Diane Horvath-Cosper, Trump, and abortions, on Slate’s Working podcast.

Here’s What It’s Like to Be an Abortion Provider and Defend Reproductive Rights

Here’s What It’s Like to Be an Abortion Provider and Defend Reproductive Rights

Slate Plus
Your all-access pass
Nov. 29 2016 4:02 PM

How Does an Abortion Provider Work? We Found Out.

Slate’s Working talks to Diane Horvath-Cosper about defending reproductive rights.

Diane Horvath-Cosper.
Diane Horvath-Cosper

Diane Horvath-Cosper

On the Nov. 22 edition of Working, Slate’s Jacob Brogan talks to Diane Horvath-Cosper, a Baltimore based OB-GYN and reproductive rights advocate.

In this episode, Horvath-Cosper talks about what it’s like to deal with pushback from protesters, lawmakers, and even hospital administrations. What originally inspired her to go into family planning in the first place? Why are compassion and care so incredibly important for the field? And what are some of the challenges she faces on a day-to-day basis?

And now that there’s widespread anxiety about the status of reproductive rights in the wake of Donald Trump’s election, how does she feel about her job?

And in this episode’s Slate Plus bonus segment, Horvath-Cosper reflects on the changing presence of abortion in mainstream culture and what that means today.

Jacob Brogan: You’re listening to Working, the podcast about what people do all day. I’m Jacob Brogan. This season on Working we’re talking to people employed in fields potentially imperiled by the results of the recent U.S. presidential election. These are the stories of passionate people doing difficult, hugely important jobs. Jobs that may get a lot harder and a lot more important in the years ahead.

For our first episode, we spoke with Diane Horvath-Cosper, an OB-GYN and family planning specialist based in Baltimore, Maryland. Deeply committed to reproductive rights, she talked to us about why she chose to train as an abortion provider and what’s it like compassionately counseling women as they prepare for abortions. She also talked about her actual clinical work, as well as the day-to-day advocacy that she engages in to support it.

That advocacy has been informed by her own experiences at the clinic and elsewhere, facing down threats and other resistance from protestors and hospital administrators alike. And, of course, she discussed what it’s like to continue that fight in an increasingly repressive and worrisome political climate.

Then, in a Slate Plus extra, Horvath-Cosper reflects on the changing presence of abortion in mainstream culture.

What is your name and what do you do?

Diane Horvath-Cosper: So, my name is Diane Horvath-Cosper and I am an OB-GYN and also a family planning specialist within OB-GYN.

Brogan: What does that mean to be a family planning specialist?

Horvath-Cosper: So, it means that I did two additional years of training beyond my residency to learn how to do abortions, especially abortions later into pregnancy. And then also to help people who have really complex contraceptive needs. And then also to do research and advocacy.

Brogan: What inspired you to go into family planning?

Horvath-Cosper: So, when I was an OB-GYN practicing doing deliveries and surgeries and things like that I liked it a lot, but I came to the realization that, you know, there were always going to be people to do C-sections at 3 o’clock in the morning. There were always going to be people to do prenatal care visits. But unless there was more people trained to do abortions, unless there were people who were willing to train others to do them, then we weren’t necessarily going to have people going forward.

There’s a lot of the people in the field that are retiring and there was a need that needed to be filled.

Brogan: So where do you work today?

Horvath-Cosper: I actually work for an organization called Physicians for Reproductive Health. And that’s actually an advocacy organization. And then I do clinical work. I try to get in three to four days a month on top of my full-time work.

Brogan: So is there a typical day for you within that kind of framework then?

Horvath-Cosper: So, I think that probably it’s useful to describe it in, you know, is there a typical clinical day and a typical advocacy day. And I think within the advocacy world where a lot of it is we’re responding to things that come up. A typical day for me in the last week has been, you know, a couple of media calls. We’ve had a lot of concerns about women and access to contraception and what’s going to happen with the Affordable Care Act. And then maybe I would review documents for medical accuracy. I’m kind of the medical expert within our organization who is on staff.

From a clinical perspective, a typical day for me in the clinics that I work in would be to arrive in the morning. We typically have anywhere between 20 and 30 patients. I spend some time doing procedures. I do things like place IUDs and do implants and other kinds of contraception on top of abortion procedures.

Brogan: When you’re in the clinic, how much of your time do you spend consulting with patients prior to conducting procedures?

Horvath-Cosper: It depends on the clinic’s structure. So, when I was in fellowship, the clinic that we worked in, the physicians would see the patient through the whole visit. So, you know, we had a lower volume of patients, so we would see people, we would do their intake, ask them about their story, let them tell us about their lives, which is really one of my favorite parts of the practice. And then we would do their ultrasound and then prep them for the procedure, do their procedure, and manage their aftercare.

Brogan: So that all happens in one day typically?

Horvath-Cosper: Yes. Typically one day. So, the vast majority of abortions happen at a point in the pregnancy where it’s a very safe, very fast, one-day procedure. In the clinics that I work in right now, because there’s such a high volume of patients, and a lot of people needing care, usually the physician isn’t the one doing all of the counseling. We have excellent, excellent, highly trained staff who see those patients for the counseling portion and the ultrasound portion. And I typically see them for their procedures.

Brogan: Does that make a difference in the way that you conduct the procedure, if you have less contact with the patient beforehand?

Horvath-Cosper: The procedure doesn’t change. I think that one of the things that really enriches the experience for me, and reminds me every day why I do this, is having that contact time with the patient. And sitting down and really hearing people’s stories and having people talk about their lives, and their hopes, and their dreams. But I also think that there’s a gift to be able to go into a room, meet somebody, and within a few minutes establish the kind of rapport that you need to do a procedure with them.

Brogan: Are there any particular things that you do, ways that you talk, ways that address people to build that rapport?

Horvath-Cosper: I think people like to talk about their lives. And they like to talk about their families. And, you know, we know nationally 60 percent of women who have abortions are already moms. And I ask people about their kids and their families. And I have a daughter and I talk about, you know, what is your daughter into. Oh, your kid is 5, what’s he into these days? And I think it really surprises the patient sometimes, because I think that we unfortunately have really kind of dissociated the experience of parenting and being a parent with this idea that people who are parents still have abortions. And it’s still OK to do that. And a lot of time it’s the abortion that allows someone to go back to their lives and be a parent to the kids that they already have.

And I think that people are sometimes surprised when I ask them about their families. It’s as if, you know, they’re shocked that you would recognize that they’re already parents.

Brogan: Do you think they feel like they have to keep that stuff out of the consultation room, out of the clinic?

Horvath-Cosper: You know, I think people come in with all different expectations, but I think one of the biggest ones that people have, and the most unfortunate, is that they don’t expect to be treated like a human being. And I think that that’s one of the most difficult things about this job is realizing how much stigma people bring in with them. And, you know, there’s the having to walk past lines of protestors outside the clinic and all the stuff that goes along with that. But just the messages that people are getting about abortion from the media, from their families, their churches, their friends. You know, all these other places where we’re hearing these stories. It’s usually not positive.

And I think having to fight that in addition to all of the other regulations and the restrictions and things like that that make it difficult for people to access this very normal medical care, to have to tell someone, “No, you’re a good mom. This doesn’t mean you’re a bad person. This doesn’t mean you’re a bad woman.” You know, people ask things like, “Do you think God will forgive me?” And that’s just always heartbreaking.

Brogan: When someone asks a question like that, how do you respond?

Horvath-Cosper: It’s difficult, because everybody has different values, right? So, I usually turn it back to the patient and I say, well, what kind of a God do you believe in? Do you believe in a God who forgives? Do you believe in a God who knows you? And understands you’re circumstances and will understand the choices that you’re making? And I can’t tell anyone what to believe, and I certainly wouldn’t want to put any beliefs on anyone else, but I think getting people to think about this in the frame of their life course, and the context of having all of these other obligations and expectations and looking within themselves for their reason for needing an abortion.

Brogan: Are people’s minds usually fully made up when they arrive at the clinic? Or by the time you’re consulting with them?

Horvath-Cosper: I would say the vast majority of people by the time they come in, they’ve made up their minds. In fact, we have national data that shows if people delay having the procedure, it’s typically not because they couldn’t make up their mind, it’s because they couldn’t marshal the resources. They couldn’t get the money; they couldn’t get the transportation. And typically by the time they call me, they’ve made up their minds already. That said, we do options counseling with everybody. We review all of the options. Every patient knows that there’s three options when you find yourself pregnant. There’s parenting. There’s adoption. And abortion. And everyone gets information about all three.

Brogan: In some states there are also pretty intense rules that govern what you have to talk to a patient about when you’re consulting with them beforehand. Have you had to deal with any of those kind of laws?

Horvath-Cosper: So, when I was practicing in Minnesota, we had a 24-hour waiting period. And we were given a list of things that we had to talk about with the patient 24 hours prior to the abortion procedure. And some of the things were things we talk about with the patient anyway, but they always enter into discussions of informed consent. So it’s not like this 24-hour consent replaces the informed consent we do about the procedure, because we do that every single time anyway. And I think the script that we used in Minnesota certainly isn’t nearly as bad or as biased as some of the scripts in other states where they have to say things like “abortion causes breast cancer,” which it does not. Or they have to say things like “abortion increases your risk of suicide,” which it does not.

But somebody would come in for their appointment and I didn’t catch the phone call, or you know, missed it and thought they could still come in. And we’d have to turn them away because the law requires that. And, you know, these laws get sold as a way to make sure women are certain about their decision, but I can tell you that by the time people make an appointment and they come in, they’re certain.

Brogan: Yeah. When you are speaking with someone, or you’re consulting with someone, do you ever get the sense that they’re bringing in a lot of immediate pressure from family, from friends, from their environment? And if so, how do you work with them as they’re processing that, if they are processing it while they’re sitting across from you?

Horvath-Cosper: Yeah. That is definitely something we see from time to time. You know, there’s a lot of feelings about reproduction, whether to have babies or not have babies, and people can get a lot of pressure from their family. And I’ve had conservations with people where you know the family member won’t leave the room and we have to take the patient to the bathroom to talk to her about what she really wants.

And people have asked me, “Well, haven’t you ever done an abortion for someone who didn’t want one?” I said, no, we’re not in the business of doing them for people who don’t want them. So, when we feel, and when we talk to patients, if we’re getting a sense that this is not what they want, we don’t do an abortion for them. And we get them alone, we talk with them, and then we make whatever referrals we need to. And, you know, we’ve called domestic violence shelters. We’ve got social workers on staff who can come talk to patients and identify resources. I mean, not everybody has got a dire situation like that. And sometimes it’s just a matter of helping empower the patient to decide what’s best for her.

But sometimes we have to get people into safe places. That’s their point of contact with the system is at the clinic.

Brogan: Are there other questions that people ask when they come in for a consultation?

Horvath-Cosper: I think people have a wide range of questions about the procedure, will it hurt, what am I going to feel like afterwards. I would say those are the most common types of questions that we get. Sometimes people want to know, especially later in the pregnancy, about the experience of the fetus. And I think that is something that certainly comes up, especially when we were seeing patients who had wanted pregnancies that were ending for medical reasons, for something seriously wrong with the fetus, or something seriously wrong with the mother. And so that’s a different kind of frame to look at the experience.

Brogan: How are the conversations, how are the interactions with a patient different in the clinic if they’re coming in because of a medically necessary procedure related to a planned pregnancy or failed pregnancy?

Horvath-Cosper: So, I think for those patients, the process is different in terms of their grief. So, not everybody grieves after an abortion, and that’s OK. I mean, it’s totally fine to move on with your life. And like I said, I don’t want to ascribe feelings to anyone that they don’t need to have.

But I think for people who are coming in with planned pregnancies where this is a loss for them, where they’re losing a wanted a baby, those people have a grief process. And it’s different. And they need different support. And also just to acknowledge some of the things that they may want done. So we’ve had patients that requested to have a special family item cremated with the fetus. Or who wanted their minister to come say a prayer, and we’re happy to accommodate all of that stuff.

Brogan: Do you try to anticipate those sorts of questions, or do you just have to wait for them to arrive and answer them as they come?

Horvath-Cosper: You know, the best policy for me has been to let the patient guide the discussion. Obviously, I want to give them all of the medical information that they need, and all the information about follow up and things like that, but I think in terms of ascribing feelings to the experience of having an abortion, people have totally different feelings. You know, we know from research that most women, the vast majority of women, don’t feel regret. That they say things like, “Well, I wish I wouldn’t have had to be in the position to have to make that decision.” Or, “I wish I had the resources right now, but I don’t.” But they don’t regret having had the abortion.

And so that’s why I don’t want to give anybody any feelings that they may not have, because it may not be their experience.

Brogan: How do you describe the procedure itself to patients?

Horvath-Cosper: Well, it depends on what type of procedure they’re having, so I do medical abortions or medication abortions, which is two medications. One that they’ll take in the clinic, and one that they’ll use at home. And for those patients, it’s going to actually seem a lot like a miscarriage. So they have cramping and bleeding like women have when they have miscarriages.

We counsel them. Everybody gets a list of instructions. They get warning signs and they get a 24-hour answering service number that they can call at any point in time.

In terms of an in-clinic procedure, it depends on where they are in the pregnancy and it depends on their own medical circumstances, but typically for the vast majority of patients it’s a five- to 10-minute procedure. We give them oral pain medications, sometimes they get IV sedation if they’re in the clinic, the type of clinic that has that capacity. But people have some cramping and some bleeding afterwards, but typically the recovery is pretty fast. And people do quite well in the clinic. This is definitely something that doesn’t need to be done in a hospital setting. It can very safely be done in a clinic for most patients.

Brogan: Is there anything that could go wrong? Is there anything that you have to prepare for in those ways?

Horvath-Cosper: Well, sure. I think with any medical procedure, from having a colonoscopy to having an abortion, to having dental work, to having open-heart surgery, there’s a list of risks and benefits. And there’s all these contingencies that you plan for. But every clinic that sees patients has a big set of protocols to what happens if there’s lots of bleeding. What happens if there’s a patient with a problem with anesthesia? All of the doctors are certified in cardiac life support. We all know how to resuscitate. And we all know how to get people to the hospital if they need it.

But just for perspective, the risk of serious complications from abortion is about 10 to 15 times less than the risk of serious complications from birth. So it’s a very safe procedure and that’s another reason why it’s so important that we maintain access to safe abortion and not drive women to the point where they’re having to do this on their own in an unsafe way.

Brogan:  When a procedure is underway, how many people are usually in the room? If it’s an in-clinic procedure?

Horvath-Cosper: Right. So there’s obviously me and the patient. And then if we’re doing IV sedation, then there’s a nurse who is administering the sedation medication and monitoring the patient the entire time. That’s her only job is to watch the patient and give the sedation. And then there’s usually an assistant who is handing me instruments and getting things that I need. And then sometimes we’ll have a support person.

Brogan: Like an emotional support person?

Horvath-Cosper: Yes. And there’s actually a big movement toward having abortion doulas. I don’t know if you’re familiar with birth doulas, but—

Brogan: I mean, I am with that.

Horvath-Cosper: Yeah. So there’s this idea, like because abortion is on this continuum of health care for women, that we would support them in the same way that we would offer support to a laboring woman. And so there’s a few places that offer abortion doula services. And I think people really appreciate having that nonjudgmental person to just really be there for them. They’re 100 percent focused on their emotional needs.

Brogan: And you said the procedure, an in-clinic procedure typically takes five to 10 minutes?

Horvath-Cosper: Yeah. Most of the people who are having abortions are having them in the first part of the pregnancy, and those procedures typically take five to 10 minutes if they’re uncomplicated.

Brogan:  And are you in the room for much longer than that time?

Horvath-Cosper: Not typically, no. No. Usually we can see a lot of times if there’s going to be a complication immediately from the procedure. We wait and we look and usually within a minute or two we know if things are going to go OK. And then we watch the patient in the recovery area for, you know, depending on how they’re doing 30 to 60 minutes. And then they get to go home.

Brogan: Do these procedures feel routine to you at this point?

Horvath-Cosper: I would say that they are routine. They certainly are something that, I mean, this is what I do. But they’re totally normal procedure, and they’re also a skill that we use to manage failed pregnancies. So this is the same procedure someone would get if they had a miscarriage but hadn’t passed the pregnancy. So we treat them in exactly the same way. And that goes for abortions in the second trimester as well. This is the exact same set of skills we would use to manage someone who had a fetal death.

Brogan:  When you first set out to do this work, did you anticipate that it would require this kind of empathy, this kind of compassion?

Horvath-Cosper: Actually, that’s why I decided I wanted to do it. I mean, that’s one of the reasons I love it is because this is a time when so many people have turned their backs on these patients. And this is a place where people don’t expect to be treated well. They don’t expect to be cared for and loved and their hands to be held and to be cried with. And, you know, this is one of the things that I love the most about this job is, you know, everybody is joyful at birth. Everybody is joyful, everybody is happy.

You know, abortion can be a hard decision. It’s not a hard decision for everybody, but I think it’s so culturally loaded that to be able to be with a person when they’re making that move is a huge gift. And it’s really why I love this job.

Brogan:  You’ve been listening to Diane Horvath-Cosper, abortion provider, OB-GYN, and family planning doctor in Baltimore. In a minute, she talks to us about speaking out against some of the threats that she’s experienced while working in her field.

We talked a little bit about some of the rules, especially in other states, that govern consultations and waiting periods. What about other targeted regulation of abortion providers, for example? Do those kind of issues affect your work at all?

Horvath-Cosper: Well, so we’re all very happy about the Supreme Court decision on Whole Woman’s Health vs. Hellerstedt, so that actually has already had kind of a trickle-down impact on some of these states that have decided not to pursue additional legislation.

So, TRAP laws are targeted regulated of abortion providers. And they were designed as a way to limit access to abortion by regulating clinics in a way that no other medical clinics are regulated. And regulating physicians who provide abortions in a way that other physicians are not regulated. So, for example, there’s a class of TRAP laws that requires abortion-providing facilities to run as an ambulatory surgical center. And an ambulatory surgical center is far more than what you need to give someone an abortion pill.

So, there are states where people were having to go to the ambulatory surgical center to have an abortion pill, which is ludicrous.

Brogan:  That’s an almost entirely outpatient procedure, right?

Horvath-Cosper: Mm-hmm. Other TRAP laws required physicians who were providing abortions to have admitting privileges in hospitals within a certain radius, maybe 30 miles, of where they were providing abortions. The weird thing about that is there’s already a system in place to get people to the hospital if they need it. So, you know, if I admitted a patient from the hospital, I wouldn’t be following her in the hospital because the hospital-based OB-GYNs would follow her. And that’s how it is for pretty much everything. You know, all specialties. It’s rare to find a doctor anymore who admits their own patients and follows in the hospital.

The other issue is that women now have to travel, you know, sometimes hundreds of miles to get to the clinic, so when they go back to their home 300 miles away, if they have a complication there the admitting privileges by the clinic aren’t going to make any difference. So that was another reason that these laws were found to be unconstitutional by the Supreme Court in the Whole Woman’s Health vs. Hellerstedt decision.

Brogan: You’ve written about other threats, I think, that abortion providers face for the Washington Post, yeah?

Horvath-Cosper: Yeah.

Brogan: What inspired you to start expanding your advocacy in that way?

Horvath-Cosper: I was Googling myself a little over a year ago, like you do—

Brogan: As one does.

Horvath-Cosper: And I found my daughter’s picture on an anti-abortion website. So, this is a site that calls people who provide abortions part of the Abortion Cartel, as if there is such a thing. And had photos of me from my previous employer, and various other places, and had a photo of me holding my daughter, who was 15 months old at the time. That brought it to a level of intensity that I hadn’t really felt before.

And that inspired me to write about what it felt like to see that. And how invasive it was.

Brogan: Does that kind of invasive threat that you face in your profession make it hard to separate the personal from the professional?

Horvath-Cosper: I’m not sure that you can separate the personal from the professional in this line of work. And I would say that even in medicine in general it’s such a demanding profession and it’s so consuming that I think a lot of us went into medicine, particularly women’s health care and family planning, because we feel called to do it. We were drawn to it not just because the need was there, but because we felt something inside that made us want to be with women in this time. So, I think for me the personal has always been the professional. And I try very hard to separate out my daughter and my family from what I do, but I think what I want going forward is my daughter to understand that what I do is to help women and I want her to know that the way to deal with bullying is not to step back and let things go, but to push back against the people that are doing the bullying. And so I hope she can look back some day and understand why some of this happened the way it did and why I chose to take this path instead of go into hiding.

Brogan: What’s it like to work constantly with this sense of threat and menace?

Horvath-Cosper: It can be terrifying. It’s a lot of trauma. So, we talk about this at our meetings that we have sometimes about this idea that not only do you take on the personal kind of trauma and stress of walking through protesters, wondering if your car is going to blow up when you turn the ignition key, wondering if people are going to be standing outside your home, or at your child’s school or day care. You know, there’s that part of it. Wondering if you should get a bulletproof vest. All of those things.

But then there’s also the stories that you hear from patients and the trauma that they’ve been through. And the way that they’re dealing with their lives and trying to manage the stigma around abortion. And so you have the trauma that you take on in your own life, and then you take on all of this trauma from your patients because you love them and you care for them. And those two together can be really—can drain you quite a bit.

Brogan: Do you have professional support systems that help you through this stuff?

Horvath-Cosper: We do. I think that the family planning community is a pretty close-knit one. And we have a lot of meetings, national meetings, and we talk a lot about these issues. And I personally have a lot of good friends now that I’ve met through fellowship that I can call on in times of need. My organization is starting a program to help assist physicians during these times where they find somebody protesting outside their home. What do they do? How do they approach the neighbors? How do they talk to the city council? How do they ensure safety? So it’s hopefully going to give some resources that are formalized and kind of centralized to do that.

But I think this idea of physician burnout is another issue. And having people say things like, “Well, get a hobby.” Great. Yeah. Sure. I have tons of time for a hobby. But I think there’s more of a recognition now that for some people the way to deal with burnout is to turn it back around and become an advocate. And for me, advocacy was a venue where I could take some of that righteous anger and some of the pain and trauma and flip it around and say this is going to motivate me to make this situation better for providers and for patients.

Brogan: It sounds like advocacy has been part of what you do and how you approach your work from virtually the start of your career, yeah?

Horvath-Cosper: Yeah. I think that being motivated to go into medicine by a sense of responsibility to other people kind of just sets you up for advocacy. I mean, it’s almost hard not to be. And I know that the old paradigm is that we shouldn’t mix medicine and politics and I know that there are some older physicians who say, “Well, we should be above politics.” Health is political. These personal decisions have become political, even if we don’t want them to be. And certainly all of the social determinants of health that affect the outcomes that my patients have, that affect their ability to access care, that is all political. And if we’re not engaging in that, then someone else is going to make decisions for us that we may not like.

Brogan: So, after you wrote that piece for the Washington Post, you famously sparred with MedStar Hospital where you were at the time. Can you tell us a little bit about that?

Horvath-Cosper: Sure. Yeah. So, while the current status now is that the civil rights complaint that we filed is still under investigation. It hasn’t been decided. But we were able to talk about filing the compliant. So, what happened was I published this article in the Washington Post. My institution had initially been very supportive. Got circulated around the department. Everybody was congratulatory. Went on Melissa Harris Perry’s show when she was on MSNBC. Talked about it. And then the Colorado Springs Planned Parenthood shooting happened. And the climate changed very quickly. And there were a lot of concerns about safety, and rightfully so. But the hospital administration’s response to those concerns was to say, “We don’t want you to talk about abortion publicly.” Under any circumstances.

And then we countered and said that’s not ever been shown to improve safety. We’ve been doing abortions here at the hospital since Roe vs. Wade. We provide excellent care to patients. People have a safe experience here, a compassionate experience here. This doesn’t change it. Talking about it doesn’t change it. What will actually improve safety is installing a security system and doing some other kind of evidence-based security measures that are recommended for all clinics.

But they held their ground, and I was fortunate enough to work with a law firm in D.C. and also the National Women’s Law Center to address the hospital with a letter, initially, to explain why this was a bad idea, bad policy to pursue, and why it was important to speak out and to counter stigma because that’s going to be what makes the cultural change, that’s going to improve safety for everybody.

And they kind of doubled down. And then that’s when we filed the complaint with the Department of Health and Human Services.

Brogan:  What was your reaction to being told not to do these interviews? What was your immediate response to that?

Horvath-Cosper: I was shocked. It was like a gut punch. I mean, these were people who were happy to have our services, happy to have the ability to refer patients to us. Had never been anything but supportive of the care that we were providing. And for them to suddenly act like we had to be secretive about it, I thought, you know, this is worse than any protestor outside my clinic. This is worse than anybody on a website saying that I’m part of an Abortion Cartel. This is somebody who is on our side but is kind of throwing us under the bus.

Brogan: Did this experience, which is still ongoing in one or another, change the way that you go about your own day-to-day advocacy and your own other day-to-day work?

Horvath-Cosper: I don’t think it changes the way that I care for patients. I think that has been a passion of mine since the beginning and it hasn’t affected my interaction with patients.

But I think that in terms of feeling the need for advocacy and for understanding why you have to number one advocate for patients, and number two, advocate for yourself and your colleagues and your ability to practice evidence-based medicine, the ability to talk about what you do and to bring abortion into mainstream medicine where it belongs—that broadened the focus for me. And I realized, too, that you’re going to find friends in places you never knew you had them, but there’s also people who are going to have a hard time with being outspoken, even if they may support you on principle, it’s the idea that you’re coming out of the dark and saying what you do and you’re proud of what you do. That can be hard for people.

Brogan: You’ve been listening to Diane Horvath-Cosper. In a minute, she talks about the ways that policy and the cultural climate affect her work, as well as the role of abortion and abortion discourse in the recent U.S. presidential election.

So, we’re recording this just after the election of Donald Trump. Throughout his campaign he made a lot of statements that are worrisome with regard to reproductive health, with regard to the ongoing status of the Affordable Care Act. How are you feeling about the sort of status of reproductive rights generally right now?

Horvath-Cosper: I think we were all obviously concerned. I think concerned is probably a really mild word for the way that everybody felt last week, but there’s a lot of unknowns. I think people are automatically jumping to this idea that Roe is going to be overturned. And I’m not saying that it couldn’t happen, but if it were going to happen it would require a test case to come through. It would require different justices to have to be appointed. I mean, it could be years, and years, and years. I’m more immediately concerned about the emboldening of state of legislatures to pass more restrictions. I mean, there are states in which abortion is nearly inaccessible. So, they’re ready—those states—to make it illegal if they’re permitted to.

So, if Roe falls, there are a whole slew of states that have legislation ready to go to make abortion completely illegal.

I think the bigger, more pressing concern at least on the outside, is the idea that we may lose the contraceptive mandate of the Affordable Care Act, which has been such a huge thing for my patients. To be able to decide on your contraception based on your medical needs, and not, “Oh, I can’t afford that, or I can’t cough up the thousand dollars for an IUD, even though I know it’s the best thing for me.” To be able to have medical discussions with people based on the medicine and based on the patient’s needs has been lovely. And I’m afraid that that’s something we might lose.

We’ve had a lot of people call in and say, “Should I get an IUD now? Should I get it now? Because I don’t know if I’m going to be able to get it after January.” And I think it’s terrible that we have to think about political decisions in the way that we counsel our patients about contraception. Like maybe you’re not the best candidate for an IUD, but you may not be able to get one. And should we be talking about that? And that’s a terrible place to be. It shouldn’t have to be what we talk about when we talk about medical care.

I think I’m worried about people losing coverage under the possible repeal or replacement of ACA. I mean, 22 million Americans have gotten coverage under the ACA. And I know that there are problems with it, but these are people who needed health care coverage. And we know that their outcomes are improved. And we know that they’re able to access care now that they couldn’t get before. And that’s cancer screenings, and exams, and blood pressure checks, and really essential health care.

Brogan:  What do you tell people who call concerned or worried about this stuff right now?

Horvath-Cosper: Basically what I just told you. We don’t know. We just don’t know what the policies are going to be. We kind of have a sense for the types of people that are being floated for these positions in the White House. We know that the vice president, future vice president’s policies in Indiana have not been favorable towards women. But I can’t say what’s going to happen and it’s hard to be reassuring when you don’t know what’s going to happen.

I do tell people if you’re wanting contraception, you should go talk to your provider. I mean, you should always be having these discussions. So if people are worried, I say this is a great time to talk to your provider about what might fit your life the best.

Brogan: A lot of the political rhetoric during the campaign season around reproductive rights fixated on late-term abortions. Very little of that language seemed to have much to do with real medical circumstances with medical realities around what late-term abortions actually entail. During one debate, Donald Trump sort of ended up fixating on late-term abortions, talking about ripping babies out of mothers. What was your response to that kind of language, that kind of representation of the sort of work that doctors in your profession do?

Horvath-Cosper: It’s frustrating because the statements that were made don’t reflect medical reality, as you said. I had about six calls with media the next day to talk about what does this mean and does this happen. And the statements that were made were just inflammatory, and they’re meant to incite this visceral gut reaction. And they do. And for me, the visceral reaction was wanting to like throw things at the TV. But for a lot of people it sounds icky and it sounds difficult and awful.

And I can tell you that people don’t wait to have an abortion until later in pregnancy because they just didn’t get around to it. Like people find themselves in that situation later in pregnancy because of something going horribly wrong with the pregnancy, or because of an extenuating circumstance that delayed the procedure, or because their states have so many regulations that they had to have a waiting period, and then they couldn’t get to the clinic because it was 500 miles away. And then they had to save the money, and had to get child care. I mean, there’s a lot of reasons for delay that don’t have anything to do with people not being responsible or people not being able to decide.

And it was just really frustrating to hear a candidate for the presidency use inflammatory language that has no relationship to reality. And even the moderator asking about partial-birth abortion. … Partial-birth abortion is not a thing. It has never been a thing. It’s a made-up term to make people feel icky. And it doesn’t represent any kind of medical procedure. We’ve never been able to define exactly what it is and it certainly isn’t something that doctors do.

Brogan: What can people, ordinary citizens, civilians, do to support the work that you do right now?

Horvath-Cosper: Oh, there’s so many things. I think making sure that your elected officials know that you’re listening and that you’re watching. Phone calls to the legislative staffers of your elected officials are probably the best way to get to them. Give money if you have it. So, the organizations that are most in need of funds and where the funds go directly to helping patients are things like abortion access funds.

So, here in D.C. we have an abortion access fund that we actually utilize quite a bit because of the Hyde amendment and its restrictions on Medicaid funding for abortions. So, the difference between somebody getting their medical care and somebody not being able to get their medical care could be $50 or $25. And those are highly impactful in the lives of my patients.

And then, you know, stay engaged. Even if you don’t think this is your issue, it’s kind of your issue. No one ever thinks they’re going to be face-to-face in front of me in the clinic until they’re there. And we’ve taken care of people who used to protest the clinic. And we’ve taken care of the daughters of people who used to protest the clinic. You know, unplanned pregnancy is a pretty unifying life experience. It happens to all kinds of people. And I think, you know, promoting policies that are evidence-based, electing officials who will uphold scientific medical policies and not these laws that are restricting access for no reason.

Brogan: What do you do to decompress to deal with the sort of every day trauma of all of the stuff you have to deal with in this line of work?

Horvath-Cosper: I sing in my car on the way home. My daughter is a huge outlet for me. I mean, I think you know 3-year-olds don’t care if you’ve had a bad day. I mean, they just want to hang out and color and play. And I think it helps put it all into perspective. And it also helps me remember why I’m doing this. And the reason—I mean, one of the big reasons that I do what I do, especially the advocacy bit, is I don’t want my daughter to have to be fighting this fight when she’s my age. I want this to be something we get to decide on as a society and I want her rights to be protected. And I want her to be able to make decisions that are best for her.

Brogan: Wonderful. Thank you for joining us today and for talking with us.

Horvath-Cosper: Of course, thank you for having me.

Brogan: Such a pleasure.

Thanks for listening to this episode of Working. I’m Jacob Brogan. We’d love to hear your thoughts about the podcast. Our email address is Working@Slate.com. You can listen to past episodes at Slate.com/Working. Working is produced and edited by Mickey Capper. A special thanks in this episode to Sarah Wides and Caroline O’Shea who helped us frame it and think about it.

Our executive producer is Steve Lickteig and the chief content officer of the Panoply Network is Andy Bowers.

* * *

In this Slate Plus extra, Diane Horvath-Cosper reflects on the changing presence of abortion in mainstream culture.

Do you have any thoughts on the way that reproductive rights get represented in pop culture, culture more generally? Does that shape the ways that we talk about it, that we think about it, the way that patients come to clinics that you’ve worked in?

Horvath-Cosper: I think we’re seeing a very good trend happening with social media, particularly things like the #ShoutYourAbortion hashtag. That was a huge thing. And I realize that the people who started the hashtag had to have security after that and the outcome for them wasn’t necessarily good. But the fact that people felt that they could share that they had an abortion, I mean, it’s still one of the most stigmatized experiences that people have in their lifetime, even though it’s one of the most common. And it’s very normative to have an unplanned pregnancy and have an abortion. It happens to a lot of people.

But I think the fact that we’re even having that platform and that discussion is a huge positive step. I think that those things are going to have to be bigger and more frequent to shift the cultural dialogue. Because right now abortion is still something that we talk about in hushed tones. It’s just in the last few decades that we’ve been able to talk about miscarriage without a lot of stigma.

So if we can’t even talk about pregnancy loss, how are we going to talk about abortion? And I believe we’re going in a good direction, but I think it’s going to take a lot of efforts on the part of the advocacy community and also women need to be supported in talking about this. And they need to be given safe places to do that. And to voice their experiences and to discuss what it meant to them.

Brogan: What about the ways that movies and television series and other cultural texts sometimes sort of talk around abortion? I think famously was it Knocked Up where they didn’t even say the word? How do you feel about those kind of allusions of abortion?

Horvath-Cosper: I think we’re getting better with representing abortion in the way that it actually is. So, there was the Scandal episode where Olivia Pope has an abortion and it was a procedure. And she did it and she survived and everything was fine. And there was also another movie called Obvious Child, which was a really lovely even-handed realistic look at what the experience was of having an unplanned pregnancy and then an abortion.

We still obviously have things like “shmashmortion.” Nobody wants to say the word. But I think that the more people that are out there making films and TV shows and writing this in, I hope we see some cultural shift when people say, “Oh yeah, I saw that on Scandal. Olivia Pope had an abortion. It was no big deal. And she was fine.”

Brogan: Well, I’m happy to say that on this podcast we can say abortion.

Horvath-Cosper: Abortion.