Abortion opponents have long used graphic photos of embryonic and fetal tissue to try to persuade people outside clinics not to have abortions. The same groups successfully used lurid descriptions of an abortion procedure known as intact dilation and extraction, or D&X, to ban it nationwide in 2003, a law the Supreme Court upheld in 2007, gutting Roe v. Wade in the process. Now that Roe is wholly gone, these activists are drawing on this familiar strategy to try to weaken state constitutional amendments protecting abortion rights—and in a new twist, they’re also using the same tactic to go after gender-affirming care. By weaponizing the often-bloody realities of health care, these elements hope to generate a reaction out of the public to build popular support against specific medical procedures.
President Donald Trump’s January 28 executive order attempting to limit care for trans youth 18 and younger calls gender-affirming care “chemical and surgical mutilation.” Last Wednesday, Department of Education Secretary Linda McMahon and Representative Dan Crenshaw met with several “detransitioners,” or people who no longer identify as transgender, to mark DeTrans Awareness Day. (The day was created in 2021 during the Biden administration, so, according to HuffPost, this was the first time the federal government has acknowledged it.) Several speakers said they regretted having mastectomies, per The Federalist, or, in their telling, having their “breasts cut off.” Andrew Guernsey, senior adviser to Health and Human Services Secretary Robert F. Kennedy Jr., attended the meeting and referred to gender-affirming care as the “mutilation of kids.”
A top anti-abortion group, Students for Life, is planning to use the 2007 Gonzales v. Carhart decision to ban medication abortion in states that recently passed ballot measures, and possibly at the federal level. In Gonzales, the court upheld the federal ban on D&X, which was smeared as “partial-birth abortion” by conservative politicians and activists. The law passed by Congress was practically identical to a state ban the court ruled unconstitutional just seven years earlier because the legislation didn’t have an exception for the health of the pregnant woman, as Roe required. (What changed in those years? Justice Sandra Day O’Connor retired and was replaced by Justice Samuel Alito.)
The Gonzales ruling repeated grisly descriptions of D&X procedures, and Justice Anthony Kennedy wrote that there was “medical uncertainty” over whether the procedure was ever necessary to preserve a woman’s health—the alleged uncertainty arose from doctors saying D&X can be medically necessary, while GOP members of Congress claimed it “never” was. Kennedy also infamously argued that women may regret their choice if they knew how the procedure was really done.
Students for Life plans to replicate the Gonzales playbook: Get lawmakers to pass state and federal laws regarding one specific abortion method—here, medication abortion—and ask the Supreme Court to uphold them. In December, the group published a “Make America Pro-Life Again Roadmap,” a strategy for restricting the abortion pills mifepristone and misoprostol following the passage of pro-choice state constitutional amendments, which it calls “mini Roes.” Any new barriers to access would be a big deal since medication abortion made up nearly two-thirds of all reported terminations in 2023. Telehealth in particular is a crucial form of access: One in five abortions is now done via telemedicine with pills.
In its document, Students for Life claims that the pills lead to “chemically tainted blood, placenta tissue, and human remains” being flushed into the water system. One of its model bills is the misleadingly named Clean Water for All Act, which would require prescribers of medication abortion to give their patients red medical waste bags that say “biohazard” and instructions for returning the products of conception to them at a follow-up appointment. (This bill bans telemedicine abortion too.) Providers who don’t follow these steps could face up to three years in prison and fines of up to $10,000. The model legislation doesn’t specify what happens if patients don’t return the red bags to their provider. While the “clean water” bills wouldn’t ban mifepristone use outright, they’d make it so risky for providers to continue prescribing the pills that they would simply stop.
Of the many problems with this legislation, a baseline issue is how it ignores that people miscarry over toilets every day, said Dr. Ghazaleh Moayedi, an ob-gyn and board chair of Physicians for Reproductive Health. “I want clean water, but I’m not worried about embryos in the water,” Moayedi said. “They’re already there from miscarriages.” This is a nonissue: Pregnancy tissue gets filtered out at water treatment plants, along with other solid waste.
The idea here is to try to gross people out to support a law that’s not principally about water but rather is designed to drastically limit access to medication abortion—and to make people afraid of the drugs, as if they’re some kind of dangerous chemical. This scare campaign to give people “the ick” is a bit absurd to Moayedi, who still remembers the first time she saw a C-section in medical school and being shocked at just how much force surgeons use to open the abdominal cavity. The procedure is, to some extent, violent, she said—as are orthopedic surgeries using power tools.
“We are made of bones and blood and nerves and connections, and that’s what medicine is about,” she said. “The focus on trans health care or abortion care specifically being something different than the rest is really just a myopic view of what the reality is.” Caring for bodies necessarily involves some amount of blood.
Conservatives are using stigmatizing language as an intentional tactic to demonize the people who need this care and to discredit those who provide it, said Ma’ayan Anafi, senior counsel at the National Women’s Law Center. “This is well-studied care. It’s care that’s provided according to well-established standards,” Anafi said. “The goal of this kind of inflammatory language is to make it sound experimental and dangerous.” Framing abortion and gender-affirming care this way creates a chilling effect that can lead to violence against providers and threats against health care clinics. “This strategy of vilifying providers has a real-world impact,” they said. “It both discourages providers from offering care that they want to provide, and it means that patients need to also be weighing their own safety and their own privacy when they’re trying to access the care they need.”
This is true even if bills fail to pass—the rhetoric is already out there.
Just calling medication abortion drugs “chemicals” is itself inflammatory. Recall that Judge Matthew Kacsmaryk wrote in his April 2023 ruling that mifepristone “blocks the hormone progesterone, halts nutrition, and ultimately starves the unborn human until death.” The decision uses the phrase “chemical abortion” 93 times.
Moayedi said she sees how this particular example of manipulated language affects medication abortion patients all the time. “They ask, ‘But will I ever be able to have a baby again?’” she said. “People think that what we mean is that you’re taking a toxin, that you’re taking chemotherapy. (Patients still want to end their pregnancies, they just want to know. “That’s how desperately people want abortions,” she said.) When this comes up, Moayedi explains to patients that it’s a common question and that the two medications mimic a miscarriage: Mifepristone blocks the hormone progesterone, which drops when people miscarry, and misoprostol makes the uterus contract. The latter is a prostaglandin, a substance the uterus releases naturally.
To Anafi, the fact that conservatives are looking to the Gonzales ruling to restrict care like medication abortion is telling: Now, as then, medical opinion is not on their side. “Gonzales teaches us that our opponents will often resort to disinformation, to inflammatory rhetoric, to outright lies,” they said. “But what’s more important than the lies is the stories of real people who seek care.” Still, the current media environment and the 6–3 supermajority on the court mean “there is more opportunity for a lot of these false narratives, both about gender-affirming care and about abortion, to lead to really harmful decisions,” Anafi said.
An abortion pill ban under the guise of “clean water” has yet to pass in any state—one actually failed in Montana this month—but Students for Life will certainly keep pushing. (Other bills in the roadmap call to ban the drugs entirely and declare that life begins at conception, which would ban abortion procedures as well.)
That’s the thing about these bills; they’re not written with a true concern for health and safety but rather reverse-engineered to achieve an ideological outcome. And the engineers typically go after children’s rights first as a kind of testing ground. Conservatives focusing on health care for trans and nonbinary children is “straight out of the anti-abortion playbook,” Moayedi said, pointing to laws requiring parental consent or notification before abortions. The movements are “two heads of the same beast,” she said.
A group claiming it’s trying to protect children from allegedly evil, scheming health care providers has an easier path to push inflammatory language into the mainstream. “Once they have gotten people into this extremist ideology, then they can continue to, quite frankly, groom them into these larger and broader oppressions on people’s autonomy and right to live freely,” she said.
After passing bans for children, they can use the momentum to restrict care for adults and call it protection. “These laws are driven by a lot of that paternalism, by a lot of that belief that people should be protected from themselves,” Anafi said. That framing is implicitly about the specter of regret, which is “belied by the evidence that we have.” A 2021 review of data from nearly 8,000 teens and adults who had gender-affirming surgeries found that an average of 1 percent expressed regret.
Lawmakers claiming their intention is to prevent regret purposely ignore how long it can take for trans people of any age to get gender-affirming hormones or surgery. “There’s this misconception that someone can just pop into a clinic and say, ‘I want all the gender-affirming care’ and then automatically get it, when the fact of the matter is that people need to go through a very long process,” Anafi said. In reality, people need evaluations and letters from mental health providers and, depending on where they live, may have to wait months before a provider has availability.
But there’s a double standard in the care that’s being restricted. “People also regret knee surgeries. People regret plastic surgery—they regret breast augmentation, and so many people have their breast implants removed,” Moayedi said. There’s no national push to regulate breast augmentation in cisgender women, but lawmakers are acting like it’s a crisis that a small number of trans people could come to regret their breast implants. “The actual percentage of trans people who regret getting medications or surgery is just astronomically lower than people that regret breast augmentation or knee replacement,” Moayedi said. “The math doesn’t math.”
It only makes sense when people absorb that restrictions on abortion and gender-affirming care are not about medicine but about “using state power to compel a particular performance of sex and gender,” as legal scholar Madiba Dennie wrote in Balls and Strikes. Because that’s deeply unpopular, the activists behind the movement are forced to concoct strained justifications like, “Mastectomies are only OK for cancer patients” and “Mailing FDA-approved medications is drug trafficking.”
To Anafi, the fact that attacks on abortion and gender-affirming care come from the same groups and lawmakers is an opportunity for solidarity. “They are coming from that same place of trying to take away people’s ability to determine their own futures, decide what happens to their bodies, their access to health care, and to live free from gender stereotypes,” they said. “These principles might bring together the anti-abortion and anti-trans movements, but they also create a basis for the movements that fight for our rights.”
