After the Supreme Court struck down the federal right to abortion in 2022, many states that banned the procedure did so with the promise that it would still be legal in certain circumstances, including rape. One study estimates that more than 64,000 pregnancies have occurred due to rape in the years since the ruling in states where abortion is prohibited.

But many people on the front lines of the issue say getting an abortion in these states after an attack is difficult or — in some cases — impossible.

There is no central database that measures abortions due to rape. For this story, NPR reviewed state records and spoke with researchers, lawyers and doctors in seven of the 11 states where abortion is illegal but legal in the case of rape. Taken together, these accounts show a patchwork of laws governing rape exceptions, confusion about who qualifies for an exemption and the role of law enforcement in the process, and widespread fear among doctors about performing abortions on rape victims .

Many victims are not able to immediately report their rapes

It is almost impossible to know exactly how many abortions are performed because of rape exemptions. When reporting the procedure, doctors are not required to include a reason. And an abortion could fall under another exemption — such as a fetal abnormality or the life of the mother.

Existing annual data suggest that in many states the number of known rape abortions is in the single digits or, in some cases, zero.

One reason for this is that in many states, rape victims seeking an abortion are required to report their assault to law enforcement. Advocates and medical professionals who work with rape victims say that in the aftermath of an assault, there are more immediate issues to consider than abortion laws.

“It’s just too much for them to handle at that point,” says Katy Rasmussen, a nurse who works with victims of assault with the Johnson County Sexual Assault Response Team in Iowa. The patients she sees are often in shock or dealing with the stigma surrounding sexual assault. If alcohol or illegal substances are involved, Rasmussen says, patients may feel shame or even blame themselves.

“Oftentimes survivors of sexual assault just want it to be over,” says Kelly Miller, former executive director of the Idaho Coalition Against Sexual and Domestic Violence. “And so, having to go through the trauma of reporting, the trauma of a forensic interview, most survivors give it all up.”

Other advocates point out that many patients experience domestic violence when they are raped. That’s what happened to Laurie Bertram Roberts. She says she got pregnant years ago after being raped by someone she lived with. Reporting him and risking his arrest, she says, could have meant losing her home.

“We shared a residence,” she says. “There was no domestic violence shelter that would take me because my family was too big.”

Bertram Roberts, who has seven children, finally broke free from this man. Now she works with people in similar situations as part of her job with the Mississippi Reproductive Freedom Fund, a nonprofit that helps people get abortion care in that state.

“There’s a perception of good and bad abortions” among people who defend state abortion bans, says Bertram Roberts. “But the truth is that exemptions are all rhetoric and not useful in practice.”

Last year in Mississippi, there were zero abortions for any reason, according to the report a recent report from the Family Planning Society’s WeCount project.

Mississippi Gov. Tate Reeves promised rape exemptions when the state’s 2022 law took effect. NPR reached out to Reeves’ office, as well as several state lawmakers who sponsored the bans and national anti-abortion groups. None of them wanted to talk about rape exemptions across the country.

One group, Susan B Anthony Pro-Life America, sent NPR a written statement blaming doctors and health systems for their confusion and inability to use the law. “If there are physicians who are confused about rape exceptions, hospital administrations and health associations should provide clarity,” the statement said.

Some doctors say they feel armed and intimidated

Law enforcement involvement makes patients and doctors feel like “potential criminals,” says Jessica Tarleton, an obstetrician in South Carolina, where doctors are required by law to report rape abortions to their local sheriff’s office.

“Someone walks into the emergency room who’s been shot, we don’t ask them what they did to be in a position to be shot. We take care of the patient,” says Tarleton. She points out that no other medicine requires doctors to legally justify care.

“In the last couple of years,” she says, “I’m aware of a patient I was associated with who sought a legal abortion under the rape exception.”

Tarleton tries to provide abortion care whenever it legally can. But she says many doctors in this state are scared and feel they don’t have enough support to perform abortions in a place where it feels legally risky. As a result, she says, many distance themselves from the practice altogether.

“Now I’m the investigator”

Iowa makes it especially difficult for rape victims to get an abortion, according to doctors and reproductive rights advocates.

This summer, after a long court battle, the state began enforcing a six-week abortion ban that makes an exception for things like rape. But directions from the Iowa Board of Medicine say doctors – before performing an abortion – must determine whether a rape is legitimate or risk legal consequences for non-compliance.

That’s an unusual level of detail for doctors to collect and document, even among the 10 other states that include rape exemptions.

“Now I’m the investigator trying to decide whether the details of the incident constitute rape under the Iowa Code,” says Dr. Emily Boevers, who works in Waverly, a city of 10,000 in northeast Iowa. She says these requirements threaten the confidentiality, trust and intimacy of the patient-doctor relationship. “I should maintain a therapeutic and caring relationship with this patient while asking all these details,” says Boevers.

So far, she hasn’t had to investigate the circumstances of the assault with a patient, but she’s practicing what she’ll say when that day comes. “Unfortunately, our government requires me to ask you some questions,” she plans to say. “If you can answer those, I might be able to help you.”

Those who enforce the laws may not always know the laws

In some states, there is little clarity about rape exemptions, even among those law enforcement officials.

Idaho prohibits abortion with exceptions for rape, incest and when the mother’s life is threatened. In order to have an abortion, victims of sexual assault must submit a police report to health care providers.

When the state’s ban took effect in 2022, victim advocates were quick to point out that law enforcement agencies don’t release police reports until a case is closed — preventing victims from accessing timely care. The following year, the Idaho Legislature amended the text of the bill so that rape victims have the right to receive, upon request, a copy within 72 hours of the report being made.

But agencies appear to meet these requirements unevenly.

Boise State Public Radio reached out to 56 Idaho law enforcement agencies about their protocols for helping rape victims since the ban. Several said they complied with the 72-hour amendment and said their in-house victim advocates are available to help victims throughout their process.

Many others appeared to be unfamiliar with the amendment. Several public records departments have said they will automatically deny requests for copies of an open case report, regardless of who made it. One agency realized it had broken the 72-hour law after it went into effect and unknowingly denied rape victims’ records.

Local agencies said they have not received any guidance from the state.

Advocates say this murky process complicates a reporting system that is already unwelcoming to victims.

“Survivors generally don’t report to these systems that were never created to be primarily centered around survivors,” says Miller, the former head of the Idaho Coalition Against Sexual and Domestic Violence. “It is simply unrealistic to expect survivors to access these systems solely for the purpose of being able to access an abortion as a result of a pregnancy resulting from sexual assault.”

State records suggest there were fewer than 10 abortions for any reason last year in Idaho.

Non-rape abortion providers are often protected by large institutions

Only a handful of doctors interviewed for this story reported performing rape exceptions — abortions of any consequence. Those who did it all worked at major academic medical institutions.

Dr. Nisha Verma of Georgia estimates that she sees someone who has been raped or suffered incest who meets the exception standard “every two weeks.”

Verma is not an official spokesperson and did not want to be identified using the name of her institution. But she says her employer has protocols and task forces to help doctors manage their legal risk. This helps alleviate doctors’ fears of losing their medical license, being fined or going to jail.

“At my institution, we’ve been working again to create a system to help us as physicians feel more supported and protected,” says Verma.

But for most people who work with victims, it’s not just about how to get abortion relief. Some states, for example, are also constrained by a lack of providers willing to even deliver babies, let alone perform legally risky procedures.

“The question is,” says Bertram Roberts of the Mississippi Reproductive Freedom Fund, “if you have an exemption in Mississippi, who is going to perform your abortion?” The state has a significant deficit of obstetricians.

Bertram Roberts says he’s never seen anyone in that state get an exemption — for any reason, let alone rape.

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