Dr. Evan James never wavered in his determination to become an abortion provider.

His belief that women had the right to do what they wanted with their bodies was steadfast during his medical training in London, Ont.

It solidified further after he spent a month learning how to perform abortions at the Morgentaler Clinic in Toronto. He found that he enjoyed the work and was not put off by a woman's tears or the tissue he extracted from her womb.

Nor did he fear the violence — bomb threats, stabbings, sniper shootings — that for years has stalked abortion doctors in North America.

Only when his personal life was thrust up against his professional beliefs was his firm stance on abortion shaken.

James and his partner desperately wanted to adopt a child.

Suddenly, there were days when he found it hard to commit to being an abortion doctor. For the first time, he began to see shades of grey instead of just black and white.

The 28-year-old obstetrics resident in Hamilton was finding out, like the generation of doctors who came before him, that being an abortion provider means accepting a life unlike any other in medicine.

More than 20 years since abortion became legal in Canada, the procedure remains among the most common for reproductive-age women. About one in four women will have one in her lifetime.

Yet physicians who provide abortions continue to face a host of obstacles.

They are proud of what they do and say their work is immensely gratifying. Yet, most do not — and will not — talk openly about their profession, one that even medical schools tend to keep hidden.

Many believe they are saving women's lives by offering them a safe way to terminate an unwanted or dangerous pregnancy. But they also know being a provider may put their own safety at risk.

They must also find ways to reckon with the ethical and personal dilemmas that can accompany their work.

No organization in Canada keeps count of physicians who perform abortions. But in interviews with more than two dozen providers, physician groups and advocacy organizations, the Star learned that there is a shortage of abortion doctors in this country.

The U.S. has seen a 40 per cent drop in the number of doctors who perform abortions since the early 1980s. Those in the field say there's likely a similar trend in Canada.

A 2006 report by Canadians for Choice, a non-profit, pro-choice advocacy organization, found just 16 per cent of Canadian hospitals provide abortions — a drop of nearly two per cent from a 2003 survey. The organization has since been notified that at least five other hospitals no longer have doctors willing to provide abortions.

“Almost anyone can be an obstetrician — and I don't mean this to sound trite — because you are providing a happy experience,” says Dr. Suzanne Newman, a family doctor who now exclusively provides abortions at three separate clinics in Winnipeg. “But very few can do abortions.”

As James's desire to have a family deepened, he began to think an uneasy thing: how could he terminate pregnancies when each abortion meant there would be one less child for adoption?

He also wondered how he would explain what he did for a living to his adopted child. After all, wouldn't his son or daughter have been born because the birth mother had not chosen abortion?

Then he began to worry about putting not just himself but also his family in danger.

This new fear — magnified by the fact he was training in Hamilton, where an abortion doctor was shot 15 years ago this month — is why James asked that his real name not be used in this story.

Those who followed were trained by the pioneers, who relayed horror stories of hospital wards full of women rendered permanently infertile, or with deadly infections and perforated uteruses from illegal abortions.

Then came female physicians eager to join the feminist fight for women to have ultimate control over their bodies.

James's generation has less tangible reasons to be abortion doctors, having lived much of their life with it being legal in Canada. For them, the sense they are saving lives is not as strong. They have to look deeper for reasons to join — and endure — a tough profession.

That is why there are fewer of them.

Like most students attracted to medicine, James chose to be a doctor because he wanted to make a difference in the world.

The youngest of two children, he was raised by his liberal-minded, professional parents to always stick up for his beliefs. The Ottawa native studied biology at the University of Guelph, completing his degree in 2003 after just three years.

In his first year as a medical student at the University of Western Ontario, James felt the pull of diverse medical specialties — obstetrics and gynecology, family medicine, palliative care and HIV medicine. Because he is gay, James also considered becoming a doctor for the lesbian, gay, bisexual and transgendered community.

His search for a way to combine medicine with social justice led him during his first year to Medical Students for Choice, an abortion education group with chapters at 133 medical schools in Canada and the U.S. Founded in 1993, MSFC pushes for greater inclusion of abortion in reproductive health services curricula.

It was at his first MSFC meeting that James learned there was a worrying shortage of abortion doctors.

“I was pro-choice, but I didn't realize there weren't enough providers,” James says. “I saw there was this clear need and a clear solution, which was go out and provide.”

Canada's largest cities, including Vancouver and Toronto, have sufficient numbers of providers. But many others face a scarcity. Kelowna, B.C., has a population of 120,000 but no resident abortion doctor (physicians travel from elsewhere in the province to perform the procedure). Ottawa, Peterborough and Sarnia have among the longest waiting lists in the country, with some women having to wait up to six weeks for an abortion.

In 2006, the last year for which national numbers are available, there were 91,377 abortions in Canada, a ratio of about 25 abortions for every 100 live births. In 2008 in Ontario there were 32,179 abortions.

In the end, James decided to specialize in obstetrics and gynecology. He excelled in medical school and dedicated his spare time to MSFC, taking on the roles of regional coordinator, then board member, and, in his fourth year, becoming the first Canadian chair of the group's bi-national board of directors.

As chair, James was the lead voice for advocating for greater abortion training in medical schools in North America. At the same time, however, he believed expressing his strong pro-choice views at Western would jeopardize his chances of getting into an obstetrics residency program.

“I didn't want to be known as the abortion guy,” says James, who was concerned several anti-abortion faculty members whom he was relying on for reference letters would fault him for his stance. “At that time, it became a lot about keeping my mouth shut.”

James saw his first abortion when he was 22, during a summer position at London's only abortion clinic, one of the few in Ontario that will end a pregnancy during a woman's second trimester.

He was keen to watch, wondering how he would feel during the procedure — and after, when the doctor looked at the pregnancy tissue.

In Canada, the vast majority of abortions are performed in the first trimester; only 9 per cent take place between 12 and 20 weeks of pregnancy. Physicians examining the tissue from an early pregnancy likely see a pinkish oblong sac with no recognizable anatomical features.

James remembers feeling a gentle shock each of those first few times. But even after viewing a second-term abortion, he was not haunted by what he saw.

“During the direct examination, you might see an arm or an umbilical cord or, even, the body. It doesn't all come out in one piece. With your imagination, you can see that it resembles a human.

“I could understand how some people would be turned off by that or very moved by that.”

During the summer training, James watched almost 100 abortions. He also came to understand the feel of the clinic, how it had both a sombre and hopeful atmosphere, and to appreciate the range of women who choose to terminate an unwanted pregnancy. He left feeling sure about his path, his resolve strengthened after seeing women make their difficult choice from a place of compassion.

“I didn't understand that until I saw it,” he says. “I very strongly believe that women make a maternal decision when they decide to end a pregnancy. Because they are deciding for that child it is the best option, that (by having an abortion) they are preventing suffering and preventing a life that they wouldn't wish upon anyone else, let alone their child. That was very powerful for me.”

For medical students passionate about abortion rights, the first step towards becoming providers is being able to watch a termination. The next is to find out whether they can do one.

“It's a little bit of a test for yourself,” says Dr. Mei-ling Wiedmeyer, a women's health fellow at the University of Toronto who is planning to provide abortions as a family physician. “There is definitely a difference between wanting to do one for political reasons and being able to do an abortion.”

Wiedmeyer is adamant about making abortion a seamless part of her practice. She will enter the clinic full-time next year.

“It's not the only thing I want to do, but if I'm interested in sexual and reproductive health, it's only right, it's only good medicine for me to do abortion. I see it as part of a range of services I should offer in order to be a good doctor.”

Wiedmeyer has plans, as a family physician, to perform abortions up to the 12th week of pregnancy. At some clinics, women who are fewer than eight weeks pregnant can opt for a medical abortion, which involves taking two types of medication.

In a woman's first trimester, a surgical abortion — “really, more of a procedure than a surgery,” says Wiedmeyer — is a straightforward process, taking no more than 10 minutes. Prior to the procedure, a doctor will determine a woman's gestational age and ensure that she receives counselling.

A woman who chooses an abortion during her eighth week of pregnancy is most likely to undergo the manual vacuum aspiration method. She is first given a sedative or general anesthetic to reduce discomfort.

After exposing the cervix with a speculum, as happens in a routine Pap smear, the doctor anaesthetizes and dilates it before inserting a catheter into the uterus. The catheter is then attached to a manual vacuum that resembles a large syringe.

Pulling up on the vacuum's plunger, the doctor sweeps the catheter along the wall of the uterus to remove what physicians call “the products of conception.”

“What helps me continue is that at the end, when they are getting ready to leave, so many women say thank you,” says Wiedmeyer, who has a warm, direct gaze. “They are really grateful.”

Raised in Columbia, Mo., a city with more than 100,000 residents and a large university but no abortion provider, Wiedmeyer was taught at an early age that girls could do and be anything they wanted. After graduating from the University of Wisconsin-Madison in 1997 with a dual degree in sociology and women's studies, Wiedmeyer moved to San Francisco, where she taught high school math. She established an after-school club to help girls learn about sexual and reproductive health, subjects she believed were lacking in the curriculum.

But four years later, Wiedmeyer realized her influence was limited: while she could educate girls about abortion, she could not ensure they were able to get one. So she decided to become a doctor.

In 2004, at the age of 29, Wiedmeyer enrolled at McGill University. She soon realized that high school and medical school had at least one parallel — neither taught their students much about abortion.

“I got one lecture on contraception. In the last sentence they mentioned abortion.”

Sixty-seven per cent of Canadian medical schools, according to a 2009 survey published in the journal Contraception, included abortion as a sexual and reproductive health topic in preclinical courses.

And a 2006 study published in the journal Obstetrics and Gynecology found just half of Canada's ob-gyn programs routinely include abortion in their training, and that a minority of residents felt competent in doing abortion. The study also found more residents participated in abortion training and more said they intended to be providers if they attended programs that had integrated abortion training. (The study's author, currently a professor at the University of Montreal, declined to be interviewed about her research due to concerns about being put in a “delicate position with the general public,” according to a media officer.)

A long-time abortion doctor in Ontario, who wants to be known only as Dr. M., says integrating abortion training into curricula, in both medical school and in residency, would help ensure more young doctors enter the profession.

Ontario medical schools teach abortion as outlined by the Medical Council of Canada's national guidelines. Students may learn the theory of abortion — how to determine if a woman is pregnant, how to counsel her about options — but they have to notify administrators if they want to observe the procedure or learn how to do it.

Dr. M. says shying away from formal abortion training — and formal recruiting — is one of the main reasons Canada has a shortage of abortion doctors.

“Providers recognize that we are few and far in between,” says Dr. M., who did his medical training prior to 1969, when abortion became legal in Canada, and whose primary concern now is to ensure women will still be able to get the procedure in his community after he retires.

“This is an essential service for women, and unless we are proactive in recruiting and educating young doctors in the area of abortion provision, we will not able to offer women a safe and sensitive abortion service.”

Wiedmeyer, like Dr. M., makes time to speak to medical students about abortion. She hopes her lectures will make those who are already pro-choice realize there is a need for abortion doctors — just as James did in his first year at Western — and consider making it a part of their practice. If you don't hear about it, she reasons, how can you possibly think it's an important thing to do?

“Every doctor who treats women is going to see a woman who wants or who has had an abortion,” she says. “Given that it is a part of the reproductive care we offer as a society — it is legal, it has guidelines and evidence like any other topic in medicine — it makes sense to include it as one of the things we learn.”

Eva, a petite, third-year medical student at the University of Toronto, emphatically believes abortion should be a part of her curriculum. The 26-year-old is a member of MSFC and, as a regional coordinator, advocates for more abortion training at her school.

“One week of second year was dedicated to women's health, and we spent an entire day on conscientious objection,” she says. “Basically all we learned about abortion is that you will never be placed in a situation where you have to learn this procedure.”

She knows medical school cannot cover every illness and procedure in depth; there just isn't time. But abortion is so common it doesn't make sense, she says, for doctors to have to ask to be trained. Besides, even if a doctor never intends to do an abortion, shouldn't she learn about it so she can describe to patients how one is performed?

Although she was eager to speak at length with a reporter, even meeting at Sunnybrook Health Sciences Centre before a night shift in the OR, Eva was reluctant to use her full name in this story. She is years away from being an abortion doctor, yet Eva is already worrying about how open she should be about her chosen career.

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His classmates have not switched sides; all are still pro-choice. Some simply found they had a greater passion for a different area of medicine. Others, after leaving the relative comfort of medical school, were reluctant to take on a profession with so much controversy.

Those who chose to specialize in obstetrics found niches that didn't necessarily include abortion. Despite its social weight, James says family planning is considered rather tame within the field.

It was during the month he spent at the Morgentaler Clinic in Toronto that James proved to himself that he could be an abortion doctor.

“It turns out,” he says, “that it's something I'm good at doing.”

Not only did he have superb technical skills, but James could quickly connect with the woman on the exam table and ease some of her distress.

“I tell them that this is something we will get through together.”

That month in Toronto, James did 400 abortions and observed dozens more. He also learned how to perform second-term abortions, something very few doctors are willing to do.

An added complication to Canada's shortage of abortion doctors is the scarcity of those who will do the procedure in the second trimester. A doctor who has no qualms giving an abortion to a woman who is 12 weeks pregnant may never be comfortable terminating a pregnancy at 20 weeks.

“They are more graphic, they just are,” says Dr. Meredith Simon, medical director of the Kensington Clinic, a free-standing abortion clinic in Calgary. “The fetus is bigger, and there is a lot more tissue.”

But James, who knows only one young doctor in Ontario who intends to do second-term abortion, is not troubled by this. He focuses his attention on the woman in front of him.

“The biggest risk factor for a second-trimester abortion is lack of referral for a first-trimester abortion,” says James. “I see second-trimester abortion as a bit of a tragedy, because to me it means the medical system has failed. Then it becomes our job to fix it.”

In the days after his return from Morgentaler, James was buoyant. He was proud that he was able to do — and do well — the thing he had, for years, been so passionate about. His path forward seemed clear: complete his obstetrics residency, learn as much as possible and become the doctor he always wanted to be.

But a month later, in August 2009, James and his partner, “Jack,” started the adoption process. They had been married for two years and felt it was time to start their family. Suddenly, James's commitment to being an abortion doctor faltered.

There had been a string of fatal shootings involving U.S. abortion doctors in the 1990s. But a brazen, more recent killing frightened Jack. In May 2009, Dr. George Tiller, medical director of a Kansas clinic that was one of only three in the U.S. that provided late-term abortions, had been shot in the eye while attending church.

The couple also began to think more about Dr. Hugh Short, a Hamilton obstetrician and abortion provider, who was shot in 1995 while watching television in the living room of his Ancaster, Ont., home.

There have been no such incidents since then. But a survey conducted this year by the Abortion Rights Coalition of Canada found 21of the country's 33 abortion clinics (both hospital and free-standing) were experiencing some degree of protest activity. Sixteen of them reported that the protesting negatively affected patients and staff.

As he walked along the corridors of the Hamilton hospital where he trained, James questioned his chosen career path. He loved delivering babies and caring for expectant moms. He fervently believed in providing abortions as part of his spectrum of care. But could he overcome his fears?

“They always want to know what it's like for me, how private do I keep my life. And they want to know how private do they need to keep their life.

“I tell them I have grown to be comfortable with this. And that they will have to do the same.”

Simon has been doing abortions for almost 18 years. Yet up until four years ago, no one outside her family and close circle of friends had any idea that it was a part of her practice.

At first, Simon did abortions part-time at the women's health clinic at Calgary's Foothills Medical Centre. It was in addition to her busy family practice, but Simon found the work rewarding.

In 1992, soon after she started at the hospital, the director of the newly opened Kensington Clinic asked her to join its staff. Simon declined, telling him she was not ready to align herself with the more visible, and thus more vulnerable, free-standing clinic. She preferred to work at the hospital, which provided more anonymity. It was enough, she said, to quietly help individual women terminate unwanted pregnancies.

Ten years later, after another plea from Kensington's director, Simon decided she was ready to join him. Her two children were grown and had moved out of the family home, and, perhaps due to added maturity or a lull in attacks on abortion providers, it felt a little less risky to be a doctor at a free-standing clinic.

Still, Simon did not tell anyone she was an abortion provider, even when she closed her family practice in 2005 to work full-time at the Kensington Clinic — something she had been dreaming about for more than a decade.

Later that year, Simon, who trained to do second-term abortions, became the clinic's medical director. It was then, at the age of 58, Simon started to tell people — even those she met for the first time — that she was an abortion doctor.

“I decided it was time to do whatever I could to make abortion a normal part of women's health care. I'm not going out and proselytizing about my position. I'm just doing and not trying to cover it up.”

Now 63 and edging towards retirement, Simon says telling young doctors about her progression from anonymous provider to the proud face of a profession helps them consider how their personal journey might unfold.

You don't have to be both an advocate and a physician, she tells them; simply being a good doctor is enough.

One year after questions started to swirl through his mind, he has made his choice.

James will be an abortion doctor.

Not only that, but James plans to do second-trimester abortions as part of his practice. He will step to the very front line, the place where there is greatest need — and greatest risk.

The decision came after a long period of reflection.

What he learned about himself is that he is not pro-abortion, but pro-choice. This means both abortion and adoption are part of the spectrum of care he believes in. With this distinction James was able to reconcile having one foot in an abortion clinic and the other in an adoption agency.

“In some ways, this wait has made me more pro-choice, because I see that women have all of these options,” says James. “I don't think I'll ever have trouble being honest with my children about telling them what I do. To me, it will allow me to say to my child: your mother had a choice, and she decided that you should be here and wanted somebody to care for you.”

That he is part of a profession that, at its roots, cares for people in need also helped James regain his firm stance on abortion.

As he considered whether he would be a provider, James read books that contained letters of thanks written by women to their abortion providers. He also thought of the hundreds of women for whom he has performed abortions, remembering how their scared faces flooded with relief when he told them he had done what they asked.

“Professionalism means doing what is right for others, not what's right for yourself,” he says. “On the day I got my medical degree, I took an oath that we all take, which essentially states that we're going to do well by our patients. To me this is the right thing to do.”

James doesn't really believe he is in danger; like others of his generation he chooses to believe the most risky years for abortion providers are in the past. Still, he will remain cautious.

From time to time he searches for his name on the Internet to see if it is linked with any radical anti-abortion groups. And on the advice of several abortion groups, he opens suspicious-looking letters and packages outside, away from his house.

He suspects that he will always hide the fact that he is an abortion doctor. And, while he knows the need for abortions is greatest in rural communities, James will practise in a large city where the mask of anonymity is more secure.

More questions might come to him, and doubts may again creep into his mind. Already he wonders whether he should be open and proud of being an abortion doctor.

James accepts that he has tough road ahead.

He hopes his child will be proud of him for taking it.

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