“American abortion is both common and clandestine,” bioethicist and attorney Katie Watson writes in Scarlet A: The Ethics, Law & Politics of Ordinary Abortion, published earlier this year.

Since Roe v. Wade was decided in 1973, more than 30 million abortions have been performed in the United States, most in the first trimester of pregnancy. But the procedure—whether it’s done by surgery or medication—is often wrapped in a cocoon of silence. Disclosure of a recent root canal might be greeted with sympathetic nods from family, friends, and co-workers. But a recent abortion is unlikely to be mentioned in casual talk or even in conversation with one’s nearest and dearest.

The question is why, and Watson posits a likely answer. “Abortion is our era’s Scarlet ‘A,’” she writes. “Today, abortion stigma brands the women and couples who have them and the health care professionals who provide them with an invisible scarlet A.”

In the book, Watson, a professor at Northwestern University’s Feinberg School of Medicine, asks how reproductive justice and reproductive rights proponents can break the logjam and introduce into the mainstream “ordinary abortion”—those procedures that do not involve rape, incest, fetal abnormality, or health risk but are instead sought because a pregnancy is ill-timed or unwanted.

Watson recently spoke to Rewire.News about the book—called “brilliant” by the prestigious Hastings Center Report bioethics journal—and the future of abortion access. This hour-plus conversation touched on many themes including the Trump administration’s threats to reproductive health, the need for bolder strategies to contest anti-abortion stigma, and the misogyny of the right wing.

Rewire.News: Before we talk about Scarlet A, let’s talk about you. What drew you to reproductive health?

Katie Watson: When I was a law student at New York University in the 1990s, I knew I wanted to work on reproductive health issues because I understood them as central to women’s equality. Thanks to a Hays Fellowship in what was then called reproductive freedom, I interned at the Center for Constitutional Rights and helped draft an amicus brief in the [Planned Parenthood of Southeastern Pennsylvania v. Casey U.S. Supreme Court case], showing the burden of waiting periods on women seeking abortions. I also interned in the clinical ethics unit of Montefiore hospital and worked on an abortion issue in their obstetrics department.

After law school, I spent two years clerking for the federal judiciary. I then worked in California as an appellate public defender for death row inmates. Then I moved to Chicago and worked for the Legal Assistance Foundation, representing battered women living in public housing and doing poverty law.

After a while, though, I felt a longing to go back to the bioethics work I’d begun in law school. That was partly fueled by the fact I’d trained as a volunteer doula at San Francisco General, where I did hands-on work supporting low-income women who had no partner, family member, or friend with them when they delivered. For me, choice always meant supporting the right to have babies, and that lonely start to motherhood really moved me. It taught me something important about the lack of support so many mothers face for the entire course of their parenting.

Rewire.News: Are you worried that Roe might be overturned by the U.S. Supreme Court?

KW: The only bright spot of the Trump administration is that we are seeing people recognize the threat we’re facing. People now understand that silence is a luxury we can no longer afford.

But we have to face the fact that our current legal crisis has been generated by a cultural crisis that we’ve been cooking up for a long time. After abortion became a constitutional right, I think many pro-choice people assumed that we’d no longer have to fight about it anymore. And that’s a reasonable assumption—great, you won, go live your life, and fight the next fight!

But the fury and energy of abortion’s opponents led to silence and siloing. The cumulative effect of both anti-abortion forces and the withdrawal of some sectors of the pro-choice movement has, over time, caused our current legal crisis, in the states and federally. It’s sad, but at least for now we still have to be in fight mode all the time. Abortion has become symbolic of women’s advancement, and it’s scary how many people are afraid of that. So it’s not just about embryos. The fight is so much more foundational than that, and that’s why it’s such a big deal.

Still, I’m an optimist—maybe some days, a Pollyanna—but that’s the only way I can keep going. I look at all this turmoil and I think, ‘Wow, we’re birthing a new country.’ We’ve been gestating the dream of equality for decades, and labor is always hard. I mean, the progress women have made in just the last decades is truly phenomenal and, historically speaking, very fast, so it’s not surprising there’s pushback.

I think we’re at the point in the labor where it just really hurts, the transition where people seize up and say, ‘I quit. I can’t take it. I want to go back!’ That’s not to say, ‘La dee dah … it will all be fine.’ Some deliveries require a gruesome operation, and some babies strangle on their own cords and die. Nonetheless, I choose to believe that we are in active labor and I want to encourage everyone who wants our rights delivered to stay in the room, stay strong, and refuse to give up.

Of course, if Roe falls, we’ll be having a radically different conversation about the kind of country we want—or, maybe not different, but much louder and more urgent. If Roe is lost, it will be a long, hard struggle to get abortion back. But I predict that it will be re-won.

Ironically, losing Roe will put pro-choice people in the position the anti-abortion movement is in now—the side that lost the big fight and is full of anger and energy and fundraising.

Rewire.News: I’ve heard some people suggest that passage of the Equal Rights Amendment (ERA) is the best way to ensure that abortion remains legal. Do you think this is a good strategy?

KW: Yes, that would definitely help. But to go back to the backlash point, we can’t pass the ERA unless enough people are on board with the vision it promotes. The relationship between law and culture, and which drives which, is key here. We won’t get an ERA unless people are ready for it, if we don’t have a critical mass of people who trust women and want to allow us to live whatever kinds of lives we want to live. So yes, the ERA would advance equality arguments and it would help the courts lead on this. But text alone will never save you. You need cultural weight behind those words.

Rewire.News: During the past 45 years, many projects—books, films, videos, speakouts—have involved women testifying about their abortions, but these personal narratives have had little impact on those who oppose abortion. Nonetheless, Scarlet A encourages us to talk about our abortions to our friends, colleagues, and family. Why do you think personal conversations will make a difference?

KW: Scarlet A pushes for personal storytelling. Public storytelling is definitely important, but it is easier to discount the stories of strangers than it is to dismiss the account of someone you know and respect. That’s a person you have a relationship with, and to stay in relationship you’ll have to integrate this new information in a deeper way. I don’t think it’s either-or, but if I have to choose between public and private storytelling, I pick the private, coming out to people you know and love and telling them that you had an abortion. Of course, in some ways this is often harder than public sharing.

Experience, however, tells me that people want to talk about abortion. At every book event I’ve done so far, at least one person in the audience has shared their story. When my 80-year-old mom told a friend of hers that I had published a book on abortion, that prompted her friend—someone she’s known for 45 years—to share the fact of her own ordinary abortion. My mother was so shocked that this woman hadn’t told her about it all those years ago when it happened!

Every conversation helps. I refuse to stop talking about abortion and stressing that it is a moral, political, and social good.

Rewire.News: Many patients, physicians, and medical staff fear that they will be hurt or harassed if others know that they are ending a pregnancy or working in abortion care. Does the threat of violence feed the silence about abortion?

KW: Of course it does. At the same time, I worry that sometimes we accidentally help it do that silencing. I was really struck by a Medical Students for Choice event when someone asked a question about violence against providers, and Dr. Sarah Prager cited research suggesting that the fields of medicine in which physicians are at the highest risk of violence are emergency medicine and psychiatry. The difference is that in other fields the violence isn’t political; violent patients and family members aren’t necessarily targeting the specialty as a whole. This is why those fields don’t talk about it as a risk factor the way we do in abortion care, and maybe that’s why these murders don’t seem to make the national news.

I want to figure out how to deplore and rage against violence in abortion care without increasing the power of that violence. I think there’s a tightrope we need to walk between calling out anti-abortion violence as the domestic terrorism that it is, and making sure that people understand that most abortion clinics are safe places to work and to obtain necessary, and ordinary, health-care services. And in terms of patients, I don’t have data to support this, but like many “coming out” stories, I predict the majority will not be greeted with violence and harassment.

So yes, there’s a tension between these poles, sure, but we need to find a way to hold both of these realities at the same time.

Rewire.News: The reproductive justice framework situates abortion in a broader social and political context. How can we promote the RJ agenda more widely?

KW: The focus on abortion has prevented us from moving further on the rest of the reproductive justice agenda in a robust way. It just kills me. If we could take every dollar people have spent defending abortion rights and opposing abortion rights, and put all this money toward contraceptive access, comprehensive sex education, paid maternity leave, affordable high-quality day care and early childhood education, maternal and child wellness, affordable housing, etcetera, etcetera, we’d have a family-friendly country that would be a much happier place for people across the political spectrum.

It’s frustrating. At the end of the day, I don’t need people to like abortion. I just need them to stop obstructing pregnant people who think abortion is an ethical thing to do, and decide it’s what they need to do. That’s the meaning of pluralism, and maintaining it requires braver politicians and outspoken advocates.

As I say in the book, we’ve let doctors become the face of the right to abortion. Regular people—those who have abortions and their allies—need to defend what we have and work to expand what we have. And if we can’t do that … I don’t know, maybe we don’t deserve legal abortion. I’ve never said that out loud before, and in my heart I don’t really believe it—of course we deserve control of our bodies and lives. But as a political matter, when such a huge percentage of those who benefit from the service won’t stand up to defend it, it’s like, well, what do you expect?

Rewire.News: What are you working on now?

KW: Right now I’m working on an article about the argument for abortion as a moral good, as opposed to a necessary evil, or just a morally acceptable choice for someone else. To argue that, you have to openly discuss the moral status of embryos and fetuses, which the pro-choice movement doesn’t seem eager to do. I want to think more deeply about the concept of “beneficiaries” I developed in my book in terms of social contact theory, how the ordinary abortions that are provided to a million patients every year benefit these individuals as well as the society we live in.

I just have so many questions about how abortion actually works. There’s so much to learn. I’m kind of afraid it might turn into another book.

The interview has been lightly edited for length and clarity.