Abortion is hard to write about, hard for many even to talk about. Of course, there’s no shortage of commentary from politicians, pundits and philosophers on the moral and legal arguments, for and against. What we need more of—particularly now that the right to an abortion seems almost certain to be forsaken by the Supreme Court—are words that describe the true, complicated experience of willfully ending a pregnancy. But who should speak and write about the experience of abortion? And how?
Women who have abortions are often understandably afraid and ashamed to publicly document their stories. Although there is a movement to counter such shame, led by groups such as We Testify and Shout Your Abortion, these tend to focus on women’s reasons for and circumstances surrounding the abortion, rather than the experience itself. A woman undergoing an abortion might remember details only hazily, due to physical and psychological stress, medication side effects, distraction and other coping techniques during the procedure. And there is the problem of representation: someone who has one abortion (or even two or three), may have a valuable story to tell, but it will be a singular one. No individual experience can serve as representative of abortion in general.1
Physicians who provide abortions may also be called upon to offer our perspective, because we see abortion up close every day. We are intimately familiar with the details, both on an individual and population level. We have seen the typical cases and the not-at-all typical ones. We have chosen this work over other, less contentious, more lucrative options, and we tend to have a deep empathy for the patients we serve.
Still, no matter how many abortions I’ve seen or performed, no matter how much empathy I hold for my patients, I am always at some remove from the woman on the table. In that clinical distance there is always the danger of misunderstanding and misrepresentation, of tangling her experience with my own assumptions and biases. In writing or talking about another woman’s abortion, I risk overstepping that tacitly agreed-upon gap between us—the one that delineates her as the patient and me as her doctor, allowing her to have her experience and beliefs and me to have mine. In the procedure room, the only thing she and I really need to agree upon or even discuss is her informed-consent document. Beyond that, she is—or at least she may choose to be—a stranger to me.
Sometimes, though, distances suddenly collapse. I find myself closer to another person than I ever expected to be, gazing through a small window to see and learn about her, and about myself and the nature of choice. The reasons she might have for making this decision, and what it feels like afterward—these are things I can usually only guess. But very rarely I have a chance to ask: Is this how it was? Am I getting this right? And to hear from her: It was like this. Let me tell you.
One afternoon, almost exactly a year ago, the clinic manager pulled me aside to tell me that my last patient of the day was not written on “the board” (a list of the day’s procedures posted in the central office) because the patient was a staff member. It wasn’t the first time I would perform an abortion for someone I knew. But it was the first time I would perform an abortion for someone who had specifically requested me as her doctor.
Over the course of the day I deduced that the patient would be one of our medical assistants—I’ll call her Sandra. I didn’t know her very well at the time. Like many on the staff, Sandra was a Latina woman in her twenties who worked a demanding job for relatively little pay, hoping to eventually return to school or advance her career. She worked hard and cared about the patients.
Normally Sandra is cheerful and easy to engage, but that afternoon she kept her eyes down, saying nothing unless I spoke to her directly. She worked the whole long day—performing ultrasounds, counseling patients, assisting me in procedures—right up to the time of her own abortion.
When I came into the procedure room, she was already lying on the table, covered from the waist down with a thin paper drape. I spoke with her briefly. Although I didn’t ask, she told me about a lapse in her birth control, a missed period. I remember that she was visibly, openly distraught—more so than I’d expected her to be. I suppose I thought, stupidly, that as someone who worked in abortion care she might have a sort of practical resignation about the whole thing, a level-headed if dismayed acceptance. Well. It’s unfortunate, but these things happen.
Which was, of course, completely ridiculous.
Knowledge of and proximity to certain types of pain do not inure us to that pain in our own lives. As a doctor I should know this. Several years ago, when I was trying to conceive my own children, I was well-aware that up to thirty percent of pregnancies end in miscarriage. On some level I thought that this knowledge would protect me against any shame or sadness I might feel should I lose a pregnancy. But of course it didn’t work that way—I was as terrified of miscarriage as anyone. The loss of a pregnancy, no matter the circumstances, is a uniquely dark moment in a woman’s life—because it is an invisible loss, the loss of someone, or something, known to no one else but her.
There was no reason that Sandra, who had been working in abortion care for about two years, should have faced her abortion with any more resignation or equanimity than anyone else. She was in agony, like many of my patients: clear in her decision, certain of it, and still devastated by it. To her it was a “choice” that didn’t feel like a choice at all.
The thing I remember her telling me then, which she has told me many times since, was how much she wants to be a mother. She longs for it, the way all of us long for something. The way I longed, in medical school, to be a doctor, the way I still long to be a writer. To have her own children is her vision for her future, her definition of fulfillment and self-actualization. “But,” she told me, “I know I’m not ready. Not emotionally, not financially, not in my relationship. I love my boyfriend, and I hope he and I have children together one day. He told me he would support me no matter what I decided to do, that it’s entirely my choice. But…”—she pursed her lips and pressed her eyes shut, holding back a fresh round of tears—“But even him saying that shows me he’s not ready either. He doesn’t realize how much it will take, how it will affect me, and our future. He’s trying to support me but… he doesn’t see how alone I feel when he says that, when he puts it all on me.”
I am paraphrasing, of course. I don’t remember her exact words, just her tone, and the general sentiment. It is one I’ve heard many times before. The partner thinks he is being supportive by saying, “It’s your choice,” or “It’s totally up to you.” Instead, what he is actually doing is reminding her that the burden of the decision is entirely on her. It takes two people to create a pregnancy. But no matter what she decides, she must bear all the weight of what comes next.
Sandra’s procedure was uncomplicated, “routine” in a clinical sense. She was sedated but awake. One of the other medical assistants held her hand and talked with her, made her laugh once or twice, wiped away her tears. She was seven weeks pregnant. It took five minutes.
When it was over, I told her the same thing I say to nearly every patient: “Everything went fine. You’re not pregnant anymore. Nothing about the procedure will affect your ability to get pregnant in the future.”
Over the course of the following year, when I occasionally found myself alone with Sandra in the lab or in the break room, I would ask her how she was doing. The first time I asked, I was surprised when she started to cry.
She told me that she’d been struggling with regret. She knew she’d done the right thing, she said. But whenever she was with her young nieces and nephews, those feelings of sadness and longing welled up in her. When a cousin her age recently gave birth, she was overcome with envy. That could have been me, she thought. She was having trouble explaining these feelings to her boyfriend. “He doesn’t understand. He says, ‘Why are you dwelling on it? It was a choice. You have to focus on the positive.’ He doesn’t understand how alone that makes me feel.” She told me she was thinking about looking for other jobs where she wouldn’t have to face pregnant women and their choices every day. She thought that perhaps the work was holding her back from healing, forcing her to constantly revisit her own decision and her own loss. “I feel like I need to let go of it,” she said, “but I can’t.”
“Regret” is one of those words in abortion care and abortion-rights advocacy that mostly goes unsaid. Like “life” and “heartbeat” and “baby,” it’s a word—a concept, a truth—that has been coopted by the anti-abortion movement to frighten and manipulate women who face difficult decisions, who are understandably afraid of what consequences or karma will await them on the other side.
It was hard for me to hear Sandra use the word—not because I had any regrets of my own or felt responsible for hers—but because it reminded me of a sentiment I sometimes heard from patients, one that had always bothered me.
Occasionally a woman will tell me before I begin her procedure, “I don’t believe in abortion.” Sometimes she’ll describe herself as “pro-life.” Then she’ll go on to say, “I’m just in a really hard situation,” or “I just don’t see any way around it. I have to do it just this once.” I have always bristled at such explanations, because I assumed these women were talking about law and policy: they didn’t believe in the legal right to abortion, or in abortion “on demand.” Their words seemed to imply a judgment against other women, while insisting on some kind of exception for themselves.
But in the year or so since Sandra’s abortion, I’ve begun to think more carefully about my own judgments and assumptions, to question what women might really be saying when they tell me they don’t “believe in” abortion. Maybe it is simply their way of saying, in those tense, vulnerable moments just before the procedure, something that has nothing to do with politics, something entirely personal: I feel terrible about this. And I know I still need to do it.
To which my response is: Yes, both of these things can be true and valid. And she still gets to make that decision. Or, rather, she must bear that decision, which I understand might feel terrible. But I wouldn’t have anyone else take that burden, or that freedom, away from her.
This was, in many respects, the conversation Sandra and I were having in those months following her abortion. She was telling me, in her own way: I don’t believe in this. She believes in abortion as a right and a service. But she did not—could not—believe in what she herself had done.
In the months that followed, Sandra told me things were getting better. Her boyfriend was gradually coming to understand how to support her by listening to and reflecting her grief, rather than by trying to explain it away. She also recognized she needed to get some support from someone besides him. She was seeing a counselor, who was helping her to identify what she called cycles of intergenerational trauma in her own family. She talked about how her own mother had had her “too young,” before she was ready to be a mom. Alone in a new country, she had been too exhausted and overwhelmed to give Sandra the time and attention she needed.
Sandra was determined not to repeat this cycle. This new determination, and a broader understanding of the forces shaping her life, helped her to have more self-compassion in the wake of her decision.
In the meantime, she was continuing to look for other jobs. She asked me to be a reference for her. Shortly before Christmas I was out for two weeks, and when I came back, I was disappointed to learn that Sandra had already worked her last day. I felt relieved when she came back to the clinic one afternoon a few weeks later. “I wanted to say goodbye,” she said, handing me a card. She told me about her new job and asked after my family. Before she left, she hugged me and whispered, “Thank you for helping this opportunity come true for me.”
I wondered what she meant by this: Help this opportunity come true. At first I thought she was referring to the new job, for which I’d written her a glowing reference letter. But later I found the same phrase in the card she’d given me: “You helped this opportunity come true.” And I thought, Of course she’s not talking about the job.
This opportunity: the opportunity not to be pregnant. The opportunity not to have to be a mother right now, even though that is very much what she wants in the future. The opportunity to be the mother she wants to be for her future children—stable, mature, emotionally and financially prepared, entirely willing, free of doubt. The opportunity to break a cycle of trauma by living the life she envisions for herself, and to give her children a better life than her own mother was able to give to her.
After our hug, I looked her in the eye and said, “You are going to be a great mom someday. You send me a picture of those babies. Promise?”
“I will,” she said, tearing up a little.
But later I couldn’t help but worry whether it was the right thing to say. As one woman to another, in a professional context, maybe it was inappropriate to refer to her ambition in any realm beyond the workplace, an imposition of my own values and hopes for her. And yet she told me herself that she wants to be a mother. Why shouldn’t I—as her colleague, as a mother, as the doctor who performed her abortion—acknowledge and even honor that ambition of future motherhood? It is, after all, the “opportunity” she had mentioned in her card and in her whispered goodbye. Why does it feel like something I’m not supposed to name?
A few days after I said goodbye to Sandra at the clinic, I received a text message from her at home. She shared a few updates, then sent a photo of a sketch on notebook paper. The drawing showed a jungle of dense, broad leaves clustered around a tiny, teardrop shaped bundle. Below it she wrote:
i doodled this picture the other day. it’s supposed to be my pregnancy encapsulated in a drop of water in a rainforest, beautifully untouched. i can’t thank you enough and although it’s such a horrible horrible pain i know it was the right choice.
The image she’d drawn, and the words she used to describe it, moved me in a way that was at once familiar from my daily work, and uniquely poignant. How fiercely, exquisitely protective she still felt toward this life that existed so briefly inside her, the way she “encapsulated” it—perfect, vulnerable, yet also safe—inside its raindrop. And the rainforest: What, I wondered, did that represent? Almost instantly, I knew—or thought I knew—the answer. It was the same answer I’d arrived at earlier, while puzzling over Sandra’s words: this opportunity. The rainforest is her life, in all its richness and love, sadness and potential. It is both her life honoring her unborn child, and her life without that child. It is the chance to give her future children what she could not have given this child. It is, in a sense, all of her, complex and conflicted and complete.
If you don’t believe in abortion, then don’t have one! Yes. But this old and excellent (if somewhat irreverent) rallying cry for abortion rights only captures part of the problem, the easy part. Where does it leave women like Sandra—women who, on the table or afterwards, tell me, I don’t believe in this? Where does it leave me, as their doctor?
Righteousness and certainty (of the kind implied in the rallying cry) are not prerequisites for a person to have an abortion. While it may not be the primary moral or legal concern of the anti-abortion movement, I do see this concept as a stumbling block for many of us in our thinking about bodily autonomy.
In a 2018 essay for the New York Times, Andrea Long Chu makes a similar point, arguing that access to gender-affirming surgery should not hinge on the question of whether it will make transgender patients “feel better.” She wrote that so far her own transition had made her feel “demonstrably worse” than she previously felt in her dysphoric body. But, she argues, this doesn’t mean doctors—or anyone—ought to deny her the gender-affirming surgery she seeks.
Her words echo what I believe I am hearing from my patients who tell me, even as they lie on the table, that they “don’t believe in” abortion: “I will live with this, or I won’t,” says Chu of her planned surgery. “That’s fine. The negative passions—grief, self-loathing, shame, regret—are as much a human right as universal health care, or food.”
Everyone who has an abortion must face this agonizing choice: the potential of birthing a life worthy of her love and protection on the one hand, and the value of her autonomy and imagined future on the other. The fact that these two possibilities might compete with one other, and that she cannot predict precisely what either will look like, is a difficulty I cannot erase. Nor should I assume that she wants me to. As Chu says: “Don’t patronize me.”
My aim is not to convince anyone of when life begins, or whether abortion is right or wrong. I have opinions on these matters, but that’s not what I can add to the abortion conversation. Instead, I believe Sandra and I, in our moment of proximity, have something to say about abortion that may be hard to hear. It is this: If you don’t believe in abortion, you can have one anyway. At least in California—where I live—this is still true, as it is in the other states that will serve as abortion “sanctuaries” for those who can reach them.
It seems critical to say this now, as women will soon be forced to reckon with—and vote on—the gray area between our personal beliefs, our choices and the laws that protect our bodies and our futures. I believe this reckoning will happen, and that it will be the force that swings the pendulum, however slowly, back toward reproductive freedom, toward a place where we can acknowledge the full, personal complexity of the decision—not just alongside the right to an abortion, but as a fundamental basis for that right. Part of what we deserve, and must fight for, is the legitimacy of our “negative passions.”
In the meantime, this is how I grant a woman all the awesome, terrifying rights and responsibilities of motherhood from the moment of conception. She doesn’t have to “believe in” abortion. She doesn’t have to tell me her reasons or her conflicted feelings. She may regret it afterwards, at least for a while, maybe even (I have to acknowledge this possibility) forever. I can still trust her to make her own decision, which no one else—not her boyfriend, not her doctor, not her governor—can make for her. That is, and should always be, her right, and her burden. It is, as Sandra called it, her “opportunity.” For the moment, it is all I can give her.
The cover image drawn by Sandra, and the correspondence included in the essay, have been shared with Sandra’s permission.