The Great Macy's Fourth of July Abortion Sale: Get 'em while you can! (offer valid only in Mississippi until 7/11/2012)

This is actually a breadline, not a bank run or a premodern Black Friday. But when I thought about it, the breadline matched the vibe of the clinic waiting room better than those. People are there -- with their spouse, mom, kid, infant -- because they really need to be. 

So...

Remember my last post, where I was kinda sick and tired of legislators playing doctor (and not in the sexy way) (but also, is playing doctor actually sexy to anyone?), and I was writing about the last abortion clinic in Mississippi being legislated out of existence, and about Rep. Bubba Carpenter, and how he was talking in what I imagine is a too-bad-so-sad wah-wah voice about how the other side talks way too much about "some poor pitiful women" who might risk their health and lives trying to end their pregnancies by any means available, and I think I might have blacked out shortly after that as an internal defense mechanism?

Yeah, I know: oof. But let's talk about Mississippi some more!

So the bill passed and was signed by the governor and its stipulations include that abortion providers must have hospital admitting privileges -- something Bubba Carpenter noted was notoriously difficult for anyone to obtain, not just abortion providers -- and that means that this last clinic in Mississippi, which has not been able to secure admitting privileges, will have to close. But then, since as Bubba Carpenter noted this law is not trying that hard to be constitutional, a judge stayed the new law until a court hearing planned for July 11 -- giving the clinic a reprieve of, uh, about a week.

And here's something that interests me as an abortioneer.

But it has also created a rush of women from across Mississippi wanting to have abortions. The clinic's three doctors normally perform about 40 abortions a week, but received more than 100 calls in one day last week from women trying to schedule appointments. Two of the doctors live out of state and will fly in to perform abortions this week, said Diane Derzis, the clinic owner.

"What women are hearing is, You may not be able to have an abortion soon," she said. "If you're pregnant and you don’t want to be, you’re thinking, 'By God, I've got to get in there fast.'"

Seems kind of weird, doesn't it? Like a run on the banks, as my arm candy quipped. You'd think that the need for abortion care is pretty much static over the course of a year, since pregnancy can occur in any season and any abortion clinic is the potential provider for at least several million people of reproductive capacity. But demand for services really does seem to have a certain flux to it. While I can't remember hearing of a run on the clinics (though I guess it's not hard to understand), I have noticed other ups and downs and maybe patterns.

I've mentioned before that I had many clients who were able to finally secure their abortion care when their tax refund came back -- and even some who specifically filed early in order to make sure they raised enough money before they reached 12 weeks when the fee would start progressively increasing. Those patients were very resourceful and very on top of it. And I sympathized with their certainty that they made little enough to be owed a refund -- my full-time job qualified me for both a tax refund and assistance from an emergency abortion fund should I ever need it.

But demand also seems to drop on holidays, especially big ones. It's hard to seek an appointment while hosting extended family, driving to grandma's, juggling your parents' or grown children's multiple Thanksgivings after a divorce, entertaining your school-aged kids at home, or arguing with your teenager about sharing the family car over winter break. You don't have as much privacy, time, or energy for taking care of yourself. Shit's hectic.

Then, weeks after a holiday, demand bounces back to levels even higher than before. Phones ring off the hook at the emergency abortion fund, they ring all day although you have multiple phone lines and someone answering every line. Same thing happening at the clinic, which is also jam-packed with people -- you have to bring more chairs into the waiting room -- and clients want to know what is the point of making an appointment if you still have to wait all damn day. (The answer is you struggle with turning people away from care, and wish there was such a thing as walk-in care, but in your state there's a law requiring advance appointments so pregnant people can take time to "cool off" and think hard about their impulsive and flighty decisions. As Sarah Silverman says, maybe they're not as hungry as they think they are.)

I say "weeks" after a holiday but we'd often remark that it seemed to be about four to six weeks after a holiday. Kind of joking, because that's how long it takes from fertilization (four) or last normal menstrual period (six) to the earliest point in pregnancy that most clinics are able to offer abortion care. Kind of not joking, because it really happened. At least three years I noticed that after a December-January lull, we'd have the most insane February and March. That's the time of year that I first became an abortioneer, actually. At first I thought that was just how it was -- that we'd have 100 appointments per day forever. (On the plus side, a lot of those were double-bookings or ambivalent patients who ended up going to another clinic for prenatal or abortion care. We didn't actually check that many patients in per day.)

I could surmise that stereotypically hectic and overburdened times (Thanksgiving/Christmas) or stereotypically romantic times (New Year's/Valentine's) or stereotypically hedonistic times (spring break, New Year's again) lead to unintended pregnancy. And surely the delaying of one's own needs during family-heavy holidays would explain part of the resurgence of appointment requests afterward. But I don't really know and I don't think there's any way to find out on a large scale. It'd be interesting, though, to ask individual women to recount the story of what prompted them to seek abortion care when they did, and why. If only such questions weren't so politically loaded, so likely to suggest there's a right and a wrong answer, maybe we'd hear a lot of honest and interesting stories.

The story of the time I was a dick

Why does she keep shouting ABORTION at me? 

Yesterday our guest blogger Amy mentioned that phone calls about abortion care often sound like this:

"Um...I wanted to know how much it costs?" and "Hi...I'm looking for some information about...abortion?" (spoken as a question, with the word "abortion" issued in a whisper)

And that her responses sometimes sounded like this:

"I would be happy to answer any questions you have about ABORTION! What type of ABORTION do you think you might be interested in having?"

I can totally relate. Who hasn't had this kind of call? It was one of the first patterns I noticed about callers when I started working on the phone lines.

Maybe Amy was more mature or less self-centered than me when she started her clinic work. But for my part, there was a real evolution in how I understood such callers. Initially, I felt frustrated to pick up the phone at my work and hear that the person on the other end of the line couldn't bring themselves to speak about my work. I experienced it as stigmatizing of ME, like they were attempting to distance themselves from my work even as they were asking me to tell them about it.

Sometimes they would ask with words like "terminations" or "D&C" instead of "abortion" -- maybe those words sounded more genteel or more like medicalese.

I'm ashamed to say that, early on, if someone called and said, "Hi, I need to know how much it costs," I would reply, "For what kind of services?" Even though it soon became clear that, if someone was calling about, say, a Pap smear, they simply said "Hi, I need to know how much a Pap smear costs." For a brief period of time, I believed that it was more important for the caller to say the word abortion than to feel comfortable asking about it.

At least that phase ended rather quickly. When a woman called and I heard echoes as she asked me questions, I mentioned her voice was sounding funny, as though she was in a bathroom or something -- and she said yes, she was at work and this was the only private place she could duck into. Duh, me.

Whether because they're not sure they've called the right place, they can't believe they're in this situation, or they can't risk being overheard by a coworker or family member, callers can't always discuss abortion openly and explicitly over the phone.

There will be time for that at their appointment, if they make one, when they meet with the counselor or health educator to express any questions or concerns about their health, the procedure itself, their experiences leading up to the appointment and how they will fare afterward. Usually patients can bring a loved one or support person into the counseling/education session, but a portion is also dedicated to one-on-one time with the staff person, in case the patient has something that might not be easy or safe to express in front of their companion. These sessions can be conducted as part of an abortion appointment, or prior to deciding whether or not to have an abortion. It's dramatically different from a phone call that might by necessity be taking place in public.

So now I know better. I learned to respond to "I need to know how much you charge" with something like, "Sure, I can talk to you about our different fees, but we provide many kinds of care here. Were you asking about a Pap smear, or...an abortion, or...?" If they are asking about an abortion, they normally stop me there and say "Yes, that's it." Easy peasy. It's okay for me to do the talking, if that's what the caller is looking for.

Not that every caller is in this situation! It runs the gamut: on one end is this (or even, as Amy writes, the ones who never call), and on the other end is someone calling to set up their appointment while also ordering dinner for five from the drive-through. But that's a story for another post.

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.

Tell it slant

Emily Dickinson advised, "Tell all the truth, but tell it slant." Tim O'Brien wrote an entire book that might be part fact, part fiction, part ambiguity, but none of it a lie. In my recent quest to speak my truth and speak it from my heart, I realized I was speaking my truth with hyperbole, sarcasm, and humor, but not with my heart.

When I write here, I employ humor to make things easier to me to say and for you to read. I meld my real life with a fake life so that you will know what I am without knowing who I am. I am unequivocally a pro-choice crusader, but my favorite color may or may not be purple.

When I tell client stories, I am well aware that they are not my stories to tell. HIPAA binds me to change details and nuances, and my own ethos binds me to relay the gist without relaying the experience that I may or may not interpret properly anyway.

The stories that clients tell us, anyway, are half truths. I may find out about the abusive boyfriend, and my co-worker may find out about the childhood molestation, and neither of us find out about the past abortion. "I'm fine" can mean both yes and no and maybe. "I'm killing my baby" can be internalized rhetoric or personal conviction or uncertainty about both or neither.

And when I tell clients that they will be OK, I can't guarantee that; I can only hope. When I call them from the waiting room Price is Right-style ("Jane McAbortionpants, come on doooown!"), the silliness covers my annoyance with a long day and my discomfort with clients' discomfort. And then I go home and say that my day was "good" because sometimes that's easier than reliving heartache and frustrations.

Thank you, readers, for hearing our abortion reality, however embellished, or minimized or raw. This is my heart.

Making a statement

Sometimes, I consider whether I would love my job as much as I do if it weren't so controversial, if the mere act of going in to work weren't so badass, if the answer to "What do you do?" weren't guaranteed to make a statement. I can't pretend that loving my job isn't partially a political act. I adore advocating for women, fighting the evil forces of the anti-choicers, and the way I feel when a client expresses her appreciation, and those things wouldn't affect me quite the same way if not for how (inexplicably) volatile choice is.

Don't get it twisted; I'm not in any way thanking the antis for making me excited to go to work. Well, unless that angers them...in that case, I will admit that on a day when I didn't sleep enough and I'm walking through puddles and my hair is looking weird, seeing the protesters outside my clinic inspires me to work harder and longer and better.

But that's the dramatic side, the one that gives me activist cred at fundraisers and boosts my ego. The quieter side is the one that truly sustains me and sustains choice and providers and clinics. If I woke up tomorrow in my dream world of abortion on demand and coffee flowing from my faucet and kittens all over my apartment, I would still leave my cat- and caffeine-filled apartment and go and proudly facilitate abortions and choice and justice. Because it would be the same amazing clients, dedicated staff, and a very much needed service. I believe in choice because of what it is fundamentally, not because of what it's been made into politically. Even if abortion were treated as casually as our society treats a Pap smear, if it bored people at cocktail parties, I would still honor and revere it, and THAT is badass.

I'm quite disappointed at the lack of stock images of women of color. I tried.

You've got mail

Dear Patients,

Maybe I met you years ago or days ago, and maybe I'll meet you tomorrow or years in the future. I hope I made or will make a positive impact on you, but your abortion experience really wasn't or isn't or won't be about me. And that's one of the things I want to say to you. Your abortion is YOURS--your story to tell, your experience to shape. You have no obligation to justify your decision to anyone. You have a right to be informed, even when it means asking uncomfortable questions like, "What happens to the fetus afterward?" You don't need to be sad if you're not, nor do you have to be happy just because you exercised bodily autonomy. We might talk about how we'd like you to be grateful and advocate for others, but my wish is that you will make the choice for you and you will honor yourself and your choice in the best way for YOU. You have every right to be scared, and you also have every right to the safest and most caring healthcare, which is what we want to give you. You are strong enough to do this, whether "this" is having an abortion or not having one. You are allowed to dwell in as many gray areas as you'd like. We, as staff, might bristle when you ask things like, "Are your instruments clean?" but you have a right to wonder and to ask and to use your voice in whatever way you can or want. You do have a voice, but your abortion doesn't have to be a political act, either. You can be selfless or selfish or both at once. You can yell at me or hug me, and I will find some part of you, large or small, to care for. Your privacy is protected and so is your dignity, and we wish for the clinic to be a safe space for you. You might have just one abortion or just fourteen, and there is not a thing wrong with either one. There is nothing wrong with YOU.

Again, this isn't about me. But I want you to know that I don't forget you, and I am so very honored to be a part of your choice, process, justice, and life.

All the best,
Desembarazarme

What I hear you saying is...

Part of the pre-abortion process at my clinic is counseling. Clients talk with a counselor one-on-one to review their medical histories, discuss the details of the procedure, ask questions about the aftercare instructions, and work thorough any lingering doubts or concerns they have. Some clients latch onto this idea and want to use it as an in-depth therapy session for things that really should be handled by a professional, while other clients roll their eyes at the idea and assume that counseling is yet another law with which the clinic must comply, a law created with the assumption that women don’t understand what an abortion is or that every human was once a fetus.

But the majority of the clients welcome the opportunity to talk with someone whose job it is to listen and to be pro-choice. I value it because it gives clinic staff a chance to develop a rapport with a client. (Not to mention the chance to debunk myths about having to slice someone stem to stern to perform an abortion.)

I actually took the counseling portion of the program for granted until I learned that some very compassionate, professional clinics don’t offer counseling to their clients. It could be a trick to save time (clients always complain about how long the process takes) or minimize cost (we ARE in a recession), and it could simply be what has worked and continues to work for individual clinics.

So, readers, I’m curious: If you’re an Abortioneer, does your clinic offer counseling? If you’re a friend of the Abortioneers, would you opt for counseling, given the choice? And if you’ve been a patient, did you have a counseling session? What have your experiences been?

Phone Etiquette

Lately, I've been thinking about how people who call doctors' offices can act strange on the phone. I've had/or my friends have had any of the following situations occur before:

1) Patient who wants an abortion ordering McDonalds while trying to schedule an appointment.
2) Patient screaming at her kid while trying to schedule an abortion (I always cringe whenever this happens).
3) Client's mother screaming at daughter (who needs/wants an abortion) because the daughter was so "stupid to get knocked up!" (Ugh. Also cringe-worthy.)
4) Patient's boyfriend who calls to "make sure she really had her abortion."
5) Patient's driver calling to pick up the patient after her abortion, but refusing to walk inside the clinic to get her.

If I could make a request of people: please don't call us and scream. Please don't scream at us, in our ear, at your child, at your mother, or at your partner when talking to us on the phone. Thanks!

I'm sure you've had crazy phone situations, too. Though sometimes I want to hang up - especially when yelling ensues - I am grateful that people are so different that they keep us on our toes.

What's love got to do with it?

"Sex is painful, but I'm fine."
"He said he'd pull out, but I guess he didn't."
"I don't think I've ever orgasmed."
"I don't really enjoy sex, but I just get through it because that's part of being a woman."
"I told him I was pretty sure I was ovulating, but he didn't listen."
"I have to put the medication IN my vagina?! Which hole is that?"
"He doesn't think it's important to use birth control."

I don't think that a lot of abortion clients are having particularly good sex. At all. I've heard all of the above statements from women I've counseled and my co-workers and I have had meetings about expanding birth control discussions to include questions about sexual side effects since so many women seen hesitant to bring those up if they even recognize them in the first place.

Our clients aren't dumb, and I'm not blaming them for the lack of sexual empowerment I've seen from working at the clinic. But they live in a society that values male sexual satisfaction to the extent that Viagra is lauded as a discovery tantamount to the Polio vaccine (vaccine/autism debate notwithstanding). They live in a society that only refers to vaginas as "down there," and limits related dialog to freshness, which brings right back to the obsession with male sexuality. We all know the axiom that if men could get pregnant, abortion would be a sacrament," and I bet you that if a man experienced pain during sex, a full-scale, multimillion dollar investigation wold be launched.

And that male-centric sexual society is the one that values the cuuuute little baybee fetus and refuses to even acknowledge the enormous amount of women's rights involved in the need for choice and the need for abortion. And sex is about communication and bonding and mutual pleasure (usually about these things. I know it's not 1956.), so if the sex complaints above are any indication, of course the couple is in no position to bring a baby into the relationship. And I'm so glad there's a choice available, but that choice sure doesn't exist in a vacuum. (No pun intended.)

It's an Abortioneer's World...Kinda

I work at an abortion clinic and I have a pregnant friend and a pregnant acquaintance. For what it's worth, one pregnancy was planned, one wasn't, and both are welcome. I can't wait to meet their babies, and I tell them that. I even call a 9-week fetus a baby in the case of the shopkeeper I chat with. It's all about the intention, and even though I can completely visualize what her 9-weeker looks like thanks to my pathology experience, and it sure doesn't look like a baby, I respect that her outcome will be, barring any complications (knock on wood), a full-term baby.

See how I knocked on wood there? After clinic work, which includes D&Cs for miscarriage management and terminations due to fetal anomalies, I can't think of a pregnancy without thinking of what could go wrong. I also can't ask about the gestational age (I do ask the pregnant ladies in my life, "How far along are you? because I know it would be odd to inquire about gestation like I do at the clinic. We try to avoid "How far along are you?" because it implies that a pregnancy will be carried to term.) without envisioning the development I've seen in pathology. I can't visualize the third trimester development because I've never seen that, but I really do feel so fortunate to have gotten such an intimate glimpse of human biology and development. (And no, I don't say to my friend, "Oh! Your baby is about the size of a mango! Have you had an anmiocentesis? Because now is when something might go wrong.")

Working at the clinic isn't just about abortions. I've met the babies of clients who have decided not to terminate and who brought the baby to see us. We also provide care for infertility and we cheer when someone gets pregnant. Several co-workers of mine have been pregnant and bring their kids to work to see all of their aunties. I once told a toddler, "I remember seeing you on your mama's ultrasound around 19 weeks!" Remember the Jennifer Baumgardner book, Abortion and Life? That's my life. Abortion and pregnancy and life and me, and they're all beautiful.

Stock photo because that's just all-round safer.

A surprisingly delicate subject*

Lately I've been spending more shifts in the surgical suite, where I check on patients' wellbeing after their abortions, sterilize instruments, or play some role in the procedure itself. Often that means serving as a "patient advocate" (attending to a woman's emotional and physical experience of the procedure, similar to the role of abortion doulas) or as an interpreter. But I'm also spending more shifts assisting the doctor providing the abortion, and that means seeing lots of vaginas.

Vulvas, to be more exact, of which the vagina is really only a small part. And here's one thing I keep incidentally noticing when I'm on this side of the sheet and stirrups: many women's vulvas are shaved! Not merely trimmed, but all the way de-pubed (whether bald or stubbly).

I don't want to be overly crass. And I'm certainly not judging -- over the years I've gone through many "hairstyles" myself. It's just that I started wondering why it's so common. I came up with a couple of possibilities:

1) That's just a lot of people's preferred habit, and the appointment day is just a day like any other.

2) You've heard that before a surgery, you're supposed to shave the area to be operated on. You figure that might be true of a "surgical" abortion even though you've been told there's no cutting involved. (You can't automatically know that a sterile speculum will be used to hold your vagina open, so that the sterile dilators and cannula don't touch your vulva on their way to your uterus, which is much more sensitive to germs than your vagina or vulva.)

3) A stranger is going to see your vulva, and that makes you anxious about being hairy. So you shave before going for pap smears, and this gyno visit is no different in that respect. You've seen "Knocked Up," and that woman's vulva -- in the middle of giving birth -- was, well, strikingly bald. Actually, how did she pull that off with her theatrically giant belly in the way? If Katherine Heigl's body double (vagina double?) had to be shaved for a delivery scene, it must mean real-life women ought to be trimmed to that aesthetic at a moment's notice, because what if you have to go to the doctor? A shaved vulva is basically the new clean-pair-of-underpants, amirite?


In contemplating these, I found myself really hoping that #3 is not at play, because I'd hate for an appointment that's likely staffed with strangers and already stressful to generate that unnecessary layer of extra anxiety. Note to potential patients: Don't worry! No one here will have a problem with your hair. At least at your abortion, of all places, of all times, I hope you can rest easy with your vulva the way it is.

Unfortunately, I also found myself thinking that my least favorite hypothesis seems like the most plausible.

And with that, we conclude the shoddiest descriptive study ever.


*The hesitation I felt when writing this post did take me by surprise. I blog about abortion, for chrissake! What could be a more delicate subject than that? But take an important personal decision, mix in the "violation of privacy" feeling that many of us get from any brush with the old stirrups and duck-lips, and then bring up pubic hair, which at a minimum probably calls up most people's anxious memories of being twelve years old and wondering if you've got too much, too little, too bushy, too wiry, omfg...And suddenly adult-you can't figure out if this feels weird because you're violating HIPAA (you're not), because you're talking about something dirty (you're not), or because you're acknowledging you saw people's vulvas (well, duh). (Otherwise you'd be doing abortions blindfolded, right?) (PPS, a nurse friend recently told me that standard nursing textbooks instruct to "note hair distribution" during a vaginal exam!)

Anyway -- I promise I wasn't staring; I promise I didn't take mental note of how much you, as an individual patient, grow/trim; and I promise that whatever you personally do with your personal hair is no biggie to me. We'll offer you safe, friendly care no matter what's underneath the sheet. Even if for some reason you've got it painstakingly waxed into an Italian status symbol.

Beyond the First Trimester

Pictured: Misoprostol tablets


Correct me if I'm wrong, but I feel like most people who know what's up know the gist of a first trimester abortion procedure. The cervix is minimally dilated, the doctor inserts a small plastic tube through the cervix and into the uterus, the tube is connected to the aspirator, which creates gentle suction to remove the pregnancy tissue, it takes five minutes, all is well, some cramping and bleeding are normal as the uterus return to a non-pregnant state. Everyone get that?

But the second trimester abortion is more shrouded in secrecy, maybe because it's less socially acceptable or because fewer clinics offer it or because it's less common (most abortions take place in the first trimester). I'm not going to get into why women do have second trimester abortions because it doesn't matter. Jezebel offered a pretty comprehensive explanation a few months ago about the ins and outs of the second tri procedure, so I wanted to offer an overview of the process and technicalities. Again, this is based on my own experiences and my clinic's protocols. Your mileage may vary.

A second trimester abortion is known as a D&E, or a dilation and evacuation procedure, and it takes place over the course of two to three days--that's the dilation process. The evacuation part is only about 10 to 15 minutes. There's still no cutting involved--everything is removed through the cervix, and it's still a minimally-invasive and safe procedure. But since the fetus is more developed, the cervix needs to dilate more to accommodate the instruments and the removal.

There are a few options for opening the cervix, including the use of Misoprostol, a medication that softens and opens the cervix or a clinician inserts small, sterile seaweed sticks called laminaria into the cervix. Sometimes, the client takes an anti-anxiety medication beforehand, and some clinicians use local anesthetic on the cervix before inserting dilators. The insertion is quick and the woman can't feel the laminaria once it's in place. It remains snug in the cervix overnight and it absorbs moisture which gently dilates the cervix to the appropriate amount. A dilating cervix causes cramping, but it's manageable, especially with pain medication and heating pads.

If the woman is measuring later in the second trimester, the doctor might also inject Digoxin, a common heart medication, through her abdomen and into the uterus in order to stop the fetal heart. This usually happens on the first day of the procedure, after the laminaria is inserted. Because the cervix is opening overnight, there's a small risk for miscarriage, so this injection is a preventative and humane measure.

The client usually spends the night near the clinic. Clinics are not equipped with overnight facilities, so the client stays in a hotel or with a friend or with someone like Vegan Vagina. And women leave with lengthy instructions and lists of phone numbers in case of emergency. If all goes well, the client returns to the clinic early in the morning for the procedure, itself. It's performed under general anesthesia or with some type of sedation. The doctor removes the laminaria if it was in place and then removes the fetus using suction and instruments similar to those that are used for a first trimester abortion. the process still doesn't cause any problems with fertility, health, etc. (I cannot say that enough.) It's normal to have more cramping and bleeding than after first trimester procedures because the uterus kind of has further to go back to normal, and the woman is more likely to have increased breast tenderness. But it's safe, it's do-able, and most importantly, it's completely necessary for the freedom and well-being of women. And because we, as providers, spend a few days with women going through the D&E process, women and their families who have entrusted us with their freedom and well-being, it's also special for us. Thank you, women.

(Un)Comfortably Numb

Sometimes when I'm counseling, clients will use the session not only as an opportunity for their questions and fears about surgery, recovery, and choice, but as an opportunity to try to get information about those mysterious other women filling the waiting room. "How far can you do this to?" they ask cryptically, grammatically ambiguously. "How could someone do that?" they continue, pitting their own 6 week abortion against another possibly 23 week abortion. And then I explain choice and circumstances and sometimes they get it, sometimes, they don't. Recently, as I described to the client what to expect, anesthesia-wise, she blurted, "Why would someone want to be awake for this?! That just sounds awful. Knock me out, please."

My opinion doesn't matter, but in the interest of full disclosure and biases, if I were to have an abortion, I'd go with general anesthesia, no contest. Sure, I'd like to know exactly what's going on, partially so that I would better be able to inform clients. But I know myself, and I would be way too tense, way too uncomfortable for my own good, for the doctor's good, for anyone's good, just because that's how I am at any medical appointment. A first-trimester (6-12 weeks) abortion takes five minutes, tops. With general anesthesia, the patient is monitored by a nurse-anesthetist the whole time -- all of ten minutes. The anesthesia travels into the body through an IV in the arm -- no masks, no machines doing the breathing for you. Yes, the medications include Propofol, the notorious Michael Jackson drug, but it's not something the client takes home with her, and if there's anything slightly sketchy in her medical history, we have a long discussion about the risks and benefits of general anesthesia. But generally (no pun intended), a clinic's anesthesia is less intense than what's used for wisdom tooth removals. Clients love it because they don't feel nor remember anything, and they wake up relatively quickly. They hate it because they give up some control, they can't eat or drink anything, they need to have a driver, and because anesthesia is scary. Most of the clients at my clinic choose to be asleep.

Being awake, on the other hand, involves BEING AWAKE. Some clinics offer sedation or narcotics, but my clinic is not one of those. And some clinics offer ONLY local anesthesia -- my clinic is not one of those, either, but it illustrates just how manageable being awake can be. It isn't for everyone. But again, it's a five minute procedure, and because there's no cutting ("surgery" is a misnomer), only minimal dilation of the cervix, being awake is do-able. And in that case, the doctor administers a local anesthetic like Lidocaine via injection into the cervix. The sensitive cervix is numbed, but numbing the entire uterus just isn't possible, and the uterus is going to cramp during an abortion -- it's just the nature of the muscle. Woman have described the cramping as stronger than menstrual cramps, but not as intense as childbirth. And based on my hand-holding experience, those evaluations seem to be pretty accurate. Some women carry on conversations with a few winces, and others nearly break my hand as they scream. Some of the clients choose to be awake because they value being present in their abortion experience. It gives them some power. Others opt for a few minutes of discomfort over the nausea they historically experienced post-general anesthesia. And some just don't see the whole procedure as that big of a deal -- why be asleep for a simple, safe gynecological procedure? Other women would rather be out of it, but with no one to accompany them to the clinic, local is the only choice. And some women opt to be awake just because it's less expensive, which breaks my heart. And speaking of heartbreak, let's not even get into the mothers of teens who insist that their daughters need to be awake so that they can be punished for getting pregnant.

I'm intrigued by this aspect of abortion -- a choice within a choice, as it were. And as a fellow Abortioneer pointed out, the choice of being asleep versus awake varies widely from clinic to clinic, city to city. Readers, what are your experiences with clients' preferences? Have you, yourself, made that particular decision? Does your clinic offer anesthesia experiences other than what I described above?

And stay tuned -- in the coming weeks, we'll also explore things like abortion by pill and why some women love it, some women hate it, some providers heart it, some eschew it. And we take requests: What abortion mysteries or intricacies would you like to know more about?

Service

Thank you to deliverance, who joins us for another guest-blogging stint this Thursday morning!
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"Serving, like healing, is mutual. There is no debt. I am as served as the person I am serving. When I help I have a feeling of satisfaction. When I serve I have a feeling of gratitude."
-Dr. Rachel Remen


Abortion work is draining.

Most service professions are, but the stubbornly looming abortion debate is inescapable.

Every once in awhile, unknowingly, my patients provide some much needed fresh air.

Last week I was assigned the role of Patient Support. This job includes assisting doctors in procedure rooms, ensuring equipment is clean, but most importantly, making sure patients have someone to help them through an abortion procedure.

Unlike many outpatient surgeries, abortion comes with a myriad of emotions. It is different than a typical surgery, because there are intangible parts of a person which need attention and care.

Many women walk in the door having absorbed persistent rhetoric meant to make a common medical procedure much harder than it should be—"Abortion is murder," "'Mommy,' I love you," "You are heartless."

Having the opportunity to make an abortion experience comfortable and safe for a woman reminds me of why I am in abortion care.

A patient affected me last week by gushing, "Thank you, you are so kind. Thank you for being there for me." Another held my hand until her procedure was finished. Another told me that our clinic was lucky to have me, and offered a complimentary pass to her yoga studio.

Abortion work may be draining, but patients are endlessly gracious.

They serve me just as much as I serve them.