In a new commentary published in the journal Women & Health, reproductive health specialist and researcher Dr. Carole Joffe, PhD, writes about the stigma surrounding abortion providers and their marginalization in relation to other physicians, discussing such issues in the context of both historical developments and recent increases in abortion restrictions throughout the United States. She concludes by highlighting the importance of differentiating between stigma, marginality and controversy, and calls for greater involvement of the medical community in supporting abortion rights.
“[A]bortion provision has been highly regulated in the United States, and abortion providers have been subjected to unacceptable levels of violence and harassment — with some researchers referring to this violence as an ‘epidemic,'” writes Dr. Joffe, a professor at the Bixby Center for Global Reproductive Health at the University of California-San Francisco.
She cites several examples of this harassment and regulatory restriction, including the deaths of several members of the “abortion-providing community,” congressional interference in the practice of abortion medicine and the “[h]undreds of ‘TRAP laws'” adopted by states that are “widely acknowledged to have little to do with safety and everything to do with forcing clinics to close,” among other antiabortion-rights legislation (TRAP stands for the “Targeted Regulation of Abortion Providers”).
Roots of Abortion Stigma
According to Dr. Joffe, the stigmatization that comes with being an abortion provider likely originates from the era before Roe v. Wade, “when illegal abortions were plentiful and supplied by a wide range of providers.” She writes that although some of the physicians who provided abortions during this time “were trained and competent” doctors “who risked imprisonment and loss of license” for performing the procedures, others “were far less competent, and often unethical — the infamous ‘back alley abortionists’ or ‘butchers’ as they have been named.”
These incompetent providers “became the face of abortion providers” because their patients were “disproportionately seen in hospital emergency rooms,” Dr. Joffe argues, adding that as a result, obstetrics and gynecology departments were very hesitant to “normaliz[e] abortion care within their hospitals.”
According to Dr. Joffe, this hesitation was “one of several factors that led to freestanding clinics becoming the major site for abortion services in the U.S.” However, in turn, this development led to some positive results, such as lowering abortion care costs compared with hospital-provided care and allowing clinics “to hire nursing and counseling staff who — unlike many hospital nurses — support women’s abortion decisions,” Dr. Joffe writes, adding that clinics have also “amassed an impressive safety record — according to researchers, … about 14 times safer than childbirth.”
However, Dr. Joffe writes that this development also made abortion more detached from mainstream medicine and more susceptible to restrictive legislation and harassment from abortion opponents. In response to these restrictions, providers “have expended huge amounts of resources on legal fees to try to challenge various restrictions, or failing that, to figure out how to best comply with them without compromising patient care,” she writes. Meanwhile, providers concerned about ongoing harassment have installed security features such as “bullet-proof glass, video cameras, and so on” both at their homes and their offices, Dr. Joffe adds.
Role of Medical Community
Dr. Joffe asks, “But what about the response from elsewhere in medicine?” She notes that others in the medical community during the years since Roe have offered “little overt defense” of abortion providers, likely because of “a combination of still-lingering memories of the pre-Roe era, wariness about the potential of retribution from the anti-abortion movements, and perhaps most significantly, the medical profession’s longstanding aversion to controversy of any kind.”
However, Dr. Joffe acknowledges that “[i]n recent times … as the number of restrictions on abortion has multiplied, and grown ever more extreme, more individual physicians and medical organizations have protested this treatment.” For example, “Marcia Angell, the former editor of the New England Journal of Medicine and currently a professor at Harvard Medical School, and Michael Greene, a professor of obstetrics and gynecology, also at Harvard,” recently penned a “blistering essay in USA Today” protesting physicians’ comparatively silent reaction to this “‘legal assault.'”
Further, she notes that “other physician groups, such as medical societies in Pennsylvania, Wisconsin, Texas, and Arizona, have begun to speak out against abortion restrictions,” as has the American College of Obstetricians and Gynecologists, which, historically, maintained “relative silence about abortion.”
“The path to overcoming the stigma facing abortion providers is not clear-cut,” Dr. Joffe writes. According to Dr. Joffe, the establishment of the “privately-funded Fellowship in Family Planning and Abortion for post-residency ob-gyns interested in specialized training” has helped to normalize the procedure within mainstream medicine. Still, abortions will likely “continue to take place in freestanding clinics, and the problems discussed here will remain” for the foreseeable future.
Although there are no “easy answers — either practical or theoretical to the dilemmas facing abortion providers,” Dr. Joffe argues that “[s]tudents of stigma need to push further to distinguish analytically between ‘stigma’ and two related concepts that are often applied to abortion providers: ‘marginality’ and ‘controversy.'” She writes, “Pushing further on these distinctions is a fruitful way for our work to proceed.”
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