Austin, Tex.—Months before Senate Bill 8 (SB 8) went into effect, staff and providers at Whole Woman’s Health—a network of abortion clinics—anxiously braced for the impact of one of the most extreme anti-choice laws in the United States. They spent countless hours in meetings strategizing how best to comply with the onerous Texas law, which bars abortion care once embryonic cardiac activity is detected, typically around six weeks of pregnancy. As more than 80 percent of pregnant people in the state receive care past this time frame, the law amounts to a near-total abortion ban.

However, nothing—not even the state’s roughly one-month Covid-19 abortion ban last year—could quite prepare the staff for the deep trauma they would face turning away hundreds of patients indefinitely over the next several weeks.

“My staff is dealing with emotional and psychological exhaustion as they are forced to be agents of the state against their will and comply with a remarkably cruel law they fundamentally disagree with,” said Amy Hagstrom Miller, Whole Woman’s Health president and founder. “This law is taking a huge toll on them—they are facing day-to-day trauma.”

Clinic staff find themselves on the other end of understandably angry and anguished daily calls from patients who are blocked from receiving the timely care they need in their home state. Whole Woman’s must also resist the desperation of some patients, past the six-week mark, who plead with clinic staff to meet them in the parking lot for abortion-inducing pills or for an after-hours procedure. Staff don’t give in; however, many are reaching their emotional thresholds.

“Our staff are compassionate people but are being forced to constantly say ‘no’ to patients under the law—and they are hitting their limits,” said Hagstrom Miller. “I’ve heard some say: ‘I’ve said as many “no”s as I can, I don’t know how much more I can take.’”

In effect since September 1 because the US Supreme Court refused to intervene, SB 8 has forced most abortion care in the second-largest state in the country to cease, pushing pregnant people to venture out of state for care—that is, only if they are able to secure the resources to do so—or carry unplanned pregnancies to term.

In a scathing ruling on October 6, US Judge Robert Pitman paused SB 8 in response to a legal challenge from the US Department of Justice, deeming the law an “offensive deprivation” of constitutional rights. However, the largely conservative Fifth Circuit Court of Appeals, appeasing Texas officials, reinstated the law just two days later. The dizzying legal volley while the bill moves through the courts adds to the uncertainty and anxiety felt by patients, providers, and clinic staff.

Compounding the daily trauma for staff is the threat to their livelihoods: In addition to barring the overwhelming majority of abortion care, the law includes a novel legal provision that empowers private citizens to sue abortion providers or anyone who “aids or abets” abortion care. And those who sue are incentivized by a $10,000 award if the suits prove successful. As a result, the law opens the door for an army of anti-choice vigilantes to sue providers—or potentially those tangentially supporting abortion—at any point, leaving clinics deeply vulnerable.

Additionally, a provision in the law says that even if a temporary injunction is in place, providers could still be subject to retroactive litigation if the legal pause on the law is eventually stayed. (Malpractice insurance does not cover her providers for this kind of suit, stressed Hagstrom Miller.) And even if a lawsuit against an abortion provider is found to be frivolous, physicians would still need to disclose that they had been sued when applying for licenses, certifications, or hospital admitting privileges, potentially jeopardizing their careers.

Hagstrom Miller says of her 17 physicians at four centers across Texas, only half have felt comfortable continuing abortion care within the confines of the law; the other half fear liability and will resume procedures only if the law is permanently blocked. The majority of providers are young women—some who fly in from out of state—and are still paying off student loans and building their nascent careers. Her clinic staff similarly are largely women of color—many are parents and must weigh the risk to their livelihoods. While a handful of clinic staff have exited since the law was passed in May, the majority have stayed on.

But those who have stayed on remain “very worried” and “extremely anxious” about the stability of their jobs. Since the law took effect, clinics are seeing fewer patients, which has the effect of severely straining their incomes.

“If we can’t see patients, we don’t have income—so by default this could be a clinic closure law,” Hagstrom Miller said, adding that Whole Woman’s clinics are only seeing about 20 percent of the patients they normally do.

Hagstom Miller is all too familiar with the possible outcome of Texas anti-abortion laws intentionally meant to strangle clinics financially and operationally. Following the passage of 2013’s House Bill 2, a Targeted Regulation of Abortion Provider, or TRAP law, three Whole Woman’s Health clinics were forced to shutter their doors, along with half the state’s clinics overall, dropping the number from around 40 to less than 20. It took one year for Hagstrom Miller’s McAllen location to reopen; three years for the Austin flagship center; and the Beaumont clinic never opened its doors again. Even after the US Supreme Court struck down two key portions of HB 2 in 2016, most abortion clinics in Texas have not been able to reopen.

While no Texas clinic so far has indicated it is at risk for immediate closure, independent providers face a greater threat than nationally affiliated organizations like Planned Parenthood, as they lack the name recognition and fundraising and mobilizing power, said Nikki Madsen, executive director of the Abortion Care Network, the national association for independent, community-based abortion care providers.

“We know that all abortion clinics need the support of their communities to weather these storms, but, unfortunately, fewer people know about indies—and that means that fewer donations, volunteers, and other forms of support are directed their way,” said Madsen.

Fourteen of the 20 clinics in Texas are independent providers, and in the United States generally, indies provide three of every five abortions, making up the majority of clinics that provide care after the first trimester. Because indies are so fundamental to abortion access in this country, the threat of closure also represents a “disproportionate threat to meaningful abortion access overall,” stressed Madsen. That’s why her group created Keep Our Clinics, a centralized fundraising program, to help independent clinics, which need tens of thousands of dollars each month to stay afloat.

“While advocates on the ground and legal experts across the country work to defeat the current abortion ban in Texas, we are working collectively to keep Texas clinics open and support clinics in surrounding states,” said Madsen.

Although providers at bigger institutions may benefit from the support of a national network, they have not been immune to the stress SB 8 has created for clinic staff. Dr. Bhavik Kumar, a physician at Planned Parenthood Center for Choice in Houston, said SB 8’s potential to increase harassment and threats of litigation has only amplified the jarring feeling he has felt practicing abortion care in a conservative state hostile to abortion rights. The law has prevented the Houston clinic from providing abortion care to nearly 500 patients, which is “disturbing,” to Kumar personally and professionally.

The Houston clinic is also experiencing difficulty in hiring new staff and, like the staff at Whole Woman’s Health, its current team is concerned about their financial stability, he said. Some are in debt; some are caretakers; some are parents; and their livelihoods and futures are compromised because of SB 8.

“There is a heavy cloud of uncertainty above all of us,” said Kumar. “It’s unsettling that our jobs are so in flux. We are human. We have lives—we have partners, family members, children. The threat of SB 8 has a ripple effect. It changes not just how we interact with our patients but how we interact with friends and family, how we plan for our lives and futures. It is draining us every day.”