SVU tackles abortion and gets much of the science on misoprostol wrong
No one expects TV to accurately portray medical issues. All of us have watched and even enjoyed shows where characters use therapies that haven’t been invented or undergo treatments to repair organ damage in ways that aren’t biologically plausible. So I guess I shouldn’t be shocked when the issue of abortion is handled in the same way. I am concerned, however, that the inaccuracies in this case might affect women’s future decisions about the method they use for abortion or where they can access those services.
Last month, Law and Order’s Special Victims Unit, SVU (Season 12, Episode 9, aired 11/17/10), took on the topic of misoprostol for abortion. For those of you who aren’t regular watchers of SVU, the story follows two detectives (Benson and Stabler) as they investigate crimes of a sexual nature. I won’t go into the contours of this specific convoluted plot which involved several rapes, a returning formerly drunk district attorney, and the theft of a college disciplinary file. Instead, I’ll focus just on the misoprostol and abortion parts of the script.
In this story, a suspected rapist is also accused of causing a miscarriage in his regular girlfriend. In the case of the girlfriend’s pregnancy, the sex was consensual and the pregnancy greeted with enthusiasm on the part of the pregnant woman (who is not the rape victim—that is a different part of the plot line). As we come to learn, the boyfriend is premed and made a mixture, which he called Love Potion #9, that he put on his penis before having sex with the pregnant girlfriend. This potion contained the drug misoprostol.
We learn that the day after sex with Love Potion #9, the pregnant girlfriend experienced cramps and subsequently lost her pregnancy. After they expose the boyfriend’s behavior, the girlfriend reluctantly agrees to testify against the boyfriend, accused of the crime of “abortion in the second degree” (yes, that is actually a crime in New York). When the girlfriend fails to show up in court, the detectives break into her room to find her dead in the bathroom.
As the young woman lies on the slab in the morgue, the coroner explains that the drug misoprostol, which was found in the girl’s system, is routinely used to induce abortions in countries where abortion is illegal. It offers women a much safer alternative to traditional means of back-alley abortions. Just as I was about to praise the conversation, it took a turn for the worse. Turns out that the cause of death was Toxic Shock Syndrome and, according to the coroner, the infection was caused by the incomplete expulsion of the pregnancy tissue. Wait, Benson (the female detective) asks, “I thought you said misoprostol was safe.” “It is,” the coroner responds, “when it is taken orally, not when it is applied directly to the cervix.”
Bummer, I thought to myself. There is enough misinformation out there about medication abortion; we don’t need TV adding to the confusion.
Misoprostol is a drug, developed for the treatment of ulcers. One side effect is that it also works to produce uterine contractions and can cause a miscarriage if used in the correct amounts. Public health researchers have been studying misoprostol for induced abortion for many years, for the very reason that the coroner notes on the show: it is very inexpensive, works remarkably well, and is significantly safer than most methods of clandestine abortion. The drug is also a safe and effective treatment for post-partum hemorrhage, a leading killer of women around the globe, especially in countries where misoprostol is still not available.
Misoprostol pills can be administered in a number of ways, by swallowing, placing under the tongue, dissolving in the cheek, or inserting into the vagina or rectum. Each route of administration delivers the drug into the blood stream in a slightly different way, making it more or less effective for the medical indication for which it is being used. All of these routes are effective and safe. To learn more about routes of administration, check out the work of UCSF colleague Karen Meckstroth. When misoprostol is used alone for abortion, vaginal administration seems to be the most effective.
So, where did SVU come up with the idea that misoprostol is unsafe if put in the vagina? You may remember that, a couple of years ago, there were several high-profile deaths of women from a deadly infection following medication abortions. The most reported case was that of Holly Patterson, who died in a local Bay Area hospital. One concern at the time of the deaths was that the drugs used for the abortion had caused the infection. In the United States, misoprostol is used in conjunction with a second drug, mifepristone (aka RU486 in France or the abortion pill more generally). To determine the safety of this practice following the deaths, research was undertaken by the Centers for Disease Control and Prevention to better understand clostridium sordelli, the cause of the infection from which Holly died.
One study that looked at the deaths of all women of childbearing age in California found that clostridium was also the cause of deaths of women following delivery, miscarriage, and treatment for cervical dysplasia, none of which involved the drug misoprostol. We now understand that clostridium sordellii is part of the normal flora of the vagina, which may gain entry to the uterus via the cervix during spontaneous or induced abortion, childbirth, or menstruation. It is usually accompanied by severe pain, and women with that symptom should seek care immediately.
During the time of these investigations, Planned Parenthood made a risk-management decision to change the route of administration of misoprostol from vaginal to buccal (dissolve in the cheek). Subsequent research has found that this is also a safe way to administer the drug. Women wanting a medication abortion in the United States will find that different providers recommend different ways to take the drug misoprostol, all of which are safe and offer advantages and disadvantages depending on women’s feelings about taste, touching their vaginas, nausea, etc. I hope the SVU coverage doesn’t scare women away from choosing medication abortion or encourage lawmakers to further restrict access to misoprostol for a larger range of obstetrical and gynecological indications.
But what the show gets even more wrong is the availability of misoprostol, which according to multiple characters is an “over the counter” ulcer medication. Misoprostol is most definitely NOT available over the counter in the United States. It is clear that the show is confusing emergency contraception, which is available over the counter, with medication abortion which is only available by prescription (and in the case of mifepristone only from a registered physician). The confusion is further cemented when Benson, in discussion with the coroner about the Brazil experience with misoprostol, calls misoprostol “their version of the morning after pill.”
The confusion between Emergency Contraception (EC and aka the morning after pill) and medication abortion is widespread, and perpetuated by those abortion rights opponents who see no difference between contraception and abortion. In reality, however, EC and medication abortion use different drugs and have different windows of opportunity for use. EC works between the time a woman has sex and the implantation of a fertilized egg; medication abortion works after the egg has implanted and a pregnancy has resulted. EC can be used up to 120 hours (5 days) after sex; medication abortion can be used through 9 weeks after a woman’s last menstrual period. Both medical therapies are legal in the United States. EC is available over the counter for women aged 18 and older and by prescription for younger women, despite significant evidence against this restriction for younger women.
This recent SVU episode is just one more show in a long line of shows that have tackled the abortion issue with varying degrees of success in achieving accuracy in its depiction of the science or the reality of abortion. Do you have a favorite episode that addresses (or should have addressed and didn’t) the abortion issue? I am writing a chapter for my book on abortion about abortion on TV. Would love to compile a complete bibliography of episodes. Please share your favorites as comment on this blog.