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Jul 29, 2017

Her own devices: Is a contraceptive implant making us sick?

Co-produced with PRX Logo

Update: Bayer Pulls Contraceptive Device from Global Markets

In Texas, women with limited access to abortions are traveling across the border to find a drug that will induce miscarriages. In Mississippi, anti-abortion groups are opening crisis pregnancy centers across from abortion clinics to persuade women to keep their babies. And one company offers permanent birth control through the insertion of a simple device – that’s ended up causing health complications for thousands of women. This week, we look into pregnancy and the ways people try to prevent it, end it and save it.

Doctors could not determine what was making Tracie Long sick. She’d always been healthy, but suddenly, she was overcome by brain fog, fatigue and chronic pain. She began to piece together the clues and discovered the culprit was Essure, an implant meant to offer a nonsurgical option for permanent birth control. Long isn’t the only one who’s had problems with Essure. Reporter Jennifer Block looks into problems Essure has caused for thousands of women and how the device got to the market in the first place.

Many women have limited access to contraception and reproductive health care because of where they live. Reporter Sukey Lewis takes us to Texas, where lawmakers seek to limit access to abortion. But women are finding their own solution just across the border in Mexico. There, women can buy a drug that induces miscarriages. This method started out in Brazil and spread by word of mouth northward into Central America, Mexico and now the U.S.

Finally, we visit a crisis pregnancy center in Mississippi. Across the country, the anti-abortion movement is establishing these centers next to abortion clinics as a way to persuade women not to end their pregnancies. Filmmaker Maisie Crow visited one and found that its methods include disseminating inaccurate information about abortions and birth control.

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Credits

Support for Reveal is provided by The Reva and David Logan Foundation, the Ford Foundation, the John D. and Catherine T. MacArthur Foundation and Mary and Steven Swig.

Transcript

Reveal transcripts are produced by a third-party transcription service and may contain errors. Please be aware that the official record for Reveal's radio stories is the audio.

 

  Section 1 of 5          [00:00:00 - 00:10:04]
(NOTE: speaker names may be different in each section)
Al : From the Center For Investigative Reporting in PRX, this is Reveal. I'm Al Letson. Back in May, reporter Jennifer Block and Reveal producer Fernanda Camarena flew across the country, hailed a cab, and pulled into a resort hotel. A middle-aged man who could easily pass for your high school math teacher got in.
"Roger": [inaudible 00:00:22]
Jennifer : Hi.
Fernanda: Hi.
"Roger": Finally got sunny and nice, right?
Jennifer : I know. It did. It did.
Fernanda: Yes.
Jennifer : It warmed up. They turned off the [inaudible 00:00:28]
Al : He was willing to talk, but there were conditions. They had to meet in the city where he was traveling for business, and he didn't want any colleagues to see him talking to a reporter, so they went into a hotel room and drew the shades.
Jennifer : So I know we probably have to close the door, but just for one moment.
Fernanda: Yeah.
Jennifer : One minute.
Al : He wanted to talk about something that's bothered him for years.
"Roger": When you see failures like this in the field, it's like, "Oh, who missed what? How did that happen? Was it a lazy person? Was it somebody trying to get greedy and just put stuff out?"
Al : This is Roger. He's a medical device engineer, and he's talking about a product he used to work on. Oh, and we're calling him "Roger" because he's bound by confidentiality agreements. Back in the early 2000s, he was hired to work on something called "Essure".
Speaker 5: If you know you're done having children, maybe it's time for Essure. A simple, permanent birth control solution performed in a doctor's office in less than an hour without hormones, cutting, or the risks of getting your tubes tied.
Al : When it went on the market in 2002, Essure was a game changer in the world of contraception. For women, they only other option for permanent birth control, besides convincing their male partner to get a vasectomy, was surgery to have their tubes tied.
Essure promised to make it easy. No surgery. No scars. Just a 30-minute visit to the doctor's office to implant a small device in the fallopian tubes that would prevent pregnancy forever. But when Roger began working on Essure, flags went up. This was a complex device, and it had to be assembled in a very specific way. He remembers visiting the Essure plant near San Francisco and noticing they weren't following the same process he was told to follow.
"Roger": If somebody made perfect blueberry pancakes and they said, "Take my recipe to your kitchen, and now you make perfect pancakes." Well they had a different oven, they had a different mixer, they had a different cook. And it's still supposed to work, but when you start changing enough things, you can have problems.
Al : Roger said he had testy conversations with the supervisors, but at the end of the day, he did his job as best he could. Still, he saw other problems with the device. And he remembers one day when Essure came up in casual conversation.
"Roger": One of my wives' softball friends was like, "Oh, yeah. I got Essure," and I'm thinking, "Oh really? I'm not sure that was such a great idea." And she was like, "You're kidding me." And I was like, "Look it, we were looking at that and we're doing stuff with it, but eh. I wouldn't recommend it."
Al : Roger left the company more than a decade age, and can't speak to whether the process improved. But now, years later, hundreds of thousands of women all over the world have had Essure implanted. And Roger's fears have turned into news headlines. More than 16,000 official complaints, or adverse event reports, have been filed with the FDA for problems like bleeding, allergic reactions, and the device puncturing other organs. Those reports include 4 deaths.
For more than a year, Jennifer Block has been looking into Essure in partnership with the nonprofit newsroom, the investigative fund. She recently went to Camillus, New York, a small town outside of Syracuse, to meet one woman that says the device caused her problems.
Tracy: Hi
Jennifer : Hi, how are you?
Tracy: Good, how are you?
Jennifer : Come on in, Tracy.
Tracy: Nice to meet you, Jennifer.
Tom: Hello.
Tracy: This is my husband Tom, Son Jordan, Son Gitano
Jennifer : Hi. Seeing Tracy Long for the first time, you wouldn't think she's sick. She's quick to smile, she looks fit, and is high energy as she leads me through the airy, suburban house.
Tracy: This used to be one, great, open room. So we divided it into two, and we made this the workout room. So we have the elliptical machine and the treadmill and the weight bench and those are TRX bands over there. We sound like ... We could have a gym here and charge people, right?
Jennifer : She's into exercise and healthy eating. She's 41 and she and her husband, Tom, have four kids.
Tom: What do you think you're going to see when we go?
Speaker 8: Good views.
Tom: Good view?
Jennifer : After their last child was born 10 years ago, they knew they were done. Tracy wanted something permanent to prevent pregnancy. She didn't want to take a pill every day. She saw an ad for Essure, read about it online, and decided it sounded good. The procedure went fine and she soon forgot about the implant.
Then, a few months later, her face went numb. She thought she was having a stroke. It turned out to be a severe kind of migraine. Over the next few years, she battled brain fog and fatigue. She chalked it up to being a tired mom. Then things got worse.
Tracy: I felt tired all the time and achy and sore. And I have a neighbor that I would run with, and I would always say to her, "I feel like my internal organs are bruised and bumping each other when I run."
Jennifer : She had joint pain, circulation issues, and swelling. Then came more intimate problems.
Tracy: Intercourse with my husband is so painful. My abdomen would feel inflamed and swollen. Just to try to cuddle together in bed, if he were to wrap his arm around my abdomen, it would hurt. And I would say, "Please get your hand off my stomach." So it did create a bit of a distance and there ... Times where there's fighting and talk of divorce and like, "Okay, well we're never intimate. We don't cuddle."
Jennifer : As the symptoms piled up, she went to her doctors.
Tracy: I was kind of flip-flop, back and forth between my OB/GYN and my primary care physician. And neither one able to find anything, and they would kind of send me to the other. And you start to feel like maybe you're a little crazy.
Jennifer : So Tracy tried to figure it out for herself.
Tracy: So here's my journal.
Jennifer : She took out her pen and an 8-by-10 daily appointment book and began to write down everything she did, everything she ate, everything she felt, every single day. She filled three separate volumes.
Tracy: One thing I always tracked was my period. This is October 16. Look it, my period started the 14th, and here's the 23rd and I was still bleeding. If I had a bowel movement, what time it was. What time I went to bed.
Jennifer : Wow, look at that. The boxes are completely filled with your writing.
Tracy: So I literally tracked everything.
Jennifer : Tracy studied all her notes looking for patterns, connections. Then it hit her. Her symptoms started soon after she got the Essure implant. She started Googling.
Tracy: And then I came across the ... It's an Essure Facebook page. Essure Problems. And that was eye-opening. It was like reading my own diary or something. I just was like reading about myself.
Jennifer : It wasn't just her. Thousands and thousands of women had posted on the page with their own stories. Some far worse than hers. The Essure page that Tracy found was created by another woman who had severe complications with the device. Angie Firmalino.
Angie: So I wanted to warn my female friends and family members about my experience and the device, but I didn't want to post it on my personal page and have men see it. So I saw this little option that you could make a group, so I made a group, and I called it Essure Problems, and I added my female friends and family members from Facebook, and kind of told my story, and said, "Hey, stay away from this device."
Jennifer : It snowballed from there. Friends of friends started posting their stories. Then strangers. There were women with chronic pain and bleeding. There were women whose devices had moved out of their fallopian tubes and punctured other organs. There were woman who had gotten pregnant. They call themselves E-Sisters, and they created an anti-Essure movement.
Speaker 10: Do you [inaudible 00:08:44]?
Jennifer : Today the Facebook group has nearly 35,000 members. Women from all over the world who have problems like Tracy's and worse.
How could a contraceptive, something meant to help women have more control over their bodies, lead to this? The E-Sisters wanted answers. Angie says the most active members started by Googling.
Angie: I think the first thing that we came across was the transcript of the approval meeting for Essure from 2002. We found it on the FDA website, we printed it out. It was like 500 or 600 pages. And we're all reading it simultaneously across the United States, texting each other, "Oh my god. Did you get to this part yet?"
Jennifer : Soon they were filing Freedom of Information requests and asking for meetings with the FDA.
Angie: There was just so much information in there, that we just had so many questions. And that kind of launched us into this we-have-to-investigate mode.
Jennifer : They traced Essure's genesis back to the late 1980s, which actually wasn't about preventing pregnancies. It was about making babies.
Speaker 11: Here is a card letting me know that she. 
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  Section 2 of 5          [00:10:00 - 00:20:04]
(NOTE: speaker names may be different in each section)
Amy Thurmond: Here is a card letting me know that she conceived after the procedure and has a little girl, and she has knitted a mermaid outfit.
Speaker 2: Dr. Amy Thurmond pioneered a procedure to unblock the fallopian tubes without surgery, so she gets a lot of thank-yous from mothers. For those of you who can't remember back to high school anatomy class, the fallopian tubes are where sperm reach an egg after traveling through a woman's uterus. They're just a millimeter wide and a few inches long. The tiniest particle can block them. Women all over the world were able to conceive thanks to Dr. Thurmond and she spoke at many conferences.
Amy Thurmond: At one of those, I was approached by a researcher, Julian Nikolchev, who wanted to develop a device for the opposite purpose, not for unblocking the tubes in women who had infertility, but for blocking the tubes to prevent conception.
Speaker 2: Nikolchev hired Dr. Thurmond to begin testing prototypes.
Amy Thurmond: Then we got together and tested a variety of products in the fallopian tubes of rabbits. We tested a chemical material similar to Krazy Glue. We tried something that some crazy Czech guy came up with in his basement that he thought would work.
Speaker 2: What ended up working was a tiny metal ribbon wrapped around a coil, which was wound with DACRON fiber, the polyester that became popular in the '70s for not wrinkling. Nikolchev raised $35 million to develop the device, and started a company called "Conceptus."
Amy Thurmond: We spent a very sweaty summer trying to get these devices into rabbits.
Speaker 2: The DACRON fibers inflamed the fallopian tubes in the rabbits, causing scar tissue to surround the device. This would close off the tubes and block the sperm. Thurmond's research led the FDA to green light clinical trials in women in 1998. Because Essure is not a drug, it would go through the FDA's Center for Devices and Radiological Health, which several experts told us has a lower standard for approval. Drugs must prove themselves with controlled clinical trials, which means researchers study two groups, one that gets the drug and one that doesn't. Devices only need to show what's called "reasonable assurance of safety and effectiveness," which is open to interpretation.
Researchers point out some major problems with the Essure study. It was too small. It didn't last long enough. It had no control group. Researchers say they should have compared the women with Essure to a group of women who had their tubes tied.
Steve Zhu: That really limits your confidence in the device itself because you only have that one group to look at and think about.
Speaker 2: That's Dr. Steve Zhu. He's published studies on high-risk OB/GYN devices, including Essure, and found what he calls "significant weaknesses" in how they're approved. Another problem with Essure's study, he says, is that the company lost track of or excluded about one fifth of the participants. What if they had problems or got pregnant?
Steve Zhu: That missing data may be deceptively positive about the device rather than truly reflecting the risks and benefits of the technology.
Speaker 2: After the clinical trials, the next step was an approval hearing. That happened in July of 2002.
Speaker 4: The focus of our comments today is on what women need to know to make an informed choice for Essure.
Speaker 2: Here again, critics say the FDA's process is flawed. The agency receives fees from pharmaceutical companies to review their products. In exchange, pharma lobbies for and gets a more streamlined approval process. The revolving door between the two is always turning. In fact, the company representative who presented Essure to the FDA panel sat on that same committee just a few years before. The FDA wouldn't talk to us, but answered questions via email.
When we asked about this apparent conflict of interest, it responded that industry reps don't vote in approval hearings.
At the end of the hearing in 2002, the panel recommended approval of the device, and four months later the FDA made it official.
Speaker 5: It's a popular birth control option who don't wanna have their fallopian tubes tied. It's called "Essure."
Speaker 2: It took a few years, but Essure caught on in OB/GYN offices and clinics like Planned Parenthood. Some doctors, like Dr. Barbara Levy, say it was a game-changer.
Barbara Levy: What I will say is, as a practicing gynecologist for almost 30 years, that having an alternative to invasive surgery for women who wanted permanent contraception was something I'm really passionate about.
Speaker 2: Dr. Levy is vice president of Health Policy at the American Congress of Obstetricians and Gynecologists. She implanted a few dozen Essures in patients while in private practice, and was also a consultant to its manufacturer, Conceptus, for 10 years. Essure also had advantages for doctors. Physicians get a higher fee for Essure. They can do the procedure in their offices instead of at the hospital, and it takes less time. A chart used by Essure sales reps estimated that physicians would net about $1,100 from private insurance. That's more than double the $500 they'd get for doing the surgery known as tubal ligation.
Health advocates say there's a financial incentive for physicians to sell it over other options.
Barbara Levy: That's actually not true. That's actually not true.
Speaker 2: Levy argues that physicians get reimbursed not just for their time, but also for the cost of the equipment needed to implant it.
You wouldn't say that that's an incentive for physicians?
Barbara Levy: It's the most efficient way to provide a service for women, but I don't think that it's a huge incentive because the infrastructure costs to be able to do something in the office is a big investment.
Speaker 2: But over time, that investment is paid off. Plus, Essure is cheaper for insurance companies because they don't have to pay hospital fees.
The pharma giant, Bayer, bought Conceptus in 2013. The company wouldn't talk to us on tape, but said that more than 750,000 devices have been sold, mostly in the United States. They point to this number as evidence that Essure works for the majority of women.
Then what's making women like Tracy and the thousands of e-sisters so sick? Roger, the engineer we met at the beginning of the story, saw clues early on.
What is this? What are we looking at?
Roger: Well, this is the nitinol. This [inaudible 00:17:02] down here is what would get soldered-
Speaker 2: We're looking at an early engineering diagram for Essure that we got a hold of, and that word, "nitinol," that Roger just used is one of the metals in Essure. It's made from titanium and nickel. Nickel is a known toxin and can make people sick. What makes nitinol safe for medical use is how its surface is treated to trap the nickel inside.
Roger: But if there's a wear point, if there's a fracture, if you've got sharp edges that could propagate a fracture, there's all these potential failure modes.
Speaker 2: Roger explains that repeated stress on a device can wear down the material, which can lead to breakage. He says companies typically do something called "fatigue testing" to make sure that an implanted device will hold up for decades. In fact, the FDA requires it for other implants like hip joints and heart stents. Researchers build machines that simulate 10 years of wear in a matter of months. Roger wonders if this was done for Essure.
Roger: I don't know what they did to mimic what's going on down there, you know? How many different environmental activities were they able to replicate? I don't know. I don't know.
Speaker 2: We looked for evidence of this type of testing in the materials the FDA has on Essure, but we didn't find it. We asked the FDA but the agency would not answer questions about whether fatigue tests were done. Bayer also would not answer questions about fatigue testing, citing proprietary information. Roger worried about this not only because the device could fall apart and end up in other parts of the body, but because the nitinol metal could break down, allowing the nickel to escape.
Roger: Nickel can be absorbed by the body.
Speaker 2: Which could cause exactly the kind of problems that Tracy and the e-sisters are suffering from.
Essure's FDA filing reported a small amount of nickel leaching, less than other implanted products on the market. Bayer told us the same thing.
Over the past few years, thousands of women have decided to have Essure removed, including Tracy Long, who made the decision this Spring. She learned that it was going to be a lot more complicated than having it put in. Tracy would need a hysterectomy. She'd lose her uterus and cervix along with the device.
Tracy Long: Never had surgery before. I'm frustrated that because of these implants that were noninvasive, that now I have to have invasive surgery and lose body organs to get them out.
Speaker 2: This is from an audio diary Tracy recorded the day before her surgery.
Tracy Long: It's very scary and confusing and really just the fear of the unknown.
Speaker 9: This right here is a consent form. This is specific for the anesthesia that we're gonna administer.
  Section 2 of 5          [00:10:00 - 00:20:04]
  Section 3 of 5          [00:20:00 - 00:30:04]
(NOTE: speaker names may be different in each section)
Anaesthetist: So, this right here is a consent form specific for the anesthesia that we're going to administer for you, okay? So we're going to do a general anesthetic and robotic-assisted hysterectomy.
Speaker 2: The next morning, Tracey's at the hospital with her doctor, Myron Luthringer.
Dr. Luthringer: So, first off, tell me what we're doing today, so we're doing the right thing.
Tracy: The hysterectomy.
Dr. Luthringer: Okay.
Tracy: Keeping the ovaries.
Dr. Luthringer: Okay. Everything that comes out does go to pathology.
Tracy: Okay.
Speaker 2: There was a brief time years ago when Dr. Luthringer implanted Essure devices. Now he removes one or two per week. Sometimes, he can take out just the device and the fallopian tubes, but he says it's not easy. That's because the coils actually imbed into the corners of the uterus itself, which is hard to repair. The metal is fragile and difficult to get out. So are the Dacron fibers.
Dr. Luthringer: So, on a lot of the patients when I'm doing the surgery now, when I open up the tubes I'm not seeing a lot of those intact fibers. I think they've been absorbed by the body.
Speaker 2: Dr. Luthringer and other doctors think the fibers may also be causing autoimmune reactions. I asked the doctor if he knows of any other device that intentionally causes an inflammatory response and scarring.
Dr. Luthringer: Not that I'm aware of. I mean, he only thing that I could consider that people would put in their body that could be toxic would be probably something more like chemotherapy.
Speaker 2: I mean, is this worth it for birth control?
Dr. Luthringer: Well, that's an answer that the patients definitely have to think about.
Anaesthetist: Okay. You ready?
Tracy: I guess as ready as I'm going to be. [crosstalk 00:21:44]
Speaker 2: It's time for Tracey's surgery, and the anesthesiologist injects something into her IV. A nurse wheels her out of the room, she says goodbye to her husband, Tom, who is by her side.
Tracy: Love you.
Tom: I love you.
Speaker 2: We go to the waiting room with Tom who sits down, opens his laptop, and tries to do some work. Then I ask him how he's feeling.
Tom: You know, she is ... I'm pretty sure she warned you about this, but, she's my best friend. Now I can't even talk. So, I'm looking forward to getting back to, you know, the unit that we were, the team that we have been. And, you know, it's not that we're still not, but there's components missing that I think we're both hopeful that this will bring back. [crosstalk 00:22:54]
Speaker 2: We wait with Tom as the clock ticks. About two hours have gone by when Dr. Luthringer comes through the heavy door.
Dr. Luthringer: So we're doing good.
Tom: Okay.
Dr. Luthringer: Everything seemed to go fine. I did not see anything unusual, complicated. We did exactly what we planned out.
Speaker 2: These days, woman considering Essure have a lot more information than Tracey did. And it's mostly because of the E-Sisters Facebook group. Their research and persistence is likely what convinced the FDA to hold a hearing about Essure in 2015. Several E-Sisters spoke about their problems. And so did immunologists and toxicologists, who had tough questions for Bayer and the FDA.
Speaker 6: How do we not have data on nickel allergy when we have a device that, that's 55 percent nickel, and 20 percent of women, in approximate numbers are known to be nickel-allergic? Why is there no data? How can we put this in the packages first and then have no clue?
Speaker 2: In 2016 the FDA order Bayer to add what's called a boxed warning to Essure's patient materials. It's the first thing you see when you go to Essure.com now, and it includes warnings about the device migrating and perforating organs, possible allergic reactions, and persistent pain. It also added a four-page checklist that needs to be reviewed and signed by both patient and doctor.
Dr. Barbara Levy says her group, the American Congress of OBGYNs, opposes both the warning and the checklist.
Dr. Levy: We understand that there were many concerns about the Essure device. We share those concerns and we want good science behind whatever investigation occurs. And so our position was that the black box warning was placed before we had that evidence to really make a good decision about the labeling.
Speaker 2: Is it fair to say that the science perhaps should have been done at the time that this product was going before the FDA for approval? That it's, you know, so many years later and we somehow don't know?
Dr. Levy: When you do pivotal trials for FDA approval of a drug or device, those trials of necessity are done on a relatively small number of people compared to the number of people who will ultimately use the product. And even though you do the best science you can for approval, in the end that postmarketing surveillance is critically important.
Speaker 2: The FDA recently ordered Bayer to conduct a larger study. This time with a control group. The results are due in 2023.
Tracy was able to go home the evening of her surgery. The next day I get a text inviting me to come visit. We're shocked when she answers the door.
Tracy: Hi. Come on in.
Speaker 2: But she quickly returns to lying on the nearby couch.
So how are you feeling today?
Tracy: Tired. I definitely slept for pretty much the past 24 hours, which is amazing to me. I definitely feel more physical impact, and just mentally I'm exhausted. The unknown is still scary to me because, will this make things better?
Speaker 2: Tracy is optimistic by nature. But today it's sinking in that, no matter what, she won't get her old body back.
Tracy: I think everybody kind of thinks, if you could go back in time and change something what would it be? Because you know it would have a ripple effect on all of your life. So, you know, I would go back and say, do not do it.
Speaker 2: On the E-sisters Facebook page women regularly post pictures from their hospital beds holding a handwritten sign that says, "E-Free" and the date. Many feel better almost immediately. In one published study, three-quarters of women who had the device removed reported almost total relief from their symptoms. For the E-sisters and Tracy, relief will only come when Essure is off the market.
Speaker 8: In June, Bayer pulled Essure from the market in Finland, the Netherlands and Canada. They said it was because of low sales, nothing to do with safety. A representative wrote that the company would also stop selling Essure in most of the countries in Europe, Latin America, and in Asia-Pacific. Now, that's almost everywhere but the U.S.
Our story was reported by Jennifer Block in partnership with The Investigative Fund, and produced by Fernanda Camarena. To find out more about Essure check out Jennifer's companion story in the Washington Post magazine.
As we just heard through Tracy's story, birth control can come with serious complications. And sometimes it just doesn't work. But depending on where a woman lives, it might be difficult to end an unwanted pregnancy. In states like Texas, it's become so difficult to get an abortion that women are sidestepping doctors, clinics, and the law. Find out what they're doing next on Reveal. From The Center For Investigative Reporting and PRX.
Speaker 9: Hey folks. It's Cole Goins from Reveal. A few years ago we launched a project called StoryWorks that pairs investigative journalists with playwrights. Since 2013 we've produced original plays from the oil field in North Dakota to the strawberry fields in California. We're about to debut our newest play in a new location, in Mississippi Delta.
Jennifer Welch, our creative director for StoryWorks, has spent the summer in Clarksdale, Missippii. She's been working with young journalists, local artists, and our partners at Mississippi Today. They've created an original play about the life and legacy of a local civil rights leader, Vera Mae Pigee. It's called "Beautiful Agitators," and it's showing in Clarksdale on August fourth, fifth and sixth. If you're near the Delta, head over to Reveal's Facebook page to get the details and reserve your free tickets. You can learn more about StoryWorks and see a scene from our previous productions on our website, StoryWorks.revealnews.org.
Speaker 10: From The Center For Investigative Reporting and PRX, this is Reveal. I'm Al Letson. We just heard about what can go wrong with a contraceptive device, but getting contraception and reproductive health care can also be hard depending on where you live. El Paso, Texas is one of those places.
Reporter Cindy Lewis met up with a man named Franz Theard.
Speaker 11: What is all this?
Speaker 10: He frowns and shakes his head a little, and she sets up her recorder and microphone.
Speaker 12: Like, I could tell that you are a bit suspicious of me. Do you have to be careful about who you talk to?
Speaker 11: Obviously. So you come in here and you bring all the ...
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(NOTE: speaker names may be different in each section)
Sukey Lewis: ... what about who you talk to.
Dr. Theard: Obviously. So, you come in here and you bring all this microphones. I don't want to be ... I giving an interview to the Drudge Report or some of this weird stuff.
Male: Theard is suspicious of journalists. He's faced personal harassment. His kids have been bullied in school. The locks were glued shut on his business. This, all because of his job and where he does it.
Dr. Theard: Actually, as it turns out, I'm the last of the Mohicans. I am the last OB/GYN physician in the county of El Paso, Texas who still performs medical and surgical abortions.
Male: Texas is a hard place to be an abortion doctor. Politicians here have passed some of the toughest anti-abortion laws in the country. In 2013, the governor signed HB2, a law that put a bunch of new restrictions on abortion clinics. More than half the state's providers closed.
Dr. Theard: Yes, we almost got shut down twice. This was blocked on appeal.
Male: In 2016, the Supreme Court overturned HB2, saying it put an undue burden on women seeking abortions. But many clinics are still closed. And the barriers don't stop there. If you're a woman in Texas trying to get an abortion, your insurance may not cover it. You may have to wait weeks to get an appointment. You may have to travel more than 300 miles to reach the nearest clinic. Theard says these obstacles are driving some women to take matters into their own hands.
Dr. Theard: We don't see as much volume as we used to. One of the issues we have is the fact that we are in the border. So, the word's out what to do.
Male: Reporter Sukey Lewis takes us to El Paso to learn how women are going across the border to bypass laws, picketers, and even the clinics.
Sukey Lewis: So, here we are going across the border from El Paso into Juarez.
I'm retracing the steps of other women who've made this trip. They travel from Texas where abortion is technically legal but hard to access.
Okay, so now we've just passed through the security point to Mexico, where abortion is technically illegal, but in some ways easier to get.
What I'm looking for is a drug called Misoprostol. It was originally developed to treat ulcers. But women also use it to end their pregnancies. My translator, Laura Camarena, is helping me search for pharmacies that might sell it.
Laura Camarena: Okay, so you want to visit like small pharmacies, or like big, fat pharmacies?
Sukey Lewis: Maybe we'll try a couple of each.
Laura Camarena: Okay.
Sukey Lewis: The story goes that back in the 1980's, a woman in Brazil, where abortion is banned, read the fine print on the packaging for this medication. It warned, "Do not take if pregnant. May cause miscarriage." She took it and it did just that. It caused a miscarriage. She told other women who had unwanted pregnancies, and soon word started to spread from women in Brazil to women in Chile, up through Central America, to women here in Mexico.
Laura Camarena: [inaudible 00:33:13] She just going in.
Sukey Lewis: We start our search on the outskirts of town, thinking a small neighborhood pharmacy might be more willing to bend the rules. See, it's perfectly legal to sell the drug to ulcer patients, but it's not supposed to be sold for abortions.
We pull up to what looks like a suburban strip mall, just as a woman in a colorful cotton summer dress unlocks the front door of a pharmacy. Laura explains I'm a journalist from the United States.
Pharmacist: She [inaudible 00:33:40]
Sukey Lewis: Can you tell me how often do you sell the drug Misoprostol or Cytotec?
Pharmacist: [Spanish 00:33:48]
Sukey Lewis: The pharmacist tells me she just has one box and that she doesn't really sell it to people because she doesn't want to get shut down. She says some pharmacies were busted last year.
Laura Camarena: But they do have calls coming in very often asking for the medication.
Sukey Lewis: And many of these calls are from women in El Paso.
Thank you so much for taking the time.
We decide to head downtown looking for a pharmacist less concerned with the rules.
Okay.
Misoprostol can be risky for women to take on their own. If they don't take enough, it doesn't work. For some women, it can cause really heavy bleeding. But if it's taken in the first nine weeks, it's considered a safe and effective way to end pregnancy. It was actually approved by the FDA in 2000, along with another drug called Mifepristone, as a two-drug combo. That's called a medical abortion. But in the U.S., this has to be administered by clinics.
Laura and I park in downtown Juarez. Tarp covered stalls line the streets where vendors are selling all kinds of things.
Big bundles of chili, toilet paper and children's clothes, fried pork rinds, toys-
Laura points me to another pharmacy, but the woman behind the counter shakes her head.
No? Okay. Okay.
This happens at a couple of pharmacies. I get the sense they're suspicious of my microphone, or maybe just of me. In one store, a woman says they've got the medication. Then the store manager steps in and says they don't. But in another shop, a guy tells us there's a few pharmacies that sell Misoprostol, no questions asked. They are down near the bridge that connects downtown Juarez to El Paso.
All right. So this one is like really close to the boarder crossing. Just like, maybe, a hundred yards or something like that.
A few minutes later, Laura and I come back out onto the street.
So we went in there, and the woman behind the counter said that she does sell it frequently. What else did she say?
Laura Camarena: She's sold out right now. She doesn't get more until Monday, and it's a thousand and 300 pesos, which is around a hundred dollars.
Sukey Lewis: You don't need a medical prescription here. Wow.
And this isn't the only place. Before we head back, we find three pharmacies that sell it. No prescription needed, and for a fraction of the price.
It's hard to know just how many women make that same journey from El Paso into Juarez to buy abortion pills. But researchers at the University Texas at Austin did a survey and estimated that between a 100,000 and 240,000 women in Texas have tried to self-abort at some point in their lives.
And is it something that you would do if you needed to?
Kayla King: Absolutely. Especially if I was in Texas and I had to deal with all of the restrictions, I would absolutely use abortion pills at home.
Sukey Lewis: That's 19-year-old Kayla King. Just so you know, she's not pregnant.
Kayla King: So I grew up in the town called Dripping Springs. It's about 30 miles west of Austin.
Sukey Lewis: She's been studying in California, but soon she's transferring back to the University of Texas at Austin, near her hometown. She's an advocate for the reproductive rights of young women who grew up like her, in the dark.
Kayla King: When I got my period, my mom related to me a story that her mom said when she got her period, which is, "Oh, we've got to keep the boys away from you now." And we never really had conversations about contraceptions, how to use them, whatever, whatever. It was just, you know, "If you get pregnant, like we will not pay for an abortion."
Sukey Lewis: In college, Kayla started canvassing for Planned Parenthood. She believed in the cause but soon found the work exhausting, sometimes scary. And politically it was frustrating, too.
Kayla King: Day after day, you know, we would read the news at work, you know, and here's our one piece of good news, two pieces of bad news. Almost every day it seemed like. So I was very tired of feeling like I couldn't win reproductive battles in the courts.
Sukey Lewis: Then she saw an article online that changed everything.
Kayla King: I saw that they were using drones to deliver abortion pills across boarders.
Sukey Lewis: Activists were using drones to fly in abortion pills to women in Ireland where abortion is illegal. To Kayla, this looked like a way around the courts and the lawmakers. She started volunteering for a group that does research and advocacy called Plan C. They want to make abortion pills accessible to everyone.
Kayla King: And our idea of self-induced abortion needs to change. With the revolution of Plan C, it's not bitter herbs and coat hangers anymore. It's a safe, effective pill.
Sukey Lewis: It's a revolution that's taking place across borders, but also online.
Kayla King: So, I'm pregnant in Texas and I have no options. I might Google like abortion pills online.
Sukey Lewis: So a bunch of websites pop up. Some of the top hits are Safe2Choose, and Women Help Women. Like Plan C, these sites were started by advocates looking to make abortion accessible and safe in places it's restricted. They've got gestational-age calculators, so women can make sure they're not too far along. And medical questionnaires to help women identify pre-existing conditions that might cause a bad reaction.
The Women Help Women site has 24-hour, online support for people who've taken the pills like the ones sold in Mexico. These sites also sell the pills, but won't ship to the U.S. because buying them online here isn't legal. Still, other sites look like they will ship here.
Kayla King: So right now I'm on Facebook. I see Cheap Clinic Abortion Pills or Sale-
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(NOTE: speaker names may be different in each section)
Speaker 1: I see cheap clinic, abortion pills for sale, 50 percent off, which seems sketchy to me.
Sukey Lewis: The FDA says it's not safe to buy pills online because there's no way of knowing if they're fake or even harmful.
National Right to Life Movement spokesman Dr. Randall O'Bannon thinks groups like Plan C are being irresponsible, promoting something that's dangerous for women.
Dr. Randall O.: There are people who have been promoting websites, trying to say where women can call in for information about how they can get these pills and use them for themselves. There are plenty of sites online, which advertise and try to sell some of these pills, which may or may ... The quality is unknown.
Sukey Lewis: He tells me these sites gloss over the health risks abortion pills can cause. O'Bannon brings up a really serious complication that can occur. Women with undetected ectopic pregnancies can hemorrhage and even die from a medical abortion. That is super rare, but he says advocates hype these pills as no big deal.
Dr. Randall O.: Every time you turn around, there's someone who's trying to advocate for it being sold over the counter at drugstores.
Sukey Lewis: Even some doctors are working on making abortion drugs available over the counter.
Dr. Daniel G.: We're actually going to start exploring that through some research.
Sukey Lewis: Dr. Daniel Grossman teaches Obstetrics and Gynecology at the University of California at San Francisco. He says some preliminary research shows that women can self-induce abortion in a safe and effective way, with some caveats.
Dr. Daniel G.: Provided they have accurate information. Provided they have access to backup care, things like that. I don't have many medical concerns about women doing this on their own. I am really concerned about legal risks that women may be assuming by doing this on their own.
Sukey Lewis: He means they may end up in jail. In 2014, a woman in Pennsylvania pled to a felony for getting the pills online for her teenage daughter. She was given a 9 to 18-month sentence in jail. And she's not the only one. If more women choose to bypass clinics in favor of home abortions, he says prosecutions might increase. But there could also be consequences for clinics that do abortions.
Dr. Daniel G.: Yes. I'm concerned that potentially this could move women out of a clinic into doing this on their own, and that clinics won't be able to survive if they're just taking care of women who are past 10 weeks of pregnancy.
Sukey Lewis: I reached out to Planned Parenthood and they declined to talk to me. But a lot of the reproductive health folks I did talk to said providers have been fighting for women's access to safe clinical care for so long, they're cautious about embracing the idea of home abortion.
But Kayla King says it's not a matter of clinics or pills, but a vital option for women in Texas.   Kayla went back home for a visit recently.
Kayla King: I was talking to my best friend. She's not very politically involved, and she was shocked that this was an option. I mean, a lot of women don't even know that this is a possibility.
Sukey Lewis: For a long time, this possibility was spread slowly by word of mouth, woman to woman. But that's changing. Now women can learn about it online, regardless of borders, or the laws where they live. And, as the word gets out, it's got the potential to upend the political and legal debate around abortion access.
Al Letson: That story was from reporter, Sukey Lewis. In the meantime, legislators in Texas are still passing laws that limit abortion. This year, Governor Greg Abbott signed a law requiring the burial of fetal remains. This will up the cost of abortion by at least five hundred dollars, putting it further out of reach for many women.
At the same time, Texas is one of several states that spends taxpayer dollars on a very different kind of support for women with unwanted pregnancies. You might call them anti-abortion clinics. We'll take you inside one of these crisis pregnancy centers next on Reveal, from the Center for Investigative Reporting, and PRX.
Byard Duncan: Hey, listeners. Reveal's Byard Duncan here to remind you about our Citizen Sleuth project. Together with the Center for Public Integrity, we're hoping to turn you into investigative journalists too. We've already done the hard part, by turning the Trump administration's financial disclosures into a searchable public database. Now we need your help to get in there and add your comments. Help us find out more about these individuals and the company they keep.
Here's something we dug up recently. Steve Bannon's home loans led us to a personal publicist. Turns out, Bannon may be violating federal law by employing her. Help us dig up more. Head over to publicintegrity.org/citizensleuth. Again, that's publicintegrity.org/citizensleuth.
Al Letson: From the Center for Investigative Reporting and PRX, this is Reveal. I'm Al Letson.
Women who want to end their pregnancies aren't the only ones going around the established system of doctors and clinics. The anti-abortion rights movement is doing it too, with what they call crisis pregnancy centers.
Macey Crow: To paint the picture for people who don't think they know what a crisis pregnancy center is, I always like to describe the signs on the highway that say, like, "Are you scared and pregnant? Call 1-800 and then a number." Those are crisis pregnancy centers.
Al Letson: That's film maker Macey Crow. She got a rare, first-hand look inside one of these centers. It happened after she read an article about an attempt to shut down the last abortion clinic in Mississippi.
Macey Crow: I was in between projects. I didn't have anything that week, so I flew down there.
Al Letson: Within 48 hours of reading the article, she was in front of Mississippi's last abortion clinic with her video camera, shooting what would become a documentary film. Here's Macey.
Macey Crow: When you show up at the clinic, you see people outside holding all types of signs. Anywhere from "Don't kill your baby" to like "Abortion is Murder" to giant aborted fetuses that are like, six-feet tall. It's like running a gauntlet just to get in the door. As you see in the film, one of the protestors, Roy, who is on the sidewalk, starts running after a couple of women as they exit the clinic.
Roy: Uh, if you're pregnant, please take and read this information. Mommy, mommy, please don't kill me, Mommy.
Macey Crow: If they're able to get a woman's attention, and the woman stops and talks to them, then they're more calm.
Roy: First thing we want people to know, it's bad for the women. And then secondly, and very importantly, there are free centers that are called crisis pregnancy centers. We help them, stay with them, we assign people to them.
Macey Crow: Everyone outside of the clinic, like, if they believe a woman hasn't already aborted, their main goal is to get them to a crisis pregnancy center. Barbara Beavers is the Director of the crisis pregnancy center that we follow. It's actually now called the Center for Pregnancy Choices.
Barbara Beavers: We're a life-affirming agency. We want to affirm the choice for life and help them make a choice for life.
Macey Crow: Barbara believes that abortion is a sin and thinks that women are going to be emotionally damaged, which is why she does everything in her power to stop women from aborting.
Barbara Beavers: You're deceiving yourself if you say you can kill your baby and it be good for you. That's just deception. That's not true.
Macey Crow: So, crisis pregnancy centers try and dress themselves up to appear as medical clinics. But they're funded by the pro-life movement. So you get in there, and they ask you questions like where you go to church, do you believe in God, how many partners have you had. The first time I went in there, they asked me if I was interested in being a born-again virgin.
I was at the crisis pregnancy center and met a number of women. One of them was April Jackson.
April Jackson: Hey!
Speaker 13: Hey. How you doing'?
April Jackson: I'm doing okay. I had an appointment at two o'clock.
Speaker 13: Okay.
Macey Crow: I went with April when she went to get a sonogram at the crisis pregnancy center.
Speaker 14: You can just have a seat right there, please.
Macey Crow: She was laying on the table as they do the sonogram. She's totally panicked and she's actually hoping that they're not going find a baby.
Speaker 14: Are you ready for me to turn on the big screen for you?
April Jackson: Not really.
Macey Crow: And-
Speaker 14: This is your baby right here.
Macey Crow: They do. Because she's pregnant, they find a fetus, and the woman doing the sonogram immediately starts calling April "mom".
Speaker 14: Now, I want to get you a picture today if you'd like one. You want one with "Hi Mom" on it?
Macey Crow: April doesn't answer, but the woman actually goes ahead and puts "Hi Mom" in big capital letters across the top of the sonogram.
April Jackson: I cannot believe I'm pregnant.
Macey Crow: April, later on, told me that at one point when she went there early on, she was told that there were no abortion clinics in Mississippi. Women have also been told that they can get breast cancer from having an abortion. That they're not going to be able to get pregnant in the future. You know, at one point when I was in the crisis pregnancy center, they gave me total misinformation about the effectiveness of using a condom.
Speaker 15: Even used correctly, there's like a 20 percent failure rate.
Macey Crow: I thought if a condom is used correctly, it's 98 percent effective.
Speaker 15: Oh, I don't believe that. I don't think that's ... I don't think that's correct. I'll find some of our data (laughs). Send you some of that. You can look at that.
Macey Crow: There's a number of fundraisers that went on while we were making the film.
Barbara Beavers: I'm Barbara Beavers and we are just so blessed to have each of you here.
Macey Crow: They had begun raising funds to open a crisis pregnancy center directly across the street from the abortion clinic.
Barbara Beavers: Having a place that's walking distance is huge because a lot of times these women are dropped off. That's the greatest need for the CPC to be as close to that abortion clinic as we can get it.
Macey Crow: I couldn't even tell you how many people were at this event, writing checks. One thing that really surprised me, Barbara ... She had invited the governor, Phil Bryant. He couldn't make it, so he actually sent someone who worked for him-
Speaker 16: He wanted me to come by and bring y'all a check-
Macey Crow: To bring a personal check.
Speaker 16: I came by to give you that, certainly.
Barbara Beavers: Well, thank you!
Speaker 16: But he wanted me to apologize for him not being able to come out here.
Barbara Beavers: Yeah, we understand that. We're okay.
Macey Crow: I think it's a mutually beneficial relationship, you know. The pro-life movement is lifting up Phil Bryant, and Phil Bryant's lifting up the pro-life movement. Since wrapping the film, the crisis pregnancy center has opened up across the street from the clinic.
Barbara Beavers: Okay, we're on go.
Al Letson: At the time her film came out, Macey counted 38 crisis pregnancy centers in the state of Mississippi. There's still only one abortion clinic. Macey's documentary is called "Jackson". You can watch it on Showtime at showtime.com.
Our story was produced by Stan Alcorn. Our show was edited by Taki Telonidis. Fernanda Camarena was our lead producer. Thanks to Deputy Editor Sarah Blustain from The Investigative Fund. We also had help from reporter Erica Hellerstein. Our sound design team is the wonder twins, my man Jay-Breezy, Mr. Jim Briggs and Claire C. Mullen, with help from Catherine Raymondo. Our head of studios, Crista Scharfenberg. Amy Pyle is our Editor In Chief. Susanne Reber is our Executive Editor, and our Executive Producer is Kevin Sullivan. Our theme music is by Commorado, Lightning.
Support for Reveal is provided by the Reva and David Logan Foundation, the Ford Foundation, the John D. and Catherine T. MacArthur Foundation, the John S. and James L. Knight Foundation, the Heising-Simons Foundation, and the Ethics and Excellence in Journalism Foundation.
Reveal is a co-production of The Center for Investigative Reporting and PRX.
I'm Al Letson, and remember, there is always more to the story.
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