Guest post: Telling my patients "No"

Happy Friday! Please warmly welcome Candid Cannula, a fellow abortioneer who's graciously joined us for a guest post this morning. I loved reading about her counseling dilemma -- one that we all grapple with, I think -- and hope you will too.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~


“I hope this is the right thing to do,” my patient – let’s call her Nicole – said right off the bat, instantly setting off warning bells. I asked her to elaborate, and her next sentence did nothing to alleviate my concerns: “Well, I’m basically being forced to do this.”

Those two sentences told me all I thought I needed to know, and I was sure that Nicole was not going to be seen today. But I pressed further, asking her all the standard questions to get a better picture of her situation. How had she felt when she first found out she was pregnant? Who had she told? Who was forcing her to be there, and in what way? Had she talked to anyone who was supportive? Had she considered continuing the pregnancy? How did she think she would feel after an abortion?

My role as an abortion counselor has two distinct parts: providing informed consent for abortion procedures, risks, aftercare instructions and contraceptive options; and discussing patients’ decisions to terminate their pregnancies, ensuring that they are confident it is the right choice for them and that they are not being coerced. I have the awe-inspiring right to turn patients away if I feel the latter criteria are unfulfilled, and it is that right that I struggle with when faced with patients like Nicole.

Her story came out in bits and pieces as we continued to talk: like so many of my patients, she had always considered herself to be against abortion and never imagined that she would wind up across from me in this counseling room. She did not think she would cope well after the procedure and she was struggling with whether it was the “right” thing for her to do. At twenty-one, she was a few years removed from legal childhood yet still dependent on her parents, and she said that they were the ones making her terminate the pregnancy. “My parents will kick me out if I have a baby,” she told me. “I’ll be homeless. I won’t have anywhere to go.”

What would you do if your parents were supportive of you either way?

“Honestly,” she said wearily, “I wouldn’t be sitting here right now.”

Nicole was not going to have a procedure that day. I was sure of it. But when I brought up the idea of her leaving, her tune changed.

“No,” she said urgently. “I have to do this.”

You told me you’re being forced. You told me you don’t want to have an abortion. We can’t see you when you’ve told me those things.

“I’m being forced, but I have to do this. I don’t WANT to do this, but I HAVE to. You don’t understand! It’s my decision too. I came here for an abortion, and I have to have an abortion.”

Nicole, what you’ve told me worries me. We find that women cope best after an abortion when they’ve been able to come to terms with it as their decision. Take some more time. The procedure, the cost won’t change between now and next week. Come back next week if you decide this is the right thing for you. We’ll still be here.

“NO!” she exclaimed. “I planned for this today. I can’t come back next week. Nothing’s going to change! You don’t understand, I don’t HAVE a choice. Yeah, I’m going to feel awful afterwards, and yeah, I’ll probably regret it in a way, but it’ll be worse otherwise – I have to have an abortion today!”

I spent a very long time with Nicole gathering the pieces of her story, asking the same questions, asking different questions, offering her resources to be able to continue the pregnancy, alternately trying to convince her to reschedule her appointment and feeling terribly conflicted about whether that was the right thing to do. I had little doubt that she would end up having an abortion, but maybe she could be in a better place with more time to own the decision. Or maybe another week would only create additional obstacles and difficulty, needlessly complicating her life further.

Where does the patient’s constitutional right to choose an abortion intersect with the counselor’s responsibility to screen and refuse service due to perceived ambivalence or coercion? What do ambivalence and coercion mean for women who lack the emotional or financial support to continue a pregnancy they may otherwise have welcomed? I came to feel that Nicole’s claim of being forced to be there was her way of coping with needing an abortion so that she didn’t lose her family and her home. She may have made a different decision if her family supported her either way, but the reality was that they didn’t, and she wanted to keep them in her life more than she wanted to continue the pregnancy. Many women are “forced” to have an abortion by various life circumstances; does it matter whether those circumstances are other people or faceless considerations like financial constraints, age, or health problems?

I’ve turned abortion patients away who have returned a week or two later, grateful for the extra time to think about the decision and better equipped to cope afterwards. I know that sometimes, it truly is better to wait when ambivalence is detected; patients can’t change their mind after the procedure. But I struggle with exercising my right to turn patients away when they protest. How do I know which patients will truly benefit from it? Doesn’t the patient ultimately know what’s best for her? Why should it be my right to deny a patient the service she insists on accessing?

Nicole had her procedure that day. Like many of my patients, I imagine no pregnancy outcome would have been positive for her. Many patients will never feel 100% confident or at peace with the decision to have an abortion. But no one would have subjected her to an assessment of ambivalence or coercion in order to continue the pregnancy, and that’s one thing that makes abortioneering such a uniquely challenging kind of work. In the counseling room, it’s often a delicate balancing act: trusting the patient to know what’s best for her, and stepping in when I judge that she is simply not ready to take the step that day.

Sunday Douchebaggery Interlude

Take a gander at this shit:

"The billboard depicts an Alamogordo businessman, [Greg] Fultz, 35, holding what appears to the outline of a baby in his arms as he is looking down at it. Next to the picture, in large print, is the statement, 'This Would Have Been A Picture Of My 2-month Old Baby If The Mother Had Decided To Not KILL Our Child!'"

Last week the woman targeted by this billboard brought suit against Mister Douchebag, on the grounds that he's violating her privacy and causing emotional distress. The judge ruled in her favor, ordering the billboard to be removed and granting the plaintiff an order of protection. Thank goodness.

Further gross details and aspects:

A) As Greg "Douchebag" Fultz admits in the rest of his letter, he is "not sure" that his ex actually had an abortion! He doesn't have proof so is guessing. The plaintiff says she miscarried.

B) Of course, whether or not she had an abortion remains HER business alone, anyhow! We don't need to explore her medical history to determine whether she did or did not "deserve" this.

C) Aside from the violation of privacy, to me this also sounded like a violation of the Freedom of Access to Clinic Entrances (FACE) Act, which prohibits intimidation to prevent people from receiving or providing reproductive health services. Unfortunately, it's not that straightforward; it turns out the language of the law forbids the use of "force, threat of force or physical obstruction" -- so, although I'd argue that this could constitute intimidation with a chilling effect on care-seeking ("If I have an abortion my manipulative douche of an ex may put up a billboard about me, like what happened to that woman in New Mexico"), a judge might not agree. But I still wonder about all the things that happen when women have good reason to fear stigma and public excoriation; one woman who survived the dangerous care at Kermit Gosnell's illegal practice (but not without lasting injury) said that she initially headed to Planned Parenthood but turned around when she saw the protesters.

D) Bonus grossness! Mr. Douchebag is 35; the plaintiff is 20. Twenty. Twenty years old! Jesus Christ, that adds a whole OTHER layer of slimy sleazy selfishness to this guy's actions. As though they didn't already sound enough like intimidation and punishment for not doing what he wanted, on top of that he's nearly twice her age and she's still at practically the beginning of her life, and HE's the one who feels robbed? Because he didn't have the right to decide how the rest of her young life was going to go?

Indeed he does feel robbed. In statements to newspapers and to the New Mexico legislature, he says:

"Women have all the power when it comes to pregnancy. The men get no say when a woman wants to go and have an abortion without the say of the father. I believe that is wrong because men are 50 percent of the result of the pregnancy."

and

"I'd like to get a bill created in honor of my baby (Baby Fultz) for all fathers. My idea is to get a bill introduced that gives biological fathers equal rights as to the welfare and decisions being made of the unborn child with exceptions to those of rape and incest and other means of illegal fatherhood."

Of course, the fact that a spermatozoon and an ovum contribute equal numbers of chromosomes doesn't really mean that "men are 50 percent of the result of the pregnancy." That's not how it works; I've never seen a male partner carrying and feeding a fetus for 4.5 months. Simpleton's math aside, I do honestly want to know, exactly what would he consider "equal rights" to a decision about abortion? If one partner (or ex-partner) decides in favor of ending the pregnancy and the other doesn't, what should happen? How do you make that a 50/50 decision?

EDIT: Further information highlights just how much this abortion-billboard stunt is part and parcel of Mr. Douchebag's manipulative, abusive strategy. The billboard reads "Created for N.A.N.I. (National Association of Needed Information"; turns out Nani is his target's first name. He abused his then-wife and has harassed and stalked her and other exes; he created a website named after his ex where he publicized her contact information; he published gross comments and "jokes" about extreme violence toward women and toward his ex in particular; he may or may not have been lying about always wanting a child, as there are allegedly court documents concerning his child-support deadbeatery. Can't say I'm shocked, as divulging private and socially-stigmatized information is a common weapon in the abuser's arsenal; but I sure as hell remain grossed out.

Surviving partner violence isn't as simple as they make it sound

We were working with a patient living through extreme domestic violence. There was some concern that she might also be experiencing verbal abuse during the appointment itself. The security guard was asked to stay alert to the situation. Under their breath, the nurses were venting fantasies of retributive violence against the perpetrator. The counseling session was long -- such sessions invariably include attempts to verify that the patient is making as free a choice as she possibly can, discussions about involving the police, explanation of what resources exist that could support a patient (and any children) in getting away from the perpetrator.

All too often, the counseling sessions also include a heartbreaking resignation by both parties that today is not the day that things will change. We've talked (and rambled) about partner violence before, and there are lots of informative reference materials online, so I know you know about the insanely cruel catch-22 of trying to escape violence and stay safe and not go homeless or hungry. A lot of times, no counselor (including one at a DV crisis center or a specialized police unit) is in a position to "convince" someone to leave their abuser. In these times, no matter how much you've tried it will probably feel like you haven't done enough to help.

And sometimes a patient is terribly unhappy with the idea of having an abortion, but never wanted to become pregnant in the first place and had little or no choice in it. I think about this every time I hear people oppose legal abortion on the basis that "most" women are "coerced" into choosing abortion. This twists a lot of situations into one word, when actually "I don't want to but feel I have to" can mean so many different things -- including "I don't want to, but my experience tells me I'll be in greater danger if I don't, and promises of support from the system won't make a difference." Whether the abuser wants her to have an abortion or doesn't want her to have an abortion is ultimately immaterial to whether we, the abortioneers she seeks out, act on the woman's own decision to have or not have an abortion. (Certain people seem to think that if a woman weighs the situation and decides to have an abortion, and this is also what her abuser wants to happen, then we should cut off her reproductive rights to spite his face. No, the punishment for violent partners isn't an unwanted baby! It's jail time.)

It's really draining to hear outsiders say things like "So your solution is that we should have legal abortion instead of fix the system to support women?" Duh, no. Why are such people always assuming you can EITHER support addressing systemic problems OR support assisting someone who has an immediate problem and faces limited possible approaches? Total false dichotomy. I favor doing both of the above, because both are needed! How is that difficult to grasp?

The patient wasn't happy about having an abortion, but she was firm in her decision. She wasn't happy with her abuser, but not confident that she and her kids would be able to survive if she left him, either. Despite our staff's efforts, this was not the day that she could decide to find a safer life.

If you know someone is abusing children, in many cases reporting is mandated and there are channels for it and the kids get "taken away" (sometimes out of the frying pan and into the fire, sadly) and they may gain state protection in the form of an undisclosed placement location or something like that. If you know someone is abusing an adult, that isn't usually the case. She cried in the recovery room and everyone was worried and angry but we had to discharge her into the care of the person who was hurting her, because she's an adult and that's what she told us to do. It sucked. 

Close your eyes and imagine something for me

welcome to your new home

What if you moved to another country and had no family there, and your first language was one that very few people in your new home had even heard of, and you spoke very little of theirs? You might be relieved and happy to find someone who shared your mother tongue and your host country's language, someone who could help you navigate this new place as well as be a friend who understood where you came from.

You might start dating this person, move in with him, end up relying on him in most aspects of your life. He might be a lot older than you, take advantage of your dependence, control your access to food or transportation or a phone, and refuse to use birth control. 

What if you got pregnant? What if you got pregnant and had always looked forward to having children and this person who had final say in your life was not a fan of the idea? And what if you couldn't get your own job or lease or even typical social services -- shelter, healthcare, food for an infant -- because your immigration status wasn't clear? What would you do? 

You might decide that, as much as you'd rather have a child, the only feasible course of action is to seek an abortion, just like he is telling you. You might have to rely on him to translate during the counseling session, and there's really no point trying to say how you really feel, because he already knows it, and he won't translate it to the counselor, and anyway what you'd rather do doesn't change what you must do. 

After the abortion you might try to spill your guts, in spurts, and using a combination of elementary vocabulary and charades, to the various staff in the recovery room. Unfortunately, if you talked to me, I might have a really hard time understanding the full extent of your situation, and try to comfort you with tissues and talk about the hope of having a child when you're in better circumstances -- not realizing that the road to better circumstances isn't visible from here. (It's a lot harder for me to write about this failure to listen well than to read J's story of a failure in his early days as an aid worker: why?) But I'd notice that you kept saying you didn't feel strong enough to get dressed and be discharged yet, even though your vital signs were normal three times in a row. 

If you talked to my more perceptive colleague, she might try to ask you if you had "somewhere else to go" -- but you don't know anyone or anyplace other than this man. She might call in a counselor and make a bunch of phone calls to informal assistance resources, trying in vain to find someone who spoke the right language. The three of you might make a plan to have you come back in a few days for "a check-up" and hope that this guy at least respects medical orders and will give you another ride to the clinic. 

All of this, to our regret, would happen after the abortion that you wished you didn't have to have, because while antis are lately fixated on stopping "coerced" abortions, they are apparently completely clueless about the forces and circumstances that actually make women have abortions they wish they didn't have to have. When language barriers don't prevent women and girls from telling us what's in their heart, when immigration laws don't leave the most vulnerable with nowhere to turn, when men don't take the opportunity to take advantage, when families don't make their daughters believe that can't possibly come home pregnant, (you fill in the blank): that's when women will only have the abortions they want. 

Ways To Not Understand "Choice," or Patriots don't get pregnant

A 'C'? A 'C'? I got a 'C' on my coathanger sculpture? How could anyone get a 'C' in coathanger sculpture?


(who doesn't like a little humorous misapplication of a classic cartoon line?)


I can never tell if it's more frustrating or funny to realize I'm talking to someone who thinks pro-choicers support coerced abortion. It happens about as often as I venture into anti world -- which means, depending on how patient/masochistic I'm feeling. The thing that seems obvious to me is, "chosen" is like the opposite of "coerced," so you'd think pro-choice might suggest...anti-coercion.

The questions (they are usually questions, though I'm not sure if they're earnest or intended as a-ha! traps) are things like "What about that woman whose husband tricked her into taking the abortion pill" or "What about the woman whose parents threw her in the trunk of the car and drove her to an abortion clinic" or "What about the woman who was told by an evil genie that she had to either get an abortion or be sold into a harem on the lost island empire of Atlantis". #1 and #2 are specific examples of questions I've been asked, and they refer to actual events that have occurred. #1 and #2 are also called 'assault' and are punishable by prison time.

The other main twisting of "choice" that I hear a lot always feels like a punch in the gut, and I do hear this one a lot because our culture is full of slut-shaming, not just in anti world. People who think they're cute pipe up with this semantic tour-de-force that goes something like, "I believe in a woman's right to choose -- she could've CHOSEN not to spread her legs!" Ah, clever. The idea being, if you're dumb enough to CHOOSE to have sex, and then get pregnant from it, you fucked up and deserve to stay pregnant. I mean, we don't let speeding drivers seek treatment for their broken limbs, do we? Fifty-five means fifty-five! So if a woman finds herself pregnant in a situation where she can't stay pregnant, even though she knew from the get-go that getting pregnant would really suck, then she's an idiot and pretty much earned what she gets, which is to take her life into her hands, nearly kick the bucket, be refused emergency care from her own doctor, be told she's crazy by another doctor and also lose her job.

Say what? Well, you should read this: Military Abortion Ban: Female Soldiers Not Protected by Constitution They Defend.

“You hear these legends of coat-hanger abortions,” a 26-year-old former Marine sergeant told me recently, “but there are no coat hangers in Iraq. I looked.”

Synopsis, though I hope you'll just go read the article: active-duty military who become pregnant are discriminated against and those who seek abortions get it even worse. So they're trapped, and might do the next logical thing: the Russian roulette of DIY. (You can also see this sergeant interviewed in the documentary The Coat Hanger Project.)

And right on the heels of that article comes word of a recent policy on the ground in northern Iraq that pretty much codifies what's been going on all along: forced unsafe abortion for female servicemembers. U.S. personnel in Iraq could face court-martial for getting pregnant:

The policy, which went into effect Nov. 4, makes it possible to face punishment, including a court-martial and jail time, for becoming pregnant or impregnating a servicemember, according to the wording of the policy and confirmations from Army officials. ... The policy also applies to married couples who are at war together.

To recap, your beloved Department of Defense:
(1) forbids medical personnel to provide abortion care except in cases of rape or life endangerment;
(2) refuses to cover the cost of abortion care except in cases of life endangerment only;
(3) by its very nature stations its personnel in places it has utterly ravaged so that, if they ever did have safe specialty health services, well they don't anymore.
...so far so good, right? The DoD is doing an awesome job preventing abortion -- hell, they've made it practically impossible!

(4) engages in under-the-table discrimination against pregnant soldiers and, now, outright criminalizes pregnancy.

So now what? Well, like I said, now you take your life into your hands, nearly kick the bucket, get refused emergency care from your own doctor, get told you're crazy by another doctor and also lose your job. It's that or jail (or maybe both). You don't have much choice.


This blog is primarily for us to share from our perspective in the field, so you might wonder if now I've accidentally digressed into extrapolation or punditry. But I could tell you a surprising (to me) number of stories from work involving women in the military, or married into the military, needing an abortion as a result of their connection to the military and then having a hard time obtaining one as a result of their connection to the military. They're not all the same situation as that of "Amy" in the RD interview -- there's a lot of different ways to get screwed over for serving one's country while uterused. Maybe this will be a two-part post, so next time (around the new year) I can share some of those with you. But you don't need to hear them all to see there's an unjust price for being a woman in uniform.