Carole Joffe still remembers the despair in the doctors’ voices and faces when they talked about the women.
The women – or often, girls – were patients, all rushed to emergency rooms in different parts of the country, some claiming to be miscarrying, others concocting back stories – but many severely, sometimes fatally, injured by illegal or self-administered abortion attempts in the years before the 1973 Roe v Wade decision.
The horrific experiences of women pre-Roe have returned to the fore after the revelation this week that the Supreme Court is considering striking down the decision that had protected Americans’ right to seek terminations for nearly 50 years – and raised the question of whether women and girls are set to return to the dark days of secret, dangerous and often fatal procedures.
One doctor saw a woman who’d inserted a catheter into her cervix, poured gasoline into it and “literally cooked the lining of her uterus.” Another treated a woman brought into the ER for a “strangulated hernia,” which turned out to be “a loop of bowel hanging out of her vagina wrapped in newspaper,” the doctor told Prof Joffe, who was researching her 1995 book Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe V. Wade.
The illegal abortionist had perforated the woman’s uterus “and pulled out the bowel with his aborting instruments and he thought it was fetal bowel. She had literally over thirty inches of bowel hanging out of her vagina,” the rescuing doctor told Prof Joffe. Against all odds, the patient lived.
Prof Joffe – who teaches in University of California, San Francisco’s Department of Obstretics, Gynecology & Reproductive Services – particularly recalls the demeanour of an experienced Philadelphia physician who “told me about holding a young woman’s hand as she knew she was dying” of sepsis.
“When he was telling me that, he didn’t cry, but he was on the spectrum,” Prof Joffe, 77, tells The Independent. “He was clearly very emotionally upset, even though I probably talked to him in 1988 and this would have been 20, 25 years earlier.”
It’s been much longer – nearly 60 years – since Dr Curtis Boyd, 85, encountered a patient who came to the ER after a botched illegal abortion; it wasn’t the type of nightmare scenario described by the previous doctors, but he was left horrified by the experience for different reasons.
Dr Boyd, who runs abortion clinics in New Mexico and Texas, was one of the physicians Prof Joffe interviewed for Doctors of Conscience under a pseudonym.
“I had one patient, her cervix was torn up ... so I knew this had been done with instruments,” he tells The Independent. “I knew it had been induced.”
Residents and other staff had been warned that “any induced abortion must be reported, so I reported it, and that was the end of it – but the next thing I know, I get paged to come to the ward, because the police are there with my patient.
“So I go up, I’m standing there, they’re questioning her. They began to really harass her: ‘Who did this? [What’s their] address?’ She didn’t tell them, so [they said] they were going to put her in jail, she could go to prison. She looked over at me and just glared at me. I was like, ’Oh, I understand.’ She was really angry at me.”
In the end, the police did not detain the woman; “they were just threatening and trying to intimidate her,” Dr Boyd says.
“I went back up later to apologise to her [and say] I’m really sorry, I didn’t realise she was going to be treated that way ... and that I would never do it again.”
He never did report another patient and went on to provide abortions himself both before and after it was legalised.
Prof Joffe found the stories relayed by Dr Boyd and others to be “deeply upsetting” – but, as a woman growing up pre-Roe v Wade herself, she wasn’t surprised, given the experiences she’d heard about from many of her contemporaries.
And some elements of her book, almost three decades later, seem deeply prophetic. In her introduction, she referenced not only Roe v Wade but the 1992 Planned Parenthood v Casey decisions and two Supreme Court appointments by abortion rights advocate President Bill Clinton; those developments, she wrote, at the time meant that “abortion – albeit in highly restricted form – will presumably remain legal for the foreseeable future.
“But from a pro-choice perspective, this legal victory may prove to be a hollow one,” she wrote in the 1995 book. “Abortion may remain legal, but for an increasing number of American women, it may well become inaccessible.”
Fast-forward 27 years, and that’s exactly what may soon be happening, according to the Supreme Court memo leaked this week. The draft opinion, written by Justice Samuel Alito, suggests that abortion legislation may be returned to state governments rather than remain federally protected – which would enable states to ban the procedures. Abortion activists worry that women will be completely unable to terminate unwanted pregnancies in Republican states.
Thirteen US states have so-called “trigger bans” in place, which are designed to take effect without Roe.
“In some ways, it’s deja vu all over again,” Prof Joffe tells The Independent, adding: “In other ways, it’s not. In some ways, it’s less disturbing than the period I wrote about – in other ways, more disturbing.”
She says: “Before Roe, illegal abortion was, medically, extremely dangerous ... the doctors themselves acknowledged, even the ‘good guys’ who were ethical and who were well-trained, they knew it was dangerous ... so medically, things were much worse.
“Thinking about what’s going to happen after June, after this decision, it’s going to be much safer; a lot less women will die, a lot less women will be injured,” she says, pointing to medical advancements such as the abortion pill and the fact that pregnant patients will still be able to obtain abortions in states where it will remain legal, though that may present financial and logistical problems for many.
“I have no illusions that some scared, especially younger [patients] like younger teens, will still do dangerous things; they’ll still ask the boyfriend to kick them in the belly, they’ll still ingest herbs that can literally be fatal, but we now have medical abortion pills that are available on the internet,” says Prof Joffe. She notes, however, that the pills are only effective through 11 weeks of pregnancy and “a lot of people get pregnant and don’t know they’re pregnant or can’t deal with it until after that” timeframe.
She says that, “as much as I am devastated by this news, I know that it won’t be the, medically-speaking, horror show that we had before Roe” – but there will be multiple, far-reaching consequences if the court decides on what is implicated in the leaked memo, she says.
“Pre-Roe, [there was] a lot of injury, very little legal surveyance,” she says; few doctors were jailed in the US, but the anti-abortion movement also hadn’t ramped up the way it would after the procedure became legal.
“Fast forward to now, it’s the opposite: There’s going to be a lot less injury; there’s going to be a ton more surveyance” and prosecution of abortion, she says. “We’ve already had women arrested for attempting their own abortions.”
Dr Boyd, who regretted reporting an illegal abortion in the early 1960s, initially was reluctant to perform the procedure while it was outlawed, given the risk to his licence and his freedom.
He was swayed, however, by a particularly insistent Texas teenager from humble beginnings who arrived in his office in a “chicken-feed sack dress” and demanded: “You’ve got to do me an abortion,” he tells The Independent.
He eventually relented and performed the procedure, pushing down the fear of being discovered.
“I tried to suppress it then, because I had to be able to concentrate on my work and do good work, and I had a very large number of patients who came to me,” he says. They were referred by a trusted “underground” network of clergy members.
“But there was that fear – inside of me, deep – there was a constant fear of having a serious complication or even a woman dying,” he said, which would have meant “going to prison for murder – there’s no getting around it.
“There was always that fear, so I had to suppress that in order to do my work. I used meditation to relieve my anxiety and stay centred.”
He didn’t realise the depth of his fear and anxiety, he tells The Independent, until the Roe v Wade decision was announced – on a day he was performing abortions with a trusted team.
He and his nurse, he says, “just grabbed each other and hugged each other, and we were both crying.
“And I said, ‘Oh, thank God, at least it’s over. It’s over’ – and it was just that relief ... we were young, idealistic, we were going to make this a fair and more just world – and we could kind of sometimes, part of the time, put out of our minds the risks we were taking and consequences.
“As I told you, it was deep inside, [and] I knew it when I had that reaction to the announcement of Roe v Wade.”
In the current climate, however, he believes that very few mainstream physicians nowadays will continue performing abortions underground, as he did, if the proposed limitations are brought in – for a variety of reasons.
“I think that not a lot of people will,” he says. “This has to be an individual decision. If you’re going to do it, you have to think – you have to realise – what you’re doing, the risks involved. You need to be prepared to accept those risks and the consequences of them, or else you end up living not only a fearful life but you end up being bitter.”
He adds: “Another reason doctors won’t do it [is that they’ll think] there’s no need to risk going to prison when the woman, she’s just going to have to get to a state where it’s legal. It’s still going to be legal probably in 24 states ... there won’t be that urgency that it’s worth [a doctor] going to prison to do this, I have a feeling.”
That leads back to the problem of access and money, which in turn leads back to the possible rise of unskilled and dangerous underground practitioners.
“I think there still will be some rogue providers who, medically, I would not trust very far – who will let it be known that they will do abortions,” Prof Joffe says, though she believes, as she previously said, that the situation will be far less dangerous than it was before Roe v Wade.
Dr Boyd is still worried.
“We’ll have a large number of states where abortions will be available under various circumstances, but the poorest of women are not going to be able to get there,” he tells The Independent, pointing out that “there’s roundtrip airfare, or you’ve got to have a car or gas money; you may lose your job; you don’t have childcare. The incredible expense of getting there and paying for the abortion, they will not be able to do that.”
All of that “leads to getting abortions done locally” and off the books, he says.
“They will go to somewhere if there’s anyone locally doing it, and they may not be qualified – and so you can expect higher complications.”
On top of that, when there inevitably are complications, he says, women will delay going to the hospital in the states where the procedure is outlawed because they’re afraid – like his patient all those years ago – that they will get in legal trouble.
Prof Joffe says that she and others in the abortion rights movement are also concerned about additional subsets of patients – both pregnant and not pregnant.
“What many of us in this world of abortion provision are concerned about – because this has already been happening in other countries – women with regular, old-fashioned miscarriages are now going to be subject to scrutiny,” she tells The Independent. “I mean, if you show up at an ER and say, ‘I’m having a miscarriage,’ and you’re in [a state banning abortion,] it is completely within the realm of possibility that you’ll be grilled whether or not you took pills – and the police may well be called,” she says.
“One other thing I’m extremely worried about – what’s going to happen to very, very sick pregnant women?”
Before Roe v Wade, many hospitals had “therapeutic abortion committees” to decide whether to allow the procedures in various circumstances, such as threat to a mother’s life or severe illness.
If such a system returns or something similar evolves, Prof Joffe says, “that’s a very subjective thing”.
“My biggest worry is [actually] several,” she tells The Independent, including “a public health crisis; thousands of women will have babies that they are not prepared to take care of; they don’t have the resources; they don’t want to be pregnant; some of them will have various healthcare conditions that make pregnancy not desirable.”
She adds: “We’re going to have children who are unwanted.”
To avoid this, both she and Dr Boyd believe abortion rights activists will create a strong network – this time not underground – to facilitate travel for people with unwanted pregnancies and help with expenses.
The movement “has been very actively planning: How do we get women from so-called ‘hostile’ states to ‘haven’ states?” Prof Joffe tells The Independent.
Even then, however, it will be impossible to help everyone, which circles back to the possibility of risky black market procedures, medical tragedies and death.
“For me, it’s not primarily about the abortion; that’s important, of course,” Dr Boyd tells The Independent, but “the real thing that drives [me] is that ... it’s just an issue which robs women’s rightful place in society [and] equality.”
Women, he says, will be relegated “clearly, heavily, into a second-class-citizen position.
“I just find it really hard to comprehend that, at this stage in our social evolution, we could so blatantly put women back in this position” because it takes “the decision-making away from them, [the ability] to control their lives, make decisions that are best for them, the families they have, the families they hope to have.?
Decades after Roe v Wade, he says, he’d hoped abortion would have been fully integrated into mainstream healthcare, though social, religious and even medical pushback has presented what this week have turned out to be exponentially increasing obstacles.
“I didn’t think this would be the case,” he says. “I thought it would be over long ago.”
This article was amended on 6 May 2022 to state that Dr Curtis Boyd used meditation, and not medication, to help relieve anxiety related to the treatment he offered prior to Roe v Wade.
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