5. Culture of Silence
SYNOPSIS
Illustration by Nicole Xu
Many physicians have been advocating publicly for reproductive health for decades, but many more have remained silent on the subject of abortion, fearing retribution from the general public and their communities. Today we talk about the culture of silence around reproductive health in medical spaces, and how breaking that silence is our only hope for reclaiming our reproductive freedom.
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Featuring
Vineesha Arelli, MD
Caitlin Bernard, MD MSCI FACOG
Emily Patel, MD
Credits
Host & Co-creator: Ali Block, MD
Co-creator: Emily Silverman, MD
Lead Producer & Editor: Molly-Rose Williams
Producer, Editor & Audio Engineer: Sam Osborn
Producer & Editor: Jessica Yung
Audio Engineer: Jon Oliver
Student Producers: Anjali Walia, Dahlia Kaki, Fiona Miller, Mulki Mehari, and Treya Tompkins
Assistant Producer: Carly Besser
Chief Operating Officer: Rebecca Groves
Series Illustrator: Nicole Xu
Music: Blue Dot Sessions
Resources
Sponsors
The Nocturnists: Post-Roe America series was made possible in part by the Josiah Macy Jr. Foundation and the Danziger Family Fund at The Chicago Community Foundation.
Support for The Nocturnists’ medical student producer program comes from the California Academy of Family Physicians Foundation.
The Nocturnists is supported by the California Medical Association, and people like you who have donated through our website and Patreon page.
TRANSCRIPT
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The Nocturnists: Post-Roe America
Episode 5. Culture of Silence
Transcript
Note: The Nocturnists is created primarily as a listening experience. The audio contains emotion, emphasis, and soundscapes that are not easily transcribed. We encourage you to listen to the episode if at all possible. Our transcripts are produced using both speech recognition software and human copy editors, and may not be 100% accurate. Thank you for consulting the audio before quoting in print.
Ali Block
Welcome back to The Nocturnists: Post-Roe America. I'm Dr. Ali Block.
Vineesha Arelli
I was in the middle of taking care of patients in the ICU.
Media Clip
And the question of abortion has been returned to the state... Now overturned Roe v. Wade...
Vineesha Arelli
As soon as I heard it, I continued on with doing the work. But, obviously, I didn't realize the effect it actually had taken on me, until one of my colleagues said, "Did I do something to upset you? Are you okay? Because you're acting in a manner that you normally don't act." And I didn't realize it was that apparent on my face.
I remember thinking, "How could you not be this angry? How could you not know this is what I'm actually angry about?" And I had to say to my colleague, who's a really nice, male physician I work with, "It's not you at all. It's... It's the fact that we just lost rights, as women." And he looked at me. I think he understood what I was talking about, but he didn't really know what to say about it. Nobody else seemed to be talking about this: the nurses, respiratory therapists and physicians. The isolation of it, with looking patronizing, made me even more angry. Like, how are we not stopping everything, to just acknowledge it for a minute, and say, "Oh, my God. How do we repair this? And how do we approach this or how do we acknowledge it? We just weren't.
Ali Block
When I first heard this story from Vineesha, I was struck by how different her experience of the Dobbs' day was from mine. I remember people around me were crying, making phone calls, texting; everyone was talking about it. And everyone seemed to be on the same page, that this was a big deal.
Part of that is because of where we each worked at the time. I was in San Francisco, and Vineesha was in an ICU in rural Tennessee. But there's something else, something we've been talking about as a team that we're going to explore in today's episode. It's the idea of the culture of silence that surrounds abortion.
Abortion is taboo. We don't talk about it, even in healthcare spaces. But it can be more subtle than that. For example, even in the San Francisco Bay Area, where it seemed everyone was on the same team, the day the Dobbs decision went down, I remember wondering, could things have been different if we had been louder, sooner? Of course there are so many people who have been outspoken and doing incredible work championing abortion rights. But many more of us have been quiet.
Today we examine the culture of silence, both within the field of abortion care, and beyond in the broader world of health care. What's behind the silence? And what are the costs? Both to the status of abortion rights, but also on healthcare workers at an individual level? What does it mean to not talk about this very basic aspect of health care. To start, let me introduce Emily Patel.
Emily Patel
I grew up in Omaha, Nebraska. My family has lived here for decades. So Nebraska is definitely home.
Ali Block
Emily stayed in the state, for both undergrad and med school, before heading to North Carolina for a Maternal-Fetal Medicine fellowship at Duke. Soon after she finished, she headed back to Omaha. For Emily, abortion was never a central part of her pull towards medicine.
Emily Patel
For Maternal-Fetal Medicine, it is not a specific part of our training. That being said, there are situations as a Maternal-Fetal Medicine specialist where knowing how to do an abortion procedure is incredibly important. And I understood that. So. during my training as a specialist, I opted to get additional training so I knew how to do that type of procedure. And now I'm one of only a couple of people in our state who can provide that service.
Ali Block
Had she not moved back home, Emily likely never would have gone into abortion care at all. There were so many providers at Duke who offered that kind of care already. But when she found herself back in Nebraska, she discovered that if she didn't provide abortions, there were very few other providers who could. So it was a pragmatic decision, not a political one.
Emily Patel
I mean, honestly, in my mind at that time, things were pretty unremarkable. The access to abortion, when absolutely needed, was there. I wasn't really thinking about it. And maybe that's the problem. You know?
Ali Block
In 2020, Nebraska state legislature made a move to tighten up abortion restrictions. They introduced a bill that would ban D&Es, the most common surgical procedure used in second trimester abortions.
Emily Patel
I specifically remember a phone call that I got from one of my colleagues, and... She comes from a political family, so she has kind of been ingrained in politics, but she's also an OBGYN. And, it's like seared in my brain. I still remember it very vividly. She said, "This bill is a slippery slope. Like, this is one thing, but they're going to start presenting more things. And I'm wondering, would you be willing to either come down and testify in person, or write a letter?" And she said, "Listen, Emily. I recognize that you... you know, recently moved back here. You're just kind of getting your feet wet in your career; you've got two young kids and a family. And this is a very divisive topic: abortion. I understand if you don't want to put your name out there. Like this is...It's... It can be very scary."
You hear about these cases where... I mean, it was just in Wichita, Kansas, where you know, Tiller was killed...an abortion provider. Will plant bombs at Planned Parenthoods, or get shot in their homes, and... Most of what happens is stuff like on social media, where people just get taken down and nasty things said about them. And, that's one thing. But I think the thing that was very scary to us was the thought of any kind of actual physical violence, or something like that.
And so, I talked to my husband about it. And he was like, "You know, I... I'm nervous about it, I'm scared for your safety. I'm scared for our family. And I'd really prefer that you not put your name to it." And so I wrote a letter in opposition, and I wrote it anonymously. And I sent it in. And, on some level, you know, looking back on it now feels a little shameful. But, it was the decision that we thought was best at that time. And it's evolved. Yeah.
Ali Block
This mindset of keeping your head down, avoiding conflict, Emily says it's how she got through her medical training. And this is really common, and something that comes up a lot on this show. Like there was this time during her training that a superior threw forceps at her in the operating room, for making a small mistake.
Emily Patel
I remember going home that night and crying, and telling my husband about this incident. He's like, "You have to report that. Like, you have to take it to the higher-ups." And I was, like, "I can't do that!" Like, "I'm a resident! Like, what if I get fired? What if they reprimand me? What if they retaliate against me?" I was like, "No. I'm just gonna mind my business, do my work, go home, and I'm not gonna say anything."
Ali Block
So that was her M.O. And it kept her out of trouble in medical school, residency, and fellowship, and in her early career. But in 2022, news of the Dobbs decision made it feel like that M.O. was no longer an option.
Emily Patel
I was getting up to go see a patient, and I got a text message. (It was on my watch.) I was like holding back tears when I walked in to go see this patient. Saw the patient, got out of there. I went back to my office and I cried. You know, it was within a few days, we met in one of our friend's basements, and talked about what we think we need to do. Like, what can we do? And the idea that sprouted from that was to form this Political Action Committee. And I was like, "Okay, well, this is the moment. Like, this is it. It's now or never. I think I'm just gonna have to put myself out there." And so, it's like my husband and I sat down and had that same conversation again. And I don't think that there was anything in our hearts that had changed, with regard to how we felt about it. I think it was just the sheer fact of this is a humanitarian crisis. Like, this is not right. This is unethical. This has become bigger than me. And, of course, I still think about my family. Of course, I still think about my kids, and their safety. It was hard. And then once we'd jumped off, you know, off into the deep end, it was like, "Alright. Well, we're here now, so might as well go full board, you know." It wasn't like a "baby steps". It was... It was like a belly flop into the deep end.
Ali Block
Within the first year, Emily and her colleagues raised over $400,000 for targeted spending on key legislative races. They testified at numerous congressional hearings, and successfully lobbied to have the Nebraska Medical Association (the most powerful medical group in Nebraska politics) commit to opposing any new anti-abortion legislation. At the same time, the Nebraska legislature tried to pass a six-week ban. It failed, but they ultimately managed to pass a 12-week one, replacing the pre-Dobbs 20-week limit. So there were some wins, and some losses. Throughout it all, Emily said the community was where she found the light she needed, to keep going.
Emily Patel
I mean, Nebraska is not a huge place. And Omaha is a pretty small community, especially in the medical community. It's not hard to find those people, and gravitate towards them. I mean, these people have been more than just my allies in this. They've... They've become some of my closest friends. Absolutely. Hands down. I feel like I could tell any of them anything. So, out of terrible things sometimes comes, you know, good things as well. We've got a group text chain. So, by the time I get off of my phone call with you guys, there'll probably be about like 40 unread messages. There are a lot of physicians who are incredibly supportive, but are not willing to put their name out. And I... I have to respect that, because I've been there. And, I think it's hard to really be thrust into something when you're not ready. And I think, once I just kind of dove in, I was like, "Okay, this feels way more authentic to who I am." I think, in my heart, I feel lighter in doing so. It feels like a weight off. You know, I'm... I'm over 40 years old now. And I...I feel like in the last year, I've stepped into what my life should look like. Like, this is what I should be doing.
Ali Block
So how do we weigh the moral, emotional and political costs of remaining silent, while balancing the real fears and all too often real consequences of speaking out? To look at this question from another angle, we talked to Caitlin Bernard, an OB/GYN and abortion provider in Indianapolis. Soon after the Dobbs decision, the fears that Emily Patel had, about initially becoming involved in advocacy work, became a reality for Caitlyn, when she found herself on the pointy end of the anti-abortion movements political spearhead.
Caitlin Bernard
For me, medicine and advocacy are totally interchangeably related, and unable to be really separated.
Ali Block
"That's not the case for everyone," Caitlin acknowledges. But for her, it's just always made sense that way.
Caitlin Bernard
I mean, my parents are like classic hippies, you know. I was born on a commune. And so, the idea of community support was just a part of the way that I grew up.
Ali Block
This ethos of community support, the question of how she can meaningfully contribute to those around her, was what initially led Caitlin to medicine. During her OB/GYN fellowship in St. Louis, she studied under longtime abortion advocate, Colleen McNicholas. And in between clinical rotations, she started going with Colleen to the Statehouse regularly to testify on pieces of legislation.
Caitlin Bernard
We knew that these pieces of legislation were gonna pass. Like, in terms of the legislative process and what happened, makes no difference whether we're in these Statehouses, because they're just going to do whatever they want. I could tell them the worst, most horrible story, all of the evidence that shows that this is insane. They do not care. But I really felt like, you know, if nobody was there in that room, then who was representing all of us physicians? Who was representing all of the patients who had obtained abortions, or would need to obtain abortions? So it, kind of, really made me feel like, okay, every single bill that's out here, we need to, at least, just go and testify for.
Ali Block
So that's what she did. By 2019. Caitlyn was living and working in Indianapolis. That year, a proposal was brought to the legislature that would ban D&Es. She went to the Statehouse and testified against it.
Caitlin Bernard
I was very pregnant when I testified against that. I think it was like 36 weeks or something like that. And then it passed. And then a couple weeks after I delivered, I got a call from the ACLU and they said, "Do you want to challenge the suit?"
Ali Block
At that point, there was only one other abortion provider who did D&Es in the state. And both Caitlyn and the ACLU lawyers were pretty sure he wasn't the type to testify.
Caitlin Bernard
You know, drives a different way to work every day; sleeps in the hospital so that people won't trace him back to his home. Doesn't do anything publicly. You know, would never say in public, "I'm an abortion provider." Would never testify in the legislature; much less, like, be a plaintiff.
And, the suit can only be brought by somebody who is personally affected by it, right? Like, it's not like some random person can be like, "I don't think D&Es should be illegal." But I could, because I do do them. And it would create an undue burden for my patients, because it would force them to undergo, for example, induction of labor instead of a D&E. So then, the ACLU lawyers, who I... obviously I'm very good friends with now... came to my house, when I was like six weeks postpartum. And we started the lawsuit. It was like this tiny little basement room, right in the Statehouse. And the room was just, like, packed, and it was so hot. And I had my white coat, because we always wear that, you know, when we go testify. So I'm, like, sweating like crazy. And the room is packed with these college kids. Like, "the Next Generation for Life". You know, and they're all wearing their T-shirts. And I'm just like staring at them. And I'm just like, "You have no fucking idea, about anything. How could you possibly have anything to say about this that would provide any helpful information for these legislators to make any decision?" And then, on the other side, was a young woman. You know, young, blonde... And she held up her ultrasound picture of her twins. And she's like, "I am pregnant right now." And you know, yada yada yada about how horrible D&Es are. She ended up working in the Attorney General's Office. You know, surprise surprise.
Ali Block
Caitlyn testified from her clinical perspective. She talked about all the situations when D&Es are critical, often life-saving procedures, if someone's hemorrhaging or if they have a life-threatening condition. She talked about the actual science of fetal pain. But, she said it felt like no one was listening. The bill passed later that month.
Media Clip
Now to the latest battleground in the fight over abortion rights. This was the scene in Indiana Statehouse, as lawmakers there considered a near total ban. CBS evening news...
Ali Block
Soon after the Dobbs decision, the state of Indiana started talking about passing a near total ban on abortion, but they didn't make a decision. Three days later, on June 27, 2022, Caitlyn received a call from a child-abuse doctor in Ohio. He had a 10-year-old patient who was six weeks and three days pregnant. Because of a trigger ban that had gone into effect in Ohio, hours after the Dobbs ruling, the patient was unable to receive an abortion in her home state. Caitlyn performed the abortion days later in Indiana, where it was still legal up to 12 weeks. Soon after, she went to an anti-abortion rally, where a reporter from the Indianapolis Star overheard a conversation she was having with another doctor and asked for comment. Caitlin shared that in the previous days, she had performed an abortion on a 10-year-old from Ohio who was unable to access care. This story rapidly became national news.
Media Clip
O'Donnell sat down with someone who's become a symbol of this debate. That's Dr. Caitlin Bernard who's an OB/GYN in Indiana, who according to state records obtained by CBS News, provided a medication abortion to a 10-year-old rape victim from neighboring Ohio. That's the...
Caitlin Bernard
Part of the initial retaliatory statement about me was that I am an activist. Right? So I was an activist acting like a doctor.
Ali Block
That statement came from Indiana Attorney General Todd Rokita. "She's lying," he suggested. "There's no way Caitlin was telling the truth." That there weren't any 10-year-olds in need of abortions, that she was just an activist trying to manipulate people into sympathizing with her pro-abortion agenda. At first, Caitlin wasn't worried.
Caitlin Bernard
I mean, the biggest thing that I remember from that whole experience was just like, "How could people not know that like little girls get raped and pregnant?" Like, how could they not know that this was literally, like, the natural course of an abortion ban? I felt less concerned about my own personal, you know, retribution, like crazy people calling me or something like that. It just didn't occur to me. It was much more of, like, I just don't understand how they could not realize what was going to happen.
Ali Block
But as time progressed, Rokita's tactics evolved.
Media Clip
Attorney General Todd Rokita alleges that Dr. Bernard broke the law. He alleges that she violated patient privacy laws, by sharing that story with the Indianapolis Star, and he alleges that she failed to report the abuse of that child. Those are allegations she and her legal team deny.
Ali Block
Caitlin's story was bad press for the anti-abortion agenda. And, because the abortion that she performed was still legal, Todd Rokita had to find a different way to take her down. So he came after her medical license. In an unprecedented move, he brought charges against her to the State medical licensing board. He suggested that she had failed to report the incident of child abuse to the proper authorities, despite the fact that there was official documentation proving otherwise. And he suggested that she had broken privacy laws when she shared the age and home state of her patient with the Indie Star. All of a sudden, Caitlin was facing the real possibility of thousands of dollars of fines, and losing her medical license – all for having talked about performing a legal abortion.
Caitlin Bernard
So at the beginning of the hearing, they had to go through these procedural processes. And one of them is that they wanted to force me to answer the questions about my tattoo, which is of a hanger. And so the first, like, twenty minutes of the hearing, with, like, everybody in the room, all the cameras, everything... was like, "We want to force her to answer these questions about her tattoo." And so, there was this back-and-forth about, "Well, what is that tattoo?" And "What does it say?" And, "Why would that be relevant?" And, "How is this... Is this important?" and... So fucking bizarre. And then, to the right is, like, twenty cameras. Just like trained on me. This wasn't like, you know, an administrative process, right? It was really just, like, a personal attack.
Ali Block
It wasn't just the personal nature of the attack that set this hearing apart. It was the legal tactics, too, that were unlike any medical board hearing Caitlin had ever heard of.
Caitlin Bernard
Literally, they used our taxpayer dollars to pay lawyers from Washington D.C. to come and prosecute me, which is just unheard of in a medical licensing board hearing. It just felt like, you know, the government of my state is against me.
Ali Block
The hearing lasted 15 hours. A wall of cameras followed Caitlin's every move, filming her testimony, her pauses, even snapping photos of her while she ate an apple during one break. And, I can tell you personally, this is every physician's worst nightmare, being brought in front of a medical board and deemed incompetent, or unfit to perform the job you've trained for your whole adult life. In the end, the board unanimously agreed that Caitlin had reported the case to the proper authorities, but they found her guilty of violating privacy laws when she shared the age and home state of the patient, despite the fact that neither of these pieces of information are listed in HIPAA. She got to keep her medical license, but they fined her $3,000 and issued a letter of reprimand.
Caitlin's continued working as clinician this whole time, it's what she would rather be doing, she says, than defending herself against the state. But although she tries not to let the legal mess affect how she shows up with her patients, Indiana's legal and political climate have fundamentally shifted what it means for her to provide reproductive health care.
Caitlin Bernard
I mean, already, you know, in literally the last two days, it's like trying to figure out if somebody will meet our criteria for an abortion in Indiana, you know, I had a patient who called and, in her last pregnancy, during her labor, she ruptured her uterus. Does that count as life-threatening enough? That this could happen again to her? Who decides that? Who's gonna second guess my medical opinion, the medical opinion of the MFM... What happens if we do her abortion, and we put it on the terminated pregnancy report; it gets sent to Indiana Right-to-Life... They send a complaint to the Attorney General's office... I'm back in a hearing again. You know, on my... On my to-do list is to call my County Prosecutor to find out what he's gonna do if somebody calls in a complaint against me. You know, and am I gonna go to jail? I mean it's a Level 5 felony, if I perform an illegal abortion. What does that process look like? You know, my hospital security brought up on, like a, you know, planning implementation call, for this new law... Like, if somebody complains to us, we're a police force. Are we supposed to arrest her? Like in her office? Like, how does that work?
I was at a conference. Sometime this Spring, I guess. And my mentor and friend Colleen McNicholas said, "You know, I gave an advocacy grand rounds at this hospital. And this person stood up and was like, you know, that Caitlin Bernard did everything that you're telling us to do, and look what happened to her. How could we possibly do these things if that's what's gonna happen to us?" And she was like, "I'm sorry, do you know her? Because I know her personally, and I can guarantee that that is the last thing that she wants to come out of this." And, it's absolutely true. That is literally... would be the worst-case scenario. It just allows them to win. That is exactly what they are trying to do. And, if that's the lesson that everybody learns from this, then it feels like it was not worth any of that, you know, personal risk. So I would much prefer that the response be like, "Look, if she can stand up and take all of that risk, then I can do what I need to do in my small space to provide that same level of integrity and good patient care and advocacy." If you leave it to the most visible abortion providers to do all of the advocacy, then, yeah, of course, we look like activists, because you're stranding us in the middle of nowhere by ourselves. If everybody is doing the same thing, non-OB/GYNs, non-abortion providers... If we, as the medical community, could actually finally get on the same page, and be up front and visible and vocal about the fact that abortion is healthcare, and a medical procedure like any other medical procedure that exists, then there would be nothing that anybody could say to that, because we are the medical establishment.
Ali Block
Next week, we turn toward the future of abortion care, by examining the impacts of the Dobbs decision on medical education. In a country split by vastly different abortion laws, what's it like to be a medical trainee? What's it like to be a reproductive health educator? And what are the ramifications of the current legal landscape on the future providers, and their patients? That's next week.
The Nocturnists: Post-Roe America was created by me, Ali Block and Emily Silverman. Our lead producer was Molly Rose-Williams and our producers were Sam Osborn and Jessica Yung. Jon Oliver helped with the mixing and Carly Besser assistant produced. Thanks to medical student producers, Anjali Walia, Dahlia Kaki, Fiona Miller and Mulki Mehari, and pre-health intern, Treya Tompkins. Our Chief Operating Officer is Rebecca Groves. The series illustrations are by Nicole Xu. The Nocturnists theme music is by Yosef Munro and all additional music comes from Blue Dot Sessions.
The Nocturnists: Post-Roe America series was made possible in part by the Josiah Macy Jr. Foundation. The Nocturnists is supported by the California Medical Association, a physician-led organization that works tirelessly to make sure that the doctor-patient relationship remains at the center of medicine. To learn more about the CMA, visit cmadocs.org.
Our show is also made possible with donations from listeners like you. Thank you for supporting our work in storytelling.
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To contribute your voice to an upcoming project or to support our work with a donation, visit our website at thenocturnists.com. You can also find resources with more information about the state of abortion in the U.S., as well as ways to advocate and get involved, at the series website. I'm your host, Ali Block. See you next week.