Yes, Medication Abortion Can Be Painful. Republicans Want to Make It Worse.

In her forthcoming memoir, The Woman in Me (out next week), Britney Spears reveals that not only did she have an abortion during her relationship with Justin Timberlake, but that she ended her pregnancy at home with pills, which was a painful, hours-long experience.

Spears writes in the book that “it was important that no one find out about the pregnancy or the abortion, which meant doing everything at home.” Both TMZ and the Associated Press reported Friday that the couple got abortion pills so they didn’t have to tell anyone. Spears says that she was afraid and in pain. “I kept crying and sobbing until it was all over,” she writes, adding that it was “excruciating.” “It took hours, and I don’t remember how it ended, but I do, twenty years later, remember the pain of it, and the fear.”

(TMZ also noted that Timberlake tried to comfort her by playing guitar while she was on the bathroom floor in tears. Buddy…a heating pad and some tea would have been more helpful.)

Yes, medication abortion can be painful. But it could get worse if Republicans have their way and get a key abortion drug pulled from the market, all while scaring people into thinking they can’t travel to other states for abortions.

It’s not clear who got the pills for Spears or which medications she took—mifepristone and misoprostol, or miso only—but she said her abortion was in late 2000. The Food and Drug Administration first approved mifepristone for use in the U.S. on September 28, 2000, but FDA approval doesn’t mean it’s instantly available for doctors to prescribe. Contemporaneous reporting says the first day the pill was offered in clinics was November 21, 2000, and Spears said she and Timberlake didn’t see a doctor. It seems somewhat unlikely that Spears obtained mifepristone that fall, though it is possible.

But when the two-drug combo was first approved back in 2000, the labeling was pretty different than it is now. People were supposed to swallow mifepristone (which blocks hormones that prevent the pregnancy from continuing), then, two days later, swallow misoprostol (which causes contractions to expel the pregnancy). In 2016, the FDA updated the labeling to say people should instead take miso by putting it between their cheek and gums and letting it dissolve; it’s known as taking the drug buccally. But studies show that miso is most effective and causes the fewest side effects when people insert it vaginally, so abortion providers prescribe it off-label this way. The big takeaway is that no one tells people to swallow miso anymore like they did in 2000. (People still swallow the first drug.)

Which brings us to a lawsuit currently pending at the Supreme Court that could undo the FDA’s 2016 label update, and roll back approval from 10 weeks in pregnancy to seven. There is an incredibly small chance the Court could agree with a notorious lower-court judge and say that mifepristone was wrongly approved from the get-go and try to pull it from the market entirely. In effect, they’d try to act like the 2000 approval never happened.

That brings me to the other possibility for Spears: Which is that she had a misoprostol-only abortion. That regimen is more painful than the two-drug combo because it relies solely on uterine contractions to end the pregnancy and involves a higher dose of miso to boot.

Medication abortions can be painful even now, but they are medically safe. (The bigger risk post-Roe v. Wade is potential criminalization, and vaginal miso can leave a residue that a healthcare provider could see if the person needs follow-up care.) Some people in states where abortion is still legal choose to self-manage their abortions with pills rather than get a procedure because the closest clinic is too far away, they can’t get time off work, or they’re a survivor of sexual assault, among other reasons. For others in states with bans, traveling elsewhere may be impossible, and using pills might feel like their only choice.

Everyone deserves to choose what kind of abortion they have, whether that’s using pills at home or a procedure in a clinic. But if conservative activists get their way—whether via passing more abortion bans, attacking abortion funds, or the worst-case scenario in the mifepristone lawsuit—they’ll try and scare people into thinking that their only options are a potentially painful home abortion or just staying pregnant.

I want to note that on Friday, Spears wrote on Instagram that she’s over the events in the book, though she didn’t refer to the abortion specifically. “I have moved on and it’s a beautiful clean slate from here,” she wrote, adding that the book “has given me closure on all things for a better future.” Just something to keep in mind if you see conservative activists painting her as somehow irreparably harmed by having an abortion over two decades ago.

In fact, the people who are most likely to have lingering mental health effects when it comes to abortion are those who were denied access to the procedure and forced to give birth, not those who received abortions. But Republican lawmakers don’t actually care about that.