.”56Close This shift greatly undermined doctors’ authority in abortion decisions, replacing the physician as gatekeeper to abortion with the state legislature, which could now set very precise terms under which abortions may take place. In Casey, the justices permitted abortion barriers that the Supreme Court had found unconstitutional in previous cases: a twenty-four-hour waiting period, state-mandated counseling, parental consent for minors, and a reporting requirement. The court also began to treat women as a group that needed to be protected from their own choices. Upholding state-mandated counseling language, for instance, suggested that women seeking abortions needed counseling, that physicians who counsel women before an abortion needed to be told how to counsel their patients, and that both parties were unreasonable and needed the state to step in.57Close Empowered by Casey, Supreme Court justices subsequently further expanded restrictions on abortion. Most significant, the 2007 Gonzales v. Carhart decision upheld the first ban on a particular abortion procedure—intact dilation and evacuation (d&e), or the so-called partial birth abortion procedure—without granting an exception to women’s health or life. More broadly, for the past two decades states have drafted increasingly inventive legislation to impose all kinds of restrictions on abortion services, ranging from requiring particular building codes to the requirement that abortion providers have privileges at local hospitals to attempts to ban abortions after twenty weeks’ gestation.58Close None of these restrictions increased the safety of abortion procedures, which were already the safest outpatient procedures available.59Close All of them made abortion services more difficult to access by placing obstacles in the way for women seeking abortion services or forcing abortion providers to raise their prices to meet burdensome and costly requirements.
Writing the History of Legal Abortion
The topic of abortion has captivated writers for decades. Given that it touches on questions of sex, life, death, and morality, this attention is not surprising. Scholars tracing the history of women’s health activism have chronicled the history of feminist challenges to illegal abortion, the emergence of the women’s health movement, and the establishment of feminist clinics which emerged as a result.60Close Others have traced the roots of antiabortion activism, the escalation of violence, and the impact on the pro-choice movement.61Close A third group of scholars have analyzed the impact of policies limiting women’s access to abortion. They have charted changes to abortion funding, tracked policies that regulate access to abortion, and analyzed the impact of legal decisions.62Close But despite the fact that policy approaches to abortion and the cultural climate surrounding abortion care underwent a fundamental shift over the past four decades, we lack a comprehensive study of the events that have changed the experiences of abortion care since 1973 and of the impact that these events have had on the abortion experience. For the pre-Roe period, the history of abortion is well documented.
Contrary to popular belief, abortion was not always illegal. Until the middle of the nineteenth century, abortion was largely unregulated. Historians have illustrated that anxieties about women’s changing roles and declining birth rates, coupled with the desire of ob-gyns to establish themselves as the primary health care providers for women’s reproductive needs, led to a public campaign that culminated in the criminalization of abortion by the late nineteenth century.63Close Although abortion remained criminalized until the early 1970s, women continued to seek the procedure. As the twentieth century progressed and law enforcement cracked down on illegal abortion, women obtained illegal abortions at increasingly higher risks to their life and health.64Close
Feminist scholars have noted that changes in medical technology, in particular the widespread dissemination of ultrasound images, significantly shaped the social meaning of pregnancy—and by extension the meaning and experience of pregnancy termination.65Close How abortion providers and their patients understood the provision of abortion care shifted as larger cultural understandings about pregnancy and the fetus changed. If many viewed abortion in the 1970s as central to women’s emancipation and a right that women should have, this view began to change in the 1980s as the proliferation of fetal images began to contribute to a reshaping of the public understanding of the fetus. As fetal images gained in prominence, antiabortion activists began to articulate fetal interests and rights and to advance the notion that a fetus might have interests that stand in opposition to the interests of the woman carrying the fetus.66Close Much has been said about the rhetoric and stigma attached to abortion resulting from these changes. But we know little about the impact that this debate has had on the experience of those delivering and receiving abortion care: abortion providers and their patients.
Indeed, anyone researching the history of legal abortion will find the record curiously silent on positive depictions of the abortion experience. The silence surrounding the abortion experience—having one and performing them—has been “a productive taboo,” reinforcing myths that abortion is never easy and positive but at best hard, at worst harmful to women.67Close Since the early days of legalization, writers discussing legal abortion have repeated pre-Roe tropes that characterized women seeking abortions as mentally deranged and physicians performing abortions as immoral and greedy. Legalization did not remove the shame that came with having an abortion. While women spoke and wrote more openly about their illegal abortions in the years after legalization, they were silent about their legal abortions. In addition, feminists, most likely to break the silence surrounding abortion, were also most critical of the male medical professionals who performed abortions. By the late 1980s, antiabortion writers had begun to dramatize the abortion experience from an antiabortion perspective, and accounts of abortion ranged from ambivalent to hostile. Gory descriptions of abortion procedures successfully pushed women and providers into the defensive, silencing an already taciturn community and leaving abortion providers and their supporters unprepared to defend the integrity and independence of medical practice as it relates to the performance of abortions particularly after the first trimester. Looking back at the rhetoric surrounding legal abortion, one observer noted in 2003 that conservatives, not liberals, had won the struggle around abortion rights.68Close
As the abortion conflict escalated, the increasingly hostile climate colored the experience of abortion providers and patients. The proliferation of negative visual images and the growing number of screaming protestors outside clinics colored the feelings that providers and patients might have about the medical procedure inside the clinic. Images and discourse outside became inevitably linked to and shaped experiences inside the clinic. The antiabortion discourse narrowed the interpretive framework for women and clinic personnel seeking to make sense of their experience and contributed further to the stigmatization of abortion care. In this context, it was, frankly, not acceptable to note that one felt good about one’s abortion experience or liked working in an abortion clinic and performing abortion procedures. Indeed, the public reception of a YouTube video posted in spring 2014 by the young abortion counselor Emily Letts who had videotaped her own abortion confirms the taboo surrounding a positive discussion of abortion. Letts sought to dispel popular myths and fears about the abortion procedure and illustrate that having an abortion could be a positive experience. Her YouTube video raised a firestorm of objections, not only from those opposed to abortion but also from abortion rights advocates who felt the video inappropriate.69Close
Yet, despite their silence in public, in private women and abortion providers expressed positive sentiments about abortion. In evaluation forms at abortion clinics and in letters to their physicians, women noted over and over again that they appreciated legal abortion services, were relieved at their ability to end an unwanted pregnancy, and felt good about their abortion. Many abortion providers, in turn, enjoyed their work and were grateful for their ability to help women in a time of need. However, only in the late 1990s did abortion providers begin to express these sentiments publicly. Responding to a growing body of antiabortion propaganda that depicted abortion providers as greedy, immoral and unconcerned with women’s health and safety and abortion procedures as painful and dangerous, abortion providers began to write about their work to correct the distortions and misperceptions.70Close And a handful of scholars began to analyze the marginalization of abortion providers pre-and post-Roe and to discuss the personal and professional toll that those who work in abortion care experience.71Close In response to the increasing stigmatization of abortion, pro-choice organizations, too, began to organize speak-outs and collect stories from women who had had abortions. Today, there are several websites where women post about their positive abortion experiences.72Close
Given these silences, finding accessible sources that might tell me about the provision of and experience with abortion care turned out to be challenging. My access to the world of abortion care came through so-called independent abortion providers, who, following legalization, started their own women’s health and abortion clinics and sometimes expanded to a chain of clinics across several states. The papers of these independent providers were tucked away in filing cabinets in the back of their clinics or in storage units around the country. To learn more about their work, I needed to gain access to and legitimacy with this group of health care professionals. In the early 2000s, I joined the National Abortion Federation (naf), a professional organization of abortion providers. At annual meetings, I approached members to ask about their papers. Over time, many of them agreed to donate their papers to the Duke University’s Sally Bingham Center for Women’s History and Culture. These collections are treasure troves. They contain often voluminous correspondence, newsletters, newspaper clippings, court documents, and rich materials from the antiabortion movement. I also began to conduct oral history interviews with abortion providers, clinic owners, and others associated with the field of abortion care. This book is based on these materials.
While this source base has proven to be extraordinarily rich, there remain significant gaps. Data on the provision of abortion care, collected by the Centers for Disease Control and the Alan Guttmacher Institute, tends to be large and aggregate. We can learn about the numbers of abortions across the nation, broken down by community size, abortion procedure, gestational age, patient age, and a variety of other factors. The existence of such aggregate data is, however, coupled with a total absence of data that can be tied to any individual abortion clinic. And if historians want to learn any details about women seeking abortion services, they have to dig deep. No historical data exists that might offer more detailed social or demographic background information on abortion patients or reveal insights into women’s thoughts about the abortion experience. Occasionally, clinics handed out patient questionnaires to assess women’s satisfaction with the services provided. But even these are scattered over time and place and frequently raise more questions than they answer. Security concerns further compound the problems of researching the history of legal abortion. If statistical information about women seeking abortion is almost nonexistent, statistical information about abortion providers is completely unavailable. We do not even know how many of them there are. Only a fraction of physicians providing abortion care, for instance, are members of naf, and its membership lists are, for security reasons, confidential. Nor do we know what kind of abortion services abortion providers perform. Although there is aggregate data on the number of procedures performed across the country, for instance, there is no data that might tell us who performs these procedures—or where they are performed. Proceedings at the annual meetings of naf and information collected by the organization are confidential and cannot be disclosed outside the organization. Sources about the two main participants in the abortion experience, then, are mainly anecdotal in nature, gleaned from correspondence, personal recollections and testimonies, and oral history interviews.
The limitations in sources also obscure the impact of race on the abortion experience. This is in stark contrast to my first book, Choice and Coercion, which traced the history of public health birth control programs, eugenic sterilization, and abortion prior to legalization between the 1920s and the 1970s. Since questions of race and class drove policy approaches regarding women’s reproductive control, race was very visible in the historical record. Historical subjects in Choice and Coercion were frequently identified by race, which allowed me to tell a story about race. As I turned my attention to the history of abortion after legalization, I found race largely invisible in the historical record. Aggregate data offers insights on the racial background of abortion patients, but until the late 1980s, statistics differentiated only between “white” and “nonwhite” patients. Starting in the late 1980s, demographers added categories for “black” and “Hispanic” patients. Yet this data existed only on the state level and offers no information beyond the number of women of different racial backgrounds having legal abortions. Letters and testimonials chronicling the patient experience frequently offer no information about the race of the author, making the experience of African American or Hispanic women, for instance, almost invisible. The record becomes even murkier if one is to write about the impact of race on abortion providers and clinic staff. Often only personal knowledge meant that I knew the race of a provider or staff member, although occasionally the context of a story identified the race of a subject. Yet, it is clear that race shapes the experience of abortion patients, providers, and clinic staff. Protestors targeted African American patients, for instance, with charges of racial genocide, and African American patients and providers drew on a civil rights tradition when they faced crowds of screaming protestors. This book, then, tells an incomplete story about abortion after legalization—but an important story nonetheless. Much more research is needed to help us understand how race shaped the experience of abortion care, including the collection of oral history interviews with abortion providers and clinic staff from a wide diversity of backgrounds.
Given the sensitive nature of this topic, where and how I collected material shaped my personal editorial decisions and determined whether or not I could write about the information I found. While I decided not to shy away from sensitive topics inside the abortion provider community, I was careful—when addressing sensitive issues—to use only information from public records accessible to anybody. Although research in archival records and oral history interviews with abortion providers generally yielded material I could actually draw on, attendance at the annual meetings of naf or research at its offices could only inform my understanding of events and experiences. And because my interest in the experience of abortion care is both politically sensitive and very personal to those narrating their experiences, it is by nature anecdotal and individual. Still, writing about the experience of abortion care and the impact that the abortion conflict has had on women and abortion providers is a pressing theme. It exposes how all abortion is marshaled into the single groove of morality, successfully excluding any consideration that places women’s control over their lives at the center of the debate.
Abortion is—and always has been—a key arena for contesting power relations between women and men. Feminists argued with male medical professionals about who should be in charge of performing abortions and how abortions should best be performed. In addition, the belief that women are incapable of acting as moral agents and cannot be trusted with the decision whether or not to end a pregnancy remains pervasive after forty years of legal abortion. Women’s ability to control their own lives and bodies, however, depends on their ability to control the most private and personal aspects of their lives: whether and when to bear children. As this book will illustrate, while the legalization of abortion made abortion accessible to most women, abortion became highly politicized and stigmatized as antiabortion activists and legislators challenged women’s ability and right to decide on abortion.
although this is not a legal history, two legal cases stand as bookends to this work: a 1974 case, Edelin v. the Commonwealth of Massachusetts, and the 2007 Supreme Court decision Gonzales v. Carhart. In 1974, Boston prosecutors charged Kenneth Edelin, a young African American ob-gyn resident at Boston City Hospital (bch) with manslaughter after he performed a legal abortion. City prosecutors sought to challenge the newly legalized procedure by attacking a particular abortion procedure, hysterotomy, and charging Edelin with killing the fetus—“a baby boy”—in the course of the procedure. Unsuccessful in the 1970s—Edelin was found guilty in 1975, but the verdict was overturned a year later—antiabortion activists finally succeeded in banning an abortion procedure—intact d&e—with the 2007 Gonzales v. Carhart decision. Indeed, Gonzales v. Carhart provides the logical culmination of more than three decades of antiabortion activism in which abortion opponents sought to redefine the fetus as a baby and pregnancy termination as murder. The 2007 case brings together a number of intellectual antiabortion strands whose emergence and development I trace in the body of the book and which, in the 1990s, provided the intellectual foundation for the attack on intact d&e.
Following the legalization of abortion, physicians across the country established a network of abortion clinics to provide abortion services to women. Even though the vast majority of abortions today are performed in Planned Parenthood clinics, only a handful of Planned Parenthood clinics participated in the early establishment of abortion services. The 1979 naf directory lists only one Planned Parenthood clinic. While ten more had joined by the early 1980s, they still made up only 5 percent of all member clinics in the mainland United States.73Close The vast majority of clinics that opened their doors in the 1970s were established by independent providers, physicians, and businessmen and were only informally connected. While some investors created several clinics under the same ownership, most of the clinics were unaffiliated. Owners and physicians of these early clinics communicated with one another, offered one another support, and established professional organizations and guidelines to guide their work. In the 1970s and 1980s, this group of nonaffiliated abortion providers carved out the framework for abortion services and, in response to the damages inflicted by antiabortion activism, in the 1990s led the abortion provider community through innovative changes in abortion care. When Planned Parenthood did begin to offer abortion services, it tended to do so in well-established markets after independent clinics had established a presence for abortion providers. Moreover, Planned Parenthood had access to donations and government funding unavailable to smaller clinics and was frequently seen as the Walmart of abortion services that pushed smaller independent clinics out of the market. Independent clinics, on the other hand, were not beholden to a larger organization and had the flexibility to try new approaches in abortion care. I will trace the emergence of this network of independent clinics, discuss the services they established, and analyze how the emergence of the antiabortion movement influenced the shape of abortion services over time. It is up to future historians to write the surely rich history of Planned Parenthood’s approach to abortion care.
Since my interest in abortion care is driven in part by an interest in the history and development of medical procedures, my analysis will focus on the development of pregnancy termination procedures and the ways in which the antiabortion movement influenced the procedures performed in the surgery room. From the very beginning, antiabortion activists described abortion procedures in gory detail and illustrated their description with graphic images and photos. Moreover, although more than 90 percent of abortions take place in the first trimester, antiabortion activists focused on the small percentage of abortions taking place after the twelfth week of pregnancy—and on the even smaller percentage of abortions performed after twenty weeks’ gestation. Focusing on abortions after the first trimester was supposed to suggest that all abortions are performed late in pregnancy. To understand the impact of this debate, I will discuss surgical procedures performed after the first trimester, although they constitute only a small percentage of all abortions performed. Some readers might consider these discussions tasteless and unpleasant. Others might object that such discussion is politically too sensitive. Yet a consideration of these procedures is essential if we are to understand the fight over abortion care and its impact on abortion services.
This book does not discuss medical abortion—the abortion pill Mifepristone. Approved by the fda in 2000, medication abortions quickly increased from 6 percent in 2001 to 23 percent in 2011 (36 percent of all abortions before nine weeks’ gestation).74Close However, the story of medical abortion, while interesting, is really different from surgical abortion. Its recent adoption made me decide to exclude it from consideration in this book.
Finally, a note on language: How people talk about abortion changed significantly over time as decades of antiabortion activism stigmatized abortion and publicly silenced those who felt good about receiving and providing abortions. Because individuals create narratives to make sense of the world and their place in it, how they talk about abortion reflects their own subjectivity and influences the understanding of those around them. While narratives reflect subjective experiences, they express a reality for the narrator. Indeed, the narratives create subjectivity—a position in the world and an understanding of the narrator as part of the world and society. In the context of abortion, narratives were most important in situating a person vis-à-vis abortion: as participant and actor or victim and object. As the abortion debate unfolded in the course of the 1970s, bodies and acts that were once apolitical gained political meaning. This is particularly true for fetal bodies, which became highly politicized. And it extended to activities of individuals on both sides of the abortion debate.
Language used in the abortion debate frequently contributes to misinformation. In this book, I refer to those opposed to abortion as antiabortion rather than pro-life, since I disagree with the implication that those not identified as pro-life are against life. Abortion is the removal of a fetus or embryo from the uterus prior to viability, the point at which independent life outside the uterus becomes possible—at the earliest around twenty-three to twenty-four weeks of gestation. Any termination of pregnancy after viability is not an abortion but a labor induction, a hysterotomy (a mini-cesarean delivery) or a pregnancy termination. The usage “late-term abortion” is a misnomer, used by antiabortion activists to give the impression that all abortions performed after the first trimester take place late in pregnancy, that is, in the third trimester. The same is true for the term “partial birth abortion,” coined by antiabortion activists to describe an abortion procedure, intact d&e, sometimes used during the second trimester. “Partial birth abortion” is a political term designed to raise the impression that the procedure is performed moments before term delivery. Finally, the occupant in the uterus—referred to by antiabortion activists incorrectly as a baby, a child, an infant, or a preborn child, among others—is first an embryo, then a fetus.75Close
This book explores the connections between personal experiences, local histories, and larger political developments. Susan Wicklund, who spent much of her life providing abortion care to women in the Midwest and in Montana, was for years harassed by the militant antiabortion group Lambs of Christ. Antiabortion harassment against her culminated in the 1990s during the so-called partial birth abortion debate, when antiabortion propaganda depicted all abortions as taking place at term, “inches before birth.” Wicklund, caught up in worries over her daughter’s safety and fears for her own life, had no time to follow the national debate. She did not even connect her own experience with the procedure—after all, she provided only first trimester abortions. Nevertheless, the debate and propaganda profoundly affected her. Trying to live with the Lambs of Christ, she became politicized, went public with her work and about the harassment she endured, and forged her political beliefs and medical practice out of this experience. Wicklund’s personal story—and her local history—give meaning to the lived experience of abortion care—a story that we usually trace in big politics: legal changes, legislative decisions, federal and state policies concerning women’s reproductive rights. This book is grounded in personal stories and local histories to illustrate the lived consequences of the politics of reproductive rights.
Eisenstadt v. Baird, 405 U.S. 438 (1972); Prescott, Student Bodies, 153.
See https://www.youtube.com/user/EmilyEstherLetts. An Internet search for abortion experience yields a number of YouTube videos in which young women describe their positive abortion experiences. At the same time, Lett’s video also led to postings critiquing her for glorifying the abortion procedure.
See, for instance, http://myabortionmylife.org/; http://www.theabortiondiaries.com/; http://www.prochoiceamerica.org/womens-voices/womens-stories/; and http://theabortiondiarypodcast.com/ (all accessed Mar. 20, 2015).
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