When Roe was overturned, a teenage girl I treat was bewildered and had difficulty comprehending the nonsensical nature of the decision, and said she was having extreme difficulty sleeping, palpitations, headaches and nausea during the day. A 19-year-old female college student told me, “It just goes to show you how selfish people can be and misinformed about certain subjects. It’s awful. Women are going to die because of it.” Several female high school students I treat have told me that they are now only applying to colleges in states where abortion is legal.
These days, with Roe overturned, I find myself bouncing things off female colleagues in psychiatry and pediatrics — as well as my three daughters who are in their 20s and early 30s — more than ever. Even more importantly, I am learning from my female patients.
Recently, abortion rates in the United States began rising, after a 30-year decline, and some of the highest rates of teenage abortions tend to be in red states where abortion has ended or will soon end. Teens especially may lack the resources to get reproductive care in a different state where it is legal.
When it comes to teenage pregnancy, what we do know — statistically speaking — is that it is better both medically and psychologically to delay pregnancy. Teenagers especially cherish their bodily autonomy, which a 17-year-old patient reminded me of when she expressed anger at Roe v. Wade being overturned: “A bunch of old men don’t have a right to tell me what I can and can’t do with my body! How can girls go to high school or college with a baby in the house, even if you are not taking care of it!”
The major child psychiatry organization in the US believes that teens facing mental health challenges here will be at greater risk for suicide as a result of the Supreme Court decision. States that make it a criminal offense to assist teens getting reproductive care will essentially criminalize efforts to support youth mental health.
A 19-year-old patient told me that she and her friends are already thinking of starting chat groups to help motto ways to circumvent what they expect to be the 2020′s version of Big Brother watching them and their bodies, and described the feeling as “creepy.”
Though most of legislation is focused on abortion providers, the future is ripe for opportunities to criminalize individuals; some of my patients are up for this challenge of using medication-induced abortion in a private manner. They have grown accustomed to making such decisions about their bodies.
“It’s a hard thing to get caught doing since it’s a one-time thing, and the pills don’t smell,” one told me, as opposed to other secretive adolescent things that grown-ups can detect.
Dr. Mindy Brittner is an adolescent medicine provider at the Institute for Family Health at Mount Sinai. She is also an abortion provider who works one day each month at Planned Parenthood. She is expecting an influx of people due to people traveling to New York for abortion. She told me about the Miscarriage and Abortions Hotline, which offers medical support to people managing their own abortions with pills they can obtain online.
Teens call from all over the country, and up until the overturn of Roe, states like Texas were on the top of the list. Many teens are people doing self-managed abortions, “which is how teens manage a lot of things.” The hotline also provides medical support to people who have already obtained medication. Teens may ask where they can obtain the medication, and websites such as plancpills.org can help teens obtain abortion medication.
Teens have a harder time with access to transportation and the need for a “cover story” if they are going to go somewhere, and the dissolution of Roe will discriminate even against minorities and more disadvantaged teens.
Dr. Karen Soren, who runs the adolescent medicine program at Children’s Hospital at Columbia, told me that New York State may get a surge from people who have family here traveling here for abortions, which will likely also serve more people with private insurance. For less fortunate women with Medicaid from other states, New York will unfortunately not accept it.
With the dissolution of Roe v. Wade, suicide rates among teenage girls, which already went up by over 50% during COVID, could rise even further; pregnant teens are at higher risk for suicide. Restricting abortion rights will likely exacerbate the current mental health crisis in children and teens. Research has shown that restricting abortion can lead to increased anxiety and lower self-esteem.
For a woman, being able to control when childbearing occurs is linked to socioeconomic status and future earning; Abortions will now become more unsafe, and unwanted pregnancy is also associated with increased partner violence. The overturn of Roe will disproportionately affect minorities, poorer women and those in rural areas.
There is a lot of misinformation claiming that abortion increases suicide risk as a way of driving anti-abortion policy. However, it seems that the opposite is true. In El Salvador, there were reports of raped teens who became pregnant killing themselves.
Brittner told me that some oral abortion medications come with a phone charger so it looks like you that’s what you ordered in the mail. Although teens are more internet savvy and better at doing things outside the formal medical system, there is a wave of paranoia now about how they will be monitored in states where abortion is now illegal. Politico recently reported that states where abortion is outlawed may be able to use Google location data from phones to track women getting abortions.
Public policy affects mental health and kids are victims of politics, their mental health held for ransom by governing laws how their bodies are protected. Teens are even more uniquely affected since they already have issues accessing health care — especially without their parents knowing — and their ability to cope with stress and problem-solve is more immature than in adults. Early pregnancies disrupt school attainment and affect future earning potential in teenage women, who are more likely to have premature babies, and deliver boys more likely to later be in jail, and daughters more likely to also be teen mothers. Though it is encouraging that the president has asked that billions of dollars be directed toward mental health, we may be filling the sink while leaving the drain open.
More unwed teen moms will thus lead to more at-risk children, particularly if they are raised in single-parent households. There are many current reports about the mental health crisis in teens and the reasons for it; this will be another trigger. Restricting abortion will likely lead to more mental health problems, exacerbating an already burgeoning and untenable trend and as usual will discriminate more against vulnerable populations.
Soren commented that “It’s chilling, it’s totally chilling, there will be a lot of unplanned pregnancies.”
“Around the country it will be a disaster,” she added. “Then if they outlaw the medical abortion pill it will be more of a problem,” since most of her teens have medical abortions. “If they outlaw the IUD then we are going back even further to the Dark Ages.”
Mifepristone (RU-486), a progesterone receptor antagonist which stops a pregnancy from growing, dates from the early 2000s and has been used for more than 20 years. It used to have to be dispensed in an office, but now can only be mailed. The main complication is an ectopic pregnancy. Typically, 24 to 72 hours later, an 800 mg dose of misoprostol is then administered, which causes uterine contraction and crampy bleeding about four to six hours later, which lasts for one to two hours, and women bleed on and off until the next period . The combination is effective 98% of the time, and can be given out at Planned Parenthood or at the doctor’s office.
These medications are approved for use at up to 10 weeks gestation. After a medical abortion, patients have to come back every two days for blood draws and then weekly until they stop bleeding. Now this medical supervision will be gone for many women, putting them at greater risk. Mifepristone began to become scarce during the first part of COVID.
Locally in Washington Heights, near Columbia University Medical Center, patients would say they had gotten pills from the bodega to “bring down their period,” which involves the simpler regimen of taking multiple doses of misoprostol without mifepristone, which can nevertheless be 90% effective but can cause diarrhea.
Prior to COVID, a doctor had to hand the pills to a patient desiring a medical abortion, but now this can be done over telemedicine, raising many issues about the implications of doing this across state lines to patients in states that outlaw abortion. The telehealth regulations vary state by state regarding whether you need parental consent.
As far as how a medical abortion works, Brittner explained that “What’s remarkable is the ‘unremarkability’ of this piece of health care which has been present throughout history in varying degrees of safety.”
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Up until a few weeks ago, it had been legal to obtain telehealth-assisted abortions. In states where this will now be prohibited, most people may simply order pills from Aid Access. Plan C did a study where they looked at where women ordered medication online. Most used Aid Access because it has the best scores for reliability.
Brittner noted that “There’re so many things about accessing medical care that are already annoying to doctors and teenage patients alike. It’s bad enough to worry about caring for patients, and rare complications such as the 1% of pregnancies that are ectopic, without having to worry about the legal ramifications of practice.”
She was especially concerned — as am I — about how you damage someone’s psyche by forcing them to do something illegal, and what it means to be a person who feels they’ve done something illegal. My patients are already expressing tremendous anxiety about what will now happen to other reproductive access including contraception, sex education and their right to privacy.
The overturn of Roe is yet another disaster for our already stressed teens that will be playing out with predictability that should not surprise us. Soren just told me about a 16-year-old patient of hers who had an early pregnancy after a plan B (“morning after pill”) medication failure. She was terrified, wanted an abortion and did not want to tell her parents.
“I told her she is lucky she lives in New York City.” In the end, she miscarried. In another state, Soren might have had to defend herself against charges of inducing an abortion and “prove” it was a miscarriage.
How will the criminal responsibility associated with abortion emotionally affect teens in this country? We will soon find out.
Slater is a clinical professor of psychiatry at Columbia University Irving Medical Center and senior attending at the New York-Presbyterian Morgan Stanley Children’s Hospital.