Title X facilities are already over-regulated

The Trump administration’s plan to impose a so-called “domestic gag rule”—a prohibition on providing, referring and counseling about abortion—on facilities receiving Title X funding for family planning services has unleashed a storm of criticism. The public comment period is now open, and the backlash promises to be fierce.

Medical groups state that withholding information about medical procedures is a violation of medical ethics. Numerous political observers note that the real intent of this measure is to deliver on Trump’s promise to defund Planned Parenthood, a major recipient of Title X funding. But largely overlooked in these responses to the domestic gag rule is that the current rules governing Title X grantees represent terrible public policy. As the public now weighs in on the proposed regulations, we should not forget that not only is the new gag rule harmful, but that the existing restrictions governing Title X and abortion care should be lifted as well because they are bad for patients and bad for public health.

{mosads}Title X, the only federally funded program devoted specifically to family planning, includes not only contraceptive services, but also pregnancy testing, STD (sexually transmitted disease) treatments and cancer screenings. As a condition of accepting Title X funds, grantees are prohibited from performing abortions with these funds. Those entities, such as Planned Parenthoods, which also provide abortions, must do this with a strict separation of abortion and other reproductive health services: separate financial accounting, separate channels to make appointments, and, as typically interpreted by many Title X directors, separate physical spaces as well.

What does this policy in practice mean for patients? Consider a promising recent development in abortion care: inserting an IUD (intrauterine device) immediately after an abortion. If a woman wants this form of birth control but cannot have it inserted right after the abortion, many clinicians advise that the woman wait two weeks, in order for the uterus to heal.

As “Nancy,” a Planned Parenthood administrator we interviewed for a research study, explained to us, an immediate post-abortion IUD is very difficult to negotiate because of Title X. “In one of our Planned Parenthoods the abortion facility’s in the basement and there’s a clinic on the first floor. So imagine a woman terminating a pregnancy, feeling crampy, maybe still recovering from the anesthesia, and now, she’s got to go upstairs and do a walk-in appointment, or make another appointment to get her IUD or another contraceptive method.” Nancy also pointed out that women can ovulate as quickly as two weeks after an abortion and therefore be at risk of pregnancy before she is able to get the most reliable means of contraception. 

Another problem with the current regulations is what “Susan”, who formerly worked to assess provider compliance with Title X regulations, told us about the confusion around these regulations as well as their chilling effects on clinicians. “Providers were confused about what was an actual abortion. Several thought that the morning after pill was abortion and refused to provide it to patients.” (The morning after pill, also known as Emergency Contraception, is a higher than normal dose of oral contraception, which inhibits ovulation, and therefore prevents pregnancy if taken after unprotected intercourse, and though it is often confused with mifepristone, the main drug in a medication abortion, EC cannot disrupt an established pregnancy).

For those women whose pregnancies were the result of rape, incest or posed a serious threat to their lives, situations in which Medicaid can pay for an abortion, Susan said Title X doctors—often the only doctors in small rural communities—sometimes refused to sign the form authorizing these abortions, out of a misguided fear that doing so would jeopardize Title X funding.

She also told us of patients who withhold information about their abortions out of fear of not being able to get post-abortion care in a Title X clinic. As Susan put it, “their medical histories were missing a chunk of their medical data due to misunderstanding, stigma and Title X regulations.”

There is no medical logic whatsoever to separate abortion from other reproductive health services. Indeed, it is the recommended practice for clinics affiliated with Planned Parenthood and the National Abortion Federation to initiate a discussion with abortion patients about whether they wish to obtain a contraceptive method, if they do not already have one.

The current Title X rules make this sensible policy unnecessarily complicated for many women and risk their health as a result. The domestic gag rule will only make an already compromised situation worse.

David S. Cohen is a professor at the Thomas R. Kline School of Law at Drexel University (dsc39@drexel.edu). They are co-authoring a book on barriers to abortion care; Carole Joffe is a professor in the Department of Obstetrics, Gynecology and Reproductive Sciences at the University of California, San Francisco (carole.joffe@ucsf.edu)