For the past few weeks, New York City has been blanketed with ads for a brand-new telemedicine site called Hers, with pastel-toned posters depicting a diverse group of millennial women clad in light-colored clothing, urging them to go online to buy their birth control pills or give their libidos a boost.

Hers, an offshoot of the male-focused telemedicine site Hims, is just one of several telemedicine sites that cater to female reproductive health concerns. Lemonaid and Nurx offer online access to a range of similar services, and even Planned Parenthood has thrown its hat into the ring with Planned Parenthood Direct, which can connect users to birth control and UTI treatments. But one reproductive health concern is noticeably absent from most telemedicine sites’ inventories: abortion.

Only two telemedicine websites will send abortion pills to people in the United States today.

Decades of research have shown that abortion pills (specifically, the combination of mifepristone and misoprostol) are a safe and effective method to induce abortions, and one that’s wholly compatible with telemedicine. Yet due to a combination of regulations, only two telemedicine websites will send abortion pills to people in the United States today. One of them, TelAbortion, is an ongoing research study that’s been approved for use in Hawaii, Oregon, Washington, New York, and Maine. The other option, Aid Access, is currently under investigation by the FDA for failing to comply with the strict distribution protocol required for abortion pills.

Despite a demonstrated history of safety and consumer need — particularly in areas where abortion clinics are rare — abortion medications are widely viewed as far too dangerous to freely distribute online. Meanwhile, telemedicine is being used to treat everything from hair loss to aging skin to UTIs. Some telemedicine services even offer access to Addyi, a controversial female libido enhancer that experts have argued is dubiously effective at best and downright dangerous at worst. But even in places like Texas, where recent legislation has created an incredibly friendly environment for telemedicine, abortion providers are still legally required to be in the same room as their patients when dispensing their services.

The discrepancy between the access restrictions around abortion pills and the availability of medications like Addyi tells an uncomfortable story about the regulatory gatekeeping that keeps women from fully taking control of their own reproductive destinies — and how sexual health needs are prioritized across the country.


When mifepristone, the first drug in the medication abortion sequence, was approved by the FDA back in the year 2000, everybody thought that it was going to really democratize access to medication abortion,” says Abigail Aiken, an assistant professor at the LBJ School of Public Affairs at the University of Texas at Austin.

Mifepristone — also known as Mifreprex and RU-486 — blocks an essential pregnancy hormone, halting fetal development. A second pill, misoprostol, stimulates contractions to empty out the uterus. Used in combination, mifepristone and misoprostol have an effectiveness rate of 95 to 97 percent, with minimal side effects (one study of more than 13,000 women found that just 0.01 percent of users required hospitalization after taking mifepristone and misoprostol). Unlike a surgical abortion, which requires specialized training to perform, abortion pills can theoretically be prescribed by a number of medical professionals, including primary care providers, nurse practitioners, and potentially even pharmacists. “Everyone thought that it was really going to improve access,” Aiken continues.

Unfortunately, the FDA’s approval of mifepristone came with a major qualification. In the United States, the distribution of mifepristone is subject to a Risk Evaluation and Mitigation Strategy (REMS), a policy that dramatically curtails the medication’s availability. Under the REMS, mifepristone prescribed in the United States can only come from one specific distributor — the Midtown Manhattan–based Danco Laboratories, which owns rights to it — and can only be dispensed under very specific circumstances.

Medical professionals who are interested in prescribing mifepristone have to meet a rigorous set of standards. They must be able to accurately diagnose both the duration of a pregnancy and whether there are any abnormalities that might make mifepristone dangerous, as well as either provide or connect patients to surgical intervention in the case of complications. Those requirements alone knock out a number of potential prescribers. Then, prescribers are required to be certified by and registered with the REMS program, which, in an era when abortion providers are frequently faced with death threats, has had something of a chilling effect. On top of all that, mifepristone can only be dispensed in clinics, medical offices, and hospitals. You can’t pick up your abortion pills at your local pharmacy, no matter who wrote your prescription. (Another form of abortion telemedicine, in which patients obtain abortion pills at their local clinic after teleconferencing with an off-site doctor who approves their prescription, is REMS compliant but significantly less convenient for patients.)

Addyi has been known to cause severe low blood pressure and fainting, an effect that is exacerbated when users imbibe other drugs.

“If the doctor is in a clinic and is dispensing [mifepristone] by mail, does that count or not?” asks Elizabeth Raymond, a senior medical associate at Gynuity, the organization behind the TelAbortion study. “Well, nobody really knows the answer to this question. When the FDA made this rule… I don’t even think they were thinking about mailing. Nobody even contemplated this option.” Raymond acknowledges, however, that “most people interpret [the REMS] as meaning that mailing is prohibited” — and that, under this interpretation, no telemedicine abortion site in the United States can truly be considered FDA compliant.

Gynuity has worked around these limitations by structuring TelAbortion as an FDA-reviewed research study, a status that offers a little leeway when it comes to interpreting the REMS. The organization hopes that as it expands the study and collects data, its research will encourage the FDA to reassess the REMS and either modify it to accommodate telemedicine or, ideally, withdraw it entirely.

Even if the FDA does decide to clarify, modify, or wholly overturn the mifepristone REMS, it will still be an uphill battle for telemedicine abortion in the United States. Currently, 19 states — including Arizona, Texas, and Michigan — require a clinician who is prescribing mifepristone to be in the physical presence of the patient, banning the telemedicine practice wholesale.


While reproductive rights activists struggle to provide patients with online abortion access, telemedicine readily provides medications that promise to kick-start your sex life. Sildenafil (the generic name for Viagra) is stocked by Hims, Roman, and Lemonaid. Hers tells potential customers that their lack of sex drive is now “optional,” advertising that there’s hope for the 50 percent of women allegedly suffering from hypoactive sexual desire disorder in the form of a medication known as Addyi (flibanserin).

It’s understandable that medications like Viagra and Addyi would be a natural fit for telemedicine. Talking about sex can be awkward and uncomfortable, and sites like Hims and Hers offer people who are genuinely suffering with sexual frustration a more discreet way to address their concerns. But these medications can come with significant risks.

In the two decades since the FDA approved Viagra, a number of red flags have been raised about its use — particularly its use by the younger population targeted by many telemedicine sites. When used recreationally, Viagra can actually cause erectile dysfunction by creating a psychological dependence. And though the hours-long erections warned of in Viagra’s disclaimers are often treated as a punchline, they are a serious side effect that can permanently damage a person’s penis.

“The whole thing makes no sense, top to bottom.”

Addyi — which, after being rejected twice by the FDA, was approved in 2015 for use by premenopausal women with hypoactive sexual desire disorder — has an even spottier track record. While Viagra tends to have consistent results, Addyi offers modest gains, providing users with about one additional “sexually satisfying event” per month (and sometimes even fewer than that). That increase in libido comes at a significant cost: Addyi has been known to cause severe low blood pressure and fainting, an effect that is exacerbated when users imbibe other drugs (including Diflucan, a popular yeast infection treatment), alcohol, or even grapefruit juice. “I think psychotherapy is a safer and more effective alternative for women with low desire,” says Meredith Chivers, an associate professor in psychology at Queen’s University in Kingston, Ontario.

“We have legitimate experts in the field… who raise doubts about the efficacy and the appropriateness of Addyi,” says Aiken, noting that those doubts have not seemed to derail the drug’s accessibility to those who want it. In contrast, she says, “We have legitimate experts in the field of abortion who do not share those same doubts about the effectiveness and the appropriateness of mifepristone,” and yet access to that medication is still heavily restricted. “There’s a disconnect there. It seems we’re more willing to listen to evidence, or lack of evidence, about some things than we are to listen to evidence about other stuff.”


The whole thing makes no sense, top to bottom,” Raymond says when discussing the restrictions on mifepristone. In the decades since the drug was first approved, there’s been copious research proving its safety, and yet the restrictions remain. “You have to think it’s political,” she concludes.

Elisa Wells, co-founder and co-director of the abortion pill education site Plan C, offers a similar response when I ask her why mifepristone still faces such heavy restrictions, while other, potentially more dangerous medications are freely available online. “It’s because abortion is politicized in this country and highly stigmatized,” she says.

But chalking up this disparity to politics glosses over the specific details of why some drugs are deemed generally acceptable for mass distribution while others are heavily restricted. Medications that aim to increase women’s libidos and supply men with on-demand erections are deemed acceptable, perhaps because they help connect both men and women to sexual pleasure. Yet a medication that helps women deal with the aftermath of that sex — one that grants women complete bodily autonomy and total say over their reproductive destinies — is considered to be far too dangerous to make freely available.

So much of the promise of reproductive health telemedicine lies in its potential to give patients direct access to the keys to their reproductive freedom — or, as the Hers website puts it, “Your body, your control.” But that control will always be limited so long as women aren’t given the choice to have an abortion.