With New York legalizing gay marriage, more and more children will be exposed to same-sex couples (much to the chagrin of conservatives). Here is great video of one little boy's reaction to seeing his first gay couple -- watch how he figures things out:

 

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Report: Despite Obamacare, Insurers Aren’t Covering Birth Control Consistently

The report from the Kaiser Family Foundation finds that insurers are not providing consistent coverage for non-pill birth control methods, and it can be fiendishly difficult to find information about which methods are covered.

CVS came under fire last year for inappropriately charging 11,000 women a co-pay for their birth control, which is supposed to be covered with no cost-sharing under the Affordable Care Act. A new report suggests that this kind of problem may be widespread.

The report from the Kaiser Family Foundation finds that insurers are not providing consistent coverage for non-pill birth control methods like the vaginal ring, intrauterine device (IUD), implant, and hormonal patch.

It can be fiendishly difficult to find information about which methods are covered by different plans, and women may not have access to an adequate appeals process if they feel they are being unfairly charged.

All Food and Drug Administration-approved methods of birth control are supposed to be covered without cost sharing, and government agencies like the Centers for Disease Control and Prevention have clearly stated that contraceptive choice is important to reduce the risk of unplanned pregnancy.

Most insurance carriers comply with the spirit of this requirement, the report finds, but there are significant and worrisome exceptions.

The report surveyed 20 insurance carriers in five states: California, Georgia, Michigan, New Jersey, and Texas.

The information about these carriers wasn’t easy to come by, the authors noted. Out of 24 companies contacted, only nine agreed to interviews, and many of those officials interviewed didn’t have complete information.

The rest of the information came from publicly available documents. Many of these documents, however, did not have clear information about how various contraceptive methods were covered.

“This makes it extremely difficult, if not impossible for policyholders to ascertain their current plan’s contraceptive coverage policies,” the report says.

Five of the 20 insurance carriers studied required co-pays for the NuvaRing, the only FDA-approved vaginal ring, and one plan doesn’t cover it at all. Two carriers don’t cover any kind of contraceptive implant, and one doesn’t cover the ParaGard, the only available non-hormonal IUD.

Only half of the 20 providers cover all three FDA-approved IUDs with no limitations, and only 11 fully cover the emergency contraceptive pill ella, which has a longer window of effectiveness than Plan B and is more effective for women over a certain weight.

Some of these limitations may run afoul of the law, while others may be a result of poor communication or misinterpretation of guidelines.

Frequently, methods aren’t covered because insurers are exercising “reasonable medical management,” which is supposed to reduce costs. Some insurers argue that because methods like the ring or the patch have the same hormonal formulation as the pill but are more expensive, it’s reasonable to cover the pill but require a co-pay for other methods. A patient may also be required to try out the pill first before covering those methods.

The Obama administration hasn’t given concrete guidance about how reasonable medical management should apply to contraceptive care. It does, however, say that insurers should have a waiver process in place for women who have a medical need for a certain method that isn’t covered.

The report’s authors noted that none of the carriers they interviewed had a formal waiver process for women who want to contest being charged for contraceptives.

All of the companies claimed that their usual appeals process was sufficient, but the report’s authors said that the timing of those processes “may be problematic and lead to delays which are not in the best interest of standards for quality contraceptive care.”

That problem is especially acute for emergency contraception, the authors noted.

Of concern, none of the carriers interviewed had an expedited waiver or appeal processes for emergency contraceptives other than the expedited appeal process required for all other benefits, which may not be timely enough for women seeking emergency contraceptives.

A spokesperson for the Department of Health and Human Services told Vox that the administration plans to release more guidance “soon” to address the confusion.

Image: Shutterstock

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How Justice Kennedy Set the Stage for D and E Bans in ‘Gonzales v. Carhart’

In Gonzales, we were handed a devastating loss that set the stage for waves of restrictive and unscientific attacks on abortion rights. Those restrictions have come to a dangerous crest with the anti-choice community's campaign against D and E abortions.

In 2000’s Stenberg v. Carhart, the United States Supreme Court struck down a Nebraska statute banning “partial-birth abortions,” a phrase coined by anti-choice activists to describe a relatively uncommon variation of dilation and evacuation abortion (D and E) known by providers as an “intact D and E.” The Nebraska law, the majority in Stenberg wrote, unduly burdened abortion rights, in part because it was a pre-viability ban that contained no exception for the health of the pregnant person. Seven years later, the Supreme Court would once again take up the issue of intact D and Es—this time in Gonzales v. Carhart, a case that challenged the federal Partial Birth Abortion Act of 2003. The law in question was modeled largely after the stricken Nebraska statute; therefore, like Stenberg, Gonzales should have been another victory for pro-choice advocatesInstead, we were handed a devastating loss that set the stage for waves of restrictive and unscientific attacks on abortion rights. Those restrictions have come to a dangerous crest with the anti-choice community’s campaign against D and E abortions.

To trace the seismic shift that has produced the current climate of attack after attack on reproductive freedom, we should look not just to the loss of Justice O’Connor and the addition of Justice Alito, but also to the actions of Justice Anthony Kennedy. Under his guidance, the Court lurched abortion jurisprudence violently to the right—most notably in Gonzales, the first Supreme Court ruling on a pre-viability ban that contained no health exception for a pregnant person. Writing for the conservative majority in Gonzales, Justice Kennedy said that patients who needed an abortion later in their pregnancy would have other options, such as standard D and Es. Even though the Court had just reached the exact opposite conclusion as it had in Stenberg, Kennedy’s opinion suggested that the ruling in Gonzales was limited and posed no real long-term threat to abortion rights. Trust him.

Eight years later, so-called dismemberment bans that target D and E procedures—by far the most common method of second-trimester abortions—have now passed in Kansas and Oklahoma. They are lurking in the background in legislatures in South Carolina and Missouri. These latest rounds of abortion restrictions seek to finish what anti-choice advocates started in Gonzales: the eradication of later abortion options for patients who need them. To do that, they’ve developed a legislative and litigation strategy that is a case study in how to undermine constitutional abortion protections and upend settled law.

And despite what Justice Kennedy may have claimed in Gonzales about leaving choices available for pregnant patients, there is nothing in the history of his abortion rights opinions that would suggest he is really interested, should these D and E restrictions go to the Supreme Court, in options other than birth.

Justice Kennedy was the only member of the current conservative wing of the court to vote to uphold abortion rights in Planned Parenthood v. Casey in 1992. This has led some people to regard him as a “moderate” or “swing vote” on these matters. Since then, however, he has yet to come across an abortion restriction he finds unconstitutional, and his opinions drip with paternalism and moral condemnation of a pregnant person in need of an abortion.

“The majority views the procedures from the perspective of the abortionist, rather than from the perspective of a society shocked when confronted with a new method of ending human life,” wrote Kennedy in his dissent in Stenberg v. Carhart. Nothing says “moderate” or “swing vote” on abortion like calling doctors abortionists, am I right? “States also have an interest in forbidding medical procedures which, in the State’s reasonable determination, might cause the medical profession or society as a whole to become insensitive, even disdainful, to life, including life in the human fetus,” he continued.

That’s not the kind of language reproductive rights advocates hope to hear from a Supreme Court justice contemplating the interests of pregnant people to be free from state-coerced birth. Nor is it the kind of language medical professionals hoping to practice medicine free from judicial micromanagement want to hear, either.

Not surprisingly, Kennedy’s dissent gets worse. “Those who oppose abortion would agree, indeed would insist, that both [intact and non-intact D and E] procedures are subject to the most severe moral condemnation, condemnation reserved for the most repulsive human conduct.”

In other words, Justice Kennedy is here to save the medical profession from itself and to protect hapless pregnant people from the consequences of their own actions.

But it’s not just Kennedy’s language in Stenberg that is problematic. It’s his equating the state passing a moral judgment against abortion to the power of the state to regulate abortion pre-viability. In Kennedy’s view, the state has apparently endless constitutional power to regulate abortion, even banning procedures that happen pre-viability despite the fact that from Roe v. Wade on the Court has consistently held that states may not do so.

In the Stenberg dissent, such rhetoric is harmless, because dissents have no legal, binding value as precedent. They can be the equivalent of a justice shaking his fist at the sky and yelling. But when the ideas in that dissent later become those in the majority opinion, like it did in Gonzales, the effect on pregnant people and their constitutional rights is devastating.

Justice Kennedy returned to his disturbing language about D and E procedures—the ones very commonly used in second-trimester abortions—in the Gonzales majority opinion, writing, “No one would dispute that, for many, D and E is a procedure itself laden with the power to devalue human life.”

And under Justice Kennedy’s guidance, the Court finally was able in Gonzales to reframe the abortion debate where the interests of the state can outweigh the interests of the pregnant person before fetal viability, allowing the government to regulate abortion in that time period. Kennedy wrote, “Congress could nonetheless conclude that the type of abortion proscribed by the [Partial Birth Abortion Act] requires specific regulation because it implicates additional ethical and moral concerns that justify a special prohibition.”

And anti-choicers have followed in those state-interest footsteps.

In the initial rounds of reaction to the D and E bans passed by Kansas and Oklahoma reproductive rights supporters quickly, and rightly, noted that unlike the previous “partial-birth abortion” bans, these latest restrictions were even broader in scope. This should suggest that despite the clear anti-abortion bias among the conservative majority, the Roberts Court would decline to uphold these restrictions. Plus, amid all his talk of D and Es devaluing human life, Kennedy had explicitly pointed out non-intact dilation and evacuation abortions as an option for women in Gonzales, right?

I wish I could say I shared that faith that the Court will do the right thing. But given the Court’s track record, I just don’t. Look at what happened with last summer in Hobby Lobby, for example: The conservatives, including Justice Kennedy, allowed for-profit corporations a religious exemption from complying with the birth control benefit in the Affordable Care Act, because such an exemption existed for nonprofit businesses. That exemption, the conservative majority in Hobby Lobby ruled, proved there were other, less burdensome ways for the Obama administration to meet its goal of eradicating gender discrimination in insurance coverage. The very next day, the Court then tried to chip even further at birth control availability in Wheaton College, when it ruled the nonprofit’s religious rights were likely violated by the accommodation process whose constitutionality it had just affirmed. Justice Kennedy, in particular, had relied on the existence of the nonprofit accommodation in Hobby Lobby as an example of how the government could get it right when balancing gender equality and religious objections to contraception. Then he’d joined with conservatives in blocking that same accommodation the very next day.

This suggests Kennedy plays a long game. In the case of the contraception benefit, it was by holding up the nonprofit exemption as an option, then working to take that option away.

The same can be said for D and E bans. Despite trying to assure folks that the reach of Gonzales was limited, the language and the effect of Kennedy’s decision shows that was never the case. He showed his hand first in Stenberg by fully embracing anti-choice language and rhetoric decrying “abortionists,” and elevating the interests of the state above those of the pregnant person. Then he played it masterfully in Gonzales by setting out all the reasons why the ruling should apply to all D and Es, before reigning the opinion in with his conclusion: that the federal law only regulated a fraction of the procedures. There’s no reason to think he won’t continue his pattern with the current D and E bans.  

If there’s good news here, it’s that it will take a while before the issue reaches the Roberts Court, which conceivably could also mean a different makeup of the Supreme Court, depending on retirements and future presidential appointments. So far only two states have passed D and E bans, and while no legal challenges have been filed yet, it’s reasonable to think they are coming. But it’s also clear anti-abortion advocates hope those challenges do come. States like Kansas and Oklahoma don’t just provide the anti-choice side with friendly state legislatures to pass what should be considered blatantly unconstitutional abortion restrictions. These states are also situated in conservative federal court jurisdictions that are extremely hostile to abortion rights, and thus likely to uphold them.

The same is not true for anti-abortion states like Ohio, Indiana, and Arizona, where anti-abortion restrictions have, for the most part, faced tougher scrutiny in the federal courts. Somewhat counterintuitively, my educated guess is that we’ll see similar bans pop up in those states, as anti-choicers hope to force a split among the federal courts on the constitutionality of these restrictions. Such a split would require the Roberts Court to step in. By the looks of things today, that has been the anti-choice plan since the ink first dried in 2007 in Gonzales. 

Image: George Washington's Mount Vernon/ Youtube

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Kansas Governor Takes ‘Punitive’ Action Against State Welfare Recipients

Gov. Sam Brownback signed a bill into law Thursday that will severely limit how low-income people can spend state welfare benefits.

Kansas Gov. Sam Brownback (R) signed a bill into law Thursday that will severely limit how low-income people can spend state welfare benefits.

HB 2258, sponsored by Sen. Caryn Tyson (R-Parker), codifies restrictions that had been imposed by the Brownback administration during the past four years.

The new law prohibits recipients from spending government benefits outside the state and on an assortment of activities such as visits to swimming pools, movie theaters, casinos, and liquor stores.

The law limits welfare recipients to just $25 per day from an ATM. Kansas is the first state in the nation to implement a cash cap of $25 per day. The national average for ATM fees is $4.35, reports Al Jazeera. The new law includes no language exempting these fees from the $25-per-day cap.

Elizabeth Lower-Basch, director at the Center for Law and Social Policy (CLASP), told Al Jazeera that the law is “disconnected” from the reality of low-income people’s lives. “The single biggest expense that people have is rent,” said Lower-Basch. “They’re just going to have to go every day to get their rent money.”

The new welfare law also bans using any federal or state funds for television, radio, or billboard advertisements that are designed to promote food assistance benefits and enrollment.

Shannon Cotsoradis, president and CEO of Kansas Action for Children, told the Topeka Capital-Journal that this will prevent low-income people from learning that they may be eligible for SNAP (Supplemental Nutrition Assistance Program, commonly referred to as food stamp) benefits and other types of assistance.

“This harmful legislation does much more than just restrict how TANF [Temporary Assistance for Needy Families] recipients can spend their cash—it also means families may never know they’re eligible for SNAP to help feed their children,” Cotsoradis said.

Brownback said during the signing ceremony that the legislation is meant to reform state welfare programs that he says too often lead to low-income people depending on government assistance.

“Too often, while well-intentioned, our poverty programs fail the poor,” said Brownback, reports the Topeka Capital-Journal. “They fail them by keeping them in cycles of dependency. This legislation helps break that destructive cycle.”

The new law reduces the lifetime limit someone can of receive TANF benefits from 48 months to 36 months. The federal lifetime limit is 60 months.

The $25-per-day cap is a measure Republicans claim is intended to prevent fraud. “Every dollar that is used fraudulently is a dollar that is not going to an American who is struggling,” state Sen. Michael O’Donnell (R-Wichita) told the Associated Press.

The Kansas Department for Children and Families recovered $199,000 in cash assistance from 81 fraud cases from July through February, reports the AP. The state provided $14 million in cash assistance to low-income residents during that same period.

Critics of the law say that it punishes low-income families who rely on the TANF program. Senate Minority Leader Anthony Hensley (D-Topeka) said the welfare crackdown is punishing low-income Kansans who have already been adversely affected by Brownback’s economic policies.

“Gov. Brownback’s reckless economic experiment has significantly increased taxes on low-income Kansans,” Hensley told the Topeka Capital Journal. “And, now, the governor has signed a punitive and highly judgmental piece of legislation that imposes illogical reforms that make it harder for Kansans in need to break the cycle and climb out of poverty.”

Brownback, since taking office in 2011, has pushed an assortment of right-wing economic policies. In 2012 the governor signed into law one of the largest tax cuts in state history, which critics said would cost the state more than $2 billion over five years.

Brownback’s tax cuts have resulted in an 8 percent revenue loss that has had a devastating effect on the state’s ability to meet basic funding levels for public education and has busted the state’s economy, according to an analysis by the Center for Budget and Policy Priorities.

The analysis concluded that the tax cuts disproportionately benefited wealthy households.

Image: Sam Brownback/ Youtube

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Losing My Lege: Debate Over ‘Confederate Heroes Day’ Pits Texans Against Liberal ‘Aggressors’

I sat around stone-cold sober earlier this week listening to my fellow Texans boast about how their innate Texanness somehow demands that they do no less than vocally support a thing called "Confederate Heroes Day," a state holiday that occasionally falls on Martin Luther King Jr. Day.

Losing My Lege is a weekly column about the goings-on in and around the Austin capitol building during the 84th Texas legislature. 

Texans love talking about what “generation Texan” we know ourselves to be. When “native Texan” doesn’t quite communicate just how actually Texan we are, we start talking about how extra actually Texan our very Texan ancestors were.

I believe I’m somewhere in the “fifth generation Texan” range, which is a thing I only bring up because I sat around stone-cold sober earlier this week listening to my fellow eleventy-generation-Texans boast about how their innate Texanness somehow demands that they do no less than vocally support a thing called “Confederate Heroes Day,” a state holiday that occasionally falls, and I am not even kidding you, on Martin Luther King Jr. Day.

The occasion was a hearing of the Texas House Culture, Recreation and Tourism Committee on HB 1242, a bill from Austin Democrat Donna Howard and inspired by a local eighth-grader named Jacob Hale, who felt like renaming “Confederate Heroes Day” to “Civil War Remembrance Day” might be a “more accurate symbol of our state’s diverse history.”

And so I am compelled to note: I feel like a Southerner and I feel like a Texan and I also feel like that time a great many of my ancestors turned against their own country because they wanted to continue to literally own other human beings is not something I feel particularly proud of or anxious to celebrate. (I know what the Confederate sympathizers would say to this, because they testified to as much during the hearing: I have been brainwashed by a nationwide education system deliberately engineered to favor the Northern Aggressors. To which I respond: ¯\_(ツ)_/¯  )

But hey, the great thing about “Civil War Remembrance Day” versus “Confederate Heroes Day” is that the former makes room for brainwashed liberal race traitors like myself and people like the white lady who told the committee members that she actually, truly, honestly, and for real prefers to call it “The War Against Northern Aggression.”

But this “Aggression” cannot stand, apparently. The hearing brought out dozens of Texans who longed for the halcyon days of antebellum Texas, who wound themselves in ahistorical knots in an attempt to valorize America’s era of slavery without just coming out and saying that they really would have preferred to keep things that way.

They decried the Confederacy’s “unfair” affiliation with the Ku Klux Klan—another apparent consequence of the Northern Aggressors’ ongoing campaign of anti-Confederate propaganda—and derided Texans who supported the Union as “traitors,” with some even bizarrely condemning Memorial Day as an overblown holiday meant to celebrate said “traitors,” and why couldn’t they just have this one little bitty thing, when so much has already been taken away from them, to wit: their ancestors’ ability to own slaves?

And on and on they yammered about “political correctness” staining the sacred moral fabric of this America-that-should-never-have-been.

I’m not worried about “political correctness.” I am worried that future generations of Texans, Texans who will pride themselves on tracking those past generations, will be taught, as I was in Texas public schools, that the Civil War merely had mainly to do with “states’ rights,” and a piddly little side-issue called “triangular trade” that inspired a meddling federal government to mess, as it were, with Texas.

But Texan Sam Houston, perhaps you’ve heard of him, was after all a noted Unionist. (And anti-abolitionist.) Just one Union monument stands anywhere on Texas soil—commemorating the Confederate massacre of 37 German Texans who opposed slavery.

“Confederate Heroes Day” only tells one side—to my mind, a largely shameful and hateful side—of a multifaceted story. Texas has a fraught and nuanced history—not just as a Confederate state and as a slave-owning state, but as a state built, as so many others were, on colonialism and oppression and appropriation. To resist a change as benign as “Civil War Remembrance Day” is to cling to, and perpetuate, the worst legacies of this deeply beautiful, and deeply complicated place.

And so this afternoon, I’ll be raising a can of Lone Star—well, perhaps Dr. Pepper—to young Jacob Hale, who at age 13 has the kind of guts and sense a Texan of any age ought to aspire to.

Image: Shutterstock

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My Diagnosis, My Choice: What It Means To Be a Carrier

Genetic conditions have made their way into public dialogue in recent years, but not many people understand the decisions patients, particularly women, have to make once they have their diagnosis.

“Are you nervous?” My gastroenterologist asked me. Tears started making their way down my cheeks as I lay on the examination table.

“Yes, I am.”

“It’s going to be fine. I’m going to have you count backward from 100 and then it will be like you woke up from a nap, OK? Start counting for me.”

“One hundred…ninety-nine…ninety-eight…ninety-se…”

Then, it was over. My first colonoscopy and endoscopy were finished. I was 25 and getting my first round of screenings and testing done. A month prior, I discovered I carry a genetic mutation known as Lynch syndrome, or hereditary nonpolyposis colorectal cancer (HNPCC), which substantially increases my risks of early onset cancers of the colon and rectum, stomach, intestine, liver, pancreas, gallbladder ducts, upper urinary tract, brain, skin, and, since I’m a woman, the endometrium, ovaries, and breasts.

Genetic conditions have made their way into public dialogue in recent years, but not many people understand the decisions patients, particularly women, have to make once they have their diagnosis. My diagnosis, while manageable, has changed my life forever, and the women I’ve spoken with, who are also carrying a genetic mutation, have had to confront similar life-altering decisions. I’ve learned through this experience that it’s critical for women to have access to information, resources, and—most importantly—other women’s stories to help them better understand what options are out there and what’s best for their situation, which may or may not be what their doctor thinks is right.

“The Family That Prays Together…”

I, like many other people in my situation, realized I had this mutation because someone else in my family got cancer. While I was teaching English in South Korea nearly two years earlier, my mother called me.

“Honey, I don’t want you to worry.” This can’t be good.

“But, I went to the doctor and they believe I have uterine cancer. It’s OK though; they caught it early.” At 59, my mother had a hysterectomy and underwent radiation therapy. But then, less than a year later, they found cancerous polyps in her colon during a colonoscopy.

Since my mother had two types of cancer so close together, her doctor advised her to have genetic testing done for Lynch. Her results came back positive, and she was told to urge her living blood relatives to get tested as well.

But when I came back from Korea, I didn’t have health insurance or a job. My mom said it was no big deal and her doctor agreed. Based on my personal and family history and genetic test results, I was told it would be fine to postpone testing for a few months since I was only 24 at the time. However, this is not always true for all patients and depends on their family’s history of cancer and the genetic condition itself.

“It’s Going To Be Fine”

About five months later after I had a steady job with good health insurance, I met with a genetic counselor, took a family history, and had blood drawn. They told me I had a 50/50 chance of having the mutation—an unlucky coin toss.

My results took about a month and a half to come in. I scheduled another meeting with my genetic counselor to discuss my results and what my condition meant—what my risks of cancer were, procedures I could undergo to reduce my risks, and what it meant for my future family plans.

I had to meet with a gastroenterologist and a gynecologist who specialize in treating Lynch patients. We talked about the different screenings I would have to do, including a colonoscopy every year, regular transvaginal ultrasounds, Pap smears, and biopsies. They both talked to me about how they wanted me to have a hysterectomy once I was done having children.

“It’s going to be fine. Have your kids and then we’ll do the surgery, just have your kids earlier, like by 35 or so,” my gastroenterologist said ever so nonchalantly.

I know her intentions were good, and I know having a hysterectomy is ultimately what I should do—as should many other patients with genetic conditions that affect women’s reproductive systems, such as the BRCA 1 and 2 mutations and Li-Fraumeni—since the procedure significantly reduces the risks of uterine, ovarian, and breast cancers. I want to have kids before 35 anyway, so no big deal right? That is unless I’m not ready to have kids by the time I’m 35. And is the procedure even covered by health insurance?

Well, that depends on the insurance company, and whether a patient’s doctor deems the procedure medically necessary for either the removal of cancer or cancer prevention. For example, Aetna medical policy states, “The medical literature suggests that a prophylactic [preventive] hysterectomy should be performed in conjunction with oophorectomy [removal of the ovaries] in women from families with Lynch syndrome I.” In other words, because Lynch patients are at risk for both uterine and ovarian cancers, a prophylactic hysterectomy in conjunction with oophorectomy is covered.

Beyond the insurance issue, though, a hysterectomy is not so easy on women. For some women, it’s hot flashes and a slight drop in libido. But for many others, like Georgia Hurst, it can be an even bigger deal.

Hurst discovered she had Lynch syndrome after her brother died of colon cancer and her other brother was diagnosed with the same. Since Lynch patients are at a higher risk for ovarian cancer and, according to the American Cancer Society, “currently there are no reliable screening tests [for ovarian cancer],” at the age of 40, Hurst underwent a prophylactic hysterectomy and oophorectomy in order to prevent cancer to her reproductive organs.

“I suffered tremendously two years after my surgery,” she said. “I started having debilitating nausea, vomiting, and migraines. I sought out various doctors for help, but they told me it was all in my head.”

Hurst was on a small dose of estrogen to counter the effects of her surgically induced menopause. She was eventually prescribed additional hormones, but those did not alleviate her emotional symptoms.

“No one close to me understood what I was going through,” she said. “My friends were having babies while I was having my reproductive organs ripped out.”

In another case, Pamela Esposito-Amery, the CEO and co-founder of the Tell Every Amazing Lady About Ovarian Cancer (TEAL) Louisa M. McGregor Ovarian Cancer Foundation, discovered she needed to be tested for Lynch syndrome when her sister Louisa was diagnosed with ovarian cancer at age 41.

“I really had no idea what [getting genetic testing done] even meant,” she said. “I knew I had to give blood and they would run a bunch of tests on [my genes], but I didn’t really think it was a big deal at all.”

But when her results came back, Esposito-Amery recalled, “I just felt like a bomb went off. I [had been] so concerned with my sister and what treatment she was getting that I didn’t even think of my own gene mutation.”

When Esposito-Amery started discussing a hysterectomy with her doctor, she and her husband had already decided not to have children. It wasn’t the idea of not being able to have children or the emotional element of a hysterectomy that scared Esposito-Amery most, though that was part of it.

“I haven’t had the surgery yet and it kind of feels like, ‘OK, last call, [a pregnancy] isn’t going to happen,’” she said. “But early menopause also puts you at risk for other things, so you try and fix one thing and it can actually affect other things.”

Those other things are an increased risk of osteoporosis, heart disease, and cognitive issues. Having your ovaries removed does not mean these issues will occur, but because of the lack of estrogen in the body, “menopausal symptoms you develop will occur earlier and are more likely to reduce your quality of life than if they occurred during natural menopause,” according to the Mayo Clinic.

“Patients Are Not One-Size-Fits-All”

Over the past 22 years, Linda Zercoe has had five different types of cancer and more than 20 surgeries. Over the course of this time, she was diagnosed with Li-Fraumeni syndrome, another hereditary genetic condition that increases a person’s risk for several types of cancer.

Before Zercoe was diagnosed with her genetic condition, she had a recurrence of an abnormal mass in her uterus that she had been told would not return. It was then that she opted for a hysterectomy at age 43.

“After the surgery I was fine,” she said. “I was pretty used to the scar from my other surgery, but I thought to myself, maybe they should have put a zipper in!”

But Zercoe said that after about a week, things changed.

“I felt trapped and enraged, like an animal,” she said. “I became obsessed with suicide and kept thinking about all the different ways I could kill myself. My mood change was so dramatic and severe. After more than a few days, I realized these feelings must be from the loss of hormones.”

The Mayo Clinic suggests that women who have an elevated risk of breast cancer should not have pre-menopausal hormone replacement therapy as it can make breasts look denser on mammograms, making breast cancer more difficult to detect.

However, Ellen Maltoff, a genetic counselor who has spent nearly 20 years in this field and has worked with more than 8,000 families, said one of the most important things doctors can do for their patients at high risk of developing cancer is listen.

“It is a delicate conversation, and people are being given these very rigid options,” she said. “There should be as much listening as there is talking from the provider’s point of view. It’s about listening to what the patient wants and where they are in life in order to guide the right surveillance and risk reduction for that individual.”

When Maltoff started her genetics career at the Cancer Genetic Counseling Program at the Yale School of Medicine, she was 25 years old, unmarried, and had no children.

“I thought about how I would feel if I heard, ‘We know this is what you thought you were going to do with your life'”—have children, not worry about cancer—”‘but now that’s over. You need to have your ovaries and uterus removed now,’” she said. “It really reframed the way I had those conversations with patients.”

There’s been discussion around this idea of more personalized medicine thanks to President Obama’s announcement at the beginning of this year to include $215 million in his 2016 budget for a Precision Medicine Initiative. The idea is to reframe the one-size-fits-all approach to treatments to take better account of “individual differences in people’s genes, environments, and lifestyles.” On March 30, the National Institutes of Health announced the formation of a team of experts to define the scope of the initiative’s research network, which includes the collection of volunteered biological, environmental, lifestyle, and behavioral information, and tissue samples with qualified researchers from a million or more research participants. The NIH also announced that the team will be delivering a preliminary report in September 2015 “that will inform efforts to accelerate the understanding of individual differences that play a role in health, with the goal of informing better prevention and treatment strategies tailored for each person.”

While I do trust my doctors and believe they have the best medical intentions at heart, there’s still a part of me that feels I’m being pressured into something I don’t fully understand. What is really going to happen to my body if I have a hysterectomy at 40? Will I be able to have hormone replacement therapy if I need it? Should I get pregnant sooner? Should I even have children at all given they have a 50/50 chance of carrying the same mutation? I’m 26, so I have time to think about these things. It does feel like there’s a clock above my head ticking away, just ticking and ticking, but at least I know now that I’m not alone, and there are other women out there hearing the same clock as me.

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Justice Alito Lets Another Nonprofit Avoid Compliance With Birth Control Benefit

In an order issued late on April 15, the justice stayed a decision by the U.S. Court of Appeals for the Third Circuit in Zubik v. Burwell.

U.S. Supreme Court Justice Samuel Alito granted another emergency request by religiously affiliated nonprofits to avoid complying with the Affordable Care Act’s birth control benefit.

In an order issued late on April 15, Justice Alito stayed a decision by the U.S. Court of Appeals for the Third Circuit in Zubik v. Burwell, a case involving challenges to the process established by the Obama administration for accommodating religious objections to the birth control benefit in the health-care law.

Attorneys for the conservative Becket Fund for Religious Liberty sued the administration on behalf of the Roman Catholic Dioceses in Erie and Pittsburgh and their affiliate organizations, arguing the self-certification process to avoid complying with the benefit violated their religious rights by “triggering” contraceptive coverage for staff and students.

A three-judge panel from the Third Circuit in February rejected those claims and unanimously held that the certification process did not substantially burden the religious nonprofits’ exercise of their religious rights in violation of the Religious Freedom Restoration Act. The Third Circuit on April 6 denied the diocese’s request for the full bench to review the panel decision.

Alito’s order directs the Obama administration to respond by April 20 to stay.

Meanwhile, the Supreme Court is considering intervening in a similar case out of the Sixth Circuit Court of Appeals when it conferences on April 24.

In March the high court vacated an order from the Seventh Circuit Court of Appeals in an almost identical challenge by the University of Notre Dame, directing the Seventh Circuit to take another look at its decision to order the university to comply with the accommodation process or face fines.

The Seventh Circuit will rehear those arguments on April 22.

Image: National Constitution Center Programs/ Youtube

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Laws Banning Abortion Procedure ‘Substituting Political Decisions for Medical Decisions’

"I’m not sure what the impact will be or how we would comply because the bill is written with non-medical language, and it’s not written by doctors. It’s written by politicians," Mary Kogut, president and CEO of Planned Parenthood of the St. Louis Region and Southwest Missouri, told RH Reality Check.

Oklahoma Gov. Mary Fallin (R) signed a bill into law Monday that criminalizes a medical procedure used during second-trimester abortions and for miscarriage management.

That came weeks after Kansas Gov. Sam Brownback (R) signed similar legislation, and now reproductive rights advocates are raising serious concerns about the lasting implications of these new, radically anti-choice laws.

“With this law, Oklahoma has joined Kansas in an alarming trend toward substituting politicians’ agendas for the judgment and expertise of doctors, and then threatening those doctors with criminal charges if they disagree,” Nancy Northup, president and CEO of the Center for Reproductive Rights, said in a statement.

Targeting Specific Abortion Procedures

The laws ban the dilation and evacuation (D and E) procedure, which is commonly used in second trimester abortion care. The procedure is a method of abortion during which a physician will dilate a woman’s cervix and remove the fetus using forceps, clamps, or other instruments. During the procedure, the fetus is usually removed in parts.

Prior to 14 weeks’ gestation, abortions are usually performed using suction aspiration, but after 14 weeks the D and E procedure must be used, according to the American Congress of Obstetricians and Gynecologists.

Depending upon the specific language of the law, D and E abortion bans may effectively ban all surgical abortion past 14 weeks’ gestation.

The bills, legislation drafted by the National Right to Life Committee (NRLC), redefine the D and E procedure as “dismemberment” abortion. The new laws’ graphic and medically inaccurate language describing the D and E procedure is key to NRLC’s strategy to pass similar laws in other states.

Fallin, in a statement about the abortion restriction, called the procedure “gruesome,” while a spokesperson for Brownback called the procedure “horrific.”

And Carol Tobias, president of the NRLC, told the New York Times that the Kansas law is the first of what NRLC officials hope will be many state laws banning the procedure. “This law has the power to transform the landscape of abortion policy in the United States,” Tobias said.

The two states are the first in the country to legislate such bans on “dismemberment” abortions. Identical bans are pending in two other states legislatures and more bills to ban the procedure are likely to be introduced in other states.

The legislative language and the rhetoric used by anti-choice lawmakers and activists is part of a decades-old strategy by the anti-choice movement to target specific procedures used during abortion.

Using Dishonest Language to Push Anti-Choice Proposals

More than a decade ago, anti-choice activists, using similar rhetoric, lobbied congressional leaders to ban the intact dilation and extraction abortion procedure. The so-called partial-birth abortion ban, a term also coined by the NRLC, was passed by Congress and signed into law by President George W. Bush in 2003.

Caitlin Borgmann, former state strategies coordinator for the American Civil Liberties Union’s Reproductive Freedom Project, told the Kansas City Star that the legislative language is designed to make it difficult for lawmakers to oppose the proposals.

“It’s meant to try to create an inflammatory description that people are going to read and then support the bill because their instinct is that this sounds terrible,” Borgmann said.

“This procedure is very hard to defend,” Mary Spaulding Balch, director of state legislation for the NRLC, told the Kansas City Star. “I want to talk about what happens to the unborn child during an abortion and more particularly during this type of abortion.”

While the NRLC has been increasingly referring to D and E abortion as “dismemberment abortion,” often while supporting legislation on the state and federal level to ban abortion after 20 weeks, the term has long been used by anti-choice activists.

After the 2007 U.S. Supreme Court ruling in Gonzales v. Carhart upheld the so-called partial-birth abortion ban, Cathy Ruse, a senior fellow for legal studies at the right-wing Family Research Council, used the term when discussing the possibility of banning D and E abortion.

“This Could Be a New Trend at the State Level”

Elizabeth Nash, senior state issues associate for the Guttmacher Institute, told RH Reality Check that reproductive rights advocates have been waiting for “another shoe to drop.” The attempt to ban D and E abortion care appears to be the first new type of abortion restriction introduced by anti-choice activist since the influx of anti-choice legislation began in 2011.

“This could be a new trend at the state level,” Nash said. “It does fall right in line with some of the trends we’ve been seeing over time. From states restricting access to post-viability abortion to the trend of 20-week abortion bans.”

Some anti-choice activists say this latest abortion ban was likely after the U.S. Supreme Court upheld the so-called partial-birth abortion. “Abortion attorneys on both sides knew that this bill was the next step,” Kathy Ostrowski, legislative director of Kansans for Life, told the Kansas City Star. “It was inevitable this was coming. It was a matter of timing.”

Bills to ban the D and E procedure have also been introduced in Missouri and South Carolina, and anti-choice activists in Arkansas have said that similar legislation is likely to be introduced during the state’s next legislative session in 2017.

Reproductive rights advocates are concerned about the possibility of a ban being passed in Missouri, where state lawmakers have, in recent years, aggressively sought to restrict reproductive rights.

“I’m not sure what the impact will be or how we would comply because the bill is written with non-medical language, and it’s not written by doctors. It’s written by politicians,” Mary Kogut, president and CEO of Planned Parenthood of the St. Louis Region and Southwest Missouri, told RH Reality Check. “Our concern is that this seems to be part of a broader strategy that is trying to ban safe and legal abortion in Missouri.”

Planned Parenthood provides reproductive health-care services at several clinics across Missouri, and operates the state’s lone clinic that provides abortion services. The clinic has been under siege by state lawmakers over the past few years, as dozens of bills have been introduced targeting the clinic in an attempt to force its closure.

“Substituting Political Decisions for Medical Decisions”

The bans on D and E abortion will almost certainly face legal challenges from reproductive rights advocacy groups. Supporters of the legislation are confident in their constitutionality, and the NRLC believes the Roberts Court would uphold the new laws.

“We believe we have five votes that would allow us to ban this particular procedure,” said the NRLC’s Mary Spaulding Balch.

Ryan Kiesel, executive director of the ACLU of Oklahoma, told RH Reality Check that there are deep concerns about the constitutionality of the new Oklahoma law, and similar laws like it in other states.

“Any time you have politicians putting their political judgements ahead of the medical judgements and medical recommendations made by a woman’s doctor, it is deeply concerning,” Kiesel said. “The Constitution has routinely held that substituting political decisions for medical decisions is not the way that we should be practicing medicine in the United States.”

Kiesel said that the use of non-medical and often inflammatory language found in bans on D and E abortion, and many other types of anti-choice legislation, are an attempt to impose a political agenda in the practice of medicine.

“The inflammatory non-medical language isn’t an accident; it’s on purpose and very deliberate,” Kiesel said. “It underscores that these bills are not about medicine, they’re not about health care, they’re not about protecting women, they’re not about protecting children. These bills are about politics.”

The impact the D and E bans will have on reproductive health care remains to be seen, but abortion providers and women in need of abortion care in Kansas and Oklahoma will soon feel the impact. The Kansas law goes into effect July 1, and the Oklahoma law goes into effect November 1.

Physicians and health-care professionals have made their concerns known about the consequences of these bans.

A letter signed by 20 doctors opposing the ban was submitted to the chairman of the Kansas House Federal and State Affairs Committee, Steve Brunk, when lawmakers were considering the ban in the GOP-dominated Kansas legislature.

“We are alarmed at the unprecedented attempt of Kansas legislators to dictate how physicians should perform a safe, common, and evidence-based surgical procedure,” the letter said. “This bill would restrict the safest and most expeditious way to terminate a second-trimester pregnancy. … This legislation could also force physicians to provide substandard care to second-trimester abortion patients.”

Dr. Jennifer Wider, a physician who specializes in women’s health, told Yahoo Health that the D and E procedure is typically performed for miscarriage management or in abortions due to fetal deformities or a danger to the mother’s health.

“Some women opt for second trimester abortions electively, but studies show that these women tend to be younger and of lower socioeconomic groups with less access to healthcare,” Wider said.

The D and E abortion procedure accounts for about 8 percent of abortions from 2002 through 2011, according to the Center for Disease Control.

In 2013, there were 7,479 abortions performed in the Kansas, with 89 percent performed before 12 weeks’ gestation, according to a Kansas Department of Health report. Among the 807 abortions that took place after 12 weeks, 584 were performed using D and E.

Women in those states seeking second-trimester abortions may need to undergo an alternative, nonsurgical method, during which a physician would medically-induce labor to expel the fetus and placenta. This type of abortion care is more painful and can be more dangerous for women.

Kathleen Morrell, an OB-GYN and a fellow of Physicians for Reproductive Health, told the New York Times that this type of abortion care can involve significant periods of waiting and may require access to hospital facilities.

“When it is safe to offer a choice of induction or D and E,” she said, “my patients overwhelmingly choose D and E. They are able to be asleep and comfortable for the procedure and then can go home to their own beds at night.”

“I Don’t Recall Calling My Congressman to Have Him Weigh In”

The public discussion about D and E bans has primarily consisted of political debates between lawmakers and activists. The voices of the physicians who provide abortion care and the women and families who have sought a second-trimester abortion have mostly been absent.

The public is generally supportive of allowing abortion early in pregnancy, according to Gallup. However, the majority of Americans do not support allowing abortion past the second trimester of pregnancy, despite the fact that the majority of abortions taking place later in pregnancy are due to reasons such as severe fetal anomalies.

When public opinion surveys ask about whether or not people support allowing abortion to remain legal in specific circumstances, such as when a woman’s life is in danger or when the fetus may have mental or physician disorders, there is overwhelming support for reproductive rights.

“There’s a lot of education we need to do around the need for abortion, around women’s decision making, around access,” Nash said.

“There’s lots of reasons why women end up having abortions later than 8 or 10 weeks of pregnancy,” she continued. “We have to make sure that we have services available to them, and that the public is aware of these needs and understands that we need to maintain access.”

Women who have had pregnancies terminated through the D and E procedure shared their experiences with RH Reality Check. Some of them spoke on the condition of anonymity. All of them shared grave concerns about the consequences of these bans.

“This choice, if taken away, leads to a slippery slope for other decisions not only for women but for all Americans,” said one woman. “If we are forced to carry dying children to term, who is going to pay for the extensive medical interventions required to care for them or keep them alive? Who decides what interventions are appropriate for such children, or how far doctors should go to keep them alive?”

April Salazar, who has shared her experience having a D and E abortion with the New York Times and Mother Jones, told RH Reality Check that she wants women to be able to choose the care that is best for them.

“I think it’s outrageous that politicians, with no medical expertise in women’s health, can outlaw medical procedures that have been proven to be safe, thereby forcing women into potentially life-threatening procedures,” Salazar said.

Julie Bindeman, a psychologist who specializes in pregnancy loss, told RH Reality Check about her experience terminating a pregnancy through a D and E abortion. During her pregnancy the fetus showed indications of brain anomalies, and further testing confirmed that the brain was not forming normally.

Bindeman, at 18 weeks of pregnancy, had a D and E abortion performed.

“It was in a hospital with a wonderfully generous physician,” she said. “I felt cared for and safe, despite these heartbreaking circumstances.”

Bindeman echoed the statements of other reproductive rights advocates for the need for the public to understand that these abortions typically occur because of dire circumstances. “These choices are not made on a whim or lightly,” Bindeman said.

Supporters of these bills, Bindeman said, have never been in her shoes, and don’t understand that for her, abortion was a life-saving procedure that gave her the opportunity to have a family. The laws do provide a sole exception in which a D and E abortion can be performed to prevent “death or to avert serious risk of substantial and irreversible physical impairment of a major bodily function” of the pregnant person.

“The decision was a heart-wrenching one and anything but simple,” she said. “We had the counsel of our physicians, family, and clergy. … I don’t recall calling my congressman to have him weigh in.”

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