Putting Politics Aside: Supporting Pregnant Women Who Have Experienced Sexual Violence

In June 2022, the U.S. Supreme Court issued its ruling in Dobbs v Jackson Women’s Health Organization (1), which overturned Roe v Wade and eliminated the federally protected right to abortion. In the year since the decision, 14 states have made abortion illegal. The issue of abortion rights has become politically polarized, with both pro-life and pro-choice factions holding strong moral convictions about their viewpoints. Every state may now set its own rules regarding the legality of abortion, with consequent requirements for rapid change in reproductive health practices in some states. Texas is one of the most restrictive states, with the inclusion of Senate Bill 8 (2), which bans abortions after detection of embryonic cardiac activity—around 5–6 weeks after the start of the patient’s last menstrual cycle—often before the woman realizes she is pregnant. The Texas Health and Safety Code Section 171.208 (3) bill additionally grants the right for any person in Texas to bring a civil action (with statutory damages no less than $10,000) as follows:

. . . against any person who performs or induces an abortion. . . [or] knowingly engages in conduct that aids or abets the performance or inducement of an abortion. . . regardless of whether the person knew or should have known that the abortion would be performed or induced.

The full ramifications of how these restrictive state laws may affect general medical health and mental health care remain ambiguous. The language of the Texas bill is vague, leading to concern by reproductive and mental health providers of potential legal liability if they discuss reproductive options with their patients. Some organizations in Texas have adjusted their rape crisis counseling services to offer less candid discussion about pregnancy options with women who have been raped and to be more vigilant about the potential for entrapment by anti-abortion activists (4, 5). Medical ethical principles for confidential doctor-patient communication and patient-centered treatment may also be in jeopardy (6). For example, Senate Bill 8 in Texas makes abortion illegal after 5–6 weeks and has no exceptions for rape or incest. Advocates for sexual assault survivors in Texas risk being sued if they offer an abortion referral to a survivor carrying a baby conceived through rape (5).

Women’s advocates propose that the Texas law could trap people experiencing domestic abuse in their abusive relationships. A recent study (7) reported that mental distress has increased among women of reproductive age following the Supreme Court decision overturning Roe v Wade and new barriers to legal abortion. Rape resulting in pregnancy is a public health problem in which sexual violence and reproductive health connect. According to the U.S. Centers for Disease Control and Prevention’s National Intimate Partner and Sexual Violence Survey, 2016/2017 Report on Sexual Violence (8), one in four women (26.8% or 33.5 million) reported experiencing a completed or attempted rape at some time (pg. 3). More than half (56.1%) of these women were raped by an acquaintance, more than one in three (39.3%) by an intimate partner, and about one in six (16.0%) by a family member (pg. 7). Almost half were first victimized as minors (pg. 11). It is estimated that one in seven of these individuals (almost 3 million women and girls) became pregnant. Two-thirds had ongoing concerns for their safety (pg. 14). These safety concerns are realistic, because women who are pregnant or have recently given birth are twice as likely to die by homicide than from any other cause of maternal mortality, most often at the hands of an intimate partner (9, 10).

Multiple medical organizations have decried the Dobbs ruling. The American Academy of Family Physicians, American Academy of Pediatrics, American College of Obstetricians and Gynecologists, American College of Physicians, as well as the American Psychiatric Association published a joint statement (11) on June 24, 2022, entitled, “Physicians: SCOTUS Decision Jeopardizes Patient-Physician Relationship, Penalizes Evidence-Based Care.” This statement said:

Our organizations, representing over 400,000 physicians and medical students, condemn the Supreme Court decision in Dobbs v. Jackson Women’s Health Organization, striking down the protections afforded to people in need of abortion care for five decades. Our organizations have consistently opposed any legislation or regulation that interferes in the confidential relationship between a patient and their physician and the provision of evidence-based patient care for any patient—and this decision will allow states to gravely interfere in that relationship by penalizing and even criminalizing the provision of evidence-based medical care. This ruling will curtail access to critical reproductive health care for millions of people across the country, will grow the health inequities that already exist in the medical system, and will set a dangerous precedent for legislative interference across medicine.

Health equity advocates have highlighted abortion access as a racial justice issue (12–15). Although women of all ages and ethnic and socioeconomic backgrounds access abortions, women who access abortion are more likely to be low-income, unmarried, and from racially or ethnically minoritized populations. Black women access abortions at three times the rate of White women (16). Structural factors, including systemic racism, unequal access to quality family planning services, economic disadvantage, suspicion of the medical system, and decreased access to educational opportunities, contribute to observed differences, especially for pregnant teens (12) The most commonly reported reasons for seeking an abortion are inability to financially support a child, unpreparedness to have a child or to have another child, and having an abusive or unsupportive partner (17). In predominantly Black, Indigenous, or Latine underresourced communities, there has been a decline in ready access to contraceptives and the option to terminate unwanted pregnancies, as well as declining access to prenatal services and obstetrical care. Recent estimates suggest that a nationwide abortion ban would increase maternal mortality by 21% overall and by 33% among Black Americans (18). Unwanted pregnancies may result in long-term negative mental health and quality of life outcomes for women and families (19). Adolescent parenthood also has been correlated with poor mental health, including higher rates of depression, elevated risk for suicidal ideation, higher rates of domestic violence, and increased risk for substance use—all of which may perpetuate a cycle of poverty (12).