The new abortion bill in Texas has made abortion care even more inaccessible and heightened the risk for providers, writes Blair Cushing

The physician George Tiller, a well known abortion provider and advocate, was murdered in Kansas by an anti-abortion extremist in 2009, two years before I entered medical school. His tragedy rippled throughout the world and was a pinnacle moment that greatly influenced my future career choices. Before entering medicine, I was very involved in reproductive health advocacy, albeit in a coastal city where the majority opinion was pro-abortion. Learning about Tiller, I was struck by the great lengths that doctors in the US must go to in order to perform abortions, especially in the south and midwest. Now, I am one of those doctors.

Three times a month, I pack my bags and fly from California to Texas to provide abortion care at Whole Woman’s Health of McAllen, the only abortion clinic in Texas’s Rio Grande Valley. The burden of travel can be strenuous, but I’ve come to see it as a necessary commute to provide essential medical care where I’m needed most.

In my home state of California, the right to an abortion is protected in the state constitution and being anti-choice is an unpopular stance among physicians. California is also home to more than a quarter of the nation’s abortion facilities and abortion care is becoming increasingly available at primary care clinics. An upcoming mandate, set to come into effect in 2023, will even requires all public universities to offer medication abortion in student health centers. Just last week, legislation was passed to further protect patients’ access to clinics and to ensure their physical safety, particularly with increasing numbers of patients now traveling from hostile states to seek care.

The realities in Texas are much more dire. There are only 19 abortion clinics designed to support the reproductive freedom of the seven million Texans of childbearing age. Just seven years ago, there were 44 abortion clinics in the state. This steady loss of places to access care is due to insurmountable barriers that the state legislature continues to create for clinics and patients. Senate Bill 8 (SB 8), the most extreme abortion ban this country has ever seen, is the worst one yet. SB 8 went into effect on 1 September and it bans abortion as early as six weeks of pregnancy—just two weeks after a missed period. With so few clinics and a 24 hour mandated waiting period, that makes abortion care nearly unreachable. 

What’s worse, SB 8 deputizes private citizens to sue clinic staff like myself and potentially be rewarded for winning lawsuits. Anti-abortion extremists coming after me is not an abstract threat. Even before this bill, it was an ever present reality for doctors providing abortions in Texas. According to data from the National Abortion Federation, in 2019, abortion providers reported a significant increase in death threats and threats of harm, rising from 57 in 2018 to 92 in 2019. Providers also reported a 125% increase in hate mail and harassing calls (rising from 1388 in 2018 to 3123 in 2019).

Many physicians, including myself, are pressured to operate in secrecy. A 2014 study revealed that 66% of abortion providers had difficulties disclosing what they do. Shortly after starting my work with Whole Woman’s Health of McAllen, there was an arson attempt on our clinic. Immediately after, I enrolled in a confidential address program in California that keeps my home address out of the hands of anti-abortion extremists. I also never tell anyone I meet while traveling exactly where I work or what I do. I routinely provide reminders to my family and friends about not disclosing personal information that links to me on social media. With this heightened vigilance around my own safety, I’ve kept a low profile and done the job that most doctors aren’t willing to do.

That’s not where the vitriol and adversities end. My professional opportunities are also extremely limited as abortion doctors are often essentially blacklisted from practice opportunities, particularly at public or religiously affiliated institutions. Last summer when the covid-19 pandemic was at its peak in the Rio Grande Valley, it created a public health crisis worse than what was seen in New York City. I temporarily relocated to Texas to keep the McAllen clinic open and expressed willingness to treat covid patients as part of relief staffing to local hospitals. Despite recruiters’ initial excitement and promises, once they saw that my CV stated my work at an abortion clinic, all communication ceased. 

This hearkens back to a 2014 Texas law overturned by the Supreme Court in Whole Woman’s Health v. Hellerstedt that required all doctors who provide abortions to have admitting privileges at local hospitals. Though it was ultimately found unconstitutional, many health facilities still refuse to credential us for even unrelated work. This discrimination is particularly prevalent at Catholic owned or other religiously affiliated hospitals, which often explicitly prohibit their doctors from performing abortions. Even our regular clinic protestors have kept up the refrain by shouting that we “don’t even have privileges here.”

As much as I am passionate about abortion care, I could not do it full time in Texas because it severely limits my professional scope of practice and ability to address the full spectrum of my patients’ needs. The emotional toll of this work was heavy even before SB 8, though much more now that we have to routinely turn away patients that we know we are capable of safely caring for. Many colleagues in California ask why I keep providing abortions in Texas. I truly believe that within medicine, there isn’t anything else I can do that will make a bigger impact on someone’s life. To have an abortion can change everything—your opportunities, your future, your health. My own abortion provided that for me and I have no doubt that now I am giving the same to others. I am confident that keeping our McAllen clinic open is the single most impactful thing I could be doing.

Abortion care is one of the few areas of medicine where the federal government and parts of the medical community put politics and ideology ahead of high quality healthcare. Physicians are demonized and patients are shamed for their personal health decisions. When SB 8 first passed, I really had to reconsider if the risks were worth it for me to continue this work and if I was willing to do it anymore with the looming threat of pointless lawsuits. I ultimately decided that it was incredibly important for me to keep going.

Now I’m also reassessing my own visibility because I feel more strongly than ever about protecting abortion access. Texas women have already lost so much because of the medical community’s silence on this issue. Reproductive rights advocates in the “post-Roe era” have long expressed their fears about how abortion access is playing out in real time right now for the women of Texas, who make up one in 10 reproductive age women in the US. If I don’t step forward now to amplify their story, who will?

To the entire medical profession, I ask you to rise up with your support. Be a staunch advocate for abortion care and confer its benefits on families and communities. If you have been trained to provide abortion care and currently don’t, you are severely needed in the south and midwest. Contact your local clinic and see how you can support them. Beyond performing abortions, all of us are always in need of compassionate and skilled physicians for trusted referrals who can partner with us to take care of patients with more complex needs. Now more than ever, we need to know who our true allies are. If you are still in medical school or residency, I encourage you to seek out abortion training so you can better advocate for your patients and care for your own community in the future.

I also implore all medical professionals to find out your institution’s stance on abortion. If more hospitals are willing to credential and establish working relationships with doctors who provide abortions, then more people will have access to the safe and high quality reproductive healthcare that they need and deserve. 

I am committed to remain in this fight so that abortion remains a choice for all Texans. I look forward to more physicians joining me to put our collective outrage into action and do what is right for our patients.

Blair Cushing is a family physician in California and an abortion provider at Whole Woman’s Health of McAllen.

Competing interests: I am a contractor of Whole Woman’s Health of McAllen and Whole Woman’s Health Alliance.