December 2023 Workshop Proceedings: Harassment and Violence Against Health Professionals Who Provide Reproductive Care

Introduction

The National Academies Standing Committee on Reproductive Health, Equity, and Society and the Committee on Human Rights co-hosted a webinar on December 11, 2023, during which expert panelists discussed long-standing concerns regarding harassment, threats, and physical attacks against health care professionals working to provide essential sexual and reproductive health care. This webinar, supported by the National Academy of Sciences W.K. Kellogg Foundation Fund, was part of a series on reproductive health topics.

Statements and opinions expressed are those of individual workshop presenters and participants.¹

Justin R. Lappen, MD
Division Director of Maternal Fetal Medicine, Cleveland Clinic; Associate Professor of Reproductive Biology, Case Western Reserve University School of Medicine

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“While our series has been primarily focused on domestic issues, we know that violence against providers of reproductive health care is an international issue, and we recognize that this is a global problem.”

Reproductive Health as a Human Rights Issue

Abortion access is part of rights to reproductive autonomy and health protected under international human rights law. (Shah)
Health care workers, including abortion providers, often play a crucial role as human rights defenders on the front lines of delivering essential health care. (Shah)
When health care workers experience harassment or violence related to their provision of care due to criminalization of abortion, it can be recognized as a human rights violation. (Shah)
The World Health Organization recommends the decriminalization of abortion and United Nations human rights bodies warn of the risk of violence where criminalization exists. (Shah)
The United Nations underscores that member states should take measures to protect those who provide abortions and related services from harassment, violence, kidnapping, and murder perpetuated by non-State actors. (Shah)

Payal Shah, JD
Director of the Program on Sexual Violence in Conflict Zones, Physicians for Human Rights

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“We recognize that health care workers, including abortion providers, often play a crucial role as human rights defenders on the front lines of delivering essential health care and working to ensure that their patients ... can exercise their rights. Where health care workers are targeted for their provision or defense of human rights, they themselves may be recognized as having experienced human rights violations. This includes both for being targeted for physical attack, but also crucially where clinicians experience undue legal attacks and harassment.”
Payal Shah, JD
Director of the Program on Sexual Violence in Conflict Zones, Physicians for Human Rights

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“The result of such [anti-abortion] laws, which are known to motivate violence and cause fear, is that clinicians are effectively called upon to be complicit in the State’s violations of patients’ rights. It has been found in ... numerous international cases to lead to violations of the right to freedom from torture, cruel, inhuman, and degrading treatment, including specifically in cases of denial of abortion to women with fatal fetal conditions.”

Violence and Harassment Against Health Professionals Providing Reproductive Care

Clinicians around the world have been harassed, arrested, surveilled, demoted, and fired for providing abortion care and advocating for patients’ rights. (Shah)
Violence by anti-abortion extremists has often intersected with a legacy of racism, antisemitism, and white supremacy in the United States. (Davidson)
Since 1977 in the United States, 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. (Davidson)
The Internet has become the newest battleground for anti-abortion violence, with online death threats, doxing, and other threats of harm having skyrocketed in the past decade. (Cohen)
Following the Dobbs decision and subsequent state-level abortion bans, many anti-abortion extremists have traveled to states where abortion remains legal to target clinics there. (Davidson)
In 2022, increases in major incidents like arsons, burglaries, death threats, and invasions were reported overall, with a sharp increase in states that are protective of abortion rights. (Davidson)

David Cohen, JD
Professor of Law, Drexel University Thomas R. Kline School of Law, and reproductive rights lawyer

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“The first known violent anti-abortion act [in the United States] occurred in March 1976, when Joseph Stockett set fire to a planned parenthood clinic in Eugene, Oregon. Just before he set fire to the building, he spoke to ... his friends not only about his opposition to abortion but also about burning down the Planned Parenthood building. Not long after that attack, others followed. In February 1977, someone set fire to a Planned Parenthood clinic in Minnesota. A year later, 1978, a man entered a clinic in Cleveland, Ohio, and threw a bag of flammable liquid in the receptionist’s face, blinding her. He then set fire to the clinic, which was filled with patients at the time.”
David Cohen, JD
Professor of Law, Drexel University Thomas R. Kline School of Law, and reproductive rights lawyer

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“The world of anti-abortion violence changed on December 28, 1991, when abortion providers became victims of gun violence for the first time. That day Don Katron and Claudia Gilmore, two administrators at a clinic ... in Springfield, Missouri, were shot by a man in a ski mask who entered the clinic, asking to see the doctor, but instead shot the two at the front with a sawed-off shotgun. Both men survived, though Gilmour was left paralyzed. Less than a month later, Dr. Douglas Karpen was shot at a clinic in Houston, Texas. He also survived. Neither gunman was ever caught, though the Army of God took credit for the attacks.”
David Cohen, JD
Professor of Law, Drexel University Thomas R. Kline School of Law, and reproductive rights lawyer

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“The progenitor of almost all Internet-related harassment of abortion providers is the Nuremberg Files website. This was probably the largest anti-abortion website, the first form of Internet-related harassment. The website included ... photos, addresses, telephone numbers, and other detailed personal information of over 200 abortion providers, and it functioned 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.”
Michelle Davidson
Director, Security, National Abortion Federation

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“In 2022, dozens of clinics across the country were forced to close as a result of state-level abortion bans and anti-abortion extremism. Some of the closed clinics were unable to report any data in 2022, and others ... only reported for part of the year. These closures account for some decrease in incidents, including reports of assault and battery, as one of the clinics that closed had reported more than 100 incidents in 2021, and reported no data for 2022.”
Michelle Davidson
Director, Security, National Abortion Federation

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“So, in 2022, many anti-abortion extremists shifted their attention to protective states after dozens of clinics were forced to close in states to ban abortion. Clinics and protective states saw a disproportionate increase ... in violence and disruption last year [since 2021]. Assault and batteries increased by 29% compared to a 67% decrease overall, stalking increased 913% compared to a 229% increase overall. Hoax devices and suspicious packages increased by 21% compared to a 3% increase. Bomb threats increased by 133% compared to an 11% increase overall. Picketing increased by 21% compared to a 2% decrease overall and obstructions increased 538% compared to a 14% decrease overall.”

Insights on the Legal Framework

Laws restricting access to abortion and the harassment providers face can impact their ability to practice medicine and create long-term impacts on health care, exacerbating disparities in health care. (Shah)
While most countries are amending their laws, in recognition of the harm caused by the criminalization of abortion, the United States is one of only four countries that has recently moved to restrict abortion. (Shah)
Some states have steep criminal laws governing abortion, provisions that can include significant monetary penalties and lengthy prison sentences. (Beasley)
The FACE Act has successfully prevented most large clinic blockades but not other forms of harassment, largely due to enforcement issues and fear that the police will be taking sides in a political debate if they enforce this law. (Cohen)
California, Colorado, Massachusetts, New Jersey, New York, Oregon, and Vermont have expanded Safe at Home laws to include abortion providers and seekers. (Cohen)

Payal Shah, JD
Director of the Program on Sexual Violence in Conflict Zones, Physicians for Human Rights

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“Our [Physicians for Human Rights’] evidence underscores how abortion bans are putting clinicians in an untenable situation, where they are unable to both avoid grave legal risk and adhere to medical standards of care and medical ethics, including their ethical obligations... to act in accordance with patients’ rights and autonomy, as well as their right to be free from torture and ill treatment. This situation is known as dual loyalty, that is a position where they must navigate arbitrary and punitive state laws, while also seeking to comply with their ethical duty to provide appropriate standard of care to their patients and ensure patients’ rights.”
Payal Shah, JD
Director of the Program on Sexual Violence in Conflict Zones, Physicians for Human Rights

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Watch the video clip to hear Payal Shah share insights from a recent study published by Physicians for Human Rights, the Oklahoma Call for Reproductive Justice, and the Center for Reproductive Rights, which assessed the ability of a pregnant person in Oklahoma to receive sufficient information to make informed decisions about their medical care and the extent to which hospitals had adopted protocols for providing emergency care.

“It’s important to underscore that while the staff made good faith efforts... to assist the callers [prospective patients], not a single hospital in Oklahoma appeared able to articulate clear, consistent policies for emergency obstetric care that supported their clinicians’ ability to make decisions based solely on clinical judgment and pregnant patients’ preferences and needs.”

Effects of Violence on the Health and Well-Being of Providers

A key strategy against abortion access around the world is fear, including utilizing the law and harsh criminal penalties to implicitly impose bans on abortion, even where the law allows for life-saving care. (Shah)
Trauma and a climate of fear have led to system level burnout and health care deserts. (Harris)
The targeted harassment of health professionals providing reproductive care at home and at work sends a clear message that providers have to be constantly vigilant about their personal safety and privacy. (Cohen)
Relatives, neighbors, and colleagues can also become targets of this harassment in order to intimidate and indirectly harass the provider. (Cohen)
Clinicians are being put in an untenable situation of dual loyalty, in which they are unable to both avoid grave legal risk and adhere to medical standards of care and medical ethics. (Shah)

Anitra Beasley, MD, MPH
Associate Professor of Obstetrics and Gynecology, Ryan Residency Training Program Director, Baylor College of Medicine

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“I moved back to Texas in 2010, and when I did, I thought long and hard about where I would live. I thought about which neighborhood I considered safe, which neighborhood I consider to be more progressive. I try and do everything that I can to dissociate my name ... from my property. I thought about what would happen if protesters came to my house, as they had for my more established colleagues. I wondered what my neighbors would think at that time, would they be supportive? What happens if someone approached my kids and how they would be impacted?”
Anitra Beasley, MD, MPH
Associate Professor of Obstetrics and Gynecology, Ryan Residency Training Program Director, Baylor College of Medicine

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“My parking spot is behind a giant eyesore machinery. Not because I’m special [but] because it provides the most cover in case of open fire. My ballistic vest stays in my trunk on the ready for the day that I am told that I need to put it on as I walk the few feet from my car ... into the building. And on the rare instances where it does leave my trunk when we’re going on a trip, beneath the extra trunk space, I have to explain to my kids why I have a bulletproof vest and why I need that for work.”
Anitra Beasley, MD, MPH
Associate Professor of Obstetrics and Gynecology, Ryan Residency Training Program Director, Baylor College of Medicine

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Watch the video clip to hear Anita Beasley describe an incident where she was followed from her clinic and how the threat of violence and harassment has impacted her mental health and well-being.

“While that incident was incredibly scary, and I can probably think of some other things which I just kind of placed to the periphery ... of my mind, I actually think the everyday is worse. The constant chipping away at my soul, the heightened anxiety, knowing I just can’t do my job, that I just can’t provide the care that patients need.”
Payal Shah, JD
Director of the Program on Sexual Violence in Conflict Zones, Physicians for Human Rights

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“Such laws [abortion bans] are known to create what’s called a chilling effect on access to abortion, even where [abortion is] legal, by paralyzing clinicians from exercising their medical discretion. Analysis of studies from around the world ... on the impact of criminalization on providers shows that even where abortion bans are not enforced againstclinicians, the fear of sting operations, harassment through the threat of litigation or professional sanction, or violence is enough to cause delays and denials of care.”
Payal Shah, JD
Director of the Program on Sexual Violence in Conflict Zones, Physicians for Human Rights

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Testimony retold by Payal Shah from a Physicians for Human Rights report on the human rights impact of Louisiana’s abortion ban to be released in March 2024.

“This is a clinician in the state, she says ‘I told my husband, if we cannot change this, I cannot practice. I mean, I have a 4-year-old and ... a 2-year-old, I cannot go to jail for my job, and it will make me feel like I’m letting so many people down and so many patients down. But at some point, do I sacrifice a year of my life going to jail, and what will it do to my license, my malpractice insurance, my ability to even work anywhere. So, it’s a lot. I think most of us feel it’s only a matter of time before one of us is maybe the example.’”

Conceptual Roots of Harassment and Violence and the Connection to Stigma and Social Polarization

Stigma and social polarization have central roles in harassment and violence against clinicians providing abortion care. (Harris)
Anti-abortion extremists often use a piece of someone’s identity, or perceived identity, to form a part of their harassment and, as a consequence, violence can intersect with racism, antisemitism, and other elements of stigma and bias. (Cohen)
Stigma has put reproductive health care providers in a context different from other health professionals and in a way that allows violence and threats of violence to be normalized. (Beasley)
Restrictive laws and court decisions that target abortion care providers have created a climate of condemnation that reinforces the idea that they are deserving of violence and harassment. (Harris)
As part of a stigma-silence cycle, a “legitimacy paradox” is created when abortion care providers avoid talking about their work due to the risks that it might bring, which feeds into the social norm that providing this care is unusual or illegitimate. (Harris)
Without curiosity about and compassion for people who hold different views, social polarization, as it concerns reproductive health, will likely continue, along with violence and harassment against abortion providers. (Harris)

Lisa Harris, MD, PhD
F. Wallace and Janet Jeffries Professor of Obstetrics and Gynecology and Professor of Women’s and Gender Studies, University of Michigan

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Watch the video to hear Lisa Harris give an example of how negative stereotypes about abortion providers have been used to perpetuate legal restrictions

“I’ll just give you an example from the Supreme Court’s decision in 2020 in the June Medical Services case. So, this case, among other things, centered ... on whether abortion care providers have legal standing to bring cases, meaning to sue a state on behalf of their patients.”
Lisa Harris, MD, PhD
F. Wallace and Janet Jeffries Professor of Obstetrics and Gynecology and Professor of Women’s and Gender Studies, University of Michigan

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“Providers are, of course, legitimate health care providers, but they are perceived as illegitimate or deviant or dangerous, and that’s why my team has called this particular vicious cycle a legitimacy paradox. And because of this stigma cycle, negative stereotypes ... are never, or only rarely, challenged and the public rarely gets to see the alternatives to these negative images. They don’t get to see the compassion and conscience that are part of many abortion care providers' decisions to offer this care.”
Lisa Harris, MD, PhD
F. Wallace and Janet Jeffries Professor of Obstetrics and Gynecology and Professor of Women’s and Gender Studies, University of Michigan

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“One thing, though, that I’ll say that is clear from this work, is that how we have a voice matters. We need to lean into our caregiving roles when we do and acknowledge the complexities in abortion, show compassion when we talk, even for people who may not believe the things ... that we believe, and we can’t sound like political pundits.”

Mitigating and Preventing Violence and Harassment

The National Abortion Federation provides resources to abortion providers and facilities to help keep staff and their patients safe, including staff preparedness trainings, facility and residential security assessments, and law enforcement assistance. (Davidson)
Research highlights the importance of health professionals’ voices in breaking stigma- silence cycles and depolarizing abortion, which can lead to more support for abortion access. (Harris)
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. (Harris)
Careful audience research needs to be conducted to develop evidence-based communication recommendations, so providers understand the impact of their voice. (Harris)
Enhanced training for law enforcement would be beneficial; in many cases when an incident occurs, the burden is on providers to identify the ordinance that has been violated and push law enforcement to investigate. (Davidson)
There is a lot to learn from dialogue with other clinicians from around the world who have, for decades, faced violence and harassment for providing abortion care. (Shah)
By using a maternal mortality and health equity framework, along with an outcomes-based approach, the message can be amplified that abortion care is health care. (Lappen)

Michelle Davidson
Director, Security, National Abortion Federation

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“For severe acts of violence, we [National Abortion Federation] respond in person to assist with threat, mitigation, law enforcement liaison, and ensure that anyone affected has the resources they need to not only be safe in that moment but to assist with recovery support, like psychological ... first aid and business continuity. Proactive security support includes security training and facility and residential security assessments, security resources on a variety of topics, and we strive to educate law enforcement on all levels regarding violence and harassment of abortion providers.”
Lisa Harris, MD, PhD
F. Wallace and Janet Jeffries Professor of Obstetrics and Gynecology and Professor of Women’s and Gender Studies, University of Michigan

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“When I testified in a case last summer to prevent our ban [in Michigan] from going into effect, literally, the vice president of the university and the Office of General Counsel folks accompanied me because they knew ... it would be scary, and they had the conversations with the sheriff’s office about what door should I go in to avoid protesters and risk. And so, I think it’s really important for institutions to not just say to health care providers who want a voice, oh, what do you need? What would be helpful? They need to proactively figure those things out and not wait until there’s a crisis to then ask what someone needs, because it’s very hard to know what you need when it’s the middle of a crisis.”
Lisa Harris, MD, PhD
F. Wallace and Janet Jeffries Professor of Obstetrics and Gynecology and Professor of Women’s and Gender Studies, University of Michigan

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“When abortion caregivers do decide to have a voice, it needs to be in ways that recognize complexity, show compassion for audiences, and help people hold any ambivalences they have about abortion and recognize that ... multiple things can be true at the same time. Abortion stops a developing human from being born, and abortion means that a woman, a person, can determine the course of their life, their family’s life, their health. Both are true at the same time. And when doctors communicate in this way, they actually calm people’s amygdala, reduce polarization, and audiences can hear them rather than tune them out.”

Harassment and Violence Against Health Professionals Who Provide Reproductive Care