Originally published in Synapse on Sept. 23, 1999.
“Disgusting, isn’t it?” said one of the directors of the national office of Medical Students for Choice (MSFC) as she handed me a copy of the Bottom Feeder mailing.
I felt like I was holding a piece of history in my hands. This paper had generated the momentum to create a national organization.
The Bottom Feeder, published by an antiabortion group from Texas called “Life Dynamics,” was sent to 33,871 medical students across the nation in 1993.
It contains crude caricatures of and jokes about abortion providers, such as, “What would you do if you found yourself in a room with Hitler, Mussolini, and an abortionist, and you had a gun with only two bullets? Answer: Shoot the abortionist twice.”
Many of the UCSF medical students who received this mailing felt like they were being personally targeted.
“It was an intimidation tactic, at a very early stage, saying to medical students ‘We know who you are, and we can find you and we can target you.’ Even by finding your home address and mailing something to you,” said Lia Carliner, a first-year medical student at the time.
And how did an anti-abortion organization gain access to the students’ home addresses? By purchasing them from the American Medical Association (AMA).
Mark Crutcher, president of Life Dynamics, contends that he simply called one of the list brokers for the AMA and asked how many medical students were on the list. There were 66,724, and the list sold for $45 per 1,000. He chose to buy half the list, every other name.
Of course, under AMA policy, the list is not to be used for such politically motivated purposes. The AMA maintained that Crutcher had falsely represented himself as a physician recruiter.
It wasn’t until after medical students began receiving the booklet that the AMA realized its mistake.
“It brought out a really visceral reaction in me,” said Danielle Casher, a fourth-year medical student at the time. “They were trying to stigmatize learning of the abortion procedure.”
A week after students began receiving the Bottom Feeder, Dr. David Gunn, an abortion provider in Florida, was shot and killed in his own home. He would be the first in a string of doctors who were murdered for their dedication to providing women with reproductive choices.
While first-trimester abortion is the safest surgical procedure in the United States, providing it has become a dangerous occupation.
Abortion is probably the only surgical procedure in which the doctor is more at risk than the patient.
“We were just first-year medical students right at the time of Dr. Gunn’s murder. Something about it just woke us up,” said Jodi Steinhauer, who is now a resident in the UCSF 0B/Gyn program.
“Some of us had been pro-choice in college, but we hadn’t yet thought of ourselves as possible future providers. The two events ended up moving us to action. We started thinking about abortion. Do we get taught this in school? In residency? And we realized that our curriculum was completely lacking.”
The Women’s Medical Student Association (WMSA) sponsored a panel discussion in March 1993, titled Providing Abortions: the personal, political and ethical dilemma, at which four abortion providers shared their stories and motivations.
It attracted 75 students and physicians. Afterwards, during a summer internship at the National Abortion Federation (NAF), Steinhauer contacted students at other schools across the nation and learned that they had staged similar panels and discussions in response to the mailing. “That was when I had the idea of starting a national network of students interested in abortion rights,” Jodi said.
Together with Sara Cada from the University of Kansas and Hillary Kunins from Columbia University in New York, Jodi began to lay the framework for what was to become Medical Students for Choice (MSFC).
At first, they worked under the auspices of NAF and Planned Parenthood of New York City, but in 1994 they incorporated as an independent organization. Now MSFC represents over 5,000 medical students and residents in the U.S. and Canada.
The goals of the organization are to build a network of support and resources for medical students and residents, to reform medical curricula and training to include abortion and reproductive health as a standard part of medical education, to increase education and training opportunities on abortion, and to encourage policy makers in medicine and government to integrate abortion into medical training.
The needs for such an organization are obvious. A 1996 study by the Guttmacher Institute, a public analysis and public education institute that researches reproductive health issues, found that the number of abortion providers has decreased by 14% since 1992.
There are no abortion clinics in 84% of the counties in the United States.
“Over the last four years California has experienced the sharpest decline in abortion access in the country, losing 62 out of 550 providers. The biggest obstacle to safe, legal abortion today is not the law. It is the absence of trained providers,” said Pat Anderson, executive director of Medical Students for Choice.
Indeed, over the last four years California has experienced the sharpest decline in abortion access in the country, losing 62 out of 550 providers.
In a recent issue of the East Bay Express, Belle Taylor-McGhee, executive director of the California Abortion and Reproductive Rights Action League (CARAL) notes that the “abortion-accessible hospitals are clustered around the LA and bay regions: Los Angeles County has five, San Francisco has three, and Alameda County has two. A handful of nearby counties have one. The rest of the state — 47 out of 58 counties — is blank. A woman living in any of these areas either has to find a clinic or a private doctor to do it quietly or make her way to the Bay Area.”
This can make it difficult or almost impossible for a woman to obtain an abortion, particularly if she is poor and does not have ready access to transportation or has several children to care for at home.
“This is a necessary thing that has to happen for women and it’s really hard but someone’s got to do it,” said Sarah Zwehl-Burke, a second year medical student, regarding the need for more abortion providers.
When asked about what led her to become involved in MSFC, Susannah Brock, one of the coordinators of the group, replied “it’s where my political beliefs and my career intersect. As a medical student I feel that you’re in a particularly good position to bridge the gap between women who need access to abortion and future doctors who will provide that care.”
“I have come into contact with women who have had an abortion and I feel that it is a very important right to maintain. The impediments to access are increasing as complacency grows in the amnesia that has developed since Roe v. Wade,” Susannah said.
Indeed, the doctors who seem most committed to providing abortions are those who saw the hospital wards before the landmark decision of 1973. They witnessed the deaths and complications that resulted from back-alley abortions.
“They were bleeding, had foreign bodies in their vagina, or came in with a temperature of 106,” said Alexander Nicholas, describing the women who received illegal abortions in a New York Times report.
“The younger doctors especially don’t have the history we have with the procedure. They don’t know how women were affected in the old days. They’re out of the loop because they never had to go through what we did.”
Abortion provider shortage
Today, 59% of abortion providers are at least 65 years old. With an acute shortage of abortion providers in the present, and the likelihood of an even greater shortage in the near future as many of the older abortion providers consider retirement, this nation is faced with a near crisis.
What does it matter if abortion is legal when there is no one to provide it?
To improve this situation, MSFC is attempting to educate students about abortion and familiarize them with the issues surrounding it.
They hope that this will allow students to make a more informed decision about whether to become a provider.
Last year’s MSFC coordinators, Amy Whitaker and Julia Mitrezski, started a program in which UCSF students could spend half a day observing an abortion provider in the clinic.
Many first and second year medical students, a handful of nursing students, and even a few fourth year medical students who had not been given the opportunity to observe an abortion procedure during their training signed up for the program.
“It wasn’t until I was standing before the door of the clinic that I realized, ‘Wow, this is serious! I’m really going to do this,’” recalls Ansley Splinter, who is now a second year medical student.
“I was really glad that I went. It was kind of weird to just meet a patient and then five minutes later you’re going through a very intimate process with them. It was amazing to see the reactions of different patients. It forced me to think about abortion. This is something I believe in, but is it something I’m going to be a provider for? It was a first step in my trying to decide whether this is something I could do or not. I needed to see that in order to progress.”
Second-year medical student Anjali Suthar also praised the program.
“I liked the set up. They put you in the counseling service first. Like a typical medical student, I wanted to go straight to the operating room, but I learned a lot from the counseling session. I followed the same person all the way through the process, from beginning to end. I think she liked the continuity of having someone with her for the whole process. I even visited her in the recovery room.”
The program allowed Anjali to “gain insight into women’s health issues, to see the reality of the political situation, and to feel that I could be supportive to the staff and the woman.”
Each year, approximately 50 students from across the country participate in the MSFC summer externship program. This program allows students to observe reproductive health care services, particularly abortion services, in a clinical setting.
The program includes a stipend and requires at least one month of work. Sarah Zwehl-Burke applied for the externship program last year and received an assignment at San Francisco General Hospital (SFGH).
Although she was formally working under the auspices of Philip Darney, MD, a renowned abortion provider and advocate of abortion rights, she spent the majority of her time assisting Rebecca Jackson, MD, a young doctor who recently finished her 0B/Gyn residency.
“It was an awesome experience,” Sarah recalled. “I recommend doing it, and I recommend doing it at SFGH if you can, but you have to be very self-motivated and assertive to get the most out of it. Rebecca was a wonderful person to work with, very dedicated and understanding.”
Jackson’s main appointment is at the Women’s Options Center at SFGH; she also provides care at Planned Parenthood and Mt. Zion.
Pain Control: Double Standard?
To Sarah, the one difference that stood out between the clinics was the amount of pain control that patients received during the procedure.
“It’s kind of odd that something so common can be so variable,” she said.
She met a fellow externship student who expressed similar thoughts.
“She was very upset about how little pain control people are given in most small clinics, such as Planned Parenthood, and wondered if this was almost a punishment that was built into the system.”
It is unlikely that most abortion providers want their patients to feel more pain, but some believe that less pain control is better because it is easier for the patient to notify the doctor if something is going wrong.
However, abortion can be a painful procedure, and providing the patient with at least a moderate level of pain control can make an already stressful and emotionally-charged event a little bit more bearable.
This year, for the first time ever, MSFC is sponsoring an elective on reproductive choices.
Heather Gunnarson, who helped plan the elective, explained, “there was a need for an elective like this. I think that I’m going to be an 0B/Gyn, so I wanted to get more experience in reproductive issues. And I wanted to be able to share that experience with other students. The course will include information about contraception, counseling, adoption, abortion, and all kinds of different choices in reproductive care.”
When asked which sessions of the course she is most looking forward to, Gunnarson replied “The class on HIV and childbearing, and the one on gay and lesbian couples with children.”
Susannah Brock believes that offering the elective is one step toward changing the medical education system to include more information about abortion.
“Abortion is not only marginalized in our society; it is marginalized in medical education. By expanding our curriculum to address topics in reproductive choice, MSFC is working to bring abortion into the mainstream of education.”
During the spring quarter of last year, the new coordinators of MSFC attended a national conference for the organization in Atlanta, Georgia.
“It was amazing,” said Sarah Page, “there were students from all over the country who were all excited about the same issue.”
One of the topics addressed at the conference was clinic violence and how the current system for providing abortions makes it easy for anti-abortionists to target doctors and harass their patients.
A 1992 study by the Guttmacher Institute found that the number of hospitals that provide abortions had fallen by 77% since 1977.
“Fewer hospitals provide abortion because influential donors who oppose abortion won’t give money if they do,” said Dr. Robert Gilford, assistant dean for education at Yale University School of Medicine.
There is also the continuing trend of mergers between Catholic Hospitals and non-religiously affiliated institutions that previously provided abortion services. After such a merger, abortion services are usually discontinued.
The result is that most abortions are now performed in small clinics that specialize in the procedure. These clinics are easy targets for violence.
One hope is that more family practice physicians and gynecologists who are in private practice will learn the procedure.
“It would be so amazing to be a family practitioner who was able to offer abortion If abortion services were more generally available, rather than being isolated in specialized clinics, patients and doctors could feel safer and more anonymous services,” said Sarah Page. “To be able to say to your patient, if you want to have the baby, I will help you through your prenatal care and delivery, and if you don’t want to have the baby, I can help you with that, too.’”
Most importantly, if abortion services were more generally available, rather than being isolated in specialized clinics, patients and doctors could feel safer and more anonymous in the political battlefield of abortion rights.
To Susannah Brock, the most memorable part of the conference was the opening presentation by Malcolm Potts, a professor of public health at UC Berkeley who will be giving one of the lectures for the Reproductive Choices elective.
“What he did was capture the attention of women and men who had gathered from all over the country who were ready to go out marching in the streets to defend abortion rights. He took that energy and focused it inside, allowing us all to think about moral dilemmas and our own stand on abortion.”
Each one of us draws the line somewhere.
To say it is okay to abort a fetus at eight weeks but not at eight months implies that we recognize a distinction between a full human being and a developing one. At some point, the fetus must be given human rights and protection.
The line is not clear, and Dr. Potts maintains that all of us, whether prolife or pro-choice, should be working to increase the availability of contraception and early abortion.
However, many of the politicians who are most adamantly against abortion are also anti-contraception.
This frustrates many pro-choice activists who are working hard to decrease the need for abortion by providing adequate contraception.
Jill June, chief executive of Planned Parenthood of Iowa, is one of them.
“If you don’t support abortion,” she says,” then by God, support birth control!”
One of the issues that is often overlooked in the struggle to maintain reproductive rights is the emotional state of the woman who undergoes an abortion procedure.
While studies have shown that a woman who has an abortion is not at risk for long-term mental health consequences, there has been little attention paid to the short-term effects.
“Like everyone, I’ve known people who’ve had abortions and it’s been so emotional for them,” said Sarah Page, “even if they really wanted the procedure and are glad, they had it, it can still make them feel sad. I went with a friend of mine to see Sweet Honey & the Rock and there was a song about the womb — and she started crying because it was such an emotional experience.”
