That Time Prostitution was Decriminalized in Wisconsin

In his unpublished autobiography, David S. Rose recalled that one of his first orders of business on being elected mayor of Milwaukee in 1898 was to set up an official red light district. “I started to make an investigation,” he wrote, “And ascertain what would be the best and safest policy for society, for the rising youth, for the suppression of crime.” Mayor “All the Time Rosy” was a Democrat and a machine politician, more or less Wisconsin’s analog to Tammany Hall, and arch enemy of Progressive “Fighting Bob” LaFollette, who is more or less Wisconsin’s patron saint.  Rose instructed the chief of police to pursue a policy of containment: sex commerce inside the boundaries of the River Street district would be ignored, and outside it would be fiercely prosecuted. The city flourished, Rose remained popular for decades, and Milwaukee grew its reputation as an “open town.”

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Milwaukee Mayor David S. Rose (source: Milwaukee Historical Society)

Milwaukee was just one of many U.S. cities that decriminalized prostitution in the late 19th century, usually in the name of two things: preventing venereal disease, and protecting children. I say decriminalized rather than legalized, because it was not, in fact, ever legal to exchange sex for money. Rather enforcement became selective and strategic, to keep the sex trade regulated and geographically isolated, not necessarily in that order. Towns and cities all over Wisconsin tried some version of the decriminalization experiment until the rise of the Progressive movement turned the tide of public opinion against the regulation approach and toward a policy of abolition. Today we know about the “segregated vice” system mostly through the work of the Progressive reformers that dismantled it. In May of 1913, the Wisconsin State Senate passed bill, “to provide for the appointment of a committee to investigate and report on the subject of white slave traffic, and kindred subjects.” The committee would come to be known by the name of the State Senator who chaired it as the Teasdale Vice Committee. From 1913-1914 the Vice Committee deployed undercover private investigators throughout the state, to report on the true status of the segregated districts in Wisconsin.

Abraham Flexner, who is best remembered for importing the European system of medical education to the U.S. (and let me tell you it’s been slow going trying to get U.S. medical education to relinquish Flexner’s curriculum), was also an anti-vice reformer. He wrote in 1918, “Regulationist and abolitionist are absolutely agreed that prostitution exists and on a vast scale; that it is infinitely damaging; that something must be done about it. They disagree only as to what that something must be.” Those in favor of segregated vice districts and those opposed to it were equally vehement in their condemnation of commercial sex and their dire warnings that prostitution was a threat to decent citizens everywhere. They used the language of infectious disease to describe the sex trade, and they addressed it with policies that used the tactics of the burgeoning field of public health. “Regulationists” tried to quarantine prostitution, while “abolitionists” tried to eradicate it with both treatment (prosecution) and prevention (sex education). Continue reading

Wisconsin’s Strange History of State-Sponsored Sterilization

“It would be a rare phenomenon if the progeny of two mentally deficient parents were not likewise deficient. Yet in every state there are hundreds such in the pauper class free to bear children of whom a large percentage are certain to have criminal tendencies, murderous proclivities or vicious social traits. The public expense and private property loss they cause is beyond computation, and their presence at large is a menace that grows with the spreading branches of their family tree. What’s to be done?  ‘Well’, says Mr. John Average Public, ‘Why not try a safe and sane compulsory human sterilization law conservatively administered as in Wisconsin?’”

Frank C. Richmond, State Director of Psychiatric Field Services, 1934

The Law

People tend to be shocked when I tell them that the last state-sponsored sterilization in Wisconsin took place in 1963. It gives one a lot of cognitive dissonance imaging that some surgeon could have performed a coerced salpingectomy one afternoon and then popped over to the cinema to watch The Birds.  But so it was, and the law that permitted such operations actually stayed on the books until 1978. Although estimating the exact number has proven difficult, between 1,500 and 2,000 people were sterilized by the state under the Wisconsin Sterilization Act.

The passage of the act in 1913 was a victory long in the making for proponents of the practice of eugenics.  Wisconsin prided itself on using science to guide state policy, and eugenics was endorsed as science by representatives from the University and beyond. Writing a half-century later, Rudolph J. Vecoli documented in fascinating detail how “the congruity between  the eugenic doctrines and  certain aspects of the Progressive mentality,” including the Wisconsin Idea of connecting university and government, folded neatly into the creation of a law to restrict the freedom of its citizens to reproduce. Nonetheless in the early years of the 20th Century sterilization remained controversial and politically risky.  A law preventing the unfit from marrying had been passed in 1907, but it was unpopular and fated to be overturned in the courts the following year.  In the intervening years, two bills that would have codified state-sponsored sterilization had been defeated in the legislature. The 1913 bill succeeded in part because it was promoted as a conservative approach that would not take the extreme measures that had been seen in other states (then as now, a lot could be achieved in Wisconsin politics with by rallying around shared distaste for Illinois).

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Education poster from 1926 (source)

Wisconsin was the eleventh state to legalize compulsory sterilization, but it was not the last.  Thirty-two states passed sterilization laws in the 20th century, and five more generated a historical record of involuntary sterilizations without the blessing of the legislature. Wisconsin is an instructive case precisely because it kept the scope of its sterilizations narrow.  While other states defined the unfit broadly or loosely, and some used sterilization as a punishment for criminals and sex offenders (in Oregon men could be castrated for having sex with other men), Wisconsin separated the concept of sterilization from punishment.  The law outlined only three conditions that justified it: epilepsy, insanity, and “mental deficiency.”

Wisconsin’s law represents one of the least extreme cases of government regulation of fertility, and as such it is among the most instructive. In his book Breeding Contempt: The History of Coerced Sterilization in the United States, Mark Largent notes that in historical debates surrounding sterilization, “Even the most aggressive opponents of coerced sterilization often set aside some particularly problematic group for the procedures,” and the same might be said to be true today. People with cognitive disabilities are often made to occupy that role of the particularly problematic group for whom an exception might be made to the concepts of autonomy and the right to reproduce, opening a back door to legitimization of coerced sterilization.  Of the three medical conditions made explicit in the law, mental deficiency provided the rationale for surgery in the overwhelming majority of cases, perhaps because it was the most acceptable.  As it was put by one prominent supporter of the law, University of Wisconsin professor of sociology E.A. Ross, “The wedge should have a very thin end indeed. Sterilization should at first be applied only to extreme cases…As the public become accustomed to it, and it is seen to be salutary and humane, it will be possible gradually to extend its scope until it fills its legitimate sphere of application.” Continue reading

Talking about Abortion with my Mother

This is the third time I have posted this week on the topic of abortion, inspired by the proposed ban in Wisconsin on terminations after 20 weeks’ gestation. The following is a transcript of part of a conversation between myself and my mother, Mary Gordon, that took place yesterday afternoon on my couch in Madison. At my suggestion, we sat down to discuss my mother’s personal experiences with abortion, before and after Roe v. Wade, and recorded it for the purpose of sharing on this blog. I have edited it for clarity, meaning that I deleted some instances of um/uh/like and whatnot, as well as a few seconds when our words were inaudible, and a minute or two when my mom’s dog started to whine and required attention. A few hours after we talked, the 20-week abortion ban passed in the Wisconsin State Senate on a party line vote.

Anna: So, thanks for doing this.

Mary: Oh, you’re very welcome.

Anna: I wanted to do this because I’ve been writing on my blog recently about the public health and scientific aspects of abortion, and how I kind of got interested in it partly cause of my public health training and my epidemiologic training. But really if I go back further it’s not like that’s what persuaded me of any of the positions that I hold now, really. Most of us kind of don’t come to them through this like pure, reasoned, theoretical process, it’s because of stories of people that we know, and that’s particularly true I think for people that want to keep abortion legal. And, for me, a lot of my thinking about this has been shaped from talking to older women, talking to women who were alive before Roe. For women of my generation I think there’s a lot we don’t get about it, and it’s easy to miss what it was really like if you don’t talk to older people. So that’s kind of my thinking.

I guess I wanted to ask you to start with what—you’ve been involved in reproductive rights movements a lot, you’re a writer, you’re very vocally and publicly involved, and you’ve had a voice for a long time. What makes you willing to talk about your own abortions now, in ways that you haven’t wanted to in the past?

Mary: Well I think that it was probably your challenging me as to why I wasn’t talking about it publicly—

Anna: I challenged you about that?

Mary: Yeah.

Anna: I don’t remember doing that.

Mary: And I think that one reason why I’ve been unwilling to talk about my own abortions—which is not shame—but I thought that if I said I had an abortion, it would suggest that I was pro-choice in order to justify the position I had personally taken, and I was afraid that that would weaken my argumentation.

Anna: That you’d lose credibility.

Mary: Exactly. And so that’s really why I have been unwilling to do it. And now that I’m older and I think actually my voice isn’t as important, and that younger women are going to have to take the cause up or it’s going to die. Oddly that’s sort of liberating, and I think now’s the time. It’s not that I was silent because of shame, it was because I was afraid of it weakening my credibility. Cause, of the things I’m ashamed of in my life, you know, including not being nice to Joseph Kelly in eighth grade, I have not had one second of regret or guilt about having had an abortion. And I can feel guilty about almost anything.

Anna: Yeah that’s really true, you’re really good at that. That’s really interesting to me, cause I remember when you told me that you had had an abortion when I was about eight or nine, cause I’d seen [something about abortion] on TV and didn’t really know what it meant—I remember that you were really worried that I was going to have some kind of crisis about the idea that you could have had an abortion when you were pregnant with me. Which had like, never crossed my mind. That always stayed in my mind as though somewhere along the line you’d been indoctrinated with the idea that this part of your history was bad for your children.

Mary: Well it’s one of the things that the anti-choice people say, that if your children knew you had an abortion they’d always think that you could have aborted them. So I guess I was afraid.

Anna: I mean I guess I knew you could have, but I also knew you never wanted to. I’ve never doubted my wantedness.

Mary: My point is that even I was susceptible to the poisonous narrative that the anti-choice people are really good at. And you would say I should have known better, but you know “It will hurt your children” is a real hot button.

Anna: Yep. You know a lot of women of my generation, and actually I myself, are taking a tack of moving past the language of pro-choice and anti-choice.

Mary: So what’s the alternative?

Anna: I think the idea of there being a binary, that doesn’t describe most people’s position on the ethics of abortion or the best way to go about enacting whatever they would like to see–

Mary: So are you saying it’s pro-abortion and anti-abortion?

Anna: No, I’m saying that to be in favor of continued legalization, wanting to keep it decriminalized, is a big umbrella that can include a lot of people who have a lot of different positions on whether they think abortion is desirable, undesirable, morally neutral, ethically fraught, always a tragedy—you know, that people have as many different relationships to the concept of abortion as they do—

Mary: So then what language would you use to replace pro-choice and anti-choice?

Anna: I think that the idea would be to move to a place where you don’t describe your position with an identity anymore, you just describe the nuances. Like, you know, Planned Parenthood had the campaign about In Her Shoes, you never really know what decision another woman’s making until you’ve been in her shoes. And just emphasizing that there are more stories out there than you could possibly imagine, and you can’t think of all the contingencies that could lead to someone choosing an abortion. I get the feeling that’s not very satisfying to you.

Mary: No, cause one of the things that the right is better at than we are is buzzwords, and they work. So I’m concerned on that level that In Her Shoes doesn’t really get the message across that you are trying to keep abortion safe and legal. I can understand the reluctance to use the word choice—

Anna: Yeah cause for a lot of women, you know, what actually constitutes choice. It’s not much of a choice.

Mary: Right, but we better work on coming up with something.

Anna: Fair enough. So, can I ask you—one of the things I wanted to talk about today is, I mentioned that from a pretty early age I knew you had had an abortion. I didn’t know until I was an adult that you had had an abortion when it was illegal. So I was hoping you could talk a little about what that experience was like for you. So to start with, how did you become pregnant the first time?

Mary: Well, as you know I’m incredibly fertile.

Anna: Women in our family are so fertile.

Mary: And I had actually had sex twice (intercourse, penetrative sex), but the last time I had had intercourse was maybe six or seven months before I missed a period. So I got pregnant with somebody who had an orgasm on my thigh.

Anna: That’s like one of those stories that I always thought they were making up in sex ed class, that like could never really happen.

Mary: But it did, cause I literally didn’t have sex for six or seven months. And so I didn’t think I could possibly be pregnant.

Anna: Yeah, I don’t blame you.

Mary: But, you know, I did know that I had missed a period, my periods were very regular. I then when to a gynecologist, who said to me “Well you’re pregnant, and if you give me $2,000”—and this was in 1969, and I didn’t have twenty dollars—

Anna: And how old were you?

Mary: I was nineteen, and I was in college, on a scholarship. [He said], “If you give me $2,000, I will arrange for a psychiatrist to say that it would be emotionally dangerous for you to continue this pregnancy.” And I just said, you know, that’s not possible and he said goodbye and good luck. And then, I was a student at Barnard, and at Columbia actually, the Protestant chaplain was helping women get in touch with a network of abortions that were supposed to be relatively safe.

Anna: Was it like the Jane network in Chicago?

Mary: I don’t think so.

Anna: That is to say it wasn’t run by other young women?

Mary: No it was pretty secret, and I actually don’t know who ran it. Just that if you wanted that number, either of you could go Earl Hall. And I got the number. I told the guy who had made me pregnant that he had made me pregnant, and he didn’t believe me. I can’t really blame him, but he didn’t. And it cost $200 and I didn’t have it. A friend of his who did believe me came up with $100, and I had to borrow $10 from everybody else I knew.

Anna: Who gave you the $10?

Mary: All my friends.

Anna: And they were willing?

Mary: Yeah. And everybody was very sympathetic. I had a boyfriend at the time who was gay. But we were very close.

Anna: You knew he was gay?

Mary: Yeah.

Anna: But he was your boyfriend?

Mary: At that time you believed that if you loved somebody enough you could turn them, and he was in therapy and his shrink told him that if we loved each other enough he would get over this terrible disease. In any case, he agreed to go with me. We had to go to a street corner in the Bronx, somewhere in the Bronx, I don’t remember. He wasn’t allowed to come with me. I got in a car with someone I’d never seen before in my life. I had to wear a blindfold. I was brought somewhere, I have no idea where, to an apartment building. We went down to the basement, there were six or seven women sitting there, just in the living room of an apartment, and women would go in this door and then they’d come out looking very white. And we kind of all bonded, cause we were in this desperate situation, we all knew why we were there.

Anna: Who were they?

Mary: I don’t know. They were a big range of ages. I think everybody was white now that I think of it, and pretty middle class. And I had to wait there basically the whole day, it was really pretty terrifying. And we also knew that the cops could come in at any minute, and not only would you not get an abortion but you’d have to go to jail. So it was really terrifying. And finally my turn came, and there was a man, a Latino man, very kind. He said he was a doctor—I don’t know. He gave me a shot of Demerol, and it hurt like hell. He did a D&C.

Anna: So the Demerol was the only pain relief you had?

Mary: Yep. And it really, really hurt. And he kept saying, “I can’t stop, I can’t stop, I have to keep going.” And then it was over. The driver came and put the blindfold back on. My boyfriend had waited in a café or luncheonette for me all day. He took me home in a cab. I went to sleep. I made an appointment to see the gynecologist who wouldn’t help me.

Anna: For follow-up care?

Mary: For follow-up care. He was willing to see me, and not turn me in, which was—

Anna: More than you could get anywhere else.

Mary: And I was fine. Apparently he did a good job, there was no infection. You know, and that was it. But it was pretty terrifying.

Anna: And who supported you through all this?

Mary: All my friends. My one friend [name redacted, they are still extremely close] spent the night with me, and everybody was incredibly supportive and kind. I was terrified that my mother would ever find out because, that would be—

Anna: Right, yeah, with Nana that would be—

Both: The end of the world.

Mary: And she never found out. And I think that just the trauma of it made me very shaky, just what I had gone through made me very shaky for a couple of months.

Anna: Just in general?

Mary: Yeah. At the same time, my gay boyfriend was kind of shoving it in my face that he liked guys.

Anna: The one who had taken you to the appointment even though he wasn’t the one who got you pregnant?

Mary: Right. And that was a trauma. And then it was—there was just a lot of political turmoil in the air. I kind of think I put my energy into anti-war stuff because it was distracting—I mean I cared about it, it was a good thing to do. I was writing poetry, it was my first writing class, I was very very nurtured by my teachers at Barnard, particularly by Jan Thaddeus [Mom’s mentor] who nurtured me.

Anna: Did she know what you’d gone through?

Mary: I wrote about it. We didn’t talk about it, but it was kind of clear from the poetry, which she thought was good. And, I would say—it happened in January, and certainly by the summer I was kind of back to myself. And then I really determined that I was going to get involved in whatever we’re calling it—pro-choice, pro-abortion—and I really think I have been since—that was 1969.

Anna: So you weren’t involved in it before?

Mary: No, I was not.

Anna: Do you feel like that’s what made you get involved?

Mary: Yes. But I brought all my friends with me, none of whom had abortions.

Anna: Did you know other women who had been through it?

Mary: Not at the time. No. Later, I did. But not in my cohort.

Anna: Did you ever consider any alternative to an abortion?

Mary: No, no. It would have been—to have had a child—I thought that giving –If I believed—and I know you don’t think I have a scientific brain, but at least—

Anna: It’s not your brain!

Mary: If I really believed—and I was 10 weeks pregnant–if I really believed that a ten-week-old fetus was a child, I would not have an abortion, I really wouldn’t. And I had enough scientific intelligence to really study and read what the size was, what the development of the brain was, what the ability to feel pain was, and I really didn’t think that it was anything but a kind of advanced birth control. I felt I would never have been able to give a child up for adoption, because that would be a child, and I thought that having brought that life into the world I was really responsible for it. And also the pain of having carried a child to term—I would never have been able to live with giving it away. And if I had had a child it would have been the end of any kind of full life that I could have had. I would have had to go home and live with my mother and not finish college, work as some kind of secretary, and it would have been a life that would have been so radically diminished that I could only see a life of depression and misery ahead of me. The shame would have been, in my community, enormous, but more than that nobody would have helped me go back to school [Mom’s family had always opposed her going to college]. It would have been—now that I look back on it I can say well, maybe when the child grew up I could have gone back to school—

Anna: How many people actually make that happen, though? You have to be a pretty extraordinary person.

Mary: I was on a path that was very important to me and having a child would have meant the end of a fulfilled life.

Anna: And being in school–knowing as much of your biography as I do–being in school wasn’t just about being in school. It was a whole life away from the life you grew up in. It was most of the people who cared about you in the world.

Mary: Yes. And again, if I had believed that the fetus was a baby I would have just sucked it up. I’m very glad that I didn’t. But I think, of the things that I doubt about myself, I don’t think that I’m a morally callous person and I like to believe that I can look at the hard truths. And I’ve never wavered in that position, that early abortion is an absolutely ethically neutral if not an ethically positive choice.

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None of the people pictured here are my mom.

Anna: For the record it’s not that I don’t think you have a scientific brain; I don’t think you have a scientific heart. It’s not the same thing. So then what I wanted to ask you is that you then had another abortion some years later, after Roe.

Mary: Yes.

Anna: One thing that someone told me when I was working with Medical Students for Choice which I found very helpful is that for a lot of people who’ve come up in an identity opposing abortion, very different from the one I grew up in, people don’t really make much of a distinction between legal and illegal abortion. It sort of seems like the same thing. So when I would share pictures from WHO of women who’d had illegal abortions that were botched and their intestines fell out of their vaginas or something like that—the friend who was telling me this was like, “That’s never going to persuade somebody, cause they’re just going to look at that and say yeah, abortion is terrible, we’ve got to do whatever we can to stop abortion.”

Mary: I do remember when I was working on pro-choice things in the early seventies, I was in graduate school, three of us that lived together shared a car, and I did have pictures of women with their intestines coming out of their vaginas which I left in the trunk. And one time this delivery boy opened up the trunk and went “AAAAAH!”

Anna: Oh dear. What did you say?

Mary: I don’t know what I said, I think I just put the groceries in really fast.

Anna: So I wanted to ask you if you’d talk about the experience with your second abortion and how it was different.

Mary: Yes. I had a diaphragm failure with my second abortion. I had a diaphragm in and it did not work. One of the things that I remember is I was able to go to Planned Parenthood in Syracuse, and this wonderful older nurse said to me, “I’ve come back from retirement to help people have abortions legally, because I saw the horror of illegal abortion and I’m so happy to be able to help women to have safe abortions without pain, and I’ve come back to work just to be a part of that.” And there was no terror, I didn’t think the cops were going to come and get me, I didn’t think that someone who could have been a plumber could have been doing the abortion.

Anna: How old were you?

Mary: I was twenty-three.

Anna: And you were in graduate school.

Mary: Yeah.

Anna: Were you in a stable relationship then?

Mary: No. And the person who made me pregnant I thought was about to get into a long-term relationship with me, and then the minute he left me he wrote to tell me that he was actually involved with somebody else.

Anna: The entire time?

Mary: Yep, as well as having given me gonorrhea.

Anna: Ugh, men suck.

Mary: So whereas I was really really traumatized for several months after the first illegal abortion cause I had been so terrified, it was really not traumatic at all.

Anna: What was it rather than being traumatic?

Mary: It was always a little bit sad. You think, gee, I wish this didn’t happen, and I wonder what this would be like—I don’t think anybody goes into –well maybe some people do, I can’t—I certainly didn’t go into it lightly. It was sad, I had to grieve it. I never regretted it.

Anna: How did you make your decision?

Mary: Again I would have – I was in graduate school, I was not in a stable relationship, I was starting a career, and you know I could not have raised—I could not have had the life I wanted to and raised a child. So the differences were really really significant. I felt safe, I felt cared for. Actually this wonderful nurse made me feel like I was doing a good thing. And it was just as easy as it could possibly be, as opposed to being utterly traumatic. Oh also the first abortion was a D&C, and this was an aspiration.

Anna: Do you mean they just used a curette the first time?

Mary: Yeah.

Anna: Gotcha.

Mary: Which is a lot more painful. The second abortion seemed to be a matter of seconds.

Anna: Were you conscious for it?

Mary: Mm-hmm.

Anna: There’s sort of not medical consensus these days about how much pain relief to provide, is the reason I asked, I was sort of curious how they were doing it back then.

Mary: Well, it didn’t hurt.

Anna: So how do you kind of feel about the experiences that you’ve had and how that’s shaped your feelings about abortion?

Mary: I like to think that I would have had the moral imagination to be pro-choice without these experiences, but certainly knowing that I really could have died—I really could have died. And you know, I did know girls in high school, it was Catholic high school, and they were pregnant and they went away and you never saw them again. And you never knew what happened to them. And in speaking to older women, I remember having had a lunch in Cape Cod, four wonderful women, I was in my thirties I think they were in their seventies, and every single one of them had had at least one abortion.

Anna: That’s something that has surprised me as well, is, it’s analogous to what I discovered when I had a miscarriage, and it turned out that a lot of people I knew had had miscarriages and I never heard about it. I found that once you start talking about abortion, particularly—well maybe with any group of women, but particularly with older women, I’m surprised how many never talk about it.

Mary: And speaking of miscarriage, I am a woman who has had abortions, a late miscarriage, and two healthy vaginal deliveries. And I’m telling you, I know what the experience—I had a miscarriage at twenty weeks. It still didn’t seem like a baby to me.

Anna: That’s interesting cause Dad, you know, Dad found that experience so devastating, and to him watching you have the miscarriage, and seeing—for you guys it was really losing a baby—and he didn’t quite use these words but he said that what came out of you really looked like a baby to him.

Mary: But I knew—that was something that I really grieved for a very long time, it really changed my life, the loss of that fetus, baby, whatever it was. But I didn’t name it. It was interesting. I didn’t have the impulse to name it, I didn’t have the impulse to bury it, I didn’t have the impulse to do a ritual around it. I mean I was sad because of the potential, but it would have seemed utterly ghoulish to bury it or name it. I knew it wasn’t a child. And that was interesting to me. Cause I certainly grieved it. But it was not a child. And Daddy felt the same way, even though he saw whatever I didn’t have to see.

Anna: So, you mentioned older women. What kinds of stories have women a generation older than you told you?

Mary: Stories of terror. A bunch of these women had gotten pregnant during the depression, and it was just not possible. I remember being in pro-choice groups with women whose mothers were very lower class and the women were doing it to each other in kitchens, and in really dangerous circumstances.

Anna: Peggy [my husband’s late grandmother] told me this story about how girls when they got pregnant would try to get a job at a bowling alley, because something about having to put up the pins, and with all these balls flying around was supposed to cause a miscarriage.

At this point the recording cut out, but we didn’t realize it till several minutes later. So the last few minutes of our conversation was lost, and we found we couldn’t recreate it after the fact. The last question I asked Mom was what she wished women of my generation and younger would understand. I posed that question to her a second time, and this is what she said:

Mary: What I hope that they understand, although it’s not something that they’ve experienced, is that when abortion is illegal or hard to come by, women die. Women have always had abortions because they’ve always needed to have abortions, for very good reasons. And a lot of them have died. And so you’re never going to stop abortion, you’re just going to stop women’s safety. And if you are concerned about abortion as a moral issue, which indeed you should be, I think it’s important to think that whatever is the nature or ontology of the fetus is pretty unknown, or certainly debatable. What’s not debatable is that if abortion is made illegal or unsafe, women will die. And to stop women from dying is certainly an unequivocal moral good. And I want that to be remembered.


Image source: https://inyourfacefeminism.wordpress.com/art-third-wave-feminist/

The Epidemiology of Abortion: A Primer

A few days ago I posted about the proposed ban here in Wisconsin on abortion after 20 weeks’ gestation–and about how honestly, we’d rather not talk about it. Today’s post involves not one but two things most people would rather not discuss: abortion and statistics. Wait, wait, don’t go! Here, have a calming manatee.

CalmingManatee

I wasn’t especially interested in the issue of abortion until I went to graduate school for my Master’s in Public Health. In my time there I came to appreciate the control of fertility as a public health issue. But it was really the training in epidemiologic methods that got me interested in the issue.

Research findings are a big part of the public discourse around abortion, specifically of the argument that undergoing an abortion is bad for your health. The safety of legal abortion is just one piece of a much larger debate, but it is an important piece. Unfortunately since most people are unfamiliar with the methodological issues involved, we have to rely on experts. Each side of any debate inevitably has its own experts, all wielding citations to published articles, so the lay public may be left with no clear idea of the state of the evidence, and could understandably conclude that this debate is just more divisive ideology with a scientific facade.

I think we can do better, though. As one of my statistics professors at Berkeley was fond of saying, “Why be a slave to some little number cruncher?” I happen to believe most people can understand the science around this issue just fine. This post is an attempt to provide a basic understanding of how people go about trying to prove or disprove a connection between abortion and subsequent health problems, and some tools to help you evaluate research claims for yourselves.

My intent is that this will be useful no matter what your perspective on the legality or accessibility of abortion. I don’t think a pretense of neutrality contributes constructively to the public conversation, and I make no attempt to hide the conclusions I myself have drawn. These issues have become so intertwined with social identity that it is rare to have a productive conversation about abortion among people with very different positions, but I’ve had such conversations and I want to have more of them. I’m not oblivious to the state of U.S. politics right now, but I continue to believe it’s possible to move the public debate away from “What side are you on?” and toward “What works?”

Ralph_Hedley_(follower)_An_argument_from_opposite_premises

“Well I read it on HuffPo so shut your cake hole, Phyllis!”

The skills that allow a critical reading of scientific evidence are relevant to anyone who has or would like to have an opinion on the ethics of abortion. As I said in my last post, we have enough consensus to start a conversation as long as we agree on the precept that good ethics begin with good facts. If you disagree with that crucial premise, however, this is not the post for you. Perhaps you would like to pass the time on this excellent site instead.

Time for some Epidemiology 101. In order to keep this simple, I’m going to focus on just one hypothesis: that abortion causes depression. It’s plausible; having an abortion is often a difficult experience, accompanied by feelings of sadness and stress. Dozens of studies have examined the question. However the principles below apply equally well to other outcomes.

Let’s say that you know a person–we are going to call this imaginary person Veronica–who had an abortion at ten weeks of pregnancy, and six months later was diagnosed with depression. You suspect Veronica’s depression was caused by the abortion. However, you already know about Rooster Syndrome (just because the rooster crowed and then the sun came up doesn’t mean the rooster made the sun rise), so you know that just because Veronica had first an abortion and then an episode of depression doesn’t mean the two events are related. So how could you prove or disprove your suspicions?

What you really want to know is this: if Veronica had not had an abortion, would she still have depression now? The only way you could actually prove such a thing is with time travel. Since you have observed what happened to Veronica after having an abortion, you could get in your time machine, travel back to the moment before, and intervene so that in this version of history she never gets the abortion. You then stay in this alternate universe to observe her for six months and compare the two Veronicas. Did she still get depression? If she did, then you know that her abortion did not cause it. If she did not get depression in the alternate universe, then you know that in the real universe her abortion set into motion a chain of events that led to her depression.

You may recall that this alternate universe is what is known in theoretical circles as the counterfactual scenario (thanks, David Hume!). Obviously, it is not real–boy I hope that’s obvious. But I bring it up because I think it helps to understand how studies are designed. A useful way to think about critiquing a study is to ask how close or far it gets us to the counterfactual scenario, given our ongoing shortage of time machines.

Even before we leave the alternate universe, though, we already have some methodological issues. You can’t simply erase Veronica’s abortion; if she doesn’t have an abortion she has some other experience instead. You are always comparing the results of the abortion to the results of something else. So how did you intervene to prevent the abortion? Did you go yet further back in time and provide her with a condom at the appropriate moment so that she never got pregnant at all? Did you get her take her to a pub crawl before she ever missed her first period, causing a miscarriage through heavy drinking? Did you provide support for her during her pregnancy in exchange for agreeing to adopt the child? Did you remove some of the barriers to giving birth, allowing her to choose to raise a child herself right now (you can probably come up with $245,000 considering you came up with a time machine)?

We can’t know without testing them what the outcome of any of these scenarios would be, but it seems plausible that they could make Veronica less vulnerable to depression. But on the other hand…

Did you make her an appointment at a Crisis Pregnancy Center where she was misinformed about how far along she was in her pregnancy so that she couldn’t schedule the abortion until past the time when the clinics in her area could perform it? Did you call up a group of  your friends to stand in front of the clinic shouting and thrusting pictures of mutilated children at her, until Veronica was too afraid to enter the clinic?  Did you close the only clinic she could get to, by lobbying your state legislators to pass laws requiring abortion providers have hospital admitting privileges? Did you kill the only abortion provider in the area? Did you get the US Supreme Court to overturn Roe v. Wade so that Veronica would–let’s say she lives here in Wisconsin–face three years in prison for getting an abortion, while her doctor would face ten?

Personally, I find it much harder to believe that these experiences would be less traumatic and less likely to cause depression than choosing an abortion. Plenty of people would disagree with me, though. But I’m an empiricist by nature and training–we can’t actually know what works by reasoning it out in our heads. The point is that none of these interventions are equivalent to each other, and none carries an equivalent risk of depression. You’re going to have to get in your time machine and go back at least nine times in order to conduct this counterfactual experiment. At least you will if you want to know if any of these strategies would actually have made Veronica healthier than she is here in the universe in which she got an abortion.

We can’t actually observe the counterfactual, so what’s the next best thing? The next best thing would be to observe two identical people, one of whom has an abortion and one of whom doesn’t. I’m not talking twins here, cause as Orphan Black teaches us, genetics do not make a person. I mean two people who are actually the same people. So we’ll get a big tub of programmable flesh, make ten pregnant doppelgängers of Veronica and…

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Okay, okay. Enough about time machines and programmable flesh; let’s take this back to reality. When it comes to abortion, you can’t observe the same person under two conditions, and you can’t observe two copies of the same person. What you can do is compare two groups. The people in the groups are not the same, but the groups are the same on average. In particular they are the same with respect to everything that predicts depression–same number of people of each race and ethnicity, same number of people at each age, same number of people with children, same number of married people, same number of people living in poverty, same number of people with a prior history of mental illness, etc. If in fact your hypothesis is correct and abortion causes depression, that doesn’t mean that you would expect to find that everyone in the abortion group has depression, or that zero people in the comparison group have it, because lots of other factors cause depression in some people and protect against it in others. But if there is a causal connection, you would expect to see meaningfully (how meaningful? ymmv) more cases of depression in the abortion group.

In real studies, investigators attempt to make groups that are the same on average by randomly assigning subjects to one group or the other. Obviously no one will be conducting a study in which every pregnant person who enters the the study is randomly assigned to Group A or Group B, and then the Principal Investigator assigns Group A to give birth and Group B to have an abortion. Boy I hope that’s obvious, cause if it’s not I hope none of you are conducting any experiments. So when it comes to studying the effect of abortion, that study design is out, too. Abortion is hard to study.

Given that there will be no randomized groups, which groups can you compare? Now at last we arrive at real-world research. Here are a few strategies researchers have employed to try to study the effects of abortion.

Skip the comparison group. One strategy is to study only people who have had abortions, and draw conclusions from just one group (example here, admittedly an old one) . But you already know what is wrong with this reasoning. This is Rooster Syndrome again. Without a comparison group of people who did not have an abortion, there is nothing to suggest that the abortions are responsible for the prevalence of depression in this group. This is the weakest kind of evidence.

Compare people to themselves. An alternative strategy is to measure the same people twice (example here), before and after the abortion, and compare how much they’ve changed. That’s more convincing, but it doesn’t help with Rooster Syndrome.

Compare pregnancies ending in abortions to wanted pregnancies or miscarriages. Most studies on this topic have compared a group of people who chose to end unwanted pregnancies to a group of people who chose to continue planned or wanted pregnancies (example here). This type of study is limited by the fact that it is impossible to know how much of the differences between the two groups result from abortions and how much result from the higher proportion of unwanted pregnancies among people who choose abortions. An unwanted or mistimed pregnancy is an extremely stressful experience, no matter how the pregnancy ends, and could explain different amounts of depression in the two groups. In epidemiologic terms, this type of bias is called confounding. The relationship of abortion to depression is likely to be confounded by the “wantedness” of the pregnancies in studies using this type of comparison group.

Compare pregnancies ending in abortions to unwanted pregnancies carried to term. Other studies have compared a group of people who had abortions to a group of people who chose to continue unintended pregnancies (example here). That removes the issue of confounding by “wantedness,” but there are still important sources of bias here.

One of the most important issues is that people who have had depression in the past are more likely than people who have never had it to have another depressive episode–no surprise there. So one important predictor of depression after an abortion is depression before the abortion. Since ones current and past mental health can factor in to how capable one feels of continuing a pregnancy, failure to account for mental health history can lead to what is known as an indication bias. In this case the perceived need for an abortion (the indication) is associated both with the probability of choosing an abortion and with subsequent depression–potentially creating a spurious association.

There are other sources of indication bias, as well. In this study, some of the reasons people in the U.S. cited for choosing an abortion included “Can’t afford the basic needs of life,” “Not enough support from husband or partner,” “Physical problem with my health,” and “Became pregnant as a result of incest.” These are things that can contribute to depression no matter how the pregnancy ends.

How close do you think those two groups of people are to being the same on average at the start of the study? If people who continue their pregnancies are more likely on average to have supportive partners, adequate financial resources, good physical health, and good mental health, they are less likely to have depression. You may find more depression in the abortion group, but it is impossible to know whether that is a result of their having had abortions or of the preexisting issues that led to them feeling they needed abortions.

Statistically adjust or “control” for sources of bias. Any of the above methods that use a control group can use statistical methods to reduce confounding bias by measured effects. This is a complex topic that I’ll have to cover another day, but I’ll just give a brief overview. You know that people living in poverty are more likely to have abortions, and more likely to have depression, so you think socioeconomic status could be biasing your estimate of the relationship between abortion and depression. So you use statistical techniques to adjust your estimate for socioeconomic status, so that the estimated association between abortion and depression can be interpreted as independent of class. At least you can try. How well you can adjust for potential confounders depends on how well you can measure them (socioeconomic status is challenging to characterize well). But most importantly, you can’t measure every kind of confounder. There will always be some patterning in who gets and abortion and who gets a different pregnancy outcome, and some of that patterning will lead to distortion. It’s an inherent limitation of observational epidemiologic studies.

Given all these different approaches, there has been a lot of conflicting evidence about the relationship of abortion to depression. These three influential systematic reviews found that there was no evidence of an association between abortion and depression and that most of the research on the topic was fundamentally flawed, but the author of a fourth review disagreed, and by choosing a different set of studies to review found evidence that people who had abortions did have more depression.

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Right about now you might be asking me what was the point of telling you all this if there’s no clear answer, and it all just depends on who you ask. But we’re not done yet, because someone came up with an extremely elegant solution to the limitations of the methods described above.

Compare people who chose abortions and obtained them to people who chose abortions but were denied them. Now we arrive at the highest quality evidence available. In comparing two groups of people that both sought out abortions, you solve the problems of confounding by “wantedness” and confounding by indication. When people are recruited at the same clinics you remove many other sources of confounding by socioeconomic and demographic characteristics, and you remove some of the influence of selection bias (when people who had abortions and have depression are more likely to join or stay in your study than people who don’t). You also get an assessment that is more relevant to the question of whether abortion should be legal and/or accessible.

There is only one study that has ever used this design. It is called the Turnaway Study, and you should remember that name because it is very important. Importantly, the subjects in this study were all at very similar stages of pregnancy, but some were just over the limit of when abortions could be performed at their clinic. Subjects did not self-select into the two groups. This is about as close to random assignment as an observational study can get, and thus the best approximation of the counterfactual scenario. Incidentally, the Turnaway Study findings suggest that having an abortion was associated with similar or even lower risk of depression as carrying an unwanted pregnancy to term.

Clearly I can’t cover all of epidemiology in one blog post, or even all of the methodological issues involved in studies of the effects of abortion. But I hope this has given you an action plan:

1. When you read an article claiming a study says “abortion causes ______” or “abortion is associated with ______,” you ask “Compared to what?”  Likewise, when a study says “women who had abortions have more/less ______,” you ask, “Compared to whom?”

2. When you read study results, think critically about how much the observed differences between comparison groups are telling you about abortion, as opposed to other things correlated with abortion like socioeconomic status, past mental health history, lack of access to contraception, lack of health literacy, etc.

3. Read a lot about the Turnaway Study. They are publishing a lot of results, all of them interesting. Right now this is the best kind of evidence we have.

Class dismissed.


Image: An Argument from Opposite Premises, Follower of Ralph Hedley [Public domain], via Wikimedia Commons

Wisconsin’s Abortion Ban is a Bad Idea–No Matter How you Feel about Abortion

We need to talk about the abortion ban that is well on its way to becoming Wisconsin law. People who believe abortion is never justified need to talk about it. People who believe abortion is morally neutral need to talk about it. Most people’s take on abortion is more complex than either of the above, and they most of all need to talk about it. The ethics of abortion are hard, and I respect that different people will give these issues years of careful thought and still come to different conclusions. If we all endorse the adage that good ethics begin with good facts, then we have enough consensus to start a conversation, so let’s begin. If you disagree, then this is probably not the post (or the blog) for you. Perhaps you would like to pass the time instead by reading this heartbreaking classic by the great American poet Lucille Clifton. Clifton knew better than anyone that it would be easier not to talk about abortion. But that’s not good enough. So this is what I have to say.

There is no evidence that banning abortion late in pregnancy leads to fewer abortions. Other states have tried it, and there is no evidence that it worked. For one thing, very few such abortions are performed–as you probably know, they are only about one percent of all abortions in the U.S. As you also probably know, these are mostly abortions performed in response to a medical diagnosis, maternal, fetal, or both. One doctor has publicly speculated that the ban may lead to more abortions as families may not have time to wait to get all the information, and may wind up ending a pregnancy that could have led to a live birth.

These are the stories no one wants to think about. It’s easier to pretend that if you want a baby, and you take the greatest possible care trying to bring your baby into the world, if you believe in the sanctity of life, and try to be a good person and a good mother, that you and your baby will thrive. We could all pretend that no pregnant woman is diagnosed with cancer, that all fetuses develop kidneys and brains, that live-born children with Trisomy 18 don’t suffer in the 48 hours during which 95% of them will die. We could also pretend that these things only happen to people who did something wrong, or who are in some way different from us. Compassion is much harder. What if a few moments’ witness to the pain of a family having to lose the baby they wanted is just too much, and it breaks us?

Some of the figures involved in Wisconsin politics right now are claiming that pregnancy never kills. It’s an easy enough lie to tell, because these scenarios are rare. Most people don’t know anyone who had to end a pregnancy to save their own life, so it’s easy for them to dismiss such stories as abstractions. Not, however, for doctors. Doctors meet the people who are living this nightmare. They have to deliver the news no one ever wants to hear. That’s one of the reasons so many doctors oppose this kind of legislation. It’s one of the reasons why the Wisconsin Medical Society and the American College of Obstetricians and Gynecologists, neither of them known for their fringe political stances, have opposed this bill in Wisconsin. As of this writing the proposed law still contains an exception for cases when carrying a pregnancy to term would kill someone–at least I think it does. The language is pretty vague, and I’m no lawyer.

But the truth is, this is all beside the point. You may think parents should not have the right to make these decisions for any reason, but we can agree to disagree. Likewise you may feel persuaded by the argument that any amount of uncertainty over whether later abortions cause fetal pain means those abortions should not happen, even if the weight of the evidence is against it. That is also beside the point. It’s all beside the point as far as this law goes, because abortion bans don’t work.

What is the purpose of this bill? It pretty clearly won’t end abortions, late or otherwise. Wisconsin women will have to obtain them in other states. To quote this econometrics paper, “The demand for abortion is quite inelastic.” That could never be more true than in the case of late abortions. It should not surprise anyone that the consequences of having to travel for an abortion can be devastating for families living in poverty. As was the case before Roe and now, restrictions on abortion do not apply equally. Money could always get you an abortion, probably even a safe one.

The real purpose of this bill is probably to provoke a ruling in the U.S. Supreme Court. Then the conversation about abortion will change. Most of that conversation will surround the ethics of abortion. And it will be a waste of time. Not because the ethics aren’t important–they are–but because they are moot. Making abortion illegal doesn’t make abortion go away. These attempts tend to backfire. Looking at aggregate data, countries in which abortion is illegal actually have more abortions. The demand for abortion is inelastic. Abortion need not even be illegal to prove that point. Even within my time in medical school, a doctor here in Madison told me about a patient who was flown in from a rural area after she nearly died attempting to give herself an abortion with a knitting needle.

I still believe that it is possible to achieve consensus on abortion in the U.S. No one actually has to change their mind or compromise any ethics in order to achieve this consensus; all we need to do is embrace the practice of evidence-based policy. Cause the evidence suggests making abortion a crime is not going to reduce abortions.  Are you bothered by how many abortions are performed in the U.S. right now? Guess what, me too. Let’s get cracking on preventing unwanted pregnancies. Are you bothered by the idea that someone might feel like they couldn’t continue a wanted pregnancy because of a diagnosis of Down Syndrome? Guess what, me too. How about we get some legislation going that supports families of children with special needs, and makes the deck a tiny fraction less stacked against people living with cognitive disabilities. I would so much rather be working on either of those issues, wouldn’t you?

And let’s not do a few other things. Let’s not make women choose between watching their child suffer and going to prison. Let’s not force women to risk their lives by continuing a pregnancy because they could not prove there was a zero percent chance of survival without an abortion. Let’s not create an underground economy for abortions because they are no longer performed legally by doctors.

On this blog I usually try to make my points with a dose of humor, but I can’t on this one. The truth is I’m profoundly depressed about the state of politics in Wisconsin, and the general unwillingness of the politicians who control all three branches of government right now to use evidence. I’m not utterly clueless. I have a pretty shrewd idea of what’s going to happen with this law. I sure hope it doesn’t lead to more abortions. But it probably will.

In Praise of C-Sections

You know who makes a really macho crowd? Biological mothers. I have watched people who for most of their lives have espoused a mainstream, less-is-better approach to pain suddenly bragging about it as though the involuntary firing of their nociceptors were an achievement. People who are completely pleasant as a rule will hear the word “epidural” and SHOONK they are transformed into The Uterus Gladiators! With savage glee they race into a totally imaginary arena, to compete with other savagely gleeful person-hatchers, in an epic fight to decide once and for all who had the most pain in childbirth, and–importantly–who sought the least relief for that pain.

Whee! This is fun! Pay no attention to that octopus.

Whee! This is fun! Pay no attention to that octopus.

You’ve probably guessed I have limited patience for this brand of one-upmanship. There are women in my life whom I deeply respect that have chosen home birth (okay only one woman but I respect the living daylights out of her judgment), and lots more that have chosen to forgo pain relief in a hospital delivery. That is a totally awesome choice if it is a thing that you want to do, and I’m glad that activists over the years have succeeded in making these options available to everyone. But if that is not your thing, oy gevult don’t feel ashamed of yourself. Like any kind of treatment there are costs and benefits to pain relief in childbirth, but that doesn’t make it bad. I’m hereby giving you permission: you do not and should not have to justify the decision to relieve your pain.

The Uterus Gladiators, however, are nothing compared to the Vagina Valkyries. You know who I mean. The women who have experienced a vaginal delivery and now feel lifetime superiority over the women who required or–gasp!–chose a surgical delivery.  “I had a baby with no medical intervention,” I hear one of them bragging before yoga class, shortly before sprouting wings and flying off to adjudicate some Norse battle deaths. You’d really think from the sound of it that medical intervention was a vice.

C-sections are often not a matter of choice, but a life and/or death situation. Sometimes they are a measure of last resort after the first, second, and third choices have been exhausted. Some c-sections are elective, but the term “elective” is loaded. Are the consequences of not electing this procedure acceptable? That’s subjective. And that’s what bothers me about the push to shame patients out of seeking medical care by convincing them that they are less–less strong, less brave, less womanly, less maternal, less natural, less smart, less aware, less educated, less thorough, less fierce in standing up for their rights, less resistant to domination by medical practitioners. My husband refers to this movement as “the crunchy granola arm of the patriarchy.” I call it rudeness personified.

Maybe it’s time for c-section veterans to start bragging. “Yeah, boyyyyy, I had a major abdominal surgery, and they took a baby out of me. And then I HEALED. And didn’t have any INCONTINENCE. And my vagina has not lost any TONE. Yeah! Yeah! Wooa wooa!”

This might be the time to warn you there’s a picture of a baby being born via c-section at the bottom of this post. If you’re not so good with such pictures, you may want to scroll slowly.

There is a real public health issue at play here. Per the WHO, ideally 10-15% of all deliveries should be c-sections. Fewer than that constitutes “underuse,” which is common in developing countries, and more constitutes “overuse,” which is common in developed countries. Where I live the rate is close to 30%.  So is this a problem, and if so how big? It’s an area of heated debate. Almost all of the evidence comparing c-sections to vaginal deliveries is observational, meaning it comes from studies that compared outcomes from women who wound up with c-sections to outcomes from women who wound up with vaginal deliveries. Obviously, women don’t wind up in these categories at random, so some factors will predict both choice of a c-section and risk to mother and baby, creating spurious associations. I’m personally skeptical that all such factors can be measured and controlled-for in an observational study.

I’d really like to see some randomized trials to help guide decision making, but to date there are almost none. The evidence base, in short, is lacking. Do remember this when everyone starts shouting. However, be comforted by the fact that one reason there isn’t a huge rush to conduct such a randomized trial is that both methods of childbirth are quite low risk. Even if one does turn out to be safer than the other when all the evidence is in (someday, I hope, sigh), this is still a choice between good and better.

I totally hear the historical argument about how birth has been medicalized, and I’m right there with anybody who wants to argue that pregnancy and birth are normal and should not be treated like diseases. But birth also involves things that are the rightful province of medicine–pain, organ damage, morbidity, mortality. No one should be required to make their decisions about these things differently than they would in another context because they are choosing it for a birth. And they are also not required to justify their choices (I said it again). Every birth is different, and you really don’t know what you would have chosen if you had had someone else’s birth experience–this goes double for cis men.

This is not just another I’m-okay-you’re-okay everybody’s-choice-is-great post for the feminine blogosphere. This is a post in praise of c-sections. I am so glad that this surgery exists. I am so glad that we have come far enough that not being able to expel a baby from your body in the traditional way does not mean that it has or you have to die. Cesarean sections save lives. Sometimes they are awesome. So how about we dismiss the Vagina Valkyries with the eyerolls they have earned, and turn our attention to making this life-saving surgery available to every woman around the world that needs it. Or wants it.

This is objectively awesome.

This is objectively awesome.

Photo Credits
Vaginal birth art: Lynn Friedman via photopin cc
C-section photo: emergencydoc via photopin cc

The Thing Nobody Knows About Me

A few days ago, I received a challenge. It’s that Facebook meme where people post six or eight or eleven things you probably don’t know about them. My friend Erin gave me the number 7. Now if you know me–and if you’re reading my blog it’s quite likely that you do–you know that dashing off seven funny stories about myself should be something I can do in my sleep (Stage 1 sleep anyway). But I couldn’t come up with a list that I wanted to share. At first I thought it was just the impossibility of topping Erin’s story about having a wardrobe malfunction while jello wrestling, but there was a better reason. When I scanned my brain for things people don’t know about me, I couldn’t bring myself to skip the thing that almost nobody knows about me: in August of 2009, I had a miscarriage.

Clearly, I was not going to announce this as part of a Facebook status that also recounted the time I went camping in upstate New York and wound up evading the sheriff of Sullivan County in a car chase. But any list of public revelations that didn’t include my most meaningful one felt like a lie. And I don’t like to lie. I actually don’t find my miscarriage hard to discuss. I tell people often enough. The issue is that I told hardly anyone at the time, and so in effect I must admit to lying by omission for four years.

A family friend who had had a mastectomy once said that after her surgery she was constantly approached by strangers whose first words to her were, “I heard you had a mastectomy. I had one too,” so that she came to feel as though no one actually had two breasts. I’ve had an analogous experience around miscarriage. With one exception, I have no regrets about telling anyone. Nearly everyone’s reactions were appropriate. The ones who understood best stepped up with emails or phone calls to tell me how sorry they were and how they were available to talk at all hours; one especially perceptive friend sent a care package with hot cocoa mix, crossword puzzles, and P.G. Wodehouse. Interestingly, the most common response I encountered was people telling me that either they or their partners had had miscarriages too–including people I was close to, and who had never told me before. I mean very close. Friends of decades. Family. Close family. In the midst of my grief I still found time to boggle at the sheer scope of the silence. If I hadn’t told them about my own loss, I would never have learned of theirs.

I didn’t tell everyone right away because what I did right away was mostly nothing. I had my D&C four days before the start of my second year of med school. I said, hey, I’ll throw myself into work. The work will heal me. Yeah…not so much. I came pretty close to failing out of med school that semester. Instead of taking a ten-minute bus ride to the library to study with my friends, I stayed home on the couch, telling myself I was working from home. I was bleeding. I was tired. I was crying all the time. In retrospect it’s fairly obvious I checked off a meaningful number of DSM criteria for a major depression, but it didn’t feel that way at the time.

A few months later, by which time I was in much better mental health (I was lucky that it didn’t take longer or get worse than it did), I found myself in our local feminist bookstore because a friend needed a place to pee. I was aimlessly browsing when I saw a title: About What Was Lost. It was an anthology of pieces by women who had lost pregnancies, and in a few cases had lost their children. It is a very good anthology, and I recommend it. All the essays are good, and a few are unforgettable. Reading it was good for me. But on finishing it, I felt it was incomplete. The subtitle is Twenty Writers on Miscarriage, Healing, and Hope. And indeed, all of these stories ended with healing and with hope. As a result there was a certain sameness to them.

First, the innocent pregnant woman. She always wanted children or she never wanted children or she still didn’t want children or she already had a child. Then she is pregnant. She underestimates the prevalence of miscarriage. In fairness, everyone’s loss is unique. Then the grief. And then the denouement: she gives birth to a healthy child, or she adopts a child, or she decides against having children. Her grief is made beautiful as the story resolves.

It’s not that I think these stories are untrue. I just question whether they are representative. I suppose it’s a bit like the trouble with writing about addiction. People who are in the depths of their disease have a hard time crafting publishable prose, so most first-hand accounts are written by people in recovery. Last week when I read Ariel Levy’s fierce account of giving birth to a son who lived for twenty minutes, I thought, “Yes. I have been waiting for this.” The raggedness of her story’s end felt like a truth I could recognize.

As a medical student I had been well aware that roughly one in five early pregnancies end in miscarriage. I had seen two patients diagnosed with miscarriage over the course of my own short pregnancy. The miscarriage didn’t teach me about hope. I hadn’t reached the age of 29 without experiencing loss; the miscarriage didn’t teach me about grief.

There are some experiences, including some incredibly painful and important ones, that don’t teach you a damn thing, because they are just bad luck. You can’t learn from random chance (unless of course you are under the illusion that the law of averages doesn’t apply to you because you are special; I had not been for quite some time). This is the truth of some losses: they just are. They debit your happiness and your ability to live, and return to you absolutely nothing.

So now you know something you probably didn’t know about me. I won’t assume we have learned anything in the exchange. But if you want to tell me about what you lost, you can.