Queen of Everything
You know Ashley Graham as the world's most glorious, body-positive model. Now get ready to meet her as a sexual revolutionary (who gives laugh-out-loud bedroom advice).
On Tuesday morning at the Planned Parenthood office in Maryvale, Arizona, eight adults and three children sit in the waiting room. “Yap! Yap! Yap!” A toddler wobbles across the room. “Are you barking?” her father says, smiling. “Come back here, social butterfly!” Diego Rivera's The Flower Seller hangs on one wall. Two pink posters read: “These doors stay open.” The girl is making a beeline across the room, past a pregnant woman holding an owl-eyed baby in her lap, past a couple filling out paperwork while they whisper and laugh, and straight to the other little girl in the room, who's wearing a pink-and-purple cape. Every few minutes someone comes in from outside—8 patients become 9, then 10, 11.... “It's beginning to pick up,” Esther Cervantes says. I thought it already had.
Esther manages the Maryvale Health Center, one of the busiest Planned Parenthood health centers in the state, serving more than 6,400 patients a year. She and Carmen Sanchez, the team leader, sit side by side at the receiving window, checking in patients, managing payments. Esther has worked for Planned Parenthood for about 15 years. She calls the Maryvale clinic “my clinic” and the four young health-care assistants “my girls,” and when a workman arrives to fix the front door, she calls it “my door,” asking if he can etch the name “Planned Parenthood” into the glass. Esther has a mass of dark hair and a down-to-earth, humorous manner. She's warm and gregarious and protective—of her staff and her patients. “She's a mother hen,” Carmen says.
The staff of the clinic is bilingual, and most live in Maryvale, a racially and ethnically mixed neighborhood in western Phoenix. More than half of the patients rely on Title X funds or Medicaid to cover all or part of their visit. It's a front-page issue these days as politicians work furiously to cut that funding from Planned Parenthood. In the two days that I visited, the clinic saw and treated 70 patients: 32 for birth control consultations, 20 for STD testing and treatment, 11 for Depo-Provera shots (a hormonal form of birth control that's 99 percent effective—if administered properly—and lasts three months), and 7 for well-woman exams. Of those 70 patients, 42 qualified for Title X funding, the federal program that provides grants for family-planning services and preventive health care; 12 had private insurance; 10 used Medicaid coverage; and 6 paid out of pocket. Abortion services are not offered at Maryvale; they're performed at only four Planned Parenthood clinics in Arizona.
The clinic has been in Maryvale for more than 30 years, serving a neighborhood that has a shortage of health professionals and is medically underserved; the median household income in Maryvale is $40,054. Esther's connection to Planned Parenthood is personal. It goes back to being a teenager in love with a boy, both of them clueless about almost everything but their attraction to each other. Esther describes her family as “a very Hispanic family where you don't talk about birth control, you don't talk about sex, you don't talk about all that fun stuff.” The first education she got was at Planned Parenthood—she was 17, and her older sister's friend had taken her there for a pregnancy test. “I remember the compassion and the educating,” Esther recalls. That was 24 years ago. She had the baby, a boy, and married her childhood sweetheart. She describes their two grown children as “Planned Parenthood babies”—both so knowledgeable about birth control and STDs that their friends come to them with questions.
Carmen is another old hand, having worked at Planned Parenthood for 20 years, long enough to see two generations of families coming into the clinic. “My daughter's our patient,” Carmen says, laughing. “Her friends are our patients. She started four years ago at Arizona State University, and she brought her roommate, everybody here.” Carmen and Esther met at the Maryvale Health Center. Carmen was working as a health-care assistant; Esther had come in for another pregnancy test. Carmen gave Esther the results. When Esther gave birth to her second child, Carmen became the godmother. Now Esther is her boss. The two work the front office together in complete synchronicity.
A blonde woman wearing skinny jeans and sneakers is at the window. “I'm not employed. I wrote down what I made last year,” she tells Carmen, sounding a little shaky. The woman explains: She just moved to Phoenix, doesn't have a job yet, and has no health insurance. Esther invites the woman inside the offices to talk privately about her financial situation. There she starts to cry, and Esther gives her a long hug. (“That broke my heart,” Esther later told me.)
The woman, whose name is Jessica*, had left her job in Tucson when her boyfriend was posted to an army base in Phoenix. Her birth control prescription's about to run out, and she needs a Pap smear, too. “I was kind of running out of time, and either I have a baby, which I can't afford, or I go and get this done,” she says.
Jessica has worked as a hairstylist, a baker, a night-shift stock person at Home Depot, and a census taker, but she's never made enough to be able to afford health insurance. She's always paid out of pocket: $30 to $35 a month for birth control, about $800 every two years for her Pap smear. Now in a new place without a job, she needs help, and she hates asking for it. Jessica is a military brat, the youngest daughter of a pilot and a firm believer in not asking for “government handouts.”
She was wary about coming to the Maryvale clinic. She worried it would be like a Social Security office or the DMV—crowded and dingy. Instead, she walked into a clean, well-lit place. “The women at the front desk were so incredibly kind, which was unexpected,” Jessica says. “They could very well walk around annoyed at people who can't afford to pay...but they were very understanding.”
Twelve years ago, Jessica went to a Planned Parenthood for an abortion. She was 23 and in a violent relationship. Her mom went with her to the clinic in Tucson. Not even one month pregnant, she was able to get a nonsurgical (a.k.a. medical) abortion, taking two sets of pills over two days. Nothing lingers from that day, except being glad her mom was there: “I don't really think much of it either way. It was something that I had to do for myself, and I did it.”
Before being seen by the nurse practitioner, Jessica sits down with Cecilia Ibarra, one of the health-care assistants. Cecilia is the baby of the office, having come on only two and a half years ago and being only 25. “They've been together for a lot longer than I have been here, but I kind of just squeezed myself in,” she says, smiling. Cecilia's dark hair is lightened on the ends, so it looks sunlit. She's got a round, pretty face; a strong, confident presence; and a dry sense of humor. The office joke is that she's Esther's child. “She's really my mom—she gave me up when I was little,” Cecilia jokes, but with a straight face. “And now we're reunited. She's not very happy about it, but I followed her here.”
Health-care assistants do the intake interviews. They also take care of STD, HIV, and pregnancy testing—anything that doesn't have to be performed by a nurse practitioner. Jessica sits in Cecilia's office, ankles crossed, jiggling her legs, cracking jokes when she can.
“How old were you when you first became sexually active?” Cecilia asks.
“Hooooh!” Jessica says, exhaling sharply.
“I'm taking you way back.”
“You are!” Jessica says. “Welcome to the depths! Ah, Jesus!”
“Something you never forget, right?”
“Uh, but I'd like to! Fourteen. I didn't even know what a wiener looked like. I thought the whole thing was covered in hair,” Jessica says. Cecilia laughs and keeps typing. “And even after I had sex the first time—still thought the entire thing was covered in hair because I didn't see it.”
Cecilia thinks of herself as an educator: “My mother was very closed off—she never talked about birth control; she never talked to me about periods. And here I have a lot of those patients. And it's not only young patients; it's also older women.”
When the staff goes out to lunch wearing their navy blue clinic uniforms and Planned Parenthood name tags, they always run into people who want help. Esther says, “If I'm in my scrubs, I'll get stopped: ‘Oh, you work at Planned Parenthood? That's so cool. I have a question....’ Once you hear that ‘That's so cool,’ I know a question's coming.”
Esmeralda is 27. Her two-year-old boy, Jeremiah Anthony, sits on her lap, mesmerized as his mother draws a shark on his forearm with a blue magic marker. As the fin comes into view, his lips curl into a sumptuous smile. Esmeralda's a great planner; even as a teenager she was clear-eyed beyond her years. “I got my first boyfriend in high school, and I knew right away I didn't want to be a teen mom. A lot of my cousins were,” she says. She didn't want to talk to her mother about getting contraceptives, Esmeralda says, because she knew she would “never let me leave the house.” Fortunately, her good friend had a cool aunt named Esther Cervantes who worked at Planned Parenthood.
Before arriving at the clinic, Esmeralda was thinking she would go on the Pill, not knowing there were any other forms of birth control, except condoms. “I went to a high school in south Phoenix. We had health education, but we never talked about STDs or birth control, HIV, none of that stuff,” she says. Arizona public schools are not required to offer sex education. If a school chooses to offer sex ed, the law requires that students get parental permission to take the class and that educators stress abstinence. Gay teens are completely abandoned since any discussion of homosexuality, including methods of safe sex, is forbidden. Oddly, some polls of Arizona residents show support of comprehensive sex education, which would suggest this is a case of the tail (90 state legislators) wagging the dog (6.7 million citizens).
“I went in thinking, I'm going to get on birth control and that's it,” Esmeralda recalls. “I didn't know there was so much more to it, that it still doesn't prevent STDs, that there's still a chance you could get pregnant, the side effects....” After hearing her options, Esmeralda decided on Depo-Provera. She thought that would be safer than trying to remember to take a pill at the same time every day.
At 18, Esmeralda switched to a five-year IUD. By 23, she had an associate's degree in business, her boyfriend had a BA in applied science, and both were employed in their fields. They decided they were ready for a baby. After Jeremiah Anthony was born, Esmeralda went back to Planned Parenthood for another IUD and continued her education. Now she's a year away from finishing her bachelor's degree, and she and her boyfriend have bought their first home. “I came about three weeks ago to get my IUD taken out, and now I'm here to have a pregnancy test,” she says, unable to hide her excitement. “We'll see.”
“Planned Parenthood really helped me,” Esmeralda says. “Because when I was 16, I couldn't tell my parents, so that was a big thing. When I was going to college I didn't have insurance, and if I wanted an IUD it would've cost me $2,000. I was in college and I had a part-time job waitressing, so I couldn't afford that.... Literally, Planned Parenthood helped me plan my way to where I'm at now.”
Elma Munoz, the clinic's nurse practitioner, sits behind a desk taking small sips of a giant-size Diet Coke that will last her the whole day. She eats her lunch here while she makes calls and reviews patient records. In the two days I'm at the clinic, I interview Elma in tiny installments, seven minutes here, nine there, whenever she can squeeze me in. She's a small woman with a soft, cottony voice. The patients call her la doctora.
“You cannot teach somebody to have that heart for the patients—that's what Elma has,” Esther says. “The girls who do the [intake] can get a lot of information, but there are certain things our patients will never tell the girls; they will only tell Elma.” They may come for cancer screenings or birth control, but they often end up talking to Elma about other issues. “I've had ladies come back with different problems, whether it's diabetes or hernias that needed to be repaired,” says Elma, who then refers them to doctors.
Many of the patients here are recent immigrants, and some are undocumented. These recent immigrants come from Mexico and Central and South America, but also from Romania, Africa, the Middle East. The Maryvale clinic is often their first contact with the U.S. health-care system, and sometimes their only one. Financial constraints and the fear of being reported to immigration authorities can keep people from seeking medical care, but over time the Maryvale clinic has built a reputation for being affordable—and trustworthy. “We built a rapport with patients, and word travels in that community,” Elma says. “My cousin will tell her cousin, who will tell the neighbor. We have a reputation that we're a safe place.”
One story that sticks with Elma is the woman who came in for an exam after having not seen a doctor in four or five years. She was an undocumented immigrant in her 30s, and an abnormal result from her Pap smear that day led to the discovery that she had uterine cancer. “Thankfully we were able to find it [and] we could start helping her, but you wonder if she had waited...” Elma says. “This was a lady with five or six kids at home and...if it weren't for us, she probably wouldn't have gone too many places. That was scary. What if that was my mom or my sister?”
There are twin pressures on this clinic: There's the threat of the federal government cutting Medicaid reimbursements and Title X funding (the latter would affect all family-planning providers, including Planned Parenthood; the former would affect Planned Parenthood specifically). By law, no federal funds can cover abortions, except in cases of rape or incest or when the mother's health is endangered. So while the politicians working to strip funds from Planned Parenthood rail against abortion, they know that what these cuts would really affect is people's access to affordable birth control, cancer screenings, and STD and HIV testing.
Then there's the threat of arrest and deportation of their undocumented patients. This past February, Guadalupe Garcia de Rayos, an Arizona mother of two U.S.-born children, who has lived in this country since she was 14, was detained and deported to Mexico. At an emotional press conference, her 14-year-old daughter, speaking through tears, said, “To me it's sad seeing what this world has come to, seeing how this world has so much hate in it.... Seeing my mom in that [Immigration and Customs Enforcement] van was unexplainable. It was really heart-dropping.”
The last time immigrants were heavily targeted in Arizona was in 2011, when the state passed one of the toughest anti-immigration laws in the country, allowing police to demand proof of citizenship or immigration papers during any stop where they suspected the person might be here illegally. Many churches and schools reported a noticeable drop in attendance as people stayed home, afraid even to go outside. And studies done after the law was enacted suggest that the impact of these policies contributed to decreases in preventive health care among those most at risk. Esther remembers the day they set up a checkpoint outside of the Maryvale hospital, only blocks from the clinic, and how many patients missed their appointments that day. Much of that law was overturned in court, but now, under the Trump administration, the fear has returned. “I can see it in their eyes when we ask for their ID,” says Esther, who always explains in great detail that this is for record keeping only and that they would never report a patient to the authorities.
When Kendra* arrives for her well-woman exam and STD testing, she has come straight from basketball practice, so she's still in sweats and high-tops. She's been coming to Planned Parenthood since she was 17; now she's 42. That first visit she came alone, taking a city bus after school, and if you could have seen her mind then, it would've looked like an animal trying to hide from a predator: Oh, my God, my mom's gonna kill me! My grandmother's gonna kill me! She was a high-school senior with a college scholarship and dreams of law school, but she was pretty sure she was pregnant and the ground was about to drop out from under her. “I think for me that was the number-one thing, that I didn't have to walk in being scared that they were going to call my mom,” Kendra says. After informing her that she was, indeed, pregnant, a staffer talked to her about how to break the news to her mother. Kendra decided on a note. “Please read this before you come back to my room,” it began.
Throughout her pregnancy, she returned to the Planned Parenthood clinic every time she had a question. Always a “school worm,” Kendra went on to college (without the basketball scholarship), got an associate's degree, then a bachelor's, and this spring she got her PhD in psychology. She has raised her two daughters more strictly than she was raised, but also with a lot more sex talk. When her girls each turned 18 and became sexually active, she brought them to Planned Parenthood for birth control. One daughter is a college graduate and teaches fifth grade. The other is in her senior year of college. “They are not young mothers. They broke the cycle,” Kendra says. “I'm so proud of that.”
Not that long ago, there were pro-choice, pro-Planned Parenthood Republicans in the State Senate, but in the early 2000s, those members began to be replaced by ultraconservative Republicans, followed by the election of two antichoice governors, Jan Brewer and now Doug Ducey. Since then, legislation aimed at shutting down Planned Parenthood and a woman's right to abortion has come at a fast and furious pace. At least 13 antichoice measures that are hostile to women's health (including restrictions on access to birth control and cancer screenings at Planned Parenthood) have been signed into law by Brewer and Ducey. Among them:
A law forbidding nurse practitioners from giving patients a medical abortion or performing first-trimester abortions. That law led to many rural Planned Parenthood health centers in Arizona being forced to close, due in part to policies that targeted women's access to health care and reproductive-health-care providers.
A law requiring women seeking an abortion to make three visits to the doctor over two days. “Given the fact that 60 percent of our abortion patients already have children at home...they're having to find child care; they're having to stay overnight at a hotel,” says Bryan Howard, president and CEO of Planned Parenthood Arizona.
A law forcing patients to receive state-directed in-person counseling, with information designed to discourage abortions, and then wait 24 hours before the procedure is provided.
A law forcing minors to get notarized statements of permission from a parent in order to get an abortion.
A law that blocks Medicaid reimbursement for nonabortion health care, making it difficult or impossible for low-income people to get contraception, infectious-disease testing, and cancer screenings. This bill was overturned in court, but last summer it was reintroduced and signed into law again. (It has yet to be enforced while the state figures out the logistics.)
In 2007, the state had 20 Planned Parenthood health centers; today there are 10.
Elma has always loved her job. “The patients are very appreciative,” she says. “I kind of fell in love with that. And I still kid around with my patients—when I was first here, I couldn't afford pills. So you see what we do, and you know it helps so many people. I guess I fell in love with that, too.”
The pressures on this clinic would make a strong man fold, but the women who work here do what most of us do when the future looks scary: They focus on the day-to-day. They do their jobs. The threat looms, of course. But then there's a real, live person right in front of you—a mother of five, perhaps, who's come for a cancer screening; or a young man, blushing as he pushes a note through the window saying he needs an STD test; or maybe a teenager with questions about planning her future.
And that looms larger.
At press time, the president had just signed legislation that would allow states to bar Title X funding to family-planning providers, though Title X money cannot actually be used to fund abortions.
*Some names have been changed.
You know Ashley Graham as the world's most glorious, body-positive model. Now get ready to meet her as a sexual revolutionary (who gives laugh-out-loud bedroom advice).