Thank you for coming to our talk, Redefining the Role of the Psychiatrist in the Post-Roe Era. My name is Johanna Beck. I am a child and adolescent psychiatry fellow at Jefferson in Philadelphia. I have no relationships to disclose, but I feel it's almost obligatory to disclose that I'm eight months pregnant. So maybe I do have some thing to, some sort of disclosure. Hello. My name is Anam Beg, and I also have no, or I don't have any disclosures to make. Thank you. I'm, sorry, I'm from Los Angeles, California. I'm a current PGY4 at Charles R. Drew University in South LA. Thank you. And I'm Faisal Kagatkar, I'm a PGY5, and a first-year child psychiatry fellow at University of Colorado, Denver. And I have no disclosures to make. Hey, Karen DeAnisotis. I'm a fourth-year psychiatry resident in Baltimore at Johns Hopkins, and I additionally have no disclosures. Thank you. OK, so the objectives of this session. At the conclusion of this session, the participant will be able to evaluate the impact of the overturning of Roe versus Wade on maternal mental health, understand the history of psychiatric involvement in the pre-Roe era, describe opportunities for psychiatrists to expand their practice and include basic reproductive care to patients, and identify avenues for reproductive rights advocacy in our home institutions and at large. So we're going to ask you to go to MentiPoll.com. You can just put it Menti.com and use the code 6347-7940. So a bunch of people from different places. Let's go to the next question. women's rights, feeling strongly about abortion access, personal interest in reproductive psychiatry, patient and personal advocacy, okay. So our hope is to address some of these topics today. Let's go to the next slide. How comfortable are you all with counseling patients and contraceptive options? There's some very seasoned professionals, some somewhat. Our hope is to sort of talk a little bit about contraceptive options that we psychiatrists can prescribe. Do you know what the laws are regarding abortion in your state? Okay, a mixed crowd. Do you or have you in the past prescribed birth control or plan B for your patients? So it seems like a lot of you all have the knowledge to prescribe but haven't prescribed birth control or Plan B. »» Okay. So we have a case presentation. So just kind of to look ahead, the way our talk is going to go is that we would like to follow a case throughout different time periods. So this is a case that is from Planned Parenthood. If anybody follows Planned Parenthood you might actually recognize the case. They emailed it out a few months ago and I asked them, could I borrow it? So if anything, I haven't changed the case but I have deleted some lines. But the rest of the text is from Planned Parenthood. So this case is going to be followed on different time points and in different locations. So if you want to pay attention to where we're at on the time. So for Day 1, 7.32 in the morning started in San Antonio, Texas. It took two days for Rebecca to realize her period was late. It took 30 minutes to pick up a pregnancy test during her lunch break, five minutes to get a positive result. Before Texas lawmakers banned abortion, Rebecca would have had options, close to home, affordable and accessible. Now she has no choice but to make the 700-mile drive from San Antonio, Texas to Albuquerque, New Mexico. Like the majority of people who seek abortion, Rebecca is already a parent. She has two children under the age of six at home. She understands what it is to be pregnant, what it means to go through labor, what it means to love and care for a child and want to give them the best life possible. She knows what is best for her and the children she already has. So at 7.32 in the morning, Rebecca hugs her two kids and goes over the final checklist with the babysitter who will be looking after them for the next three days. She's lucky she found a neighbor who can watch them on short notice. Even if she isn't sure how she can afford to miss three shifts at work and pay for extra child care. She gets into her car and begins the 11-hour journey to Albuquerque, where abortion remains legal and accessible. It's more than 700 miles each way, and she tries not to think about how much the gas will cost. Day two, it is 6.10 in the morning, and we are in Albuquerque, New Mexico. Rebecca is exhausted from her long drive. With traffic and rest stops, it takes her nearly 14 hours yesterday to make her way from San Antonio. She spent 14 hours wondering how her kids were doing without her, 14 hours worrying about the cost of the trip and the risk she's taking by missing work, 14 hours of anxiety, sadness, mixed with an unbelievable fury that she has to endure this to get an abortion. As tired as Rebecca is after her journey, she hardly sleeps at all. She's been awake in her hotel room, a $140 expense since before the sun came up. Now alone, she worries about her appointment. What if it gets canceled for some unexpected reason? Would she be able to reschedule? Can she make this journey again? It's early in her pregnancy, and she knows that her procedure is low risk. Still, what if something does go wrong? Will she be able to get follow-up care back in Texas? What if she needs to stay longer in Albuquerque? Can she afford the hotel? Will she lose her job? What if she misses more work shifts? What if her neighbor can't keep watching her kids? There are still hours left until Rebecca's appointment at a Planned Parenthood health center. Sleep is impossible, so she gets up early and starts getting ready. Day two, 1130 a.m., still in Albuquerque, New Mexico. Rebecca walks into the Planned Parenthood health center and breathes a deep sigh of relief. Rebecca is scheduled to have a procedural abortion, which takes as little as five to ten minutes. Her appointment will last a few hours, though including an exam with her provider, time to ask questions and go over the plan again, and recovery time in the post-procedure room. Much of this feels routine, like any other doctor's visit, checking blood pressure and heart rate, answering questions about her medical history and her allergies, but Rebecca also shares her anxiety and her relief. It's been such a lonely, difficult, worrisome journey. She talks about how hard it was to find reliable information in Texas about how to access care. She talks about the cost of travel, about missing her kids, about all the stress. It feels good to share her story, and with her consultation over, with hundreds of miles behind her and hundreds of dollars spent to get here, Rebecca is finally able to get the care that should have been available to her in the community where she lives. We're now on day three, it's 657 in the morning, and we are in Albuquerque, New Mexico. Rebecca checks out of her hotel. Everything went smoothly yesterday. Her whole appointment, including the consultation with her provider, her procedural abortion, and a little more than an hour of recovery time spent in the post-procedure room was just a few hours in total. Before getting in the car to start her long journey home, she takes a few ibuprofen to alleviate cramps and lines her underwear with a pad to catch any bleeding. She has a long drive ahead of her. It's day three, 8.32 p.m., now in San Antonio, Texas. Rebecca finally gets home after driving nearly 24 hours in three days just to get an abortion, a procedure that took as little as five to ten minutes. So that's the case that kind of sets the stage for the different discussions, the different parts of our discussions we'll be having today. As I mentioned, my name is Karen Dionysotis, I'm a fourth-year psychiatry resident in Baltimore, Maryland, and I'm going to be talking about what reproductive access to care looked like prior to the Roe decision in the pre-Roe era. So up until about the mid-1800s, abortions were actually legal and very commonly practiced in the United States. They utilized the English common law that abortions could be provided prior to quickening or when you can feel fetal movement and were not criminal offenses. One of the things that I think is really important in being a part of organized medicine and a part of organizations is really acknowledging our part in some of the things that have happened in the past. So I'm a very, very proud AMA member, but I learned a lot in researching this talk about how the AMA was part of the movement towards making abortion legal across the country. The AMA was formed in 1847 and the focus was really and the concern was on that physicians were not involved typically in these procedures that were happening. So midwives and other nurses, oftentimes family members, were really the ones providing this sort of care to women in the home. And physicians really worried about patient safety and that's kind of the angle that they brought this up. That being said, it really did lead to kind of a snowball effect. And as we say in the AMA very frequently, a lot of unintended consequences came from this sort of advocacy work. By the mid-1800s, Massachusetts was the first state to enact a state law making abortion a criminal offense. And then by the 1880s, most states had laws restricting abortion with exceptions in some cases, if a doctor was necessary, if they said it was necessary. By 1910, all states held laws criminalizing abortion and making it illegal with very rare exceptions. And then in 1930, we began to see some of the consequences of criminalizing abortion. So in 1930, 2,700 women died due to unsafe illegal abortions, which was 18% of maternal deaths that year. I will point out that at the end of this era, in the 1980s, 1910s, 1930s, physicians at this time were then, given that these laws were criminalizing, oftentimes physicians could be put in jail or fined for being involved in either recommending someone get an abortion or supporting a patient or advocating for a patient to get an abortion. So on top of these laws, kind of similar to what we're seeing now, physicians really began to question how they could best support their patients and also really began to worry about their own safety and their own licensure. And then as abortion became criminalized, the stigma surrounding it grew. I think that this chart on the right really speaks more than what I can share. But at this point, you can see how deaths from abortion in the 1960s are kind of up above 200 per year. And then as abortion became liberalized and re-legalized in 15 states in that 1970s point, we get to a point and then we begin to drop off substantially until we get to Roe v. Wade at 1973. And then we see further drop off in terms of death of pregnant people from abortion. So two options you really had prior to 1973. If someone became pregnant and could not have or raise this child, continue with this pregnancy, there were two options. So having an illegal abortion or having a legal, a legal abortion. So illegal abortions in as late as 1965, they accounted for about 201 deaths, which again is 17% of all reported pregnancy related deaths that year. So one in five people who are getting an abortion, an illegal abortion died, which is a really, really substantial number. Between the 1950s and 60s, about 200,000 to 1.2 million women each year had illegal abortions. Obviously that range is like wild, right? But that was the big thing about having abortions illegally is that there was so much secrecy involved, which also then led to a lot of shame and stigma. The other option was for people to have a legal abortion. So in such cases, as I mentioned before, women could obtain a legal abortion by getting approval from a hospital committee who was established to review abortion requests. So this would require meeting with a physician and then them stating that you had a medical reason to get an abortion. This often was only really available to people who were very well-connected, who knew people, and honestly who had a lot of money, most of them being white women at that time. In some states, a woman could receive an abortion if it would protect her physical or mental health, again, needing to be corroborated and examined by physicians, or if the pregnancy had resulted from rape and incest, though that was actually pretty far and few between. People would also travel to the UK where abortion was legal, but again, obviously that was really restricted to people who had the most money and access to that sort of travel in time. So we're going to touch a little bit about kind of what this looked like if a woman went to a physician and wanted an abortion. We found that, or like the stories talk a lot about how this kind of actually landed into the sphere of psychiatry. And so it actually became referred to as like psychiatric abortions, right? Having psychiatric implications for abortion being the leading cause of people being able to get abortions for medical reasons. I think there were plenty of studies that also then looked at were abortions emotionally harmful for people who have a history of psychiatric illness. And so as you can see in this first study, it looked at 46 women, 65% had previous pre-existing psychiatric problems, 44 women did not have any ill effects that could be directly traced to an abortion. And so there was just a lot of conversation around mental health in this era and psychiatrists as being the gatekeepers for people being able to have access to abortion, which was something I did not know about and I think is really fascinating as we're kind of looking into the future. So now a little bit further in history, in 1962, the American Law Institute, which was a group of people who were lawyers, policymakers of that sort, came together and they would put out these model legislations. And so in 1962, they released the model penal code on abortion. Their recommendation was that for people who were pregnant, if they had a condition that would impact, at that time, you know, a pregnant person's mental or physical well-being, if it was for rape or incest, or kind of if they knew that there were any sort of fetal abnormalities. And in those cases, they suggested or wrote about how it would be appropriate or feasible for people to get an abortion. In 1965, we saw that the Supreme Court struck down a prohibition of the sale for contraception. So a state in Connecticut, they tried to prohibit the sale of contraception, even to people who are married. And so this was struck down by the Supreme Court, and then cited this right to privacy. And I think this is something that we hear frequently when we talk about abortion as a right. So what was really fascinating to me is that along with kind of the activists and the lawyers, the clergymen actually kind of came to the table as well and advocated for abortion to be legalized. So the Clergy Consultation Service was founded in 1967, and it was a counseling service that was for women with unwanted pregnancies, and they supported and advocated for these women to get the care that they needed. Also at that time, the AMA House of Delegates now in 1967, you know, saw a lot of the complications that pregnant people were having with abortion, and then again, deciding that this was a patient safety concern, they began to endorse liberalization of state abortion laws. And then in 1967, also Colorado became the first state to reform its abortion law based on the ALI recommendations. So that being, you know, making it available and legal for women whose physical, mental health, or their life were endangered, as well as if the pregnancy resulted from rape or incest, or a fetus had a severe defect. Another Supreme Court decision in 1972, Einstein v. Baird, struck down a law limiting contraceptions to married people, and so this established formally and legally the right for unmarried people to obtain contraceptives. And then also in 1972, 13 states had statutes based on these ALI recommendations, and four states had repealed anti-abortion laws completely. And those four states were Alaska, Hawaii, New York, and Washington. So this is a map of what things looked like in 1972, which is the year prior to Roe v. Wade. So you can see where there are full anti-abortion law repeal in those four states, as I had mentioned, as well as reformation of the law in those 13 states utilizing the ALI statutes. So this is 17 states in general who had reformed or repealed. So interesting statistics. In the year prior, so in 1972, over 100,000 women left their own state to obtain a legal abortion in New York City. According to an analysis by Guttmacher Institute, an estimated 50,000 women traveled more than 500 miles to obtain a legal abortion in New York City. Nearly 7,000 women traveled more than 1,000 miles, and some 250 traveled more than 2,000 miles from places as far as Arizona, Idaho, and Nevada. A serious complication or consequence of having to travel long distance to obtain an abortion was the result of delay in having the procedure performed. So instead of being able to have the procedure performed at an earlier week, it often took a lot of time to make these logistics and get appointments set and travel. And so women were having abortions later at 12, 13, 14 weeks, and that does raise the risk of complication for women or for pregnant people. Interesting, about three, so three of the four states who fully repealed their anti-abortion law, they required the person seeking an abortion to be a resident of their state for at least 30 days prior to the procedure. And I think that this was to try to limit the people mass traveling to these states, but they still did see an influx of then 35-day residents as that happened. And then New York did not have a residency requirement, which really put it on the map for people who are capable of traveling, which again were affluent white women. In the year prior, so in 1972, so the year prior to the Roe decision, maternal mental health was the most common indication for a hospital abortion, accounting for more than 85% of all cases in the 12 states that reported the stated reason for abortion. So after learning about our past without access to reproductive care, how do you envision the role of the psychiatrist now that Roe has been repealed? I think this is something that we just kind of wanted you to think about in your seats and maybe turn to the person next to you and share your thoughts, or if you're brave enough to vocalize them, we'd love to hear them. I think one of the things that I really think about is kind of these medical indications for obtaining abortion. And I'm wondering, again, there's not a lot of actual medical reasons not to, but there are quite a number of psychiatric reasons. And so back to this time, many women would seek psychiatrists and say that they were suicidal, and that was really the indication for them getting an abortion. I think a lot of the things that are written about this era look back on those women as being, like they were described as histrionic and dramatic and in kind of these really harmful terms to utilize women trying to seek health care. And so I'm interested to see, kind of looking back from where we are now, how we're going to be describing women who are doing everything in their power to be able to have control over this. Yes, please. Hi. I wonder if they would care, because they don't seem to care about medical reasons or rape or anything. So patients might come and say, they'll say, oh, well, maybe you'd have to admit them to a psychiatric ward or something until they give birth or something like that. I'm not certain that the way it is going right now. I'm sure the pendulum will level eventually. But at the moment, it seems to be all going in the direction of limiting rights for women. Thank you for sharing. Yeah. I was going to say that some of this might stem out of the eugenics movement being very popular in the late 1800s, well into the 1900s. I mean, there is sterilization of patients at state hospitals. I think a lot of the reasons this existed had at least something to do with the idea that we don't want, not that we don't, but that society would be better off not having babies with mentally ill parents. So at least I'm not sure that's the case, but I think there's probably something there. Thank you. So I've talked to psychiatrists who, at the time in New York, were doing those consultations. So the way it worked was these were psychiatrists who respected women's right to choose. And the way the law was, well, it wasn't just in New York. It was in other states, too. A woman would have to have a psych consult with a psychiatrist who would have to declare that they needed the abortion for mental health reasons. And once they had that psychiatrist's signature on a piece of paper, they could take the piece of paper and go get their abortion. And the psychiatrists were saying the whole thing was sort of a sham, frankly. They would meet with them, and they always found that. They would ask things like, well, are you upset about being pregnant? And do you wish that you weren't pregnant? And if you're denied an abortion, it'll cause you anxiety? They would say yes, and that's what happened. And it may go back to that, because now the anti-abortion legislators are kind of in a bind, because they're trying to pass all these laws, but it's not popular with the public. So one out for them would be to make an exception for mental health. And if they do make such exceptions to mental health, we might see a return to exactly what I'm talking about. And that would be another role that psychiatrists might play. Yeah, thank you so much for sharing that perspective and what your colleagues had shared with you. I think that that's exactly kind of what was happening. People were really just looking for any way to support themselves and their families and to, oh. It's also true what you said about New York. Women were coming by the thousands. And the providers there couldn't take care of them. They were begging them, please, please, please take me, because they were just so overwhelmed. Yeah. Thankful we did have one of those four states who were allowing non-residents to come in to access that sort of care, absolutely. So I think on top of one of the things that I forgot to mention, that on top of being a pretty substantial wealth disparity, there also was a pretty substantial racial disparity when looking at people who died from abortion, right? Thinking of people who had access to legal abortion versus illegal abortion. And so the statistic, I have to find it on my phone, but it's that people were 12 times. So if you were not white and you had an abortion, you were 12 times more likely to die from that procedure than a pregnant person who is white. So that's also pretty egregious, right? And I think kind of looking back on that time now, it's really, really important for us to think about how these laws that we're passing now are going to have similar impact for our patients that we take care of. All right, I'm going to pass it on. Thank you. So like I said, my name is Johanna Beck, and I am a first year child and adolescent psychiatry fellow at Jefferson in Philadelphia. And we're going to transition now to talking about access to care in the post-Roe era. And when I tell you I've made these slides and then had to remake them, because you can only imagine how the news is these days, bear with me. I have a date for every headline. So we wanted to explore how this case would vary across the US. There's various heat maps of abortion access that you can find online. This one that we will be following is from the Guttmacher Institute. The New York Times has one. Planned Parenthood has one. I'm sure there's others that I'm not familiar with. But they're nice ways to kind of look to see what is the most updated legal situation regarding abortion in each state and what the neighboring states are looking like. So you see the darker the red here, the more restrictive it is, the darker the blue, the more protective. So we'll start with Texas, because that was where our case with Rebecca started. She started in San Antonio. Texas is listed as one of the most restrictive states in the country. It had a complete ban as of July of 2022. There are very limited exceptions, and the exceptions are very vague, which is also what's causing a lot of problems for obstetricians and gynecologists, as well as emergency medicine physicians, as well as emergency medicine physicians, or anybody treating pregnant people. So the exceptions include to save a pregnant person's life or to prevent serious risk to the pregnant person's physical health. But again, that's not, at this time, legally defined as to what is saving their life. Do you have to have a certain blood pressure? Do you have to have, like, how close to death's doorstops do you need to be? So this does lead for a lot of ambiguity. You may legally travel outside of the state of Texas to get an abortion, like the woman in our case did. However, one third of reproductive age women in the state of Texas have incomes below 200% of the federal poverty level. So just looking at what happened in our case, taking three days off of work, having to drive 700 miles, stay in a hotel room, and then also pay for the actual procedure at Planned Parenthood, this cost is really racking up. That probably cost our patient almost close to a couple hundred to $1,000 just within those three days. The patient themselves are exempt from legal prosecution. So if you have an abortion in the state of Texas, even though it's illegal, nobody can prosecute you. But they can prosecute the provider who helped you get one, which obviously factors into then the first part as to what is saving a woman's life. It's going to make a lot of providers really think about when can I pull the plug and when can I help. Here are some headlines regarding Texas abortion laws. Again, these are changing all the time. But the Texas ones are at least a little bit more consistent. So there was a few I wanted to hone in on. The first one is really particularly interesting. The Texas abortion law means woman has to continue pregnancy despite a fatal anomaly. So this is a very sad news story about a woman who is now pregnant with her second child. Her and her husband wanted to grow their family. This was a very much wanted pregnancy. But the baby has a condition called alobar holoprosencephaly, which essentially is where there is no two hemispheres. The baby has just one hemisphere. There's no midline. It causes a lot of facial abnormalities. These babies don't tend to survive. The 20 or so percent that do make it to birth die within weeks to months or even days. It's usually a very upsetting death because they have a lot of seizures. It's also very dangerous to deliver these babies vaginally because they collect a lot of fluid in their heads. So at 28 weeks, this woman's baby was measuring. The head of the baby was measuring at the size of a 40-week baby, so full term. And this woman had sought care outside of the state of Texas because in any state where abortion is legal, this would certainly qualify as a reason to as a fatal anomaly for this baby. And unfortunately, her health insurance would not cover having an abortion outside of her state. So I think the bill she was looking at was like $12,000. So she had to go back to Texas and is now awaiting for her Texas providers to allow her to deliver this baby, which she would like to deliver vaginally because her goal is to still grow her family and she would like to get pregnant again. But at this point, because you're not allowed to abort a baby at 28 weeks, she is probably going to end up having a C-section at full term. It's unclear what the outcome will be. But it will be an interesting case to follow. And having a C-section at this time is now going to be more dangerous because this baby's head is going to be huge at 40 weeks. It's going to be a major surgery. And she's not going to be able to get pregnant right away, which was her initial plan. She's probably going to have to wait a year to 18 months before she can try again to have a healthy pregnancy. The case below this, the three Texas women, you might have heard about this in the news. There were three Texas women who were sued for helping their friend. The husband found text messages between the group of women. Interestingly, there is an update on this case that the women are now countersuing him. And I appreciated that, Karen, you mentioned the privacy, the right to privacy in the 1960s. Because that is actually the point that they're arguing, that the women are countersuing. That you invaded our privacy of our conversation on a computer or on a cell phone. So that's an interesting case as well. And then other things, smuggling an abortion pill. How is that going to play out if you take an abortion pill over state lines? And also how this is affecting OB-GYN care. You have OB-GYNs in the state of Texas saying, I'm not going to be doing this anymore. I don't think I can work in this environment. So we'll transition to Georgia, because that's also in the south, not too far away from some of these other more restrictive states like Alabama. Here, abortion is banned at six weeks and later. So just as a reminder, the first two weeks of pregnancy are not pregnancy. Week one and week two is you just had a period, or you just had your period two weeks ago, right? Or I'm sorry, you just, yeah. It's from your last period. So really, a woman who is six weeks pregnant is really only two weeks pregnant. So keep that in mind. In Georgia, patients are forced to wait 24 hours after counseling, but it doesn't have to be in person. You could be in your home state of Texas and be counseled over telemedicine to get an abortion. You cannot use state Medicaid, so the poorest people in the state must pay for this out of pocket. And if you are a minor, you do require parental consent or notice. Another limiting factor is that only physicians can provide abortions, so even the safest of abortions, which would be using like misoprostol or mifepristone, they cannot be prescribed by anybody other than an MD or a DO. You cannot use an NP or a mid-level. A lot of the Georgia laws are still up in the air. I just looked again today to see if there were any updates to any of these news stories, and I could not actually find any. So the Supreme Court in Georgia has been hearing arguments on the state's heartbeat bill. But there's a lot of strong universities in Georgia as well, like trying to discuss how important safe and legal abortions are. But unfortunately, even though we see six weeks abortion ban, we see like, think, how can it get less than that? A lot of anti-abortion activists are unhappy and are still trying to fight for Georgia to look more like the state of Texas. This is the slide that has had to change the most if you were paying attention with what's been going on in the news lately. So this slide is not updated, but you'll see, I have it on like another two slides. So North Carolina is, was previously known as the state to go to in the South, that if you needed an abortion, this was a state that was very welcoming. It was banned at 20 weeks or later. However, there was a 72 hour waiting period, but it didn't have to be in person. You could not use state Medicaid funds. The abortion must be provided in person, meaning that you cannot mail the pills. You do need parental consent and only physicians could do it. But there were also some protections. So if you were paying attention, you could do it. But there were also some protections. So there were some protections from harassment and physical harm for anyone entering an abortion clinic. And then there was a shield law as well to protect abortion providers from investigations from other states. When I first made this slide, these were the original headlines I pulled, that there are this talk of limiting abortion further and how North Carolina became an abortion destination in the South. This is pretty cool. So what Planned Parenthood has in their offices, as when a patient is waiting in the exam room, they have notebooks around with pens where patients can write their stories. And this was one of the stories that came out in a North Carolina Planned Parenthood clinic. And I believe these stories and similar stories are the one that inspired the original Rebecca story that we read at the beginning. But I do think it's really notable because she talks about the grants and how they really helped her with the cost. She says, they helped with the procedure cost, gas for traveling and my hotel for overnight. I would not be able to be here if it weren't for these grants. So this is the updated slide. So if you've heard in the news, the legislative body in North Carolina made a law banning abortions after I believe 12 weeks. The governor vetoed it. And then because they have the two thirds majority, they reinstated it. So this has really been a hot topic in North Carolina. 12 weeks might make this still an option for some women in the South traveling for an abortion, but not for all women. I think another important thing to talk about when we're thinking of the weeks and what's going on is that you don't have an anatomy scan until about 20 weeks. So while some gross abnormalities might be caught sooner, some other things might not be known until that 20-week mark. So when we shorten abortion limitations to 12 weeks, we're really cutting out a lot of choice for pregnant people who might not know the full outcome of their pregnancy just yet or the full trajectory. So now we can transition to states that are a little bit more protective. So New Mexico, which is where our patient in the story went, is considered very protective. There really aren't many limitations. There's no restriction based on gestational age. You can use state Medicaid funds to pay for your abortion. It does not have to be only a physician. Anyone who is a qualified medical professional can prescribe these pills or perform abortions. And there is also a shield law so that if you provide an abortion to a patient from another state that you can be protected. That doesn't mean that it's all sunshine and roses over there. So the New Mexico Supreme Court blocked local abortion ordinances. There was a lot of response to anti-abortion laws in neighboring states that New Mexico has been trying to shield their providers from facing legal repercussions. But that doesn't mean that activists for the anti-abortion side have not tried to set their sight on New Mexico. And that is still something that they are trying to fight. So just some other considerations. You know, obviously we didn't talk about, we didn't hone in on Florida, but that is also a place where things are changing rapidly. Wyoming has outlawed abortion pills. South Carolina has considered the death penalty for women who receive abortions. It has not passed at this time, but this is something that's been considered in their state legislature. And then we also have the pending Supreme Court case with MIFA-Preston having its FDA approval. That should be probably coming up this year sometime to see that outcome. We want to talk a little bit about other considerations to watch. I see a few members of the military, and I think this would be pertinent to any provider providing care to members of the military. The Hyde Amendment, which was passed by Congress in 1976, had an injunction that prevented it going into effect for a year. 1977 basically prohibits the use of federal funds for abortions except for covered abortions, which are described as in cases of rape or incest or when the patient's life is at risk. So in the military, we cannot provide care to individuals unless they are for covered abortions, given the Hyde Amendment. But on February 16, 2023, the Department of Defense issued policies outlining administrative absence and travel allowances for non-covered abortions. So service members may choose to delay pregnancy notification to commanders but must notify no longer than 20 weeks of gestation. Service members may be granted an administrative leave for a period of up to 21 days to receive or to accompany a dual military spouse or a dependent who receives non-covered reproductive health care without taking leave. The policies also authorize travel and transportation allowances for a service member or an eligible dependent and for an attendant or escort if a service member or eligible dependent is incapable of traveling alone. These are the policies, so still there aren't federal funds provided for the direct act of abortion, but to access these non-covered abortions, there are policies outlined. Where do we as psychiatrists fit in the post-war era? Will we as psychiatrists be placed again in a position to gatekeep abortion? How will telehealth impact this? From history, we do know that this will most commonly affect people of lower socioeconomic status, and how can we as a profession advocate for these patients? And what is our role as physicians in reproductive health care? These are some questions that we may not necessarily have the answers for, but these are questions to watch for as these legal changes get implemented across the country. An important topic, I think, for us to consider is in the field of forensic psychiatry. There are many ways where psychiatrists can be involved in this arena, the first one of which is informed consent. So all adults are presumed to have medical decision capacity in having a psychiatric illness does not preclude medical decision capacity. But given these laws, some patients, psychiatrists may have to consider doing psychiatric evaluations for competency. We might be called in that arena. And essentially, our role might be similar to doing an evaluating for consent for any serious irreversible medical condition. But it might be even more tricky. What about those patients who have psychiatric illnesses? What about, in particular, the patients that have postpartum psychosis, and how it might impact them if they were to get an abortion or not? And as we do know, oftentimes there is a level of ambivalence associated with patients who were contemplating getting an abortion. How would that factor in in the capacity evaluation itself? And with the patients we see with psychiatric illness, they are more prone to coercion. How do we delineate, how do we sort of better understand if our patients that have psychiatric illnesses were coerced in the first place, or was that an independent decision that they made to seek an abortion? Another area we may see are called Jane Doe evaluations. So essentially, if a minor wants to get an abortion, there are states that allow minors to get an abortion as long as they receive parental consent or notification, or parents receive notification, or by a separate judicial bypass. And that judicial bypass requires a Jane Doe evaluation, which is basically where psychiatrists come in and try to evaluate the maturity of the teenager, the younger, the minor, if they have the maturity to consent to that decision, to the abortion. And that could be a lengthy evaluation. There aren't too many laws describing what Jane Doe evaluations entail. But certain states do have some sort of quasi policies on how do you do these Jane Doe evaluations, but might vary state to state. And also, the concept of maturity in a minor may vary state by state. And going back to what I think one of our audience members talked about, the psychiatric necessity of abortion, like in the post-Roe era, there was psychiatrists were arbitrators, were the gatekeepers for abortion. Do we come back in that role? And while we may be recalled in that role, but it might depend on the state laws that may prevent or allow us to determine psychiatric necessity for abortion. For example, Ohio's heartbeat ban, which was recently passed, explicitly excludes psychiatric indications for abortion. So it might vary state by state. Another consideration is criminalization of pregnancy outcomes. Pregnancy and postpartum women may be civilly and criminally prosecuted for their actions involving actual abortions or attempts to get abortion, as well as alleged fetal harm. There are certain fetal personhood laws that basically certain states might consider fetuses to be persons, and they have stricter laws in the terms of the harm that is associated with that fetal being a person rather than a fetus, and the criminal culpability that might be associated with it. So our role might be in risk assessments, in understanding what is the criminal responsibility, how do we mitigate response in mitigation, in risk assessment, in child custody, as well as in parental rights? And also, if our patients have mental illnesses, how do those factors lead to the action, and how do you sort of assess the other, like a biopsychosocial formulation, trying to understand the culpability of their actions? In states that prosecute women, or in states that may prosecute women who've attempted or received abortion services, that might mean that they might lead to higher incarceration, and we might be involved in taking care of these incarcerated pregnant people. So more involvement in the judicial system, so I see an increased role of forensic psychiatrists being involved in taking care of pregnant people who have received abortion services, as well as in surveillance and reporting. Certain states, like as we are mandatory reporters of child abuse, we might become mandatory reporters of pregnant people who receive abortion services, and how do we go about that? Lots of considerations in the forensic sphere, as we can imagine, and which will obviously be determined by lots of factors in how things move in the next months to years. But besides where things might go, I think us as providers, as physicians, we have a lot of, we have a role in advocacy, and that could be through the patients we see, as well as a whole through organized medicine, and APA is involved in advocacy, AMA is involved in advocacy as well. This is a position statement from APA in 2020 that opposes all constitutional amendments, legislation, regulations, curtailing family planning and abortion services to any segment of the population, and supports freedom to act to interrupt pregnancy must be considered a mental health imperative with major social and mental health implications. This is the amicus brief that APA joined the Dobbs v Jackson case in September 2021. It's pretty small, but you can see there are multiple organized medicine associations, like the AMA, the ACOG, American Academy of Nursing, and other organizations that were supporting this as well. All right. Hello, everyone. Again, my name is Anam Beg. I'm a current PGY-4 in Los Angeles, California, and I'm going to talk about our last main section, which is contraception and contraception counseling. Okay. So I'm going to start out with some statistics. According to the Guttmacher Institute, we use that website a lot for our content, in 2018, approximately 46 million U.S. women between the ages of 15 through 49 were sexually active, but not pursuing pregnancy at the time. Of these women, 65% reported using contraception, and contraception use in this age group was actually lowest in the youngest women between the ages of 15 and 24. And although we talk about contraceptives, in this case, to prevent pregnancy, there are other indications for hormonal contraceptive use for treating other mental or medical conditions, such as acne treatment, very common treatment for premenstrual dysphoric disorder, PMDD, endometriosis, and also for regulating menstrual periods in patients who have heavy or irregular bleeding. Okay. So here's some more data from Guttmacher Institute. The table on the left there is basically showing multiple types of contraceptive methods used by women in 2018 in the U.S., and the methods are actually arranged by effectiveness. So the one on top, the very first one, permanent female method, which is like essentially surgical procedures for removing or occluding the female reproductive organs, is at the top, the most effective method, followed by the pill, oral contraceptive pills, all the way down to the bottom, which is no method at all, like the least effective method. And interestingly, these three are actually the most commonly used methods. The most popular option is actually the least effective method, which is no method at all, the very last one on the bottom there. And this is important to note because that proportion of women that are not using any method at all, the most popular option, are actually at the greatest risk for experiencing an unwanted pregnancy. And so as a result, they might end up using more emergency contraceptive options. And that's what's shown on the right-hand side, those bar graphs there, basically shows the increase of the use of emergency contraceptive pills, which has increased significantly throughout the years. All right, so this slide basically is why contraceptive counseling is important for mental health providers. And we've already talked about, you know, some of the mental health implications of, you know, experiencing an unwanted pregnancy, which is already challenging for the average person. But the burdens of an unwanted pregnancy are even greater in patients who have mental health conditions, and especially already vulnerable populations, which include younger patients, underage girls, and also women of color, including among others. It's important to note that mental health patients are actually at higher risk of becoming victims of sexual violence. And it has been found that these people who have mental health conditions and a history of trauma are found to have the highest risk of adverse outcomes if denied an abortion and we kind of touched on that a little bit earlier so this is really just kind of like emphasizing that point and again you know the the most vulnerable populations tend to be you know including women of color minors we talked about immigrants people who have you know low access to health care and other resources as well as people who have cognitive issues and other mental health conditions and then finally most importantly those experiencing restrictive abortion policies in their state who have limited access to travel or means in order to obtain an abortion if necessary and so that's why it's very important for mental health providers to be aware of this and kind of become familiar with how to counsel their patients and then most importantly know like what their their local state laws are regarding counseling and prescribing these treatments as well as like any restrictions and limitations and then of course how to deal with that like referring to you know someone else or elsewhere so that their patients can get those services okay so here are some guidelines about contraceptive counseling things to consider when you're you know about to approach your patient to discuss this important topic ACOG the American College of Obstetrics and Gynecology actually recommends counseling pre-pregnancy counseling in anyone who can contribute to a pregnancy so it's you know more inclusive language and it also means that you know it's recommended that you also counsel the partner who will be part of the pregnancy and then generally ask them like if they're planning to become pregnant within the next year so you can start you know bringing that up and you know as we always talk about in our medication consents when we're talking about any treatment you know with our patients we want to tell them about like not just the risks and benefits of the treatment but also alternatives and then also you know the the flip side like the consequences of not getting that treatment what are the risks and benefits there and that the same goes for contraceptive and like pre-pregnancy counseling as well so the the relative risks and benefits as well as how they will be affected how their psychotropic medications will be affected and then you know depending on whether they become pregnant or not and then the effects of the pregnancy itself on their mental health as well as their medications and how to manage that making a plan and notably you know it's very important patients who do have serious mental illness including schizophrenia and bipolar disorder they're at the highest risk of relapse during pregnancy so very important to have that conversation and have a plan and I'm going to come back to this last point in the later but just want to mention that you know there have been some studies that find an increased risk of adverse mood symptoms in women with who already have psychiatric condition and then they can take they take OCPs like from the the medication itself we'll we'll come back to that point so I just want to go over some data gathering points so generally it is recommended to use the biopsychosocial model it is the most comprehensive holistic model out there it covers all you know the psychosocial cultural factors and other factors that you want to include in your counseling process in addition to obtaining your your usual full medical psychiatric history review of medication supplements over-the-counter surgeries etc you really want to focus on the social history getting a detailed social history especially regarding trauma you know intimate partner violence any abuse and history of coercion and of course also sexual history including practices and again you know you really want to focus on their functioning sexual performance prior to prescribing OCPs because there is of course some risk of decrease or some risk of sexual side effects from the treatment and then finally of course you know in our population for various reasons also in younger patients like adolescents they may not understand their contraceptive options and so it's very important to talk about coercion and any trauma trafficking etc any unwanted sexual encounters and also if you can involve their their partner if willing next again you know you you want to have a comprehensive discussion with your patient when we already talked about kind of like the risks and benefits and then you know also addressing common things to expect like changes in bleeding that can happen with treatment and then sexual side effects we we already touched on it's also important to use this conversation to discuss and really explore like any barriers to you know the patient not willing to accept contraceptives or some of the most common actually reasons for avoiding these medicines is fear of side effects concerns about return to fertility fertility being affected by these medicines and also past experiences and then of course you know this is just kind of like opening a conversation you're generally going to follow up with the patient multiple times make contact with them throughout your visit once you you know decide to talk to them about actually prescribing starting these medicines and so it's really important to just you know try to reinforce this information as much as possible to encourage adherence and also to you know watch out for side effects and other concerns okay so I quickly just wanted to review the menstrual cycle I'm not going to go into detail you're all very familiar with that the reason why I mentioned is because contraceptive methods do affect parts of the menstrual cycle so I have this diagram here and you can see the the different phases there the follicular luteal phase men sees happening and then notably like the hormonal fluctuations and that's what we're going to focus on so on the slide I mentioned some very common emergency contraceptive options and how they act like the the mechanism of action during the menstrual cycle so we mentioned Ella very common abortifacient also called eulapristol the generic name if given in the early follicular phase and that that's down here like after the the sloughing has happened there and the follicles growing it can prevent ovulation because it occurs prior to ovulation there but if given after during the luteal phase it can help prevent implantation that's and then plan B OTC levonorgestrel has multiple mechanism of action it can prevent ovulation as well as fertilization and implantation and the mechanism a little bit different it actually acts on the the transport in the fallopian tube and endometrium so going back to that point about like the mental health effects of hormones so most patients actually who are taking these medications generally do not experience adverse mood effects some studies do show you know like like I mentioned before like with especially in women who have pre-existing mental health conditions they can experience worsening or they may not there's actually a lot of mixed data but overall you know not too much significant mood changes because it actually depends on many factors there's a lot of confounding factors and some patients are more sensitive to the normal hormonal fluctuation that happens and so of course giving them hormones you know that also can affect that that level the way the levels drop naturally and so you know they may or may not experience those kind of effects and interestingly there are a lot of types of progesterone components now and not all of them some of them have mood effects some of them don't so for example some newer ones that are more anti-androgenic like desogestrel and drosperinone have been associated with fewer negative mood symptoms compared to other types of progesterone components used in these contraceptives and so we kind of mentioned this already but you know these are some tips first of all you know you definitely want to find out like what your institution and state laws and policies are regarding actually prescribing contraceptives if you decide to have that conversation with your patient and then of course you know having a backup plan like if you can't actually prescribe like you know either referring them out to their primary care doctor or their gynecologist or elsewhere in six US states including California, New Mexico, Hawaii, Colorado, and Oregon pharmacists can actually prescribe contraceptives which is really handy and so you know it's important to communicate with other care members to have a plan and then you know depending on other like comorbidities it would be important to discuss you know the some adverse effects and really reduce those risks of adverse effects by taking those into consideration things like substance use other medical issues cardiovascular problems and really you know determining maybe if alternative contraceptive options would be better like progesterone only etc and then this last point I thought was really important because you know a psychiatrist medications like valproate are very very commonly prescribed and we know that it has you know that's associated with very severe birth defects if taken during pregnancy and so it's very important that if you have a patient that you're you know of reproductive potential that you want to start on Depakote for example like you have this conversation about you know contraceptive use you know getting them protected before prescribing that okay so this table here this is from a paper by Hall et al called contraception and mental health and basically it's really handy table I'm showing the different types of methods along the the top there the long-acting reversible contraceptives which are like you know the IUDs the implants as well as progesterone only and the combined oral contraceptives and then down along the left there you can see like the different things that you would take into consideration like comorbidities BMI other like mood disorders like PMDD and depression etc that can kind of help you you know determine what would be a better option for a certain patient okay and then very quickly I want to just mention a couple of important drug interactions so generally OCPs and contraceptives you know they can actually play well with most psychotropics but these are some notable interactions I want to point out so generally oral contraceptives for example are metabolized by the cytochrome p34a and so if you have any like cytochrome 3a4 inducing medications like a lot of anti-seizure drugs and you're taking them concurrently with OCPs those you know their levels would be reduced and as you can see here sorry Ani et al you know showed that there's a very high rate of contraceptive failure up to 40% higher in those types of patients who use medications that in or that are strong inducers of cytochrome 3a4 and then on the other hand lamotrigine and levatiracetam are considered relatively cytochrome neutral so they are not likely to reduce OCP effectiveness but you know it could go the other way like OCPs they induce 1a2 so they can actually reduce lamotrigine levels and so in patients who are on medicines metabolized by cytochrome 1a2 like clozapine olanzapine etc it's very important to actually reduce the OCP dose like half it to avoid adverse effects and in some cases where you know the the risk of OCP failure is too high you would actually need to consider you know alternatives or even supplementing with other contraceptives so one of my colleagues found this great app on the CDC website basically it's just an app version of the the PDF they used to have this huge PDF table of basically like you know medical comorbidities and and how to use that to determine how to which contraceptive options would be better for your patient so this is really handy and then I just want to wrap up here so you know again why why this is important because a large proportion of sexually active women are not pursuing pregnancy and so the risk of unwanted pregnancy is super high and we need to address that and we already talked about like the the mental health the increased mental health burdens of dealing with an unwanted pregnancy and you know it can really exacerbate patients who have underlying mental health conditions certain populations are at risk including minorities and underage and mentally impaired people and also people have limited access to care and abortion like we mentioned in our presentation today and so data gathering should always include a thorough social history sexual history and history of trauma and any type of sexual coercion and we already mentioned very important you know prior to starting psychotropics like Depakone and carbamazepine which have known birth defects risk we have to have you know we have to discuss contraception planning and in those patients prior to prescribing and some notable interactions include strong cytochrome 3a4 inducers and medications metabolized by cytochrome 1a2 and you know there are a bunch of options that psychiatrists can either prescribe or refer out as needed to other health care providers and again most women taking OCPs do not experience negative mood changes that really just depends on the individual's vulnerability to hormonal fluctuations which can have many variables and so you know that that's that's why we think it's important really prevent helping prevent unwanted pregnancies does save lives and that's why I wanted to talk about this today all right thank you okay so so we're gonna wrap up with our final mentee poll the first two questions will be a self-assessment if you bear with me one second I'll pull it back up it's we're using the same code is that what we used last time so again if you've accidentally logged out it's mentee.com and use the code six three four seven seven nine four zero so we mentioned this in the talk how many women died from illegal abortions in 1930 oh yep it's at the top this see it six three four seven seven nine four zero I have to give this crowd a lot of credit because I could have been nicer and given multiple choice answers than to ask you to recall a random number buried in this slide show. But a lot of you have it. It was 2,700. So 2,700 maternal deaths in 1930 was about almost one in five of maternal deaths, about 20%. So kudos to all of you who got that number. Our next question, what percentage of pregnancies are unplanned in the U.S.? I will say the answer. I was just giving people a little bit more time to answer. Some of you got it. It's 50%. 50% of pregnancies are unplanned in the US. And approximately 1 5th of pregnancies end in elective termination. What was the most common indication for a hospital abortion in 1972 in the pre-Roe era? Yes, I think you all realize that we're all psychiatrists here and it was maternal mental health. You're all correct. And then this is, you know, just for you all to think about. So how do you see the role of the psychiatrist changing in the post row landscape? We can talk about this a little bit in the middle, but now that we've talked about everything and, you know, considering, you know, potentially prescribing plan B or, um, which is actually also over the counter, um, how, where do you see this headed? You can respond with a little short answer. It should be in psychiatric residency training. Greater need to advocate for patients and help them access resources, likely to be asked to provide reason for abortion, gatekeepers for abortion via psyche valves. Any other thoughts? Is anybody still typing? Advocating for pro-mental health abortion laws, support and connection to resources, mm-hmm. Advocacy, right? Okay. I think that was it, actually. So, you know, at this time, I think we just wanted to take, oh, what did I do? We just wanted to take questions. How do I get out of this? Oh, here we go. I got it. Sorry. I can do it. What questions do you all have? Like, we would like to just open it up. We have, like, maybe five, well, probably we're out of time, but we can spend five minutes with discussion, if anybody would like to stay. Or comments, yeah. Great presentation, all of you, and such a timely topic. So I'm Frank Clark. I'm a psychiatrist out in South Carolina, and I did not know about the potential death penalty, and I'm curious, do you think, if that is passed, will other states that are very restrictive follow suit? That's a toughie. I think that law, or that potential law, is one of the biggest gut punches in all of the laws that have been suggested. From my most recent research, there hasn't been any movement on that, but it would be very interesting to see how that plays out. I mean, you see states like Texas saying that you cannot prosecute the woman, and the emphasis is on prosecuting the provider. So to kind of have that pivot to potentially even threatening the death penalty, let alone imprisonment for the woman, is just so different, even for the most staunch anti-abortion activists. So I wish I had a crystal ball. I really don't, but I will tell you, I pray that's not the case, right? But yeah, I appreciate your question. I'm curious if anybody else has thoughts about that. My thought is they wouldn't. I don't think that will even go through, even if it does. It's anti-anti-abortion, because it's usually against death. Andrew Lancia, University of Illinois in Peoria. I'm curious, looking at long-term effects with abortions becoming less frequent and people delivering, looking at long-term effects, so 18 years when the kid is an adult, maternal satisfaction with delivering and the child's satisfaction with living. Were they happy that they were born and whatnot? Is there any studies that actually looked at mothers who had the baby and now they're adults? Do they look back and regret or appreciate it? Yeah, I'm glad you asked that question. I want to see if it's in our works cited. There is something called the Turnaway Study. I'm not sure if you're all familiar, are any of you familiar with the Turnaway Study? I'm trying to find it. It's definitely cited somewhere in here. If it's not, I can send it to you. But there was a study. I forget what year it took place in. It was in the pre-Roe era. 2008 to 2010, and I think they followed up for pregnancy outcomes. Every six months, they followed up with the mothers for, I think, 10 years. Or not 10 years. 10 years is too long. I think five years. But 2008 to 2010 was when the industries were recruiting women, and they had six-month evaluations for the women that were turned away for reasons of being past the gestational age for obtaining an abortion. And as I said, I think it's five years. They did six-month evaluations every six months. And they talked about what were the satisfaction levels, quality of life, socioeconomic status in those subsequent evaluations, and trying to see the trajectory for those women that were turned away from obtaining an abortion. I can't find the citation right now, but there is a paper that discusses this topic. I mean, I will tell you just myself, as a child and adolescent psychiatry fellow in Philadelphia, I predominantly see a lot of inner city children who had a lot of difficult exposures, clearly, when the mother was pregnant, to different substances and to different things and seeing how these children are progressing is very difficult. I do imagine what it would be, what it is like for a lot of these mothers as well, having gone through what they've been through. And also just to add, I think the turn away study talks primarily about these quality of life indices, but also I was reading another paper about there not being any difference in satisfaction, regardless of what direction they took, if they received an abortion versus not receiving an abortion. Just following up on what you talked about, there was a book, Freakonomics, by Levitt and I forgot the name, from the University of Chicago, who went back and did an analysis and they looked at the crime, and it seemed to be about 18 years after Roe versus Wade, crime started falling, and their argument, their thought was that women were able to get abortions, so that women who had unwanted pregnancies and were forced into birth were therefore less involved and less committed as mothers, and that those children might grow up to commit more crimes, that was their argument. And you may see another thought you didn't, I don't know if it was brought up, but with the denial of women to have abortions, there may be mental health consequences to those women, which psychiatrists will see all the time. To also add that with the Hyde Amendment in place, that effectively nullifies use of federal funds, so people who are dependent on Medicaid won't get the essential, they can't access abortion and reproductive care, while the state can decide to use state funding for abortion and reproductive care, but no federal funds can be used for that, so that directly impacts women of lower socioeconomic status, and minority women in particular. And also women of lower socioeconomic status can't afford to travel faraway places, they can't get on a plane to New York like other people can, so, yep. Thank you. The other thing I realized we forgot to mention is if you look in, on the APA app where you can see, you know, the things we've uploaded, the slides and whatnot, I should have pulled them up on the computer, but I forgot to do this, we made a handout on the Psychiatrist Guide to Prescribing Birth Control, I've run it by multiple gynecologists and they all approved it. So if you want to take a look at that, it talks a lot about also, like, which population might be better for this birth control or that birth control. There was a birth control that is, I believe it just got FDA approval, the OPIL, which will be over the counter, which is pretty cool, Plan B is over the counter, and just to be clear, we're not advocating that psychiatrists, you know, put in an IUD or do anything invasive, but, you know, it really, I have personally prescribed Plan B to a patient and it was like a pretty cool moment. We actually did it right when Roe versus Wade overturned when I was in session with a patient, and I told her, like, I apologize that I'm interrupting our session to tell you this, but it just came across my computer screen because it was a tele-appointment and I know if I don't tell you this when you leave here, this is going to be really difficult for you because she was a young, very pro-woman patient, and I told her Roe versus Wade was just overturned and we kind of sat in that grief together for the rest of the session, but I said to her, you know, I don't know what I can do, but I can give you a prescription for Plan B if you ever should need it, and she was like, yeah, I would love that, and it was kind of a cool moment for me, just being able to offer that to her, and since then, you know, in my work in child and adolescent psychiatry, I do have a trans boy who I see who it's really distressing for him to get menses, so I do refill his birth control, and it's been helpful. Yeah. On that note, psychiatrists are licensed physicians. They're perfectly qualified and capable of prescribing medication abortions with mifepristone and misoprostol. Yeah, thank you. We were wondering, you know, I think at the beginning of this talk, we asked would people be open to prescribing birth control, and there was actually a lot of no's, or that they did not plan to prescribe birth control. I'm wondering if this has changed any minds or if anybody would consider prescribing Plan B if a patient said that they needed it. I think a lot of people also don't feel like they, like, have the education to be able or have the skill base to be able to prescribe birth control, and I know, like, in my program in Baltimore, we have a reproductive mental health clinic that we rotate through, and so prescribing birth control has been part of my training, so I think that that gives me a level of comfort with that that I'm not sure if everybody has in looking at the nuances of which birth control to prescribe, right, and kind of looking at especially, like, the metabolism of the birth controls versus the medications everybody's on, and so we're hopeful that this empowers you as a psychiatrist to feel more than capable of being able to, like, kind of provide this service to your patients as physicians. Any other comments? Well, we appreciate you all coming, and we hope you feel just as strongly as we do.

psychiatrists

reproductive health

Roe v. Wade

abortion laws

maternal mental health

advocacy

historical role

state-specific restrictions

vulnerable populations

forensic psychiatry

contraceptive counseling

comprehensive care

systemic advocacy