Calculated Risks

Curtis Boyd was a thirty-year-old doctor not long out of training when, in 1967, a pregnant teenager named Sallie walked through the door of his private practice in Athens, Texas, and told him, “I need you to do me an abortion.” Sallie wasn’t one of his patients, but her sack dress and home-cobbled shoes told him they had “more in common than our appearances would suggest.” Like Sallie, he’d grown up down a dirt road on the rural outskirts of Athens, seventy miles southeast of Dallas. He imagined that Athens, with its population of five thousand, must have seemed like a metropolis to her, as it had to him in his youth. “That she had come to town by herself,” he writes, “was reason to take notice.”

As a young man Boyd had been a lay preacher in his community of foot-washing Baptists, “a small fundamentalist sect that believes—above all else—that our lives are predetermined by God.” By the time he finished medical school he had migrated to the Unitarian Church, whose welcoming values of compassion and service felt truer to his evolving faith. Nevertheless, he returned to small, conservative Athens. He married a woman he’d met on a visit home, and they soon had three small children. He and a medical school classmate, with whom he’d sold Bibles door-to-door during summer vacations, opened a family practice in town, where he also served as the county health officer and a member of the school board.

Boyd could have told Sallie that he wasn’t trained to give her an abortion, that indeed he’d never seen one performed. This would have been only a half-lie. A first-trimester abortion is technically the same as the dilation and curettage (D&C) used to manage complicated or incomplete miscarriage. In residency Boyd had learned to perform D&Cs for the “legions of women” who came to the emergency room in the process of miscarrying, sometimes with infections or uncontrolled bleeding. After Roe v. Wade legalized abortion in 1973, those patients “miraculously disappeared,” confirming what most doctors already knew: that these complications were often the result of illegal abortions.

In the 1960s D&Cs for miscarriage were performed only in operating rooms under general anesthesia, not in doctors’ offices. More to the point, abortion was a felony in forty-nine states and the District of Columbia. Sallie, Boyd writes, “had no idea what she was asking of me.”

He explained that he couldn’t perform her abortion: “It’s illegal.”

“I don’t care,” Sallie replied, “’cause I gotta have one.”

Boyd couldn’t bring himself to turn her away. He admitted her to the hospital with a diagnosis of “inevitable miscarriage,” performed the “surprisingly easy” procedure, and sent her home with an appointment for a follow-up visit to discuss birth control. She never returned.

Boyd didn’t see the abortion he performed for Sallie as revolutionary—particularly because, as he told himself at the time, he had no intention of performing more illegal abortions. But it was a radical act, and a turning point in his career. He began accepting referrals from the Clergy Consultation Service, a national network of religious leaders who connected women seeking abortions to discreet and reputable doctors, and he soon found that he could barely keep up with the demand. It was all done in secret—or so he thought. But by 1968 his partner in the family practice had caught on, and insisted that they separate. Boyd moved his practice—and his family—to Dallas, then to Santa Fe, New Mexico, where “medically justified” abortion had recently been decriminalized. In 1973 he and his wife divorced: “I was no longer the conventional man she had married.”

During the six years since Sallie had walked into his office, Boyd had performed thousands of abortions, most of them illegal. Shortly after his divorce—and the Roe decision—he returned to Texas and opened Dallas’s first legal abortion clinic. There he met Glenna Halvorson, a counselor on his clinic staff, whom he married three years later. We Choose To: A Memoir of Providing Abortion Care Before, During, and After ‘Roe’ is the humble, at times blisteringly frank account of their decades pioneering and providing abortion care in the American Southwest.

In alternating chapters, they take turns describing how they developed their techniques “essentially from scratch.” As Boyd gradually taught himself to perform abortions well into the second trimester, Halvorson-Boyd advanced the field of abortion counseling toward an informative, nonjudgmental model based on the belief that “the meaning of each pregnancy rests in the hopes and dreams and fears of the parents.” Boyd later helped to establish the National Abortion Federation; Halvorson-Boyd served a term as board president. But at the start they were two people practicing in relative isolation, at the limits of the law and of medical knowledge.

“Was I wise and compassionate,” Boyd asks of those early years, “or arrogant and foolhardy?” The answer, of course, is that he was both. He chose to undertake a calculated risk in order to protect the dignity and the lives of his patients. This is what abortion care—or what remains of it—amounts to in some parts of the country today.

My early abortion education couldn’t have been more different from Curtis Boyd’s—and not merely because I trained in the 2010s in California, where abortion was, and still is, legal. As a resident I learned to perform first-trimester abortions through a program called TEACH, which trains family doctors in abortion and miscarriage management as part of comprehensive reproductive health care. I began by observing not one but several abortions before gradually easing onto the doctor’s stool—first inserting the speculum, then injecting lidocaine, then dilating the cervix, and finally emptying the uterus—until I was performing the complete procedure under my attending physician’s watchful eye. Only after dozens of procedures was I allowed to enter the room alone.

In between patients, my mentors—all family physicians—talked with me about abortion stigma and doctor–patient power dynamics, how these can affect patients’ experiences, and how a conscientious doctor can mitigate those effects: Knock on the door before entering the room. Carefully handle the metal instruments so as not to clink them together. Before you touch her, ask, “Are you ready to begin?”

After graduation I took a job at a women’s reproductive health clinic in California’s Central Valley, one of the state’s “abortion deserts.” The clinic needed a doctor who could perform first- and second-trimester procedures, and so the medical director quickly trained me up to twenty-two weeks—a considerably riskier and more complex procedure than the early terminations I’d been doing as a resident. But she didn’t throw me in unprepared. At her high-volume clinic in Los Angeles, we did nearly a hundred procedures together over three days. Whenever I hesitated, she stepped in to make me watch her technique: “See my hands? See my angle here?” In my early months alone in the Central Valley, I called her with questions, sometimes midprocedure. She always answered.

This kind of training was radical in its own right. It departed drastically from a traditional approach to surgical training that regards patients—particularly women—as at best beneficiaries of a trainee’s budding skills and at worst specimens for practice. The point was that I should learn to actually care for the person in front of me. Her safety and well-being came first, my learning second.

Ten years later I still care mostly for abortion patients, but also for patients with desired pregnancies and others at all stages of their reproductive lives. In the same period, the work of caring for women in the United States has come under threat, culminating in the Supreme Court’s decision in Dobbs v. Jackson Women’s Health Organization (2022), which overturned Roe and effectively allows states to force women to remain pregnant against their will. But the threat runs deeper. The Court has proven itself to be not only dismissive of but actively hostile toward women’s claims to their own human worth—that is, their claims to bodily autonomy and even physical safety.

Consider our country’s current lethal triad of abortion restrictions, intimate partner violence (IPV), and gun violence. In New York State Rifle & Pistol Association v. Bruen (2022), the Supreme Court struck down a state law that required civilians to demonstrate “proper cause” for carrying a concealed handgun in public, arguing that in the absence of historical precedent any restrictions on Second Amendment rights are unconstitutional.¹ Justice Stephen Breyer noted in his dissent that women in the US are five times more likely to be killed by an intimate partner if that partner has access to a gun. Knowing that the Dobbs decision would be handed down the following day, Breyer might also have noted that homicide is the leading cause of death among pregnant women (exceeding any medical cause by more than twofold), that two thirds of pregnancy-related homicides occur in the home, and that most murders of pregnant women involve firearms.

A study of data collected prior to Dobbs also showed that states with more abortion restrictions have higher rates of IPV-related homicide, particularly by firearms,² while data from the Turnaway Study showed that access to abortion correlates with decreased future risk of violence from a sexual partner.³ Federal law prohibits persons convicted of misdemeanor crimes of domestic violence from possessing guns, and according to United States v. Rahimi (2024), states may prohibit anyone subject to a domestic violence restraining order from possessing firearms. But not all states have or enforce such laws, and when they do exist they’re often full of loopholes. (For example, they often apply only to spouses, not to current or former dating partners.)

I am not the first to note that a Supreme Court that simultaneously increases the rights and protections of gun owners while decreasing the rights and protections of women creates a horrific situation for pregnant persons and indeed for anyone trying to escape an abusive relationship.⁴ This is the society in which health care providers, and others whose job it is to care for women, must do our work: one where a leading presidential candidate, a self-proclaimed pussy-grabber, can be heard batting around potential gestational age limits for a federal abortion ban (“People are agreeing on fifteen [weeks]. And I’m thinking in terms of that. And it’ll come out to something that’s very reasonable”) as though pregnant women were contestants on one of his reality TV shows, their freedoms at the mercy of his tyrannical whims. Meanwhile, under the current patchwork of state laws following Dobbs, some women are crossing state lines to obtain abortions while others are forced to carry pregnancies that they do not want and that may well endanger their lives—owing to medical conditions or merely to the fact that their partner owns a gun.

The effect on training is likewise grim. In states with abortion restrictions or all-out bans, opportunities to teach hands-on skills—never mind the kind of compassionate training I was fortunate to receive—have all but disappeared. Some residents are lucky if they learn to perform D&Cs for miscarriage management, as these procedures, too, are dwindling in states where doctors fear criminal prosecution. Meanwhile, California has passed a bill allowing out-of-state medical residents to train in abortion care as “guests” in California residency programs, as well as a “shield” law to protect physicians from abortion-related lawsuits originating in “hostile” states. So the map is inconsistent and arbitrary, but the consequences are pervasive: to practice as though women’s lives were as valuable as men’s has become, once again, a subversive act.

Warren Hern’s Abortion in the Age of Unreason: A Doctor’s Account of Caring for Women Before and After ‘Roe v. Wade’ would seem at first glance to broadly overlap with Boyd and Halvorson-Boyd’s We Choose To. Hern did his medical training around the same time as Boyd, though Hern never performed an abortion pre-Roe; before 1973 he worked on federal and state family planning policy that helped lay the groundwork for safe, legal abortion. Both men went on to become among the first and few physicians in the US to perform third-trimester abortions. Hern still performs abortions, and trains other doctors in abortion care, in his Boulder Abortion Clinic in Colorado.

We Choose To largely leaves aside the politics of abortion and the long history of violence against practitioners in the US. Although Boyd and Halvorson-Boyd have experienced plenty of such violence, they tend to minimize it—even as the book opens with the burning of their Dallas clinic by “anti-abortion vigilantes” in 1988. “The crime was never solved,” Boyd writes, “and I’m not sure I cared. What mattered most was that they could not stop us. We were open for business as usual. We were serving patients, and that was our ultimate goal.”

In contrast, Hern’s account reads as an impassioned, at times rambling treatise that can veer into an all-out rant, as when he decries “the fanatic opposition to safe abortion by a highly totalitarian and effective fascist minority.” For him the politics and violence are inseparable from the work itself; several times he mentions the bulletproof vest he wears to his clinic. His tone is almost constantly (if understandably) defensive. He rejects the term “abortion provider” because it commodifies abortion as a product for consumption: “I don’t ‘provide’ abortions. I am a physician. I ‘perform’ abortions,” he writes. “I went to ‘medical school,’ not ‘provider school.’”

Hern also rejects, in a 1993 address to the American Public Health Association—reprinted in the book nearly in its entirety—the notion that anyone other than doctors should be performing abortions, including nurse-practitioners, midwives, or (heaven forbid) women “on themselves and on each other.” This last idea he calls “suicidal fantasy.” Thirty years ago perhaps it was. But that was before the FDA approved the highly safe and effective two-drug regimen of mifepristone and misoprostol for early pregnancy terminations (currently up to ten weeks’ gestation). Today more than half of abortions in the US are medication abortions. Technically these aren’t “performed” but “provided” to patients in the form of pills, often by nurse-practitioners and midwives.

Since the FDA eased restrictions on mifepristone in 2021 in response to the Covid-19 pandemic, medication abortion now increasingly takes the form of a telehealth visit: a doctor or nurse gathers details about the pregnancy and screens for medical conditions; a pharmacy then dispenses the pills, which the woman takes at home. Additionally, the wide availability of mifepristone and misoprostol from outside the formal health care system (on the Internet and through various underground organizations) now allows many women access to what is known as “self-managed abortion.” If this sounds like a euphemism for “illegal abortion,” that’s what it is—at least in states that choose to prosecute it as such.

Unlike the coat hangers, intravaginal Lysol injections, and other methods of pre-Roe infamy, however, self-managed abortion with mifepristone and misoprostol is effective and safe, with a low complication rate similar to early abortion within the health care system. But regardless of safety, Hern argues that self-managed abortion

short-circuits the big question of how we shall run our society and what shall be the status of women. If women can do this themselves and it is not necessary to have a political and legal climate where it can be done by skilled physicians in a modern and properly equipped setting where women are treated with care and dignity, then what are we fighting for?

Indeed. And yet I and many of my colleagues do believe in self-managed abortion. (If Hern has changed his views since 1993, he doesn’t explicitly say so in the book.) For the past two years we have been imagining, witnessing, and in some cases facilitating the evolution of self-managed abortion as a “new normal” abortion—one that doesn’t depend on a clinic, a doctor, or even a prescription, but emerges from networks of women helping one another. While it may look very different from the first abortion I performed, or the one Curtis Boyd performed for Sallie, self-managed abortion is fundamentally similar in that it forsakes many of the old teachings, traditions, and biases of the health care system in order to put the woman first.

But as Hern suggests, the displacement of abortion from a procedure openly performed by medical practitioners to an underground process managed by women themselves is hardly a sign of progress. “Suicidal fantasy” or no, self-managed abortion does not solve the problem of secrecy. It is the secrecy, in fact, that compounds and creates risk in a process that would otherwise be straightforward and safe. What doctors like Boyd and Hern knew fifty years ago remains true today: in a society that drives abortion underground, women will never be truly safe.