This story has been updated.
AUSTIN — Joe Nelson arrived at the abortion clinic at 8:30 a.m. on Sept. 8. The doctor made himself a cup of coffee, chatted with the receptionist, then settled into a desk cluttered with paperwork and maxi pads. He answered some emails. Then he opened his book on Zen Buddhism and read.
He did not see a patient for almost two hours.
Before Sept. 1, when Texas banned almost all abortions, Nelson rarely sat down. The only full-time doctor at Whole Woman’s Health in Austin, he hustled from room to room. For lunch, he would scarf down a protein bar.
Nelson used to perform up to 30 abortions a day; since the ban took effect, he might do two or three. That didn’t change when a federal judge issued an injunction on Oct. 6, temporarily blocking the law, which bans abortions once early cardiac activity can be detected, around six weeks gestation, before most people know they’re pregnant. Like many other doctors in Texas, Nelson decided to continue complying with the ban until other courts weighed in. On Oct. 8, the conservative-leaning U.S. 5th Circuit Court of Appeals lifted the injunction. Abortion after six weeks is, once again, illegal.
The Texas law empowers private citizens to file lawsuits against anyone who helps facilitate an illegal abortion in Texas, rewarding those who successfully sue with a $10,000 bounty. Doctors who perform abortions are prime targets, on the hook for damages, the bounty reward and the plaintiff’s legal fees. Alan Braid, an abortion provider in San Antonio, was sued two days after he explained why he had performed an illegal abortion.
Nelson, 35, has over $200,000 in student debt and pays child support for three kids. Since the law passed in May, he’s been trying to decide whether this work — his “life’s calling,” he says — is worth the risk.
At Whole Woman’s Health, one of the largest abortion providers in Texas, nine of the network’s 17 doctors in the state stopped performing abortions when Senate Bill 8 took effect. Many of those doctors are in their 30s and 40s, said Amy Hagstrom Miller, chief executive of Whole Woman’s Health. They know lawsuits could jeopardize their medical licenses, she said. Even if a lawsuit goes nowhere, she added, they will have to disclose it anytime they apply for malpractice insurance, hospital admitting privileges or a license to work in another state. Some doctors with other jobs have been forced to quit, Hagstrom Miller said: Their employers decided the law was too much of a liability. Others may have been deterred by a drop in their salaries, which can fluctuate depending on how many patients they see.
Doctors like Nelson will likely remain in legal limbo until the law is evaluated again by the U.S. Supreme Court, which refused to step in last month when abortion rights advocates requested an injunction. Even if the high court rules in their favor, Texas clinics will likely struggle to snap back to the way they ran things before Sept. 1: Too many doctors have stopped providing abortions.
As they wait, Nelson said, “the uncertainty is excruciating.”
Unlike the majority of his colleagues, who fly in from out of state to perform abortions, for Nelson, Texas is home. He lives in Austin and was raised in Fort Worth, in a Mormon family where he says he was taught to “multiply and replenish the earth.” Much of his congregation, he said, believed there was no greater evil than abortion.
Every once in a while, Nelson’s mother, who is Mormon, softly prods her son with the same question: When might you be ready to try something new? Since he started performing abortions full-time four years ago, Nelson has tried to make her understand. All day long, he tells her, patients come to him with a “compelling need” — and he can do something to help them.
“If I can keep doing this for the rest of my career,” he’ll say, “I will be very happy.”
Twelve days after the ban took effect, Nelson took a few deep breaths, sat up straight and logged into Zoom for a job interview. For the next hour, he fielded questions from a chief executive about his professional strengths and weaknesses.
She wanted to know what drew him to abortion care — and why he was applying to do something else.
Nelson spent most of his young adulthood listening for God’s call. Growing up Mormon, he was taught that divine directions would take the form of his own thoughts. If an idea occurred to him — if he spotted a woman sitting alone on a train, for example, and thought she might be open to the gospel — he felt compelled to act.
“I was taught to always be ready. Any time I felt an inkling to reach out and do something, to do it, without question,” he said. To not obey his gut impulse, he told himself then, would risk thwarting God’s plan.
Four months into his first serious relationship, at 21, Nelson was sitting next to his girlfriend in a sacrament meeting when he had the idea to propose. He leaned over and asked her to marry him.
By the time Nelson turned 25, one year into medical school, he was married with three sons under 3.
In college, Nelson worked three jobs on top of his classes, regularly coming home after 11 p.m., he said. They couldn’t afford a babysitter, so his wife, Leah Nelson, couldn’t work. Nelson switched his major from music theory to physics and started looking into medical school. He still has scars on the insides of his arms from donating plasma for cash.
“There was no way out,” he said.
Nelson left the church in 2014. In the months between medical school and residency, he said he finally had blocks of time to think. One day, he stood in the middle of a field and tried to talk to God. By the time he got home, he said, he knew he’d stopped believing. Nelson’s marriage, built in the shadow of Brigham Young University, could not withstand his defection. His wife left for a few weeks with the kids, then Nelson moved out. He saw his sons every other weekend. Now they live in the Northeast, and visit for a few weeks each year.
In Nelson’s absence, Leah has raised three kids almost entirely on her own. Even when they lived down the road from Nelson, she said, her sons rarely saw their father. “He was so involved in his career, then residency, then he found his love of abortion care,” she said.
Leah tried not to get angry, reminding herself that this was something she loved about her ex-husband: When he chooses something, she said, he “puts his whole heart and soul into it.” His sons faded from his life as abortion came to the fore. One of her reasons for moving across the country, she said, was to remind Nelson how much he loved them.
Now Nelson lives in Austin with his second wife, Whitney Mollenhauer, who was voted “most likely to start a protest” by her graduate school peers. They are both ex-Mormons and refer to each other as “partners,” because the terms “husband” and “wife” do not match the life they’re building together. At home, Nelson wears skinny jeans with tight V-neck T-shirts, a tiger tattoo dancing down his right arm. He identifies as queer and is proud to be, as he says, “a little femmy.” Many patients have had traumatic experiences with White male doctors, he said. He wants them to know he is different.
When his kids visit over the summer, snuggling into the bunk beds he keeps in the spare bedroom, Nelson takes them to the park and splashes around with them in the pool. They have fun together, he says, but he still spends his therapy sessions talking about the ways he falls short as a dad.
Nelson moves about the world with intention. Watching him as he chops basil or tidies the floor, it’s clear he’s trying to be present as he goes through the motions, a reflection of his Buddhist practice. This is particularly obvious when he talks about his patients. His voice gets softer, and he speaks with a seriousness that reflects his commitment to the work. He wears his patients’ trust as a badge of honor. The process of earning it, he says, is the best part of his job.
When he started residency, Nelson wasn’t planning to do abortions. He was in his third year when one of his patients, a 19-year-old with epilepsy, got pregnant unexpectedly. As he delivered the news, he said, she started to sob. The patient decided to go home and talk to her parents about her options, he said. A few weeks later, she came in with her mother for her first prenatal appointment. If Nelson could have offered to perform the abortion himself, he’s always wondered whether things might have been different. After that, Nelson said, he knew he wanted to learn how.
While Nelson has stopped listening for God’s call, he uses familiar language to talk about abortion care. This is what he’s “supposed” to do, he says. It is the only thing that “feels natural.” Unlike the various callings he felt throughout his time as a Mormon, however, he says this one does not derive from a momentary impulse: He knows what an unexpected pregnancy feels like.
After they had their first son, Nelson and his wife decided to wait a few more years to have kids. A doctor told them they wouldn’t need birth control until his wife finished breastfeeding.
She got pregnant with their second son five months after their first was born.
“Abortion didn’t feel like an option when I was that age. And, you know, here my kids are, I love them to death,” he said. “But I know how difficult it can be to be that overwhelmed.”
On the sidewalk outside of Whole Woman’s Health, Heather Gardner smiles and waves at Nelson as he drives into work. The executive director of the Central Texas Coalition for Life, she tries to “cover” the clinic every day they perform abortions, recruiting volunteers or standing there herself in an antiabortion T-shirt and silver earrings shaped like tiny feet. Nelson rarely looks her way, she said. If he ever did stop to talk, she said she’d ask why he got involved in “such a gruesome procedure.”
“There are many things you could be doing besides dismantling tiny babies,” she would say. As she watches patients file into the clinic after Nelson arrives, Gardner said, her heart feels “heavy,” because they’re making a decision “they can’t take back.”
But that money is split between the clinics, their staff and the doctors, and barely covers operating costs, said Flor Hunt, executive director of Teach, an organization that trains abortion providers. Because the Hyde Amendment prohibits Medicaid or any other federal programs from covering most abortions — and many antiabortion states also bar private insurance companies from subsidizing the procedure — clinics and their doctors have to operate almost entirely on out-of-pocket payments. Clinics have to keep costs low so the procedure can remain accessible to low-income patients, Hunt said.
Abortion clinics have always struggled to attract and retain doctors in antiabortion states, where doctors and their families face constant harassment and threats to their safety, said Hunt. Since 1993, at least 11 people have been killed in attacks on abortion clinics, including four doctors. Across the Southeast and Midwest, many clinics recruit providers from out of state, flying them in to perform abortions.
In a state like Texas, the hurdles to becoming an abortion provider begin in medical school. While the majority of family medicine residency programs offer training in labor and delivery, Hunt said, only six percent offer abortion training. The 40 programs that include abortion in the curriculum are clustered in the Northeast and California. There is not a single one in Texas.
Through medical school, at Baylor in Houston, and his early years of residency in Fort Worth, Nelson didn’t know any doctors who had been trained in abortion care. When he asked administrators about his options for training, they immediately shut him down, he said. More than once, he said he was told, “We don’t do that here.”
That year, Nelson paid his own way, and used his time off, to be trained by a doctor in San Antonio, Tex.
A few months before his residency ended, Nelson heard about a job at Whole Woman’s Health in Fort Worth. One of the doctors there was in his 80s, Nelson said, old enough to remember a time before Roe v. Wade.
“He couldn’t let his community go without a doctor until he knew there was someone else to replace him.”
Among abortion providers, Nelson said, “that is the rule.”
When Senate Bill 8 was first introduced in the Texas legislature in March, Nelson didn’t pay much attention. For Texas, it didn’t seem that remarkable, he said. Then he read the full text of the bill.
“I thought, ‘Oh my god. This is going to end abortions, period.’ ” The language used to describe the consequences for physicians accused of violating the law was terrifying, he said. If the law took effect, Nelson felt sure physicians like him would stop practicing.
He thought about the call he received in the summer of 2020 from the Texas medical board: Someone had reported him for performing an illegal abortion. At the time, Texas Attorney General Ken Paxton had halted abortions across the state: To better combat coronavirus, doctors had to immediately stop performing procedures deemed “medically unnecessary,” including abortion. Doctors at Whole Woman’s Health, including Nelson, continued to prescribe the abortion pill.
When Nelson heard from the medical board, he said, “my stomach dropped.” His mind skipped to the worst-case scenario: He would lose his license. He wouldn’t be able to support himself or his kids. While the complaint was eventually dismissed, Nelson said, it made the legal risks of his job impossible to ignore.
Once the six-week ban passed in May, it wasn’t long before clinic staff started to quit. In July, the Austin branch of Whole Woman’s Health lost five staff members in three weeks, including the clinic director and Nelson’s surgical assistant. “We got gutted,” said April Collins, the receptionist. Few explicitly mentioned Senate Bill 8 when they left, but Nelson said he suspected the law factored into their decisions. Low on staff who could help Nelson during the procedure, the clinic had to stop performing surgical abortions.
Working overtime, the clinic staff has been able to do just enough to keep the clinic open, Collins said. If Nelson was ever to leave, she said, she can’t see a way forward: “Whole Woman’s Health would effectively shut down without him.”
Nelson hasn’t told her that he’s applying for another full-time job.
In November, Nelson started working part-time for a telehealth company that provides gender-affirming care to transgender patients. His abortion job didn’t pay much, and with all the antiabortion restrictions that cropped up in Texas, Mollenhauer said, the couple thought it would be smart for Nelson to have a “backup."
He was surprised by the level of trust he was able to build across a screen. He celebrated with patients who could finally afford testosterone and talked through options with those who weren’t sure they were ready for hormone treatment. When the telehealth company announced they were hiring another full-time physician over the summer, he decided to apply. Those patients needed him, too, he said. At least until the six-week abortion ban was permanently lifted, he felt there was more he could do to help them.
On Sept. 9, his last day at the clinic before his job interview, he watched a woman walk out of the ultrasound room, head down.
“No?” Nelson asked the sonographer as she wandered over. She shook her head.
“It’s so tiny,” she told him, referring to the cardiac activity she saw on the ultrasound machine. “But it’s there.”
When it comes to these laws, other physicians at Whole Woman’s Health call Nelson “conservative.” He has performed relatively few abortions since the ban took effect. On Oct. 7, when other physicians began performing abortions after six weeks, he chose to wait.
He has decided to take the full-time position at the telehealth company.
While Nelson accepted the position on the condition that he can continue providing abortions part-time, he still feels a little guilty. Looking around at his colleagues, who stopped complying with the ban during the injunction, who aren’t reaching for their “backup,” he wonders: Am I doing enough?
For the past few weeks, he has toggled between that question and another: Am I doing too much?
Right now, Nelson feels confident about his choice to continue providing abortions for as long as he can, despite the risks. But every once in a while, he said, he allows himself to imagine a different future — one where he doesn’t spend hours on the phone with lawyers, where he helps transgender patients become their full selves, where he uses his real address instead of a P.O. Box, because he’s not scared of anthrax or late-night knocks on the door.
If only he could take a step back from abortion care, he said.
“Wouldn’t it be simpler?”
Correction: An earlier version of this article included photo captions that misstated the name of Whole Woman’s Health. It is Whole Woman’s Health, not Whole Women’s Health.