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Tumon Bay near Hagåtña, Guam.
Tumon Bay near Hagåtña, Guam. Photograph: Tassanee Vejpongsa/AP
Tumon Bay near Hagåtña, Guam. Photograph: Tassanee Vejpongsa/AP

Getting an abortion on Guam requires a $1,000, eight-hour flight. A lawsuit could change that

This article is more than 3 years old

The ACLU is suing the US territory over restrictive laws that block people from accessing telemedicine medication abortions

Getting an abortion on Guam, a remote US territory in the Pacific Ocean, has never been simple. Before 2016 there were only two abortion doctors on the entire island, and anti-abortion protesters would often stand outside their clinics with signs.

But since 2018, it has been impossible. That year Guam lost its last abortion provider when Dr William Freeman retired and moved away, and the doctor who took over refused to conduct them. This means that the closest US abortion clinic is now in Hawaiʻi, an eight-hour and $1,000 flight away. The number of abortions on Guam dropped from more than 200 a year in 2017 to zero.

Now, the American Civil Liberties Union is suing Guam officials, including the attorney general, over restrictive laws that block people from accessing telemedicine medication abortions, which would allow the doctors involved in the lawsuit to prescribe and send abortion medication directly to patients.

The lawsuit, filed in January, is backed by two Hawaiʻi-based doctors who are licensed to practice in Guam, Shandhini Raidoo and Bliss Kaneshiro. The Food and Drug Administration requires abortion medication be dispensed in clinics or hospitals, but the pair are part of a project called TelAbortion, which has an agreement with the FDA that allows them to provide virtual abortion consultations and medication by mail. Similar programs exist in 12 other states and Washington DC.

Abortions on Guam dropped from more than 200 a year in 2017 to zero in 2018. Photograph: Brandon Fike/Alamy Stock Photo

In the lawsuit, Kaneshiro said that before 2018 she only saw patients from Guam in rare cases with a fetal anomaly that required a specialist, but since then she and her colleagues have seen up to 10 patients every year coming to them for abortion services.

“Denial of a wanted abortion has both short-term and long-term negative effects on a person’s health and wellbeing, along with that of their family,” wrote Kaneshiro in the motion for preliminary injunction. “A person who has been denied access to abortion has no choice but to continue their pregnancy to term, which leads to substantially increased risks.”

Kaneshiro said the risks include a greater likelihood of living in poverty and staying in an abusive relationship as well as attempting to end one’s own pregnancy.

Telemedicine medication abortions allow patients to meet with a doctor via videochat, and then receive and take the two medications needed to induce a miscarriage – mifepristonem and misoprostol – in the privacy of their own homes. When possible, a majority of women choose medication abortions over procedural abortions; they are substantially cheaper, costing about $240 for the medication and appointments, compared with anywhere from $400 to $7,000 for a procedural abortion.

Kaneshiro said Guam residents have requested services from the TelAbortion project, but two Guam laws have stopped doctors from providing them. The first, a law from 1978, requires abortions be “performed” in a “clinic or hospital”. Criminal penalties for violating this law include a third-degree felony and the loss of medical license.

“The purpose of the law was actually not to restrict access to abortion but rather to decriminalize abortion,” said Alexa Kolbi-Molinas, an ACLU attorney working on the case. “So, because this law was enacted long before medication abortion was available, it is not clear how to apply it in this context.”

The second law was passed in 2012 and requires a doctor and patient have an in-person meeting “in a private room” where mandated information is shared at least 24 hours before an abortion, which bars telemedicine as an option.

Colonization, Catholicism and CHamoru values

While not illegal in Guam, abortion has a complicated history in the territory due to restrictive laws and the lingering influence of Catholicism, a holdover from its colonial history.

Guam made national headlines in the 1990s after its legislature passed a restrictive law prohibiting abortion except when the mother’s life was endangered. At the time, there was a local abortion rights movement led by attorney Anita Arriola, the now-governor Lou Leon Guerrero, and nursing director Rita Lujan Bevacqua. The latter testified that a man had called her clinic and said his wife was pregnant, but they already had six kids and felt they couldn’t have more. He was too scared to leave his name or come in for help.

The US ninth circuit court of appeals eventually struck down the law, saying that it violated Roe v Wade.

More than 70% of Guamanians still identify as Catholic. Photograph: Ken San Nicolas/The Guardian

Guam, which has a population of about 165,000 people, was originally inhabited by the CHamoru people. It was colonized by Spain in the 17th century and Catholicism was brought to the island, which was ceded to the US in 1899.

Dr Michael Lujan Bevacqua is a teacher of CHamoru language, history and culture, and the son of Rita Lujan Bevacqua, the abortion rights activist. He says that the right to an abortion is in line with ancient CHamoru values.

“When the Spanish came to colonize the island in the 17th century, the priests were shocked and appalled at how much power CHamoru women had in society at that time,” Bevacqua says.

“If you think about what ancient CHamoru values would have been on this issue, it would have been that women should be empowered to make those choices.”

While the Catholic church’s influence on Guam has waned following sex abuse scandals, over 70% of the island residents still identify as Catholic, and anti-abortion sentiment is apparent. Freeman said many landlords on Guam would not rent him office space and that he had received death threats because of his work.

“You asked what it is like being the only abortion provider on Guam: scary,” said Freeman.

Guam’s first female governor, Lou Leon Guerrero, supports abortion access, but many other lawmakers do not. The government of Guam has strict reporting requirements for abortions, including disclosing where they took place and detailing demographic information about the patient. That makes it easy for anti-abortion protesters to target clinics, especially on a relatively small island.

Jayne Flores, the director of Guam’s bureau of women’s affairs, said abortion is only a small part of a larger conversation about education, poverty and women’s health that needs to be had in the US territory. Guam has a higher poverty rate than anywhere else in the 50 states. Although less than 40% of Guam residents are CHamoru, they accounted for almost 60% of all abortions before 2018. The majority of women seeking abortions are mothers with children, according to the lawsuit, but there have also been troubling cases, including a 2019 report of an 11-year-old girl who had been raped, and was forced to carry her pregnancy to term.

“We have high rates of teen pregnancy, we have high rates of sexual assault, and we have high rates of domestic violence,” said Flores.

The lawsuit seeks a court order to render the two laws in question unenforceable when it comes to telemedicine medication abortion services. The case is now moving through the courts.

Vanessa Williams, a lawyer on Guam working with the ACLU, said she had received “gratitude” from people on the island for challenging abortion restrictions. “Not just because we are fighting for women to be able to exercise a constitutional right, but also because lack of access to abortion exacerbates the endemic issues of poverty and violence Guam faces.”

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