Investigative Summary:

After Texas lawmakers passed the country’s most restrictive abortion law, more people began turning to online pharmacies for access to medication abortion. State leaders then passed more legislation attempting to stop pills from being sent through the mail, but the law may do little to halt organizations operating outside the state and the country.

AUSTIN (KXAN) – Hours after Texas’s most restrictive abortion bill became law, activist Jessica Craven posted a TikTok. With a New York Times article in the background, Craven talked to her 96,000 followers about an online website offering medication abortion to people in Texas.

“The good news is AidAccess, an international organization that cannot be sued by anyone in Texas, is now offering to send folks in Texas abortion pills,” Craven posted on Sept. 1. Her post was shared more than 24,000 times. The comment section is filled with questions about where to find the pills — and how to spread the information to more people in Texas.

Watch the Tik Tok on Jessica Craven’s page.

The service she was referring to is not new. Since 2018, pregnant people could request abortion-inducing medication from AidAccess, get a prescription from a licensed physician through the service, and have it mailed to their home in discreet packaging — without visiting a clinic.

This year, Texas lawmakers passed two new laws restricting abortion: one banning abortion once fetal cardiac activity is detected (usually around six weeks into a pregnancy) and the other banning abortion medication being delivered through the mail. But, neither has managed to stop online abortion pill providers from delivering abortion medication to those who want it in Texas.

Christie Pitney is one of the US-based providers for AidAccess. The founder of the organization, Dr. Rebecca Gomperts, is based in Europe. Pitney says the non-profit has no intention to stop prescribing abortion medication to eligible people in Texas.

“SB 8 applies to people who are accessing abortions within Texas, from a physician licensed in Texas, and so you can see the kind of workaround there, that Dr. Gomperts isn’t in the US — and so that’s how she’s able to continue prescribing and caring for these patients,” Pitney said.

Medication abortions in Texas: By the numbers

During the pandemic when Texas Gov. Greg Abbott halted elective procedures, including abortions, for four weeks, a University of Texas Austin professor found data showing requests out of the state to AidAccess nearly doubled — from 406 expected requests to 787 actual requests. The study found requests to AidAccess increased in 39 states from March 20, 2020, to April 11, 2020. Of all of those states, requests to AidAccess increased the most in Texas.

The graph shows the percent change between the actual number of requests from March 20, 2020, to April 11, 2020, compared with the expected number of requests for self-managed medication abortion. During this time period, abortion procedures were suspended along with elective surgeries in Texas. SOURCE: Demand for Self-Managed Online Telemedicine Abortion in the United States During the Coronavirus Disease 2019 (COVID-19) Pandemic.

AidAccess says requests have — again — surged in Texas since Senate Bill 8 became law.

“We got a window into what we are dealing with now on a wider scale under Senate Bill 8.”

Abigail aiken, ut austin professor

“We got a window for what we are dealing with now on a wider scale under Senate Bill 8,” said UT-Austin professor Abigail Aiken. “They are the same pills you would get in a clinic, but they are used and sourced completely outside of the healthcare setting – and that option [self-managed abortion] is incredibly important because it is a safe and effective way of taking care of your need to end your pregnancy.”

‘A safe, at-home abortion’

Medication abortion is a two-step regimen consisting of Mifepristone and Misoprostol. It was approved by the FDA in 2016 as a safe and effective method to end a pregnancy up to 10 weeks along.

A box of Mifeprex at Whole Women's Health in Austin (KXAN Photo)
A box of Mifeprex at Whole Women’s Health in Austin (KXAN Photo)

The FDA reports from 2000 to 2018, more than 3.7 million women have used abortion medication, specifically Mifepristone. Of those, the FDA reports less than 1% — 4,195 — experienced adverse reactions to the drug. The FDA reports 24 deaths associated with the drug since the product was approved in September 2000.

But the FDA warns not to buy the medication over the internet. The FDA issued warning letters in 2019 to some of these organizations, including AidAccess and RAblon, asking they stop providing and prescribing abortion medication to US citizens.

“The FDA remains very concerned about the sale of unapproved mifepristone for medical termination of early pregnancy on the internet because such a sale bypasses important safeguards designed to protect women’s health,” the FDA’s Office of Media Affairs wrote in an email to KXAN.

Forward Midwifery posts about the abortion pill on their TikTok account.

Over the years, UT Professor Abigail Aiken has studied the effectiveness and safety of people using abortion pills sourced online and used outside the healthcare clinic setting, largely at home.

In 2021, Aiken published a study that found more than 57,000 people in 2,458 counties in the United States requested abortion medication from in the first two years it offered telemedicine in the US.

Aiken published a study in 2017 in which she analyzed data from more than 1,000 women in Ireland who got medication pills through an online telemedicine service. The website, Women on Web, was founded by the same physician who created AidAccess for patients in the United States.

The study found nearly 95% of the women reported: “successfully ending their pregnancy without surgical intervention.” The study also found 9% of people reported “experiencing any symptom for which they were advised to seek medical advice” and concluded women were “able to self-identify the symptoms of potentially serious complications.”

The websites offering abortion medication do not all operate the same. Plan C, an online resource conducting its own research into abortion pills available online, has become known for breaking down the differences between the websites — including price point and estimated delivery time. The landing page of the website boasts “a safe, at-home abortion is here.”

While sites like AbortionRX and BuyMTPKits sell the pill much like an online store, sites like AidAccess are supported by doctors, requiring a medical screening before being approved for the pills.

For states like Texas, AidAccess uses a model where its Europe-based founder Dr. Rebecca Gomperts writes a prescription for patients who are eligible and sends the prescription to a mail-order pharmacy in India, which then ships the medication directly to patients.

‘If they can do that now, this bill will not change that.’

Weeks after SB 8 became law, the governor signed the second bill restricting abortion: Senate Bill 4. This bill took aim at online abortion medication providers, abortion telemedicine – and specifically an FDA decision changing how abortion medication could be dispensed during the pandemic.

Previously, the FDA required abortion medication to be dispensed in person. The FDA decided in April it would exercise discretion if abortion medication was sent through the mail or through a mail-order pharmacy during the pandemic if it was done under the supervision of a certified prescriber.

Texas lawmakers feared the change opened the door for abortion medication to be given out without patients first seeing a doctor. Sen. Eddie Lucio, a pro-life Democrat, said on the Senate floor he introduced SB 4 to protect women from potentially deadly adverse reactions to abortion medication that could come as a result of not having a doctor in the process.

“This regimen is potentially dangerous, and it was approved with specific precautions that are now in jeopardy. These serious risks can only be adequately assessed and treated by a licensed healthcare worker in an in-person visit,” Dr. Jeffrey Erwin said during a Senate Health and Human Services committee meeting.

“I would hate for women to line up to go into Mexico, or somewhere else to get an abortion, but it is a moral decision on their part. And it’s one that I have no control over. It’s between them and their God.”

Sen. eddie lucio

But, the bill does more than require physicians to consult with patients before dispensing abortion medication. Under the bill, people caught helping someone get an abortion through the mail or online would face a state jail felony of up to two years in jail. The bill also reduces the timeframe for medication abortion from the FDA’s recommended 10 weeks to 7 weeks. A pregnant person who has a medication abortion in violation of SB 4 will not be held criminally liable.

“I have talked to women who oppose abortion, period — and who understand the argument that women seeking an abortion, these drugs without the proper medical supervision — it’s going to be detrimental to them as well,” Sen. Lucio said.

Critics of the bill point out Texas law already required patients to do two clinic visits before a surgical or medication abortion. Texas law also already had statutes banning abortion telemedicine and mailing out abortion medication. Whole Women’s Health in Austin says even before SB 4, the clinic was not legally allowed to send abortion medication through the mail.

There’s also the question of whether this law will have any impact on companies, like AidAccess, that are operating outside of the state — and even the country. AidAccess providers are confident that it won’t. However, the bill’s author, Sen. Lucio, believes the law will allow for them to extradite those who are sending abortion pills to people in the state to Texas to face penalties.

Richard Hearn is the current attorney for Aid Access in the United States. Hearn disclosed he is not attempting to practice law in Texas, and his opinion should not be relied upon as that of a lawyer licensed in Texas.

“I believe any attempt by Texas to extradite physicians working for Aid Access from Europe would fail,” Hearn said. “First, in my opinion, SB 4 is facially unconstitutional and any attempt by Texas to extradite a licensed AidAccess physician in Europe would be challenged by AidAccess in Federal Court. I would expect the Dept. of Justice to support AidAccess and not Texas. Second, even assuming Aid Access’s challenge to the constitutionality of SB 4  in the U.S. court system failed, I doubt the extradition request would be granted by the European country receiving the request for a multitude of reasons.”

Blake Rocap, a healthcare attorney for abortion advocacy non-profit AVOW, also says it is unlikely organizations operating outside the US and Texas will face any penalties under SB 4.

“It’s not a matter of people just being able to go on the internet and get the drugs. If they can do that now, this bill will not change that,” Blake Rocap with Avow testified on the Senate floor. “What will change is the ability for physicians to provide the care their patients need between 7 and 10 weeks.”

Photojournalist Richard Bowes, News Director Chad Cross, Director of Investigations & Innovation Josh Hinkle, Photojournalist Chris Nelson, Digital Director Kate Winkle and Graphic Artist Jeffrey Wright contributed to this report.