is director of the Center for Occupational Psychiatry and a retired clinical professor at the UCSF School of Medicine.

Robert C. Larsen, MD, MPH

Leakage of a draft opinion of the majority in the case of 

Dobbs v. Jackson Women’s Health Organization 

has resulted in a consensus that the US Supreme Court will likely reverse the decision of 

, and undo its protections for women and their health care providers to determine the best course of care.

 In my opinion, physicians, including psychiatrists, have a duty to advocate for patients who we counsel and treat based upon the best medical evidence. 

 has been settled law assuring women access to a standard medical procedure for almost 5 decades—or so we thought.

A conservative majority on our nation’s highest court is now poised to outlaw a medical procedure used by many American women every year. What follows in this article is one physician’s description of the probable consequences for American women should 

 be overturned. I leave it to legal scholars and the editorial boards of major newspapers to critique the quality, or lack thereof, with respect to inconsistency and selective reasoning evidenced in the court’s draft decision as written by Justice Samuel Alito.

I began my training at Northwestern University Medical School in 1974, the year following the 

 decision. Construction of a state-of-the-art women’s hospital began in 1972 with the opening of Prentice Women’s Hospital on that Chicago campus in 1975. The hospital was designed with an entire floor dedicated to cases of sepsis. You might ask how large numbers of adult females might have infections in their circulatory system. The answer is quite simple: illegal abortions. While pneumonia, autoimmune disease, and renal calculi (kidney stones) are common causes of sepsis, 

 is no longer a leading cause in the post-

 era. As a result of the constitutional right to this gynecologic procedure, an entire floor of a major hospital became obsolete before it even opened. That portion of the hospital went vacant until it was reconfigured, at least in part, as a fertility clinic. From this physician’s perspective, the result of eliminating safe, legal abortion for many will be a surge of infectious disease, hospitalizations, chronic pain, infertility, and deaths in women of reproductive age.

According to the Guttmacher Institute, an abortion rights advocacy group, although American women across all races undergo abortion services, 49% live below the federal poverty level, and 60% are in their 20s.

 If states ban abortion, it will have the greatest impact upon poor and working-class young adults, as they are least likely to be able to afford travel expenses for an out-of-state procedure. Aside from increased financial costs and inconvenience, I contend outlawing abortion will have many other adverse repercussions for our patients.

According to the Associated Press, at least 26 states are expected to outlaw abortion, if 

 is overturned, some by “trigger” laws in place.

 Although there will be states like California that enact laws to protect 

, there will be others where access to abortion will be more restricted or even banned once there is a fetal heartbeat, as in Texas currently. That has consequences for addressing mental and medical care for our patients.

We can also expect to see health care matters become a subject for criminal prosecution. Recently, a 26-year-old woman who miscarried though reported having induced an abortion was charged with murder by 

. The charges were later dropped as federal law under 

 Will health care providers be required in some jurisdictions to report suspected or confirmed cases of abortion where it is illegal? Will physicians and those who assist in performing abortions be at risk of prosecution? Another ramification of the high court’s pending decision will be to reduce the number of physicians and nurses with proper training to safely and competently perform surgical abortions. Some schools of medicine and nursing will no longer be allowed to have abortion procedures be a component of the curriculum under post-

Many Americans are unaware that “medication abortion” has been the primary means of abortion in the US during the 

The United States Food and Drug Administration no longer requires an in-person doctor’s visit to prescribe this effective and safe pharmaceutical agent.

 Plan C is a 2-drug abortifacient comprised of mifepristone (Korlym, Mifeprex) that blocks progesterone and misoprostol (Cytotec) that induces uterine cramping and bleeding. Plan C is readily available through reputable online sources. While considered safe to use through the first 11 weeks of a pregnancy, medical consultation is advised if symptoms such as heavy bleeding, high fever, or severe pain occur.

Although Plan C may become prohibited in states that ban abortion, history shows us that this will not stop women from using it. I witnessed the need for illegal abortions pre-

, as evidenced by a planned sepsis ward. It is highly likely that women in a post-

 era will terminate unwanted pregnancies despite the increased risk to their health or of resultant criminal charges. The reality is that abortion has taken place throughout history. The religious, moral, or political reasons to restrict or ban abortion will not eliminate it. Do we really want hospitals in Chicago, New York, Dallas, Miami, Phoenix, and many other major cities to have sepsis wards?

Although clinicians should support family planning and appropriate birth control, psychiatrists are acutely aware that mistakes happen and much of life is unplanned. Thus, there will remain a demand for abortion after access to the procedure or pharmacotherapy is restricted in parts of America.

 is likely to be a monumental development that will impact the lives of our patients. Along with the aforementioned resultant infections, hemorrhages, and deaths, there will be an increase in the incidence of reactive depression and debilitating anxiety disorders among women of childbearing age. As a result of studies of psychosocial stressors by researchers such as the psychiatrists Holmes and Rahe, it is well accepted that such stressors can contribute to health problems.

 Psychological distress and depressive symptoms correlate with acute and chronic psychosocial stressors.

 Women who terminate a pregnancy in a post-

 era could be expected to experience complications like infection and bleeding, hospitalization, financial problems, changes in sleep or eating, and legal charges. These are just some of the likely stressors that put women who choose to end a pregnancy in jurisdictions outlawing abortion at increased risk for a clinical depression and/or an anxiety disorder (psychological distress). Because this is a medical issue, I hope that other doctors become advocates for access to abortion as an appropriate and necessary medical procedure.

The opinions expressed are those of the author and do not necessarily reflect the opinions of Psychiatric Times

Wounded Workers: Tales From the Working Man’s Shrink

1. Gerstein J, Ward A. Supreme court has voted to overturn abortion, draft opinion shows. 

https://www.politico.com/news/2022/05/02/supreme-court-abortion-draft-opinion-00029473

2. Editorial Board. Editorial: Alioto’s draft ruling is so self-contradictory that it calls court’s judgment into question. 

https://www.stltoday.com/opinion/editorial/editorial-alitos-draft-ruling-is-so-self-contradictory-that-it-calls-courts-judgment-into-question/article_73f7ab1a-6078-59d2-a0a8-ecb18800ecf2.html?msclkid=a160a1aaced611ecade257e7f4e7bbe3

3. United States Abortion Demographics. Guttmacher Institute. Accessed May 9, 2022. 

https://www.guttmacher.org/united-states/abortion/demographics

4. Beam A. California leaders commit to putting amendment in state constitution to protect abortion. Associated Press. May 3, 2022. Accessed May 9, 2022. 

https://apnews.com/article/california-reproductive-rights-state-governments-fcfe3d2b24fe6fe502d01d72a891f1c6

5. McShane J. Texas district attorney drops case against woman charged with murder for self-induced abortion. NBC News. April 11, 2022. Accessed May 11, 2022. 

https://www.nbcnews.com/news/texas-district-attorney-says-indictment-woman-charged-murder-self-indu-rcna23782?msclkid=df2b6efed07811ecbf77586ac452f600

6. Aungst C. The facts about Plan C (medication abortion). GoodRx Health. September 17, 2021. Accessed May 11, 2022. 

https://www.goodrx.com/conditions/abortion/plan-c-medication-abortion

7. Haberkorn J. A new focus on pill access. 

https://enewspaper.latimes.com/infinity/article_share.aspx?guid=d7f1108a-ec10-432e-9e21-b7dcc9f00b7a

9. Bailey ZD, Williams DR. Stress, health, and disparities. In: Zigmond MJ, Rowland LP, Coyle JT. 

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Legislating Medical Procedures

As physicians and psychiatrists, we are entrusted with the secrets, fantasies, and longings of those in our community who seek out our clinical expertise. If we are fortunate to have a long career, there are lessons to be learned by both doctor and patient. For myself, I wished to give back some of what I had learned while recognizing the humanity of those individuals sent my way as a result of trauma, tragedy, and misfortune. A bank teller robbed one too many times, a firefighter who survives a helicopter crash only to have murderous fantasies for the pilot, or a respiratory therapist who has all 4 limbs amputated after contracting a deadly infection from a hospitalized patient—all are real life stories, possibly similar to the ones you may hear from your patients.

Wounded Workers: Tales from a Working Man’s Shrink

 to honor my patients—America’s working men and women.

 These tales recognize the sacrifice made by many of our patients, who face loss, violence, victimization, and death as part of them their jobs. Some stories from those you might expect have dangerous occupations, like police officers, but also farmworkers, retail clerks, health care workers and other employees. Their stories are both heartbreaking and heartwarming and present us, the clinician, with opportunities to do better by our patients by way of advocacy. For instance, although readers will no doubt be uncomfortable with the saga of Chapter 21, “Raped with a Gun,” it makes clear that woman’s desperate need for advocacy.

Perhaps by sharing my experiences with these patients and the lessons they taught me, you will glean clinical pearls that will help you with your patients. For instance, what do you say to a woman who’s been raped with a gun? I did not know. The police report, the ED record, the medical file addressing the victim’s physical injuries, her deposition transcript, and correspondence from attorneys representing employer and employee recounted a graphic account of a physical, sexual, and emotional assault that lasted 2 hours. As I reviewed pertinent records before my initial meeting with a convenience store clerk who was punished by her assailant for having too little cash in the register, feelings of both anger and dread welled up in me. I felt anger not just toward the criminal, but also the employer who had disregarded recommendations to improve workplace safety measures after 2 prior robberies. The dread later came from hearing her tale of terror and humiliation, knowing she had survived, but at what cost? Dread for asking the victim to again relive the assault. Let me remind my colleagues, it is always worse for the traumatized to retell their horrors than it is for clinicians to hear and document such tales. Occupational psychiatry is not a subspecialty for timid doctors.

, I have been doing book readings to audiences across the country, talking to groups of physicians, attorneys, nurse practitioners, public health professionals, public library patrons, and others interested in these tales. In these presentations, I share 3 take-home messages.

1. Do no harm. Do not make it worse than it already is. In my experience, early-career physicians are often prone to prescribing treatment before an accurate diagnosis and case formulation have been achieved. Some arrogant doctors continue this ill-advised practice throughout their careers. Taking brisk action as a physician can have deadly consequences outside of true emergencies and crisis scenarios. Let us keep in mind that iatrogenic illness is a leading cause of death in the US behind cardiovascular illness and respiratory disorders. Medical errors, questionable clinical judgment, unnecessary surgeries, and other physician-based interventions are estimated to cause 230,000 to 284,000 deaths per year in America according an Institute of Medicine study.

2. Walk in your patient’s or neighbor’s shoes for a day. Get to know someone before trying to change their life. Instituting an antidepressant might be worth considering, but first listen to your patient. An unsophisticated person with a personal history of recovery from substance abuse might reject that treatment recommendation. Had the psychiatrist taken the time to explain that antidepressants are not considered drugs of abuse, the patient could have accepted a trial of medication. Walking in the patient’s shoes involves developing an understanding of and empathy for our patients.

3. Selectively advocate. You will know who to advocate for as they will come to you, having been forgotten and cast aside. It is no secret that psychiatrists become involved with their patients’ lives from the past, in the present, and for the future. For me, I am drawn to the worker who has incurred serious physical and/or mental injury. In Chapter 17 of 

, “I Am Unlovable,” I consulted on the case of a young woman who described herself with those three words. She had lost her arm to a laboratory accident when a high-speed centrifuge essentially ate her limb. I noted that outpatient psychiatric treatment could be instituted to address her understandable depression months after her amputation stump had healed. More importantly, my intervention was to point out that the injury was preventable as she could not reach the kill switch on the machine that took her arm. This injury should have been investigated by the employer or its insurer under the premise of maintaining a safe workplace. Also, the evaluating orthopedist had not recommended the obvious. My specific recommendations were followed as I had indicated she would be 100% permanently disabled due to a clinical depression that resulted in a self-image of being “Unlovable.” Fifteen months later with my recommendations having been followed, that amputee returned to my office smiling after she had been fitted for a state-of-the-art prosthesis and had a plan for retraining as a pharmacist. While costly to the workers’ compensation insurer, it was a bargain compared to a lifetime total disability award in a 23-year-old. That is what I mean by advocacy.

One patient who moved me was “Mariana,” and I share some of her story in the chapter titled, “Because That’s Where the Money Is.”

Mariana was on duty in April 1974 when members of the Symbionese Liberation Army (SLA) conducted a takeover style robbery of the downtown branch of Hibernia Bank. She was glad to be alive after the angry masked thieves had left without shooting anyone. ‘Maybe our training got us through,’ she thought…

So, my future patient continued to show up to work, on time, praying that she’d get one day closer to retirement...

The armed woman took the envelope with a gloved left hand and dropped the cash into the handbag. Then the right hand came out of the same black leather designer purse holding a silver object, now pointed at Mariana’s forehead. ‘Don’t ever call me that, you old bitch.’ There was a distinctive clicking sound, but for reasons unknown no shot was fired. ‘Consider yourself lucky. My advice to you: Find another line of work,’ the blonde hissed. And then she was gone.”

Tales like this make it clear that advocacy for victims of unspeakable acts becomes part of my duty as an occupational psychiatrist. No one gets referred because “my boss does not like me.” In hindsight, I could have done more for Mariana. Her sacrifice should have been recognized by her employer. Her long-term employment ended suddenly. A thoughtful luncheon with her coworkers could have filled some of the void Mariana felt after the last robbery. This is advocacy meant to benefit an individual. Doctors may choose to advocate for the collective.

In the chapter, “We Have a Problem with Guns,” I explored the need for gun safety laws. Along with police officers, clinicians, and gunshot victims, I have testified before legislative committees in support of benefits for workers with mental injuries and for workplace safety while acknowledging gun violence of epidemic proportions.

While a call went out for backup from other police units in the area, Aamir crawled to the side of the building away from where the suspect had been shooting. It was dark, yet in the dim light Aamir soon saw the suspect burst out of a side door, yelling, ‘Come kill me, you mother f******.’ He still had the AK-47. If he saw the officer, it would be all over for Aamir. The officer took aim while he lay bleeding on the pavement. Later he recalled thinking at the time, ‘Is this a justifiable shot?’ Then he fired four times, hitting the target with three rounds that ended the alleged rapist’s life.

I am honored that clinicians, attorneys, judges, and scientists have praised 

 and the book also has received a Gold Award from the NonFiction Authors Association (NFAA) in the categories of Mental Health and Medicine. I feel grateful that occupational psychiatry and the tales of these individuals are impacting others.

I will leave you with this parting thought from the chapter “Giving Back”: “If you are engaged in meaningful work, those for whom you provide service will decide your value.”

Wounded Workers: Tales from a Working Man’s Shrink.

Is US health really the best in the world?

An occupational psychiatrist reflects on lessons learned as well as the need for advocacy. 

Wounded Workers: Let Their Tales Be Told

While I read out of curiosity Ronald W. Pies, MD’s, commentary on Russia and the applicable label of 

 I found myself concerned that physicians, and perhaps especially psychiatrists, believe we have much to offer mankind that goes far astray from our chosen area of expertise. Had the author offered opinions about Russia’s president, the Goldwater Rule of the American Psychiatric Association (APA) might have constrained him. Ironically, psychiatrists have been informed that offering opinions about public figures without conducting an interview and having consent to disclose information is unethical. However, a highly esteemed colleague may venture into offering speculative opinions about nation states by applying the psychological understanding of individuals, which was never intended to replace sociology and political science, and the resultant assessment is worth publishing.

Psychiatrists at times have offered opinions about public figures and have received criticism from their colleagues for doing so. When Senator Goldwater ran for president, a number of psychiatrists warned their fellow citizens about that candidate’s character and potential recklessness. More recently, psychiatrists and psychologists warned Americans about our most recent past president having dangerous mental illness at a Yale University conference held in 2017. While there was much information available in the public domain, there was criticism of those mental health practitioners for violating the Goldwater Rule. Similarly, a now deceased colleague, Jerrold Post, MD, published in 2019 his last book, 

Dangerous Charisma: The Political Psychology of Donald Trump and His Followers

 which raised ethical concerns. While well researched, that analysis of a president’s character was critiqued for offering opinions in a manner that violated the 

. Why is it that there are ethical concerns about psychiatrists offering professional opinions on public figures based upon extensive published accounts, while a colorful analysis about a world power as “paranoid” deserves the front page in 

I found the opinions offered by Dr Pies to be worth considering, yet psychiatrists should be careful about using our understanding of individual human behavior to develop formulations of governmental bodies. If Dr Pies may offer his perspective on Russia having PGD, then maybe we should be more accepting of mental health professionals offering opinions about political figures based upon vast amounts of data and well-founded, applicable theories of psychopathology. I suggest it is time for the APA to reconsider its restrictive 

. (As an effort toward full disclosure, the author resigned as a fellow in the APA because of the resurfacing of the Goldwater Rule during the Trump presidency.)

Does Russia suffer from “paranoid government disorder”?

Dangerous Charisma: The Political Psychology of Donald Trump and His Followers. 

Should we be more accepting of mental health professionals offering opinions about political figures based upon vast amounts of data and well-founded, applicable theories of psychopathology?

Robert C. Larsen, MD, MPH

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Legislating Medical Procedures

Wounded Workers: Let Their Tales Be Told

Is It Time to Reconsider the Restrictions of the Goldwater Rule?