By Mark Hemingway, RealClearInvestigations
September 8, 2022

Since the Supreme Court’s decision to overturn Roe v. Wade in June, Planned Parenthood CEO Alexis McGill Johnson has tried to present new state laws restricting abortion as an opportunity for the nation’s largest abortion provider. “Now that we are in a world where we are no longer defending Roe,” she told Time magazine, “we have actually an opportunity to reimagine and reconstruct something better.”

The sense that Planned Parenthood's fortunes are on the upswing is palpable, given the liberal backlash against the Roe ruling -- among women especially -- blowback evident in recent off-year voting and opinion polling. OpenSecrets says the organization reported a 4,000% increase in donations just after the decision, and half of the donations were from new donors. It is planning on spending $50 million on elections this fall, an unprecedented amount for a midterm cycle. 

But close observers of the abortion debate say there’s limited potential for the organization to embrace a broader role – for example, in dispensing abortion drugs over providing surgical abortions. Its shift in that direction had been under way long before the Supreme Court ruling, but it faces competitive challenges, since abortion drugs are widely available over the Internet, and new risks, since the drugs more easily evade regulatory scrutiny.

Another controversial growth option in Planned Parenthood’s future is far afield from pregnancy: distributing hormones used by children and others to change their gender. CEO Johnson has said that providing “gender-affirming care” is one of the services that “is going to become even more important.” But that option carries big risks, complications, and uncertainties too.

Can Planned Parenthood evolve? For years, despite evidence to the contrary, it has emphasized its versatility, casting its operations as “community health clinics” that provide a variety of essential health care services, especially contraception and testing for sexually transmitted infections. In 2011, Cecile Richards, Planned Parenthood’s president at the time, suggested in a television interview that the organization provided mammograms, a point soon repeated by President Obama and others. In 2015, a Washington Post “fact checker” concluded, “The myth that Planned Parenthood actually offers mammogram X-rays to patients has been long debunked, and needs to stop being repeated.”

An oft-cited talking point from Planned Parenthood’s own fact sheet was that “3% of all Planned Parenthood health services are abortion services.” In this accounting, the cost of services wasn’t taken into account – prescribing oral contraceptives at a cost $20 and a second-trimester abortion that costs in excess of $2,000 are both counted as services Planned Parenthood provides, but they are obviously not comparable in terms of the organization’s income or incentives. Again, a Washington Post fact-checker declared the 3% figure “misleading,” dinged the organization for its lack of transparency about abortion services, and gave Planned Parenthood “three Pinocchios” for the claim.

So there’s little doubt that abortion is Planned Parenthood’s main business. Over the last three decades, its position as America’s leading abortion provider increased markedly, according to James Studnicki, a former professor of public health at the University of North Carolina and Johns Hopkins who is now vice president and director of data analytics for the pro-life Charlotte Lozier Institute. Between 1995 and 2014, abortions dropped 50% at non-Planned Parenthood abortion providers, “but Planned Parenthood abortions were up 142%,” says Studnicki, summarizing the results of a peer-reviewed paper he published in 2018.

By 2019, Planned Parenthood was responsible for about 40% of all  abortions in the U.S., compared to 10% of abortions in 1995, Studnicki said. In recent years, the total number of abortions in America has has been increasing, reversing a long trend of historical decline. There were 930,160 abortions in 2020, the Guttmacher Institute reports, an 8% increase from 862,320 abortions in 2017.

Nevertheless, Planned Parenthood's reach was diminishing even before the Supreme Court decision, as several states passed laws restricting abortion access -- restrictions the group now thinks it can capitalize upon. Tessa Longbons, a senior research associate at the Charlotte Lozier Institute, said that between June of 2021 and June of 2022, Planned Parenthood closed or merged 25 centers out of approximately 600 facilities the organization runs around the country. Danika Severino Wynn, vice president for abortion access at Planned Parenthood, told The New York Times that more closures are possible in response to the court’s June decision: “Affiliates in these states that are extremely hostile to abortion access are being forced to make the difficult decision whether or not to suspend providing abortion services following the court’s decision, due to their state’s legal landscape.”

Planned Parenthood did not respond to RealClearInvestigations’ request for comment, nor did the Guttmacher Institute, a pro-abortion research group historically affiliated with Planned Parenthood.

Regardless of whether Planned Parenthood closes additional clinics or pursues other sources of revenue, its core mission of providing abortions appears unlikely to change – although its proportions of chemical and surgical abortions likely will.

Nationwide, chemical abortions made up over half of all abortions as of 2020. A number of individual Planned Parenthood affiliates have reported that more than 60% of the abortions they are doing are chemical abortions as opposed to surgical abortions.  

Chemical abortions typically involve a combination of two drugs – mifepristone (aka RU-486), which kills the fetus; and misoprostol, which causes the uterus to shrink, expelling the detached embryo through the vagina.

Because women can order these drugs online and self-administer them, it is not clear how Planned Parenthood will be able to dominate the market as it does with surgical abortions, which require doctors and expensive facilities. There are also unresolved legal questions, especially if some states outlaw the sale of these drugs, and liability questions regarding negative outcomes.

Currently, abortion drugs are approved by the Food and Drug Administration only through the first 10 weeks of pregnancy. Though even abortion-rights advocates concede that intense pain and bleeding for two weeks are normal outcomes, advocates are pushing for approval of mifepristone and misoprostol later in pregnancy when the potential for complications increases significantly as the fetus grows larger.

Just how common life-threatening side effects are in chemical abortions is disputed. An oft-cited 2009 study on women in Finland published in Obstetrics & Gynecology found one out of every five given abortion drugs in the first trimester experienced a complication, compared with one out of 20 women who underwent a surgical abortion. The most common adverse event was potentially life-threatening hemorrhaging, which represented 16% of the total complications.

In contrast, the Guttmacher Institute cites a study published in the pro-abortion journal Contraception showing “serious complications requiring hospitalization for infection treatment or [blood] transfusion occur in less than 0.4% of patients under the standard protocol.”

In 2013, a bulletin from the American College of Obstetricians and Gynecologists noted that researchers in North Carolina were unable to find American volunteers for a study on whether the drugs were effective in midterm abortions because of the trauma and risks involved. American women “strongly preferred” surgical abortion under anesthesia.

Abortion researchers have instead resorted to performing drug trials on women in developing countries. In 2017, Gynuity Health Projects, a New York-based group aligned with Planned Parenthood, began trials on second-term pharmaceutical abortions in Burkina Faso, despite concerns -- voiced even by the study's director in the country -- that critical health infrastructure was lacking to deal with the known potential life-threatening side-effects of chemical abortions, such as the ability to readily provide blood transfusions in the event of hemorrhaging.

In June, New York magazine published a series of explicitly pro-abortion features on “Life After Roe” with the aim of helping women obtain abortions. One of those features was a first-person account of a drug-induced abortion:

My gynecologist told me to expect a “bad period.” … The actual problem was, as with so many experiences in women’s health care, my doctor didn’t adequately prepare me. She told me I’d have the cramping and bleeding of that “bad period” but didn’t describe the range and type of pain I might experience. Instead of offering sufficient pain medication or techniques to moderate pain, she prescribed six Tylenol with codeine, though she didn’t think I’d “need” them. I did, but who knows if it even helped? My pain came in waves; a grinding in my pelvis, like a mortar and pestle in the range of my pubic bone. (Years later, when I was in labor with my child, I realized I’d already experienced early contractions—during my abortion. Medication abortion can be a sort of in-between of the two experiences, a “bad period” and birth.)

And rather than explaining that I would bleed heavily for days — I spent at least 24 hours in a sort of towel cocoon until I felt as if I could bear to wear anything on my bottom half — she simply said I would “see some clots” but shouldn’t worry unless I soaked through two maxi-pads in an hour for two hours. After it was all over, I bled for two weeks with more mysterious contents in the pads: material that looked like coffee grounds (Google told me they were tiny clots), larger clots, dark blood, pink blood. Blood loss and the hormonal switching made me exhausted, weak, and bloated.

After my termination, physically, I felt off — mentally and emotionally, I felt even worse for being so ill-prepared and uninformed. As my husband put it, “We didn’t even get a f---ing pamphlet.” (I should say, my doctor wasn’t “bad” — and my experience wasn’t atypical.)

Last December, the FDA further loosened the safety regulations around mifepristone by removing the previous FDA requirement that the drug be administered in person by a doctor. Those seeking an abortion can consult with a doctor via telemedicine, receive the pills by mail, and go through the process of inducing an abortion without ever setting foot in a clinic. The FDA’s decision was announced just 15 days after the Supreme Court heard oral arguments in Dobbs v. Jackson, the case that would go on to overturn Roe v. Wade when the ruling was announced in June.

Pro-abortion rights groups don’t discount the risks of opting for an at-home abortion via telemedicine. A Gynuity “evaluation of a direct to patient telemedicine abortion service in the United States” found 8% of patients in the study given abortion pills via telemedicine ended up going to an ER or urgent care clinic.

Further, whether FDA approval of a drug would pre-empt a state ban remains a controversial legal question. “When [the FDA] approves an abortion drug for safety and efficacy, it's not talking about safety for the unborn human being obviously,” says Edward Whelan, a senior fellow at the conservative Ethics and Public Policy Center. “It's talking about safety for the mother and efficacy in killing the unborn human being. And when a state enacts a law barring that drug, it's not disagreeing with the FDA judgment on safety and efficacy.”

Abortion drugs could create other forms of legal jeopardy, according to Jonathan Mitchell, the former solicitor general of Texas. “It’s easy to just have a state pass a law that says if you manufacture this drug or distribute it in any way, you’re strictly liable for any personal injuries – not only to the mother, but also to the fetus,” he said. “You’ll be sued for wrongful death, put out of business, and all you need is one state to do this …  how many drugs have been taken off the market due to lawsuits over personal injuries that are far less dangerous than this?” 

For now, the regulatory uncertainty is causing some Planned Parenthood affiliates to act cautiously about offering chemical abortion for fear of running afoul of state laws. Montana, where chemical abortion is legal, and the four more restrictive states bordering it provide an illustration. Montana has seen an influx of out-of-state women seeking abortions. But Planned Parenthood of Montana, which runs three clinics in the state, has stopped offering abortion pills to anyone who doesn’t live in the state. According to NPR, the president of Planned Parenthood of Montana circulated an internal memo “citing concerns about the potential for civil and criminal action.”

Despite its initial caution, “I think Planned Parenthood will find ways to continue to provide chemical abortions even where they don't have facilities available,” says Studnicki.

As for “gender affirming care,” its growth has not gone unnoticed by Planned Parenthood.

Planned Parenthood’s annual report for 2018-2019 made no mention of hormone treatments for transgender patients, but its last two annual reports have touted it. According to its most recent annual report, Planned Parenthood has clinics in 33 states and the District of Columbia that provide cross-sex hormones to people who identify as transgender. In 2020, Planned Parenthood’s website claimed, “Nationally, Planned Parenthood is the second largest provider of Gender Affirming Hormone Care,” though that claim has since been scrubbed from its website.

About 1.6 million Americans identify as transgender and that number is growing quickly. A report released ethis year by the Williams Institute at the University of California, Los Angeles, shows that the number of young people identifying as transgender doubled between 2017 and 2020 and now represents between 1.3% and 1.4% of all Americans under the age of 24.

Given the growing market for transgender services, the financial incentives for Planned Parenthood are considerable. Last year, Abigail Shrier, author of “Irreversible Damage: The Transgender Craze Seducing Our Daughters,” published an interview with a Planned Parenthood employee who supports the organization’s core mission related to abortion, but had serious misgivings about how Planned Parenthood was doling out hormones.

According to the employee, “Trans-identifying kids are cash cows, and they are kept on the hook for the foreseeable future in terms of follow-up appointments, bloodwork, meetings, etc., whereas abortions are (hopefully) a one-and-done situation.”

The cost of prescription hormones alone can vary from around $400 to $1,500 a year, not including the cost of blood tests and other medical services necessary for transgender treatments.

The Planned Parenthood employee further told Shrier that one or two new biologically female teen patients were coming to the clinic she worked at every day. They were sent to a gender counselor at the clinic with “no actual professional credentials or formal training other than being [a male-to-female transgender person].” The gender counselor would send “notes to an actual licensed mental health professional somewhere off-site, and rubber stamp approve the patients to begin their transition. This is basically how they circumvented the requirement to speak to an actual counselor.”

Such apparent vulnerabilities in its operations suggest that Planned Parenthood’s effort to, in Johnson’s words, “reimagine and reconstruct something better” in a post-Roe environment remains unclear. 

“If they were a health care provider interested in women's issues such as prenatal care, if they were interested in essentially providing any other kinds of service, they might find different ways to continue to engage,” says Studnicki. “But my expectation is that over time, Planned Parenthood, at least as a clinic, will disappear in communities where abortion is restricted.”