Abortion Stigma Affects Doctors' Training And Choices

By Sandra G. Boodman
Special to The Washington Post
Tuesday, September 1, 2009

When Devin Miller, leader of the abortion rights group Medical Students for Choice at Virginia Commonwealth University, heard about the slaying of George Tiller, a Kansas physician who performed late abortions, she "took a step back" to ponder her future. The second-year student plans to become an obstetrician-gynecologist or family physician and expects she would sometimes terminate pregnancies. But the May 31 death of Tiller, who was shot in the head at church, allegedly by an antiabortion activist, has left the 23-year-old deeply shaken.

"I think for a lot of students right now, it's very hard to be confronted with the constant negative energy and constant fighting" that surrounds abortion, said Miller, who grew up in a southern Virginia city where antiabortion sentiment runs high. Just learning about the procedure at the state school in Richmond can be a challenge. Medical students who want training in the procedure usually must arrange an elective "externship" in Northern Virginia, she said.

Thirty-six years after it was legalized, abortion remains one of the most common procedures in American medicine -- and the most stigmatized. In 2005, 1.2 million abortions were performed, dwarfing the number of appendectomies (341,000), gallbladder removals (398,000) and hysterectomies (575,000). "There's this feeling it's dirty and should not be spoken about," said Miller. "It's hard to be brave and seek everything out yourself."

Her soul-searching underscores a long-standing problem some reproductive health experts say is worsening: a shortage of physicians willing to perform abortions. Although nearly one-third of American women will have an abortion by age 45, according to the Guttmacher Institute, a respected New York research organization, the number of abortion providers dropped from 2,908 in 1982 to 1,787 in 2005. Eighty-seven percent of counties in the United States and 31 percent of metropolitan areas have no abortion services.

Even before Tiller's death, and before abortion became entangled in the rancorous debate about health-care reform (antiabortion groups say it will expand abortion, a claim reform advocates say is false), the American College of Obstetricians and Gynecologists warned that "the availability of abortion services is in jeopardy."

In a January report, an ACOG committee found that one-third of American medical schools provide a formal lecture about abortion. Unlike most clinical experiences, which are integrated into the curriculum, abortion training is often optional, leaving time-starved trainees to learn about the procedure on their own. Medical school administrators contacted for this story declined to discuss abortion education.

In 1996, concerned about the lack of training in OB-GYN residencies, the Accreditation Council for Graduate Medical Education required that "induced abortion must be part of residency training" but allowed residents or programs with moral or religious objections to opt out; all residents must learn how to manage abortion complications. A 2008 study found that among OB-GYN residents who said they wanted to provide abortions once they started practicing, about half actually did.

"Our doctors are graying and are not being replaced," said Susan Hill, president of the National Women's Health Foundation in Raleigh, N.C., which operates abortion clinics in largely rural states, including Georgia, Indiana and Mississippi, where only one doctor in the state performs pregnancy terminations.

"We need young doctors and we need them badly," said Hill, whose clinics have been firebombed or set ablaze 18 times. "The situation is pretty grave, pretty dire."

A report in the journal Contraception last year found that 66 percent of physicians performing second-trimester abortions are more than 50 years old. Unlike their younger counterparts, many older doctors cite searing memories of days before the procedure was legal, when they cared for women who tried to perform abortions on themselves using lye or coat hangers.

Scaring Young Doctors

The shortage of doctors willing to perform abortions "has huge public health implications," said Lois Backus, executive director of the Philadelphia-based Medical Students for Choice, founded in 1993 after the murder of a Florida doctor -- the first of eight people killed in clinic-related violence in the past 16 years. Because about half of pregnancies are unintended, most doctors will at some point treat women confronting a choice about pregnancy, Backus said.

Although such care was once common, few physicians currently offer abortion services in their offices, fearing they will be targeted by abortion foes. Instead, Backus said, many tell patients facing unwanted pregnancy to look in the Yellow Pages or call Planned Parenthood.

The problem, said Backus, who formerly headed Planned Parenthood of Philadelphia, is that some Planned Parenthood clinics don't do abortions, while others have long waits for appointments.

Researchers report this month in the journal Obstetrics and Gynecology that mifepristone, the early-abortion drug approved for use up to 63 days after a woman becomes pregnant, has not significantly expanded access to abortion, in part because relatively few family physicians prescribe it. Hill said that some women don't learn they are pregnant early enough to use the drug. Others have trouble raising money for a procedure. The average price paid for a first-trimester abortion performed with local anesthesia outside a hospital in 2005 was $413, according to the Guttmacher Institute.

At the time of his death, Tiller, 67, was one of three physicians in the United States known to perform late abortions -- the 1 percent of procedures after the 20th week that are typically limited to women with life-threatening problems or severe fetal anomalies.

Like Tiller, the two remaining physicians, LeRoy Carhart, 68, of Bellevue, Neb., and Warren Hern, 70, of Boulder, Colo., live and work under siege conditions. Both have received protection from federal marshals because of numerous death threats. Last week, a 70-year-old Spokane, Wash., man was arrested on federal charges in connection with a June 23 threat to kill members of Hern's family that was phoned in to his Boulder clinic. An attorney for the man, Donald Hertz, has said he intends to plead not guilty to the charge.

Veteran antiabortion activist Randall Terry says he is gratified that Tiller's killing and recent media interviews given by Hern, who drives a bulletproof car and works behind four layers of bulletproof glass, have succeeded in scaring young doctors who might contemplate providing abortions.

Terry, who lives in Northern Virginia, and other activists have long maintained that it is not necessary to make abortion illegal if obtaining it becomes impossible. That's why they support plastering neighborhoods with "Wanted" posters featuring the photographs of physicians who perform abortions, creating Web sites that track them and their spouses, and picketing their homes or offices, activities they describe as protected free speech. Targeted doctors call it harassment.

"We want them tormented," Terry said, describing how he recently advised an activist to disrupt a presentation on abortion at a Kentucky medical school. "If they become a child killer, we will make their lives miserable. It will be so costly for them socially and emotionally."

"What young person is going to want that lifestyle?" he asked.

Kristan Hawkins, 24, executive director of Students for Life of America, an Arlington-based group that includes chapters on 20 medical school campuses, said her group's goal is to drive abortion out of medical school and residency training altogether.

"They have a very old population of abortionists and need to recruit new ones," Hawkins said. "I think there's a generational split." Younger doctors, she added, are less supportive of abortion.

Hill agrees that a generation gap exists but said it reflects experience, not opposition to abortion.

Most doctors have never seen the results of botched back-alley abortions that typically wound up in hospital emergency rooms before 1973, when the Supreme Court legalized abortion.

"I'm 62, and physicians younger than me do not remember these women," said North Carolina obstetrician-gynecologist David Grimes, former chief of abortion surveillance for the Centers for Disease Control and Prevention. Grimes recalled taking care of a woman with a red rubber catheter protruding from her cervix and a fever of 106 degrees. "You see something like that as a young doctor, you don't forget it."

Hill agreed. "Younger doctors," she said, "have never known abortion to be illegal or even threatened."

Generation Gap

The same cannot be said of Joseph Booker.

Booker, 65, a board-certified OB-GYN, has described himself as "Yankee, pro-choice, outspoken, and black . . . a bad combination in Mississippi."

For 18 months in the mid-1990s he was guarded round-the-clock by U.S. marshals. Today he is the only doctor who performs abortions in Mississippi, which has one of the nation's most restrictive abortion laws, requiring, among other things, that a woman make two visits to a clinic 24 hours apart before receiving an abortion. Booker's practice is the target of frequent protests; he sometimes wears a bulletproof vest to work.

His Jackson clinic sits across the street from the state's medical school, where abortion is not taught. Many of the women he sees are from the Mississippi Delta, the poorest region in the nation's poorest state. His youngest patient was 11.

Who will take his place if he retires?

"That's a good question," he replied.

In Jacksonville, N.C., 72-year-old OB-GYN Takey Crist isn't sure of the answer, either. Crist has not faced the harassment experienced by Booker; no one has contacted his neighbors to ask if they knew a "baby killer" lived in their midst. He began performing abortions in 1973, the memory of treating University of North Carolina students who had undergone illegal abortions in neighboring South Carolina fresh in his mind. Among them, he said, was an 18-year-old freshman forced to undergo a hysterectomy to treat a life-threatening infection. "It left an impression on me," said Crist, the only doctor in Jacksonville who performs abortions.

In Crist's view, the marginalization of abortion largely reflects the jitteriness of medical school administrators who have bowed to political pressure from abortion opponents and state lawmakers who provide funding.

But the absence of younger doctors willing to replace him, he fears, indicates their "lack of intestinal fortitude to say, 'This is what I believe is right.' "

Megan Evans, 26, a third-year medical student at George Washington University Medical School, says she plans to be in the vanguard of the next generation of doctors providing abortions.

President-elect of Medical Students for Choice, which has groups on more than 120 U.S. medical campuses, Evans said that the GWU chapter is one of the most active in the country and that administrators at her school are supportive.

Students at GWU receive four hours of instruction on family planning and related topics, including an hour-long lecture on abortion.

"In comparison to other schools, that's a lot," said Evans, who has a master's degree in public health and worked at an inner-city health center in Boston that provided abortions. "I think some of us feel there should be more."

"The goal," Evans said, "is to make 'abortion' not a dirty word."

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