About 10 years ago, a young woman in the military walked into the Women’s Options Center at the University of California-San Francisco and spoke with Aisha Wagner, who was a practice assistant at the time. The woman had simultaneously learned that she was pregnant and had kidney cancer during a recent trip to the emergency room. Because there’s a risk of fetal anomalies during chemotherapy, she needed an abortion. But TRICARE, the military’s health insurance, rejected her request.

Wagner, now a family physician, wouldn’t accept TRICARE’s refusal and became determined to get this life-saving medical procedure approved. She spent much of the next week on the phone, climbing up the ladder of managers until she finally learned that a military doctor must speak to TRICARE on the patient’s behalf. Then, she faced a new challenge: Several military physicians told Wagner they were uncomfortable stating the procedure was necessary. Finally, one doctor agreed to advocate for the abortion.

“This woman volunteered to put her life on the line for her country, and they were refusing to provide a safe procedure so she could proceed with her cancer care,” Wagner explains, still in disbelief years later. “Initially, they said they don’t cover abortions. There was no understanding of her situation and no sympathy or compassion. I couldn’t comprehend why they didn’t understand what was needed. It was heartbreaking. I would put down the phone and tear up, and when I went home, I cried.”

Wagner was fighting against a law enacted by Congress in 1984—Title 10 U.S.C., Section 1093—which restricts the military’s ability to perform abortions. Currently, the law prohibits the Department of Defense from paying for abortions via TRICARE or using their facilities to perform abortions unless the “life of the mother would be endangered if the fetus were carried to term or in a case in which the pregnancy is the result of an act of rape or incest.” There is no exception in the case of fetal abnormalities.

But this young woman experienced what many others in the military have endured: It’s not only challenging to prove that your pregnancy will jeopardize your life, but once proven, it’s unlikely that military medical staff have received the proper training to perform an abortion.

Currently, medical programs that teach obstetrics and gynecology are required to provide residents with opportunities to learn how to perform abortions, but OB/GYN residents can choose to opt out of abortion training, and the military’s abortion restrictions make it even more difficult for military residency programs to provide this experience.

A report created for Congress in 2013 noted additional barriers, namely that few students in military medical schools volunteer for abortion training as they tend to have more conservative social views, and those who are interested in learning often remain silent because their request may “ruffle the feathers” of their superiors. Additionally, because the medical team must volunteer to perform the procedure, if an essential member refuses to do so, the training is essentially vetoed for the group.

Once TRICARE approved coverage of the abortion for Wagner’s patient, she returned to the clinic to abort her pregnancy, and ultimately save her life, with her husband by her side. In fact, she was forced to travel off-base for her procedure as she didn’t meet the requirements for an on-base abortion: Her life wasn’t technically at risk at that moment, as she could have received chemotherapy while pregnant—it was the life of the fetus that was in danger.

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Proving rape or incest, a clause added to the law in 2013, isn’t any easier, according to Daniel Grossman, an abortion provider and the director of Advancing New Standards In Reproductive Health (ANSIRH). In fact, the stigma attached to survivors of sexual assault often prevents women from seeking an abortion that would be covered by TRICARE.

“There is a lot of underreporting of sexual assault,” says Grossman, who’s also a professor of obstetrics, gynecology, and reproductive sciences at UCSF. “Women often believe that it isn’t worth reporting because of the stigma attached. They see that nothing is done, and it can damage their career. In cases where a woman got pregnant after sexual assault and can receive an abortion at a military facility, many don’t go through the military system because of their concern for confidentiality, while others don’t even know it’s available.” (If a woman takes a pregnancy test at a military facility, the result is recorded in her file and her commander could find out.)

Even with pregnancies resulting from consensual sex, Grossman says women believe they’ll be punished, targeted for retaliation, or their career will suffer if they seek an abortion. So many remain quiet while the weight of their circumstances takes its toll on their mental health.

Alex Ferencz was a 23-year-old Marine corporal when she learned she was pregnant. Ferencz had a brief relationship with another Marine while separated from her husband. The combination of an adultery charge—which often results in a demotion—and the stigma of an abortion required extreme caution.

“In Arizona, there’s a mandatory waiting period and, at the time, I had to wait one week between my initial phone call and my appointment,” Ferencz remembers. “I wondered every day if it was the right decision because I was forced to wait.”

Her job involved working with dangerous chemicals with labels that warned of the risk of fetal deformities. During the week before her appointment, she'd stare at these labels and wonder if she was making the right decision. At this point, changing her mind would mean that she'd exposed the fetus to hazardous materials.

“It was a super lonely mindf--k,” she says. “I ended up breaking down and crying, and then telling the highest-ranking guy in my shop that I was pregnant. He was concerned about me and handled it professionally—he didn’t tell anybody. I could’ve gotten in trouble, and it would have completely changed my reputation.”

She also shared the news with her married, pregnant roommate who found Ferencz sitting in the backyard at 3 AM after taking a pregnancy test. She asked her squadron's doctor if, hypothetically, TRICARE covered abortions and was told it doesn't. Although her roommate provided comfort and encouragement, Ferencz went to Planned Parenthood alone, using her personal savings to cover the costs. She chose a medication abortion, which requires two pills: the first terminates the pregnancy and is taken at the clinic, while the second is swallowed at home 24 to 48 hours later, creating contractions and softening the cervix to pass the pregnancy.

Ferencz was fortunate that she didn’t live in a barracks at the time, allowing her the comfort to pass her pregnancy in the home she shared with her two roommates. However, because a friend was scheduled to visit the morning after she took the second pill, discretion was necessary.

“When I woke up the next morning after taking the second pill, there was blood all over my bed,” says Ferencz, who now works in reproductive rights outreach for Progress Now Colorado. “I had taken Vicodin and passed out. I had to hide everything, scrub the sheets and clean up so no one saw it. That shouldn’t have been on my mind at the moment. It was very isolating.”

Luckily, Ferencz’s civilian family members were supportive, helping her process the experience. Many servicewomen aren’t as lucky since mental health care in the military can be of poor quality and comes with confidentiality risks. They worry that, since military mental health professionals have a responsibility to update and maintain patients’ military files, their confidentiality isn’t truly protected. It’s challenging to openly share your struggles knowing that the person assigned to help you may be required to document information that could jeopardize your career. So, some choose to suffer privately.

One traumatic experience that military women who’ve had abortions sometimes share is passing their pregnancy without pain medication. For a 2017 study published in Perspectives on Sexual and Reproductive Health, Grossman and a team of researcher interviewed women in the military who’d had abortions and analyzed their stories, like that of an Air Force officer who refused anesthesia with her surgical abortion because she was required to report all prescription medications for her military records. Doctors say this isn’t uncommon.

“With an abortion, we routinely give women several medications so they are not so uncomfortable passing their pregnancy,” says Jenny Abrams, a family physician in Seattle, Washington, who has treated servicewomen who travel by plane, ferry, or car to see her—additional costs to receive an abortion. It’s often a combination of anti-nausea meds, a strong ibuprofen, and a small amount of a narcotic, like oxycodone, she says.

“Once, while explaining what to expect at home, a married military woman refused the narcotic. I asked her if she’d had a bad experience, and she responded, ‘Oh no, I can’t have it in my urine in case I have to take a drug test,’” Abrams recalls, adding that the woman assured her the pain was manageable, explaining that she'd experienced it before.

Although Wagner says abortions are very safe medical procedures, if complications like infection or excessive bleeding do occur, TRICARE won’t cover the treatment if it didn’t cover the abortion. Servicewomen would need to travel off-base for treatment relating to a non-covered abortion (such as antibiotics or a blood transfusion) and pay for this care out of pocket. Depending on the complication, the number of hours before care is sought, and the length of travel to an appropriate medical facility, women’s lives could be in danger. In other words, servicewomen may risk their lives to protect their career.

Abortion can be significantly more dangerous during deployment where substandard local care forces women to purchase abortion medication online, which delays treatment, and the drugs often arrive without instructions. “They don’t want to leave their unit,” explains Grossman, who has also researched this topic. “Instead, they want to finish the job they were sent there to do. Many are supporting their family and would make less money if they were sent home. So they look for ways to obtain medication in their deployed setting.”

Experts like Grossman who advocate for the Department of Defense to provide abortion coverage, argue that the government is ignoring basic healthcare needs. He believes that providing access to abortion is also an issue of troop readiness: If military doctors were better trained to provide abortions, women could quickly and safely return to their jobs, he says.

“When politicians try to restrict access to safe and legal care, it only threatens women’s health,” says Abrams, who’s lobbied in Washington, DC, with Physicians for Reproductive Health. “They deserve as good of quality health as men. Women shouldn’t be treated as second-class citizens.”