In the spring of 2018, the Austria-based organization Aid Access started providing the two drugs needed for a medication-induced abortion, mifepristone and misoprostol, by mail to people in the United States. Its founder, a Dutch physician named Rebecca Gomperts—whose other organizations Women on Web and Women on Waves have worked to make abortion pills available online and by sea for years—estimates that Aid Access has fulfilled requests from 600 U.S.-based women in the span of six months, despite having virtually no public rollout. But in March of this year, the Food and Drug Administration sent a letter to Aid Access, along with an online pharmacy named Rablon, ordering both services to stop the sale of mifepristone and misoprostol—despite the fact that, when used as directed, the drugs are proven to be safe and effective. That hasn’t stopped Gomperts.
“I will not be deterred,” Gomperts wrote on the Aid Access website that same month, adding that: “When U.S. women seeking to terminate their pregnancies prior to 9 weeks consult me, I will not turn them away.” While Aid Access gives people the option to self-manage their abortions in the privacy of their own home, the fight to keep the online provider open has turned public. This is just one example of how abortion providers are holding their ground against federal and state lawmakers who wish to roll back access.
On Monday, 75 organizations, doctors, and researchers joined that public fight, signing an open letter that stands behind the work of Aid Access and articulates something healthcare providers have known for a while: that right now in the United States, the risk involved with seeking a self-managed abortion is legal— not medical.
“[D]ue to the politics of abortion, medication abortion has been over-regulated by the FDA, and pushed further out of reach for many by state restrictions,” the letter reads. The signees—which include Women on Web and the National Abortion Federal—also point out that Aid Access’s fight against the FDA must be viewed in the context of the current political climate. Attacking telemedicine providers like Aid Access is just one tool in abortion opponents’s toolbox to roll back access to abortion, wherever it exists.
But that doesn’t mean, necessarily, that self-managed abortion—or abortion by mail—are going away anytime soon, or that providers like Gomperts don’t stand to make some gains now in the fight to increase access. Jezebel spoke to Farah Diaz-Tello, senior counsel at the reproductive justice organization If/When/How, about the battle to protect access to self-managed abortions. Our conversation has been edited and condensed for clarity.
JEZEBEL: What is the biggest misconception around self-managed abortions?
FARAH DIAZ-TELLO: I think the biggest misconception that people have is the overall sense of what it looks like. People have a lot of ideas from prior to Roe v. Wade, the image of the coat hanger and all that, and they might think that self-managed abortion doesn’t exist anymore. Or that it’s extremely unsafe and it’s people acting out of desperation. The reality is that—thanks to reproductive health technologies and people having more access to information than they did in the ‘60s and before—self-managed abortion can be a safer and satisfying experience. It’s not necessarily an act of desperation for everyone. Maybe there’s no provider in their area, or abortion has been made inaccessible by lawmakers, or it’s too expensive. But maybe some people also prefer a more self-directed option. And so the ability to, in this instance, get pills sent to them to their home and consult with somebody over the internet would be a really appealing thing.
The other thing is about medication abortion, specifically. People may have absorbed the misinformation abortion opponents are putting out, and believe that abortion with pills something that is uniquely dangerous or particularly harmful. A lot of people might not know that abortion with pills has been around for about two decades and has proven to be extremely safe. So the excessive, onerous barriers that are placed on accessing it are actually just serving to cut people off from the really important medication that can be life saving.
Do you think that anti-abortion lawmakers take advantage of the lack of knowledge around medication abortion and seize that as an opportunity to play up what they see as medical risks involved?
That’s definitely consistent with the patterns we see overall. If you think about the states where people have to go through forced, inaccurate counseling [in order to obtain an abortion], where doctors have to relay information that has been debunked—all of that is a tactic to dissuade people from having abortions. They very often call [medication abortion] a chemical abortion, when in fact every medication, every vitamin, you know, most everything we ingest is a chemical of some sort. It’s a very intentional misinformation campaign.
It’s interesting to hear you talk about the safety and efficacy of the drugs, because I think when we talk about abortion in the U.S., and even the way it’s portrayed in movies, it’s typically talked about as this big decision that can be very dramatic and something that could have all of these repercussions. Why do you think, if medication abortion has been around for two decades, it’s less well known in the States?
You bring up a really interesting point of how abortion is portrayed in the media. I think in general abortion can be a plot point for the development of the character, and so it usually has to be viewed with some kind of drama. I think it’s only recently that we’ve seen some very realistic portrayals of abortion. Certainly, for many people, it is a weighty decision and it is a moral decision and it can be very meaningful. And for some people, it is something that they would just like to get it taken care of. There’s not even a question that they know what the right thing is. I think that we’re seeing that more in the media. Maybe the reality that someone could get an abortion with pills is something we’ll start to see more of.
Aid Access is not the only online abortion pill provider; the FDA letter was also addressed to an online pharmacy named Rablon. But I’m curious about what happens if Aid Access is forced to shut down. Is there anything stopping another organization from offering these same drugs online?
No, not at all. And in fact, there are others that do. I think Aid Access has gotten a lot of attention because Rebecca Gomperts has been very outspoken about her reasons for doing it. People know who it’s run by and the cost is kept low. With other online pharmacies or websites, it may not be clear who runs them, and there may be more of a profit motive. I mean, they don’t see themselves as online abortion providers; they see themselves as online pharmacies.
But certainly, people are self-sourcing abortion pills—sometimes because they can’t get the medication where they are, but sometimes because they prefer to do this in private. It’s a need that existed before this current political moment, so I think as long as there’s a need there’s going to be people who try and meet that need.
What is it the significance of the letter that the FDA sent Aid Access? What can the FDA do if Aid Access doesn’t comply with their order to stop selling abortion pills directly to consumers?
The significance of this letter, I think, mostly comes from the fact that they are targeting medications that are known to be safe and effective and treating them as though they pose a risk to public health. We have to take this in the current context, where some states are seizing on the potential of a Trump-stacked Supreme Court by placing restrictions on abortion that could force the court to reconsider Roe v. Wade. You cannot separate the political context from the potential consequences of this letter, which would be to get these services to stop or shut down. What the FDA can do if they don’t is not entirely clear to me at this point. But what does seem clear is that this type of warning—whether or not it is intended to be—it can be used as a political tool to try and restrict access to abortion. And we know this because more than 100 Republican and anti-choice lawmakers sent a letter to the FDA applauding the action and telling them that they should do more to control online sources of medication. What the FDA should do instead of playing into this politicized, selective enforcement is focus on increasing access and ensuring people can get the care that they need.
It almost sounds like they don’t have to do anything other than send the letter, that the warning alone might be enough to dissuade people from looking into self-managed medication abortion.
Yeah, I think that that’s right. One of the most striking things about the warning letter is that it tells [Aid Access and Rablon] to stop distributing the medications because the condition that they’re intended to treat is not amenable to self-diagnosis. Essentially what they’re saying is that pregnant people are not able to diagnose whether they’re pregnant, and they’re not able to manage their own pregnancies and own miscarriages and abortions. When in fact, most people who find out they’re pregnant self-diagnose. They go to a pharmacy and pee on a stick and determine that they’re pregnant. And I would venture that the majority of people who have a miscarriage also manage that themselves. And an abortion with pills is nothing more than a prompted miscarriage. A miscarriage that is induced by medication and a miscarriage that happens spontaneously are indistinguishable and would be treated the exact same way by healthcare providers. So what [the FDA is] saying is that we need to put these pills out of reach of pregnant people who need them—because pregnancy is so dangerous that pregnant people can’t handle it themselves. It’s just absurd.
When people become pregnant, they potentially face conditions like preeclampsia or hemorrhages, and [laughs] we’re not saying you need to sign a consent form before you become pregnant. You know? It’s not treated in the same way. But people undertake the risks of becoming pregnant, of giving birth, of having miscarriages all the time—so separating this out as something that is uniquely dangerous essentially just allows the state to exert control over people and to limit their choices.
How do you stay optimistic in this fight? Have there been any stories that give you hope?
I am still optimistic, even doing this work and seeing the very worst case scenarios of what can happen. I think that the idea of self-managed abortions, of being able to access abortions in a safe, effective, and private way that promotes people’s dignity, has so much promise. And the demand is going to eventually be so much that policy will have to follow.
Right now, a lot of states have been trying to move forward [to make sure] people within their borders have a fundamental right to make decisions about pregnancy. So that’s a hopeful thing. The other hopeful thing is that people are finding out about self-managed abortion, and I hope that we can get some political momentum around that. The fact is that whatever the law on abortion has been, people have always found ways to end pregnancies and I’m hopeful now that we have effective ways that people can use safely, no matter what happens to the law.
Open Letter on FDA and AidAccess by GMG Editorial on Scribd