Abortion

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| Carole Joffe, PhD

WHAT SHOULD STAFF IN abortion-providing facilities say to abortion patients prior to the procedure? This seemingly sim- ple question is of course not sim- ple at all, in light of the deep social and political divide over abortion that continues to char- acterize the contemporary United States, some 40 years after legal- ization. This conflict has inevita- bly had consequences for how abortion is organized as a ser- vice. Beyond their efforts to over- turn Roe v Wade,2 opponents have sought in numerous ways to regulate the delivery of abortion,

The field of abortion counseling originated in the abortion rights movement of the 1970s. During its

evolution to the present day, it has faced significant challenges, primarily arising from the increasing

politicization and stigmatization of abortion since legalization. Abortion counseling has been affected

not only by the imposition of antiabortion statutes, but also by the changing needs of patients who

have come of age in a very different era than when this occupation was first developed. One major

innovation—head and heart counseling—departs in significant ways from previous conventions of the

field and illustrates the complex and changing political meanings of abortion and therefore the chal-

lenges to abortion providers in the years following Roe v Wade. (Am J Public Health. 2013;103:57–65.

doi:10.2105/AJPH.2012.301063)

including staff interactions with patients. State legislatures, for example, have passed laws that mandate that patients be forced to view their ultrasounds and hear detailed descriptions of their fetus’s development; numer- ous states have also dictated scripts—often containing untrue statements—that clinic staff must deliver to patients.3

Abortion rights supporters, and particularly those who work in abortion-providing facilities, vehe- mently reject opponents’ argu- ments that such regulations are in abortion patients’ interest; rather,

they argue, these requirements exist to make access to abortion more difficult and the experience more upsetting. Although they reject what they see as politically driven restrictions, however, those involved in abortion provi- sion are not in complete agree- ment about what precisely the abortion experience should be for patients. In particular, opinions differ about what the nonmedical component of abortion should be, that is, the talking, or counseling, portion of the abortion visit. Alissa Perrucci, author of a recent highly regarded book on abortion counseling, has commented on the “lack of consensus on the breadth and depth of responsibil- ity that abortion providers have toward working with patients’ emotions.”4

What is commonly referred to as counseling in the abortion set- ting actually involves three sepa- rate functions: obtaining informed consent, which includes ruling out coercion; patient education, which involves explaining the actual technical aspects of the procedure and possible complica- tions; and counseling, which

and the Evolution of Abortion Counseling

Politicization ofAbortion

The

“Our patients are not coming to ‘exercise their constitutional rights.’ They want to talk about prayer and forgiveness.”

—Claire Keyes, Daily Beast1

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involves addressing the patient’s feelings about her forthcoming procedure.5 The first two func- tions are fairly straightforward (albeit often compromised by leg- islative mandates), but counseling practices have varied consider- ably among different abortion- providing settings and have changed over time.

The field of abortion counsel- ing has evolved considerably from its origins in the abortion rights movement of the 1970s. The field has faced significant challenges, primarily from the increasing politicization and stig- matization of abortion since legal- ization. Abortion counseling has been affected not only by the imposition of antiabortion stat- utes, but also by the changing needs of patients who have come of age in a very different era than when this occupation was first developed. One major innovation, head and heart counseling, departs in significant ways from previous conventions of the field and illustrates the complex and changing political meanings of abortion—and therefore the chal- lenges to abortion providers—in the years following Roe.

Abortion counseling can be viewed as a case study of a new occupation, created by one social movement—the abortion rights movement of the 1970s—but sharply affected by another, the antiabortion movement that shortly followed. Abortion coun- seling can be understood as a movement-affiliated occupation that ultimately found itself torn between the political needs of the larger abortion rights movement and the emotional needs of many of the individuals served by the provider wing of that movement. To understand the history of abortion counseling and its cur- rent challenges, I conducted

interviews with 25 veteran abor- tion counselors who have worked in this field since the years sur- rounding the Roe v Wade deci- sion in 1973.6

ORIGINS OF ABORTION COUNSELING

Abortion counseling as a dis- tinct component of the abortion visit had its roots in the early 1970s, before Roe, in the first freestanding clinics established in New York City and Washington, DC, both of which had by then legalized abortion. The motiva- tion of the clinic founders (mainly physicians) to incorpo- rate a specific counseling func- tion into abortion care stemmed from the dearth of knowledge about delivering this procedure to large numbers of healthy women. Before the early 1970s, legal abortions had been largely confined to a few women, typi- cally very ill or carrying severely compromised fetuses, who went before therapeutic abortion com- mittees in hospitals and had their abortions performed under gen- eral anesthesia.7 Abortion legal- ization in New York and Washington coincided with two medical developments: the intro- duction of the vacuum suction machine to US physicians and localized anesthesia methods that increased the safety of abortion and made it feasible to offer out- patient procedures in freestand- ing clinics.8 At a landmark medical meeting on abortion in 1968, doctors sympathetic to abortion expressed concerns about what it would be like to provide outpatient abortions to large numbers of women who would be coming from all over the country and shortly thereaf- ter returning to their home communities.

These physicians realized, often to their discomfort, that legal abortion was unique as a medical procedure, in that other- wise healthy women were them- selves diagnosing their condition and its solution, rendering the physician a mere “technician.” Some of those at the meeting bristled at the idea of acting as a “rubber stamp,” in the words of the famed obstetrician–gynecolo- gist Alan Guttmacher,9 and expressed confusion as to whether it was an appropriate role for the physician to discuss the social, psychological, and

” “Abortion counseling has been affected not only by the imposition of antiabortion statutes, but also by the changing needs of patients who

have come of age in a very different era than when this occupation was first developed.

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advocacy-oriented counselors brought with them to their work also led to skepticism about, if not aversion to, more conven- tional forms of therapy in the clinic. As Barbara, who opened a clinic on the West Coast with a friend shortly after Roe, put it,

From the very beginning, we used the word “counseling” only because we didn’t have another word for it, and it came out of our mouths only every once a while. But mostly we used the word “advocate.” . . . We were women’s advocates, we did in- formation sharing, we did in- formed consent. . . . We thought counseling was patronizing. We always thought that women should come to us as they are and our role wasn’t to fix them. . . . They didn’t need fixing! They needed tools, they needed information, they needed to take control over their lives.

Yet during this same period a more professionalized concept of the role of abortion counselor was being developed, one that focused more sharply on counsel- ing techniques and that put the patient’s feelings at the center of the abortion experience. This model was most strongly associ- ated with Washington, DC’s Pre- term Clinic (one of several Preterm Clinics operating in that period) which quickly became known as a major training center for abortion workers from all over the country. As a 1976 Pre- term manual stated,

The new element [in freestand- ing abortion clinics] is the intro- duction of a counselor in full partnership with the medical team that is concerned with emotional and physical aspects of patient care. Counselors are trained to work as co-profes- sionals with the physician and

other medical staff. 14

Terry Beresford, author of sev- eral influential works on abortion

moral aspects of abortion with the patient, along with the medical ones. The response by Robert Hall—another leading physician advocate for legal abortion of that era—is one that seems to have carried the day: “She [the patient] should receive some guidance (but) not necessarily from a doctor.”10As the first free- standing abortion clinics were established, the founders drew on allies from the feminist health community to work as counsel- ors. These were typically women in their 20s, who had been a crucial part of the political coali- tion to legalize abortion and who, often, had themselves undergone an abortion.11

ADVOCACY VS PROFESSIONALISM

In this formative period, two different, if overlapping, models arose regarding what this new occupation of abortion counseling should comprise. Many of the feminist activists who were among the first counselors to be hired, particularly in New York, understood their job as primarily political. They saw their task as advocacy for the abortion patient: that is, to protect her from facili- ties that the counselors perceived as unsafe or overpriced. Inside the clinic, the counselor’s role was to guide the patient through- out the abortion process, attend- ing to both her emotional and her physical needs.

Counselors adhering to this advocacy model would meet out- of-town patients at the airport, accompany them to the clinic, inform them of all that would be occurring, and answer any ques- tions. During the abortion itself, the counselor would continue this advocacy by speaking on a patient’s behalf to the doctor,

and sometimes to clinic manage- ment, about any distress she might experience. As a counselor from that period recounted, some years later, to a researcher,

It blows my mind, thinking about it now, about how much power we [counselors] had. . . . The doctors were just terribly nervous about the whole thing and were willing to listen to us—about what kind of counsel- ing services there should be, about all kinds of things. If one of the doctors they hired was causing too much pain or say- ing disgusting things to patients, we’d run into the director’s of- fice and get him fired.12

Indeed, the chapter on abor- tion in the 1973 edition (though not later editions) of the feminist health classic Our Bodies, Our- selves states, “Probably the most important person you would come in contact with during an abortion would be the abortion counselor.”13

The atmosphere surrounding this form of advocacy counseling in the early 1970s was overtly political, with the victory of legal abortion viewed by the newly hired counselors as inseparable from the women’s liberation movement of that era. As Cathy, who worked in one of the first legal abortion clinics in a major northeastern city, described in an interview the culture of her clinic and its first generation of counselors,

We were jubilant when Roe became the law of the land. And the fervor and joy that we brought to our work was very evident. . . . There was al- most a giddiness about women’s rights and women’s bodies. . . . Women’s liberation was very much part of the whole group of us.

The feminist politics that many of this first generation of

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were provided, and that would increase referrals, Baker said in an interview. She described her early days in the clinic as a time of discovery. She and two other newly hired counselors learned on the fly:

It was trial by error. There was nothing written about abortion counseling. We would just go in and talk to the woman, and we’d come out, and at the end of the day we’d get together and we’d discuss the women we saw, what they said, what we said to them.

Despite being given consider- able freedom by the clinic man- ager to devise their own protocols for counseling, Baker and her colleagues quickly became frustrated by the time pressures they felt—in particular, not to keep the clinic doctor waiting, if a particular counseling session was taking up too much time—a tension that exists in many clinics to this day.

And when I went to the first three-day workshop that Terry Beresford gave for all of us fledglings across the country, we all had the same complaints: we were being rushed, and we wanted to be able to have more time with the patients, because things would come up. They would start talking about guilt, they would start crying, they would start talking about killing the baby—we couldn’t say to them, “’scuse me, I have 10 minutes for this [counseling session].”

Attendance at Beresford’s train- ing sessions was a transformative experience for Baker and facili- tated her own professional devel- opment as an eventual leader in the field. Recalling the “empower- ing experience” of the Baltimore workshops, she described a boost in confidence in her professional abilities as a counselor, especially in possessing the skills to deal

budget, would not be kept wait- ing. As security and other costs began to rise, the hiring of ade- quate numbers of counselors became one of the easiest items in the clinic budget to cut. Beresford explained,

So the goal of counseling changed. . . . At Preterm, the goal had been to make this ex- perience life changing for the woman. Later, the goal became, “don’t let anybody get through who’s really disturbed or doesn’t know what they’re doing.16

Beresford expressed both wist- fulness that the original Preterm model was lost—“We used to get letters from people that would make you weep about what the experience had meant to them, it changed their lives”—and recog- nized that such a model, where patients were offered up to an hour of individual counseling, and sometimes more, could not be replicated elsewhere or indeed, continued even at the several Preterm Clinics themselves.

Beresford, after her Preterm experience, worked at Planned Parenthood of Baltimore, Mary- land. In the late 1970s, she inau- gurated the first training sessions for abortion counselors that drew participants from across the country. These workshops, beyond the practical skills they developed, helped to forge an occupational identity and sense of community for counselors in both independent clinics and Planned Parenthood facilities.

One attendee at a Beresford workshop was Anne Baker. She started work in a newly opened midwestern abortion facility in 1976 after graduating college. The physician-owner of the clinic thought his facility would be more reputable if counseling

counseling15 and a leading trainer until her recent retirement, became involved in abortion work while at the DC Preterm Clinic, where she ultimately became director of staff development. Beresford and the clinic’s first medical director, a fervent cham- pion of in-depth counseling, devel- oped their own approach, as Beresford recalled in an interview:

You would help the person de- cide if they were clear about their decision, you’d help to weed out people who were being coerced and you would be preparing the patient to be relaxed and comfortable for an outpatient procedure. . . . So every women would be seen for at least up to an hour, as needed. . . . The model was to help the patient do some self-ex- ploration so she reaches under- standing of herself, her feelings, and her options, and can then take an action, and is assisted in taking that action. . . . Your job as a counselor is to affirm her competency and her sense of self-worth, and her ability to act on her understanding.

In short, the model of counsel- ing initially developed at Preterm was not just about abortion per se. The model also used the experience of the abortion deci- sion—“often the first important decision a woman may have had to make in her life,” as Beresford and other counselors frequently put it—as a vehicle to lead the woman to confront other impor- tant issues in her life.

Beresford acknowledged that as the abortion field grew, the very expansive view of counseling that had been developed at Preterm became difficult, if not impossible, to sustain, for several reasons. One was clinic flow—that is, patients needed to be moved pre- dictably and smoothly through the abortion process, so doctors, whose salaries were the most expensive element in the clinic

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contrast between those she saw in a New York State clinic in the early 1970s and those she was seeing in her midwestern state by the late 1980s:

When I started, we didn’t see patients who were “ambivalent.” They would drive through a snowstorm to show up in an- other state—or they were going to have a baby. It was really crystal clear!

But counselors were now see- ing some patients with no mem- ory of, or affinity with, the feminist and pro-choice sensibili- ties of the 1970s that had ani- mated both clinic staff and many of the first generation of patients. Patients were now more apt to be apolitical, if not politically conser- vative; religious; poor; and, increasingly, women of color—in short, quite different from the mostly White, college-educated, strongly feminist-identified, mainly secular group of counselors (simi- lar to many of the patients they had seen in an earlier era) that gathered in Dallas in 1989.

In transition were not only the types of patients coming to the clinics, but also the society-wide “feeling rules” governing abor- tion, to use the formulation of the sociologist Arlie Hochschild.19 Numerous forces in American society during the 1980s—the presidency of Ronald Reagan,20 the increasing strength of the National Right to Life Committee and similar organizations, and the widely distributed film The Silent Scream, which purported to show a late abortion—were driving a change in the dominant feeling rules regarding abortion from a woman’s right to a shameful, immoral, and selfish act.21

The impact of these changes at the clinic level, revealed in November Gang discussions, was that noticeably more patients

with challenging patient issues: “Now when they [patients] brought up guilt, we weren’t so afraid of it, we could go into it.” Baker compiled a list of counsel- ing techniques that seemed to work particularly well and even- tually wrote several influential works on counseling.17

Baker also innovated a system of second evaluations, in which patients whom counselors per- ceived to need extra attention would be seen again by either Baker herself or another senior counselor. This move to second evaluations was an early version of the triage that would be expanded on by the head and heart model of counseling.

THE NOVEMBER GANG

In 1989, a group of about 30 women who worked as counsel- ors or clinic managers in inde- pendent clinics (as opposed to Planned Parenthood or hospital- based clinics) began meeting informally to discuss their work and to offer one another personal support. This group (which meets to this day) became known as the November Gang because of the date of its first meeting, which was convened by Charlotte Taft, a longtime counselor and then a clinic director in Texas, and another counselor from Utah.

The immediate precipitant for the first meeting was the

Supreme Court decision in Web- ster v. Reproductive Health Ser- vices, handed down in July 1989.18 Webster, which allowed extensive new abortion restric- tions, also led many to fear an eventual overturning of Roe. The original members of the Novem- ber Gang were alarmed by the possible implications of this rul- ing and were dismayed that the national pro-choice organizations seemed helpless to respond. However, what drew them to gather in an airport hotel in Dal- las, Texas, was not only national abortion politics. The increasing strength of the antiabortion movement, culturally as well as politically, in the 15 years since legalization also deeply con- cerned them. Meeting partici- pants were increasingly aware of how the antiabortion move- ment’s success in stigmatizing abortion was shaping the responses of their patients, more of whom were now coming to the clinics visibly conflicted.

Robin, a midwestern coun- selor, colorfully captured the hunger that many of the counsel- ors then felt, both for community building and for confronting the impact of larger abortion politics on their work. As she recalled in an interview, when she heard about that first November Gang meeting,

It was the first time I was going to leave my two young kids at home. . . . I said I would crawl on my belly over broken glass. . . . I just knew I had to get there.

At these first meetings, those who had been involved in abor- tion since Roe, or in some cases before, acknowledged the chal- lenges presented by some con- temporary patients. Robin, for example, remembered drawing a

” “Baker also innovated a system of second evaluations, in which patients whom counselors perceived to need

extra attention would be seen again by either Baker herself or another

senior counselor.

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Although checking with the patient on the second item, coer- cion, had long been part of coun- seling practice, the other issues had not been as systematically addressed by counselors. In Taft’s clinic, and in the others that adapted her model, patients whose responses to the state- ments raised concern not only were given more counseling, but also were asked to do more reflec- tion on their own, with the help of materials supplied by the clinic. Over time, the most widely used of these supplementary materials have become a workbook, devel- oped by a longtime counselor and clinic manager, Margaret John- ston.23 In this workbook, origi- nally published in 1998, the prospective patient is led through exercises that explore her feelings about abortion, her assumptions about her support system’s reac- tion if she has the abortion or continues her pregnancy, her anticipated emotional reactions about adoption, and so on.

To implement this mode of counseling, many early Novem- ber Gang attendees had to relin- quish their previous commitment to a more unobtrusive approach. As Arlene put it,

It involved really getting women to talk about where they are in their process, to step away from this, “Her feelings are not my business, if she made it through the door, it’s all okay.” We had to acknowledge that women were coming in with ambiva- lence, that some women come into clinics who shouldn’t be there, that being able to say no to someone who’s not in a good place in their decision is the right thing to do, and we’ve got to learn the skills to do it.

Clearly, head and heart coun- seling implied changing several long-standing clinic conventions; the most striking change, rarely done, was sending an ambivalent

A woman comes in, and in her head she says “I know that an abortion is the right decision for me,” but her heart is breaking. So she wants an abortion and then she changes her mind, or she’s sobbing, or she says, “I think an abortion is killing my baby, but I have to have one anyway.” So it became an easy way for us to describe what we were trying to do when we said, “If we can get the woman to connect her head and heart before her abortion, how much healthier will she be afterwards.”

CHANGES IN COUNSELING PRACTICE

The core of Taft’s argument, which formed the basis of this new approach, is that “just as there may be medical contraindica- tions to providing an abortion . . . there are attitudinal contraindi- cations to providing an abortion as well.” These attitudinal contra- indications can in most cases, Taft believes, be resolved through counseling, but if they are unresolved, the patient is not an appropriate candidate for an abortion. Taft’s staff used a checklist of statements during the patient’s first contact to deter- mine whether the woman needed more extensive counsel- ing before an abortion could take place:

1. I’m against abortion but I have no other choice.

2. I don’t want an abortion but someone else is forcing me or pressuring me.

3. I believe that having an abor- tion is the same as murdering a born person.

4. I believe if I have an abortion I will never be forgiven and I will be separated forever from God or my Higher Power.

5. I believe I will regret having an abortion.22

were showing signs of difficulty with their abortion decision. Arlene, an interviewee who worked in Florida at that time, recalled in stark terms her grow- ing realization of such changes: “Every so often you’d walk through the recovery room and you’d see a woman just falling apart.”

It was admittedly difficult for some of the counselors to acknowledge the ambivalence, if not anguish, of some patients. As one early Gang participant said,

I think we fought so hard to protect abortion rights that there was a real hesitation on anybody’s part to address that [for] some women, abortion might be hurting them. They shouldn’t be a candidate for an abortion, or at least they weren’t ready to have it on the day they came in.

Similarly, Meg, an East Coast counselor recollected,

We would talk at great length about “if we are doing such great work, why are we losing politically?” And we realized that we were doing work that was all about access and not about the quality of the experience.

Some at those first meetings even gave grudging credit to antiabortion forces for being more attuned to patients’ con- flicted feelings. As Meg said,

They tapped into things that pa- tients were concerned with. . . . I . . . felt bad that they were doing a better job at listening to women than we were . . . and we weren’t doing anything. In fact, we were quite adamantly denying that reality.

At these early November Gang meetings, Taft introduced her colleagues to a new model she had developed with her staff: head and heart counseling. As she later explained in an interview,

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written widely, and controver- sially, on the alleged psychologi- cal damage suffered by abortion recipients.29 WEBA, a group now apparently defunct (although sim- ilar groups are active), was very effective in staging opportunities for its members to speak about their regretted abortions.

Several of the women I inter- viewed specifically mentioned their concern about creating recruits for WEBA as an addi- tional motive for identifying ambivalent clients. Anne Baker was forthright about her con- cerns about WEBA, regarding both the psychological manipula- tion vulnerable abortion patients might be subjected to and poten- tial harm to the abortion-provid- ing community. Explaining her realization that some clients should not have an abortion the day of the appointment, or per- haps ever, Baker said,

We felt like we had an obliga- tion also to protect ourselves. . . . We decided early on we are not going to provide fuel for the fire of WEBA So if a woman is cry- ing and distressed and [saying], “Everyone else is trashy but me out in that waiting room and I know I’m going to feel horrible, I’m going to regret it but this is what I need to do,” well, we could say, “No, not here, not now. We are going to send you home, here are some things you can read, here are some coun- seling referrals. You can come back, but we want to be able to see some kind of change in your acceptance, in your ability to cope.”

Robin gave an example of a patient who raised enough red flags that her abortion was delayed (although eventually it took place). “This patient said to us, ‘You have to do my abortion, because you guys are baby kill- ers and you all are going to go to hell anyway.’”

patient home for further consid- eration of her decision.24 In such cases, most patients returned later, more comfortable with or, in Taft’s terminology, more “resolved” about the decision to abort. In some cases, such patients did not return, and counselors acknowledged that it was not known whether they went to another clinic or ulti- mately decided against an abor- tion. In some cases, women who had been urged to delay later wrote to the clinic, enclosing pic- tures of their child and thanking the counselors for helping lead them to this outcome.

Yet another change brought about by this new approach con- cerned the delicate issue of the language used in counseling, which had long vexed the abor- tion-providing community.25 As Cathy, one of the original November Gang attendees, reflected in an interview on her realization at an early meeting,

All of a sudden it occurred to me, why am I not using her lan- guage? You know, we were told, you never, never say “baby.” And if a patient says “baby,” you correct her. You tell her, “It’s not a baby, it’s cells, it’s a fetus,” whatever. And after a point, it felt offensive to be denying this woman her own experience, using her own language. And so once that hit me, I remember [realizing] if you can hear that, then you can hear everything else that she’s saying.

Similarly, Robin described her decision to take on the potentially explosive issue of patients’ occa- sional use of the word “killing.”26 After her exposure to discussions of head and heart counseling, she changed her previous practice of avoiding such language when brought up by the patient. “If the patient used that language, we didn’t correct her. We took the language she used and we talked

to her. And what we found was that patients were opening up to us in ways they had not before— because they weren’t being cor- rected, which they might have seen as a criticism.”

Meg recalled the difficulties but ultimately the importance of hearing the patients’ concerns about killing:

A woman says, “I feel like I’m killing my baby” . . . we were like, “OK, let’s just stick with whatever her reality is and ask how that is for her.” . . . We would have conversations about killing, and “Is killing the same as murdering? Is there ever a time when killing is justified?” . . . We could go from there to “Well, you’re trying to protect the lives of the three kids you’ve got.” . . . To explore those issues with them in a safe place—you had the feeling you might be the only person they’ve ever had that conversation with.

Several interviewees acknowl- edged that these changes in lan- guage were difficult to accept for those in the pro-choice movement, even among their own clinic peers. Cathy recol- lected colleagues’ jeers at a national conference when she shared her changed language practices. “There were real fears at that point that we were play- ing into the hands of antiabor- tion people, of allowing patients to use that language.” Meg simi- larly recalled her own staff writ- ing to a feminist journal to object to an article she had writ- ten urging these language innovations.27

Yet another change came with the acknowledgment that many more patients now than in the immediate post-Roe period were raising spiritual concerns. Cathy related in an interview,

That was another thing that was a no-no when I went to

school [graduate work in coun- seling]. You know, “the spiritual or religious stuff had no place in counseling.” But that isn’t how it was for our patients. . . . They would say everything from “Am I going to burn in hell?” to . . . “What if God de- cides to punish one of my other children?” It was a major theme for a small percentage of women. In fact it was in some cases the only thing that they were worried about.

Anne Baker, though not for- mally part of the November Gang, was very influential, through informal contacts with many group members, in estab- lishing the rationale of addressing spiritual issues with abortion patients. Starting in the early 1980s, after hearing so many patients raise religious issues, she invited local clergy to help her largely secular staff deal with such concerns.

An Episcopal priest came and talked to us. And he was just amazed at what we had to deal with in our counseling sessions. He said, “You are having an in- credible opportunity. . . . You’re working with these people in the moment of their greatest need for pastoral counseling.”28

RESPONSE TO CLAIMS OF ABORTION DAMAGE

The development of head and heart counseling was primarily driven by the desire to attend to the emotional well-being of abor- tion patients. However, another impetus was the growth of sev- eral antiabortion organizations that specifically targeted women who regretted their abortions. The best known of these organi- zations at the time of the Novem- ber Gang’s founding was WEBA (Women Exploited by Abortion), a group started in 1982 by David Reardon, a psychologist who has

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and suicide. Often the time allocated to counseling must be spent undoing the fright caused by such state-mandated in- formation.

4. A. Perrucci, Decision Assessment and Counseling in Abortion Care: Philosophy and Practice (Boulder, CO: Rowan and Littlefield Publishers, 2012), 6.

5. A. Baker and T. Beresford, “Informed Consent, Patient Education and Coun- seling,” in Management of Unintended and Abnormal Pregnancy: Comprehensive Abortion Care, ed. M. Paul, S. Lichten- ber, L. Borgatta, D. A. Grimes, P. G. Stubblefield, and M. D. Creinin (Oxford, UK: Wiley–Blackwell, 2009), 48–53.

6. I used the real and full names of in- terviewees who have written about abortion counseling. For other inter- viewees, I used only a pseudonymous first name. I selected interviewees from a pool of counselors I know to have been involved in abortion from the pe- riod around Roe. I obtained other in- terviewees via the snowball method; that is, initial interviewees suggested others who had similarly worked in the field for a very long period. All inter- viewees worked at (or were retired from) independent freestanding abor- tion clinics.

7. The therapeutic abortion committees, and their often unfair practices, such as developing informal quotas and favor- ing private patients over ward patients, are discussed at length in L. Reagan, When Abortion Was a Crime: Women, Medicine and the Law, 1867–1973 (Berkeley, CA: University of California Press, 1997). See also C. Joffe, Doctors of Conscience: The Struggle to Provide Abortion Before and After Roe v. Wade (Boston, MA: Beacon Press, 1995), 119–127.

8. Joffe, Doctors of Conscience, 135– 138.

9. R. Hall, ed., Abortion in a Changing World (New York, NY: Columbia Uni- versity Press, 1970), 2:108.

10. Ibid., 109.

11. C. Joffe, T Weitz, and C. Stacey, “Uneasy Allies: Pro-Choice Physicians, Feminist Health Activists and the Strug- gle for Abortion Rights,” in Social Move- ments in Health, ed. P. Brown and S. Za- vestoski (Oxford, UK: Blackwell Publishing, 2005), 94–115.

12. C. Joffe, The Regulation of Sexuality: Experiences of Family Planning Workers (Philadelphia, PA: Temple University Press, 1986), 36.

13. Boston Women’s Health Book Col- lective. Our Bodies, Ourselves: A Book By and For Women (New York, NY: Simon and Schuster, 1973), 147.

that their own political commit- ment to the larger abortion rights movement was interfering with another deeply held political and occupational commitment —to best meet the diverse needs of their patients. Acting on this real- ization, they broke, not without controversy, with previous coun- seling conventions.

About the Author Carole Joffe is with the Bixby Center for Global Reproductive Health, Department of Obstetrics, Gynecology, and Reproduc- tive Sciences, University of California, San Francisco.

Correspondence should be sent to Car- ole Joffe, ANSIRH, 1330 Broadway, Suite 1100, Oakland, CA 94612 (e-mail: jof- [email protected]). Reprints can be or- dered at http://www.ajph.org by clicking the “Reprints” link.

This article was accepted September 2, 2012.

Acknowledgments The author gratefully acknowledges sup- port from the Society of Family Planning to conduct this research.

I thank Heather Gould, Katrina Kim- port, Steph Herold, and Leslie Reagan for their comments on an earlier draft of this article and Elisette Weiss for her ex- cellent research assistance.

Human Participant Protection This research received approval from the institutional review board of the University of California, San Francisco.

Endnotes 1. E. Thomas, “Reality Check for ‘Roe,’” Daily Beast, http://www.thedailybeast. com/newsweek/2006/03/05/reality- check-for-roe.html (accessed June 28, 2012).

2. Roe v. Wade, 410 US 113 (1973).

3. In a rigorous review conducted sev- eral years ago by the Guttmacher Insti- tute, researchers found that 23 of the 33 states that had specific requirements for information to be imparted to pa- tients included “information not in keep- ing with the fundamental tenets of in- formed consent.” R. Gold and E. Nash, “State Abortion Counseling Policies and the Fundamental Principles of Informed Consent,” Guttmacher Policy Review 10, no. 4 (2007): 6–13. Such counseling mandates include information that is misleading, or, in some cases, blatantly untrue, such as the alleged link between abortion and breast cancer, infertility,

SIGNIFICANCE OF HEAD AND HEART COUNSELING

It is not possible to say with any precision how many of the approximately 1790 abortion- providing facilities in the United States30 employ the head and heart counseling approach, nor more generally what their coun- seling practices are. The many pressures facing beleaguered pro- viders—the huge security costs, which cut into the resources available for hiring and training counselors; the necessity to devote limited counseling time to state-imposed counseling man- dates, as well as to calming down rattled patients confronted by screaming picketers as they approach the clinic—have made it difficult for many to offer more than cursory counseling of any kind. The facilities most likely to incorporate aspects of the head and heart approach are affiliated with the Abortion Care Network, an association of independent clinics.31 Seemingly, the most adopted aspect of this approach is emotional triage. The concepts and techniques of this form of counseling continue to be shared at network conferences, as well as at meetings of the National Abortion Federation, an umbrella group of abortion providers.

The development of head and heart counseling is a moving story of clinic workers whose political identities were forged in the Roe era, who gradually came to perceive a gap between them- selves and many of their patients and to realize that these patients had quite different understand- ings of the abortion issue and therefore different needs as abor- tion recipients than had previ- ously been the norm in abortion care. In simplest terms, these counselors came to understand

14. A Guide for Training Abortion Coun- selors (Newton, MA: Preterm Institute, 1976), 1.

15. T. Beresford, Short Term Relationship Counseling (Baltimore, MD: Planned Parenthood of Maryland, 1977); How to Be a Trainer: A Self-Instructional Manual for Training in Sexual and Reproductive Health Care (Baltimore, MD: Planned Parenthood of Maryland, 1980); and A. Baker and T. Beresford, “Informed Consent, Patient Education and Coun- seling,” in Paul et al., Management of Unintended and Abnormal Pregnancy, 48–53.

16. To be sure, this expansive notion of what the abortion experience might be has not entirely disappeared. Amy Hag- strom Miller, who runs several clinics in Texas, Minnesota, and Maryland, has re- cently written about abortion in terms quite similar to those used by Beresford to describe the original Preterm model: “An unplanned pregnancy experience shines a bright light on a woman’s life. The experience challenges her to look at everything—her hopes and her dreams, her relationship choices, her ideas about family and career, her plans for the future, her intentions. For many women, abortion can be a transforma- tional experience—one where she ac- tively chooses what she wants for her life, one where she is in charge.” A. H. Miller, “Work to End the Stigma,” (St. Paul, MN: Minnesota Women’s Press) http://www.womenspress.com/main.asp ?FromHome=1&TypeID=1&ArticleID= 4099&SectionID=124&SubSectio nID=684 (accessed July 3, 2012).

17. A. Baker, Abortion and Options Counseling: A Comprehensive Reference (Granite City, IL: Hope Clinic for Women, 1995); and A. Baker, Coping Well After an Abortion (Granite City, IL: Hope Clinic for Women, 2007).

18. Webster v. Reproductive Health Ser- vices, 492 US 490 (1989). The deci- sion upheld a Missouri law that imposed restrictions on the use of state funds, fa- cilities, and employees in performing, assisting with, or counseling on abor- tions. The Supreme Court in this deci- sion allowed for states to legislate in an area that had previously been thought to be forbidden under Roe v. Wade and confirmed some abortion providers’ fears that some of the justices were ready to overturn Roe altogether or, at the very least, that more regulations on abortion provision were certain to come.

19. As Hochschild argues, emotions have a social as well as a psychological component, and different groups in society struggle to assert the legitimacy of their favored frames of how one is “supposed to feel” about certain phenomena,

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especially contested ones. A. Hochs- child, “Emotion Work, Feeling Rules, and Social Structure,” American Journal of Sociology 85, no. 3 (1979), 551– 575.

20. The antiabortion movement had been growing in size and influence ever since the 1973 Roe decision; however, the election of Ronald Reagan in 1980—an effort to which the movement had contributed many resources— marked a turning point in the move- ment’s influence in political circles, in- cluding Reagan’s Cabinet picks, selection of Supreme Court nominees, and so on. This political coming of age of the antiabortion movement is well documented in M. McKeegan, Abortion Politics: Mutiny in the Ranks of the Right (New York, NY: Free Press, 1992).

21. Of course, as a perceptive anony- mous reviewer for this journal pointed out, the feeling rules surrounding abor- tion may well have changed for the counselors as well as for their patients. This is an intriguing question for which my interviews do not contain a direct an- swer. In the most general terms, it is fair to say that the abortion-providing com- munity—counselors as well as clinicians— has always had a diversity of views about abortion (e.g., some see abortion as sad but necessary and others reject that formulation, viewing the abortion decision as often the first decision a woman has made for herself and the first step in taking control of her life). However, I speculate that the counselors I interviewed had less change in their own views about abortion than did the general public, including patients, be- cause so much of their professional and political identity revolved around the protection of legal abortion. The various admissions made by interviewees of their regrets about not “hearing” their patients sooner suggest this.

22. C. Taft, “Abortion Counseling—the Full Head and Heart Process” (unpub- lished paper), 2010. This paper was cir- culated by Taft to fellow members of the Abortion Care Network, to help them make best use of the Pregnancy Options Workbook (see note 23). One of the earliest compilations of head and heart counseling principles was Abortion Resolution Workbook: Ways to Connect the Head and Heart, a 1991 booklet pre- pared by the staff of the Routh Street Women’s Clinic, in Dallas, where Taft then served as clinic director. Eventu- ally, portions of this approach were in- corporated into a two-page precounsel- ing needs assessment form written by Anne Baker for use in her Illinois clinic and reprinted in the leading textbook on abortion provision in the United States: Paul et al., Management of Unin- tended and Abnormal Pregnancy, 52–53.

Carhart, stated, “While we find no reli- able data to measure the phenomenon, it seems unexceptionable to conclude some women come to regret their choice to abort the infant life they once created and sustained. Severe depression and loss of esteem can follow.” Gonzales v. Carhart, 127 S.CT. (2007), 1610.

30. The figure of 1790 abortion-provid- ing facilities in the United States comes from the Guttmacher Institute, http:// www.guttmacher.org/media/ nr/2011/01/11/index.html (accessed June 28, 2012). In one of the few stud- ies of clinic counseling practices, a re- search team from the University of Cali- fornia, San Francisco surveyed 27 clinics and found that 96% of them re- ported providing information about the abortion procedure; nearly as many stated that they checked on the “cer- tainty of patients’ decisions.” Some 74% reported that they “assess the patients’ feelings and provide emotional support.” H. Gould, A. Perrucci, R. Barar, D. Sink- ford, and D. G. Foster, “Patient Educa- tion and Emotional Support Practices in Abortion Care Facilities in the United States,” Women’s Health Issues 22, no. 4 (2012): e359–e364. No reliable studies of counseling effectiveness nor of the superiority of one model of counseling over another have been published.

31. Planned Parenthood clinics that pro- vide abortions have taken a more stan- dardized approach to abortion counsel- ing, have not used the head and heart model, and, in general, have done less in-depth counseling. However, the Planned Parenthood Federation an- nounced a new approach to meeting the emotional needs of its abortion pa- tients and developed a training program for all staff who interact with abortion patients. Its new training manual states, “Addressing emotional issues is similar to addressing physical ones. So, just as we provide antibiotic prophylaxis to pre- vent infection, this training supports giv- ing clients ‘emotional prophylaxis.’” Not unlike head and heart efforts, this man- ual also stipulates that patients should be screened for potential risk of poor coping after an abortion, such as “stigma and social disapproval of oth- ers,” “coercion or history of abuse,” and so on. Talking About Abortion (New York, NY: Planned Parenthood Federa- tion of America, 2008), 1,2.

23. Johnston M, ed., Pregnancy Options Workbook: A Resource for Women Mak- ing a Difficult Decision (Binghamton, NY: Ferre Institute, 2006); and John- ston M, ed., A Guide to Emotional and Spiritual Resolution After an Abortion (Binghampton, NY: Ferre Institute, 2008). These publications are also available at http://www.pregnancyo- ptions.info (accessed June 28, 2012).

24. The counselors I interviewed esti- mated that the number of patients whose initial screening led to their being sent home or, if they lived too far from the clinic, their abortions being delayed for a few hours of further re- flection and work with clinic-provided materials such as the Pregnancy Options Workbook, was 1% to 5% of the total patient load. A somewhat larger group, approximately 10% according to some interviewees, proceeded with their abor- tions as scheduled, but only after more extensive counseling than was received by other patients. These figures are con- sistent with a large study recently com- pleted by researchers at the University of California, San Francisco, which ex- amined data from the precounseling needs assessment forms and clinic in- take forms of more than 5000 patients at one US clinic and concluded that 87% of women seeking abortions had “high confidence in their decision” be- fore receiving counseling. D. Foster, H. Gould, J. Taylor, and T. Weitz, “Attitudes and Decision Making among Women Seeking Abortion at One U.S. Clinic,” Perspectives on Sexual and Reproductive Health 44, no. 2 (2012): 117–124.

25. Joffe, Regulation of Sexuality, 94.

26. Alissa Perrucci offers an extended and sensitive discussion of how to coun- sel patients who believe abortion is murder, yet wish to have an abortion: Decision Assessment and Counseling in Abortion Care, 87–115.

27. It is impossible to answer the ques- tion of whether the practices of those using the head and heart approach—that is, acknowledging the emotional difficul- ties some women have with abortion, and incorporating into the counseling session such previously taboo language as “killing” and “baby”—have hurt either the larger abortion rights movement or others in the abortion-providing commu- nity who do not use these practices. However, the fears earlier expressed by some have not come to pass. In 2003, Glamour magazine published an article on the November Gang, and this gener- ated predictably negative attention from several antiabortion groups: “Are you ready to understand abortion?” Glamour, September 2003, 264–267, 294–295, 299. Since then, however, the denuncia- tions of abortion and its alleged harm to women by abortion opponents have

ignored both the November Gang and its counseling approach. It is possible that abortions that are denied or delayed for the most conflicted women, as urged by head and heart adherents, in fact have reduced the number of women who come to regret their abortion, but no evidence exists to verify this.

28. Liberal clergy from a variety of de- nominations were active in abortion referrals in the pre-Roe era. For an ac- count by its founders of the Clergy Con- sultation Service, see A. Carmen and H. Moody, Abortion Counseling and Social Change: From Illegal Act to Medical Prac- tice (New York, NY: Judson Press, 1973). After legalization, direct clergy partici- pation dropped off, although a notable exception, besides Baker, was the late George Tiller, who was assassinated by an anti-abortion extremist in May 2009. Tiller, who provided post–24- week abortions to women who were carrying fetuses with anomalies or who had serious health conditions of their own, hired a chaplain to minister to these grieving patients and devoted a special space in his clinic to meditation and prayer. See C. Joffe, “Working with Dr. Tiller: Staff Recollections of Wom- en’s Health Services of Wichita,” Per- spectives on Sexual and Reproductive Health 43, no. 3 (2011): 199–204. More recently, there has been an up- surge of interest in bringing spiritual el- ements into the clinic for those patients who wish this, and two groups in partic- ular, the Religious Coalition for Repro- ductive Choice and Faith Aloud, have been prominent in these efforts.

29. Reardon, who holds a BA degree in electrical engineering, subsequently re- ceived a PhD degree in biomedical eth- ics from Pacific Western University, an unaccredited correspondence school of- fering no classroom instruction. His claim, made in numerous books and arti- cles, that abortion causes mental illness, has been repeatedly challenged by lead- ing psychologists, such as Brenda Majors of the University of California, Santa Bar- bara; Nancy Russo of the University of Arizona; and Julia Steinberg of the Uni- versity of California, San Francisco. A task force of the American Psychological Association has on several occasions challenged the existence of “postabortion syndrome.” B. Major, M. Appelbaum, L. Beckman, M. A. Dutton, N. F. Russo, and C. West, “Abortion and Mental Health: Evaluating the Evidence,” American Psy- chologist 64, no. 9 (2009): 863–890. Nevertheless, to the dismay of many in the abortion-providing community, the notion of postabortion syndrome re- ceived a substantial boost in legitimacy in 2007, when Justice Anthony Ken- nedy, writing for the majority in the Supreme Court’s decision in Gonzales v.

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