She ended her relationship two weeks prior upon realizing her ex-boyfriend was too manipulative. They talked about having a baby in the future, though under the right conditions—perhaps marriage and definitely with medical supervision given Terry's age, her blood pressure condition and previous history of preeclampsia.
She chose abortion because it was the right decision for her and her family and yet the spiteful thoughts about ending the pregnancy came rapidly and without reprieve. She felt stupid. Her sister, though, wouldn't hear it.
"That’s not stupid; things happen," she told Terry. "We’re still entitled to be human."
No one had ever said this about abortion to Terry.
That conversation sustains Terry, who is relaxed and smiling in the clinic. But Terry, who's had previous abortions, still feels the stranglehold of shame. She hears society insisting that it should have license to lay bare her choices and decide if she is worthy of its compassion or condemnation.
"The stigma behind it is major, it’s heavy," she says, "and it’s like, I’m not a loose woman. I do have morals. It’s not the 'way out', like it’s going to be so easy to do. This is not easy."
Terry feels society's obsession with pulling one's self up by her bootstraps to overcome impossible odds. Never mind poverty, an abusive relationship, deferred education, losing a job or any of the other reasons women cite when having an abortion; they should just find way to make it work. She knows this message is one women carry in their hearts and heads for a lifetime.
The American ethos, she knows, doesn't involve becoming weak or bowing out.
"You just fight, but who are you doing that for? I can fight and add on another child for my household—cause it’s not just for me," she says. "I can fight and add on another child to my household and put stress on myself and die when I’m 45, possibly. Or I can say, 'I’m going to fight for what I have now and the piece of mind that I have now.'"
Terry doesn't know this, but the clinic she's visiting today has worked for more than a decade to create an environment that enables women to wrestle with these complicated emotions and leave feeling, even in some small way, liberated from the shame and stigma that threatens to haunt them for years.
Whole Woman's Health may play a minor role in Terry's life, but it has waged the biggest battle to protect abortion rights in the past 25 years. On Wednesday, the Supreme Court will hear oral arguments in Whole Woman's Health v. Hellerstedt a challenge to controversial abortion regulations passed in Texas, in 2013. A decision in the plaintiff's favor would restore abortion access in Texas and stem a flood of similar bills in states around the country.
Yet, even if that happens, the stigma surrounding abortion will persist; it's what has enabled lawmakers in Texas and elsewhere to pass more than 200 restrictions on the procedure in the last 5 years.
More than four decades after Roe v. Wade, politicians continue to legislate the deeply personal decision women face when they come to know their limits and the stakes of motherhood and choose to end a pregnancy. Fearful of being branded selfish or labeled a murderer, women often turn this choice into a burden or secret. Whole Woman's Health and its founder have created an antidote to this kind of abortion experience, and it's why their approach represents a new way of understanding one of the most polarizing subjects in American culture and politics.
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As much as we yearn for a single abortion story to make sense of a complicated ethical question, like Terry's they have endless permutations and Amy Hagstrom Miller, 48, has spent nearly three decades listening to hundreds, if not thousands, of them.
Hagstrom Miller, founder and CEO of Whole Woman's Health, is fond of saying she's in the "stigma eradication, self-esteem boosting and identity examination business."
Pregnancy and abortion can reveal who we are, who we want to be, she says. Women contemplate their values, religion and spirituality. They linger on sexuality and what it means to be a mother. They recall moments of intense shame, often reflecting on the price of living in a woman's body. They think about sex, wondering if they've committed a sin by seeking intimacy that can bring one's soul to life.
Abortion can be the first time a woman takes full control of her body, life and destiny. Yet, our public debate forbids us from exploring that complexity. A woman who ends a pregnancy — one in three American women have — is often judged as selfish or a murderer.
"When you think about how many women in our culture have an abortion and you think about how many other people experience the abortion with them, it’s amazing to me that abortion is still so stigmatized," she says.
While Whole Woman's Health, a company comprising eight clinics in Texas, Illinois, Maryland, New Mexico and Minnesota, has a reputation for empathy and holistic care, its national name recognition lately comes from the lawsuit that led it to the Supreme Court.
Hagstrom Miller is fighting restrictions that require physicians to obtain admitting privileges at a nearby hospital and forces providers to build expensive ambulatory surgical centers.
Texas argues that the measures were implemented to protect women's health and safety following the 2011 discovery of Dr. Kermit Gosnell's gruesome abortion practice in Philadelphia. That case, for which Gosnell received a 30-year prison sentence, was the direct result of state officials failing to enforce existing regulations.
Professional organizations such as the American Medical Association and the American College of Obstetricians and Gynecologists say the Texas' justifications are not "medically sound" and stress that abortion is extremely safe, with a much lower mortality rate than childbirth.
The Texas restrictions were so difficult to comply with that dozens of clinics were forced to close. They permanently shuttered the Whole Woman's Health Clinic in Austin and, until an injunction prevented the law's full implementation, temporarily closed its McAllen clinic for six months.
That clinic, on the Texas-Mexico border, is the only one that provides abortions to 900,000 women of childbearing age in the Rio Grande Valley. The nearest clinic to McAllen is in San Antonio, a three-and-a-half hour drive that requires passing through an inland border checkpoint.
Texas says its restrictions don't unduly burden women, but there are now just 19 abortion providers in Texas, which is home to more than five million women of childbearing age.
The real design of these laws, says Hagstrom Miller, is to make abortion difficult or impossible to access, a motive David Dewhurst, Texas’ former lieutenant governor, publicly acknowledged at the time.
If a majority of justices find these laws unconstitutional because they place an undue burden on women, the decision will restore abortion access in Texas and stem a flood of similar bills in states around the country. With the absence of recently deceased Justice Antonin Scalia, a tied decision of 4-4 would let the lower court ruling stand, a devastating outcome not only for Hagstrom Miller, but also her patients. The decision is expected by the end of June.
This case, though, is about more than reaffirming a woman's constitutional right to access safe and legal abortion. It is a chance to confront abortion stigma and challenge the public to think beyond the tyranny of the abortion wars, which holds both sides to absolutes.
In recent years women have stepped forward to share their own abortion stories, at minimum risking humiliation and threats of violence. When former Texas legislator Wendy Davis filibustered the passage of the 2013 restrictions, she talked candidly about her own abortions. Hundreds of Texas residents later launched their own filibuster and, one after the other, spoke about their experiences.
The 1 in 3 Campaign, a storytelling initiative created by the nonprofit group Advocates for Youth, has been collecting such accounts since 2011 and submitted an amicus brief to the Supreme Court highlighting dozens of positive stories about abortion. Last fall, the #ShoutYourAbortion hashtag went viral with thousands of women and men sharing their experiences online.
Advocates are careful to stress that not everyone can or should publicly reveal an abortion, but that kind of testimony suddenly brings a woman's life and her unique circumstances into sharp focus when politicians and the public have been concerned largely about her unborn child.
"We've seen a lot of abortion storytelling, which I think is one of the ways stigma gets reduced and people 'come out of the closet,'" says Hagstrom Miller.
The abortion rights movement is working to harness the collective support with an "abortion forward" messaging campaign that replaces the decades-old, defensive mantra of "safe, legal and rare."
In Texas, Hagstrom Miller founded a nonprofit called Shift, which aims to transform the cultural messages surrounding abortion.
"We’ve been taught that good women don’t have abortions," says Hagstrom Miller. "Who's benefiting from perpetuating this stigma and how women have bought into it?"
The San Antonio Whole Woman's Health clinic is in a single-story brick medical office complex, miles from the downtown corridor.
Patients walk up to the office, with its tinted windows, press a buzzer and announce themselves. Inside, at 9 a.m. on a Tuesday morning, nearly every seat is occupied. Heads turn when the door opens, then patients go back to looking at their phones or hands.
Magazines are fanned out across an end table — OK!, Parents, Allure, Women's Health — alongside a box of tissue and a journal women use to write down their thoughts, questions and feelings. Framed posters on the wall portray empowerment: An illustration of a woman leaping victoriously over a great divide, another of a woman in an orchard reaching for the sun, joined by the quote, "Every choice we make can be a celebration of the world we want."
Several patients sit with a partner, friend or family member. One teenager, dressed in ballet flats, has come with her mother. One young woman is seemingly accompanied by her boyfriend, who is wearing military fatigues. Another patient's head gently rests on her partner's shoulder.
Many women are here for abortion consultations and procedures, but others need reproductive health services like birth control and STD testing and treatment. Women awaiting abortion care will likely spend four or five hours completing each of their two appointments; Texas has a 24-hour waiting period, which necessitates an additional visit. The wait has grown longer as state restrictions have created additional bureaucracy and closed clinics elsewhere.
Tori, a 21-year-old single mother of two, is 10 weeks pregnant. She was homeless and in the second week of addiction recovery when she discovered the pregnancy.
She always opposed abortion. When Tori became pregnant for the first time at 15, it was because her boyfriend decided to take her virginity through rape. An honors student, she managed to graduate with several college credit courses before enrolling in a school to become a medical assistant. Her second child is two years old.
Tori is optimistic that her children, who currently live with her mother, will be released from Child Protective Services supervision soon.
"When I found out I was pregnant, with everything that was going on, I was like, I’m not ready for it all," she says. "I never had to chose between some thing I had no control of and my love for my kids."
By the end of her appointment today, Tori will describe Whole Woman's Health as a "sanctuary."
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Like Tori, most patients don't know what to expect beyond the waiting room. They don't know that the walls are painted purple and that each room in the clinic is named after inspirational women like Ella Fitzgerald, Michelle Obama, Malala Yousafzai and Georgia O'Keefe. They can't envision a recovery room with leather barcaloungers and heating pads where patients are given purple fleece blankets and tea brewed specifically for Whole Woman's Health to alleviate cramping and nausea.
"You’d be surprised how many women come in the clinic...and how many times at the front window we hear, 'Oh it’s so bright in here.' Or how many times you’ll hear patients say, 'Everybody’s smiling, everybody’s so happy," says Marva Sadler, director of clinical services for Whole Woman's Health. "They don’t expect for us to talk in our normal voices. They expect us to whisper because it’s supposed to be a secret and they don’t want anybody to know."
Sadler has worked for Hagstrom Miller and Whole Woman's Health for seven years. She manages the clinic's business with the aim of ensuring that every patient has a tailored experience.
This isn't the traditional medical model of "emptying uteruses," as Hagstrom Miller describes it. Instead, the goal is to treat the "mind, body and heart" and actively engage a woman in her care. She chooses which finger is pricked for a blood draw. She selects which arm is used to gauge her blood pressure. The physician explains the different anesthesia options and she gets to voice her preference. These may seem like small gestures, but to Hagstrom Miller, they create a partnership between patient and provider.
"To me that’s a sign of advancement when I can let a woman have those choices and participate in what’s going to happen," she says.
This feminist approach to abortion, which has deep roots among many providers, also reflects changing values about healthcare. Medical experts have long touted the benefits of patient-centered care and millennial patients have challenged the old-fashioned paternalism of medicine.
In abortion care, though, changing that dynamic has profound implications.
Abortion, say opponents, is without exception tragic. An amicus brief filed with the Supreme Court by the Justice Foundation, a Texas legal organization that opposes abortion, lists the names of thousands of women who say they were psychologically or physically injured by abortion.
Such stories are important to hear, but they often define the abortion experience for the public, even when research disproves the claim that women who end a pregnancy are at a higher risk for post-traumatic stress disorder.
In this climate, abortion providers have to transcend not only a culture of medicine that often patronizes patients, but also a culture that forcefully tells women how to feel about pregnancy—and is convinced that abortion turns women into regretful victims.
Learning how to dismantle this stigma is immersive work. At Whole Woman's Health, an entire chapter in the employee handbook is dedicated to "fear, shame and stigma." New employees spend a day at the clinic as an anonymous patient, having their blood drawn and getting into stirrups for the ultrasound.
"Every little thing makes a difference," says Dr. Bhavik Kumar, one of the clinic's two physicians. "How we interact with a patient, how we call them by their name, how we allow them to speak, allow them to tell us how they’re feeling, make them feel human in this moment, if nothing else, really can start to chip away at [the stigma].
The state, says Kumar, has embedded shame into its regulations. Patients are required to have an ultrasound during which Kumar is mandated to describe what he sees. He must play audio of the "heartbeat," the cluster of cells in early pregnancy that create cardiac movement. Many women are distraught, and he reminds them that it is not the sound of a fully developed heart.
Abortion opponents say women need these regulations because physicians unethically keep the details of a procedure from patients, but Kumar sees it differently.
"The state required script sends the message you’re not capable of making the decision on your own or there’s problems with the way you’re thinking," he says. "There’s no other medical [procedure] where that comes close."
The staff of Whole Woman's Health tries instead to let the patient guide them through her journey. If they call their pregnancy a baby, they will too. If she talks about God, they might ask about her God's values. If she can't claim ownership of her decision to have an abortion, they will decline to give her one.
When Tori looks at her ultrasound, she asks for a printout of the image and the technician eagerly complies.
"I feel supported, not encouraged or shameful or anything," she says. "Nobody’s made me feel like I’m a bad person."
The experience, Tori says, has converted her to an advocate for abortion access.
The problem with abortion stigma is that sanctuaries are temporary.
"Part of our work is to inoculate people from the culture they’re going to step into...and prepare people for the harsh world and the silence," says Hagstrom Miller.
They often encounter that as quickly as the clinic parking lot where clinic protestors regularly confront patients before and after their appointments.
The sight of protestors can fill a person with panic and dread even when she's not the intended target of their efforts. For patients, that experience can be visceral; blood pressure quickens, some may cry, some are terrified to leave the clinic.
Artemisa Cerda stands on the sidewalk holding a large umbrella decorated with words like hope and love, and a rendering of Christ's face. Her car displays posters of well-developed fetuses.
"We’re not here to judge anyone," she says. "Whether it be the abortionists or the workers or the women who come here, [or] those who bring them here."
She prefers not to use terms like murder or killing, even if she believes they are true. She tries to offer help instead.
"If they need financial assistance, we can provide that," she says. "If they need a second opinion, we have doctors that would be willing to give them a second opinion. If they need spiritual guidance, we have that too. Whatever their needs are, we’re here to assist or help them."
As an independent protestor, Cerda can offer none of these things personally but shares referrals to crisis pregnancy centers, post-abortion counseling and adoption resources.
Because clinics are located in or near public spaces, protestors are protected by the first amendment.
"It's part and parcel of the stigma that women don’t really understand their own options and they’re making a decision [opponents] find morally distasteful so other people should have the right to accost them and prevent them from making that decision," says Lucinda M. Finley, a professor of trial and appellate advocacy at SUNY Buffalo Law School who has argued before the Supreme Court in defense of clinic buffer zones.
People have the right to disagree about abortion, but the act of singling out patients so aggressively is part of what makes stigma so difficult to eradicate. It is a symbolic gesture that shows women how they'll be stripped of power and pride if they openly talk about their abortion and advocate for themselves and their families.
Hagstrom Miller's suit does not, and could not, take on protestors, but it has allowed advocates to raise the specter of stigma with the Supreme Court in a different way.
Laws like the ones passed in Texas perpetuate stigma by casting abortion as a malevolent procedure when it is in fact very safe. And when these laws result in clinic closures, they force women to desperation. In constitutional terms, they deny women equality and dignity, principles enshrined by the Supreme Court as essential to human and civil rights.
Those deeply held values are what won the argument for same-sex marriage and, prior to that decision, struck down other laws that discriminated against lesbian and gay people. One of the amicus briefs filed in support of Whole Woman's Health v. Hellerstedt argues that abortion stigma is akin to the stigma LGBT people experience, and that both types keep people in a "closet" unable to publicly fight for their political interests.
Part of transforming a culture of shame, though, requires addressing the things even your allies don't feel comfortable discussing.
At the Abortion 101 workshops offered at Whole Woman's Health clinics and by Hagstrom Miller's nonprofit, Shift, progressive activists touch the medical equipment and hear how an abortion is performed. Participants may find themselves at a loss for words when debating the subject or secretly feel unsure about some aspects of abortion, like second trimester procedures or people who chose to end a pregnancy more than once. Facilitators do not encourage a tidy resolution.
"I don’t have the answer...because there isn’t one right answer," says Rachel Jacobson, Shift's Texas state director. "It’s about you coming to terms with what does your moral compass tell you and what your moral compass informed by."
That Hagstrom Miller is helping abortion advocates identify the stigma they carry is radical but essential for the movement.
"[Amy] is one of the people leading the way in making sure we’re not just talking about safe and legal, but saying safe and legal and accessible provided with dignity to people who are making thoughtful decisions," says Kelly Baden, director of state advocacy for the Center of Reproductive Rights, which is representing Hagstrom Miller's case before the Supreme Court.
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When Terry, the single mother of three, returns to Whole Woman's Health to have her abortion, she encounters a protestor who insists she doesn't understand the details of the procedure or the risks.
"I know the risks; I'm a nurse," she says.
"Why are you there, then?" he replies. "You're on the wrong side."
Terry is having an abortion because she wants to get back to her life: track practice for her teenage son, guiding her adolescent daughter through crushes on boys, helping her 19-year-old daughter take care of two children.
"I’m fighting for some kind of normalcy," she says. "I put it to myself this way: A real mom will do what she has to do, in this sense, for those who are here."
The staff at Whole Woman's Health call her by name. They ask about her grandchildren and talk about her work as a nurse.
"They were humanizing it," she says. "It made me a lot more comfortable. Leaving there, I felt better about being able to deal with it.
[Things] aren't the same, but I didn’t leave heavier than when I came in."
