PUBLIC HEALTH THEN AND NOW

Living Through Some

GIANT CHANGE
The Establishment of Abortion Services
| Johanna Schoen, PhD

This article traces the establishment of abortion clinics following Roe v Wade. Abortion clinics followed one of two models: (1) a medical model in which physicians emphasized the delivery of high quality medical services, contrasting their clinics with the back-alley abortion services that had sent many women to hospital emergency rooms prior to legalization, or (2) a feminist model in which clinics emphasized education and the dissemination of information to empower women patients and change the structure of womens health care. Male physicians and feminists came together in the newly established abortion services and argued over the priorities and characteristics of health care delivery. A broad range of clinics emerged, from feminist clinics to medical offices run by traditional male physicians to for-profit clinics. The establishment of the National Abortion Federation in the mid-1970s created a national forum of health professionals and contributed to the broadening of the discussion and the adoption of compromises as both feminists and physicians influenced each other's practices. (Am J Public Health. 2013;103:416425. doi:10.2105/AJPH.2012.301173)

ON JANUARY 22, 1973, THE US Supreme Court legalized abortion in its decision Roe v Wade.1 Minutes after the news was broadcast, Susan Hill, then a 24-year-old social worker in Miami, Florida, received a call from physician Sam Barr. Would she like to join him in opening an abortion clinic, Barr inquired. Two weeks later, the new clinic opened its doors to hundreds of women seeking legal abortions from all across the Southeastern United States (S. Hill, interview with J. Schoen, January 2004). Across the country, a group of feminists in Iowa City, Iowa, who

had previously referred women to underground abortion providers, called local physicians to ask when they were going to start offering abortion services and how much it would cost. They virtually hung up on us, one of them remembered. I mean they were just incensed that we had called because they had no intention of changing what it was they were doing.2 Frustrated with the response, and inspired by the court victory and the growing womens self-help movement, they decided to open their own clinic. And in Highland Park, Michigan, 21-year-old office

assistant Renee Chelian began to schedule abortion patients for physician Gilbert Heguera. Prior to the Roe v Wade decision, Chelian and Heguera had flown every weekend to Buffalo, New York, where abortion had been legal since 1970. There, they had provided abortion services out of a small office. Now Heguera closed his Buffalo clinic and moved all the equipment into his regular obstetrics and gynecology (ObGyn) office outside Detroit, Michigan. For me, everything changed, Chelian remembered. All of a sudden, I had a dream about what I thought things should be like. (R. Chelian, interview with P. Johnston, 2008).3 With the legalization of abortion and the simultaneous introduction of vacuum aspiration, a previously clandestine procedure became safe, quick, and inexpensive almost overnight. Within a decade, abortion-related deaths fell by 98%, signifying a dramatic improvement in womens health. Abortion rates climbed from 744 610 in 1973 to more

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than a million in 1975, leveling out at around 1.5 million abortions per year by the 1980s. The ability to terminate an unwanted pregnancy opened unprecedented opportunities for a whole generation of women. Physicians and women came to the field of abortion care with disturbing memories of illegal abortions. Many physicians interested in providing abortions had cared for women suffering from the complications of illegal abortion and had seen patients die. Now they hoped to establish services that offered safe abortions to all women. And many of the women who found their way into the emerging field of abortion care in the early 1970s had experienced an illegal abortion, participated in underground abortion referral services while abortion was illegal, or had friends or relatives with such experiences. Frustrated with traditional medical care, which they viewed as patriarchal and paternalistic, and inspired by the emerging womens movement, they looked to the field of abortion care as an opportunity to bring a feminist vision to medicine. Both groups came together in the early 1970s to establish a new system of abortion care. At times uneasy alliesphysicians found young feminist women challenging and demanding while young women found male physicians patronizing and dismissive of their concernsthey nevertheless negotiated different aspects of abortion care and established a broad network of abortion clinics, which influence abortion services to this very day.4 Legalization made abortion the safest and most widely performed surgical procedure in the United States. During the century of criminalization, women continued to seek abortions, but their

ability to find safe and affordable illegal services varied significantly over time. By the 1950s and 1960s, the systematic persecution of illegal abortionists drove abortion underground. The quality of abortion services deteriorated, turning the procedure into a humiliating and sometimes dangerous exercise. For a whole generation of physicians who entered medical school and internships in the postwar era, their experience with abortion was tied to memories of women who arrived in hospital emergency rooms with complications from illegal abortions.57 Those memories were frequently frightening. All physicians recalled their despair trying to save a womans life before she bled to death or died of an overwhelming infection. In addition, many physicians were frustrated with a system in which women with money and connections could obtain a safe abortion from their private physicians or travel abroad while women without such resources ended up in the emergency room with complications from illegal procedures. In some urban public hospitals, entire wards were relinquished to care for patients admitted with complications from illegal abortions. These hospitals wards were staffed by residents and physicians who were profoundly influenced by their experiences with these patients (T. Crist, interview with J. Schoen, May 2001).8,9 The adoption of vacuum aspiration in the early 1970s contributed to the ease and speed with which patients gained access to abortions after legalization. Prior to the introduction of the suction machine, physicians seeking to terminate a pregnancy performed a Dilation and Curettage (D&C) abortion in which the

cervix is dilated and the contents of the uterus scraped with a curette. D&C abortions were relatively unpleasant to performa very bloody procedureand carried risks, including perforation of the uterus, hemorrhage, and infection (C. deProsse, interview with J. Schoen, October 2002). Vacuum aspiration was not only quicker than performing a D&C, it was also safer, more likely to result in the complete removal of all tissue, led to less blood loss and fewer major complications, and was more adaptable to local anesthesia.10

Physicians and women came to the field of abortion care with disturbing memories of illegal abortions. Many physicians interested in providing abortions had cared for women suffering from the complications of illegal abortion and had seen patients die. Now they hoped to establish services that offered safe abortions to all women.

Following the 1970 legalization of abortion in New York, the Centers for Disease Control and Prevention began to collect and compare data on the different abortion procedures. Sixty-six institutions across the country participated in the study. With collection of this data, abortion procedures assumed a hierarchy that spoke to the safety and convenience of the procedures. Physicians quickly realized that legally induced abortion was a remarkably safe surgical procedure. Complication rates were lowest for suction abortion. Between 1972 and 1977, the death-to-case rate for vacuum curettage procedures performed at 12 weeks gestation or earlier was 1.2 per 100 000 procedures.

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A routine tonsillectomy carried a risk of death twice as high as that of legal abortion. Before 16 weeks gestation, abortion was safer than its alternative: pregnancy and childbirth.11,12 Starting with the 1970 legalization of abortion in New York, and following on a nationwide scale in 1973, physicians began to provide abortion services in a wide variety of settings. Between 1973 and the end of the decade, the number of abortion providers climbed by 76%, from 1550 in 1973 to 2734 in 1979. The proliferation of outpatient clinics which provided abortion services in a nonhospital location shaped the setting of abortion care for decades to come. If in 1973, 81% of abortion providers were tied to a hospital, by 1979 that number had dropped to 56%. In urban areas, almost three quarters of all women received their abortions in free-standing clinics.13 Because the establishment of clinics that provided abortion services was relatively inexpensive, yet offered a reliable income, starting an abortion clinic appealed to a variety of groups. Physician abortion providers (most of whom were male) followed a traditional medical model and sought to incorporate abortions into their regular practices although some clinics focused solely on the provision of abortion. Feminists sought to establish feminist health clinics to create a more feminist future in medicine and provide an alternative to traditional medical care. Businessmen, too, started abortion clinics, hoping for a healthy return on their investments in the new medical market. In this emerging marketplace, physicians, feminists, investors, and patients debated and shaped the character of abortion services for decades to come.

This article focuses on the establishment of free-standing abortion clinics in the 1970s. Whereas, today, the Planned Parenthood Federation of America (PPFA) is the largest group of abortion providers, the organization was slow to come to the field of abortion care. Only a handful of Planned Parenthood clinics began to offer abortion services in the early 1970s. Most PPFA clinics only moved into the field of abortion care after independent abortion providers had already established abortion clinics in a given place (T. Beresford, interview with J. Schoen, September 2012).14 The article is based on a growing collection of archival materials and oral history interviews documenting the history of legal abortion. Over the past 10 years, I have approached abortion providers to conduct oral history interviews and convince them to donate their papers to an archive. While these sources document the rich history of legal abortion services, they are by no means comprehensive, representing only a fraction of those who established abortion clinics. The anecdotes and experiences described in this article represent the subjective experience of those individuals who happen to participate in this archival project. Yet, journalistic accounts and sociological analyses of abortion care and countless conversations with providers at annual meetings of the National Abortion Federation (NAF) indicate to me that these episodes are characteristic of providers in the field at large.

OPENING ABORTION CLINICS

With the legalization of abortion in 1970 in New York, the

increasing availability of abortion services in several other states, and, three years later, legalization nationwide, some physicians moved quickly to provide abortion services in their practices. Charles deProsse began to perform legal abortions in his group practice in Ithaca, New York, in 1970. deProsse and his colleagues had performed therapeutic abortions before 1970. Anticipating the legalization of abortion in New York, they purchased a vacuum aspiration machine. Since deProsses practice was the only one in Ithaca willing to provide legal abortions, the number of abortion patients increased drastically and included patients from out-ofstate. In New York City alone, 55 347 residents and 83 975 nonresidents sought legal abortions within the first year of legalization. But the increase in patient load was not unmanageable, and deProsse and his colleagues were able to integrate the new abortion patients into their regular ObGyn practice (C. dePosse, interview with J. Schoen, March 2011).9 Following the nationwide legalization of abortion in 1973, Heguera began to perform abortion services in his already established ObGyn practice in Highland Park, Michigan, north of Detroit (R. Chelian, interview with P. Johnston, 2008). Physician Takey Crist, who opened his own ObGyn office in Jacksonville, North Carolina, in January of 1973, immediately included abortion services in his practice (T. Crist, interview with J. Schoen, May 2001). And physician Sam Barr opened the EPOC Clinic in Winter Park, Florida, just outside Orlando. Modeled after the Preterm clinic in Washington, DC, which had begun to offer legal

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abortions in 1971, Barr hired two other physicians and several counselors and began to provide abortion services to women from Florida, Georgia, South Carolina, Alabama, Louisiana, and Mississippi (S. Hill, interview with J. Schoen, May 2004). But the model of the freestanding abortion clinic appealed not only to physicians. It also offered feminists seeking an alternative to traditional medical care the opportunity to open an abortion clinic and put their vision of woman-centered health care into practice. Feminist clinics were part of a nationwide movement of women who opened womens health clinicsmany of whom did not provide abortion services. To some feminists, however, the integration of abortion services was a logical extension of their commitment to feminist health care. Many saw womens access to affordable abortions as central to womens self-determination and realized that abortion services provided clinics with a steady income allowing them to support a range of other services not as easily reimbursable. California womens health activist Carol Downer established a group of clinics, the Feminist Womens Health Center (FWHC). Intrigued by Downers vision, feminists in Michigan, New Hampshire, Florida, and Georgia opened clinics affiliated with FWHC in Detroit, Concord, Tallahassee, and Atlanta, respectively. The young women in Iowa City decided to form a feminist collective and open their own clinic and feminists in Vermont and Massachusetts followed suit. Prior to the legalization of abortion, these women had been active in abortion referrals and had conducted self-help classes to women interested in learning

about their bodies. Once they decided to establish feminist clinics, they met on a regular basis to discuss the details of the services. After finding a location, the women in Iowa City and Atlanta renovated the spaces themselves, sought donations to equip their clinics, and opened on a shoestring budget with a staff of volunteers. The Emma Goldman Clinic for Women (EGC) opened its doors to the public on September 1, 1973. The collective hired Dick Winter, a local physician, to perform abortions on Tuesdays and Thursdays, and staffed the clinic with collective members, all lay health workers, who received on-the-job training. The FWHC in Atlanta found their physicians among the medical residents at Emory University. In addition to abortion, the clinics offered birth control counseling, feminist psychotherapy, childbirth preparation classes, massage services, and legal self-help (L. Randall, telephone interview with J. Schoen, October 2012).2,3,1518 Yet, the legalization of abortion did not translate into a climate in which it was easy to open free-standing abortion clinics. To be sure, some parts of the country, states like New York, Florida, and California, saw the establishment of a range of outpatient abortion services in a very brief time. In Florida, EPOC opened its doors in Winter Park only two weeks after Roe v Wade. To the South, a Miami physician offered abortions until the 20th week of pregnancy. Just north of Miami, there was a new clinic in Ft. Lauderdale. In Tallahassee, FWHC was preparing to open a feminist clinic, and Tampa had a feminist health center that offered education and referred women needing abortions to other clinics. These clin-

ics followed each others progress closely and referred patients to each other (S. Hill, interview with J. Schoen, May 2004). Atlanta followed a similar pattern (L. Randall, telephone interview with J. Schoen, July 2012). But in much of the country women continued to lack access to abortion. Abortion services in New Jersey, for instance, were few and far between. Three out of four New Jersey residents seeking abortion services (approximately 30 544 women) had to leave the state to obtain an abortion. For some women, even the distance between South Jersey and New York, a hundred miles, could be too far to travel, making abortion 19 services inaccessible. Businessmen stepped into this void. Joseph and Stuart Yacknowitz, a father and son pair who owned the largest kosher catering service in the Northeast, began to invest their money in abortion clinics as soon as the service was legal. Like many business men in the 1970s, they recognized that the high demand for abortion services and the small number of existing service providers promised lucrative returns. In 1976, they hired Susan Hill, who had since left Sam Barrs Florida clinic, to manage their already existing clinics and to open several new clinics. They formed the National Womens Health Organization (NWHO), and in the late 1970s, Hill opened an additional 6 clinics in some of the countrys most underserved areas. Although the ultimate authority lay with the Yacknowitzs, Hill was given free rein to implement her philosophy toward patient care (S. Hill, interview with J. Schoen, May 2004). But opening abortion clinics in small-town America met significant local opposition. It became a

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confrontation all the way around, Hill remembered (interview with J. Schoen, May 2004). Between 1976 and 1980, Hill and the NWHO opened clinics in Wayne, New Jersey; Wilmington, Delaware; White Plains, New York; Fort Wayne, Indiana; Raleigh, North Carolina; and Fargo, North Dakota. In almost every state, local authorities met NWHO efforts with procedural obstacles. In Wayne, New Jersey, a heavily Catholic area outside New York City, the townships health officer demanded that Hill present a Certificate of Need (C.O.N.). Such certificates, which regulate the construction of hospital facilities, are expensive, difficult to get, and not intended for physicians offices. Hill objected, arguing that requiring a C.O.N. violated the 1973 Supreme Court Ruling Roe v Wade, which declared that any restriction on abortion performed during the first three months of pregnancy was illegal. Unable to get permission to open, NWHO threatened to sue the city of Wayne. State health officials relented, and in September 1976, the New Jersey Womens Health Organization (NJWHO) opened its doors to the public. But the victory was short-lived as opposition to the clinic moved from the state to the municipal level and to the sidewalk in front of the clinic. Led by city councilman James Duggan, an Irish-American, Catholic, conservative Republican and member of the Knights of Columbus, demonstrators began to picket the clinic and the medical directors private home. In addition, Duggan introduced a resolution to the Wayne Township Council asking that the county prosecutors office investigate whether NJWHO was a clinic. If the office determined that NJWHO was a clinic rather than

a physicians office, it would not only need a C.O.N., but also a zoning variance and a sprinkler system. In practice, Duggans efforts would shut NJWHO down. While NJWHO remained open, the procedural challenges tied the organization into a lengthy battle with local authorities.2024 Such conflicts between abortion providers and state and municipal officers became so common and protracted that abortion attorney Lynn Miller described the situation in the 1980s as Kafkaesque.25 Despite such procedural hurdles, the number of abortion providers rose steadily throughout the 1970s, and abortion became generally more accessible. Whereas 25% of women reported in 1973 that they had traveled outside of their state of residency to obtain an abortion, by 1980 that number had fallen to six percent. Because of the rapid spread of vacuum aspiration, the fastest growing categories of abortion providers were free-standing clinics or physicians offices. What kind of abortion services women were to receive and how they experienced legal abortion depended not only on the kind of abortion provider a woman visited, but also on the philosophical orientation and organizational structures which shaped abortion services inside the clinic walls.

MEDICAL VS FEMINIST MODEL

Abortion clinics established in the 1970s tended to follow either a medical or a feminist model. This classification is somewhat fluid. Feminist clinics had enough of a distinctive philosophy and identity to have their own membership category

when NAF emerged in the mid1970s. Of 129 members listed in 1978, 15 clinics (more than 10%) self-identified as feminist. Most were FWHC clinics, although some, like EGC, were independent of FWHC. But not only clinics identified as feminist. Many women who worked in abortion clinics or owned abortion clinics also identified as feminist and sought to establish feminist health care services, although their clinics often belonged to a different category (such as non-profit clinics or physicians offices). Moreover, clinics sometimes changed categories, declaring themselves feminist clinics some years but not others. And, of course, there were also feminist physicians who were pioneers in providing abortion services and had medical offices. I will refer here to feminist clinics when I talk about clinics whose founders had the creation of feminist health care services as their primary intention, such as FWHC or EGC. I will refer to feminists when I talk about women whose feminist ideals influenced their work in abortion care but who worked from a medical model. Physicians emphasized the delivery of high quality medical services, contrasting their clinics with the back-alley abortion services that had sent many women to hospital emergency rooms prior to legalization. Integrating abortion services into existing medical practices and making them the subject of scientific inquiry, physicians argued, would ensure the safety of the procedure and prevent the complications and deaths associated with illegal abortion. Feminists, by contrast, hoped that the legalization of abortion would change medical practice. Women associated with

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the FWHC and feminist collectives like the EGC were most absolute in their rejection of traditional medicine, which they criticized as patriarchal and paternalistic. Women like Renee Chelian and Susan Hill did not share FWHCs outright condemnation of the medical profession. But while they sought to work within the parameters of traditional medicine, they, too, hoped to create medical practices more responsive to womens needs. And although the creation of feminist clinics was not their primary objective, they negotiated with physicians and clinic owners for practices they sought would make services more woman-friendly. Education and the dissemination of information were at the top of feminists list. As part of the womens health movement, feminist clinics like the FWHC or the EGC embedded abortion services into a comprehensive program of health education geared at transforming patient consciousness. Activists sought to reclaim the mystery that had surrounded so much of womens health by educating patients about their bodies and encouraging them to make their own choices (L. Randall, telephone interview with J. Schoen, October 2012).26 Offering free information over the phone was part and parcel of a democratization process geared at empowering patients. People were calling us all day long to ask the simplest questions, Chelian remembered (interview with P. Johnston, 2008). How do you put on a condom? And how do you know if you have crabs or lice? . . . [I]t was basic information that they had never been able to get from anybody else. Feminists also sought to offer written educational materials, complete with

images that did not depict all female bodies as pregnant. Some set out to write their own educational materials, ranging from short pamphlets to educational treatises which included in-depth discussions of a number of health issues.3,27,28 Clinics offered free pregnancy testing and free samples of birth control pills. For poor women, in particular, this was significant. Prior to the introduction of overthe-counter pregnancy tests, getting a pregnancy confirmed meant makingand paying for an appointment with a physician. After leaving a urine sample at the doctors office, women had to wait several days for the lab results. Once the physician received the results, he might inform a patient over the phoneor make her come in and pay for another appointment. Women with limited financial resources often chose to wait. As Chelian remembered,
If you were pregnant, you just waited long enough. If you didnt have a miscarriage and you didnt have your period, you were going to have a baby. So, by the time you missed your third period, you went in for maternity care, but not before in case you werent pregnant (interview with P. Johnston, 2008).

and the offer of a range of options, then, were crucial to many of the young women who worked in abortion clinics and envisioned a more feminist future for womens health care. Feminist clinics not only sought to empower women patients to make their own informed choices regarding reproductive health care, but hoped that their services awakened a feminist consciousness in their clients. The staff at the Iowa City EGC offered extensive education, talked women through the abortion procedures, and encouraged womens participation by offering them choices. No detail was too minute. Whether women wanted their legs in stirrups or out became a significant political issue. As one collective member commented,
When you get right down to it, that is what the revolution is all about, deciding whether a woman is gonna have a choice to have her legs just out or have them in the stirrup. . . . The thing is that a woman could choose. We were concerned about that. Thats what makes us feminist.29

Together with the offer of free birth control pill samples, which many clinics handed out to their abortion patients, these developments proved revolutionary for womens ability to control their reproduction. We all felt we were living through some giant change, Chelian commented. We were seeing women who were experiencing for the first time in their lives the opportunity to have control over their reproductive lives (interview with P. Johnston, 2008). Information

Equally important to feminist clinics was the delivery of services by women rather than men. One EGC collective member explained: We felt that if we, as women, we could provide those services, it would be better yet, than a male physician perhaps that [sic] was out to make a profit.26 Indeed, collective members discovered that drawing blood, assisting in deliveries or abortions, or performing menstrual extractions was a tremendously empowering experience.18,30 Experiencing feminist services, they hoped, would trigger a similar sense of empowerment for patients and ideally lead patients themselves

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In feminist clinics, the reversal of hierarchiesthe feminist collective as employer, the physicians as employeeslimited the amount of influence physicians had over clinic details. To ensure that clinic services would be feminist in nature even if abortions were performed by men, EGC and FWHC members observed their abortion providers as they delivered services.
to question traditional gender relations. At times, the hope for a transformation in patient consciousness became an expectation that patients change. Every woman, the assumption was, should challenge traditional gender norms and become a little more feminist.
Women who went to the clinic were kind of asked to change a little bit. Like, if you went because you needed an abortion or you went for whatever reason, you were given information and then you were kind of expected, like take this and learn from it and change yourself a little bit. . . . It was this idea that women needed to change. We need to kind of break out of the ways weve been brought up, to defer and not to make our own choices, and to just come out and say: All this is available. We can do it.31

members feared, for instance, that training male gynecologists how to fit cervical caps might give even more power to men in gynecology and thus mean a loss of feminism.18,32,33 Within the parameters of a feminist clinic, women could debate these issues and, because they retained ultimate control over the clinic, determine how to structure patient services. But feminists like Renee Chelian and Susan Hill, who sought to change physicians medical clinics to become more woman-friendly, tended to meet resistance. Physicians adherence to a medical model and their desire to maintain authority over the clinic further limited feminist influence. Chelian recalls arguing with Heguera about answering patient questions over the phone. You dont get paid to sit on the phone, he told her.
If people want to ask questions, they need to make an appointment for an office visit and they can come in and pay for the doctors time because thats what patients do. And Ill answer their questions. (R. Chelian, interview with P. Johnston, 2008).

But although EGC and FWHC feminists felt that all services should be provided by women, they also quickly realized that they had to rely on male medical professionals if they wanted to offer abortions. Collective members worried about the effect this might have on the clinic as a womans space. Of similar concern was the question whether the collective was willing to train men or whether training should be limited to women. Collective

The integration of abortion into ObGyn services itself, feminists realized, would not lead to change in the hierarchical relationship between physicians as the arbiters of basic information about sexual health and patients in need of health education. There wasnt gonna be any evolution and any changing with him, Chelian concluded about her work with Heguera (interview with P. Johnston, 2008).

THE CLINIC AS WORKPLACE

Thrown together within the confines of the abortion clinic, feminists and physicians grappled

with the personal and political implications of their collaboration. In feminist clinics, the reversal of hierarchiesthe feminist collective as employer, the physicians as employeeslimited the amount of influence physicians had over clinic details. To ensure that clinic services would be feminist in nature even if abortions were performed by men, EGC and FWHC members observed their abortion providers as they delivered services. Indeed, because patients were always accompanied by a woman advocate and other women assisted in the pregnancy termination procedure, abortion providers always performed procedures under the watchful eye of several women. At the end of procedure days, EGC collective members would meet with the providers to offer their criticism. It might be how I said something to a patient while I was doing a procedure, one of the clinics abortion providers, Charles deProsse, recalls. It might be what I didnt do when I was examining a patient with respect to explaining every detail of what I was doing (interview with J. Schoen, October 2002; see also L. Randall, telephone interview with J. Schoen, October 2012).18,34 Physicians working at feminist clinics struggled with their lack of influence over clinic policy and with the nontraditional atmosphere of the clinic. This was probably further aggravated by the fact that the employers were considerably younger and less educated, with a predisposition to criticism to top. Physician discomfort extended from the nontraditional atmosphere in the clinic to the system of criticism. Physician Ric Sloan found street clothes and bare feet inappropriate for a clinic setting, and in a

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moment of heightened frustration called the clinic a backyard still.35 deProsse conceded that sometimes the women made important points in their critique. At other times, however, they seemed rigid in their expectations and the criticism the result of their hostility toward traditional medicine rather than grounded in real complaints.
I sort of felt that I was the focus of some minor degree of animosity towards traditional medical care as I sat there with four or five or six women, all sort of picking things apart. . . . At times, maybe, it was not appropriate. . . . They were just doing something to sort of needle others [rather] than have good complaints (C. deProsse, interview with J. Schoen, October 2002).

Women physicians who considered themselves feminists, too, grew frustrated at the limited influence they had because, as abortion providers, they were treated the same way as their male colleagues.18 The women, Ric Sloan complained, were running him,35 while deProsse summarized his feelings with the comment: I was reduced to being a technician (interview with J. Schoen, October 2002). Remarkably, while some physicians left or threatened to leave as a result of these tensions, physician support for the clinic grew steadily and most of EGCs providers decided to stick with it. I was always accommodating, deProsse remembered. This was their clinic and I was perfectly happy doing that as long as it was within professional bounds (interview with J. Schoen, October 2002). A shared sense of disillusionment with traditional health care and a joint commitment to alternative care provided the common ground on which feminists and male abortion pro-

viders continued to meet. Most of the physicians who worked at feminist clinics understood their work as an extension of their political activism. Several EGC physicians had previously worked at Iowa Citys Free Medical Clinic or migrant clinics. All supported the clinics mission to involve women more closely in their own health care decisions, and most concluded that the personal gains outweighed the drawbacks at the clinic. As deProsse remembers from conversations about the difficulties with his colleagues: Wed sort of talk with each other about it and generally it ended up that one or the other of us would say, Oh, you know, thats the way it is (interview with J. Schoen, October 2002; L. Randall, telephone interview with J. Schoen, October 2012).36,37 Whereas in feminist clinics it was the physicians who had to figure out whether they were willing to stick with it, in the more traditional medical settings it was often the women who weighed the advantages and disadvantages of the setting. Abortion clinics that ran on the medical model could provide important professional avenues for young women seeking a job in the womens health arena. During her two years with Sam Barr, for instance, Susan Hill honed her skills as an administrator and director of counseling, and gained significant knowledge in the field of medicine. Barr took her along to surgery, allowing her to observe hysterectomies and other procedures she otherwise never would have seen. He was a wonderful gynecologist, she remembered. I learned so much, I loved what I did (S. Hill, interview with J. Schoen, January, 2004).

But opportunity came at a price. Sam Barr also sexually harassed her. As Hill recalled,
He would talk to me about what we were going to do and planswe wanted to do a womens hospital. And then he would stick his tongue down my throat. It was very bizarre behavior and at the time I really wasnt equipped to really understand what to do. . . . The price you paid was that I cringed when I had to be alone with him. . . . It was just horrible at that point (interview with J. Schoen, January, 2004).

Indeed, sexual harassment was a problem frequently reported by women who worked in traditional settings. Eventually, Hill decided to leave. She spent several years as a consultant for businessmen who ran for-profit abortion clinics. But there, too, work always seemed to come with unwanted sexual advances. Hill remembers most of these businessmen as extremely sleazy. While crucial to the quick expansion of abortion services around the country, their treatment of female employees frequently mirrored that of Barr (S. Hill, interview with J. Schoen, January, 2004).18 Sexual harassment, of course, was not the only problem that young women faced. Like male physicians in feminist clinics, many women in medical settings were frustrated by the lack of influence they had over service delivery. Physicians could not be criticized or were not interested in improving the experience of their women patients. If feminists expected that the legalization of abortion would result in more than safe abortion services, their expectations remained largely unfulfilled. Nevertheless, physicians and businessmen provided important financial and institutional backing for an emerging network of

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abortion clinics and could offer women like Susan Hill and Renee Chelian the opportunity to help shape womens health services. By the mid-1970s, both had left their initial places of employment and gained positions in which they controlled clinic operations. I got to do what I wanted to do, Hill recalled of her employment running clinics for the Yacknowitzs. And I got to use their money to do it. . . . It was the perfect choice. (interview with J. Schoen, May 2004). The opportunities provided by these clinics offered a generation of women an avenue into the medical field, not only as medical staff, but as

academics, and policymakers. NAF was to serve as a place of information exchange and was to ensure the safety and high quality of abortion services. Consolidation did not come easily to this diverse group. From the very start, NAF was plagued by profound disagreements about the best ways to deliver abortion care. Arguments that had previously taken place inside clinics now took place on a national scale as NAF members sought to hammer out compromises on a range of issues. Feminists continued to mistrust male doctors, many male doctors were offended by feminists, and many in the movement distrusted abor-

The opportunities provided by these clinics offered a generation of women an avenue into the medical field, not only as medical staff, but as counselors, health administrators, and clinic directors. Once in those positions, women could participate in the shaping of more feminist and woman-centered clinics.

counselors, health administrators, and clinic directors. Once in those positions, women could participate in the shaping of more feminist and woman-centered clinics. In 1976, physicians, nurses, counselors, administrators, and owners from abortion clinics around the country came together to establish NAF, a professional organization for those who provided abortion services. They represented a diverse set of clinicsfrom feminist health collectives and physicians' medical offices to for-profit clinics and were joined by researchers,

tion entrepreneurs. But the addition of new voices such as those of administrators, nurses, and clinic owners to the arguments surrounding abortion care complicated the debates and distracted from the traditional tensions between feminists and male medical professionals. The beauty of NAF was that there were many different voices around the table, Lynn Randall, a former NAF board member from the Atlanta FWHC remembers (telephone interview with J. Schoen, July 2012). In this forum, NAF members were able to discuss their disagreements and participate in

decision-making. The voices got listened to, Randall concluded, and usually the end product was something that no one person would have wanted or foreseen but it ended up being a good product at the end. The rise of more militant anti-abortion activism further helped to unify the abortion-provider community in the 1980s. Facing increasing attacks from the outside, abortion providers and their allies found that political disagreements between feminists and male medical professionals diminished in importance.38 The professional collaboration among NAF members also meant that members influenced each other. Feminist clinics and feminists working in traditional clinic settings were at the forefront of pushing health professionals to greater inclusion of education and information. They emphasized the importance of patient participation and passed this information on to male medical professionals, transforming teaching practices to become more woman-friendly. Physicians and businessmen, in turn, provided important financial and institutional backing for an emerging network of abortion clinics and presented women with the opportunity to help shape womens health services. The opportunities provided by these clinics offered a generation of women an avenue into the medical field, not only as medical staff, but as counselors, health administrators, and clinic directors. Once in those positions, women participated in the shaping of more feminist and woman-centered clinics.

Health Care Policy, and Aging Research, Rutgers University, New Brunswick, NJ. Correspondence should be sent to Johanna Schoen, Department of History, 16 Seminary Place, VanDyck Hall, Rutgers University, New Brunswick, NJ 089011108 (e-mail: johanna.schoen@rutgers. edu). Reprints can be ordered at http://www. ajph.org by clicking the Reprints link. This article was accepted December 3, 2012.

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About the Authors

Johanna Schoen is with the Department of History and the Institute for Health,

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