Dispatches from the Abortion Wars: Talking to Carole Joffe

There is no area of medicine except for abortion in which secrecy, constant politicization of a medical procedure, and even fear and shame about medical work is par for the course. While many women seeking abortions find their access to this legal procedure diminishing, abortion providers also face onerous obstacles to providing care, and increasing danger in doing so.

In Carole Joffe's new book Dispatches from the Abortion Wars: The Costs of Fanaticism to Doctors, Patients, and the Rest of Us, she often uses pseudonyms to protect the privacy of doctors and clinic workers she interviewed. As she details, many physicians are actively discouraged from incorporating abortion into other forms of medical practice, and the choice to perform abortions in some areas may make practicing any other type of medicine virtually impossible.

Similarly, the risks and complications of performing abortions in isolation prevent many doctors from ever doing them. Knowing that they will not be backed by a supportive community and may be targeted by fanatic activists, they may simply choose to opt out of providing care they believe to be necessary and ethically unquestionable. In these and many other ways, Joffe's comprehensive overview and history of the past 35 years details the very real and often urgent implications for women when health care providers-doctors, nurses, pharmacists-are targeted by violent extremists.

Throughout the book, Joffe explores such divergent but related topics as advances in fetal medicine and widespread use of ultrasounds, which became popular in the 1980s and have affected many peoples' relationship with the fetus; how anti-abortion activists' tactics play on other people's guilt of possessing sexual freedom, and how abortion practitioners who feared the police pre-Roe now fear protestors instead. She details the specific issues facing teens and the double standard that is applied when young people can be judged as too immature to make the decision to choose to terminate a pregnancy without parental consent, yet are judged fit to have a child nonetheless. Joffe also investigates the relationship between economic hardship, childbirth, and reproductive justice and writes passionately about how strictly pro-abortion advocates must make space for the reproductive justice movement to flourish if it is going to promote the health and rights of all women.

It is telling that the most extreme violence against abortion providers takes place during pro-choice presidencies, and perhaps most salient for many readers looking ahead, Joffe pays respectful homage to Dr. George Tiller, who provided essential care in the most extreme circumstances of incest, rape, and complications late in pregnancy when so many others could or would not. Joffe ends her detailed account by looking at a future in which new leaders must come forward to take up Tiller's-and our collective-cause.

Joffe, also an RH Reality Check contributor, recently spoke to me about her timely, if controversial, book.

Q: In Dispatches from the Abortion Wars, you explain the importance of the role of the deputy assistant secretary for population affairs (DAPSA) in the Department of Health and Human Services, who is in charge of federal family planning programs and oversees Title X of the Public Health Service Act. However, former DAPSA appointees have lacked substantial professional experience in family planning and have been appointed based more on their moral stances than credentials. Why is such an important role so frequently overlooked in the debates about federal laws regarding reproductive freedom?

Well, this role is overlooked by most Americans, but carefully looked at by advocates on both sides of the abortion debate. In general, it is fair to say that most Americans are apolitical, not especially interested in government, and know relatively little about the workings of the federal bureaucracy.

Q: You write about how many ob-gyn practitioners lack basic abortion training. Do you think the medical community's larger lack of understanding of abortion procedures trickles down the population at large? How do you think this affects women's general knowledge of abortion technology and options?

Even though most ob-gyns don't perform abortions, I do not believe that they don't understand what abortion involves -- many ob-gyns, for example, perform procedures (e.g. d and c's) that are similar to abortions. I believe the American public's misunderstandings of abortion procedures stem directly from the very effective propaganda campaigns waged for years by the anti-abortion movement. In particular, the so-called "partial-birth abortion" campaign led many people to believe that most abortions took place very late in pregnancy and involved near-term fetuses. In fact, only 1 percent of all abortions take place after 21 weeks.

Q: You explain some of the ways primary care physicians have incorporated abortion into their practices. Can you talk about some of the hurdles these doctors face?

They face the problem of obtaining malpractice coverage. They face the problem of having supportive colleagues, who share their commitments to abortion care, and who will provide coverage for them if they have to be out of town. In spite of these obstacles, some primary care doctors-and where it is legally permitted, nurse practitioners, midwives and physician assistants-have successfully incorporated abortion care into their practices.

Q: Why isn't the general public more aware of the everyday threat of violence and dangers abortion providers can face?

I think the general public is aware of the violence that providers face. I think the public is less aware of the other obstacles -- such as targeted regulations against abortion providers ("trap laws"), lack of collegial support, malpractice problems, etc -- that face abortion providers. I am quite convinced that the overwhelming majority of the public is very much against the violence faced by providers, especially when it results in murder, as we saw recently with the assassination of Dr. Tiller in Kansas. But though this violence brings sympathy for the providers (and disgust with the extremists), I also think the legacy of this violence is to mark abortion as something that is always controversial, and that many people therefore simply wish to avoid thinking about (until/unless they need one!).

Q: With the enormous costs in terms of time and resources spent on security, police backup, cleanup and HAZMAT for clinics under the threat and reality of violent actions-including anthrax threats, acid attacks, and arson -- why are anti-abortion activists not considered domestic terrorists?

Excellent question! Certainly by the abortion rights community, they are thought of in this way -- when the violence first started to pick up in the late 1980s, I recall advocates going to the administrations of Ronald Reagan and the first President Bush and saying exactly that -- these are domestic terrorists... but not until the Clinton administration, and the first killings of providers in the 1990s, was the problem taken seriously. Clinton signed the "face act" -- "freedom of access to clinic entrances" -- which made it a federal crime to interfere with someone trying to enter a clinic. This did reduce the then quite common blockades and sieges of clinics. And after Dr. Bart Slepian of Buffalo was killed in 1998, then-Attorney General Janet Reno convened a task force within the Justice Department on clinic violence. I do believe that the Dept. of Justice, especially under this administration, takes violence against providers seriously. The problem of course is with implementation of laws at the local levels. For whatever reasons, the local FBI and the local police in Kansas did not respond to reports of Scott Roeder (the murderer of Dr. Tiller) having vandalized a Kansas clinic the day before the Tiller murder, even though Roeder's license plate number was reported to these authorities.

Q: What effect do you think the recession is having on women's access to abortions? How much more limited are poor women now than they were previously?

There are widespread reports of more women needing reproductive health services -- both contraception and abortions -- and not being able to afford them. The various funds that help poor women pay for abortions (35 states do not allow use of Medicaid funds for this purpose) report that they are running out of money, because the requests have escalated. Our access to data on how many abortions are taking place is always lagging by a few years -- but I suspect that this period of recession will ultimately be revealed to be one in which the number of both unintended pregnancies and abortions rose.

Q: How will a significantly restricted universal healthcare bill affect low-income women who seek abortions?

Well at this moment, it is not clear there will be any kind of healthcare bill, and it almost certainly will not be universal, to my great disappointment. From the start, it was clear that the best the abortion rights movement could hope for was the status quo -- that is, as the Capps Amendment (named for Rep. Lois Capps of California) put it, the bill would be abortion neutral, leaving in place the Hyde Amendment, which prohibits the use of public funding for poor women. But both the Stupak Amendment in the House, and the Nelson "compromise" in the Senate, would make the abortion situation worse-ultimately resulting, as health policy scholars from George Washington University concluded, in a situation in which insurance plans which now offer abortion coverage, would cease to do so -- making it harder to obtain such insurance, even with private funds.