As an abortion provider in Montana, Dr. Samuel Dickman has seen patients routinely who tell him they became pregnant after a rape. His sense was the patients who were telling him were only a fraction of the true number. "There are certainly far more survivors of rape who become pregnant as a result, who — for totally understandable reasons — don't want to disclose that fact to a medical provider that they just met."

Dickman used to live and practice in Texas, and he began to wonder about patients who became pregnant due to rape in states where abortion is no longer an option. (He is also the medical director of Planned Parenthood Montana and a plaintiff in several lawsuits challenging abortion restrictions in Montana.)

He and a group of colleagues have arrived at an answer. They estimate in a research letter published Wednesday in JAMA Internal Medicine that 64,565 pregnancies have been caused by rape in the 14 states where abortion is banned.

The figure, while an estimate that may spark some debate, is an important data point since the Dobbs v. Jackson Women's Health Supreme Court decision overturned the federal guarantee of abortion rights. While there once was political consensus that abortion should be permitted in cases of rape, that has changed. Few states with total bans on abortion have exceptions for rape. Those that have exceptions require victims to report the rape to authorities, something that research shows happens only in a small fraction of sexual assaults.

A data challenge

To arrive at the figure of nearly 65,000 rape-caused pregnancies, researchers first estimated the number of rapes that occurred in the states with abortion bans, while those bans were in effect — time periods that vary state-to-state.

"We used the best available research and data that we're aware of to come up with the fraction of women of reproductive age who are survivors of — and the terminology here is horrible — completed vaginal rape," Dickman explains. "The foundation was a survey that the [Centers for Disease Control and Prevention] conducted that we think is probably the most accurate estimate of not just the sexual assaults that were reported to law enforcement, but also those that weren't reported to law enforcement."

They then used Bureau of Justice Statistics data on criminal victimization and FBI Uniform Crime Reports to assess the number of vaginal rapes of women, ages 15-45, that happened in those 14 states while abortion bans were in effect. The number they arrived at is approximately 520,000 rapes.

Finally, they calculated that 12.5% of those assaults would result in a pregnancy, based on CDC data. "These are hard numbers to come up with — there's no kind of systematic collection at the level of health care providers to be able to answer this question of what's the pregnancy rate among people who have been victims of a completed vaginal rape," Dickman acknowledges. "This is kind of the best we could do."

Their total estimate of pregnancies due to rape in states with abortion bans is 64,565.

Dickman, who is also a researcher at the City University of New York, says he and his colleagues were shocked at the numbers their calculations yielded.

"I was horrified," he says. "Sexual assault is incredibly common — I knew that in a general sense. But to be confronted with these estimates that are so high in states where there's no meaningful abortion access? It's hard to comprehend."

"Part of why we do research is because when I think about the individual patients, it's too much," he says.

Certainly not all of the people who become pregnant due to rape want an abortion, observes Dr. Rachel Perry, a professor of OB-GYN at the University of California, Irvine who was not involved in the study. "We do know that those who become pregnant after rape are more likely to choose abortion than to continue their pregnancies," she says. That would suggest there have been tens of thousands of Americans who wanted an abortion after a rape and had no meaningful access.

In Perry's view, the methods that Dickman and his colleagues used to come up with their estimate were appropriate, given the lack of concrete data on sexual assault and pregnancy. "Seeing these numbers makes us realize that — even if they aren't exact — it is a huge problem," she says.

Each number, a story

Samantha Hansen has been an outspoken rape survivor for years, but only recently shared that she became pregnant as a result of the attack. She was a college student at Brigham Young University in 2014, when she was watching Netflix with someone she considered a friend.

"I went into the other room to go pop popcorn," she recalls. "It's my belief that he slipped something into my Coca-Cola, because when I came back and started sipping my Coke, it wasn't too long before I couldn't move a single muscle."

She doesn't remember the details of the rape. "The rest of the night is bits and pieces of flashes — and me trying to fight to regain control of my limbs."

The next day, she took a long shower. "Then I went through my apartment — anything that was touched that night went in a garbage bag, which then went in the dumpster outside of my apartment," she says. Then she took the emergency contraception pill called Plan B. Like many rape survivors, she didn't go to the doctor or report the incident to law enforcement; she just tried to pretend it never happened. In the following weeks, she couldn't sleep, she lost weight, and her grades fell.

Weeks later, she noticed she'd missed her period, and a pregnancy test came back positive, despite having taken Plan B. She went to Planned Parenthood to talk through her options and wrestled with the decision. She had decided to continue the pregnancy but ended up having a miscarriage.

Hansen still lives in Utah. She has written about why she thinks abortion bans without rape exceptions harm rape survivors. Last year, she spoke out against a state bill that would have required rape survivors to file a police report to have access to abortion.

"Having had my autonomy stripped of me that night that I was raped, having the ability to make that choice of — can I take back control of my body and either keep or abort? — was so, so pivotal to my healing," she explains.

A policy question

Since the Supreme Court overturned Roe v. Wade, a few key cases of abortion after rape have become flashpoints. A 10-year-old from Ohio who received an abortion after rape was the center of a political firestorm in Indiana soon after the Dobbs decision. And Hadley Duvall, who was raped by her stepfather and became pregnant when she was 12, appeared in a campaign ad for Democratic Kentucky Gov. Andy Beshear. That ad has been credited with helping Beshear win reelection.

Polling consistently shows that most Americans think that someone who is raped and becomes pregnant should have legal access to an abortion. Duvall is now working with Kentucky lawmakers to add a rape exception to that state's abortion ban.

Yet rape exceptions for abortion laws have fallen out of favor among anti-abortion rights groups, and the majority of states with abortion bans do not include such an exception. Students for Life, an anti-abortion rights group that strongly opposes rape exceptions did not immediately return NPR's request for comment for this story. In a blog post, the group explains, "SFLA opposes rape and incest exceptions because we understand that a child is no less worthy of life based upon how they were conceived."

In a practical sense, abortions after rape would also be difficult to obtain in states that have abortion bans if all clinics providing abortions have closed, which is the case in multiple states.

Samantha Hansen in Utah says she's glad researchers worked to quantify the number of pregnancies from rape in states where abortion is banned.

She says the 65,000 estimate may surprise some people. "I'm not surprised," Hansen says. "If anything, I'm over here going — it's probably higher."

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