Last week, a Doonesbury cartoon that was a commentary on Texas House Bill 15 (from the 82nd legislature) became a meme via social networks.* The Princesses saw it courtesy of the Grand Overseerer. The panel shows a woman, who is seeking an abortion, undergoing a procedure mandated by Texas House Bill (HB) 15. She is having the procedure under duress. That is, she doesn’t want to do it, but she goes along the procedure as a means to abort her pregnancy. Her doctor is complying with the law while at the same time showing his irreverence for it. That is, he thinks the law $%*&ing stinks.

This cartoon was one in a series of six panels Gary Trudeau (the creator and artist for Doonesbury) dedicated to TX HB 15. Here’s the story arc of Trudeau’s series on TX HB 15:

Panel 1: A woman shows up at a doctor’s office for the requisite sonogram and is directed to the “shaming room” (instead of the waiting room) to fill in her paperwork.

Panel 2: The woman is greeted by the author of TX HB 15 who starts off by asking a seemingly routine intake question and then calls the woman a slut.

Panel 3: The doctor gives the woman an orientation on the procedure by reading a prepared statement. The statement basically says patients and doctors are not equipped to decide what is best in regards to pregnancy termination, so the state has intervened.

Panel 4: The meme. This is panel where the woman undergoes the sonogram (under duress).

Panel 5: The doctor continues complying with TX HB 15 and describes the physical characteristics of the fetus to the woman.

Panel 6: The woman finally exists the appointment and asks how to proceed with an abortion. She is informed she has to wait 24 hours before she can have the procedure.

Wow. The story’s not so funny when you read a dry synopsis like this. Which is kind of good because it’s not a funny topic. This comic series is less comic and (far) more commentary, but I still found it entertaining as dark humor. I definitely had a “WTF?” response when I read the series, laced with shock this bill passed and shame it passed in my home state. I very much appreciate Trudeau’s message and the way he chose to convey it. It is very clear that, like the doctor in the comic, Trudeau thinks this TX HB 15 $%*&ing stinks.

Two things from the meme cartoon became sources of controversy. First, the comic (using visual cues) states TX requires a transvaginal sonogram. The doctor holding the transvaginal 10-inch “wand” is the most disturbing image in the Doonesbury TX HB 15 series (IMO). I have to admit, I didn’t really believe my state (red though it be) would incorporate such a physically invasive procedure into the law.** So, I read the original bill and the final law and saw no mention of “transvaginal” sonograms (use of the wand), only references to “obstetric” sonograms (any form of sonogram). I thought maybe Gary Trudeau was taking artistic license to point out how invasive this law is (wand or no), but he has stated in interviews that is how the Texas law reads — that a “transvaginal” (or wand) sonogram is required. So, I asked the Grand Overseer what I was missing. A former colleague answered and said it has to do with the part of the bill that requires the physician describe the fetus to the woman, including how many weeks old the fetus is (gestational age) and and playing the fetal heartbeat (heard auscultations).

In regards to gestational age, TX HB 15 specifically requires the physician to inform the woman “the probable gestational age of the unborn child at the time the abortion is to be performed” (Section 2.a.1.C). Hmm…gestational age can be determined using date of last menstrual period or a transabdominal sonogram (on top of the belly). Why was Trudeau focused on the wand? As far as I can tell, he focused on the wand because the most accurate method for determining fetal age and hearing fetal heart beat early in a pregnancy is using the wand.

“Transabdominal ultrasound cannot reliably diagnose pregnancies that are < 6 weeks’ gestation. … Transvaginal ultrasound, by contrast, can detect pregnancies earlier, at approximately 4½ to 5 weeks’ gestation.” — Mama’s Health

In regards to fetal heart rate,TX HB 15 specifically requires the physician “makes audible the heart auscultation for the pregnant woman to hear” (Section 2.a.4.C and 2.a.4.D). The wand is also the best method for determining the presence of and hearing fetal heartbeat early in pregnancy, another stipulation in the law.

While the transvaginal sonogram is not the ONLY way to see and hear the fetus, it is the BEST way to see and hear the fetus. The earliest a fetus can be scanned is 4 weeks, because that’s when the fetal sac is clinically detectable. But a woman can be confirmed pregnant from a urine test  within 2 weeks or from a blood test within 7 to 12 days after conception. A woman may learn she is pregnant and choose to abort much sooner than the 6 weeks it takes for an abdominal sonogram to be reliable. Indeed, according to a (not so recent) report by the CDC, about 22% of abortions occur within the first six weeks, so almost a fourth of all women seeking abortions fall into this category. A doctor may have to use the wand to fully comply with the law when dealing with early pregnancy termination. [Note the earlier an abortion is performed, the safer it is for the woman.] The physician can try an abdominal scan first, but if that doesn’t yield reliable information, the next step — again to fully comply with the law — is to use the wand. The law states the visuals and audio are to be presented “in a manner consistent with current medical practice,” which leaves the type of sonogram wide open for interpretation.

I say if some doctor comes at your girlyhood with a 10” wand, you return it to her as two 5” pieces.I think this is horribly invasive and $%*&ing stinks. Remember that as you read on.

The second controversy was about the doctor in Trudeau’s scenario calling the sonogram state-sanctioned rape. This spawned a lot of commentary from a lot of people, both agreeing and disagreeing with Trudeau’s accusation of rape. Jax and I were both drawn to a guest post from a physician on John Scalzi’s website.*** This doctor makes an impassioned argument for why a transvaginal sonogram is arguably rape and provides a list on how to actively and passively subvert the law.

“I do not feel that it is reactionary or even inaccurate to describe an unwanted, non-indicated transvaginal ultrasound as “rape”. If I insert ANY object into ANY orifice without informed consent, it is rape. And coercion of any kind negates consent, informed or otherwise.” — Guest Physician

*thinking*     *rapping fingers against desk*

I am not sure I fully agree with this assessment. The physician here focuses on “informed consent” and “coercion” in his argument transvaginal sonograms constitute rape in this context. I agree that rape is contingent upon permission — no argument here in regards to the legal definition of rape. I don’t agree the issue here is about “informed consent.” Informed consent in a medical setting usually unfolds passively with an implied conversation. The physician basically says (usually without actually saying it), “(1) I am going to do this. (2) Do you understand? (3) Do you agree to let me do it?” I’m not sure where the process hits a snag for this physician — at (2) or (3).

Let’s consider this for a moment and play devil’s advocate. When I am sick and go to the doctor, I let her examine me fully and probe me with things in unmentionable places. Do I want to be poked in my unmentionables? No. Do I know what she’s going to do when I get there? Not always. Do I let her do it? Yes. Do I feel coerced? Sometimes.§ But I let her proceed because I want to get better. My end goal (getting better) is met by allowing the doctor to do what she thinks is best (probing my unmentionables). I guess I think the same thing happens when a woman seeks an abortion. Her end goal (terminating her pregnancy) is met by allowing the doctor to do what is required (probing her unmentionables). So this issue — for me — is not about informed consent.

I know that sounds kind of cold and unfeeling, but remember I am playing devil’s advocate here (and remember I think this is horribly invasive and $%*&ing stinks).

For me, the snag in the doctor-patient conversation above is (1). That’s arguably coercion on the part of the state because TX is mandating an invasive procedure. So while the doctor is saying “I am going to do this,” in a normal medical conversation, in the case of abortion it’s more like Trudeau scenario where the doctor is saying, “I am going to do this because the state says I have to.” Gah! But even this argument gives me pause. The state is mandating an invasive procedure, yes. But let’s be honest with ourselves, all states mandate invasive procedures via inoculation requirements.§§ So the issue is about more than the procedure being coerced.

So what is the issue about? Because there is an issue about something. I am not in any way supporting this law or trying to make excuses for my state. But arguing for the right cause (objection to this law) for the wrong reasons (calling it rape) is a bad course. It inflames the issue via rhetoric instead of educating voters via facts. And it can have unintended consequences, like frightening underserved and undereducated women (and girls) who’ve never been to the doctor before (and might never go if they think going means they will be raped).

I say the issue is about (a) the law calls for (depending on fetal age) an invasive procedure (b) on a vulnerable population §§§ (c) in a highly personal and sensitive area (the girlyhood). I’ve covered my objection to (a). Pregnant women are legally (and ethically — in terms of research) considered a “vulnerable population” in public health because they can be both physically and emotionally sensitive (and vulnerable). My objection to (b) is that TX HB 15 targets physicians treating pregnant women (most of whom are young, less than 25) in an intense emotional state, making a painful and difficult decision, who are highly susceptible to fear-mongering, shame and manipulation. Shame on you TX 82nd Legislature for putting politics over healthcare. Shame. Shame. Shame! Finally, much of the indignation I feel towards this law is because it controls women’s fertility. I don’t want to marginalize men, because their health and their rights to choose how to manage their health are just as important as women’s. But there are no laws that control men’s fertility – which I am glad about. I just wish my state would extend that courtesy to women, too.

What do you think, Realm? Do you agree that TX HB 15 $%*&ing stinks?

* I haven’t included the actual cartoon to avoid copyright infringement. Lots of folks are copying and pasting / posting this image, but since we are representing the Realm (and not just ourselves), I refrained from copying and posting here.

** BTW, Texas happens to be the home of Roe v. Wade.

*** If you are a science fiction fan and you haven’t heard of John Scalzi, go get Old Man’s War right now and read it. What are you still doing here? Go!

§ Have you ever had a conversation with a doctor where they’ve told you what they want to do and you say, “I don’t want / like that. What are my other options?” And they say, “You don’t really have any other options”? I have. And because I was sick or scared (or both) I’ve deferred to their medical expertise (this is the intimidation part of coercion) and let them do what they proposed even though it wasn’t what I wanted. Is that coercion? It sounds like coercion to me. It felt like coercion to me. But I didn’t think it was malicious or even patronizing. I thought it was an exchange between a professional offering the best advice based on the information available at the time and a layman taking that advice because of a lack of other information at the time.

§§ I think immunizations are right and good. Any connection between inoculations and impeded child development have been disproven emphatically.

§§§ A vulnerable population is defined by the Office of Human Subjects as a population that merits special attention when obtaining informed consent for participation in a research study. Vulnerable populations include (but are not limited to) pregnant women, children and prisoners. The idea of protecting vulnerable populations came out of the Nuremberg Code of 1947 and the purpose of identifying vulnerable populations was to avoid human rights violations. You can learn more in this tutorial. [Warning: a video will open with sound.]

+ Featured image, “A Thinking Woman” by ÁWá.