MSFC Update - May 1999

An Abortion Doctor's Hardest Choices

BY SUSAN WICKLUND, M.D., WITH ALAN S. KESSELHEIM

From the moment she walks into the clinic, the girl projects an aura of tension. She's only 13, too young, too frail, to be called a woman. Her father hovers protectively, a narrow, furtive man with a sharp edge to his voice. "I just want to do what's best for my daughter," he keeps saying. "She's made a mistake. I want what's right for my little girl."

When asked if his wife knows what has happened, his eyes dart away. "I don't want to bother her with this." The girl says nothing. He insists on being with his daughter while we do her lab work and during the group counseling session, where she huddles silently in her chair, hands between her knees, responding to questions only by nodding or shaking her head.

"Are you sure you want an abortion?" a counselor asks. She nods, fidgeting in her chair. "Do you understand what an abortion is?" Another nod.

Later, one of the counselors pulls me aside. "I know she's really, really young," she begins, "but still, something seems off. She keeps her head down all the time. She won't make eye contact. Maybe she's just scared, but..." The unfinished sentence hangs in the air.

The father follows close behind as I move with her toward the procedure room; he turns back only when I insist on spending a few minutes alone with his daughter.

"I do this with every patient," I reassure him. "It won't take long. I'll let you back in during the actual procedure."

Now, for the first time, I am alone with her. Over ten years, working in half a dozen clinics throughout the country, I have learned that this is the point where I must pause and ask the hard questions.

Intimate conversations between doctor and patient don't have to be part of the process of getting an abortion. Legally, all I'm required to do is obtain a patient's "informed consent"-which is supposed to ensure that her decision is voluntary and that she understands the procedure, the alternatives, and the risks-along with her legal permission for an abortion, as indicated by her signature on the consent form. I have colleagues who believe that a woman who has walked into a clinic has already demonstrated her commitment to ending her pregnancy. To probe further just stirs things up unnecessarily, they say.

My experience tells me otherwise. I turn to the frightened girl in my office and start by gently asking her peripheral questions: how long she's been menstruating, whether her periods are regular, how many siblings she has. When she answers, her voice is a thin whisper. I review the procedure with her, show her the instruments, describe again what the fetal tissue will look like at this early stage. She folds her arms around her chest, as if to hide herself.

"Are you absolutely sure you want this abortion?" I ask.

"Have to," she says, barely audible.

"Excuse me?"

"I have to."

"Why do you have to?"

She says nothing.

"Is anyone pressuring you? Is this really what you want?"

No response.

"Do you want to be pregnant?"

"No."

"Do you want this abortion?"

She shakes her head no.

I sit down next to her, place my hand on her skinny arm.

"Do you have a boyfriend?"

No answer.

"Did a boyfriend get you pregnant?"

She turns away. I notice she is shaking.

"Listen." I am whispering now, too. "Sometimes things happen that are hard to talk about. I need to know how you got pregnant. Did someone do something bad to you?"

The girl is mute, won't look at me.

"Who made you pregnant?" By gently squeezing her arm, I urge her to answer.

Finally she turns to me, eyes glistening. "It was my daddy," she breathes.

"The man in the waiting room? Is that your daddy?"

She nods.

"Has anyone else ever touched you in that way?"

"No."

"Does your mom know?"

No answer. She is through talking.

"We are going to take care of you," I tell her. "We can't do the abortion today. We have time to deal with that later."

"But I have to!" she pleads.

"I am so sorry this has happened to you. You've done nothing wrong. I promise we'll keep you safe."

When I come out of the procedure room, her father bounds forward. I have to block the door to keep him from coming through, and he gets irate.

"I want to see my girl," he demands, thrusting his face up to mine.

"It won't be long," I say. "She's very young and we have to prepare carefully. Please be patient."

In the meantime, we are frantically contacting the authorities. All the while, I have to suppress my urge to scream at him, to claw his face for what he's done.

In the end, the police arrive to handcuff the father at the same time that social workers are whisking the daughter out the back door. Two weeks later, I will end her pregnancy, but that is the least of the life hurdles facing this sad, young girl.

Few counseling sessions are as dramatic as that incest survivor's. Months go by between stories like hers. But even the ordinary patients, the ones who arrive in my office week in and week out, are grappling with highly charged issues. And so am I.

Last fall's murder of Dr. Barnett Slepian thrust abortion providers into the limelight once again, but while we are reminded all too often of the violence that surrounds clinics, we rarely hear about what actually goes on in the privacy of the examining room, about the difficult conversations that take place between women and their doctors. And we almost never hear about the sometimes anguished choices doctors must make at this crossroads in a woman's life.

I know what it feels like to be at that crossroads. Once, I was 22 and in need of an abortion. The only "counseling" I received was on how I would pay for the procedure. Though my abortion took place decades ago, I still recall my fear, the questions I longed to ask but didn't because I never got the chance.

That's why, within months of starting my own practice, I began to draw my lines. Regardless of the policy of the clinics where I worked, I refused to arrive in the procedure room to find a woman with her feet already in the stirrups, an IV dripping a sedative into her arm. I insisted on talking with each woman before she was sedated, no matter how far behind schedule we were or how certain about her choice she seemed. "You are in control," I say to every patient. "You can stop me at any point to ask questions or tell me not to go on. I use a local anesthetic so you can speak with me the entire time."

The back-and-forth dialogue can be grueling, frustrating, haunting-and, sometimes satisfying. It's not uncommon for my staff to spend hours counseling one patient, who may return four or five times before deciding what to do. Sometimes my patients get angry with me for my persistence.

The truth is, even women who say they feel certain about the decision to end-or continue-a pregnancy often feel torn by conflicting pressures. They may have a partner who is coercing them. They almost always have plans that will be altered by the arrival of a baby.

In another counseling session, a woman named Peggy tells me she went through years of infertility problems before finally conceiving her first child. But pregnancy-when it came-turned out to be its own kind of torture. Peggy was sick the entire time, often bedridden, and after a difficult birth, she succumbed to a years-long siege of profound depression.

She is in her early 30s now, and her little girl is 3. She tells me that she and her husband have already discussed at length whether to try for a second child, and ultimately decided that the trauma of the first pregnancy, and Peggy's lingering depression, were too daunting. Now, unexpectedly, they are pregnant again. Given their past battle with infertility, this is an unexpected gift, a chance that may never come again. It is also an agonizing dilemma.

"We had so much trouble having one baby," Peggy tells a counselor. "Now this, without even trying."

"What are your feelings about being pregnant?"

"Very conflicted," she admits. "On the one hand, I think, 'How can I throw away this chance? What will people think? How will I live with myself? But then I try to imagine another pregnancy, another child, and it scares the hell out of me."

"Why?"

"The first pregnancy was so incredibly difficult. And the depression afterwards was even worse. In fact, it's still going on."

"So what makes you want to consider going through with this pregnancy?"

"Maybe it's meant to be. Maybe this time would be fine. Plus, our child would have a sibling. If I take my health out of the picture, I'm convinced that two kids makes a better family."

The counselor gives Peggy some exercises to do before their next session. "I want you to list the pros and cons of this pregnancy," she says. "Actually write them down. Then think ahead five years and imagine your family-both ways-and write about each scenario in as much detail as possible. Talk it over with your husband some more, and come back in a week."

In the next session Peggy seems clearer about wanting an abortion.

"When I thought ahead, I was really, truly frightened," she admits. "I'm having so much trouble just getting through each day as it is."

Her doubts continue to bubble up.

"The problem is, I feel unbelievably guilty," she says. "What would people think of me?"

When Peggy takes a break to use the bathroom, the counselor asks her husband what he thinks, why he's been so quiet during these long discussions.

"This is her decision," he says. "I don't want to force it. Another baby would be fine with me. But I'm very worried about Peggy. She is so maxed out right now."

Still unresolved, they leave the office, but when they return a week later, Peggy has the look of someone who has shed a burden. "It finally clicked," she says. "I realized that I can't make this choice based on what anyone else thinks. All the pressures I feel to continue the pregnancy are external. Whenever I look at the situation from my perspective, it seems totally clear. I can't do it."

I perform Peggy's abortion the following day.

To me, the doctor's role is not to shape the outcome, one way or the other. My aim is to lead a patient through any confusion to a deeply considered decision.

I mull over the stories of so many women. How many doctors, I wonder, end up struggling over their own choices as often as I do?

Reprinted by permission of New Woman magazine. Copyright 1999 Rodale Press, Inc. All rights reserved. For subscription information, call 1-800-627-2557.