The Doctor Prescribing Abortions from Overseas

Within a few weeks, if Roe v. Wade is overturned as expected, a Dutch doctor named Rebecca Gomperts may quickly become the most controversial abortion provider in America — even though she isn’t in America.

Gomperts and her organization, Aid Access, is already the only provider openly providing telehealth abortion in the 19 states that currently restrict access to such services; if you go the website of Plan C, a group providing information about abortion pills by mail, Aid Access is the sole provider listed for many of them.

Demand for remotely prescribed abortion medication is likely to grow substantially if Roe v. Wade is overturned as state-based “aiding and abetting” laws increase stigma and concern about liability among doctors and pharmacists and more clinics are forced to close. For many more Americans, Aid Access could soon become the only source of physician-supported pills-by-mail, where pills-by-mail are perhaps the only accessible means to an abortion.

Gomperts is a doctor licensed in Austria and based in the Netherlands who adheres steadfastly to the notion that abortion is health care and health care is a basic human right. For more than two decades, she has worked to provide abortions to women in countries that restrict access; her organization Women on Waves has provided abortions on ships in international waters near countries where abortion is illegal, and delivered pills across borders using drones or robots. In 2005, she created Women on Web to mail abortion pills around the globe.

Now, the United States is one of the countries on her list. In 2018, Gomperts launched Aid Access specifically to provide medication abortions to Americans using telehealth and the U.S. mail. Previously, ordering abortion pills by mail generally involved scouring the internet for information on what to order and how, paying a potentially unreliable online pharmacy several hundred dollars and hoping the pills arrived as promised. Aid Access offered something very different: a consultation with a physician, trusted pills and a sliding scale.

Aid Access mails abortion pills — typically mifepristone and misoprostol — to people who are up to 10 weeks pregnant. Once it got going, it turned what was covert into something approaching mainstream, even in anti-abortion states. And it was able to do so because Gomperts and many of her colleagues operate beyond the reach of U.S. state and federal laws, with prescribing doctors and a pharmacy based overseas.

Soon after Aid Access launched, the Food and Drug Administration sent a letter to Gomperts requesting that she stop. She did not. When the Texas law banning abortion after six weeks took effect last fall, Gomperts began offering “advanced provision” pills, so people could have them on hand if needed. It’s a practice she told me she hopes U.S. doctors will begin using as a means of evading restrictive abortion laws, by writing a prescription for perfectly lawful medications for someone who is not, in fact, pregnant.

Aid Access receives tens of thousands of requests for pills from Americans each year (more than 57,500 in its first two years). It now partners with U.S.-based physicians to serve patients in states where telehealth abortion is legal, with pills shipped quickly from a U.S. pharmacy. People in states without a local doctor may use a mailing address in another state, or they may receive consultation by a physician overseas with pills shipped from a high-quality pharmacy in India.

I first spoke with Gomperts in 2018 and was struck by her complete lack of equivocation on an issue that so often is layered, on all sides, with legal, moral and clinical rationale: “Unjust laws should not be respected,” she told me then.

I expected similar forthrightness when I called her to talk about the post-Roe future of telehealth abortion. Gomperts’ experience gives her insights into the abortion debate that may surprise many Americans. For instance, she told me that access to abortion tracks with a country’s democratic direction — the more authoritarian, the more restrictions. And she noted that already in America, access to abortion has more to do with a person’s wealth and access to information and child care than it does to local laws “Laws don’t matter when you have money, right?” she said.

Candor, Gomperts made clear, may be one very important means of preserving abortion access in the United States. “Asking for the reason why people want to have an abortion is already framing it,” she told me. “Because it means that people have to have a reason. You don’t need to have a reason to have an abortion. The only reason you want to have an abortion is because you have an unwanted pregnancy. Period.”

This transcript has been edited for length and clarity.

Chelsea Conaboy: I’ve heard various people involved in reproductive rights describe the draft of Justice Alito’s opinion to overturn Roe as not unexpected, yet still shocking. But you’ve been planning for this likelihood. Why?

Rebecca Gomperts: When I started in 2018, there was already a huge request for pills from the U.S. For me, what was always important were the obstacles to abortion care —it doesn't matter what causes them. What matters is that they exist. The obstacles that we saw in 2017 and 2018 were cost and distance [to a clinic].

Plan C had done research on pills provided by online pharmacies, looking at if they were real and the cost, and it was really expensive. We got feedback from women: “I can't use these services because I can't afford it.” And then of course, Trump came. … The moment that Trump was able to install the last Supreme Court judge, it was clear — or even before that — [that Roe] wasn’t going to stand.

If Hillary would’ve won, then this wouldn't have happened. But the need [to help people overcome obstacles to abortion] would have still existed.

Conaboy: Given your extensive work on abortion around the world, I wonder, is there something that you see about the American fight over abortion today that perhaps Americans themselves don’t understand?

Gomperts: Yes and no. In the end, laws don’t matter when you have money, right? And that is the case everywhere in the world. If you have money, access to information, or privileges, you can always find an abortion provider, whether traveling or locally or whatever. It’s by definition always a problem of poverty. And one of the problems in the U.S. is huge poverty.

I always felt that, in the U.S., there is this mentality that if you’re poor, it’s your fault. And that is just not true. It’s the system that causes poverty, not people themselves. And it’s the system that keeps people poor. That’s also what you see in the studies — the Turnaway Study [by Diane Greene Foster and colleagues] shows that. You keep people poor by denying abortions.

Conaboy: Is the United States, by increasingly restricting access to abortion, an outlier globally? Or is it the vanguard?

Gomperts: It’s not an outlier in the countries that have very autocratic regimes. So the U.S. has placed itself in the same category as [Hungarian Prime Minister Viktor] Orbán and as [Turkish President Recep Tayyip] Erdoğan and as [Russian President Vladimir] Putin. It’s these countries where there are autocratic regimes and the democratic processes don’t function anymore, where abortion rights are being turned off. And in all the countries where the democratic processes are improving, there is an improvement of access to abortion, or there’s an intent to do that.

Conaboy: The core of Aid Access’s work has remained the same since you launched in 2018, but it seems that so much of how you deliver your service and how it’s perceived has changed.

Gomperts: Covid really changed everything, because suddenly telemedical abortion services was what was saving abortion access in many places. In the UK, telemedical abortion services became mainstream. And that is now also part of the mainstream abortion services in France, in Ireland, in Canada, in Australia — in many, many places.

In the U.S. of course, the FDA immediately allowed for telemedical abortion services during Covid. That also made it possible for U.S. providers to join Aid Access. So there are now nine U.S. providers using Aid Access as their front-office system and back-office system, and they’re serving people in their states, where they’re registered to practice.

Conaboy: But there’s a growing gap, isn’t there? In the states where telemedicine abortion is legal, it has quickly become a mainstream thing. But in the states where it is explicitly banned or where abortion will be severely restricted without Roe, it is something very different.

Gomperts: There’s a couple of things here. Misoprostol is available in all the pharmacies around the U.S. — also in Texas. And misoprostol on its own is really effective for use in abortion. You don’t need the mifepristone. So, I think there are still ways to think around what can be done locally.

If you think about how to oppose what is happening, it would be for all the doctors there now to prescribe mifepristone and misoprostol to everybody who is not pregnant. Even if these laws take effect — all the women, the moment they get to menstruation, they get a package of abortion pills. You don’t have to wait until somebody’s pregnant. That way, the laws don’t apply anymore.

Conaboy: As you see it, is there any reasonable medical argument against providing pills in advance?

Gomperts: There’s nothing. If you buy bleach in the supermarket, that’s more dangerous. If you don’t use it as you’re supposed to use it — you drink it instead of use it to clean — you die.

Abortion pills are something that, actually, you cannot die from. There’s no way that you can overdose on it. And what we know from research is that you don’t need to do an ultrasound for a medical abortion. The World Health Organization says you can just determine the duration of pregnancy based on menstrual cycle. People can make a really good prediction of how long they’re pregnant.

The reason why many women are pregnant longer when they access abortion services is because they have obstacles to obtaining an abortion — because of cost, because of child care, because of domestic violence. But if you have those medicines in the cabinet, that obstacle doesn’t exist anymore.

Conaboy: Can you talk about the push toward criminalizing people who have sought abortion, not just the providers?

Gomperts: With Women on Web, we have had a couple of cases of women that used our service — a few in Northern Ireland. One of them, it was her flatmate that denounced her. The other was a doctor. The problem with what is happening with these laws is that it internalizes the fear and the stigma and the judgment so much. We can only advise people now to lie to everybody. You just have to say, 'Well, I had a miscarriage,' because you can’t say, 'I had an abortion.' Somebody else can out you, can denounce you. The impact of that consequence is huge.

What the criminalization does is, it’s framing abortion as something that is bad. And it’s not. An abortion is perfectly fine. It’s just something that people use to organize their lives.

We always have to have excuses, why an abortion is necessary. But why? I mean, we don’t ask people why they want to have a child, and that is even more impactful on your life than it is to have an abortion.

Conaboy: We spend a lot of time in the United States talking about the reasons abortion is necessary and framing the political debate around which reasons, if any, make abortion acceptable.

Gomperts: [Abortion] is a very good way to take control over your life. There’s nothing wrong with having one abortion or two abortions or three abortions. A lot of the abortion rights people sometimes feel uncomfortable about this. But if you really, sincerely believe that we have to trust women to make a decision about their own lives, then that is the consequence. If you believe that we live in a democratic society where people have the freedom to make decisions about their own lives, then that is the consequence. Because the status of the fetus doesn’t change whether the reason is rape or it’s the first abortion or the second abortion or whatever — the fetus is the same. And so, once you believe that people are entitled to make a decision about this for themselves, then it doesn’t matter whether it’s more or less. Or how. Or when.

Conaboy: To what degree do you see the future of abortion rights a matter of who controls the information about how abortion pills work and how to use them?

Gomperts: One of the problems is that people rely on Google to find information online. The Google algorithms are determined by other, non-transparent decisions. Even sources like TikTok, Instagram, YouTube — these are the sources that people use to find information, so these companies are now really key and essential in order to make sure that women can find information about abortion pills. They are the gatekeepers.

We have been censored, of course, a lot. Facebook has taken down our posts. YouTube has taken down our posts. Women on Web has been blocked. Women on Waves is censored, for example, in Saudi Arabia and Brazil. In Turkey, as well. We will really have to look at what the states can do in terms of censorship.

Conaboy: One of the things that has gotten a lot of attention in recent months is the fact that many people seeking abortion — about 60 percent — already have children. We know this through the Turnaway Study and prior studies. I think this comes as a surprise to many people. Is it consistent with what you see internationally?

Gomperts: Yes. I think in the Netherlands it’s half of the women. What I see is that all the women who choose abortions who already have children, they do it for their children. They do it because they want to give their children a better life. They do it because they want to give their children everything that they can give and everything that they need. They know that an extra child is going to take away from the child that they have and from what they have to offer. It’s not because of egoism; it’s because of capacity.

Conaboy: Meaning that mothers are not infinitely renewable resources, in terms of finances, in terms of time, in terms of attention, in terms of their physical capacity — right?

Gomperts: There’s a lot of misconceptions about abortion, about who needs it and why. And it’s very important to break down these misconceptions. Another misconception is that it’s a really difficult decision. It’s not. Ninety-nine percent of women feel relieved. They might be sad because they might not have wanted to be in this position.

As a provider, you can really frame this kind of experience as well. Asking for the reason why people want to have an abortion is already framing it. Because it means that people have to have a reason.

You don’t need to have a reason to have an abortion. The only reason you want to have an abortion is because you have an unwanted pregnancy. Period.