GENDER OCTOBER 7, 2013
Early in her medical career, Dr. Elizabeth Miller counseled a 15-year-old girl who was afraid of getting pregnant but wasn’t using birth control. She gave the patient some routine advice: Talk to your boyfriend about using condoms. “Two weeks later, she was in our ER with a severe head injury, having been pushed down the stairs by her boyfriend,” says Miller, now the chief of adolescent medicine in Pittsburgh’s children’s hospital. It hadn’t occurred to Miller that the teenager wasn’t using condoms because her controlling boyfriend wouldn’t allow it. “I’ve dedicated the last 13 years to trying to fix the mistake that I made,” she says.
About one in three women in the United States experience violence in a romantic relationship at some point, and victims of abuse are between four and six times more likely than other women to become pregnant when they don’t want to be. One ordinary pill has become an important option for women trapped between a pregnancy they didn’t intend and a partner who threatens to hurt them if they end it: RU-486, the most common of several drugs prescribed for “medication abortion.” The physical process it induces looks exactly like a miscarriage, creating an out for women who can’t openly defy their partners’ wishes. Rebecca Levenson, who teaches reproductive health care providers about partner violence, says doctors and counselors should teach women how to describe a miscarriage to a skeptical or angry boyfriend or spouse. “It can reduce the chance the partner is going to be furious,” she said. But a case before the Supreme Court this session (Cline v. Oklahoma Coalition for Reproductive Justice, tentatively slated for October) may make medical abortion far less available.
The state of Oklahoma is appealing a ruling from its Supreme Court, which struck down a law that would require doctors to follow the rules the Food and Drug Administration laid out when it first approved the abortion pill in 2000. This sounds like a perfectly reasonable safety precaution on its face, but as doctors have learned more about the drug in the intervening 13 years, many protocols have changed. As Linda Greenhouse reports:
Instead of 600 milligrams of Mifeprex, doctors now use only 200. While the original FDA label specified that the drugs should be used only up to 49 days of pregnancy, doctors have found the regimen safe and effective for up to 63 days—nine weeks of pregnancy. Instead of requiring a second office visit for the second drug, as specified by the FDA, doctors now often give the patient the second drug to be taken at home, saving her an unnecessary trip. The 200-milligram regimen is so widely accepted that the 600-milligram dose is now considered bad medicine, and many doctors would refuse the procedure entirely rather than follow the old guideline.
The importance of the drug has evolved as well; it has become a lifeline for low-income women who realize they are pregnant in the nine-week window when the pill is effective. Surgical abortion is often harder to arrange, requiring multiple visits—especially in states that impose mandatory waiting periods—and a friend or partner to drive the patient home after the procedure when she is under anesthesia (a particular problem for victims of abuse who fear that word will get back to their partners). Medication abortion, on the other hand, can be accomplished in two visits: one to get the pills and a follow-up a few weeks later. Oklahoma’s law would add at least one unnecessary trip to the clinic. In the past, some women who live in rural places far from a clinic have even gotten abortion pills through telemedicine conferences with doctors, though 17 states have outlawed this practice in recent years.
Medication abortion has become a favorite target of the national anti-abortion movement. The Oklahoma law hews close to a prototype the notorious group Americans United for Life (AUL) released as part of its annual model legislation packet this spring. (AUL has established itself as one of the biggest purveyors of TRAP—Targeted Regulation of Abortion Provider—legislation, which limits abortion on procedural grounds while falsely claiming to protect women’s health.) AUL-style provisions to limit medication abortion also appear in the omnibus bill that passed the Texas legislature this summer, and are already in effect or under development in Ohio, Arizona, and Iowa, according to the Guttmacher Institute.
While abortion restrictions proliferate, Miller and her colleagues are uncovering more and more evidence of the link between violent relationships and unwanted pregnancy. “Violence is about power, and certainly control over her reproductive decision-making is a very important component,” Miller says. In one study, she and her co-authors interviewed teens whose boyfriends poked holes in condoms to get them pregnant (‘‘Like the first couple of times, the condom seems to break every time. You know what I mean, and it was just kind of funny, like, the ﬁrst six times the condom broke. Six condoms, that’s kind of rare. I could understand one, but six times.”) or barred them from taking oral contraceptives (“I was on the birth control, and I was still taking it, and he ended up getting mad and flushing it down the toilet, so I ended up getting pregnant.”). Miller’s co-author, Jay Silverman, a professor of medicine and public health at the University of California, San Diego, told me he’s seen men coerce women to get an abortion, or not to get one—some abusers even exert control by getting their partners pregnant, then forcing them to get an abortion. But the most common scenario is the one that can be aided by a medication abortion: An abusive man threatening to hurt his partner if she ends a pregnancy. This is about twice as common as the reverse situation.
Miller says awareness of the link between domestic violence and unwanted pregnancy is just taking hold, and Levenson told me so far, only a tiny fraction of providers at family planning clinics know to screen for coercion and abuse. The American College of Obstetricians and Gynecologists didn’t acknowledge the link between partner violence and abortion until 2012, and only recommended that ob-gyns and staff at family planning clinics screen for it as recently as February, 2013. If the Supreme Court decides to reverse the lower court’s ruling, it could eliminate an important option for women with very few places to turn.
Nora Caplan-Bricker is an assistant editor at The New Republic.