‘If I Don’t Lie, It’s Illegal’: How Forced Counseling Affects Abortion Patients

When I provide patient-centered counseling to people seeking abortion care, I have to undo the damage from biased counseling mandated by the state.

[Photo: A young woman listens as her doctor speaks.]
Even though having an abortion is 14 times safer than giving birth, some abortion providers have to inform patients about risks of death, infertility, and even breast cancer—talking points deployed by the powerful anti-choice movement in Texas and nationwide. Shutterstock

I’m a counselor at an abortion clinic in Texas, where patients have to navigate roadblocks to care every day, including forced counseling against abortion.

Over the past year, I’ve counseled hundreds of people. Although I do provide some state-mandated counseling 24 hours before the procedure, most patients visit me separately on the day of their abortion. It isn’t unusual for people to enter my counseling room with their guard up, viewing it as yet another barrier imposed by the state before they can continue with their health-care decision. In reality, clinics that offer abortion counseling do so in order to provide patient-centered care that considers people’s unique experiences. But patients were confused so often that, eventually, I changed the way I began every interaction.

Before providing patients with an overview of what to expect from our counseling sessions, I now let them know that I won’t question their decisions. Recently, I told a patient who seemed uncomfortable after I introduced myself that I don’t need her to convince me that her reasons for having an abortion are good enough. While I wanted to make sure it was her decision to be there, I reminded her that she’s in control of what she shares with me. “Oh, thank God,” she told me, explaining that she had dreaded meeting with me because of what she expected counseling to be like. We talked about her life, her reasons for being there, and her goals for afterward. We developed a rapport. As she walked out, she thanked me for being “so nice” and not at all what she had expected.

Thirty-four states require that patients receive state-mandated counseling before an abortion can be performed, according to the Guttmacher Institute. Twenty-seven of those states also have mandatory waiting periods, forcing people to wait 24 to 72 hours after counseling before receiving the health care they have sought.

Typically, state-mandated counseling includes providing resources on alternatives to abortion (like adoption and continuing the pregnancy), inaccurate information and terminology about fetal development (such as the presence of a “heartbeat,” the ability for a fetus to feel pain, and language like “baby”), and the medical risks of abortion and of continuing the pregnancy.

Even though having an abortion is 14 times safer than giving birth, some abortion providers have to inform patients about risks of death, infertility, and even breast cancer—talking points deployed by the powerful anti-choice movement in Texas and nationwide.

Because of the “Texas Woman’s Right to Know Act,” we have to tell patients all of those things before their 24-hour waiting period can begin. We have to give them printed materials with that information, too. A separate booklet we’re forced to provide includes a list of anti-choice pregnancy clinics that offer free sonograms but don’t discuss abortion care. The idea behind state-mandated counseling is that people need “ample” time to make a decision based on the dubious information doled out by the state.

Here’s the thing: No other medical procedure requires this kind of biased counseling, which until 1992 the U.S. Supreme Court had found unconstitutional. The patients I speak to are capable of making informed decisions without state interference.

Part of my job includes providing these state-mandated materials and reciting a script about alternatives to abortion—a script that includes how the patient’s partner in the pregnancy is responsible for child support regardless of whether they’ve offered to pay for the abortion. It’s frustrating for me as a provider, and as someone who’s had an abortion, because we deserve to be trusted to make family planning decisions. Much like the patients I speak to, I knew I had the options of continuing the pregnancy and of adoption, but I showed up to an abortion clinic for a reason.

Forced counseling and waiting periods devised by lawmakers who oppose abortion rights disproportionately affect low-income families and people in rural areas without an abortion clinic nearby. Patients in Texas who live more than 100 miles from the nearest abortion provider may receive the counseling over the telephone; otherwise, they must make two trips on separate days. That means missing work and losing income, securing transportation and child care multiple times, and sometimes not paying rent or utilities because of all the costs added to abortion care by these onerous regulations.

The anti-choice counseling creates confusion for patients who receive separate counseling on the day of their abortion, which generally includes reviewing consent forms, checking for understanding, assessing for coercion, describing the abortion process, answering patient questions, and providing a space to discuss emotions and thoughts surrounding their decision without shame or judgment.

Some patients fear they won’t be able to have children later on if they want them. When I ask if that’s because of the information we had to provide them earlier, the answer is almost always yes. It’s times like these I’m reminded why patient-centered counseling is so valuable, even though not all clinics are able to offer it. Texas policymakers wants patients to fear they won’t be able to have children later, and it’s a privilege to be able to talk them through those fears. I always let patients know that although the state makes us tell them it’s a risk, the American Congress of Obstetrics and Gynecology says abortions without complications (that’s the overwhelming majority of abortions, since complications are very rare) do not affect fertility—a comforting fact for many.

Dr. Jessica Rubino, an abortion provider in Texas, said that while she complies with the law by providing state-mandated counseling, she also makes room in each visit to offer patients actual facts.

“It has the effect of exhausting me and confusing my patients. When you go to the doctor, you expect your physician to give you expert, sound medical advice. That’s why you go,” she told me. Dr. Rubino said this should be “exactly the same” when accessing abortion. “If I don’t lie, it’s illegal. If I don’t tell them the truth, I’m a bad doctor and committing malpractice—also illegal. It’s a lose-lose [situation]. Which is exactly what the Republicans who pass these draconian laws want. They don’t want patients to have the correct information.”

Even though most people who have abortions are confident in their decision by the time they come to the clinic, state-mandated counseling is grounded in the myth that people feel conflicted. Research shows most abortion patients aren’t conflicted—and that even experiences accompanied by complicated emotions don’t result in regret.

But it’s no surprise that after going through various political hoops to receive abortion care, some people find more counseling overwhelming. Abortion providers deserve the ability to provide patients with accurate, evidence-based care, and people who have abortions deserve to be trusted to make these decisions in the first place.