After the Supreme Court overturned the federal right to abortion in 2022, many states that banned the procedure did so with the promise that it would still be legal in some circumstances, including in the event of rape. One study estimates that over 64,000 pregnancies have occurred due to rape in the years since the ruling in states where abortion is banned.
But many people on the front lines of this issue say getting an abortion in these states after an assault is difficult or — in some cases — impossible.
There is no central database that measures abortions performed because of rape. For this story, NPR looked at state records and talked with researchers, advocates and doctors in seven of the 11 states where abortion is banned but legal in the case of rape. Taken together, these accounts show a patchwork of laws governing rape exceptions, confusion over who qualifies for an exemption and law enforcement's role in that process, and widespread fear from doctors about performing abortions for assault victims.
Many victims aren't capable of immediately reporting their rapes
It's all but impossible to know exactly how many abortions are performed because of rape exemptions. When they report the procedure, doctors aren't required to include a reason. And an abortion could fall under a different exemption — such as a fetal anomaly or life of the mother.
Existing annual data suggests that in many states, the numbers of known abortions performed due to rape are in the single digits or, in some cases, zero.
One reason for that is because in many states, rape victims who want an abortion are required to report their assault to law enforcement. Advocates and medical professionals who work with rape victims say in the aftermath of an attack, there are more immediate issues to consider than abortion laws.
"It's just too much for them to manage at that point," says Katy Rasmussen, a nurse who works with assault victims with the Johnson County Sexual Assault Response team in Iowa. The patients she sees are frequently in shock or dealing with the stigma around sexual assault. If alcohol or illegal substances are involved, Rasmussen says, patients may feel shame or even blame themselves.
"Often, sexual assault survivors just want it to be over," says Kelly Miller, former executive director of the Idaho Coalition Against Sexual and Domestic Violence. "And so having to go through the trauma of reporting, the trauma of a forensic interview, most survivors opt out of all of that."
Other advocates point out that many patients are experiencing domestic violence when they are raped. That's what happened to Laurie Betram Roberts. She says she became pregnant years ago after she was raped by someone she lived with. Reporting him and risking his arrest, she says, could have meant losing her housing.
"We shared a residence," she says. "There was no domestic violence shelter that would take me because my family was too big."
Bertram Roberts, who has seven children, did eventually disentangle herself from this man. She now works with people in similar situations as part of her job with the Mississippi Reproductive Freedom Fund, a nonprofit that helps people get abortion care in that state.
"There's a perception of good and bad abortions" among people who defend state abortion bans, Bertram Roberts says. "But the truth is the exemptions are all rhetoric and no practical use."
Last year in Mississippi, there were zero abortions for any reason, according to a recent report from The Society of Family Planning's WeCount project.
Mississippi Gov. Tate Reeves promised exemptions for rape when the state's 2022 law went into effect. NPR reached out to Reeves' office as well as to lawmakers in multiple states who sponsored these bans and to national anti-abortion groups. None of them wanted to speak on the subject of rape exemptions across the country.
One group, Susan B Anthony Pro-Life America, sent NPR a written statement laying blame with doctors and health systems for their confusion and inability to utilize the law. "If there are doctors who are confused about rape exceptions, hospital administrations and health associations should provide clarity," the statement read.
Some doctors say they feel weaponized and intimidated
Involving law enforcement makes patients and doctors feel like "potential criminals," says Jessica Tarleton, an obstetrician in South Carolina, where by law, doctors must report abortions performed because of a rape to their local sheriff's office.
"Somebody comes into the emergency room who's been shot, we don't ask them what they did to be in a position to be shot. We take care of the patient," says Tarleton. She points out that no other kind of medicine demands doctors legally justify care.
"In the past two years," she says, "I am aware of one one patient that I was associated with that sought a legal abortion under the rape exception."
Tarleton tries to offer abortion care whenever she legally can. But she says many doctors in this state are scared and feel they don't have enough support to provide abortions in a place where it feels legally risky. As a result, she says, many distance themselves from the practice altogether.
"Now I'm the investigator"
Iowa makes it particularly difficult for rape victims to get an abortion, according to doctors and reproductive rights advocates.
This summer, after a long court fight, the state started enforcing a six-week abortion ban, which makes an exception for certain things like rape. But directions from the Iowa Board of Medicine say doctors — before performing an abortion – must determine whether a rape is legitimate or risk legal consequences for noncompliance.
It's an unusual level of detail for doctors to collect and document, even among the other 10 states that include exemptions for rape.
"Now I'm the investigator trying to decide if the details of the incident constitute rape as per Iowa Code," says Dr. Emily Boevers, who works in Waverly, a town of 10,000 in northeastern Iowa. She says these requirements threaten the privacy, trust and intimacy of the patient-doctor relationship. "I'm supposed to maintain a therapeutic, caring relationship with this patient while I query all these details," Boevers says.
So far, she hasn't had to investigate the circumstances of assault with a patient, but she's practicing what she'll say when that day comes. "Unfortunately, our government mandates that I must ask you some questions," she plans to say. "If you are able to answer these, I might be able to help you."
Those who enforce the laws might not always know the laws
In some states, there is little clarity on rape exemptions even among those officials charged with enforcing the laws.
Idaho outlaws abortion with exceptions for rape, incest and when the life of the mother is threatened. To get an abortion, sexual assault victims have to produce a police report for medical providers.
When the state's ban went into effect in 2022, victim advocates quickly pointed out that law enforcement agencies don't release police reports until a case is closed – preventing victims from accessing timely care. The following year, the Idaho Legislature amended the bill's text so that rape victims are entitled to receive, upon request, a copy within 72 hours of the report being made.
But agencies appear to follow these requirements unevenly.
Boise State Public Radio reached out to 56 law enforcement agencies across Idaho about their protocols to assist rape victims since the ban. A handful said they complied with the 72-hour amendment and said their in-house victim advocates were available to help victims throughout their process.
Many others seemed unfamiliar with the amendment. Several public records departments said they would automatically deny requests for copies of a report on an open case, regardless of who made it. One agency realized it hadn't been complying with the 72-hour law after it went into effect and had unknowingly denied records to rape victims.
Local agencies said they had received no guidance from the state.
Advocates say this murky process compounds a system of reporting that's already unwelcoming to victims.
"Survivors generally don't report to these systems that were never created to be centered around survivors in the first place," says Miller, the former head of the Idaho Coalition Against Sexual and Domestic Violence. "It's just unrealistic to expect that survivors will access these systems just for the purposes of being able to gain access to an abortion as a result of a pregnancy from a sexual assault."
State records suggest there were fewer than 10 abortions for any reason last year in Idaho.
Providers of rape-exception abortions often are shielded by big institutions
Only a handful of doctors interviewed for this story reported performing rape exception-abortions with any consistency. Those who did all worked at major academic medical institutions.
Dr. Nisha Verma in Georgia estimates she sees someone who has been raped or experienced incest who meets the exception standard "every couple weeks."
Verma isn't an official spokesperson and didn't want to be identified using her institution's name. But she says her employer has protocols and task forces to assist doctors in managing their legal risk. That helps mitigate doctors' fears of losing their medical license, being fined or going to jail.
"At my institution, we have really again worked to create a system that helps us as doctors feel more supported and protected," Verma says.
But for most people who work with victims, it's not simply a question of how to get abortion exemptions. Some states, for example, are also constrained by a shortage of providers willing even to deliver babies, let alone perform legally risky procedures.
"The question is," says Bertram Roberts of the Mississippi Reproductive Freedom Fund, "If you got an exemption in Mississippi, who's going to perform your abortion?" The state has a significant shortage of obstetricians.
Bertram Roberts says she's never seen anyone in that state get an exemption — for any reason, let alone rape.
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