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The Search for an Abortionist
The Classic Study of How American Women Coped with Unwanted Pregnancy Before Roe v. Wade
By Nancy Howell Lee OPEN ROAD INTEGRATED MEDIA
Copyright © 1969 The University of Chicago
All rights reserved.
ISBN: 978-1-4976-2032-2
CHAPTER 1
The Social Structure of Abortion in America
Somehow, in the mysterious way that issues appear and disappear from the public agenda, abortion has arrived on the scene as a lively and current topic of debate. Only a few years ago, serious discussions of abortion were met with indifference or disbelief, and investigators despaired of finding a rational response from the public. Today, it is widely acknowledged that abortion is one of the most common forms of illegal activity practiced in the United States, and revisions of the laws concerning abortion have been passed or are under consideration in many parts of the country. The explanation of why a subject is taboo at one time and au courant soon after is not obvious, and is, to a sociologist, as interesting a question as the practice of abortion itself.
Without attempting to explain the rapid change in interest and opinion, we can note that it is related to a worldwide trend toward liberalization of the laws controlling access to medical abortions which is accompanying the great increases in population all over the world. Japan and most of the socialist countries have made it national policy to provide legal medical abortions upon the request of patients. The Scandinavian countries and, since 1967, the United Kingdom make abortion available to women on an individual basis under a range of social, economic, and medical situations. In the United States, where abortion primarily comes under the jurisdiction of the states, the laws currently permit only medical factors to be taken into account in determining whether legal abortion shall be permitted, although the mental health clause of the laws of some states is used as an elastic provision to include some cases which primarily involve social factors.
At the same time that interest in changing the laws has been developing, there has been a revolution in contraceptive technology. "The pill" was first approved for prescription use in the United States in June 1960. By 1967, an estimated five million American women were taking the pills every month. The widespread acceptance of the pill, and the essentially zero rate of accidental conceptions associated with its use, suggests hope that the present rate of accidental conception, which amounts to several million per year, can be drastically reduced and that the vast majority of unwanted pregnancies can be avoided before they occur.
The third factor involved in the increased interest in abortion is the promise of new pharmacological techniques of abortion. There have been numerous hints that a "morning-after" pill or a "once-a-month" pill will be available in the near future. Such a drug would eliminate the need for most operative abortions, legal or illegal.
Safe abortifacients, liberalization of abortion laws, and near-perfect contraceptive techniques may change the form of the abortion problem in the future, but they are utterly irrelevant to the experiences of the many women who have been seeking and finding abortions in the past and at the present time.
Of these women, we know very little. An accurate picture of the composition of the population of women who have abortions cannot be expected while abortion remains illegal and while people are understandably reluctant to answer questions which may place them in jeopardy. In the absence of accurate information based on random samples, a certain amount can be inferred from facts that are well established, or at least estimated on the basis of partial data. The size of the population of women who obtain deliberate abortions, for instance, is estimated as on the order of one million per year, although the true number may be as low as two hundred thousand or as high as two million. Approximately ten thousand of these women succeed in having their abortions performed legally in a hospital; the rest go to illegal practitioners in the United States or leave the country to seek abortion where it is more readily available. Most of the women who leave the country to have an abortion go to Canada, Mexico, or Puerto Rico, where the laws are similar to those of the United States, rather than travel to more distant countries where abortion is legal. It is known that many, perhaps most, abortions obtained in America are performed by physicians, many of whom continue to maintain a regular practice with abortion only a profitable sideline. To say that most abortions are done by doctors is not to say that most doctors do abortions. It is clear that most physicians will not perform abortions outside a hospital, and do not offer any help to women who come to them in the hope of getting an abortion. Some abortions are performed by abortionists who are not physicians. Many of these are older women trained as nurses or midwives, who perform abortions in their own homes or in their patients' homes. Some abortionists are prosecuted by the law and sent to jail: most of these are arrested as a result of botched abortions which require the hospitalization of the patient.
Of the women who get abortions, it is clear that not all, by any means, are unmarried women escaping illegitimacy. Studies of some groups, like the Kinsey group and various birth-control clinic populations, suggest that while the abortion rate is higher for unmarried women, married women, especially those who have had all the children they choose to have, probably obtain the majority of all abortions. Estimates of the proportion of married women among abortion seekers vary from 40 to 90 percent. Nor is abortion exclusively or even primarily an activity of one social class or another. Substantial numbers of both rich and poor women are known to obtain abortions.
The fact is that many people in the society manage to arrange an illegal abortion when they wish it, including vast numbers who are ordinarily law-abiding and perfectly respectable. This offers a some what startling perspective on our sometimes naive notions of how a complex society operates and how people operate within a complex society. The task of arranging an abortion is not a simple one. Whether or not the abortion seekers are aware of it, there is an effective time limit operating on the search for an abortionist. Most abortionists refuse to accept cases in which the pregnancy is advanced beyond the twelfth week, when induced abortions become more difficult and dangerous to perform. Since the pregnancy shows no signs before two weeks, and is rarely confirmed before five or six weeks, those seeking abortion usually have less than six weeks in which to make a decision, locate an abortionist, raise whatever money is necessary, and have the abortion carried out.
This is a tight schedule of events—events which are complicated, difficult, and time-consuming. It is surprising, on one level, that such a large number of people are willing to undertake the risks of an illegal abortion rather than carry out the pregnancy. It is even more surprising, when one thinks about it, that hundreds of thousands of times each year people manage this complicated procedure, in the absence of institutional facilities to help them. One would think that the sheer level of activity generated by so many people carrying out such a demanding task would make abortion a highly visible activity in the society. Yet outside certain small circles, abortion is carried on almost invisibly. Many people know of a few cases among their friends and acquaintances; most physicians know of a larger number; and a few cases come to wide public attention when the patient dies or is taken to a hospital seriously ill. But still it is true to say that a very small amount of public notice is generated by what must be a great deal of activity.
Part of the explanation for the invisibility of abortion is that the participants, both patients and abortionists, are trying to keep it quiet to avoid confrontation with the law. Even the best intentions to keep it secret would not be successful, however, if it were not also true that the provision of illegal abortions is extremely decentralized. Each case is handled in an ad hoc way, working through the personal connections that individuals happen to have established before the need for abortion arose. Some of those who obtain abortions do not need to search for an abortionist, either because they find that they can have a legal hospital abortion, because they use self-induced techniques to perform it themselves, or because they happen to have access to a practicing abortionist. The vast majority of women, however, have to locate a specialist in abortion, an illegal practitioner who is willing to take the risks of breaking the law. These illegal practitioners, of course, cannot advertise their practice or make it freely available to their potential customers for fear of attracting the attention of law-enforcement agencies. Some abortionists are extremely surreptitious, operating from transient locations like hotel rooms and concealing their identity, even from their customers, by false names and even masks, while others remain in the same location for years and depend upon the loyalty and discretion of their customers to protect them from the law. In any case, there are no publicly available channels like the yellow pages of the telephone directory which permit potential customers to locate abortionists. In order to find an abortionist, most people seem to ask their friends and acquaintances for leads, people who may not have information about abortionists but who do have the kind of relationship to those seeking abortion that motivates them to try to help and to keep quiet about it. To have an abortion, it is not necessary, initially, to know of an abortionist. Instead, one need only search through one's own acquaintances to find a person who has had some experience with abortion in the past. If there are no such persons among one's acquaintances, it is very likely that there will be among the acquaintances of those acquaintances. In this way, the individual asks for help from persons known to him or at least comes with an introduction from someone they both know. The activity is relatively invisible because the searches can be conducted through the channels of private conversations, telephone calls, and personal letters. The search, starting from ordinarily law-abiding citizens, can reach through a number of intermediary steps to an illegal practitioner without ever requiring the search to come into the public domain and involve a confrontation of strangers agreeing on an illegal activity.
This procedure depends upon a great deal of cooperation and participation by the persons who form the links between the couple who want to terminate the unwanted pregnancy and the abortionist. It must involve millions of Americans each year, both in direct participation in seeking abortion and in supplying information to those who are seeking. While there is no central organization or coordination, the association of those who perform abortions, the intermediary people who hold information on how to locate them, and those who seek abortions for themselves makes up an obscure form of social organization which is quite different from what we usually think of as social organization.
One tends to think of social structure as the ways in which large numbers of people are related to one another through social units to which they belong. One thinks of individuals belonging to families, families clustered into communities, communities into states, and states into a nation, for example. Or we think of individuals as related to others through their occupational roles, and groups of workers related to others through business organizations, through labor unions, or through markets. Consideration of the social structure of an activity like abortion requires the use of the concept of informal as well as formal types of social structure.
Social structure also includes the connections between persons which exist apart from organizations and institutions. The most general form of the question of informal social structure consists of the study of how individuals are related through their personal friends and acquaintances—what Simmel called overlapping social circles and what are now called acquaintance networks. In recent years it has come to be called "the small world problem," from the cliché uttered when two complete strangers discover that they both know a third person. Each person in a large society knows a certain number of others, which may be a very small proportion of the total number in the society. Each of those persons, in turn, knows a similar number of others, many of whom will not overlap with those known by the first person or others in the group known by the first person. Counting all one's acquaintances and all the acquaintances of one's acquaintances takes one to a large number. Carrying out the process a few more steps may include the majority of the people who live in the United States. It is possible, therefore, to describe the informal social structure of a large population by the length and complexity of the pathways formed by personal acquaintance among the members of the population.
The informal aspect of the social structure of abortion, similarily, consists of the connections between individuals who hold information about how abortions are arranged that has been used or could be used to provide contact between persons seeking abortion and abortionists. In order to clarify the concept of an information network and to begin to think in concrete terms of what the informal social structure of abortion must be like, even in the absence of empirical evidence, let us consider a hypothetical data collection and analysis that would shed light on the subject.
Imagine that every adult in the United States has been asked to tell what he or she would do in order to arrange an induced abortion, and that all have given complete and honest answers to the question. Some would say that they would make contact with a particular abortionist known to them. Others would say that they would ask a person known by them to have such information. Still others might not have any specific information themselves, but would ask someone who might be more likely to have such information. Finally, some people would say that they do not know anything about it because they never had occasion to consider the problem; some of these would not consider arranging an abortion for any reason.
To interpret the results, imagine taking a very large map of the United States and plotting the location of all the abortionists named in the interviews. One would leave some space on the edge of the map to plot the location of abortionists outside the country who were named by the informants. Next, one would plot the location of those who named each of the abortionists, drawing a line to connect them to the one or more abortionists named. Then one would use a different color to plot the people who said they would ask someone whom they knew had access to an abortionist, or whom they thought might have access to an abortionist. Finally, one would plot the location of those who refused to entertain the question. One would not draw lines connecting them to anyone else, as they are not a part of the network of information about abortionists. When one finished with this hypothetical task (which could not possibly be completed in a single lifetime, even if the information could be obtained) one would have a complete inventory of the information on hand about how to arrange an abortion.
One would no doubt find that certain parts of the map were densely filled with lines, while other parts were relatively empty, reflecting both the distribution of population and regional differences in the use of abortion. If the map was not hopelessly cluttered with data, one would see a number of distinct networks of people connected directly or indirectly to an abortionist. There would be roughly the same number of distinct networks as there are practicing abortionists available to the population. The size of these networks would vary a great deal, from a few people to an estimated one hundred thousand who could directly reach one unusually well-known doctor who recently retired. Those who can directly reach the abortionist will usually include all his previous patients, usually a few friends or relatives of each patient who were told exactly where the abortion was performed, and anyone else who may have had occasion to learn the abortionist's location. The abortionist may have a referral system of his own, consisting of doctors, pharmacists, and others who come in contact with people seeking abortion. At the second step from the abortionist would be persons who know that someone in the first circle knows how to arrange an abortion, but who could not reach the abortionist directly. One would surely find some cases in which a single person names two or more abortionists or pathways to different abortionists, which link the various networks, and one would surely find some ineffective networks, composed of persons in contact with an abortionist who is no longer practicing, and some networks which are not connected to any abortionist at all. Some of the information plotted, then, must be wrong, representing an unworkable strategy that would not actually lead anyone to an abortionist.
(Continues...)
Excerpted from The Search for an Abortionist by Nancy Howell Lee. Copyright © 1969 The University of Chicago. Excerpted by permission of OPEN ROAD INTEGRATED MEDIA.
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