Current Affairs

The Obstacle Course Facing Those Seeking Abortions

Abortion could just be treated as normal healthcare. But it isn’t, and as reproductive rights expert Carole Joffe explains, when women seek abortions, they face an absurd and cruel array of obstacles.

Carole Joffe is one of the foremost experts in reproductive rights in America. Michalle Goldberg of the New York Times has said that “nobody knows more about reproductive rights than Carole Joffe.” A professor in the Advancing New Standards in Reproductive Health Program in the Department of Obstetrics, Gynecology, and Reproductive Services at UC San Francisco, her most recent book is Obstacle Course: the Everyday Struggle to Get an Abortion in America, co-authored with David S. Cohen. Joffe is a recipient of a Lifetime Achievement Award from the Society for Family Planning and the Abortion Care Network.

Joffe recently joined Current Affairs editor in chief Nathan J. Robinson on the Current Affairs podcast, as part of a series of interviews on abortion rights in America. The interview transcript has been lightly edited for grammar and clarity. 

Robinson

A lot of abortion discourse focuses on law and policy changes, such as time limits and different restrictions. But over the course of your career, you have focused on how these legal and policy changes actually affect people on the ground, zeroing in on the real world of women and doctors and abortion counselors and families to talk about what it actually means to have various restrictions. Your book Obstacle Course is about what it is actually like for women to try to get an abortion. So maybe we could start with: what don’t people understand about what is left out of the dialogue around abortion that, from your interviews and your research, you really see on the ground?

Joffe    

Well, let me start here. One out of four women are expected at some point in their life between the ages of 15 and 45 to have an abortion. Two things flow from that. Three out of four women don’t. And, more to the point, people don’t talk about their abortions. There’s a lot of stigma. So the extraordinary difficulty is that people—I will use people and women in this interview interchangeably—people don’t realize how extraordinarily difficult it can be. People also don’t realize the incredible toll that it takes on abortion providers, in many cases, to provide the service given the legal harassment and the physical harassment, and so forth. All of which is to say it’s a little bit different now as we are approaching what possibly may be the end of Roe vs. Wade. In general, as you point out, people don’t really talk about the realities of what it means to have to get an abortion. I’ll give you an example. I’ve studied this for many years. But it was not until my co-author and I did interviews for our last book, that one of the people we talked to talked about a patient who had sold the family dog so she could help pay for the abortion. It’s that kind of detail that has been missing.

Robinson    

When I was 19 years old, I worked at a Planned Parenthood clinic for a summer, and one of my jobs was to book abortion appointments for women, and I had to get them to take a questionnaire if they couldn’t pay for it. And I had to go through this process so that if they answered the questions correctly, they would get a subsidy. It wasn’t till I did that, that I understood the problem with means-testing things, because you’re forcing people to disclose parts of their life in order to get access to this medical procedure. I have a memory that stays with me. I talked to a woman whose house had just burned down. And she needed an abortion because her house had burned down and she obviously could not afford to have a child at that moment in her life. But she also didn’t want to revisit it—unearthing this stuff just so she could get this necessary medical procedure paid for, even though the subsidy program was quite generous if you were under a certain income threshold. But even the questionnaire was this obnoxious, difficult burden. It’s something that I didn’t notice until I actually went to work in the clinic. 

Joffe    

Outside of the abortion world we as a society are dealing with that very issue with the reconciliation bill now being discussed in Congress. Progressives want the programs to be universal, and the Joe Manchins of the world want it only targeted toward the poor. What we know from years of looking at social policy—well beyond abortion—is that when programs are universal, not means-tested, they’re usually better. And with respect to abortion, 17 states actually allow Medicaid to pay for abortions. Now Medicaid, of course, is means-tested. But at least if you’re in a Medicaid state, you automatically get your abortion paid for. You don’t have to go through the kind of interview that you had to do with the people you spoke to. 

Robinson   

The book is called Obstacle Course, and in it you discuss the many different kinds of obstacles. One of the major ones is paying for it. When you actually focus in on the stories of people who are trying to find the money somewhere to pay for their abortion procedures, as the clock is ticking, you realize that unintended pregnancies are such an inherently stressful part of a person’s life. And then added on top of that is the question of whether they’re going to be able to come up with the money in time.

Joffe  

That’s right. But what I found out when we did the interviews for this last book—I started doing this work around abortion in the 70s, so I’ve been looking at it over time—was that one thing that has occurred is that the pool of people getting abortions has been getting poorer and poorer. That’s in part because there’s better contraception available now. But contraception is expensive. It costs $1,000 to have the latest version of LARC, or long-acting reversible contraception [Editors’ note: LARC also includes implants], such as an IUD, or intrauterine device. It is very effective and very cost-effective because it lasts 10 years. But poor people don’t have $1,000 to pay upfront. And it’s not just paying for the abortion. It’s paying for travel. A lot of travel goes on now. It will be even more so should Roe vs. Wade be overturned, which is quite likely. You pay for travel and you lose wages. Many states have waiting periods, so you have to drive maybe 500 miles to the nearest clinic. In Texas, which of course now has almost no abortions, even when they had them, you come one day, but you have to come again the next day. Some states have 72 hour waiting periods. Utah, for example. So you’re talking two nights of hotel and lost wages and childcare. 60% of abortion patients already have children.

Robinson   

Yes. People know that there are obstacles in the abstract. Reading your book, one finds out a lot more about what that actually means. You talk about how difficult it is when people need childcare, the clinic is far away, and you have stories of people sleeping in the parking lot of clinics. And this affects mostly poor women, and also mostly women of color, as you point out. There are things that you don’t have yourself, but maybe you have a family member or a friend who could help you. That’s another person that they have to talk to about their abortion. So there’s this additional burden of stress and discomfort.

Joffe   

Yeah. Let’s back up. In general, poor people have more difficulties accessing healthcare than people who aren’t poor. But the real kicker about abortion is the stigma. If, for example, in rural areas, there’s not always readily available healthcare, sometimes you need to drive a long distance. That’s true. But you can ask your parents, your boyfriend, your friend, can you drive me tomorrow to such and such place? I need an ultrasound because of my kidney stone. It’s a very different kettle of fish when you have to assess, who can I tell? Who can I ask to drive me to get an abortion? One key theme of our book is something we call abortion exceptionalism. It refers both to legal and personal issues. Legally, abortion is treated very differently from other medical procedures of comparable complexity—or lack of complexity in the case of abortion. But we have extended this concept to other issues as well. Abortion exceptionalism, for example, means it’s very difficult to ask other people to help you unless they are very trusted.

Robinson  

Yeah. Having worked in an abortion clinic, I had to drive through a crowd of protesters to get to work. But there are things in the book that still shocked me. I knew about certain things, but I didn’t know about—you open with this story about one of these crisis pregnancy centers, basically a fake abortion clinic built next to the actual abortion clinic, hoping to get women to go into this fake clinic where they basically lie to people and say, oh, yes, we’ve been expecting you, and then they give them all this propaganda. The ruthlessness of abortion opponents in waging war! This is not an obstacle course arising naturally. There is a very, very committed movement dedicated to throwing as many obstacles in people’s way as possible.

Joffe   

Yeah, the crisis pregnancy centers are a real problem. Like you said, the pattern has been, whenever possible, to buy the building or buy the lot next to an abortion clinic and have a very similar name. An abortion clinic will be called, let’s say, Women’s Health Services. So the crisis pregnancy will call itself, Women’s Health Clinic. How are patients supposed to know the difference when they drive up? People from the crisis pregnancy center wave them over. And what I learned, too, was that there are thousands of these crisis centers. One sees crisis centers far more far more than abortion clinics at this point. A number of red states, including Texas, give thousands and thousands of public dollars to these crisis pregnancy centers, which are often run by religious groups. And they take the money. None of these red states publicly fund abortion, but they take the money away from family planning programs [to give to crisis centers]. So instead of going to a clinic and getting contraception, you now go to a crisis pregnancy center where you get pep talks about how not only is abortion bad, but they also sell this contraception.

Robinson    

One of the important points about some of the obstacles that are thrown in women’s way is that some of them don’t actually really succeed in deterring or changing women’s minds. But what they do succeed in doing is making sure that any woman who has an abortion is going to have a more stressful, unpleasant, or traumatizing experience. You talk about the states that require showing the patient an ultrasound even if they don’t want to see the ultrasound. The same is true with a lot of the protesters, right? I remember, in my experience working at the abortion clinic, that very few people were turned away by the protesters or didn’t go because they had to wade through a crowd of protesters. But certainly when they came in, they were deeply agitated, and so the protesters do succeed in making sure that women who have abortions feel the stigma.

Joffe    

You’re absolutely right about that. However, I do want to point out that the abortion providing community—the doctors, the counselors, the clinic managers, the clinic staff, the medical assistants—try very, very hard to counteract this. As a medical sociologist, I find very often that other medical settings are impersonal. But abortion has been under such attack so that, paradoxically, those who want to work in this field are obviously a very self-selective bunch of people. I have seen extraordinary acts of compassion, of calming the patients. In one project I did last summer, after this book was out, I interviewed abortion workers during COVID, looking at what is was like to provide the service during COVID. I found all kinds of interesting innovations. But I remember several doctors, at different interviews, told me that one of the hardest parts during COVID was after the procedure. They would normally go hug the patient, or, in an appropriate way, physically comfort them, and they couldn’t do that anymore. I think that gives you a window into the kinds of compensations that abortion clinic staff make in response to the screaming and the yelling that bombards their clinic.

Robinson    

One of the points that you raised in the book is that abortion providers want to make sure that the women who come in actually want to go through with the procedure. There’s this idea that the clinics need to be forced, by law, to make sure to do all these things that make sure that the decision is not going to be regretted—the waiting periods and so forth. But what you point out is that these legal measures don’t actually succeed in that regard. Certainly waiting periods succeed in making sure that every woman who has an abortion in that state experiences horrible anxiety and tedium. But waiting periods don’t have much to do with informed choices. These providers are already very committed to making sure that people make informed choices.

Joffe   

That’s true. Several doctors told us that they had nightmares that they did an abortion on somebody who didn’t really want one. I remember one clinic director telling me, we always say to patients, “there’s no do over.” Now, most people who show up in an abortion clinic have—to use social science jargon—a very high decisional certainty. This has been documented. Some of my colleagues at UCSF have actually done a study in which they interviewed abortion patients versus breast cancer patients, and I forgot the other category. But after the procedure, they asked them, do you feel you made the right decision? And abortion patients came up very, very high. So most come to a clinic knowing exactly what they want, but not everybody. I have talked to the clinic workforce, who tell me that they tell some patients, “you don’t seem ready.” For example, in some clinics people are asked to fill out questionnaires. It’s called, needs assessment. One of the questions is “Do you think you’re committing murder by having an abortion?” If somebody checks, yes, I think I’m a murderer, or I think I’m committing murder, they’re going to talk to the clinic director or the counselor, who will say, if you really think you’re committing murder, you’re not gonna feel okay about this, right? Is this really what you want to do? You have other options, right? So, yes. In a small number of cases, the clinic takes a proactive step of making sure people really are doing what they want to do, because it’s not about being hard. For some women, abortion is just a routine procedure. For other people, it is hard. And that’s not a counter indication. A lot of things we do in life are hard, but they’re the right thing. This is trying to weed out those people who will have deeply, deeply conflicted feelings afterwards, perhaps for many, many years. This is who the clinics are trying to weed out. And again, it’s a very small number.

Robinson   

One of the key points about waiting periods imposed by law is that they are explicitly overriding doctors’ judgments about what their patients need, because any doctor who felt that a waiting period was necessary could say to a patient, “Well, I won’t treat you for 24 to 48 hours,” that would be a doctor’s judgment, in a world in which there was no legal requirement. But the law says, “We don’t trust doctors to make judgments about what is good for their patients. So we’re going to impose what we think of as sound medical judgment.” Again, obviously, most legislators aren’t doctors. And in some cases, one of the incredible things that you point out in the book is that in some cases, it actually mandates for providers to tell lies to patients, to say things that they as doctors believe are untrue or misleading and that will scare people and give them a false impression of medical science.

Joffe 

Yeah. This is shocking. You can’t make this stuff up. In many U.S. states, there’s a state mandated script. You have to tell the patient that she’s at higher risk for breast cancer—not true. She’s at higher risk for suicide—not true. She won’t be able to have children when she wants to—not true. So this is a horrible bind for health professionals. If health ethics means anything, it means you don’t lie to your patients. That’s a no-brainer. So they try to find workarounds. The state of Louisiana, for example, has said that, “I must tell you x, y, and z, however, I don’t actually believe it.” Patients who come to clinic are not necessarily well versed in abortion politics. They don’t understand the larger abortion war in this society. So some of the providers we talked to said that patients asked them, “well, why are you telling me this? Why are you making me freak out about breast cancer that my mother died from?” So that’s been going on so long, it’s become normalized. It’s really a shocking thing. Again, Nathan, I would raise the issue of abortion exceptionalism.

Robinson    

What other domains—

Joffe   

When you go to have your broken arm in a cast? 

Robinson  

“I’m sorry, I have to read you this thing that says, you know, your broken arm may cause all of these things it doesn’t actually cause.” I actually wrote an article about the Supreme Court’s inconsistency on the question of compelled speech, because the Supreme Court often takes a very negative view of what’s called compelled speech. On the First Amendment, the government making you say things is obviously inherently extremely coercive. So they say that the government making you pay union dues is coerced speech. But this is a case in which you have the most coercive speech imaginable, which is that you are telling a doctor that they have to say a thing that they believe to be untrue. It’s explicit authoritarianism. It’s the government telling you what you have to say. As you say, it’s normalized. We don’t realize how weird and horrifying and invasive that is.

Joffe   

Well, Nathan, it gets even worse. We talk about this in the book. Doctors are compelled to say things that are not true. Crisis pregnancy centers say things that are not true all the time. They say you’ll die from an abortion, you will never have children again, you’ll go to hell, etc. And the state of California–which is a very liberal state–actually tried to put a stop to this. They tried to make crisis pregnancy centers at least acknowledge that all their statements weren’t true. And the state of California lost in court. It was a Supreme Court case. And the Supreme Court said, well, it doesn’t really matter what they say, because–we can compel speech in a healthcare situation, but since they’re not really healthcare, they can say whatever the hell they want.

Robinson  

It’s extraordinary. There has been a really, really ruthless effort in the recent Texas abortion law–quite a clever and insidious way of building this giant labyrinth of obstacles. As you mentioned, you’ve been studying this for decades. You’ve seen the changes that have occurred. My impression is that it is harder today than it has been in a long time to get an abortion. Even before what we anticipate will be the overturning of Roe vs. Wade, there has been a real significant increase in these obstacles, thanks to the conservative movement. Is that the case, that the right has been succeeding in a way they haven’t for a while?

Joffe    

Yeah. We can really go back to the 2010 election. Obama won in 2008, setting off within conservative circles deep, deep rage and resentment. We all remember the backlash against his healthcare thing. We remember the rise of the Tea Party, the 2010 elections. And to put it in the plainest terms, a lot of people in America were not happy that a Black man was president of the United States. And that’s the simplest way we can put it. So the 2010 elections. Normally, the president in power–his party loses seats in the midterms. But the 2010 midterms saw huge Republican gains at the state house level. Republican governors were elected in state houses that had been more or less divided between Democrats and Republicans. So now we have many more Republicans. And I should say that the states are where the action is with respect to regulating abortion. I mean, bracketing what the Supreme Court, of course, will do next year. So after 2010, we had a huge influx of restrictions which have continued to this day. 2021 is not over. And we’ve already had more restrictions than ever before. I mean, there’s somewhere between around 1,600-1,800—we don’t have the latest figures tabulated yet–but somewhere between 1,500-2,000 state-level restrictions have been passed and implemented. So abortion is regulated to an unbelievable level, which has led–big surprise–to a number of clinics closing, which of course makes abortion even harder. So yeah, it really is that midterm election of 2010.

Robinson   

You point out that 90% of counties in the United States don’t have an abortion provider. So there are the large distances that people have to travel. And I think one point that I do want to return to is the class divide here, or the way that every restriction necessarily falls hardest on poor women, and especially women of color. You cite in the book the excellent work of Michelle Oberman—her book Her Body, Our Laws looks at El Salvador, where abortions are really heavily restricted. What happens is that rich women are able to travel to places where abortion is legal. If you have the means, abortion often remains accessible. But the criminalization–actually throwing people in jail, and all of the various hardships for abortion–always fall the hardest on people who have jobs, people who have children. You mentioned that 60% of people that have abortions already have children. All of this falls the hardest on the people for whom the hardships are the most difficult.

Joffe   

That’s actually correct. Just to state the facts for your listeners: 50% of abortion patients in the U.S. live below the federal poverty line, which is very low to begin with. Another 25% live just above it. So the face of the abortion patient today is a very poor woman who is disproportionately likely to be a woman of color. And I’m glad you mentioned my friend and colleague Michelle Oberman’s work because it’s very chilling. She studied El Salvador, where women suspected of having an abortion are thrown in jail. Abortion is entirely illegal in El Salvador. Women who are suspected of trying to self-abort or having an illegal abortion are jailed. But women who have regular miscarriages are often thrown in jail because sometimes you can’t really tell the difference. A woman is pregnant and starts bleeding. Either she’s having a miscarriage or this miscarriage was induced. I invited Michelle to give a talk at UCSF a year or so ago. And as she was talking, we were all thinking: is this what’s going to happen here?

Robinson

Right.

Joffe

There’s been a lot of talk now in the media of what will happen if Roe goes. A big talking point of very well meaning people is that we will go back to the bad old days when women died. It’s probably not true. Here’s the situation before Roe. In one of my earlier books on abortion I did document how many women were killed, how many were injured, because there were very crude methods of abortion that took place outside of regular healthcare facilities. But there wasn’t actually that much legal surveillance. Women were not put in jail. Some abortion providers were put in jail, but not many. And it’s not a big surprise. We didn’t have the same highly organized anti-abortion movement we have today. Now fast forward to the present. Let’s say abortion becomes illegal in the United States, or at least in half the states, which will probably happen if we overturn Roe. A lot of women will no doubt attempt something we call in the book, self-managed abortion. But then the quote unquote good news relative to what happened before is getting abortion medication off the internet. In fact, it’s very safe. It’s already going on. Women in Texas are–I heard some data the other week that women in Texas are contacting a group called Aid Access, which is based in the Netherlands. They take a medical history, and if you’re an appropriate candidate, they send you the pills [to have a medical abortion]. So the quote unquote good news is that we won’t have thousands of women dying, or being injured like we had before Roe. There will be some. These pills only work up to 10 or 11 weeks [of gestation]. And anyway, it’s not a cure all. But it will make the situation much safer. We won’t have the same coat hangers that we truly did before. But the kicker is, we will have much more legal surveillance. Some women have already been arrested for attempting their own abortion and have been put in prison. Nothing like what professor Oberman is describing in El Salvador. But similar. So the fear I have of the post Roe era is that we will have a lot of arrests. We’ll have arrests of people who are attempting their own abortion, which is illegal in this country. It is not legal to do your own abortion. We may have some arrests of medical personnel who attempt to help them. Texas law is a very chilling blueprint for the future.

Robinson    

They’re coming up with other things beyond arrest, like allowing these private lawsuits where you can basically extort money from people if you find out that they’ve been complicit in any way. A really important point is that with criminalization, everything you ban is enforced by violence. And usually it is enforced against people with the least means, the people who can’t afford lawyers, people who can’t afford to hide from the state. So we have a really, really brutal world where the state is monitoring and policing us. One final thing I want to ask you: other than obviously participating in the political fight to protect abortion rights, which is critical–other than that, are there things that people can do that are useful, for example, contributing to abortion funds or providing transportation? For the average concerned person who believes in abortion rights, what can they do? Donate to Planned Parenthood? What are the most vital things that we need from ordinary people in the abortion fight right now?

Joffe  

Well, I’m glad you asked that. The most important things are exactly what you just said. One thing that became very clear to me as my co-author and I were researching this book—and I really didn’t understand it, till we did this research—is how extraordinarily important volunteers and advocates are. Again, it’s abortion exceptionalism. Most branches of healthcare are not dependent on the network of kind-hearted Samaritans who are willing to drive people, who are willing to watch their kids while they have their procedure. I mean, it is really extraordinary, the extent to which abortion in this country is dependent on this network of volunteers who escort people to clinics. I don’t know if you had escorts when you worked for Planned Parenthood, but many clinics have escorts who literally shield the patient by holding a tarp over her head, so she doesn’t have to see the people screeching at her and calling her murderer and holding signs saying she’s gonna go to hell. I was deeply, deeply moved when I heard these stories.

We tell a story in the book of a woman in her late 60s, who went on a three-day odyssey with this woman she had never met before, because the community where the woman was supposed to get an abortion couldn’t do the procedure because the woman was too far along. And she had a very complicated health history. So this woman drove her from the South to Washington, D.C. And then in D.C. the clinic couldn’t deal with her. So they drove to New York, where she finally got her abortion. Then they drove home through a blinding thunderstorm. I mean, this level of decency just blew my mind. I still have to ask the question, you know, “Is this a way to do healthcare?” What if this particular patient with this particular problem who lives in the state with only one clinic that only performed abortions up to a certain number of weeks—and she lives in a city that also has a state-of-the-art university hospital—why didn’t she get her abortion right in that hospital? And what happens to patients where there’s not such a kind-hearted Samaritan? So I am both very moved by this volunteerism and at the same time frustrated that that’s how healthcare has to be done in this area of healthcare.

Robinson   

It’s like when you see the supposedly inspiring GoFundMe campaigns for people’s healthcare. Oh, it’s so lovely. It’s so inspiring to see all these people come together and you think, but it shouldn’t have to be that way. Chapter Nine of your book is called “An Alternative Vision.” And in some ways it’s funny that you call it this “alternative vision”—as if it’s this utopia, because the subtitle is “abortion as normal healthcare”—it’s this grand vision of treating this medical procedure as…a medical procedure. It’s sad that we are so far from abortion just being treated as healthcare. And even then, in the U.S., healthcare is so inaccessible, and so unfair that even if abortion were on the level of other healthcare in this country, it can still be costly and it can still be inaccessible to people. Well, Professor Carole Joffe, the book is called Obstacle Course: The Everyday Struggle to Get an Abortion in America, co-authored with David S. Cohen and out from the University of California Press. Thank you so much for talking to me. This was really illuminating.

Joffe 

Well, thank you very much. 

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