Choice by Mail

Abortion rights are at a crisis point in America. The US Supreme Court has upheld a Texas law that allows any private vigilante anywhere in the country to sue any person who “aids and abets” an abortion in Texas, functionally outlawing nearly all abortions in the state. This summer, the Court is also set to rule on a case that could overturn or radically reshape Roe v. Wade, the 1973 decision that legalized abortion nationwide. Feminist activists, who have long struggled to make abortion more accessible to poor and rural women by way of abortion funds and political advocacy, are now looking toward a future in which far fewer American women are entitled to safe, legal abortions in their home states. Some are trying to come up with strategies to help women safely end their pregnancies outside of the formal healthcare system.

Enter Rebecca Gomperts.

Gomperts is one of the world’s most radical abortion rights activists, although she doesn’t necessarily see herself that way. In her view, she’s a medical doctor who took an oath to help people in need. And that means providing safe abortions to people who need them—whether the state allows it or not.

Born in Suriname, she grew up in the Netherlands, and studied conceptual art at college before turning to medicine. In the early years of her medical career, during which she sailed around Latin America as a ship’s doctor and environmental activist with Greenpeace, Gomperts saw the heavy toll that unsafe abortions exact on the lives of women. In 1999, she founded Women on Waves, a mobile abortion clinic that brought the procedure to women around the world by way of a rented boat that sailed to countries with restrictive abortion laws and distributed miscarriage-inducing medications to women in need.

Seeking to reach more people, Gomperts founded the nonprofit Women on Web in 2005, which uses telemedicine and the Internet to distribute misoprostol and mifepristone—the two-step medications that safely induce abortions—and information on how to use the pill combination safely and effectively, so that a person anywhere in the world could essentially self-induce a miscarriage privately in their own home. In 2018, Gomperts began a related venture, Aid Access, working with abortion providers specifically in the United States to provide medication abortion by mail in an increasingly restrictive America.

This project brought her into conflict with the Trump administration and with the Food and Drug Administration. When the FDA sent Gomperts, who is now based in Austria, a cease-and-desist letter, she refused to comply. When President Trump’s Health and Human Services Secretary Alex Azar blocked US-originated payments to Aid Access and seized its packages, Gomperts sued him and the FDA.

Under the Biden administration, the situation with the FDA has changed. In December, the agency announced it would permit abortion-inducing medication to be distributed by mail in perpetuity. Several conservative-controlled states nevertheless ban telemedicine abortions.

Gomperts spoke recently with the New York Review about her work to provide abortions when abortion is outlawed, the connection between abortion bans and the rise of global authoritarianism, and why American women should start stocking up on abortion pills now. What follows is an edited transcript of our conversation.

Jill Filipovic: What was the transition from Women on Waves to Women on Web? Why make that shift?

Rebecca Gomperts: What happened after the first ships campaign, and especially the one in Ireland, was that we started getting many e-mails from pregnant people all over the world who were asking, “When is the ship going to be here?” And we didn’t even have a ship. We just rented the ship. We started thinking, well, we have to do something else—and it’s just pills, so it should be possible to send them by mail. A lot of legal research was done on how to do this in a sustainable and a legal way, and we found the loopholes. And so that’s how Women on Web started in 2005.

And what are the typical legal loopholes? I would imagine it differs from country to country, but generally, in countries that restrict abortion access, how is it legal to provide abortion-inducing medications to women?

What is interesting is that [misoprostol and mifepristone] are just medicines, and they’re actually on the essential medicines list of the World Health Organization. People around the world are allowed to order medicines for their own use from other places. The pills themselves are not illegal, because they can be used for all kinds of indications. Swallowing the pills is not breaking the law either—it’s only when women are pregnant that they’re potentially breaking the law.

It’s also very hard to prove somebody intentionally had a miscarriage. And the abortion pills themselves essentially induce a miscarriage, it’s very similar, and in the really rare event that somebody needs medical care, aftercare, it’s not possible to prove it was intentional.

What we’ve seen, though, is that in some countries doctors are putting women under a lot of pressure to “confess” that they used medicines themselves to try to induce an abortion.

From the perspective of the organization, Women on Web is based in Canada, and there is no abortion law against this in Canada. And the doctors who are working for Women on Web are doing so from countries where it’s allowed to prescribe the medicines from a distance.

I saw that you were going head-to-head with some members of the Trump administration over this. Now that the FDA has changed its medication abortion rule, does that affect your work or resolve your FDA complaint?

No, it doesn’t entirely. But it solves the telemedical part, for sure. It solves part of it.

I’ve been working in telemedical abortions now for sixteen years. We were the first service that existed doing this. It’s been a really amazing journey on the way to having this officially recognized as being acceptable, safe, and preferable for women. Because you have to understand that women who go to a telemedical service come from two different places: from empowerment and from disempowerment.

The women who come from empowerment prefer to use a telemedical service because they know they can do it from home; they want to be in the comfort of their own home and with the person they want to be with when they have the miscarriage. But in the place of disempowerment are the women who are unable to access the local services that exist. Those barriers can be financial, it can be because of domestic violence, or because of other very real barriers that people face in their lives. And telemedicine addresses both of these patients.

Can you talk about how wider access to misoprostol has affected the ways abortion rights activists work and abortion providers offer services?

It’s been very exciting to be part of that revolution from the beginning. My work started in 1999. Misoprostol was available in some countries, especially in Latin America, but there were very few women who actually knew it was used for abortion. The first safe abortion hotline giving information about misoprostol was launched in 2004, during the Women on Waves campaign in Portugal, because misoprostol was very easily available over the counter there. And then that work took us to Latin America, where we trained all the local women’s rights organizations.

There was a division at that time between the medical professionals and the feminists, and a lot of doctors were not very supportive of the use of misoprostol—especially feminist doctors, because many of them believed that it let doctors off the hook, and that doctors had to be willing to provide abortion services instead of putting the responsibility back on women. We thought something else: that actually it’s extremely empowering for women to do this themselves. And the feminist groups did also. The training of the feminist groups really changed things—to put this knowledge in the hands of women, where it belongs.

It’s been very interesting to see that revolution unfold itself and spread over the whole of Latin America, with so many groups involved in training one another, and the growth of underground networks that get the pills and provide them to women—it has been a real revolution. And it’s women who have taken control and power over this very important medicine for women’s health.

In Africa, it was a little bit different, but in countries like Indonesia and Pakistan, where we also trained women’s organizations, we saw the same things happening.

I would imagine even many Americans who are pro-choice may have reservations about “putting abortion in the hands of women,” simply because it flies in the face of how most of our health care and our model of clinic-based abortion care works. Why do you think the move to telemedicine and medication abortion is safe, effective, and necessary, or preferable to the status quo?

It is safe. There have been millions of women who have used the two-step medication; it’s safer to use than over-the-counter painkillers. There are more people dying of overdoses from, or allergies to, paracetamol than there are from medical abortion. It’s a very, very safe combination drug.

Women have been giving birth by themselves or with the help of another woman for centuries, and early-term abortion is easier and safer than giving birth, for sure—many times safer. In the Netherlands, one in 20,000 women die as a consequence of giving birth; from miscarriage, it’s less than one in a million.

You mentioned that some women seek medication abortion out of empowerment, and some seek it out of disempowerment and essentially a lack of other options.

That also has to do with the enormous medicalization of this process. A miscarriage usually doesn’t need any medical treatment or oversight. But the US is a very medicalized society. For example, in the Netherlands, home birth is the normal way of giving birth. That is absolutely not the case in the US. When you look at the number of caesarean sections in the US, it’s so much higher than in other countries in Europe, and that has to do with the medicalization of the female body. And that is connected to the way the US is also a very litigious society.

Given that we in the US do have a relatively litigious society and one with pretty sophisticated law enforcement, are there particular legal issues that come with working here that you haven’t faced working in other countries where abortion may be restricted?

No, not really. I think the difference is that when we’re working in another country and face a legal complaint—and we have already had some court cases—we can trust the legal system to be fair. And so, we won those cases. In the US the problem is that it’s so expensive to go to court, and there’s no legal aid, or very bad legal aid, for those who can’t afford it. There is so much legal injustice in the US that is not the case in other countries where we’ve been working.

With the new law in Texas that allows any citizen in the country to sue anyone who “aids and abets” an abortion, are you concerned about legal liability or vulnerability there?

I’m not working in the US. I am a doctor registered in Austria; I do my medical practice in Austria. I adhere to all the laws in Austria, and, most of all, to my medical oath. It’s very simple: when there are people in need of urgent, time-sensitive medical care, as a doctor you don’t have the luxury of saying, “I am not going to help you.” That is what you’re trained to do.

There are many international human rights agreements that protect the right of women to have access to the medical care they need, and safe abortion specifically. These international agreements overrule local laws if those laws are in violation of the human rights law. The human rights law is the only law that I need to comply with.

Internationally, where are you seeing progress on abortion rights and access?

Progress is everywhere except for in the US, to be honest. No, that’s not true: there are some other places where there are real challenges. Poland, for example; Hungary is another, Turkey, and Russia. And what they all have in common is that they’re countries that are really struggling with the rule of law and with democracy in general. These are countries where democracy has been undermined systematically.

In countries where democracy is stronger or the political situation is moving toward more democratic governance, and where human rights are more respected, they all move toward legalization of abortion—like Ireland, Northern Ireland, Gibraltar, Thailand. South Korea has legalized abortion, Argentina has legalized abortion, Mexico has legalized abortion. It’s also a sign of what is happening in general in these countries. Women’s rights are a very clear indication of where a society is headed.

Why do you think that is? What’s the connection between women’s rights and either a pro-democracy movement or a shift toward antidemocratic, authoritarian governance?

The connection is that, in countries that restrict abortion access, all rights are being violated or undermined. In Hungary, there is no free press anymore. All the press is controlled by pro-governent owners or companies, or by the government itself. So it’s not just women’s rights. It’s that all the freedoms are affected.

But another link you see in Russia, Poland, and Hungary is the influence of Eurocentric, pro-natalist movements—where they want more white babies born, and the way to do it is to control women’s bodies and use them as political instruments. By forcing women to have babies they don’t want, you keep people poor. And people who are poor have no voice, they have no say.

When it comes to abortion access in the US, do you have any expectations or predictions about what might happen, especially in conservative states?

What many Americans may not understand is that the problems of access were already there. People have to pay for abortion services, and that can be 650, 800, 900 dollars. And for somebody who lives under the poverty threshold, that’s totally impossible. What we see with Aid Access is that some people have problems paying even one hundred dollars. And even if there are abortion funds, they cover only part of the travel or the procedure and never the full cost. So there were already a lot of problems with accessing abortion, especially for vulnerable parts of the population.

Banning abortion in these states has created even more social injustice, because the women who can afford it will trek over to other states, and the women who cannot afford it are the ones suffering the consequences. There is already a huge underground market in the US [for abortion-inducing medication], whether it’s through feminist groups or by other means. You can find misoprostol online. Women can do medical abortion themselves, and it’s safe, so, in fact, I don’t think you will see what you used to see before Roe v. Wade, when women were dying from back-street and coat-hanger abortions.

But the problem is the later-term abortions. Medical abortions can easily be done very safely at home in the first trimester. After twelve weeks, during the second trimester, the risk is a little bit higher, but even then it is possible to safely do an abortion with medication. What we’ve seen already in some of our e-mails is the difficulty people are having in finding the medicines in time to use them before thirteen weeks.

For example, Google’s algorithms are changing all the time so that services like Aid Access or Women on Web are harder to find, because Google is giving preference to official government websites. The algorithms of Google are suddenly becoming the de facto gatekeeper to access to safe abortion services in the US.

As a result, we’ve already seen cases of people trying to induce abortions by jumping off stairs, or taking huge doses of vitamin C or other medicines, which does not work and can be dangerous. This is already happening.

Do you know of any efforts to pressure companies like Google and Facebook to make medically accurate and useful information about medication abortion more available to women?

Oh, yes. YouTube and Facebook have banned Women on Web so many times, but we always fought it, and because we had access to the news media, we were able to solve it. That is easier. The Google algorithm is a little more hidden, and it has only been a problem since the Covid-19 pandemic began: it was actually part of an effort to make unscientific information about Covid harder to find. But it’s extremely difficult to fight it because nobody understands how the algorithms actually work. It might be something that we would eventually start a court case over. But that is what people don’t realize: it’s Google that is filtering people’s access to information.

Access to information about the pills is less of a problem than getting access to the pills themselves. The algorithms are making it much harder to find the places where you can obtain these medicines.

How can women who are searching online tell the difference between reputable telemedicine abortion services and any random person who sets up shop?

That is the problem. One of the issues is that people have to be educated in using the Internet: for instance, you could Google to see if there is any other information about such a site—have other people written about it on social media, on Reddit, say—because that is where you can find information about these sites and whether they’re reliable or not.

There are certainly many sites that are not reliable, but there are many that are. Plan C [an organization that assists people in finding abortion-inducing pills online] has done a study on the websites that are offering abortion pills and found that they offer real medicines. The problem is they don’t don’t always provide information on how to use them; there’s no oversight, no supervision from a doctor. That matters because, for example, Aid Access always provides extra doses of misoprostol, since research has shown that repeated doses help to complete the procedure, and result in a higher success rate, especially later in pregnancy. And many of these other sites don’t do that.

What kind of medical oversight or supervision is necessary to complete a medication abortion oneself?

Not much, but people need to have the information: how to use the medicines, and when to look for medical care if there are complications. That’s it. And that information is pretty widely available—really specific knowledge that we have built up over the years, which the websites selling the medicine don’t give. This includes advice about using the medications orally rather than vaginally, the slightly higher risk of complications if a person has had multiple previous caesarean sections, and the signs of ectopic pregnancy.

Having a good help desk and medical oversight can, in exceptional cases like ectopic pregnancies, be lifesaving. But there shouldn’t be any doctor having to prescribe this drug treatment; it should be a medicine that is available over the counter.

In places like the US and Hungary, what should women be doing now to prepare to protect and advocate for ourselves, and for other women who may have fewer resources and may be more vulnerable?

Of course, people should organize to stop these regimes from doing what they do, but that is not so easy, and what they’re up to is happening already. So I’d say: make sure that people have as much as information as possible about medication abortion, and make sure that they have stocks. Get as many pills as you can, I would say. And buckle up.

So women should have misoprostol and mifepristone on hand, whether they’re pregnant or not?

Absolutely. The shelf life of mifepristone is really long. So yes, get it and make sure you have it on hand.

What can American feminists and abortion rights activists learn from your work, and from the work that activists have been doing for so many years in countries that have long had these restrictive legal landscapes?

What I’ve found very interesting from our work with groups all over the world is that initially there’s a lot of self-censorship and fear, because the laws are often very unclear and people are afraid they can be prosecuted—especially in the US. Removing that self-censorship is really important.

You need to do things publicly that challenge these laws in order to discover that you shouldn’t be too afraid of them. The people usually targeted by the law are the really vulnerable ones who do not have networks of support, but if you have a community and you work together, you can do a lot you didn’t think was possible.