Point of View

Understanding Depression

Understanding Depression and the Role of Medication



Article ThumbnailUnless you live in a bubble, is it not a universal human experience to face
adversity? The scriptures testify to it certainty, especially for “everyone who
wants to live a godly life in Christ Jesus” (2 Tim. 3:12 NIV). So what
happens when we encounter trials?
“I found myself in trouble and went looking for my Lord; my life was
an open wound that wouldn’t heal. When friends said, ‘Everything will turn
out all right,’ I didn’t believe a word they said” (Psalm 77:2 The Message).
So when people are “looking for the Lord” in their times of trouble,
shouldn’t we be compelled to reach out with the gospel in word and deed,
just like the Apostle Paul did in the New Testament?

God, the human body, and depression
The body is a finely tuned homeostatic mechanism that not only reflects
intelligent design, but also reveals a compassionate God who equipped it
with systems to respond to every life contingency. As a physician, I marvel
at both the body’s complexity and its ability to adapt (sometimes in an
instant) to change in our circumstances. The brain’s capacity to mediate
emotion in the process of such adaptation is a good example of how fearfully
and wonderfully we’re made.
One could think of depression as the body’s “alarm system.” Any
alarm system is designed to warn us of some real and/or imminent danger.
Imagine, for instance, that you went to bed one night, and an hour later you
were suddenly awakened by the deafening scream of your fire alarm. You
race down the hall, hustle your children out of the house to safety, and then
watch as your home burns to the ground. Wouldn’t you be overwhelmingly
grateful that you had a fire alarm that worked the way it was designed?
Like any good alarm system, the symptoms of depression are
designed by God to get our attention and warn us of danger to our spiritual,
psychological, and physical lives. Therefore, appropriate analysis and
therapeutic intervention must address all three of these areas in order to
maximize full restoration and healing.

Depression and the brain
Since my training is in the biological sciences, I would like to explain as
clearly as I can the essential role of neurotransmitters for the normal
functioning of the human brain and emotions. Christians and non-believers
alike are subject to the way God has created our bodies to function, just as
we are all subject to gravity. One of the hardest questions to answer is
“When should medical treatment be considered? When has the line been
crossed from human emotion to medical disorder?” Dr. Stephen Stahl, M.D.,
one of the world’s leading authorities on the functions of brain chemistry,
has said:
Depression is an emotion that is universally experienced by
virtually everyone at some time in life. Distinguishing the
“normal” emotion of depression from an illness requiring
medical treatment is often problematic for those who are not
trained in the mental health sciences. Stigma and
misinformation in our culture create the widespread, popular
misconception that...depression is...a deficiency of character
which can be overcome with effort. For example, a survey in
the early 1990s of the general population revealed that 71%
thought that mental illness was due to emotional weakness;
65% thought it was caused by bad parenting; 45% thought it
was the victim’s fault and could be willed away; 43% thought
that mental illness was incurable; 35% thought it was the
consequence of sinful behavior; and only 10% thought it had a
biological basis or involved the brain.
There is abundant evidence of a complex mind-body interaction. This
interaction, interestingly enough, makes it challenging to sort out the origins
of change even at the physiological level. We know, for example, that
emotional and behavioral changes made in therapy—changes that involve
making different choices in life—can prompt changes in brain chemistry just
as much as changes in brain chemistry can prompt corresponding changes in
emotions and behavior. In other words, psychological causes and brain
chemistry are intricately linked to one another.
The average person has moods that, from time to time or for a season,
may fluctuate slightly higher or lower than normal. It’s when these moods
fluctuate greatly or remain oddly high or low for extended periods that a
person might begin to consider depression as the cause. Depression is really
part of a spectrum including not only low or depressed moods but also
elevated or "manic" moods. The majority of depression is considered
"unipolar," which means sufferers only experience periods of depressed
mood. But others experience times of being very "up" even to the point of
irrational euphoria and significant impulsivity. The treatment for people who
have "up" episodes in addition to their depression (called “bipolar”) is
different than people who only have depressed or “down” episodes. “Mania”
is what physicians call this abnormal state of mood where the euphoria
creates significant problems including impulsivity, agitation, irritability,
racing thoughts, lack of sleep, and reckless spending.
Differentiating between people who only have a depressed mood
versus people who can fluctuate from either a depressed mood to a euphoric
mood is very important before starting the treatment process. People who
only have unipolar depression (also called major depressive disorder
(MDD)) are often treated with antidepressants to lift the mood from
depressed to normal. People who have various forms of bipolar depression
are typically treated with a "mood stabilizer" to keep them from becoming
euphoric, and then an antidepressant medication is added to keep them from
becoming depressed again during the next mood swing.

What causes depression?
The symptoms of depression should serve as an alarm system to begin an
investigation of the following areas in a person’s life:
A. Genetic factors
B. Environmental factors affecting psychological and spiritual
C. Other medical issues
Every one of these factors can adversely affect the brain and how it
functions at the molecular or hormonal level, causing a deficiency of
specific chemicals called neurotransmitters. Neurotransmitters are hormones
that “hand off” or “transmit” a signal from one nerve cell to another. In order
to function normally, you need to have a full reservoir or “tank” of these
hormones in the nerve cell ready to be released and thus communicate the
bioelectrical “message” to the next nerve. For our purposes, depression is
nearly synonymous with a depletion of these neurotransmitter hormones,
much like running out of hot water while taking a shower. If the brain does
not have an adequate amount of these hormones, the body’s nerve-messages
don’t get delivered, and the body begins to malfunction. Some people inherit
a tendency to have low hormone levels because their nerve cells either break
down more of the hormones than other people’s do, or their body simply
does not make enough of them.
In addition, when people experience significant loss, like a divorce or
death of a child, or experience physical or emotional burnout or a number of
other factors that create severe stress, the brain works overtime in
anticipation of the worst possible situation. In this “full combat alert” state,
the mind plays a “what-if” game, expending energy trying to anticipate the
worst possible scenario and making early preparation for all of the
possibilities. This reaction of the body to these strongly disturbing situations
can deplete the body’s neurotransmitters, again increasing a person’s risk for
Medication can lend assistance in all these situations by regulating the
level of neurotransmitter hormones, allowing the “message” to be sent from
one nerve to the next in a more normal fashion (like having instant hot water
for your shower). A common misconception about antidepressant therapy is
that antidepressants are habit-forming or force a dependency upon the user,
placing them in “bondage” at the hands of the physician or leaving them
vulnerable to spiritual manipulation. However, antidepressant medications
are not addicting like Valium, narcotics or cocaine; these directly stimulate
the nerves provide an altered state of consciousness or euphoria.
Antidepressants work to regulate the process by which nerves deliver their
messages from the brain to the body; consequently, they ARE NOT habitforming,
nor do they manipulate a person’s thoughts or values. It is
important to understand this, as misinformation and stigmas in this regard
can prevent some from seeking vital medical treatment or even supporting
the treatment of others. Many patients use antidepressant medication for a
season, only to stop taking it once the patient and his/her health-care team
decide it is appropriate and safe to do so. As with any medication, a patient
should only stop an antidepressant treatment regimen under the advice of the
prescribing doctor.
Some of the confusion as to why certain people struggle with
adversity more than others can be answered in the concept of individual
variability. Each person is unique, and so physicians must individually
assess the potential for significant depression. Some people can go through
divorce, lose their job and seem to manage just fine, while others seem to
collapse into depression if they get disappointed by not getting a new car.
Just like the color of your eyes and hair, there is individual variability in
your body’s ability to manufacture or metabolize (break down) the brain’s
hormones. If you inherited a tendency to have low levels of these hormones,
you will be more vulnerable to experiencing a chain of events that leads to
depletion and, therefore, it is more likely that medication can provide relief.
Can significant depletion be caused by long-term emotional stress?
Yes. Can significant depletion be caused by an environmental stressor? Yes.
Can significant depletion be caused by family genetics? Yes. Therefore, how
should the issue of using medications be viewed? As a necessary evil? As
something to avoid at all costs? Is medication a panacea that should be given
to everyone?
The good news is that 90 percent of people who need it can be helped
significantly with their depression once they have found a suitable
medication. With this help, they are much more amenable to the work of
psychotherapy and open to receive spiritual guidance, which is more likely
to bring about lasting change.

When is depression severe enough to consider medication?
Physicians rely on the specific DSM-IV (the fourth edition of the Diagnostic
and Statistical Manual of Mental Disorders) criteria in evaluating the
following symptoms to make the diagnosis of major depressive disorder
(MDD). If a person has at least four of the following symptoms nearly every
day for at least two weeks, you meet the criteria for depression:
(1) Depressed mood and feeling of hopelessness;
(2) Loss of interest in daily activities and pleasures;
(3) Inappropriate guilt and feelings of worthlessness;
(4) Appetite changes causing either weight gain or weight loss;
(5) Sleep problems, especially early morning awakening;
(6) Agitation and restlessness;
(7) Concentration difficulties and inability to make decisions;
(8) Fatigue and lack of energy;
(9) Recurring thoughts of suicide, in which life seems empty and not worth
(10) Irritability and feeling “stressed out.”
A qualified physician will review the preceding list of symptoms and
the potential risk factors on the basis of your genetics, environmental
circumstances, and other medical conditions, medications, and history of
substance use and abuse. Self-assessment tools like the Beck, Zung, or PHQ
may also be used in an attempt to quantify the symptoms, confirm the
diagnosis and monitor improvement with therapy.

Don’t antidepressants increase your risk of suicide?
In 2004, the FDA issued a “black box” warning to physicians that
antidepressant may cause increased suicidal thinking in young people less
than 19 years of age. As a result, physicians became more cautious about
prescribing antidepressants, and many people became afraid to start taking
them. In 2008, the American Journal of Psychiatry published an article that
showed that as a result of the FDA warning, deaths from suicides actually
increased 14%. Thomas Insel of the National Institute of Mental Health said,
“We may have inadvertently created a problem by putting a ‘black box’
warning on medications that were useful. If the drugs were doing more harm
than good, then the reduction in prescription rates should mean the risk of
suicide should go way down, and it hasn’t gone down at all—it has gone
up.” He concludes by saying, “If I had a child with depression, I would go
after the best treatment but also provide close monitoring.”

What if I choose not to use medication and just “tough it out?”
Depression’s impact is not limited to the sufferer; it can drastically affect
relationships with others, especially loved ones. The brain’s neurotransmitter
activity affects cognitive and emotional functioning, impacting a person’s
attitude, motivation, perception of others, and ability to respond
appropriately. Depressed patients often express that “everything is more
difficult to do” and “nothing seems fun any more.” And because cognitive
ability can be impaired by your mood, the depression can even prevent a
person from seeing how their mood is affecting other people. If you think
you might be suffering from depression, talk to those closest to you—those
you trust intimately—and ask if they perceive any difficulty in your mood or
relationships. It might surprise you how much your behavior has affected
those around you and how obvious the condition is to others.
There is even some evidence that over extended periods of time, if
people remain depressed as a result of low brain neurotransmitter levels,
actual shrinkage in the hippocampus (deep part of the brain) can occur,
which could potentially be associated with increased likelihood of
Alzheimer's-type dementia. There is evidence that when neurotransmitter
levels are low, this causes low levels of BDNF (brain-derived neurotrophic
factor), which causes nerve cells in the brain to shrink and eventually die.
Raising levels of neurotransmitters with the use of antidepressants also
increases the brains level of BDNF and encourages the "regrowth" of
damaged nerve cells.
More than 60% of people who committed suicide suffered from a
major depressive disorder. About 8% of people with major depressive
disorder will die by suicide. Note the following risk factors for suicide:
• Diagnosis of a chronic depressive disorder
• Past history of suicide attempts or suicidal thoughts
• Family history of suicide
• Depressive episodes requiring hospitalization
• Change from inpatient to outpatient status
• Severe worrisome anxiety symptoms
• Panic attacks (recent history)
• Severe loss of pleasure in life
• Alcohol abuse: moderate or worse

What about counseling? Does it work?
Multiple studies have proven that counseling and psychotherapy plus
medication are more effective than either one alone. For many people,
counseling and psychotherapy alone can lead to healing and resolution of
depression. But just like getting on the “right” medication, finding a skillful
counselor who can help you resolve emotional, relational, and spiritual
issues may take time. You may want to check out the web site for the
American Association of Christian Counselors at www.aacc.net to find a
Christian counselor in your area.
I firmly believe in the “integration” paradigm when considering the
subject of depression and personally see on a daily basis the change in
people’s lives—whether it be from spiritual transformation, Christian
psychotherapy, or use of medication—often in combination, since each area
affects the others.

How does God view those who are depressed?
God is intimately involved in the process of our healing and wholeness. His
desire is for our good, and He does not use depression to punish us. As result
of His movement in our lives, He gives us the privilege of helping others.
More insight on this topic can be reviewed in my colleague’s article from
last week.

Final Thoughts
The symptoms of depression are very common; they are not due to
emotional or spiritual weakness. Depression is evidence that brain hormones
(neurotransmitters) are depleted. Depression will affect you in every way:
your body, your mind, your emotions, and your spirit. Therefore, assessment
and treatment must address each of those areas. There can be multiple
triggers, inciting events, and genetic or medical conditions involved, so steps
should be taken to restore those levels with proper therapy and medication
after an accurate diagnosis as to the cause is made.
Most people are more aware and open about the physical symptoms
than the psychological symptoms of their depression. There is no blood test
to make a diagnosis of depression, but a careful professional assessment can
be highly accurate. Many Christian people feel ashamed that they need to
take antidepressant medication because they feel they have disappointed
God by their choices or behavior. Some people are afraid antidepressants are
"addictive,” which they are not. Depression is a highly treatable condition,
but it can be very difficult or impossible to "fix yourself" with sheer
willpower. The vast majority of people suffering with depression can be
dramatically helped with appropriate antidepressant medication and
counseling/psychotherapy, as needed.
Be patient to find the right therapy regimen and/or antidepressant that
works the best for you. Remember most medications will have a few
nuisance side effects, but most disappear or diminish with time. God could
choose to heal someone instantaneously, but in my experience He more
often uses available medical therapies as well as effective spiritual
counseling and psychotherapy to accomplish full restoration. God truly is the
“Great Physician!”
What would happen if, rather than avoiding those who are hurting or
“in a bad place,” we were actually “compelled” to come alongside them with
Deleted: , (insert link here)
encouragement to seek help by considering an evaluation for counseling or
medical treatment, accompanied by participation in a Christian group or
fellowship? There is nothing greater in life than to see others find freedom
and wholeness in Christ!
Gregory M. Knopf, M.D. has been a family practice physician for 30 years and is the founder and medical
director of the Gresham-Troutdale Family Medical Center. He is a graduate and Clinical Associate
Professor of Family Medicine at Oregon Health Sciences University. Dr. Knopf has a particular interest in
the treatment of anxiety and depression. He speaks across the country on the topic, principally for
professional audiences, and for the general public and churches as well. He is the co-author of Light on the
Fringe: Finding Hope in the Darkness of Depression with Gary Lovejoy, Ph.D. and also wrote A
Christian’s Guide to Depression and Antidepressants: Clearing Up the Confusion.


Click here for the original article.
After 15 minutes of arguing with a billing operator, the director of the Red River Women's Clinic in Fargo, N.D.,

begins preparing for the patients who will soon arrive. Staff members trickle in. One puts a DVD of old sitcoms on

the waiting-room television. Another straightens a pile of magazines. Someone brews a pot of coffee. By 10 a.m.,

the clinic is bustling with patients. Before the day is over, 18 women will undergo surgical abortions at Red

River. Four others will receive abortion-inducing medication.

Kromenaker, a social worker, was born in January 1972, one year before the Supreme Court decided Roe v. Wade. She

has spent her entire adult life providing abortion services and is among hundreds of clinic directors across the

U.S. navigating an ever increasing number of state-imposed abortion regulations. At Red River, the only abortion

clinic in North Dakota, a woman must wait 24 hours between scheduling an appointment and arriving at the facility.

Once there, she must undergo a counseling, verification and testing process that lasts up to five hours. If she is

a minor, she must notify her parents; get permission from one or both, depending on who has custody; or get

approval from a judge. Like Medicaid programs in some 30 other states, North Dakota's does not cover abortion

services except in instances of rape or incest or to protect the life of the mother.

In the past two decades, laws like the ones that govern appointments at Red River have been passed with regularity

as pro-life state legislators have redrawn the boundaries of legal abortion in the U.S. In 2011, 92 abortion-

regulating provisions--a record number--passed in 24 states after Republicans gained new and larger majorities in

2010 in many legislatures across the country. These laws make it harder every year to exercise a right heralded as

a crowning achievement of the 20th century women's movement. In addition to North Dakota, three other states--South

Dakota, Mississippi and Arkansas--have just one surgical-abortion clinic in operation. The number of abortion

providers nationwide shrank from 2,908 in 1982 to 1,793 in 2008, the latest year for which data is available.

Getting an abortion in America is, in some places, harder today than at any point since it became a

constitutionally protected right 40 years ago this month.

It might seem as though recent electoral victories by Barack Obama and congressional Democrats set the stage for a

reversal of this trend. The President's campaign mobilized Democratic voters and women around the issue of

reproductive rights--an effort that produced, according to some exit polls, the widest gender voting gap in

history. But while the right to have an abortion is federal law, exactly who can access the service and under what

circumstances is the purview of states. And at the state level, abortion-rights activists are unequivocally losing.

Part of the reason is that the public is siding more and more with their opponents. Even though three-quarters of

Americans believe abortion should be legal under some or all circumstances, just 41% identified themselves as pro-

choice in a Gallup survey conducted in May 2012. In this age of prenatal ultrasounds and sophisticated neonatology,

a sizable majority of Americans supports abortion restrictions like waiting periods and parental-consent laws.

Pro-life activists write the legislation to set these rules. Their pro-choice counterparts, meanwhile, have opted

to stick with their longtime core message that government should not interfere at all with women's health care

decisions, a stance that seems tone-deaf to the current reality.

Pro-choice activists' failure to adapt to the shift in public attitudes on abortion has left their cause stranded

in the past, says Frances Kissling, a longtime abortion-rights advocate and former president of Catholics for

Choice. Kissling is part of a small group within the pro-choice movement trying to push the cause toward more

nuanced stances. "The established pro-choice position--which essentially is: abortion should be legal, a private

matter between a woman and her doctor, with no restriction or regulation beyond what is absolutely necessary to

protect the woman's health--makes 50% of the population extremely uncomfortable and unwilling to associate with

us," she says.

At the same time, a rebellion within the abortion-rights cause--pitting feminists in their 20s and 30s against

pro-choice power brokers who were in their 20s and 30s when Roe was decided--threatens to tear it in two. Many

young activists are bypassing the legacy feminist organizations that have historically protected access to

abortion, weakening the pro-choice establishment at the very moment it needs to coalesce around new strategies to

combat pro-life gains and connect with the public.

As memories of women dying from illegal pre-Roe abortions become more distant, the pro-choice cause is in crisis.

In 1973, female lawyers from the Center for Constitutional Rights said Roe v. Wade was "a tribute to the

coordinated efforts of women's organizations, women lawyers and all women throughout this country." Writing a new

playbook for the pro-choice cause--one that ensures that Roe is not overturned and that access to abortion is

preserved and even expanded--would require the same kind of coordination. If abortion-rights activists don't come

together to adapt to shifting public opinion on the issue of reproductive rights, abortion access in America will

almost certainly continue to erode.

In many ways, the fight to preserve access to abortion is even more daunting than the fight to legalize it 40 years

ago. In a dynamic democracy like America, defending the status quo is always harder than fighting to change it. The

story of pro-choice activism after Roe reveals that there may be nothing worse for a political movement's future

than achieving its central goal.

Around her workspace at Red River, Kromenaker has tacked up photographs of her daughter and phone numbers for the

Fargo police department and a security hotline operated by the National Abortion Federation. In the filing cabinet

behind her desk, she keeps a green folder full of mail from pro-life activists. The correspondence ranges from

vaguely threatening notes to prayers on behalf of Kromenaker, the doctors who work at Red River and their patients.

Kromenaker is proud and outspoken about her work, but she takes different routes to work every day to avoid falling

into a routine that might make her a target for pro-life zealots. (Abortion doctor George Tiller was at his regular

Sunday church service when he was shot and killed by a pro-life activist in 2009.) "Even if I'm at Target looking

at clothes, I never let my guard down," she says. It might seem like paranoia to be so vigilant, but in the late

1990s, Kromenaker testified at the trial of a man accused of trying to start a fire at a clinic where she worked

before Red River.

In 2011, Kromenaker testified again, this time at a committee hearing in the North Dakota state senate, which was

considering a bill passed by the house that sought to ban medication-induced abortions, among other provisions.

Despite Kromenaker's testimony and the efforts of pro-choice activists in North Dakota, the bill passed the state

senate 42 to 5 and was signed into law on April 18, 2011. (Red River is suing to overturn the law, which a judge

has blocked from going into effect.)

In November, feminists celebrated the defeat of U.S. Senate candidates Todd Akin of Missouri, who said a woman's

body can resist a pregnancy in the case of "legitimate rape," and Richard Mourdock of Indiana, who said pregnancies

conceived in rape are "intended" by God. Even before Election Day, Cecile Richards, president of Planned

Parenthood, said, "This past year and a half has been a remarkable period of unifying women and men and a whole new

generation of folks who understand that none of these rights or access can be taken for granted."

Yet the candidate who beat Mourdock, Democrat Joe Donnelly, is also pro-life and believes abortion should be

illegal except in cases of rape or incest or to protect the life of the mother. Voters in Indiana also elected

conservative Republican Representative Mike Pence as the new governor. Pence has been introducing legislation since

2007 to eliminate federal funding for women's-health clinics that provide abortions, including a GOP House effort

to defund Planned Parenthood in 2011. And in North Dakota, which has a Republican governor and legislature,

Kromenaker is girding for new legislation she expects to be introduced that would grant fetuses "personhood" status

and directly challenge the constitutional basis for Roe v. Wade.

The modern era of state restrictions on abortion began in 1992 with the Supreme Court's decision in Planned

Parenthood v. Casey. The court upheld Roe v. Wade but said states have a right to regulate abortion as long as they

don't write laws that impose an "undue burden" on women. Pro-life politicians enacting laws to limit abortion are

now testing the limits of the Casey ruling. Their ultimate goal is to land another abortion case before a

sympathetic Supreme Court in an attempt to overturn Roe. Along the way, in what Charmaine Yoest, president of the

antiabortion group Americans United for Life, describes as a strategy to "work around Roe," pro-life activists hope

to severely--or completely--curtail access to abortion at the state level.

In Mississippi, pro-life activists pushed for passage of a 2012 law requiring that doctors who perform abortions

have admitting privileges at local hospitals. None of the out-of-state physicians who perform abortions at the

state's sole abortion clinic have these privileges. The clinic remains open while a federal judge examines the

constitutionality of the law and whether it presents an undue burden to women seeking abortions. Governor Phil

Bryant, who signed the law, said it was part of an effort to "end abortion in Mississippi."

The Volunteer Women's Medical Clinic in Knoxville, Tenn., was open for 38 years before it closed in August 2012,

citing the state's Life Defense Act, passed earlier in the year, which also requires doctors to have hospital

admitting privileges. A doctor who worked at the facility obtained hospital privileges but died suddenly of a

stroke, and clinic director Deb Walsh said she couldn't afford to keep her doors open while she tried to replace


In Virginia, the state board of health adopted a rule last year requiring abortion clinics to comply with

architectural zoning regulations for hospitals. Like the Mississippi law and one just enacted in Michigan requiring

abortion clinics to be licensed, the Virginia rule seems designed to make clinics safer, but there is little

evidence that women's health had previously been in danger. Loretta Ross, who co-founded Sister Song, an Atlanta-

based reproductive-rights group focused on the needs of women of color, is among those in the pro-choice movement

who marvel at the pro-life strategic vision even though she opposes its goals. "The entire women's-health movement

was predicated on the lack of women's safety and gender consciousness in health care settings," says Ross. "It is a

classic example of our opponents learning from us and taking our script."

In fact, those most affected by new zoning laws are independent clinics like Red River, whose tight margins make it

financially burdensome for them to adapt to new requirements. Planned Parenthood is the largest abortion provider

in the U.S., but independent clinics collectively deliver the majority of abortions in America. And as abortion

services have become concentrated in specialized clinics--as opposed to hospitals, which accounted for the vast

majority of abortion facilities in 1973--clinics have become easier targets. Pro-life groups celebrate every clinic


The other strength of the state-based clinic laws, which often are based on text written by pro-life activists and

lawyers and distributed to lawmakers, is that they are hard to campaign against. The zoning regulation in Virginia,

for example, would require abortion clinics to widen all hallways to 5 ft. (1.5 m). "Is that the kind of thing that

will rally voters?" asks Cristina Page, author of the book How the Pro-Choice Movement Saved America. "'We're not

going to expand these hallways to be 5 ft. wide!' is not a compelling message. The villain is now in the fine


When the Red River clinic opened in downtown Fargo 15 years ago, the surrounding area was a sea of blight and empty

storefronts. In the years since, the area has undergone a dramatic revitalization that recently earned it a spot on

a list of great neighborhoods in America. Two doors down from the clinic, customers of a deli check out using

iPads. Across the street, a boutique hotel and restaurant serves upscale cocktails and locally sourced food.

The beige brick building that houses the clinic looks like a vestige of a more hostile era. A glass-block wall

shields those inside from view. The lock on the interior door is operated by a switch inside, and patients are

buzzed in only if they have appointments. Twenty to 25 abortions are performed every week at Red River, and the

procedures are usually all scheduled on a single day. On these days, a staffer inside watches a set of closed-

circuit televisions monitoring the entrance and the handful of protesters from a local Catholic church who show up

and mill around out front with graphic signs showing aborted fetuses.

The atmosphere outside is tense, but inside, on the second floor, the waiting room is filled with sunlight. Lush

houseplants are perched everywhere, and signs and posters decorate the walls: YOU ARE BEAUTIFUL. WE TRUST WOMEN.


Kromenaker, who has run Red River since it opened, was born in a small town in northern Minnesota. Her family later

settled in a suburb of Minneapolis, and Kromenaker graduated from Minnesota State University at Moorhead, just a

few miles from Fargo. She and her husband, a California native, have stayed put in part so she can continue her

work. "We're committed to this clinic," she says.

In Fargo, Kromenaker is battling the state legislature and the local pro-life community. But in Washington,

establishment pro-choice activists are dealing with another set of threats that are mostly self-inflicted. What

pro-choice activists call "the movement" is in many ways more fragmented than it's ever been, thanks to a widening

generational divide. The problem is rooted in leadership, which is concentrated in a small but powerful army of

women who were in their 20s and 30s when Roe was decided and who now oversee a number of establishment feminist

organizations, including NARAL Pro-Choice America, run by Nancy Keenan, 60; the National Organization for Women,

headed by Terry O'Neill, 60; and Feminist Majority, run by co-founder Eleanor Smeal, 73.

Some of these leaders and their similarly aged deputies have been reluctant to pass the torch, according to a

growing number of younger abortion-rights activists who say their predecessors are hindering the movement from

updating its strategy to appeal to new audiences. This tension had been brewing for years, but in 2010, Keenan told

Newsweek that she worried that the pro-choice cause might be vulnerable because young people weren't motivated

enough to get involved. The complaint struck young activists like Steph Herold, 25, as an effort to place blame on

others for mistakes the establishment pro-choice movement has made along the way. "They are the generation that

gave us legalized abortions, but they also screwed up," says Herold, pointing to the pro-choice establishment's

failure to stop the 1976 Hyde Amendment, a law that prohibits federal funding of abortions and disproportionately

affects poor women. At a conference last May, Herold heard a women's-clinic owner who has worked in the abortion

field for some 40 years echo Keenan's complaint--that young people aren't involved enough in the pro-choice

movement. Herold was furious. She stood up and, trembling, walked to a microphone. "We're counseling your patients

and stuffing your envelopes," Herold told the clinic owner. "You should be talking to us and not just about us."

The power struggle isn't based on differences over the right to access abortion. Young activists fighting for

reproductive rights have the same hard-line view of abortion access as their predecessors: they say it should be

unrestricted by state governments and that the decision to terminate a pregnancy should be left solely to women and

their doctors. But the infighting could splinter the movement if the younger generation abandons those feminist

institutions that have traditionally been the headquarters for voter-mobilization campaigns, fundraising and

lobbying, the lifeblood of any political movement. Erin Matson, 32, became a vice president of NOW in 2009 but

recently resigned. "When you want to build a jet pack, sometimes that means you have to leave the bicycle factory,"

she says.

Matson says she is considering starting a new organization to specifically target young people. "A number of young

women are just saying, 'To hell with it, I'm just going to lead,'" she says. "It's easier for young women to

exercise leadership right now than before we had this technology." The technology Matson refers to is the Internet.

Last February, when the Susan G. Komen breast-cancer foundation eliminated its long-standing grant funding for

Planned Parenthood, a backlash quickly ensued on Twitter. Under tremendous pressure, Komen reinstated the funding.

After the episode, says Herold, "No one can say anymore that young people don't care about this issue."

In addition to being nimbler at Web-based activism, young feminists have another advantage when appealing to

millennial voters, who will make up some 40% of the electorate by 2020: relatability. "We need more leaders in this

movement who are of reproductive age," says author Page, 42. Sandra Fluke, the law student Republicans barred from

testifying before a congressional committee last year, was a valuable asset to the pro-choice cause in part because

of her relative youth. She spoke publicly about the personal reproductive rights and birth control choices of her

peers. Keenan, who has become aware that her own age might impede her effectiveness, announced last May that she

would step down in 2013. She said she hoped a younger person could replace her. "They're chomping at the bit to

have their opportunity," she says.

Young abortion-rights activists have a strategy to modernize the cause, which includes expanding it. They often

don't even mention the term pro-choice, which they say is limiting and outdated. Instead these young leaders have

embraced a cause known as reproductive justice--a broader, more diffuse agenda that addresses abortion access but

also contraception, child care, gay rights, health insurance and economic opportunity. "It's a more holistic

frame," says Matson. "And you see younger people connecting with that."

The term reproductive justice was coined in the 1990s by black feminists who wanted to broaden the appeal of

reproductive rights and speak to the needs of African-American women, whose abortion rate is 3½ times that of white

women. "The pro-choice movement would focus on 'Let's open more clinics.' The anti-choice movement would say,

'Let's stop women from going into them,'" says Ross, 59, of Sister Song. "Those of us in the reproductive-justice

movement would say, 'Let's ask why there is such a high rate of unintended pregnancies in our community. What are

the factors driving that?'"

Addressing issues like economic disparity marks a major shift from the pro-choice messages of the 1970s that made

choice the optimal virtue and an end in itself. But the shift, says Ross, is the natural maturation of the pro-

choice movement and worth the extra effort. The abortion rate in impoverished black communities has remained

disproportionately high despite efforts by Planned Parenthood and others to provide access to family-planning

services. "What this proves," says Ross, "is that if people are not convinced that they have realistic economic and

educational opportunities, you could put a clinic in a girl's bedroom and she would still think early motherhood is

a better choice."

Eye contact can be hard to come by at Red River. Many patients walk the halls with their heads down and their arms

crossed. In journals scattered throughout the clinic in which women are invited to express their feelings, patients

write about nonsupportive husbands and boyfriends and ask God for forgiveness. They write about how they can't

afford to support another child and how they are so glad Red River exists. Amid the low hum of ringing phones, the

sound of a staffer reading a state-mandated script to women wafts through the clinic's upper floor: "North Dakota

law defines abortion as terminating the life of a whole, separate, unique living human being."

When her name is called, a surgical-abortion patient descends a set of stairs and steps into a room where a

technician performs an ultrasound. Afterward she enters an exam room and is met by the physician on duty. On this

Wednesday it's Dr. Kathryn Eggleston, who informs the woman that she's reviewed her chart and asks, "Are you

confident in your decision to have an abortion today?" If the woman says yes, the abortion begins; the whirring of

the vacuum aspirator used to extract the fetus can be heard in the hallway. Within 15 minutes, Eggleston emerges

from the room and enters another where the removed contents are examined and photographed for the medical record.

In the recovery room, where patients rest in overstuffed leather recliners, Kromenaker chats with a 20-something

woman who declined Eggleston's offer to go on birth control. "Do you have a boyfriend?" Kromenaker asks. No.

Kromenaker runs through a few ancillary health benefits of birth control anyway, hands the woman some condoms and

pats her shoulder.

A 24-year-old patient who drove 80 miles (130 km) alone to reach the clinic says she and her boyfriend decided

together not to continue her pregnancy, which was six weeks along. "Neither of us is anywhere near baby time right

now. We argue over who will take the dog out some days, so I don't think the diaper changing would go much better."

Another young woman at the clinic that day is less sure. When Eggleston asks if she is confident, the patient says

no. Eggleston questions her further, and once it's clear that the woman is conflicted, she gives her prenatal

vitamins and sends her home. The woman returns a week later. This time she does not change her mind.

About three-quarters of the patients at Red River are under 30. More than half have at least one child; about one-

third have had a previous abortion; fewer than 4% are minors. These statistics roughly mirror national data. In

all, more than 50 million legal abortions have occurred in the U.S. since Roe v. Wade. According to the Guttmacher

Institute, a reproductive-rights group whose statistics are cited by both pro-life and pro-choice activists, nearly

1 in 3 American women will have an abortion by age 45. Some 90% of abortions occur in the first trimester of


The abortion war, like many other political fights, is largely waged on the margins of reality. Review the policies

that have stoked widespread national debate and it's easy to assume that late-term abortions and those performed on

underage girls or women impregnated by rape or incest constitute the bulk of terminated pregnancies. In truth,

these are mere slivers of the abortion story in America. And on the whole, there is little public disagreement on

the merits of abortion in such cases. Most Americans support access to abortion in cases of rape or incest or when

the mother's life is threatened, along with a raft of common state abortion restrictions. Gallup data shows that

79% of pro-choice Americans believe abortion should be illegal in the third trimester of pregnancy and that 60%

support 24-hour waiting periods and parental consent for minors.

Establishment abortion-rights organizations oppose nearly all abortion-specific regulations. Pro-life activists

view their opponents' hard line as an opportunity to use public support to push for laws that have the indirect

effect of making the process of terminating a pregnancy more time-consuming and expensive. "As we work on this

common-ground package of legislation, we are more where the American people are," says Yoest of Americans United

for Life.

Activists like Yoest are playing a long game that kicked off when the antiabortion movement wholly adopted the

label pro-life in the 1970s. Then, in the 1980s and '90s, as pro-life protesters were dragged to court over their

activism at abortion clinics--blockading entrances, "counseling" patients seeking abortions and occasionally

resorting to violence against doctors and staff--they slowly built a formidable legal apparatus that serves their

cause today, says Joshua Wilson, an assistant professor of political science at John Jay College whose book The

Street Politics of Abortion will be published this year. Of pro-life activists he says, "If they can get laws on

the books, great, because they have the legal resources to defend them when they're challenged. It's an integrated

strategy that's very impressive."

The antiabortion cause has been aided by scientific advances that have complicated American attitudes about

abortion. Prenatal ultrasound, which has allowed the general public to see fetuses inside the womb and understand

that they have a human shape beginning around eight weeks into pregnancy, became widespread in the 1980s, and some

babies born as early as 24 weeks can now survive. Cultural norms about unwed pregnancy have shifted as well in the

decades since Roe v. Wade. "In general, the pro-choice movement leaves people with the feeling that we don't see

these things as complex because the answer is almost always, Well, it's a woman's decision," says Kissling,

formerly of Catholics for Choice. "And that's true, but we don't have kitchen-table conversations at the national-

advocacy level."

Kissling opposes the specific state laws pushed by pro-life activists but says the pro-choice movement's effort to

"normalize abortion" is counterproductive. "When people hear us say abortion is just another medical procedure,

they react with shock," she says. "Abortion is not like having your tooth pulled or having your appendix out. It

involves the termination of an early form of human life. That deserves some gravitas."

While a return to the pre-roe days of back-alley abortions seems inconceivable--even in the face of so many new

state laws restricting access to abortion--there is concern among pro-choice advocates that in places like North

Dakota, where the nearest abortion clinic could be hundreds of miles away, women might be driven to take

unnecessary risks. Those in the abortion-provider community say they worry that women in rural areas might try to

purchase pregnancy-terminating medication on the Internet without a doctor's supervision. Amplifying this fear is

the fact that the generation of doctors who stepped up to perform legal abortions after Roe have retired or died

without a robust new class of physicians to take their place. Efforts are under way at many obstetrics-gynecology

and family-practice residency programs to offer abortion training to more doctors, but the specter of protests and

unwanted attention remains. "It's a vicious cycle," says Eggleston of Red River. "If more of us were doing it,

there would be less stigma."

The smaller number of doctors willing to perform abortions has likely contributed to a fairly steady drop in the

overall abortion rate, from about 30 per 1,000 women ages 15 to 44 in 1981 to about 20 per 1,000 in 2008, according

to Guttmacher. Widespread access to birth control, which the pro-choice movement strongly supports; changing

attitudes about family and fetuses; and state regulations are also cited as reasons. In theory, a lower rate of

abortion might be something for both sides of the abortion debate to share credit for and even celebrate. But it

also illustrates the ultimate challenge for pro-choice advocates. Their most pressing goal, 40 years after Roe, is

to widen access to a procedure most Americans believe should be restricted--and no one wants to ever need.

The original version of this story equated late term abortion with "partial birth abortion," the latter of which is

illegal in the U.S. Abortions in the second and third trimester of pregnancy are performed using other procedures.


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