Abortion was sold to women as reproductive justice, and the abortion pill, mifepristone, as the means to access justice through bodily autonomy.
While the Food and Drug Administration’s approval of mifepristone originally came with Risk Evaluation and Mitigation Strategies (REMS), safeguards included in this protocol have been progressively removed, leaving mifepristone in a state of near-total deregulation. In-person dispensing requirements were removed under President Biden, and the Obama administration previously eliminated prescriber reporting requirements for non-fatal adverse events, as if death was the only outcome that mattered.
Where nearly two-thirds of abortions are performed with mifepristone, women across the United States are experiencing serious adverse events thanks to the removal of REMS, and abuse and coercion are accompanying the drug’s availability via mail-order ecosystems.
Even in cases where women unquestionably choose to take the abortion pill, momentarily setting aside cases of coerced or forced abortions as explicit reproductive violence, these women cannot be blamed for the system itself that has failed them. Instead, the harm to—and even death of—women by the abortion pill must be shouldered, at least partially, by the social, economic, and political systems enabling this structural violence.
Applied Structural Violence
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Progressive institutions and mail-order abortion providers have emphasized the abortion pill as a means for women in low-income neighborhoods, rural areas, or pro-life states—following the Dobbs decision—to achieve equal opportunity in accessing abortion. This equity-forward model has instead been the reason federal agencies under Democratic presidents have stripped away safeguards for women, namely, in-person dispensing requirements.
In pursuit of privacy and autonomy, removal of in-person dispensing requirements has left women isolated and without the patient-doctor relationship, and all the safeguards that provides. When abortion pills are made available online and attainable outside this professional relationship of support, there is no standard of care for the use of this drug. Women are left without knowledge of normal or abnormal side effects, which can lead to disastrous consequences.
Dutch philosopher and ethnographer Annemarie Mol opens with this anecdote in The Logic of Care: Health and the Problem of Patient Choice:
Who would be so paternalistic, [the gynaecologist] says, as to deny this woman her choice? End of discussion. As if it were a magic wand, the term “choice” has ended the discussion. All the possible advantages and disadvantages of the treatment, all its goods and bads, have been turned into private concerns. They are not to be questioned. Interestingly, the gynaecologist’s words come straight out of the abortion debate that had taken place in the Netherlands barely a decade earlier.
Choice has become an idol for patients and physicians alike in the United States health care system, and women’s health has borne the greatest burden. Health care should be a collaborative practice, but removal of in-person dispensing requirements places women in social care deserts.
No woman can afford this, but poor women are especially vulnerable to systemic abuse. In particular, they are exposed to health risks that stem from insufficient or unclear medical instructions, a risk that’s particularly heightened when it comes to the abortion pill. Improper use and lack of in-person patient care can, in the most extreme cases, cost lives. Patients needing to navigate the health disparities often accompanying lower socioeconomic status benefit the most from quality doctor-patient relationships. Where these women need more communication with their providers, removing in-person dispensing also removes the requisite social aspect of care.
Still, to limit the structural violence against women from chemical abortion to only social damage would be a massive understatement. Women’s physical lives are endangered.
In-person dispensing, or at minimum an in-person consultation before a first prescription, is the standard for drugs with possible serious adverse events, including hemorrhage, infection and ruptured ectopic pregnancy. Even telehealth is not adequate in many cases. Physicians cannot provide excellent care for their patients, especially those belonging to vulnerable or risk-probable populations, such as pregnant women. With abortion services relegated to telehealth, women are denied the assurance that a prescribing physician is aware of all the medical and socioeconomic factors that influence health outcomes.
Beyond ultrasounds being necessary to rule out ectopic pregnancy, the consultation associated with in-person dispensing is imperative to screening for intimate partner violence. While men have unfortunately always been perpetrators of reproductive coercion, FDA deregulation has strengthened the ability of men to control women’s decisions: many women reporting being forced to abort their wanted child against their will.
By stripping away these institutional, regulatory safeguards for women, the FDA and related federal actors have become instruments of structural violence against American women.
Real-World Outcomes: Insights from Health Claims Data
Women’s experiences have not lined up with the reported adverse event rate of the original FDA approval. Responding to this discrepancy, the Ethics and Public Policy Center (EPPC) turned to an all-payer health claims data set and published a series of analyses suggesting mifepristone was never as safe as the FDA and its manufacturers claimed. The clinical trials data submitted to approve mifepristone cited a “less than 0.5%” rate of serious adverse events, but the EPPC found more than 10 percent of women face “sepsis, infection, hemorrhaging, or another serious adverse event within 45 days following a mifepristone abortion.”
This analysis does not even consider the bulk of serious mental health adverse events including self-harm and suicide that often happen outside the 45-day window. Considering mental health is essential to contextualizing the structural violence women experience, especially those of low-income or minority populations.
Regardless of whether the FDA-reported adverse event rate was accurate at the time of the drug’s approval, both anecdotal and empirical data point to a significant rise in complications that pose a threat to a woman’s right to informed consent—a core tenet of medical decision-making.
The data examined by EPPC, notably, pertained to abortions performed between 2017 and 2023. This timeframe is reflective of major degradation in REMS, shortly after new Obama-era guidance and the removal of in-person dispensing requirements under the Biden FDA. Narrowing examination of the data to this timeframe provides the greatest quantitative insight into the structural violence of mifepristone deregulation.
Just this month, EPPC released its most recent findings in the series of analyses focused solely on outcomes for women following the removal of in-person dispensing requirements. It was no surprise to find that removing the safeguard of the physical, doctor-patient relationship increased adverse events by a statistically significant amount.
Case Study in Coercion: Rosalie Markezich
Structural violence against women is not theoretical. No adverse event is merely a number in a database, but a real woman subjected to systemic violence. Rosalie Markezich is one of those women.
Deep down, I knew [the pregnancy test] would be positive. And deep down I was hoping it would be positive. And when I saw the pregnancy test, I just smiled. I was overjoyed that Plan B had not worked.
These were Rosalie’s words when she found out she was pregnant. However, she feared her boyfriend’s reaction. Though he expressed immediate excitement at the prospect of having the baby and moving in together, he soon changed his mind and suggested Rosalie get a mifepristone abortion. He placed an order under Rosalie’s name from an abortion pill distributor his sister had used “multiple times before,” then electronically transferred the money to Rosalie to pay for them. Rosalie paid the prescribing doctor and had no other contact before receiving the drugs. The pills her boyfriend had ordered arrived at her home in Louisiana days later. No informed consent. No confirmation of pregnancy. No ultrasound to rule out ectopic implantation. No confirmation Rosalie was the one to place the order for the pills.
When Rosalie did not take the pills, her boyfriend took her on a drive and later grew angry when she said that she wanted to keep the baby. Since no one knew she was with him, she feared for her safety. She had previously been a victim of domestic violence and knew her current boyfriend had a criminal record and a history of anger issues. She eventually relented and took the drugs, mifepristone and misoprostol, at the same time, hoping they would fail. She immediately tried to throw up the drugs, but it was too late. Her baby did not survive the abortion.
Now, Rosalie Markezich is one of the plaintiffs in the State of Louisiana v. the U.S. Food and Drug Administration currently being litigated by Alliance Defending Freedom. The plaintiffs are suing the FDA for unlawfully approving mail-order abortion drugs. With the right safeguards in place, women like Rosalie will no longer have to fear being coerced into aborting their children.
Rosalie speaks for all the women victimized by the abortion industrial complex when she wrote to the court: “I often re-live the experience of feeling forced to abort and lose my baby, causing me to become anxious, depressed, and afraid.”
Ending Violence through Public Policy
Just as public policy systematized this violence toward women, it can be harnessed to mitigate and eventually institute positive peace. As the name implies, positive peace is more than just the absence of structural violence, but the implementation of new institutions that promote justice.
Though the FDA has promised to independently review the safety of mifepristone, the documented experiences of women—and those undocumented due to private abuses—should be enough for implementation of in-person dispensing. Though the lack of in-person dispensing requirements is not the sole cause of structural violence concerning chemical abortions, it is arguably the lowest-hanging fruit when it comes to securing certain safeguards. Restoring in-person dispensing would allow women to regain the benefit of direct physician screening and increase the chances they receive the informed consent required by law.
Unfortunately, this is an imperfect end. Even under federal regulation requiring the abortion pill to be dispensed in person, women will be left isolated to their homes to complete the abortion, absent immediate medical care or greater support networks.
True “positive peace” would require removing abortion drugs from the market. But until that happens, policymakers cannot sit idly by and let abuse continue. Women who have suffered the violence of coercion and force should not be left in their isolation or to the continued pressures of their abusers. Even women who willingly took the abortion pill with informed consent must have access to reversal. No one can be left a victim to “choice.”
Mifepristone cannot be the only thing removed from the market; another drug would take its place. Rather, the very idea that women can achieve reproductive justice through abortion, chemical or otherwise, must be rooted out and replaced with positive care networks that meet women where they are. Changing the narrative is the only way structural violence will see its end.
