*Patient's name has been changed for privacy protection
It was a usual Tuesday afternoon. I was wrapping up my clinic, glancing at the inpatient census to see what call might have in store for me, and taking a quick look at tomorrow's schedule. I noticed with delight a familiar patient, Josie*, scheduled for a new OB appointment. She and her husband had come in recently to discuss an infertility workup, but it's always nice when couples get pregnant before needing interventions.
Call came and went, and the following day I was in the middle of running errands when I got a frantic flurry of texts from Sarah, my amazing NP who (graciously) does my new OB appointments. Unfortunately, her texts didn't arrive with joyful news. Josie confided in Sarah information she had not been able to share with anyone else. Not her friends, family, husband, or the authorities.
Around her ovulation a few weeks prior, Josie had reluctantly joined a group of girlfriends for a night out to celebrate a coworker's birthday. She thought it might take the stress off waiting to find out if her and her husband would finally conceive, since they had been trying for 16 months. Like any dedicated infertility couple, they had been timing their intercourse for conception. Tragically, the night of celebration ended with Josie as a victim of the most personally violating crime -- while out with friends, she had been drugged unknowingly and raped.
Like most rape victims, Josie stayed silent about her assault. Now, 2 weeks after living with the shame, guilt, and pain of her attack, she found out she was pregnant. Months and months of trying, years of hoping, and dozens of negative pregnancy tests later...this one was positive. But there was no joy and celebration like there should be. Josie could not know who the father of this pregnancy was -- her husband or her rapist. And given the timing and prior lack of success with her husband, there was an unfortunate chance this pregnancy was a product of rape. Understandably, she could not bear the thought and mental health anguish of carrying that pregnancy to term.
As soon as I spoke to Sarah, I was on the phone with colleagues in maternal and fetal medicine (MFM) and genetics, seeing how early we could provide Josie with information. Amazingly, technology can determine paternity for a pregnancy as early as 7 weeks gestation. However, Josie lives, and I practice, in Texas. This was November 2021, just a few months after passage of SB8, which bans abortion in the state of Texas after 6 weeks. The act also authorizes members of the public to sue anyone who performs or facilitates an abortion after 6 weeks for a minimum of $10,000 per abortion, plus court costs and attorneys' fees, without a limit to the number of suits per incident.
I brought Josie in the next day. We cried together in my office as we reviewed the options. She could choose to terminate now, but time was running out. At this point, she was just over 4 weeks gestation. She could wait and determine paternity, but if she were pregnant as a product of her rape, she would need to travel out of state for termination. This was not something she had the resources to do. She could not afford the time off work for interstate travel, and the waitlist for appointments in surrounding states was growing daily. Waiting was not an option for her. Carrying a pregnancy and raising a baby that was a product of rape was not an option for her. Josie sought out termination before her sixth week.
The mental health impact of the abortion ban has had its obvious impact on Josie. But she is not alone. The American Psychological Association and American Psychiatric Association have aired about the risks to mental health for the women of Texas and nationwide due to bans on abortion. that women who are denied abortion are more likely to experience higher levels of anxiety, lower life satisfaction, and lower self-esteem than women who received an abortion. These effects appear to continue for women throughout their lives as well as the lives of the children born as a result of an unwanted pregnancy. Studies that unwanted pregnancy has been associated with deficits to the subsequent child's cognitive, emotional, and social processes. The ripple effects of abortion restrictions can last for generations. The Texas ban, like all abortion restricting efforts are disproportionally harmful to low-income individuals and people of color, the LGBTQ+ community, and the medically underserved.
With no exception in SB8 for rape or incest, it is harrowing to think of the thousands of other women who will have to face this obstacle to pregnancy termination. Over reported being raped in Texas in 2020, the most of any state. This likely represents less than a third of cases due to the vast under-reporting of sexual assault. A pooled by the National Intimate Partner and Sexual Violence Survey shows that U.S. women, about 2.4% of the population, experienced a rape-related pregnancy. Seven percent of these pregnancies were due to rapes like Josie's, where the perpetrator was a stranger. In Texas currently, there are of child bearing age. This means more than 10,000 women in Texas will become pregnant as a result of violent rape by a stranger over two decades. This does not account for the hundreds of thousands who become pregnant from rape by a known partner.
Although I would argue that any woman having to make this choice is unacceptable, Josie's case is unique because first and foremost, she knew she was pregnant right at her missed period. Many women, especially with irregular cycles, or who may be on birth control and have a contraceptive failure, would not be so astute to test for pregnancy at that early gestational age. The "6 week" time frame in which abortion is allowed per SB8, which of course is only 2 weeks after a period should have arrived, falls well before many women realize they are pregnant. As many as of pregnancies are diagnosed after 6-7 weeks gestation. It is only because she and her husband had been trying to conceive and struggling with infertility that she bothered to take a test.
Josie barely had time to begin to process the trauma of her attack before she had to make an unwinnable, unfathomable choice. Her most precious dreams were stolen by a rapist, and her agency and options for self-determination were stolen by a legislature out to limit access to reproductive care without thought of the innumerable consequences for health and well-being they could not fathom -- because they do not have to. The millions of nuanced reasons that women seek and consider abortion, sometimes ending very desired pregnancies, are not something lawmakers consider when passing such restrictive and harsh laws. And it shouldn't matter whether the pregnancy is a result of rape or any other reason. The decision about pregnancy should be left to women and the doctors who counsel them, care for them, cry with them, celebrate, and mourn with them.
Unfortunately for the women of Texas -- and several other states pursuing similar laws -- the decision has been made by people who have no knowledge of our patients and their life stories, no concern for their well-being or safety, and no investment in caring for them or their baby after delivery.
is an ob/gyn in Fort Worth, Texas.