Harassment and Violence Against Health Professionals Who Provide Reproductive Care

Proceedings of a Workshop—in Brief

OVERVIEW

On December 11, 2023, the National Academies of Sciences, Engineering, and Medicine’s Standing Committee on Reproductive Health, Equity, and Society and the Committee on Human Rights co-hosted a virtual public workshop to explore concerns related to the harassment of, threats to, and physical attacks against health care professionals working to provide essential reproductive health care. During the webinar, medical and human rights experts discussed both longstanding concerns related to violence and harassment against health care professionals providing abortion care in the United States and within the context of the 2022 Supreme Court decision in Dobbs v. Jackson Women’s Health Organization. This workshop was the fourth in the After Roe webinar series organized by the Standing Committee on Reproductive Health, Equity, and Society. The series is designed to consider society-wide effects of limits on access to reproductive health care to elevate challenges and strategies to protect health and well-being.

The panelists explored human rights frameworks as related to the provision of abortion care, the effects of violence and harassment on the health and well-being of health professionals, the history of violence and harassment against health professionals providing reproductive care, recent data, and the conceptual roots of the violence and harassment.

This Proceedings of a Workshop—in Brief is a high-level summary of the topics and discussions that occurred during the workshop. It should not be viewed as providing consensus conclusions or recommendations of the National Academies.

FRAMEWORK FOR REPRODUCTIVE HEALTH CARE PROVIDERS AS HUMAN RIGHTS DEFENDERS

Moderator Justin Lappen, Cleveland Clinic and Case Western Reserve University School of Medicine, opened the webinar by explaining that, although past webinars in the After Roe series focused primarily on the United States, the issue of violence and harassment against health care professionals is an international problem. He added that the 75th anniversary of the Universal Declaration of Human Rights was the previous day, December 10, 2023.

Payal Shah’s, Physicians for Human Rights (PHR), presentation highlighted “human rights and global solidarity as we consider the impact of abortion bans on clinician safety and security.” She explained that, following the Dobbs decision, PHR has focused on

working with partners throughout the country to document human rights violations that are occurring¹ and to gather evidence and understand the range of effects on health care workers and hospitals in states that have enacted abortion bans. Shah described how the organization is using this evidence base to conduct “advocacy² to hold the United States accountable for violations of human rights before United Nations bodies and the Inter-American Commission on Human Rights, which is a key regional mechanism for ensuring compliance with human rights in the United States.” Shah identified two principles that guide PHR’s work in this area. The first is abortion access is part of “rights to reproductive autonomy and health protected under international human rights law,” and the second is health care workers, including abortion providers, “often play a crucial role as human rights defenders on the frontlines of delivering essential health care” and may be recognized as having experienced human rights violations when they experience harassment or violence related to their provision of care.

Shah explained that concerns about human rights violations related to reproductive health care in the United States have increased in recent years. She highlighted that the U.S. Department of Justice Reproductive Rights Task Force indicated that it has litigated more cases of abortion-related violence and threats against clinicians and clinics in 2022 than in the prior 3 years combined. She noted that the experiences in the United States are similar to what is happening in other parts of the world where health care providers are being harassed, threatened, surveilled, and demoted or fired for providing abortion care and advocating for patients’ rights, despite the fact that abortion care is recognized as essential health care and a human right.

A key strategy against abortion access around the world is fear, Shah said. One example is using criminal penalties to implicitly impose bans on abortion access even in circumstances where the law provides exceptions for lifesaving care. She explained that this causes a “chilling effect” wherein the threat of criminal or legal penalties against clinicians, whether enforced or not, can lead to delays in, or denials of, health care. Abortion bans also create stigma against health care professionals who provide abortion services, Shah said, noting that the World Health Organization’s Abortion Care Guideline includes a recommendation for decriminalization of abortion and that United Nations human rights bodies have warned of the risk of violence where criminalization exists.

The harassment, violence, and stigma associated with abortion bans have taken a specific form in the United States, Shah said, and were a concern before the Dobbs decision. She explained that, prior to Dobbs, the Supreme Court of Texas upheld Senate Bill 8, which exposed clinicians to frivolous lawsuits from private individuals for providing abortion care, creating a climate of stigma and fear which deputizes the enforcement to private parties and may potentially incite violence against those who aid and facilitate a pregnant woman’s access to abortion. Shah noted that many countries are changing their laws owing to the recognition of the harms caused by abortion restrictions and that the United States is one of only four countries that has recently expanded restrictions on abortion access.

Research developed by PHR has shown how fear and stigma related to abortion bans in the United States has affected many clinicians’ ability to provide care, Shah said. Clinicians are being put in an untenable situation of dual loyalty, she said, in which they are “unable to both avoid grave legal risk and adhere to medical standards of care and medical ethics.” Shah described a recent study³ published by PHR, Oklahoma Call for Reproductive Justice, and the Center for Reproductive Rights that assessed the ability of a pregnant person in Oklahoma to receive clear, sufficient, and necessary information to make informed decisions about their medical care and the extent to which hospitals had adopted protocols and guidelines for providing emergency care. At the time the study was conducted, four overlapping and sometimes contradictory abortion bans were in effect in Oklahoma that imposed severe civil and criminal penalties on health

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care professionals. The study found that hospitals in the state provided “opaque, contradictory, and incorrect information about when abortion is available” and “lacked clarity on the criteria and approval processes for abortion” despite “good faith efforts to assist callers.”

Shah closed by underscoring that abortion bans in the United States are leading to violations of patients’ rights, as well as the rights of health care providers. She said that the UN Human Rights Committee spoke out in November 2023 about the risks clinicians face as a result of the criminalization of abortion.⁴

EFFECTS OF HARASSMENT AND VIOLENCE ON THE HEALTH AND WELL-BEING OF PROVIDERS

Anitra Beasley, Baylor College of Medicine, related stories of violence and harassment experienced by clinicians providing abortion care, listed ways in which this violence has been normalized, and discussed the effects of violence and harassment on the health and well-being of providers. Beasley described how she has not previously spoken on this aspect of her work because of the “threat to my physical and psychological safety.” She said that although she was aware of incidents of violence prior to entering the medical profession, the threat seemed remote. This changed in 2009 when Beasley was informed that George Tiller, a physician who provided abortion care, had been murdered while in church, a place that so many people consider not only sacred but safe, simply because he provided abortions. Beasley described her personal experience working to identify neighborhoods that would be safest for her and her family to live in when she moved to Texas, and the efforts that many physicians take to separate their names from their home addresses.

Beasley went on to describe the precautions taken in the workplace. She said that most of the abortion care she provides has taken place at stand-alone abortion facilities. Beasley said it is a rarity not to encounter protestors when entering the gated parking lots where she works. She explained that protestors are sometimes quietly praying, but at other times they yell at her that she is “killing babies and committing race-based genocide.” Designated parking spots for those who work at the facility are determined based on how much cover the area can provide in the event of “open fire,” she said. “My ballistic vest stays in my trunk on the ready for the day I am told that I need to put it on as I walk the few feet from my car into the building,” Beasley said, adding that she has had to explain to her children why she needs a bulletproof vest for work.

Because of the precautions taken and safety trainings provided, Beasley said that she feels safe once inside the building and added that she has attended active shooter training “more often than I can count.”

In terms of legal concerns, Beasley explained that she has been investigated for murder for providing abortion care and emphasized that, in Texas, she practices under the threat of litigation under a bounty hunter law where anyone can sue anyone who provides a prohibited abortion—a term that is not well-defined, she added. Beasley noted that there are steep criminal laws with financial penalties and “jail time up to life in prison and capital punishment.”

Beasley closed by describing an incident in which she was followed by a protestor after a Saturday clinic. Because of her training, Beasley was immediately aware of a car pulling away from the curb and then following her. Instead of going home, she adjusted her route and called a friend to write down details about the car and call the police if Beasley did not make it home. Beasley added that she called a friend rather than the police because she was unsure whether they would be concerned about an abortion provider. She said that, although this incident was incredibly scary, the most difficult challenges are the daily anxiety and feelings of not being able to simply do her job to provide care to her patients without the threat of violence or harassment.

HISTORY OF HARASSMENT AND VIOLENCE AGAINST HEALTH PROFESSIONALS PROVIDING REPRODUCTIVE CARE

David Cohen, Thomas R. Kline School of Law at Drexel University, provided an overview of the history of anti-abortion violence and harassment to offer context

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for current concerns. Cohen said that violence and harassment against clinicians who provide abortion care in the United States dates to the 1970s when a small group of abortion opponents staged the first reported clinic invasion in Maryland in 1975. The following year, the first documented violent anti-abortion act took place when Joseph Stockett set fire to a Planned Parenthood clinic in Eugene, Oregon, having spoken to friends beforehand about his anti-abortion sentiments. Cohen described more attacks that followed in the middle-to late-1970s, including a 1978 incident in which the perpetrator threw flammable liquid in the receptionist’s face at an Ohio clinic before setting fire to the building. Fire-bombings were also used as a method of attack during this time, Cohen explained, and, in 1979, Peter Birkhead bombed a clinic in New York throwing a flaming torch and a can of gasoline into a room where a doctor was performing an abortion.

Cohen noted that anti-abortion extremism took an even more disturbing turn in 1982 when physician Hector Zevallos and his wife were kidnapped by a group called the Army of God. Zevallos was forced at gunpoint to make an anti-abortion video to send to President Ronald Reagan, Cohen said. During this time, several books and pamphlets were written advocating extreme actions against abortion providers and some advocated murder.

In 1991, Cohen explained, abortion providers became victims of gun violence for the first time when two administrators at a Missouri clinic were shot and a doctor was shot at a clinic in Texas. Cohen noted that the shooter was not caught in either case. Then in 1993, Dr. David Gunn was shot and killed while walking from his car to the entrance to the Pensacola Women’s Medical Services clinic. Cohen said that, since Gunn’s murder, there have been “10 other anti-abortion murders in this country,” most recently in 2015 when a police officer and two patient companions were murdered at the Planned Parenthood clinic in Colorado Springs, Colorado. During this time, there were 29 attempts at anti-abortion murder via gunshot or bombing, Cohen added.

Cohen said that, since the 1990s, anti-abortion extremism tactics have changed in some ways. He noted that the Internet has become the newest battleground and that death threats and other threats of harm have skyrocketed in the past decade, particularly those online. Cohen explained that the progenitor of almost all internet-related harassment of abortion providers is the Nuremberg Files website, which provided photos, addresses, telephone numbers, and other detailed personal information of over 200 abortion providers and served as “sort of a hit list, indicating those who had been murdered with a strike-through font and those who had been injured by anti-abortion violence shaded in grey.” Cohen said that there are other similar websites that compile personal details about abortion care providers across the United States.

Aside from online threats, clinicians who provide abortion care experience targeted harassment that is distinct from attacks on and protests at clinics, Cohen explained. Providers are harassed at home and at work, and they receive hate mail and death threats, among other types of harassment. He added that relatives, neighbors, and colleagues can also become targets of this harassment in order to intimidate and indirectly harass the provider. Cohen noted that this type of harassment sends a very clear message that providers have to be constantly vigilant about their personal safety and privacy.

Cohen closed by describing two laws that have been put in place in response to the harassment and violence targeting individuals providing abortion care. The 1994 Freedom of Access to Clinic Entrances (FACE) Act “prohibits force, threat of force, or physical obstruction that injures, intimidates, or interferes with someone trying to provide or access reproductive health services,” he said. Cohen added that this has been stopping large clinic blockades but not other forms of harassment, largely because of enforcement issues and fear that the police will be taking sides in a political debate if they enforce this law. Cohen explained that some states have expanded their Safe at Home laws—which protect victims of domestic violence by keeping their home address and other identifying information from public databases. California expanded this to include abortion providers and seekers in the early 2000s, and New

Jersey did so in 2019. Since the Dobbs decision, Cohen said Colorado, Massachusetts, New York, Oregon, and Vermont have also expanded Safe at Home laws.

DATA ON INCIDENTS OF HARASSMENT AND VIOLENCE

Michelle Davidson, National Abortion Federation (NAF), began with an overview of NAF and the work of the organization’s security department. NAF is a professional association of abortion care providers in the United States, Canada, Mexico, and Colombia, and provides clinical standards and guidelines that can be used at any abortion-providing facility. Davidson said that NAF members include private and nonprofit clinics, Planned Parenthood affiliates, women’s health centers, physicians’ offices, and hospitals, who together care for more than half of the women who choose abortion in the United States and Canada each year. Davidson noted that NAF provides the only ongoing, accredited, continuing medical education exclusively in abortion care to advance the clinical skills and update the medical techniques of abortion providers. Davidson said the organization’s Security and Safe Access Program provides 24/7 emergency response and support for members and, for severe acts of violence, respond in-person to assist with threat mitigation, law enforcement, acting as a liaison, and ensuring that anyone affected has the resources they need to address immediate and continuing safety concerns.

Davidson described NAF’s research efforts, explaining that the organization has been compiling statistics on incidents of violence and disruption against abortion providers since 1977. This data is collected from NAF members and other organizations to identify trends or patterns in violence and harassment targeting individuals providing abortion services and to report activities to law enforcement where appropriate. NAF compiles and publishes an annual violence and disruption report based on the collected data. Davidson said that, since 1977, there have been 11 murders, 42 bombings, 200 arsons, 531 assaults, 492 clinic invasions, 375 burglaries, and thousands of other incidents of criminal activities directed at patients, providers, and volunteers.

The compiled data for 2022 indicates increases in several categories of violence and harassment, Davidson said, adding that NAF estimates underreporting in picketing, hate mail, internet harassment, obstruction, and trespassing. The year’s statistics show increases in major incidents like arsons, burglaries, death threats, and invasions overall with a sharp increase in violence and destruction in states that are protective of abortion rights. Davidson said that following the Dobbs decision and subsequent state-level abortion bans, “Anti-abortion extremists were emboldened and traveled to states where abortion remained legal to target clinics there.”

Statistics from 2022 overall show a decrease in some activities, including trespassing and assault and battery, which NAF suspects can be attributed to many abortion clinics being forced to close after the Dobbs ruling. Davidson said that there were four reported arsons in 2022, and three of those took place in states that are protective of abortion rights. One such event took place in Wyoming when an individual broke into a clinic and set it on fire. Davidson said that states with abortion protections saw a disproportionate increase in violence and disruption last year because many anti-abortion extremists shifted their attention to those states. For example, Davidson noted in states with abortion protections, assault and battery and stalking increased by 29 percent and 913 percent, respectively, while nationwide there was a 67 percent decrease in assault and battery and a 229 percent increase in stalking.⁵

Davidson closed by noting that increases in violence and harassment have extended to clinicians beyond abortion care providers in recent years. Davidson explained that, in recent years, providers of gender-affirming care have also been targeted with violence and harassment and some of this targeting is coming from the anti-abortion extremists that are known to us.

CONCEPTUAL ROOTS OF HARASSEMENT AND VIOLENCE AGAINST HEALTH CARE PROVIDERS WHO PROVIDE ABORTION CARE: STIGMA AND SOCIAL POLARIZATION

Lisa Harris, University of Michigan, focused her presentation on the roles of stigma and social polarization in generating violence and harassment

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against clinicians providing abortion care. She said that both have central roles in harassment and violence, and both point to possible interventions to prevent violence.

Harris explained that her first experience with the stigmatization of clinicians who provide abortion care occurred in medical school when she received a pamphlet titled “Bottom Feeders,” sent by an anti-abortion group that was filled with “awful cartoons” targeting abortion care providers. Harris described the pamphlet as an effort to mark and stigmatize doctors who provide abortion care, and to perpetuate negative stereotypes of them. In addition, the pamphlet included a cartoon that suggested shooting abortion care providers was justified and illustrated the ways in which doctors who provide abortion care are labeled and stigmatized.

Harris said that sociologists in the 1960s first introduced the concept of stigma. Erving Goffman defined stigma as “an attribute that is deeply discrediting and turns a whole and usual person into a damaged or tainted or discounted person.” Everett Hughes coined the term dirty work to describe work that has been stigmatized. Stigma generates a loss of humanity, Harris emphasized, saying “that loss of humanity is central in how and why violence happens.” She added that, according to psychologist Greg Herek, “When law and policy demonize a group or a class of people” it leads to “a climate of condemnation.” In the case of abortion access, restrictive laws that target providers simultaneously reinvigorate the stigmatizing stereotypes that they rely on, Harris said. She used a 2020 Supreme Court ruling as an example: the case decided whether or not an abortion provider can sue a state on behalf of patients, and Justices Gorsuch and Alito, in their dissent, drew on a wide range of negative stereotypes and wrote that clinicians who provide abortion care have “a record of abandoning their patients and that they were indifferent to serious medical complications.”

Harris explained that stigma leads to “vicious cycles.” In many cases, people may choose not to discuss stigmatized subjects, and this perpetuates stigma because “silence leads to stigma, which leads to more silence.” In the case of abortion access, there are stigma-silence cycles for patients and for care providers. Harris described the “prevalence paradox” cycle for patients, which is created because, although abortion is prevalent with one in four people ending a pregnancy over the course of their reproductive life, it seems rare or unusual, because people do not talk about it. In the case of healthcare providers, a “legitimacy paradox” is created when abortion care providers avoid talking about this work because of the risks that might bring, and this silence feeds into the social norm that providing this care is unusual or illegitimate.

Because of these cycles, negative stereotypes are never, or only rarely challenged, and the public rarely gets to see the alternatives to these negative images. Harris described the importance of breaking the stigma–silence cycles. She explained that her research carried out in collaboration with strategic communications researchers has highlighted the role of doctors’ voices in “depolarizing abortion” and added that breaking the stigma–silence cycle can lead to more support for abortion access. Harris said that her research indicates that doctors can most effectively interrupt the cycle when they communicate about “the complexities in abortion, show compassion when they talk, even for people who may not believe the things that they believe, and avoid sounding like “political pundits.”

Harris closed by discussing the role of social polarization in harassment and violence against abortion care providers. She described how social polarization has been shown to increase the likelihood of violence in many societies and noted that when political polarization increases, so does terrorism. Harris explained that, if polarization continues, the harassment and violence abortion care providers face is unlikely to stop. She said that psychologist Peter Coleman has suggested that “polarization feeds on simplicity” and therefore the “antidote to polarization is complexity,” adding that it is important to foster curiosity about and compassion for people who hold different views. Harris explained that when abortion caregivers have a voice, in particular a voice that leans into complexity and nuance, they can intervene in both stigma and social polarization.

DISCUSSION

To close the webinar, speakers responded to questions posed by audience members.

The speakers were asked to suggest ways to mitigate and prevent violence and harassment against health care professionals providing reproductive health care. Shah noted that it can be difficult for clinicians to speak out because of risk of retaliation, so it is important to find ways to help providers tell their stories. She added that laws restricting access to abortion and the harassment and violence providers face can affect their ability to practice medicine and create long-term improvements in health care, exacerbating disparities in health care.

Several speakers emphasized the role of institutions in facilitating clinicians’ ability to speak out. Harris noted that institutions need to support and facilitate the voice of health professionals in their employment and not discourage them from speaking out on access to abortion. She added that her institution purchases identity protection services for anyone in their family planning unit because her state does not have a protective law like the extended Safe at Home laws described earlier. Cohen explained that harassment and violence targeting clinicians providing abortion care is “an attack on all medical workers,” and this framing can lead to more support from institutions and colleagues. Davidson pointed out the importance of understanding the power dynamics, specifically the desire to control, that often accompany violence by anti-abortion extremists and its intersection with a legacy of racism, antisemitism and white supremacy in the United States. Both Cohen and Harris noted that anti-abortion extremists often use a piece of someone’s identity, or perceived identity, to form a part of their harassment. Davidson suggested that enhanced training for law enforcement would be beneficial, adding that, in many cases when an incident occurs, the burden is on care providers to identify the ordinance that has been violated and push law enforcement to investigate.

Speakers were asked to share suggestions for how to move the needle in reducing polarization related to abortion and the provision of reproductive health care. Beasley said that it is important to remember that abortion care is health care and has an effect on a range of health outcomes, including maternal morbidity and mortality, and cancer survival. Harris added that her team’s research found that most people view abortion as a contested political issue and not as health care and noted that to end polarization, it will be important to have “compassion and curiosity for people who may not agree with us.”

DISCLAIMER This Proceedings of a Workshop—in Brief has been prepared by Jamie Durana as a factual summary of what occurred at the meeting. The statements made are those of the rapporteur or individual workshop participants and do not necessarily represent the views of all workshop participants; the planning committee; or the National Academies of Sciences, Engineering, and Medicine.

MEMBERS OF THE STANDING COMMITTEE ON REPRODUCTIVE HEALTH, EQUITY, AND SOCIETY Claire Brindis (Chair), University of California, San Francisco; Andreia Alexander, Indiana University School of Medicine; Elizabeth Ananat, Barnard College, Columbia University, and National Bureau of Economic Research; Ned Calonge, Colorado School of Public Health; Judy Chang, University of Pittsburgh School of Medicine; Ellen Wright Clayton, Vanderbilt University; Cat Dymond, Atlanta Birth Center; Michelle Bratcher Goodwin, Georgetown University Law Center; Barbara Grosz, Harvard University; Vincent Guilamo-Ramos, Johns Hopkins School of Nursing; Lisa Harris, University of Michigan; Justin R. Lappen, Cleveland Clinic and Case Western Reserve University School of Medicine; Monica McLemore, University of Washington School of Nursing and School of Public Health; Rebecca R. Richards-Kortum, Rice University; Sara Rosenbaum, George Washington University; Yvette Roubideaux, Colorado School of Public Health; Alina Salganicoff, KFF; Susan Scrimshaw, University of Illinois at Chicago; LeKara Simmons, AMAZE; Melissa Simon, Northwestern University; Lisa Simpson, AcademyHealth; Tracy A. Weitz, American University and Center for American Progress; Katherine L. Wisner, Northwestern University Feinberg School of Medicine.

MEMBERS OF THE COMMITTEE ON HUMAN RIGHTS Martin Chalfie (Chair), Columbia University; Nadine Aubry (Ex Officio), National Academy of Engineering International Secretary; Chris Beyrer, Duke University; John Carlson, Yale University; Giselle Corbie, University of North Carolina; Carlos del Rio (Ex Officio), National Academy of Medicine International Secretary; Vanessa Northington Gamble, George Washington University; Wesley Harris, Massachusetts Institute of Technology; Michele Heisler, Physicians for Human Rights and University of Michigan; John Hildebrand (Ex Officio), National Academy of Sciences International Secretary; Andrea Liu, University of Pennsylvania; Douglas Massey, Princeton University; Jonathan Moreno, University of Pennsylvania; Deb Niemeier, University of Maryland; and Ellen Ochoa, Johnson Space Center (Former Director).

*The National Academies of Sciences, Engineering, and Medicine’s planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published Proceedings of a Workshop—in Brief rests with the institution.

REVIEWERS To ensure that it meets institutional standards for quality and objectivity, this Proceedings of a Workshop—in Brief was reviewed by Maureen G. Phipps, Brown University, and Ashley R. Brant, Cleveland Clinic. Leslie Sim, National Academies of Sciences, Engineering, and Medicine served as the review coordinator.

SPONSOR This workshop was supported by the National Academy of Sciences W.K. Kellogg Foundation Fund.

STAFF Rebecca Everly, Director; Tracy Sahay, Program Officer; Julie Pavlin, Senior Board Director; Ashley Bear, Board Director; Natacha Blain, Senior Board Director; Priyanka Nalamada, Program Officer; Laura DeStefano, Director of Strategic Communications & Engagement; Melissa Laitner, Senior Program Officer, Special Assistant to the President; Adaeze Okoroajuzie, Senior Program Assistant; Kavita Shah Arora, Consultant.

For additional information regarding the workshop, visit https://www.nationalacademies.org/event/41348_12-2023_after-roe-preventing-harassment-and-violence-against-health-professionals-who-provide-reproductive-care-a-webinar

Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2024. Harassment and violence against health professionals who provide reproductive care: Proceedings of a workshop—in brief. Washington, DC: The National Academies Press. https://doi.org/10.17226/27518.