Hi, everybody. Good morning. Thank you for coming. I'm Madeline Becker. I'm a psychiatrist. I work at Thomas Jefferson University in Philadelphia, Pennsylvania. And through the APA, I have roles and I serve as a member for the Committee on Women's Mental Health with an amazing group of women. And I serve on the Council for Consultation Liaison Psychiatry and also I co-chair a work group on the Dobbs decision. And I'm delighted to be here today with my expert colleagues to talk about the overturning of Roe versus Wade and the implications for women's health. So I'm going to introduce, we have several speakers, one of which is not here, so she has a recording. But what I want to tell you is that we're going to talk about the history of Roe versus Wade, the implications for women's health and well-being, and the impact on psychiatrist's role in caring for pregnant patients. And because we're talking about a lot of different issues, we have three different speakers. We have Nicole Huberfeld, Nancy Byatt, and Paul Applebaum. And I will introduce each of them before they speak as we go along. Hi, everyone. I'm Nicole Huberfeld. Thank you so much for having me. I wish that I could be with you live. But unfortunately, I need to be in Boston and participating in graduation activities, which is a happy event. But I would really love to be with you in San Francisco. And I will be with you for the Q&A for our panel today. So I have the task of speaking about how law is a determinant of health. And so what I'd like to do is speak with you first about how the right to privacy existed before the Dobbs versus Jackson Women's Health decision came about last June, what that did in terms of protecting rights related to intimate relationships and personal decisions. I'd also like to help you to understand what variability between states looked like before Dobbs was decided, and also the kind of conflict and chaos that has arisen in the wake of the Dobbs decision, how there is conflict between states, even within categories of restrictive states and protective states, and how this makes it so that there are also new conflicts arising between states and the federal government. All of this will set us up to discuss what conflict between the states means for access to health care, what it means for health, not just for patients, but also for the moral distress that physicians are experiencing. And I'll let my other colleagues on the panel take it away with speaking more specifically about the impacts on health and health equity that Dobbs has had in the past almost year. And so what I'm going to do is share some slides. But before I do that, I would just like to mention that I think it's really important for us to use inclusive language. However, I cannot always use inclusive language when speaking about people who are pregnant or capable of pregnancy, because the law is rooted in its equality doctrine in a gender binary. A lot of the law, especially law that came out of the Supreme Court pertaining to equality and even privacy, is rooted in the idea that women have been treated differently than men in the United States and globally. And so we need to understand that sometimes I must use words like woman, female, mother. And in fact, even more importantly, this is a precise reflection of what the laws coming out of restrictive states look like, because those states often purposefully use the gender binary in their language, again, using words like woman, pregnant woman, mother, et cetera. So to the extent possible, I'll use inclusive language. But it isn't always possible. And I apologize in advance that that is the case. I'd also like to mention that we could really talk all day about the level of conflict that's occurring at the state level. This is truly shifting all the time. And so I've included links in my slides that will help you to keep yourself informed if you so choose. So you may be aware that there has been a doctrine called the right to privacy in the United States. And this right to privacy really protects three kinds of liberty interest. First, there's the right to procreate, which is the right that is not just a right to bear children, but also rights related to family and the right to marry. And we'll see that this is related, too, to the idea that there is a right to prescribe, to purchase, and to use contraceptives. And up until last year, there was also a right to access medical care that ends a pregnancy. So where did this begin? Well, just about 100 years ago, we were in the throes of the eugenics movement. And the Supreme Court had a number of eugenicists amongst the justices. And they held in 1927 in an infamous case called Buck v. Bell that the state of Virginia could choose to sterilize people who were deemed, quote unquote, feebleminded. And this is the case that gave us the famous quote, three generations of imbeciles are enough. However, as you're probably aware, the eugenics movement also gave rise to Nazism. And so in 1942, the Supreme Court reversed course. And it held in a case called Skinner v. Oklahoma that Oklahoma could not use sterilization as a penalty for people being convicted of certain kinds of crimes. And the court said famously, this is legislation which involves one of the basic civil rights of man. Marriage and procreation are fundamental to the very existence and survival of the race. The power to sterilize, if exercised, may have subtle, far-reaching, and devastating effects. And so this led later to cases like Loving v. Virginia, the case in which the Supreme Court held that Virginia couldn't outlaw marriage between Black people and white people, and cases like Obergefell v. Hodges, in which the Supreme Court held that the right to marry also meant that same-sex couples could marry. This case also led to other decisions, for example, upholding parents' rights to raise their children as they see fit, allowing parents to school their children in other languages or in religion. And as time went on, this led to the question as to whether if there was a right to procreate, there was also a right not to procreate. And so in 1965, the Supreme Court held in Griswold v. Connecticut that there were various constitutional guarantees in the Bill of Rights that create zones of privacy. And this meant that the right of privacy protects married couples' choice to use contraceptives. And the person you see here is Estelle Griswold. She was the leader of Planned Parenthood in Connecticut, who was purposefully challenging Connecticut's law outlawing the use of contraceptives. And she was working with doctors at Yale. And so they made it so that this was a sympathetic case to the justices and one that was comfortable for them to think about because they were comfortable thinking about married couples and what they might do in the privacy of their marital bedroom. However, privacy doesn't just encompass what people do in their own home. It also encompasses the physician-patient relationship. And it encompasses information shared in the physician-patient relationship. So there are a number of different aspects to privacy. Just a few years later, in Eisenstadt v. Baird, and by the way, this is Bill Baird. He was an activist in and around the Boston area. And you can see here, he's advocating for easy access to contraceptives near the BU campus. In Eisenstadt v. Baird, the Supreme Court held that it was a violation of the Equal Protection Clause for people not to be able to use contraceptives if they were single, given that married people could also use contraceptives. Now, in between these two cases, Roe v. Wade had actually been heard in 1970. But the Supreme Court asked the parties to revisit their arguments and come back to the court, making it so that Roe v. Wade wasn't decided until 1973. In 1973, the Supreme Court held, as you all probably know, that there's a constitutional right to privacy that protects a woman's decision to terminate pregnancy when that decision is made with the physician. And that was a decision that was rooted in the trimester framework, making it so that the state could not outlaw access to abortion before the line of viability, i.e. when a fetus is viable outside of the pregnant person's body. Even after the point of viability, the court said that the state or other regulator has an obligation to preserve access to abortion to save the life or health of the pregnant person after the point of viability. So there must always be exceptions under the Roe v. Wade rubric. For years, people challenged Roe v. Wade. So I think we should understand that this really is a 50-year decision that Dobbs brought to a head. And so one of the things that happened in the interim is that it was decided by Congress that Medicaid would not pay for abortion under a rider on health and human services funding called the Hyde Amendment. The Hyde Amendment makes it so the Department of Health and Human Services cannot use federal money for paying for abortions unless they save the life or health of the pregnant person or except in instances of rape or incest. But there were lots of other challenges occurring. And in 1992, the Supreme Court once again upheld Roe v. Wade and said a state cannot prohibit abortion before viability. However, the court also noted that the state has a legitimate interest in protecting women's health and the potential fetal life throughout pregnancy and upheld certain elements of Pennsylvania's law, which made it so that many states in that time period had waiting periods, 24-hour waiting periods that required a physician to deliver certain kinds of information and then the patient to wait for 24 hours before having the abortion procedure. Also, some of those laws evolved into requiring patients to view ultrasounds while the physician was describing what's on the ultrasound. Many states also implemented parental consent laws. Those parental consent laws must have a judicial bypass if a minor is unable to speak with their parents about obtaining healthcare. But parental consent laws became quite common even in states like Massachusetts that we think of as being protective of access to care. And of course, the Hyde Amendment came about and led to some states also restricting payment for abortion through private insurance. Some states also made it so that if a patient has a living will that says, you know, if I'm catastrophically injured and I can't speak for myself, I would want you to remove life's disseminating treatment. Some states say if a patient is pregnant, then their living will doesn't apply and healthcare providers have an obligation to keep that patient alive. So everybody is probably aware that most patients who access abortion tend to be lower income. Many of them are people of color. Many people are not aware that even before DOBS was decided with Roe v. Wade in place, many people had to travel hundreds of miles to access a safe and legal abortion. And in the states that have made access to care harder, they tend to have higher infant mortality rates. They also tend to have higher maternal mortality rates and the teen birth rates tend to be higher in these states. So that when we were coming up against the DOBS decision, in the United States, black women were facing three times the maternal mortality risk of white women and Hispanic mothers also were facing a high risk, but just about the same as white mothers. And so it's important to understand that maternal mortality in the United States was already notably high, especially for such a wealthy nation. Recent trends in restrictive state laws reflect that we were seeing changes in the approach to try to challenge the Roe and Casey rubric. So states were implementing longer waiting periods, not just 24 hours, but 48 hours, 72 hours. Some states were requiring medically inaccurate informed consent. So as medication abortion became more consistently used, some states were requiring healthcare providers to tell patients that their medication abortion could be reversed. And this is still going on now. There were extra licensure requirements being imposed on healthcare providers, such as the targeted regulation of abortion provider laws that made it so that there were special rules for abortion clinics. There were also additional exclusions from public and private insurance coverage. And some of those were actually extended by the Affordable Care Act. And then states also started to look at fetal pain laws saying if a fetus can feel pain, then it shouldn't be aborted, which reflects that there is some neural activity that can be detected before viability. And states started to enact pre-viability fetal heartbeat laws. And so the Supreme Court heard cases related to some of these newer restrictions on abortion, such as Home Women's Health versus Hellerstadt, where the Supreme Court struck down targeted regulation of abortion provider laws, understanding that many, many clinics would close in the state of Texas under these track laws. And that's what you see in this map. And then the court upheld its decision in Home Women's Health in 2020, making it so that it was quite clear that the court saw that there was an undue burden on patients when trap laws were enacted in the states. Nevertheless, again, coming into DOBS, what we saw was that 36% of US counties are maternity care deserts, and nearly half of US counties do not have any obstetric providers. And what this means is in rural areas where hospitals are closing, many hospitals, if they don't close, will close the departments that are expensive for them to keep open. And that includes, for example, obstetrics departments, because if you don't have a dense population, you don't have a lot of babies being born, which means keeping those departments staffed is expensive for hospitals. So many people have to travel for any kind of care, which is critical for understanding what reproductive justice means, because it's not just about abortion. It's about choosing when to have children and having children in a healthy and safe way so that both the parents and the children themselves are healthy. So travel distance is a barrier to health. So what changed between cases like Whole Woman's Health versus Hellerstedt and June Medical Services and DOBS versus Jackson Women's Health? Well, what changed is personnel, quite frankly. The balance of the court shifted when Ruth Bader Ginsburg passed away and Amy Coney Barrett was appointed to her seat, making it so that there were six justices who were willing to hear this challenge that came through Mississippi, where Mississippi had enacted a fetal heartbeat law that restricted access to abortion after 15 weeks. And then Mississippi also enacted laws restricting access to abortion at six weeks and making it so there was no access to abortion. And so the court was at first asked to decide whether or not it was always unlawful for a state to outlaw abortion after 15 weeks. And Chief Justice Roberts was willing to hear that question because the vast majority of abortions are obtained before 15 weeks. And he thought it wasn't an unreasonable question. But then when Amy Coney Barrett was appointed to the court, Mississippi changed course in its legal tactics and it asked the court to overturn Roe and Casey. And suddenly the court had the right balance to do that. And as you all know, it did so. No fewer than six times in the course of this decision, the court says we're going to return the issue of abortion to the people's elected representatives. So what does that mean to return the issue of abortion to the people's elected representatives? Well, you have to remember that there was high variability between state laws before this case was decided. But some states had in place what we call trigger laws. Trigger laws make it so that at the moment that the Supreme Court overturned Roe v. Wade, the state would have a law in place that outlawed access to abortion in that state. And that's what you see here in the maroon states. And this is a map that comes from the Center for Reproductive Rights, which is doing sort of real-time tracking of state laws. And you can kind of slice and dice this map. It has a nice hover over feature. So I recommend it as a resource. So these are states that have trigger laws. What I'm also highlighting here is states that enacted Texas-style whistleblower laws. So you may be familiar with, for example, SB-8 out of Texas, which made it so that the state itself could not enforce restrictive abortion laws, but that private whistleblowers or bounty hunters could. And other states, Oklahoma and Idaho, have also enacted whistleblower laws like Texas's to facilitate private action against people who obtain abortions where the private actor thinks it might violate the law. In addition, what you see with blue is Texas and Idaho have laws that are so restrictive that they conflict with the federal law called EMTALA, which I'll talk about more in a bit. So states that had trigger laws in place aren't just states with trigger laws. They also have other laws that are relevant to our conversation. And all of these laws overlay with the pre-existing restrictions on abortion in many states. Some states now have a total ban on access to abortion. Some states now have a six-week ban on access to abortion, which many people would say is effectively a total ban because many people don't know they're pregnant by the time they've reached six weeks from their last menstrual period. Many states have implemented telemedicine limits or bans on access to abortion. And these telemedicine limits go hand in hand with limitations on medication abortion because many people obtain medication abortion through telemedicine. And in fact, as you're probably aware, due to the COVID-19 pandemic, telemedicine and medication abortion became the majority method of abortion in the United States. Now, this is also because the Biden administration working with the FDA made it so that access to medication abortion became easier during the course of the pandemic. Instead of having to go pick up the medication from a physician, a patient could obtain it simply from a pharmacy like any other medication. And so many states now operate in conflict with the FDA's protocols for medication abortion. And in fact, this week, the Fifth Circuit is hearing arguments out of Texas as to whether Mifepristone was appropriately approved in the first place by the FDA. One thing that I think is important to note is that these kinds of restrictions are just getting going. In other words, when the Dobbs case was decided, most state legislative sessions had ended already and most state ballot initiatives had already been completed so that it's really the 2023 state legislative sessions that have started real action on either protecting or restricting access to abortion. And so for example, in some states, there is constitutional protection for access to abortion like Florida, but Florida has been trying to restrict access to abortion because it doesn't want to be the go-to Southern state for access to abortion simply because its constitution allows access to abortion. Or other official documentation. Many of you may have heard through the news that Idaho has enacted a trafficking of minors bill that makes it unlawful to take minors across state lines to access abortion. North Carolina is a state that has had a 20-week restriction on access to abortion, which in the wake of Dobbs seems actually fairly generous. And now just yesterday or the day before, North Carolina's legislature overrode the Democratic governor's veto and limited abortion access to 12 weeks. This is important because North Carolina actually has become a destination for accessing abortion for Southern states, especially people in the Southeast. Utah has a bill that would ban abortion clinics, making it so that people have to use hospitals to access abortion. And of course, Utah has vast rural areas where people simply don't have hospitals that they can access with any ease. And some states like Wyoming have funny constitutional provisions that were anti-Affordable Care Act provisions, making it so that individuals in the state had a constitutional right to access any healthcare that they wanted to. Wyoming is one of those states. And in Wyoming, there's a bill that tries to make it so abortion is not deemed healthcare under that constitutional provision. Now it's not all doom and gloom. And I think it's important to note that when we look at what happened with ballot initiatives in the 2022 election, most of the ballot initiatives actually represented a desire on the part of the public to protect access to abortion, at least to the point of viability. And so whether there was a movement afoot to try to read protection for abortion out of state constitutions, or whether there was a movement afoot to affirmatively protect access to abortion, both won during ballot initiatives that were decided in the 2022 election cycle. And some states have also done things like added money to grants to community organizations or created dedicated funds trying to help people access abortion. In those states effectively creating abortion safe havens as they're sometimes called. And some local governments have tried to do this within abortion restrictive states. An example of that is St. Louis within Missouri. Likewise, some states are ensuring that Medicaid has secured access to abortion for Medicaid beneficiaries, even though the Hyde Amendment doesn't allow federal spending on Medicaid beneficiaries in this way, these states have set aside their own money to facilitate funding for Medicaid beneficiaries. And some states are now taking action to make sure that private insurers will cover access to abortion, at least in certain circumstances. Some states have laws that protect access to abortion. And as I just mentioned, some states also have constitutional protections for access to abortion. And what is happening there is that state constitutions actually often are more specific than the U.S. Constitution. And so they might specifically state that there's a right to privacy, a right to autonomy, or that their equality protects access to care, or even more specifically that it's sex-based equality is read into their constitution. And so constitutional protections in certain states may conflict with existing state laws, but the constitution in the state would win. And so in some states, you have both constitutional protections and statutory protections for access to abortion. Some states have shield laws. Shield laws make it so that if a healthcare provider offers care that is lawful in the state in which the provider is offering care, then that provider's license is not jeopardized by providing lawful care. And I say it that way because this is in many states, not just about access to abortion, but all reproductive care and sometimes even gender-affirming care as well. And so I think that's important to mention because these issues are getting folded together in state legislative sessions. States that are working to outlaw access to abortion have also been working to outlaw access to gender-affirming care. And states that have been working to shield access to care have been doing so in both dimensions as well. There are additional actions that states have been taking to protect access to care in the 2023 legislative session. So for example, Illinois is working to expand the kinds of healthcare providers who can perform abortions. So not just limiting it to physicians, but also for example, nurse practitioners or expanding what pharmacists may be able to do. Same thing in Hawaii. In Minnesota, there are actions to codify the right to abortion in state law and a shield law. New Hampshire just codified abortion rights and removed physician penalties for providing necessary abortions after 24 weeks and rejected abortion limiting bills, which is notable because New Hampshire does sometimes have somewhat conservative tendencies. And states like Vermont also have been working toward shield laws. Now, it's important to note that within these categories of protective states and restrictive states, there are conflicts between those states' laws. So if a state outlaws abortion for any point in pregnancy and its neighbor state outlaws abortion at six weeks, that's a conflict between their laws. And a person crossing state lines who finds out that they're pregnant in five weeks, who returns to their home where no abortion is permissible, is still violating their home law, arguably, and that restrictive, permissive, or protective categorization is a little deceptive there. So I encourage you to try to think about this with nuance because those nuances also matter in terms of understanding what it looks like to have federal and state conflicts. So as soon as the Dobbs decision was leaked, President Biden created a task force on reproductive healthcare access that began to make recommendations as to what the federal government could do to try to protect access to abortion without trying to enact laws like the Women's Health Protection Act, which passed the House before the midterm election, but hasn't made it anywhere in the Senate. And so, for example, the Department of Justice has explained that the Emergency Medical Treatment and Labor Act, the federal law that makes it so that patients arriving in emergency departments must receive needed care, is interpreted to preempt state laws that would outlaw access to abortion if a patient presents in an emergency department and has a medical emergency that would require that the standard of care be to provide an abortion. Now, again, in Idaho, the Department of Justice won that argument, but in Texas, the Department of Justice lost that argument because Texas is arguing that they didn't follow proper administrative procedures. So there's actually two different kinds of decisions in those places, and I suspect we'll see more action on that. Again, the FDA rules for medication abortion are an issue in the Alliance for Hippocratic Medicine case versus FDA that's being heard in the Fifth Circuit Wednesday of this week. And so there will be more information on that fairly soon. In the meantime, there has been some expansion of access to medication abortion by the Biden administration, including expanding pharmacy access, which again would conflict with some existing state laws. The Biden administration has funneled more funding to Title X, which provides family care, family planning care. And they have encouraged states to use Medicaid waivers to improve access to care, but it's difficult to know what that looks like when we're talking about abortion. When we're talking about maternal mortality, importantly, many states are taking the Biden administration up on expanding postpartum Medicaid coverage to a year, which is evidence-based policymaking that will help to improve maternal mortality in many places. And so I encourage you, if you want to follow this to check out this chart that Kaiser Family Foundation has created, which helps you to see what's happening in terms of different federal state conflicts. And so, as I said, this conflict is just beginning because there's so much happening in terms of the state legislative sessions and what states are trying to do at this time. And this link will take you to a litigation tracker that again is offered by Kaiser Family Foundation, a reliable nonprofit. And I'll just note that just yesterday, there's a really important study that was released by the same folks who performed the Turnaway Study, documenting clinicians' stories about how care has changed after DOBS. And clinicians are saying things like, my hands were tied, an anesthesiologist was crying on the phone, fearing for a patient's life. Physicians are perseverating about whether they can legally provide standard of care medical treatment. One primary care provider said to a nurse that offering a helping hand to a patient, just even getting onto a gurney while having a miscarriage could be construed as aiding and abetting an abortion, and that they shouldn't even touch the patient who was miscarrying. And some patients were told postpartum that they couldn't have a DNC because DNCs were now illegal for any reason. And I mentioned this for a couple of reasons. First of all, this does implicate mental health because a patient, for example, who was raped and was experiencing morning sickness was having PTSD episodes every time she had morning sickness and tried to take her own life. Yet, as you'll hear, some states are saying that psychiatric care doesn't count as life-saving care for someone who may need access to an abortion. And so I think it's totally critical for us to be clear that these changes in law make it so that there is an atmosphere of confusion and confusion leads healthcare providers to be fearful to provide care. And if they're fearful to provide care, then patients don't get access to the care that they need. Thank you so much for hearing me out, and I look forward to your questions. We'll save our questions for the end. And I want to thank Nicole Huberfield for doing that. I thought that it was a very important part of this presentation to teach you all, as we're all physicians, to hear from a lawyer, to understand the state of the United States and the laws and how they differ and how that impacts how we respond as healthcare practitioners to the current environment. I'm going to next introduce Dr. Nancy Byatt, who's a friend, colleague, and who serves with me on the Committee for Women's Mental Health through the APA and also on the DOBS Committee, the DOBS work group. She's a professor of psychiatry and also of obstetrics and gynecology and population and quantitative health sciences at University of Massachusetts Medical School. She developed the Massachusetts Child Psychiatry Access Program, MCAP for Moms. It's a statewide national program that has increased access to mental healthcare for millions of perinatal individuals. It has become a national model for perinatal mental healthcare and has impacted state and national policies and funding. She's also the founding executive director for the Lifeline for Family Center and the Lifeline for Moms. Dr. Byatt's research focuses on designing, implementing, and evaluating scalable approaches for improving parental and child mental health services and outcomes. With over 10 years of continuous federal funding for her research, Dr. Byatt's achievements have led to numerous publications and book chapters. She is going to talk to us today about the end of row and the implications for women's mental health. Welcome, Dr. Byatt. So thank you, Dr. Becker, for that introduction. So what I'm gonna talk about, as Dr. Becker mentioned, and to Dr. Huberfeld for her wonderful introduction of the legal aspects of this, I'm gonna talk clinically about the implications for women's mental health. So as we, you heard a little bit from Dr. Huberfeld about some of the impact, I'm gonna focus it specifically on perinatal mental health. So we know that perinatal mental health and substance use disorders, they're common and they're undertreated. So one in five individuals will experience a mental health or substance use disorder during pregnancy or the postpartum period. And these illnesses are very, even if they're detected, they're undertreated. So our group did a systematic review and we found specifically for depression that even if somebody screens positive for depression, less than a quarter of those individuals will even get to an initial mental health appointment. So the vast majority are going untreated. As you heard from Dr. Huberfeld, our country has an increasing maternal mortality rate and it's really unacceptable. And the most recent data from the Maternal Mortality Review Committees makes it very clear about the role of mental health in this. So mental health and substance use disorders are now the leading cause of pregnancy-related deaths in the United States. So 23% of the deaths are due to mental health and substance use disorders. And actually, maternal suicide deaths are more common than maternal deaths caused by postpartum hemorrhage or hypertensive disorders. They're almost 10% higher than any of these cardiovascular causes. And so this is being recognized, right? These illnesses are common, they're undertreated, and women are dying. And many professional organizations and policymakers are recommending people are screening these settings and this is addressed in healthcare settings. And when we think about the healthcare setting, let me see if I can use the clicker, oops, I need to go forward, there we go. We think about the healthcare setting, right? At the center is the patient and their infant, right? That's what we should be doing all this work with and for individuals that we're serving. And then around that is the partner and the family. And then there's the healthcare system. And as you heard, a lot of my research and our research at our center has focused really on changing healthcare systems to increase access. However, around that is all these social determinants of health, the circumstances in which we live, born, and age, the environment in which we live. And then those which often are adverse and drive structural inequities are driven by these structural inequities and biases, including policies and laws. And when we think about reproductive healthcare, denying women reproductive healthcare creates an adverse political determinant of health. So you might be wondering, well, who gets an abortion? Like who is seeking this? How often does it happen? So one in four individuals will have an abortion by the age of 45. And the vast majority of people seeking abortions have a low income. And often that income is below the federal poverty level. So you heard from Dr. Youhubeheld briefly about the Turnaway Study. And I'm gonna summarize some of the data from that. The Turnaway Study was a prospective longitudinal study that examined the effects of unintended consequences of an unintended pregnancy on women's lives. And so they conducted the study from 2008 to 2010, and they recruited just under 1,000 people from 30 abortion facilities around the country. And each site where they recruited individuals from had the latest gestational limit within 150 mile radius. So if they couldn't get the care there, they weren't gonna be able to get it elsewhere. Because there was no one nearby who could provide an abortion. And what they did was they followed individuals who were able to access a wanted abortion versus people who were denied an abortion. When they did the Turnaway Study, they obtained a lot of quantitative data. They also talked to women and heard their stories and obtained qualitative data. And I'm gonna describe a composite from the Turnaway Study that describes a lot of the things that they were hearing about in these women's stories. So someone who I'm gonna call Dawn lives in Texas, and she finds out she's pregnant at 13 weeks gestational age. She had been using contraception, she missed taking a few of the pills, and she finds out she's pregnant. She's 20 years old, she already has a two-year-old, and she's single. The father of this pregnancy is a different father, and she's already struggling, and she's living just at the poverty line. And she is seeking an abortion because she is concerned about her ability to take care of her existing child. She feels she's concerned about the finances of taking care of that child. She's concerned about the logistics of having someone to care for two babies. And she thinks that it's gonna be better for her existing child if she can terminate this pregnancy. She also is concerned about her relationship with her partner, or the father of the baby, which relationship with which she wants to extricate herself. She's concerned that they won't be supportive financially, emotionally, or with any parenting. And also, she's experiencing interpersonal violence in this relationship. So this is a composite of sort of many of the reasons why people are seeking abortions. And what they found in the Turnaway Study is that people seek abortions because they feel that it's best for them and their family, just like we heard about with Dawn. So women in the study gave many reasons for wanting to terminate their pregnancies, and the primary reasons were they couldn't afford to raise a child or another child. The reasons related to the man involved in the pregnancy. 30% of the individuals in the turn away study wanted to terminate their pregnancy because of the relationship with the partner. And 8% specifically talked about domestic violence. And they also wanted to care for the children that they had. And when they went back, they followed these individuals over five years. And at the end of the five years, they asked the women how did they feel about the abortion from the women that were able to access one. And over 95% of the women felt all the time that the abortion was the right decision. So this concept that we're going to save them from making a bad choice is just absolutely not true. There's absolutely no evidence to that. And it turns out that these women are right. Being denied an abortion is associated with worse outcomes for women and for their families. So when women are denied a wanted abortion, children are negatively affected. Families are at higher risk of falling into poverty. And the women's existing children are more likely to have socioeconomic challenges themselves and also for them not to meet developmental milestones when their mothers are unable to access abortion care. So women's instincts on this is right. And the data backs it up. So when women have control over the timing of having children, their children benefit and the family benefits. And the data also shows that when women or children who are born later to women who are able to get an abortion, they have better economic security, we see better maternal bonding, and they're more likely to meet developmental milestones. So that's sort of the impact of this on the baby and on the family and the existing children. I'm now going to transition to talking about the impact on perinatal health and mental health. So we often hear that, well, part of the reason why we're restricting abortion is because it's going to be negative for mental health. There's absolutely no evidence for that. Being denied an abortion is associated with elevated levels of anxiety, stress, lower cells of steam soon after the abortion denial. And there's absolutely no evidence that abortion causes negative mental health outcomes, which is often purported when you see these restrictive abortion laws. And then also, what there is evidence for, however, though, is that the stigma related to abortion, for example, in the Turnaway study, many of the women met with protesters when they went to the clinic. That is indeed very stressful, can be quite traumatizing, and that is associated with negative outcomes. So it's the stigma associated with abortion that's linked with the negative outcomes, not the abortion itself. And then we often hear, well, we're saving women from this risky activity, and it'll be better for their health. Also not true. So the risk of mortality and morbidity from childbirth is far higher than the risk from an induced abortion. Having an abortion is often compared to a simple procedure at the dentist, which we often don't think twice about. We know we need to get our fillings. We know we need to get a root canal, or what have you. And as we heard, these disorders are also a leading cause. Mental health and substance use disorders are a leading cause of mortality. And so as we heard from Dr. Huberfeld, restricting abortion, it's already starting to, and it will continue to increase maternal mortality and morbidity. And we already see that, that states that have these more restrictive laws have higher mortality rates. This is going to worsen. And in general, what they found in the Turnaway study was that the risk of mortality from childbirth is 14 times higher than the risk of abortion. So it's a much riskier proposition to carry, particularly unwanted baby to term, than to have an abortion. And then the other thing I want to note, as you heard about from Dr. Huberfeld, is there's absolutely no question that this will disproportionately impact and further marginalize individuals who already have limited access to affordable and safe medical care. So black women in the United States are three to four times more likely to die than white women. And also, when people, many of the risk factors for mortality are also socioeconomic marginalization. And so we know that most women, the majority of women seeking abortions are from communities that have been marginalized, and often, whether that's due to race, ethnicity, whether that's due to racism, whether it's due to other forms of oppression. And so when we restrict access, those are the individuals that are going to have an even, particularly when there's socioeconomic marginalization, are going to have a harder time getting abortions, and they will have to take these unwanted pregnancy to terms and we will see a worsening of these inequities. So when we think about the case of Dawn that I described, ideally, Dawn would have had access to abortion care. She would have been able to make those decisions that were best for her and her family and improve the outcomes for her family. I'm now gonna transition to talking about how this is gonna impact us as psychiatrists and our practice. And I'm gonna give a case example of this. So I, as you heard from Dr. Becker, I started a statewide program in Massachusetts called MCPAP for Moms. It's a perinatal psychiatry access program, and we provide consultation to providers across the state. OBs can call, psychiatrists, anyone working with a pregnant or postpartum individual. And recently, I got a call from a psychiatrist who was working with a patient that had very complex bipolar disorder with psychotic features. This patient had a history of postpartum psychosis. We know that with postpartum psychosis, there's an increased risk of infanticide and suicide as well. And this patient had this history, and she was on lithium, and she had an unplanned pregnancy, but she wanted to take the pregnancy to term. And she was very concerned about taking the lithium in pregnancy. Just to say, lithium can absolutely be used in pregnancy, or to actually say that it's often considered the treatment of choice for bipolar one for women of trial-bearing age, and can be continued in pregnancy with some close monitoring. The patient, however, was very concerned about being on lithium in a pregnancy, and really felt that she either had to terminate the pregnancy, or, because she didn't want to go through the pregnancy not on lithium, because she was concerned, appropriately so, about postpartum psychosis. So she had a choice that she felt like was either terminate the pregnancy, or stay on lithium in the pregnancy, and she was very concerned about the risk. The psychiatrist had talked to her about this a lot, but he said, I really want you to see her for a consult, so she can see a perinatal psychiatrist and have this conversation. He just fell out of his depth. We were happy to see her. That's a conversation that's providing evidence-based care, right? If I was in Alabama, I could be criminalized for doing that consultation. So this is an example of ways it can affect our practice. That would be against the law in some states to do that, and could be criminalized. And then the other example I want to give is when we think about, for general, that was an example of people who are practicing perinatal psychiatry and specializing this. I want to give an example of how this can impact our practice broadly. For any of us who are saying, you know, women are, you know, all of us, the individuals, all of us are seeing individuals of reproductive age, regardless of whether we specialize in this. And, you know, Dr. Applebaum, Becker, and I are all in the APA work group on abortion. And one of the residents who is in the work group emailed actually Dr. Applebaum and I and said that she had this case. And I'm going to summarize it for you. So the patient had complex bipolar disorder, had, with psychotic features, and had been on Depakote, stable on Depakote for quite some time. Generally, most psychiatric medications can be continued in pregnancy. Depakote is one of the ones that's truly a teratogen. It's linked with neural tube defects and is one that really does need to be discontinued and I would argue shouldn't be given to a woman of childbearing age. In this case, they had tried other things. She'd been on many medications. It was the only med that worked for her and they felt clinically, which sounded appropriate, she needed to be on it. But she also really needed to be on contraception. They lived in a rural part, the patient lived in a very rural part of Alabama, could not access contraception care. They tried to refer her, she could not access care. So they had this patient on Depakote. We know that 50% of pregnancies in the United States are unplanned. She has bipolar disorder and she could have an unplanned pregnancy and the baby could have neural tube defects and she could be forced to take that unwanted pregnancy to term. So I think for us as psychiatric providers, we really need to be thinking about providing, talking about family planning more proactively, especially if we're in a state with restricted access to abortion and thinking about providing contraception care ourselves. I know to show a little bit of data from a randomized controlled trial that we did, we did a sub-analysis from a randomized controlled trial. Grace Masters is my MD-PhD student and this was an analysis that she led that's under review and what we found was we looked at, when Grace did this analysis, she looked at people and she looked at, we followed women from pregnancy until a year postpartum. And we looked at, we compared people that have, whose depression continued, who had depression symptoms at five to seven months postpartum versus don't and how did it impact their use of contraception. So what we found was that when women had persistent depression symptoms, they were less than half as likely to use contraception in the way they intended. And they were five times more likely to use tier three contraception, which is much less effective forms of contraception. And so when we think about this, expanding psychiatric practice to think about contraception care really may help us as psychiatrists promote better outcomes. So we're often treating women of childbearing age with chronic depression. And based on our findings in this study, individuals with sustained depression are less likely to use contraception and this can increase the risk of an unplanned pregnancy. And when they are using contraception, it's not as effective forms of contraception. And in many of our states, with restrictive abortion laws, they may be forced to carry unwanted pregnancy terms, particularly when people are on. And again, they only met Depakote and a couple of the anticonvulsants or medications that are teratogenic. But regardless, this isn't about, we wanna do this because we don't wanna continue meds in pregnancy and they're teratogenic. Most psychiatric meds can be continued except Depakote and a couple of the other anticonvulsants we use for bipolar disorder, which are a higher risk. We know that if women have to take an unwanted pregnancy to term, that it worsens their outcomes, mental health outcomes. It worsens, increases the risk of maternal mortality and of the family's outcomes. If we wanna promote healthy families, we need to be thinking about contraception care. Thinking about our role in ensuring access to that. So the Dobbs decision really limits and interferes with reproductive and mental health care. And it allows government intrusion into clinical decision-making. And sometimes when I'm talking about these people ask, well, is this about whether people should get an abortion or not? No, it's not. Regardless of someone's values, regardless of whether they wanna get an abortion, the point here is that women should have the access to making a choice and access to evidence-based healthcare. This is evidence-based healthcare. It's not about whether we agree that people can have their values and choose what they, but they need to be able to make that choice. It's not about what that choice is, it's about the choice. And it's violative of reproductive and human rights to not allow that choice. And it also is not evidence-based. I wanna just, before I close, note about family relationships. So we heard from the Turnaway study that the existing children and also the later children bonded better with the parents when they had access to abortion. And we know that family relationships play a pivotal role in the physiology, biology, and physical and mental well-being. And for children, mental health is a component and a result of a positive caring relationship. Most of the trauma that we all see as psychiatrists is related to that parent relationship. When there's a disrupted attachment or bonding, it has a lifelong impact. And whether you're a child psychiatrist, adult psychiatrist, we're often spending a lot of time working through that with people, right? And these abortion laws will make our job harder because they're gonna, they can make that challenging. And when we think about child mental health, it's most malleable to safe, stable nurturing by caregivers. And access to abortion is a part of what's needed to promote those, to create that environment. And so when we think about our mental health crisis, you know, we're often reacting to things. We're adding hospital beds, we're using polypharmacy. You know, we're doing all of these things, but if we take a step back, we really need to be promoting healthy and resilient families, and access to abortion care is a critical part of that. So just a thank to all my, you know, I didn't talk about my research studies today, but for all my collaborators and funding, and we will now move to Dr. Applebaum. He'll be talking about in more detail about implications for psychiatric practice. Thank you. Thank you. Thank you very much, Dr. Byatt. Thank you. Thank you very much, Dr. Byatt. Now it's my honor and pleasure to introduce our last speaker today, Paul Applebaum, who is the Elizabeth K. Dollard Professor of Psychiatry, Medicine, and Law, and the Director of the Center for Law, Ethics, and Psychiatry in the Department of Psychiatry at the College of Physicians and Surgeons of Columbia University. He directs Columbia's Center for Research on Ethical, Legal, and Social Implications of Psychiatric, Neurologic, and Behavioral Genetics. He's the author of many articles, many I'm sure of which you've read, and books on law and ethics in clinical practice and research. Dr. Applebaum is the past president of the American Psychiatric Association and the American Academy of Psychiatry and the Law, and is now a member and former chair of the Standing Committee on the Ethics of the World Psychiatric Association. Dr. Applebaum is here to talk to us about the role of psychiatrists and ethics and access to abortion. Thank you. Okay. So thank you and hi, everybody. I'm going to focus in this talk on the implications of everything we've heard about so far today for us as practicing psychiatrists. And although I have no disclosures in terms of financial interests, I do have a memory to share. I did my OBGYN rotation late in 1973, in the fall, winter of 1973. And on my first day on the rotation, the residents to whom I was assigned showed me around. Here's the labor and delivery unit. Here's the post-op unit. And we walked past a ward, this was the old days, and there were wards, that was dark. There were lots of beds in there, but the lights were off. And I said, well, what's that in there? And he said, oh, that's where we used to have all the women with septic abortions who had gotten back-alley procedures. We don't need that anymore. This was months after Roe, just months. And the change was just enormous. And I think, because we haven't really talked about what women do when abortions aren't available legally yet, that just keeping that in mind is extremely important. Okay. So I'm going to focus today on the potential role of psychiatrists as gatekeepers for abortion and then I'll touch very quickly on liability and confidentiality issues. We can talk more about those in the discussion if you want. So pre-1967, all states severely limited the performance of abortions. In some states there were no abortions that were legally available, but most states had exceptions when the life of the pregnant woman was at stake. And in general, psychiatric grounds for determining that the life of the pregnant woman was at stake required an evaluation from a psychiatrist specifying that the woman would take her own life unless a procedure was performed. In the six years before Roe v. Wade in 1973, this situation began to evolve very rapidly at the state level and three states, California, Colorado and North Carolina, further liberalized their abortion statutes and in particular expanded the exceptions for psychiatric indications. So, California is a good case example here. It permitted abortions in its newly modified statute. If there was a substantial risk that continuation of the pregnancy would gravely impair the mental health of the mother to a degree that she would be dangerous to herself or the person or property of others or would be in need of supervision or restraint. It's a quasi-civil commitment standard that you'll recognize there. Psychiatric evaluations were required. They were reviewed by a medical board which had the up or down authority on approving the procedure. Data from California in that period show that after implementation of this law, 86% of the applications for legal abortion were made on mental health grounds and 89% of those applications were approved. There was a similar statutory change in Colorado and in the nine months after that change, two-thirds of the abortions in the state were performed for psychiatric indications. So, psychiatry became the major conduit through which abortions could be obtained and you'll see why that's important today in a few minutes. Although the approval rates were very high, psychiatrists went on record in the American Journal of Psychiatry with their concerns about psychiatric involvement in the process. One wrote, the reality is we don't have the capacity to predict with any degree of certainty which women will experience major psychiatric illness as a result of unwanted pregnancy. And the evaluations themselves were difficult, as you might imagine. Another psychiatrist wrote that the normal motivation that promotes cooperation in these evaluations isn't present. This is a familiar scenario for forensic psychiatrists. The patient may consciously exaggerate all of her symptoms and frequently can be considered manipulative and malingering. Her greatest need is to convince the psychiatrist of her inability to continue with the pregnancy. So psychiatrists felt on the hot seat in these evaluations, and it was widely accepted that many psychiatrists were approving applications regardless of whether the technical criteria were actually being met. So another psychiatrist wrote in this period in the New England Journal, there are no clear-cut psychiatric indications for therapeutic abortion. The risk of precipitation or exacerbation of an existing psychosis is small and unpredictable, and suicide is rare. Humanitarian reasons frequently determine the decision, although they may masquerade under psychiatric labels. So psychiatrists were facing an ethical dilemma in this period. Many of them believed, as is still true today, that pregnant women have the right to choose to end their pregnancies for a much broader range of reasons than the law back then, and in many states today, permits. But to act on that belief meant often generating untruthful reports, testifying that there were psychiatric indications for abortion, predicting, for example, that a woman would kill herself if the abortion were not permitted, when in reality, that wasn't their clinical judgment. And as we have pill mills today, we had abortion mills. There were practitioners you could go to, and you knew that you'd get that note that was required to grant you access to an abortion. This put psychiatrists in an extraordinarily uncomfortable ethical position, as you could imagine yourselves being, if a patient came to you desirous of an abortion, with the kinds of social backgrounds Nancy was describing just a few minutes ago, would not long ago have had no problem getting that abortion, but now you're the gatekeeper. You're the one who's being asked to testify that the indications for a psychiatric exception are met. Now all this changed, as I suggested in the opening, in 1973 in Roe v. Wade, when the court finds a constitutional basis for access to abortions, but it started creeping back in some ways. So another Supreme Court decision, 16 years later, a Missouri case, Webster v. Reproductive Health Services, upheld a Missouri statute that prohibited the use of public funds or facilities, this is Medicaid, for abortion, except when it was necessary to save the life of the mother. Well, there you are. Now you're being asked to decide again whether the mother's life is at issue here. So where are we today post-DOMS? As you've heard, a growing number of states have adopted, are adopting, restrictive abortion laws. That number seems likely to increase. Of those laws, a small number have no exceptions to a ban on abortions. They are absolute. Most allow exceptions in the case of a threat to the life, and in some cases the health, of the mother, and some have exceptions for rape and incest. But it's not as simple as thinking we're just returning to the situation as it existed before Roe v. Wade, because many of the new statutes specifically exclude psychiatric indications. So this is Tennessee, the highlighted portion. No abortion shall be deemed authorized under these exceptions if performed on the basis of a claim or a diagnosis that the woman will engage in conduct that would result in her death or substantial or irreversible impairment of a major bodily function or for any reason relating to her mental health. So we don't want to hear about suicidality. We don't want to hear about psychosis. We don't want to hear about serogenicity of the medications she's taking. If it's mental health related, please leave. We're just not interested in that. It's essentially what the Tennessee legislature is saying here. Some get there, but maybe using somewhat less direct language. This is Oklahoma. Medical emergency, which is the situation in which an abortion exception is allowed, means a condition in which abortion is necessary to preserve the life of a pregnant woman which is endangered by a physical disorder, a physical illness, or a physical injury, including a life-endangering physical condition caused by or arising from the pregnancy itself. So the fact that physical is repeated here four times is not an accident. This is a deliberate attempt to exclude psychiatric indications for abortions. Some statutes, however, open the door a little bit to abortions on the basis of psychiatric exceptions. First, Alabama tells us, as an example of this, that serious health risk to the unborn child's mother does not include a condition based on a claim that the woman is suffering from an emotional condition or mental illness. But if a psychiatrist and another physician, so two physicians licensed in Alabama, one of whom is a psychiatrist, with a minimum of three years of clinical experience, examine the woman and document that she's got a serious diagnosed mental illness, and because of it there's a reasonable medical judgment that she could engage in conduct that would lead to her death or the death of the fetus, then the termination can be performed. So in Tennessee, psychiatrists play no role. In Alabama, the door is open to psychiatrists becoming involved in certifying exceptions to the abortion preclusions. And other states just don't address psychiatric conditions at all. This is Louisiana. It shall be unlawful for any person to perform an abortion unless necessary to prevent a serious health risk to the unborn child's mother, which would seem to allow psychiatric exceptions to serve as the basis for abortion. So where does that leave us? It's not accidental that most states' abortion bans today are excluding psychiatric indications for a threat to the life or health of the mother. It is a direct response to the perceived behavior of psychiatrists in the years leading up to Roe v. Wade. We were the entry point, and in many cases people were responding to the psychosocial needs of the women who were coming to them rather than actually doing evaluations that were intended to focus on psychopathology and actual risk to the woman's life, and everybody knows it. And groups like the National Right to Life Committee are specifically lobbying legislatures not to adopt psychiatric exclusions and in fact to preclude them. But we as psychiatrists are sort of uncomfortable both ways. This gatekeeping role is extraordinarily uncomfortable for us. On the other hand, to see patients who may in fact be in life-threatening situations as a result of the situation they find themselves in being denied access to abortion is even more uncomfortable for us. So it's a very difficult challenge for us. How might we think about dealing with these kinds of challenges we're going to face? So before Roe, as you heard psychiatrists writing about openly, there were no clear standards for determining when the life or health of the pregnant woman was endangered for psychiatric reasons. Today, now, this is an urgent issue. The development of consensual standards for determining when a substantial risk to the life or health of the woman or the fetus exists might in fact not only aid psychiatrists in those states where these determinations have to be made, but it may help to persuade some legislatures that a psychiatric exemption is not just going to be an end run around their abortion bans, but is something that is implementable in a controlled and ethical fashion. And this is a role that an organization like this one could certainly take on. So let me say something briefly, because I want to leave time for our discussion about just two other issues that are looming for us and our colleagues, at least those of our colleagues who are in states that have criminalized abortion. Some of those states have criminalized not just performing an abortion, but also aiding an abortion, aiding and abetting a woman who is seeking an abortion. And in those states, should prosecutions be implemented, there may be efforts to obtain the records of psychiatrists to confirm that an abortion occurred and to identify the people who assisted in it, including family and friends, and who may be susceptible to statutes like the Texas statute, which would make them civilly liable. In such states, psychiatrists are going to need to be very, very careful about what goes in the medical record related to pregnancy and related to abortion. And this is one of those instances where omitting information from the record is going to be more protective of our patients and more strongly in their interest than including every detail of what the patient told you during the session. And as we all know, electronic medical records now are often widely available across systems, and that means you have no idea who could access the information that you put into the record. So, something to keep in mind. Liability is the last issue I want to touch on. The states that have criminalized assisting or abetting, or like Texas, Oklahoma, and the other states that have followed them in allowing civil damages, I think Idaho was the third, have not really clarified what it means to aid or abet an abortion. And Nancy alluded to this earlier. So the question for us as clinicians in those states would be, when does discussing the patient's decision-making about whether to seek an abortion, which you could imagine easily occurring during a psychiatric session, when does that cross into aiding or abetting and therefore leave you civilly liable? Could a psychiatrist safely suggest exploring out-of-state options for an abortion? Could a psychiatrist mention that methipristone could be obtained by mail, at least at the moment, it can still be obtained by mail? Would that constitute abetting an abortion? I don't know the answers to this, and I don't think there are answers today. We're going to have to watch how the case law develops as the courts interpret these very broad terms of the statute. But again, psychiatrists need to be careful, and documentation will play a role here. And again, omission may be safer than inclusion with regard to some of these issues. But this is an unfolding story, and there are some answers that we just don't have. So to conclude, the reversal of Roe v. Wade by the Dobbs Court is going to harm numberless people, pregnant people, their families, and the people who are trying to help them. And we as psychiatrists are going to face serious clinical, as you heard about, but also ethical challenges in the gatekeeper role, in the record-keeping role, in the role of assisting our patients' decision-making. And those issues don't have easy answers right now. I encourage all of you, particularly in those states where abortion laws are in flux or restrictions have been imposed, to really watch very carefully what's going on at your state level and get good legal advice about the parameters within which you can operate. We still have to have our patients' interests first, but this is a tough environment in which to try to do that. So thank you, and let me stop there. Thank you very much. And right now we're going to welcome questions from our audience. And we're also going to pull in Dr. Nicole Huberfeld so that she can also answer some questions remotely. Hello, I'm Bruce Hirshfield from Sparks, Maryland. Wonderful presentation. I don't know of any way to more disrupt the United States of America than taking rights away from Americans. And I would suggest that in history, it's one thing not to have rights. It's another thing to lose rights that you always had had. So that, for example, in Haiti, the slaves revolted the only successful slave revolt in history, when Napoleon tried to reimpose slavery after it had been lifted. So I think it's just going to be a disaster for the United States, particularly to take away rights from some Americans and not other Americans. It seems to me to upset the whole idea of the United States. I did have a legal question. I'm so happy to see Dr. Applebaum here today because he's someone who's so wildly respected, along with the other people on the panel. I don't understand the statement. I think it was Nancy Byatt. Dr. Byatt said that if you help a patient in Alabama by offering advice, I assume in your office, because these days you no longer can have tele-psychiatry where you're consulting to Alabama from Massachusetts. But let's say somebody from Alabama comes to Massachusetts and you say, yes, you can have an abortion and she has an abortion in Massachusetts. I don't understand the legal concept that would allow Alabama to reach into Massachusetts. I understand they could try to extradite you. For example, if you did it in Maryland, Governor Moore would tell them to drop dead. But I don't know what the governor of Maryland would say, Massachusetts would say. And also it's hard for me to imagine even if extradition was implemented, you have a right to fight extradition on your home court. And I can't imagine that a jury in Massachusetts would insist you going back to face the music in Alabama. Or what's the legal concept why you would have to? I would just suggest staying away from Alabama in that event. Yeah. To clarify what I meant when I said that, I'm so glad you mentioned it. To clarify what I meant, I meant if I was practicing in Alabama. I didn't mean if I was, and I'll let Paul comment more, but that's what I meant. I didn't mean if I was in Massachusetts and they were Alabama. I meant if I was practicing in Alabama. So I appreciate you clarifying that to make that clear. So thank you. So as we all have been told numerous times these days, we need to be licensed in states where the patient is located if we're doing telepsychiatry. And one of the reasons for that is because the practice of medicine is governed at the state level. It gives that state some leverage over us in terms of governing our conduct. So if you're seeing, you know, if you're licensed in Alabama but you're working in Maryland and you're seeing a patient in Alabama, Alabama law is applicable. And I mean, we don't know how our states will respond to requests for extradition should states with restrictive statutes choose to pursue practitioners in other states. And I'd rather not be the first one to find out how that's going to end up. Hi, I'm Lajane Alhaji. I'm a CL psychiatrist at University of Miami. Thank you for this awesome talk. I'm curious for some of us who are working in states that severely restrict access to abortions or performance of abortions and working with marginalized communities who may not be able to travel out of state, for example, should an assessment of, you know, risk for self-induced abortion or partner-induced abortions be included in our psychiatric evaluation? Oh, sorry. Can I just pause you for one second? I think Professor Huberfeld wanted to respond just to the most recent question. Okay. All right. Professor Huberfeld, can you go ahead? Can you hear? We're now muted. Okay. Let me unmute. She was hearing a bit of an echo. Okay. Professor Huberfeld, are you able to hear? You can respond to that prior question about the question about extradition into another state. She heard something because she heard that. Yeah. Yeah. Can you hear me okay? Is there an echo? No echo. So the extradition question I think is... Go ahead. This is what SHIELD laws do, and there's a bit of a delay, I think, so I'll try to speak a bit slowly. The SHIELD laws... Let me type it into the chat, so perhaps that will be easier for her. Nicole, you can go right ahead. We can hear you fine. OK, SHIELD laws specifically state that providers who are performing health care that is lawful in the state in which the provider is offering care will not be extradited to other states. So the extradition question is very much going to depend on which state you are in. Historically, we have relied on states to cooperate on extradition questions. And so this is actually new territory for states to say, we will not cooperate with your laws, Texas, if we are Massachusetts. And so Paul's point is correct, but you need to know whether you're in a SHIELD state or not. If not, then historically, a state could and probably would extradite you. But I think in this new post-obs environment, that may not occur. Let me just add one nuance to that, which is the state licensure board can still take action against you. And as we all know, one state's adverse action then gets reported to all the other states where you're licensed and to your malpractice insurer. And it can have consequences as well. And there's no way to shield yourself from that if you're licensed in that other jurisdiction. What about civil liability? Nicole, there was a question about civil liability. Do you want to say something about that? Yeah. Nicole? I'm not sure she got that. Can we go to the next question just so we have some sense of time? Should I repeat the question? Yeah, please. There she is. Here she is. It's just the delay. What kind of civil liability are you thinking about? Yeah. Do you mean affecting licensure or affecting something else? No, no. They are private individuals who sue you, right? Isn't that right? So I guess that's the question. The question, Nicole, was to what extent would the SHIELD laws prevent laws like the Texas statute that allows civil suits from being implemented? Or would you be susceptible to those? I'm letting her know, it's okay, we can move on to the next question, just in the interest of time. So the Texas law that allows whistleblowers to implement the restrictive laws in Texas does not apply outside of Texas. So you would have to be in Texas for that law to apply to you, meaning that the whistleblower would need to bring an action against you in Texas, or in Oklahoma, or in Idaho. If you could repeat the question, that would be great. For some of us who are working in states that severely restrict abortions and working with marginalized patients who are continuing their undesired pregnancy, should we include a risk assessment of, you know, risk of self-inflicted or self-induced abortion or partner-induced abortion? And, you know, what's our role there, especially with your comment of, you know, omitting might be more protective, right? So what would your goal be for including a risk assessment of that sort? Well, I guess my thoughts is, you know, just like, you know, what we hear about, you know, prior to Roe v. Wade being enacted, you know, using things like mechanical tools, et cetera, that can increase the risk of medical issues or even psychiatric issues, you know, should this be something for us to worry about with our patients? Yeah, it may well be something for you to worry about with your patients. I agree. That's a good question. Hello. I am, I consider myself a family psychiatrist. I am a child trained from Maine, and I think that I'm probably the most liberal when it comes to talking to patients about reproductive health, and I've prescribed birth control for folks who are in a real pinch, and when I talk with my colleagues about that, I realize that I'm the exception. And I'm just wondering, so our organization recently adopted the APA guidelines for metabolic screening for antipsychotics, and it was really helpful to have that resource to go to for our organization to say, let's do this, you know, this is kind of good standard of care. And so I'm wondering, especially hearing the statistic about women who, or people who are childbearing having worsened depression symptoms are less likely to take birth control regularly and less likely to use reliable forms of birth control. Could the APA develop guidelines that people could adopt in their organizations on how to talk to people about reproductive health, and even maybe some language around how it's really okay to prescribe contraception? I think it's a fantastic question, and you know, a lot of us, and you're on the work group as well, so I think the APA work group that's working on this, we're actually sort of considering that, and yeah, I agree with you, I think it's a great idea, and we will bring that back to the work group, who can, because we're coming up with some, yeah, I mean. Position and policy right now. So thank you for that. Okay. Yeah, and some guidance around it, so we'll take that into account. It's a great suggestion, and I totally agree. You can say Casey Moss from Maine says, yes, let's do this, as soon as possible. I'm glad to hear that you're doing that. That's great. Thank you. There we go. Yeah. Hi, Rick Martinez from Denver. Thank you all for really a terrific panel and great discussion. I'd like to open up a little bit and just have any one comment. I keep struggling with the question of individual and collective conscience in this issue, and we haven't talked about it much, but obviously it's going to take some very brave souls, physicians and professionals, to step up in those jurisdictions where, obviously, trouble awaits, liability awaits, et cetera. So I was wondering if you all could comment a little bit about that issue on an individual basis, and then secondly, organizational conscience, AMA, the APA. It seems that we're in a position, as organized medicine, to perhaps do more in terms of providing, having the back of those brave individuals who may have to step up in the near future, given this, what I consider, tragedy in America right now. Yeah. So let me say something from an organizational perspective. As you well know, as the chair of the Council on Psychiatry and Law, the APA has been involved in a series of advocacy efforts, both legislative but also in the courts, to try to preserve abortion rights in this country. And I anticipate that that involvement will continue. APA has generally not gotten involved at the trial level, for good reasons, actually. But we have a mechanism through the Committee on Judicial Action for involvement at the appellate level on behalf of psychiatrists who, for example, might be caught in one of these statutory spiderwebs. Whether it will take a brave psychiatrist, I agree, and one who has the best interests of their patients in front of them, to challenge these laws through their behavior in an attempt to protect their patients' interests. I suspect those brave psychiatrists exist out there, and I, for one, would agree with you completely that we should be prepared to support them if and when that happens. Thank you. And I'll just also add, thank you for that question, that we have brave psychiatrists but we have brave physicians, and all of us make a bigger impact than one person. This is a very, very important time to join advocacy efforts with APA and with AMA, who directly approach these topics. And they have an organized system of dealing with advocacy for health care issues that affect physicians and patients. This is a very good time to join AMA if you haven't, and APA has a whole advocacy branch, so yes. And you know what? Doctors really do make an impact. People listen to us, and we're the ones on the other side of the situation. So if we say no, it makes a big difference. So yes, thank you for bringing that up. Next question. Hi. So my name's Nancy Chinoy, and I'm a psychiatry resident at Baylor in Houston, Texas. So I guess I work in a reproductive psychiatry kind of environment, and our state has had like policy days where we go and we talk to legislators. So I guess my question is, what resources do we have in restrictive states, such as Texas, where our local psychiatric advocacy branch does not have a clear set of policy objectives related to abortion, with the idea being that it would detract from other mental health policy objectives important to the organization and important to the state? Yeah. Yeah. You know, I think that's really challenging. I don't have an answer to it, but I'll just share that, you know, like there's a Maternal Mental Health Leadership Alliance, which is an organization that does a lot of advocacy for women's health. And I, around this, I was talking to them, like we need, and I said to them, like, similar to what you're asking, we need to be advocating for, you know, this around abortion, because this is worsening outcomes. And they were like, absolutely not. And the first, and then what they explained was that, you know, they are making a lot of headway in increasing funding for various programs, and they have made a lot of progress, and they were very clear that we have to stay bipartisan, and as soon as we start advocating for abortion, we won't be seen that way, and it will undermine our ability to do anything else. And not to say I'm condoning that, but that may be sort of part of the perspective, and these are folks that, like, their whole focus is maternal mental health, but they are staying away from abortions. It creates a big challenge for people that want to be advocating for funding, but at the same time, it's like, we're advocating for funding to do things, so they're reacting to these social, like, these, like, political determinants of health, so it creates a, I don't have an answer for it, but I wanted to sort of share that, and that perspective, but Paul, you may want to add. Yeah, and I think that's exactly true for APA district branches as well, who have to weigh a lot of, a lot of considerations. However, that being said, although I'm not one to routinely argue for going outside APA to do advocacy, this may be a situation where the local psychiatric society is unwilling to take on an issue like this for organizing outside those channels, maybe even with their implicit blessing to try to get changes made, for example, to the Texas laws that would, you know, expand exceptions for women with, with psychiatric conditions. Okay. Thank you so much. Thank you to all our panelists from far away and near, and thank you all for coming to this talk. I really, I'm very happy to have you here, and go and do advocacy work for whatever organizations you're in. Do it this year. Thank you so much for coming. Have a great day.

Roe v. Wade

Supreme Court

abortion rights

Dobbs decision

state laws

maternal mortality

mental health

Turnaway Study

marginalized communities

ethical challenges

psychiatrists

advocacy

legal framework