Julie Bindeman on Reproductive Mental Health Care, Dobbs, and Beyond

Julie Bindeman: Reproductive Psychology is not the kind of specialty you’ll find in graduate school departments. In fact, I’m working with some colleagues to look at what is the curriculum around reproductive health in graduate programs these days. Thus far, it’s not as encouraging as I would hope it would be. 

The reproductive time period actually can be anywhere from the time somebody begins to menstruate or begins the ability to produce sperm, all the way to—for men and cisgender men—more so end of life, and for cisgender women into the early 40s-ish (from perimenopause through menopause). So, it’s several decades of a person’s life.

For so many of those decades, cisgender women in particular, spend time trying to avoid pregnancy. It becomes very interesting when everything that we’ve been taught about preventing pregnancy gets turned on its head when we want to become pregnant. We have a lot of conversation in our schools about sex ed, but we don’t have any about fertility and what that means and what that looks like.

So it’s the whole gamut between the attempts at getting pregnant, even deciding, “Do I want to have a family,” and considering that; “Do I want to have a family now with this person, do we feel like we’re compatible;” all the way to, “We’re struggling to get pregnant and we need to seek out a reproductive endocrinologist for infertility,” which is a very specialized doctor.

So, I think, because there’s a specialty in the medical world, and because psychology is a little bit slower to catch up, historically speaking, the idea of a moniker of a reproductive psychologist provides some clarity about what I do, which is different than other psychologists, but also is a very particular niche that involves a lot of study.   

JB: There’s a concept called the “reproductive narrative.” It encapsulates the idea that we all start having a reproductive story early in life, and that story changes, and it’s just as valid of a story if someone is not interested in parenting as it is if someone is very interested in parenting. And when we meet potential partners, we have to see how our reproductive stories mesh, and sometimes they mesh really well, and sometimes there needs to be some negotiation.

JB: Here, let me assist you with it. One of the big concerns for some clients who come to me about deciding whether they should get pregnant or not, is, “Is it safe for me to carry a pregnancy in the state in which I live, and if it’s not, do we need to move?” They explore concerns like, “Do we need to move just for our pregnancy?” In certain states, people are really putting their lives on the line just to have a family.

JB: I wasn’t surprised. When the leak came in terms of what the ruling was going to be, there was already so much talk about. People were saying, “this can’t be it,” and “they’ll never do that,” and “we’re talking about established precedent for 50 years.” Unfortunately, I was sitting there saying, no, this is it, this is what the intention is. It’s only going to get worse from here.

I remember even having a conversation with my dad, who said, “No, that’s just like hysterical thinking.” Looking back to when the Dobbs decision was finally released, I wish I could say I was surprised. I was not! I had been seeing this coming since Trump was elected, quite honestly. That was the reason that I marched the day after the inauguration. I could see it coming. It was very clear to me that they were going to use whatever mechanisms of power that were available to restrict reproductive rights. So that was one part.

As a mom of someone who was born a cisgender female, I was and am also worried because my child has their whole life in front of them, and you know, I’m not sure if they’ll have a family or not. They might. They might not. That’s yet to be seen. So, I’m concerned for what their choices might look like and what is available.

I have two kids that were born cisgender male, and I worry about them and their potential partners. I knew this was going to impact IVF too. So, when the ruling in Alabama came down, people were like, “Oh my God,” and I was like, “Yeah, no, of course it’s going to IVF next, because the logical conclusion is personhood and personhood being conferred to an embryo.   

JB: I happen to live in a state (Maryland) that is very protective of reproductive rights and, in fact, has a shield law. I submitted a letter to the committee that was reviewing it when it was a bill to say that in addition to physicians, let’s protect mental health professionals, because I think that’s an important inclusion that we have, in terms of what we might know.

When I think about worst-case scenarios, I think about people connecting the idea of personhood or person status to a fetus, and then connecting it to laws that already exist. So, if you don’t realize you’re pregnant and you have some wine, is that now endangering the welfare of a child or child abuse? Or if you have an abortion, is that considered child abuse, feticide? I think they will go after women. Even though right now they’re going after physicians, I think they will go after women eventually. It just makes logical sense to me. So that’s sort of my catastrophizing, but again, I don’t think it’s that far off.

As a therapist, I think there have been several weeks of my career that have been indelibly difficult, and nothing I learned in graduate school has been helpful. I was a grad student during September 11th in Washington, DC. That was tough because how do you process an experience with someone when you’re living it too?   

And I would say that for my clientele, the next time I had that experience was the 2016 election. I had clients, who, like me, were grieving, because we saw what the implications could look like.

And then I would say that the third time it happened in my career was the Dobbs decision. I had people calling who were panicked about it. “Are my embryos safe?” was a question I got asked a lot by clients, and I would be like, yeah, for now they are—you know, again, depending upon where you live.

Many of my clients were feeling helpless and angry, and of course, I shared that sense of anger and righteous indignation. I think it’s really challenging to be a clinician when you’re experiencing in real-time exactly what your clients are experiencing too, when you don’t necessarily have the perspective that often we are able to bring to our clients, when we’re not living what they’re living. When we do live what our clients are living, it’s so hard to have that sense of perspective, because our fear centers get activated, or at least mine does.

For clinicians who are either practicing or considering practicing in this domain, it’s important to know your state laws and how they apply to you. If you’re a clinician in Texas, for example, where they have that SB8—which is the bounty hunter laws that it’s so lovingly referred to as—clinicians are in danger under what that law is, and it is a civil penalty. So, anyone can rat you out for any reason, especially if they’re motivated by money. It’s a $10,000 fine. That’s not nothing! Most of us might not have that lying around to pay. So that becomes a very real risk.   

There are other states that are starting to look at that. There are other states that are looking at assisting minors in having abortion care. So as clinicians, I think for the time being, HIPAA protects us, but it’s really important that we are careful about what we say in our notes because notes can be subpoenaed. And so, if I’m talking to a client about an abortion they are planning or an abortion they had, I’m not going to come out and write, “... spoke about abortion.”

I might say something like, “spoke about family planning” and have it be really vague. I think those of us that are practicing in PSYPACT states also need to be aware of what are the other laws in the states where our clients might be sitting in that we don’t necessarily know because they’re not necessarily connected to the statutes that relate to psychology.   

JB: As a clinician who is very up to date on the laws of my state, which I know most others may not be, I’ve been an advocate for many years. I’ve helped to lobby to get some of those laws passed. And so, I wasn't concerned, because I knew my state legislature—and in a lot of ways, I know many of them personally—that they were going to protect reproductive rights, and that is what they have done the last couple of years too. So, they did not disappoint.

Our state has done some really great things. As I said, they passed a shield law, they’ve expanded who can perform abortions. So instead of it having to be only a physician, it’s been expanded to physician assistants, nurse practitioners, and midwives, which is awesome. More care, we like it! Our Governor has gotten our own sort of storage of mifepristone and misoprostol— ‘mife’ and ‘miso,’ as it is.

So, I didn’t feel that light switch. One of my best friends who lives in Texas did feel that light switch. She had also been living under SB8 two years prior, so she was not surprised. She had had some time too, to be like, okay, now we’re really going to do this because we don’t have the Supreme Court protections. What’s happening in Texas is legal versus legally dubious.   

JB: One of the things I do as a reproductive psychologist is to conduct third-party evaluations for prospective gestational carriers. And as part of that conversation, we talk about abortion and because they are not pregnant, there’s no concern. I can talk about abortion till I’m blue in the face. They are not pregnant. Everything is a hypothetical.

But I may talk hypothetically, if they live in Texas and there is a problem with the pregnancy. I may say something like, “You are now eight weeks pregnant. You cannot get care in Texas. Let’s talk about where you can go to get care? You know that your doctor is not going to be able to save your life should your life be on the line unless it’s really dire and, you would have to ask yourself if this is something I want to risk?” It’s about looking at each client’s risk profile, which has changed since Dobbs.   

JB: Of course I bring it up. I bring it up because everyone thinks that once you get pregnant, it ends with a baby, and that’s just not the case. Not that I’m trying to freak my clients out that are newly pregnant and excited and whatnot, but we talk about, “Hey, have you had a conversation with your partner, should this pregnancy go in a way that you don’t expect? What might that look like? And, you know, it’s a hypothetical because it’s a very rare occurrence. And, I’d rather you have this conversation before it happens than have to have that conversation for the first time as it is happening because it’s just too much to unpack in that moment as you have to make a critical decision about the pregnancy.”

JB: Absolutely. I come at this from the side of the law of my state, which is specific in saying that mental health is a reason for someone to obtain abortion care past 24 weeks. I also come to it from a religious perspective, which may sound kind of odd, but in the religion that I grew up in and that I practice, which is Judaism, one of the tenets is that you save the existing person at all costs. My religion doesn’t see a developing fetus as an existing person. It sees it as a potential person. So, unless that fetus is basically sticking out of someone’s vagina—sorry to be so graphic—and has taken a breath, it is not a person.

JB: When people think about this, and they’re like, “oh, but I don't see people who are having babies because I work in geriatrics, or I work in pediatrics. This isn’t important to me. I don’t need to know this stuff.” And to that, I say, “actually you do, because how are you talking to your parents of the kids you work with about, what was the reproductive story that that child was born into? Were there losses before that child was born? After that child was born? Was it a long journey? Was it an uncomplicated journey? Was it fraught, and you weren’t sure this baby would ever get there? This is in addition to, was the baby in the NICU or anything like that, that you’re going to want to know about your patient.”

I also think it’s important because if we’re seeing young kids, their parents are often trying to expand the family, and sometimes it doesn’t work as easily as the first time. And so, how do you support a young child who knows there’s something happening with their parents but doesn’t know what it is and doesn’t have that understanding of what infertility might be or pregnancy losses might be? How do you help the parents talk to their child about it? How do you help, as a therapist, talk to the child about it, give them a place to have their own thoughts and expressions?   

For those that work with an older population, and I’ve had older clients who have been still traumatized by the Dobbs decision, because of the abortion they had in the 70s, either pre-Roe or post-Roe. Or even talking about how this is going to impact so many people and having that empathy for it. And that sadness of what I thought I knew, what I thought I could trust, that 50 years of precedent went down the drain.

So, it’s come out in lots of different age groups, and I think it’s really important. I’ve had male clients talk about it too, their concern about abortion and it not being an option—and not in that kind of cavalier, like, I don’t want to deal with that kind of way, which I think we often ascribe to men when we’re talking about abortion. That doesn’t seem to be the case, but somebody I care about might be very impacted by this.   

JB: So let me first dispel a couple of myths that have existed about abortion. Abortion does not cause future infertility. Although I can’t tell you how many of my clients who had abortions when they were younger, and then as they wanted and were ready to have a family, struggled with infertility, how they made that causal. But I’m like, nope, there is nothing causal to that.

Abortions don’t cause cancer, so that’s really important to know. Also, there is no such thing as post-abortive syndrome. That is not a thing. I appreciate the American Psychological Association for a deep dive that they did in 2008. And one of their conclusions was, nope, there is no need to add something to the DSM about post-abortive syndrome. It is not a thing.

What I think is important for clinicians to think about is what research tells us, which is that most people with access to abortion feel relief. Now, there are some circumstances like terminating for medical reasons—I’m not lumping that into that. That’s a very different, specialized circumstance. But the majority of people who are seeking out mostly first-trimester abortions experience relief—95% of them!

In that 5% who might not, they might experience regret. And where this gets confabulated is the idea that regret becomes mental illness versus regret is a feeling just like lots of other feeling experiences a human can have. And it is a feeling that will come and go. And so, we don’t need to pathologize regret!   

JB: When people ask me how I found this work, I tell them I came to it honestly. My early grad school experiences centered on teens and kids. That’s what I was really interested in, and so I worked at a high school, where one of my seniors was pregnant. The way the school managed it was incredible. They threw her a baby shower, and when the baby was born, different people watched the baby so she could still go to class so she could graduate on time. What an incredible community to circle around her and help her. It was amazing.

As I continued, I worked at another school that was Catholic, and one of my seniors got pregnant. That was a very different experience. It was interesting in that conversation where we had to sit with the mom and tell her what was going on, and the mom was like, okay, cool, we’ll get an abortion. And the kid was like, nope, I don’t want that.

At the time, I didn’t make much of those experiences. I later had my own kid. When he was about 18 months old, my husband and I reflected on how great he was and decided we needed another one because the world needs another one just like him—since all children, of course, are carbon copies of one another, right?!

We did not have an issue conceiving the second time, although I had in my mind it would be a little harder because I anticipated it would take six months. In retrospect, I guess I was ambivalent, thinking I would have more time than one month. I wasn’t quite ready to have another kid, but there it was.

That pregnancy was over just as soon as it started, when at eight weeks, the ultrasound showed that I had had a miscarriage. It’s called a “missed miscarriage” because it was shown on ultrasound and I had no knowledge of it. I had a D&C. Interestingly, I had begun specializing in postpartum health after my son was born, so after the miscarriage, I wanted to learn the difficulties of the postpartum experience.

We don’t talk about postpartum and how hard it is. We really don't talk about pregnancy losses which seem to be shrouded in secrecy. So, it wasn’t until my own miscarriage that I realized how insensitive I had been when my friends had had miscarriages. I didn’t know what to say, and so I went to the platitudes, that I think most people go to because we want to be helpful. Rarely are platitudes helpful!

My doctor was optimistic and encouraged us to try again, which we did. I became pregnant very quickly, and while everything seemed to be progressing in those early weeks, I was bleeding. Our anatomy scan at 20-weeks suggested that we have a second opinion. We were referred to a maternal fetal medicine specialist (MFM), where we learned that our baby had hydrocephalus, and ventriculomegaly, in which the brain ventricles were measuring much larger than they should have.

We were told that the best-case scenario was that our baby could live into his 40s with the developmental quality of life of a 2-month-old. That was not a best-case scenario for me! That was not the life I would want to bring into this world, and it was not what I would want to do to my son, not what I wanted to do to my marriage.

We called our clergy and talked about options, one of which was labor and delivery, and the other was that we could drive to New Jersey for a surgical abortion. I was confused because I knew abortion was legal in my state, so why did we have to go somewhere else for surgery? I later pieced together that six months before, a physician named George Tiller, who had performed an abortion in Kansas, was shot to death. His death created so much of a chilling effect that the doctors in my area stopped performing abortions. I ended up having to labor and deliver a little boy who died. It was awful, and both very different, and compounded by my miscarriage. We were later told that this was a lightning-strikes-once situation, a one in a million, and that we should try again when we were ready.

It took me about four months before my cycle came back and my story gets redundant in this way. We tried for one month and got pregnant. I was very nervous during that pregnancy, which we learned was with a girl. I was getting scanned all the time and found out at 18 weeks that the also had ventriculomegaly, hydrocephalus, and partial agenesis of the corpus callosum. Because I was 18 weeks, I was able to access a surgical abortion with one of the kindest doctors to whom I was, and am, very grateful.

We tried again quickly because I didn’t know if I would have the courage to keep trying. And we got pregnant immediately, and this was a pregnancy where I didn't feel any symptoms, and I was disconnected from it.

At 18 weeks, the MRI showed that we were having a girl and that she was healthy. I was excited and terrified. I asked them to show us the pictures of the last baby we lost and the baby I was carrying, and the differences were so clear. The brain of the baby I was carrying had all sorts of contrasting grays and whites, compared to the blackness in the image of the baby we had lost, which represented fluid. It was a beautiful picture. I went through the rest of that pregnancy fairly terrified, and I think my MFM probably had some vicarious trauma because she had been with me from the beginning.

We went back for my checkup at 36 weeks, and she asked me, “how do you feel about having a baby this week?” I had four more weeks so I said, “I’m good.” She half-joked, “it wasn’t really a question. You’re going to have a baby this week. When would you like to have your baby?” She just didn’t want anything to happen to this child. So, my daughter was born weighing 5 lbs. even. She was fierce. We had a “normal” stay in the hospital, and then they let us go.

When she was about 14 months old, I said to my husband, “hey, so, you know we always talked about three.” He looked at me like, “are you effing crazy?” I said something like, “I must be, but I really want to try for three. If it works, great. If it doesn't, that’s fine.” And, again, we got pregnant the first time we tried. When we got an MRI at 18 weeks—and this pregnancy just felt so different to me because I was in a place where whatever happened, happened— and my husband was really excited because it meant we could get a minivan. I remember saying something like, “I will not get a minivan unless we have the number of children we might need for a minivan.” He was like, “okay!”

Our son was born healthy, and now I have an 11, 13, and an almost 17-year-old. We are very, very done.  

JB: Can I read you something as you say this? 

JB: In the acknowledgement section in my book, I write about my story and actually dedicate the book, to the two babies we lost. “...I am grateful for these two babies I said goodbye to before I could say hello to, as they awoke me to the passion for reproductive mental health, and, primarily, the intersection of abortion and mental health.”

JB: It’s a really interesting question that I look at from two different vantage points. So, one vantage point is if you’re a therapist with just sort of a normal population, whomever that normal population might be, and you become pregnant, the pregnancy itself is a disclosure, isn’t it? Like there’s a point in pregnancy where you just can’t hide it, and so it’s a disclosure, and I think it’s useful for patients to know so that they can plan, and they’re not surprised.

And then, you know, there can be a lot that might come out in the transference around maternity and nurturance, and things like that. So, I think it can actually lend itself to a lot of really useful therapeutic material. I think if you’re working with the population that I’m working with, I didn’t have a choice but to disclose because I wanted to give my clients an opportunity to change therapists if they needed to. I wanted to acknowledge, “Hey, seeing me pregnant could be really triggering, and I don’t want you to feel like you have to stay with me. Because I get it, and it can be really, really hard.”

It also came out in other ways, like with a client for whom it took months to disclose that, as a child, she had experienced terrible sexual trauma committed by a relative. She was with me through my losses, and she was with me through the birth of my daughter. After my daughter was born, she was able to say she felt like her “badness” and “evilness” contributed to my losses. She felt responsible for them.   

JB: Yeah! We did some good work around that. Without the disclosure, that work couldn’t have happened. I didn’t show up at my office Friday afternoon after that first ultrasound. So, you know, I had to have someone tell my clients something. And again, lots of interesting things came out from it.

JB: Not so much within the larger professional bodies. Perhaps NASW. I couldn’t tell you specifically. Where I get a lot of my resources is through an organization called the American Society for Reproductive Medicine, and within it, a professional group called the Mental Health Professional Group. Thats where a lot of the research and work is being done. APA has had more since the Dobbs decision. Sorry to be pitching my book, that wasn’t my intent, but the reason I decided to edit this book was because there wasn’t anything for the mental health professional that had a client that was now experiencing or considering abortion.

You can’t refer someone out when we’re talking about days or weeks to decide to have an abortion. You have that ethical obligation not to abandon our clients, and we have an ethical obligation to not practice outside of our competency. And so, this book is to fill that gap in between competency and not abandoning clients.   

JB: I think it depends on how much you want to do. There are lots of advocacy opportunities such as volunteering for a state delegate campaign in your district and talking directly to them, I found that useful and interesting. Or, talking about it at a City Council meeting where you can go on the record. You can talk about healthcare in that kind of way. These are sort of smaller things that people can do.

There’s organizations like the National Abortion Foundation. They not only have abortion funds through them, but also provide a warm line to people. I don’t think it’s a hotline. They train people so that they can help talk to people that are struggling. So that’s a great organization.

There are lots of local abortion funds. That’s a great way to get involved again, you know, depending upon how involved you want to be. So, for a birthday fundraiser one year, I’m going to pick out an abortion fund. This is where I want my contributions to go, like, contribute to this in my honor.

I have lobbied at the state level, even not in my state. I’m happy to talk to anybody. And my husband had the opportunity to go to the City Council meeting, which is where our delegates were going to talk about what happened in session. He said, “I was going to share our story, but do you want to do it? I can give the time to you.” And I said, “Oh honey, they have heard it from me. They need to hear it from you.” I was really, really proud of him.  

JB: In my state, that is not an issue for people because it’s so protected here. That being said, I’m part of PsyPact, and was working with someone in a restricted state who had gotten a poor prenatal diagnosis and who was trying to decide what to do. Part of our worked centered around getting more information. A lot of her wait-and-see was about getting further along to get more information about the pregnancy. And every piece of information she got was like adding crap to the pile. There was never good news that she was given. It was just bad, bad, bad, bad, bad.

They got to the point where they felt, “our baby is not going to survive, and this is awful, and I think we’re both ready to terminate the pregnancy.” But she lived in a state where accessing that kind of healthcare was really challenging. She had resources, she was smart, and she had people that she could connect to that could help her connect to other people.

So, initially, her abortion was denied by the hospital. They’re like, nope, we’re not going to do it. And then it was denied by insurance, they’re like, nope, we’re not going to cover it. And the hospital is like, well, if your insurance says we can’t do it, we can’t do it. So, it was sort of this merry-go-round.

She was finally able to get connected to the vice president of her insurance company and shared with him what she had gone through, and what was happening, and what she needed in terms of healthcare. He pulled the strings he needed to pull so that she could have an abortion. But otherwise, she would have had to travel.

And we do see that a lot. We’re seeing more and more people that have to carry to term because they don’t have the luxury of traveling. And while abortion funds are great, they can’t fund the entire expense of traveling and procedures, particularly later in pregnancy.   

JB: I don't know if it’s a question per se, but just something to leave people with. My abortions defined what I do and defined how I work and gave me purpose in terms of the scope of practice. However, they don’t define who I am. They are just a part of who I am, but they are not the defining measure.

And I think when some people experience trauma related to their abortion or traumatic abortions, it doesn’t mean that all abortions were traumatic, are traumatic. But when people experience that kind of trauma, it’s so easy to have it define them, that they become defined by their trauma. We see them all the time in our patients, regardless of what kind of trauma it was. Or they’re trying to run from it so much that they—so they’re not defined by it. Through a lot of work that I’ve done, I feel like it’s a part of me. It’s one aspect of me. It is not the whole description of me, but there was a time where it was—like it was all I was doing.   

JB: Well, if you're thinking about Norma, who was the original plaintiff in Roe versus Wade, she was the third generation of people who had unintended pregnancies but had no recourse, and she wanted a recourse. What ended up happening in that pregnancy—she had already had two other babies who had gone into foster care and then eventually were adopted—and so this third one, she adopted out because the courts were (are) are really slow.

There is a fantastic book called The Family Roe. The way it is written, and how it weaves it all, is just incredible. I think you asked earlier, too, about what resources are available for clinicians. There is an email that you can subscribe to. It’s a Substack you can subscribe to, and the journalist’s name is Jessica Valenti, and her Substack is called Abortion Every Day. She is really keeping tabs on what is happening on a granular state level, not just federal, but she’s been keeping tabs about like, what is the status of getting abortion on the ballot in different states, and what are the shenanigans that some representatives are trying to do to prevent it.   

JB: Thank you, Larry.