In 1969, when abortion was completely illegal in Texas except to save a woman's life, Karen Hulsey became pregnant.
She was 20 years old and living in Dallas at the time, and the diaphragm she was using for birth control had failed her. Her boyfriend, she discovered, was married, and refused to help raise or pay for a child.
"It was just at a time in my life where I knew I couldn't take care of a child, and he wanted no responsibility," Hulsey recalled in an interview with The Huffington Post.
Instead, the man offered to pay for her to travel to Mexico, where he knew of a clandestine abortion provider. She wrestled with the decision and was three months pregnant by the time she agreed to go.
"I was not only very afraid of the ramifications with God, but very ashamed and embarrassed," said Hulsey, who was raised Catholic. "I struggled with the decision for a long time."
Hulsey left Dallas at midnight on a chartered plane, with no idea where she was going, and landed in a field south of the border in the middle of the night. A woman Hulsey had never met before was waiting for her when she stepped off the aircraft.
"I was scared to death," Hulsey said. "Of course, he did not go with me -- I went alone," she said of her boyfriend at the time. "That was the stipulation."
From there, things only got worse.
"A car came and picked us up and took us to what was considered a clinic in a little bitty building with dirt floors," Hulsey recalled. "Even at that age, I knew this was not a good thing. I had worked as a nurse's aide at that point in my life, and I knew about sterilization and everything else, so this just mounted my anxiety and fears."
Hulsey said the doctor put her feet in stirrups and performed a "very rough," painful gynecological exam. He then sedated her for the abortion procedure.
When Hulsey began to wake up, she realized that the doctor was raping her.
"I was of course very drowsy, and the doctor was on top of me having sex with me," she recalled. "I had just barely opened my eyes, and he was all involved in what he was doing, and I immediately closed my eyes, because I knew if I acted like I knew what was going on I'd probably get killed, never to be seen or heard of again."
After the man finished assaulting her, Hulsey said she cautiously opened her eyes.
"I went ahead after a little bit of time and acted like I was coming out from under the anesthetic, and he told me I'd had a little boy," Hulsey said, choking back tears. "I was given a Kotex and taken back to Texas with no further care."
Hulsey discovered upon returning to Texas that she had not completely expelled the placenta -- a possible complication of surgical abortion. She was rushed to the emergency room, hemorrhaging from the botched procedure.
Years down the road, when she was ready to have children, she had three miscarriages due to the damage the illegal abortion provider had caused to her cervix. She underwent surgery to make it possible for her to hold a baby inside her body, and even then, her daughter was born two months premature and weighed less than three pounds.
"I thought that I had sinned and was being punished for having gone to Mexico and done that, and that's why I had a baby that was so sick," said Hulsey. "I think that's baloney now, and that's why I'm willing to talk about it."
Four years after Hulsey's ordeal, Texas became the original battleground state in the fight for legal and safe abortion. The 1973 Supreme Court case Roe v. Wade arose out of a challenge to the Texas law that criminalized the procedure except to save a woman's life. Dallas County District Attorney Henry Wade defended the abortion ban against a 21-year-old pregnant woman using the pseudonym "Jane Roe." Roe had tried to obtain an illegal abortion near Dallas, where she lived at at the time, but found that authorities had already raided and shut down the clandestine providers nearby.
The Supreme Court ultimately ruled that states must make abortion legal at least until the fetus is viable, around 22 to 24 weeks into pregnancy. The Guttmacher Institute, a reproductive health research organization, estimates that before Roe, as many as 1.2 million women a year in the U.S. resorted to primitive, self-induced abortions or sought out illegal, amateur providers. Thousands of women ended up in hospitals each year with severe complications related to illegal abortions, and in 1965 alone, nearly 200 women died from those procedures.
The proliferation of well-trained, regulated, legal abortion doctors in the last 40 years has led to "dramatic decreases in pregnancy-related injury and death," according to the National Abortion Federation.
Now, however, Texas and other states are reversing course. State lawmakers enacted more abortion restrictions between 2011 and 2013 than they had in the previous decade, a trend that appears likely to continue in 2014. The Guttmacher Institute estimates that nearly 300 anti-abortion bills are currently pending in state legislatures.
The new restrictions have had a significant impact on women's access to abortion. A Huffington Post survey last year found that since 2010, at least 54 abortion providers across 27 states had either closed or stopped performing the procedure. Sixteen more shut their doors after Texas lawmakers passed some of the toughest abortion restrictions in the country last summer. A federal appeals court upheld two of the new restrictions in a ruling last week.
As a result, researchers and women's health advocates say, women today are resorting to many of the same dangerous methods they relied on in the pre-Roe era: seeking out illegal abortion providers, as Karen Hulsey did, or attempting risky self-abortion procedures.
In 2014, four decades after the Supreme Court upheld a woman's right to choose, pregnant women once again find themselves crossing the border to Mexico and haunting back-alleys in search of medical care.
The situation is particularly dire in Texas. In 2011, the state had 44 abortion clinics, but more than half of them have since shuttered due to new anti-abortion laws. In September, when a state law requiring all abortions to take place in ambulatory surgical centers goes into effect, reproductive rights advocates expect 14 more clinics will have to close, leaving only six facilities to serve the nearly 75,000 women who seek abortions in Texas each year.
The poorest area of Texas, the Rio Grande Valley near the Mexican border, has no remaining abortion clinics. Women who live there have to drive roughly 240 miles to San Antonio for the nearest clinic, but many of them are Mexican immigrants with restrictions on their work visas that prevent them from traveling that far.
In addition, the state has slashed funding for family planning, forcing 76 clinics that offer birth control and other reproductive health services but do not perform abortions to shut down.
"It's a horrible natural experiment that is taking place in Texas, where we are going to see what happens in 2014 when U.S. women don't have access to legal, safe abortion," said Dan Grossman, vice president of research for Ibis Reproductive Health, an international nonprofit.
Anti-abortion advocates say the idea of back-alley abortions returning is just a scare tactic their opponents use to try to keep abortion legal.
"That is a statement that's been purported by those who are anti-life, but in actuality, we haven't seen any evidence of that taking place here," said Melissa Conway, a spokeswoman for Texas Right to Life.
But Grossman, who is part of a research team that is currently studying the effects of the new abortion laws and family planning cuts in Texas, said he is already witnessing the consequences of the new restrictions.
"It seems like [women] are becoming more desperate to find an option," he said. "We've heard reports of women taking herbs or other substances, or intentionally getting punched in the stomach or beaten up -- the same kinds of things they did before abortion was legal."
Ironically, in the years following Roe v. Wade, Texas had been a beacon of hope for Mexican women seeking abortions, since the procedure is illegal in most of Mexico.
"Texas has always been a place where people in Mexico came to get safe abortions," said Lindsay Rodriguez, president of the Lilith Fund, which helps women in need pay for abortions in Texas. Now, she said, "traffic's going to start going the other way."
Indeed, the lack of abortion access in Texas is already pushing pregnant women back across the border. At Mexican pharmacies, they can purchase misoprostol, a drug with the labeled use of preventing gastric ulcers -- but which can also induce abortions.
In the U.S., misoprostol is available only by prescription from a licensed abortion provider. The drug, first manufactured by Pfizer under the name Cytotec, is prescribed in combination with another medication, mifepristone (labeled RU-486), for abortions in the first trimester of pregnancy. The FDA has approved this combination of drugs for medically induced abortions in the first trimester, which account for almost a quarter of all non-hospital abortions in the U.S. each year, according to the Guttmacher Institute. The medications are extremely safe and more than 90 percent effective when taken together.
American women are learning that if they don't have access to an abortion provider, they can obtain misoprostol illegally and take a high dose of it on its own to end a pregnancy. The drug is 75 to 85 percent effective in completing an abortion when taken properly up to nine weeks into a pregnancy, according to Ibis Reproductive Health, but it is relatively complicated to self-administer. A woman has to put 12 pills under her tongue in specific time-intervals, and she needs to have access to follow-up care in case she has complications or the pills don't work.
"I've seen women who have used 50 pills all at one time," said Amy Hagstrom Miller, the CEO of Whole Women's Health, a network of abortion clinics in Texas. "They put them in every orifice of their body, because they had no idea how to use it. That's the scary part -- using any means necessary to self-induce."
Taking misoprostol under the wrong circumstances and without medical supervision, doctors and women's health advocates warn, can lead to life-threatening complications. A woman who takes the pill with an ectopic pregnancy, for instance, risks heavy internal bleeding due to rupturing of the fallopian tube. If a pregnancy does not pass completely, meanwhile, women run the risk of infection, fever and sepsis.
"Those are the major complications we're going to be seeing in these communities without clinics," Miller warned. Hemorrhaging and infection, if not properly treated, can lead to death.
Still, misoprostol is generally considered a safer and more palatable alternative to more primitive methods of self-abortions, and demand is quickly increasing among women living in areas where abortion is illegal or impossible to access. Rebecca Gomperts, a Dutch physician and founder of Women on Web, a digital community of abortion rights supporters, has published instructions on her website teaching women to take misoprostol properly on their own. She told HuffPost that her team regularly receives calls from women all over the U.S. seeking information about where to find the drug.
"In the United States there are import restrictions on abortion medications, so we just need to help women get access to them," she said in a phone interview. "Sometimes that means we refer them over the border to Mexico."
The trip across the border is often risky for women because of heavy drug cartel activity on the highways. And Mexican pharmacies have capitalized on the growing demand for misoprostol by marking up the cost to $200 or $300 per box.
Women in the U.S. can also obtain the pills illegally at flea markets in South Texas, or for about $100 a box over the internet, but Gomperts said the black market is awash in dubious drugs masquerading as misoprostol.
"There are a lot of fake websites out there, and there are a lot of people who take advantage of women's desperate need," she said.
Women who try to obtain the pills illegally, either online or on the black market, also run the risk of getting arrested. What's more, women in the Rio Grande Valley who have obtained the pills are too afraid to share their stories, even anonymously, because they don't want the police to crack down on the places that sell them.
"When the media first covered the flea market, it got raided by police and people got arrested," Miller said. "When people start to cover this stuff, then the women can't even get black market abortions. The culture in [South Texas] is one of extreme fear and caution -- the women are so afraid of being put in jail."
Women outside of Texas face the same obstacles. Jennifer Whalen, a 38-year-old Pennsylvania mother, was charged with a felony in December after she ordered a package of misoprostol and mifeprestone online from an overseas pharmacy for her pregnant 16-year-old daughter. Abortion is difficult to access in Pennsylvania due to severe restrictions on clinics there, and the closest clinic to Whalen's town was across state lines in New York.
Whalen was charged with one count of medical consultation and judgment after her daughter had to go to the emergency room to be treated for an incomplete abortion and a urinary tract infection.
"We know that prohibition and criminalization will never stop women from having abortions," said Lynn Paltrow, executive director of National Advocates for Pregnant Women. "Illegal, self-abortions are a form of civil disobedience. Women will violate unjust laws and bear the health risks and the legal consequences, without causing harm to the people or institutions that make their decisions criminal."
In addition to pushing women across the border into Mexico in search of misoprostol or other abortion solutions, the dwindling number of clinics in Texas and elsewhere has also revived the concept of "miscarriage management" -- an idea that similarly harkens back to pre-Roe days, when doctors would quietly tell women to figure out a way to induce their own miscarriages so that they could legally intervene to treat the bleeding.
The New Republic reported that one of the last remaining abortion providers in Texas' Rio Grande Valley, Dr. Lester Minto, resorted to the idea of "miscarriage management" when a law went into effect in November that prohibited him from providing abortions. Minto offered treatment to women who had already started their own miscarriages for $400, lab work and ultrasound included. The visit would last two to three hours at most.
“Nothing here is back alley,” Minto told the magazine. “We do follow-ups with everybody. We still treat them just like we always did."
But even Minto's practice is now closed, leaving women few options for follow-up care when they try to self-abort in the Rio Grande Valley. The treatment Minto was providing would cost $2,000 to $3,000 in a hospital, require a general anesthetic and take up an entire day, Miller told HuffPost, which is out of reach for many poor and uninsured women.
With so many doors closed to them, back-alley remedies may soon be all that are left for many women.
"The situation politicians have put women in right now is untenable," said Jessica Gonzalez-Rojas, executive director of the National Latina Institute for Reproductive Health. "Making abortion out of reach only pushes women into the shadows."
Karen Hulsey is particularly concerned about the situation facing women today. For five years in the 1990s, she worked as a physician's assistant at an abortion clinic in Brownwood, Texas. There, she helped treat Mexican immigrants who had had traumatizing experiences similar to what she herself went through in 1969.
"I saw the effects of abortions on girls in Mexico who were raped, and the results of those abortions, as far as the shape of their vagina and their cervix," she said. "It was just abhorrent, the scarring from the methods that were being used. I would not be surprised if the same thing were going on today."
Hulsey, now 65, retired in 2000 after being diagnosed with post-traumatic stress disorder, which doctors said she developed after her abortion and rape in Mexico. Although she has two children now, she said she has had trouble holding down a healthy romantic relationship because of what she went through.
Now that Texas lawmakers are spending so much time trying to limit access to abortion, she said, she is reminded of her trauma constantly.
"There are very few weeks that I don't think about the severity of what I went through, especially with it being so up front in the news right now," she said. "Every time anything like that comes up, I think, 'Oh you people just don't have any idea what you're doing. No clue what you'd be sending girls back to.'"