Reproductive and sexual coercion: counseling strategies

Dr. Miller is Chief, Adolescent and Young Adult Medicine, Children’s Hospital of Pittsburgh of UPMC, and Associate Professor of Pediatrics, University of Pittsburgh School of Medicine, Pennsylvania.

Dr. Chang is Associate Professor of Obstetrics and Gynecology, University of Pittsburgh School of Medicine, Pennsylvania.

The authors have no conflicts of interest to report with respect to the contents of this article.

Funding support for this article is from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (R01HD064407 to Miller and R03HD079507 to Miller and Chang).

An estimated 42.4 million US women, or more than 1 in 3, will experience rape, physical violence, or stalking by an intimate partner during their lives, according to the Centers for Disease Control and Prevention (CDC) 2011 National Intimate Partner and Sexual Violence Survey (NISVS).¹ Intimate partner violence (IPV) is the use of physical, sexual, emotional, or verbal threats or violence between married or unmarried partners, homosexual or heterosexual. The behaviors-such as stalking, cyber threats, and control of finances or movement-are intended to control or demean.

IPV disproportionately affects younger women, as underscored by the CDC survey, which showed that 69% of those who had experienced IPV reported the first occurrence before age 25.¹ Such victimization is associated with unintended pregnancy, sexually transmitted infection (STI), condom non-use,^2-4 inconsistent condom use,^5-12 and fear of condom negotiation.^2-4 Coerced sexual experiences are also common, with 28% to 42% of women in college samples reporting at least one such experience.^13,14 Among women who reported ever being raped, 80% reported that the first assault occurred before age 25 and almost half experienced their first rape before age 18 (30% between age 11 and 17 and 12% at or before age 10).

IPV is connected to poor reproductive health when male partners control women’s reproduction by attempting to impregnate a partner against her wishes (pregnancy pressure), controlling outcomes of a pregnancy (pregnancy coercion), coercing a partner to have unprotected sex (sexual coercion), or interfering with her attempts to use birth control (birth control sabotage). Cumulatively, these partner behaviors constitute a phenomenon described as reproductive coercion (RC).^15,16 Examples of birth control sabotage include removing condoms during intercourse, discarding birth control pills, and preventing a woman from obtaining contraception. The prevalence of RC was approximately 10% among women surveyed by the CDC. RC can occur in the absence of physical and sexual violence, and is independently associated with unintended pregnancy.¹⁷

Because of the association with a variety of reproductive and sexual health concerns, it is not surprising that IPV and RC have been experienced by many women who seek care confidentially in reproductive health and adolescent care settings.^18-20

In one study of female family planning clients ages 16–29 in California, 53% reported IPV and 25% had experienced RC.²¹ Among women reporting RC, 79% had also experienced IPV.²¹ Similar studies among patients seeking ob/gyn care have found a 16% prevalence of RC with significant overlap with IPV.²²

Related: Intimate partner violence can lead to pregnancy termination

In another study from Pennsylvania, 5% of patients reported experiencing RC in the past 3 months, which is associated with an 80% increase in past-year unintended pregnancy compared to women not experiencing RC, and a 2-fold increase in IPV and recent RC combined.¹⁷

Thus, addressing IPV and RC in the reproductive health setting may reach significant numbers of women at risk of violence and unintended pregnancy.¹⁵ Health providers are also in a position to offer contraception that a partner is less likely to be able to influence (such as IUDs) as a harm-reduction strategy.

Healthcare providers can make a difference

Repeatedly, surveys of women-both with and without a history of IPV-show that women want their healthcare providers to bring up the topic of IPV.^23-27 Discussions about IPV/RC are associated with cognitive and behavioral changes for women that promote their safety and reduce risk of poor health outcomes. In several qualitative studies, women with IPV histories described how positive encounters with healthcare providers led to changes that ultimately improved their situations.^28,29 In one study, women who were offered information about IPV and RC in a palm-sized brochure were more likely to leave a relationship that felt unhealthy or unsafe.³⁰

Another study found increased safety behaviors-eg, hiding money, removing weapons from the home, and establishing a coded method of calling for help from friends and family-among pregnant victims of IPV who underwent a brief informational intervention.³¹ In another study, women who talked to a healthcare provider about their abuse were almost 4 times as likely to use an IPV intervention as women who did not. Those who used an IPV intervention were 2.6 times more likely to leave their abusive relationship, and those who left reported improved physical health.³²

Research shows that the key components associated with an IPV victim’s increased willingness to consider changes in her situation are an increased awareness of IPV and options for addressing it, a sense of external support, and improved sense of self-efficacy or perceived power.³³

The Readiness Model for IPV victims developed by Cluss and colleagues provides a framework for addressing IPV and RC: Integration of IPV assessment with education and resources, use of validating, empathetic, and supportive communication to increase women’s sense of external support, and use of open-ended questions and patient-centered communication to improve patient autonomy and empowerment.³⁴

Office-based IPV/RC assessment can be the first step in recognizing abuse. However, a woman may define IPV narrowly and thus not recognize her own experience of violence, domination, intimidation, or control as IPV or “domestic violence,” nor may she see herself as a victim.^35,36 IPV/RC assessment should thus include a definition.

The American College of Obstetricians and Gynecologists (ACOG) recommends that physicians screen all patients for IPV. In particular, ACOG highlights routine ob/gyn visits, contraceptive counseling visits, and preconception visits and the first prenatal visit, trimester check-ups, and the postpartum visit.³⁷

Also read: CDC finds widespread IPV in US

Universal education approach

In one qualitative study, women with IPV histories advised health providers to consider offering IPV resources regardless of disclosure. They explained that while they may be too afraid or not ready to share their experience of IPV with their provider, they would still be willing to read or consider any information, resources, or support and possibly act on this information later.³⁴

Another study supporting the idea of universal education showed that women who received routine IPV education, both with and without a history of IPV, benefitted from increased awareness. Overall, the intervention group was 60% more likely to end “unhealthy” relationships than those in the control group-regardless of IPV history.³⁰

Thus, education for all women seeking reproductive health services can support informed decision-making, use of advocacy services, harm-reduction strategies, and safety planning.^38-44

Raising the topic of IPV/RC

Any discussion of IPV/RC should occur in private, without accompanying individuals (including partners) in the room.44 For minors, as well as in states where domestic violence may require a mandatory report, always disclose the limits of confidentiality before beginning the discussion.

The National Center for Youth Law offers guidance on minor consent and confidentiality at www.teenhealthlaw.org/resources_for_other_us_states/. Depending on such reporting requirements, an introductory script may be:

“As we talk about a range of topics during your visit, we want to make sure you understand that everything is private and confidential here, unless the person sitting in front of me says they are planning to hurt themselves or someone is actively hurting them. Then we may need to get other authorities involved to help keep that individual safe. What questions do you have for me?”

 IPV/RC should be introduced as a topic during all types of clinical visits and a discussion can be initiated by trained medical assistants and nurses. ACOG suggests starting with the following statement: “Because violence is so common in many women’s lives and because there is help available for women being abused, I now ask every patient about domestic violence.”³⁷

The use of a palm-sized brochure (see www.healthcaresaboutipv.org/tools) is one strategy to facilitate the discussion while ensuring that all women know that the clinical staff care about IPV/RC and that the office is a safe place to discuss concerns about relationships and to be connected to helpful services.

The information can be introduced using normalizing language such as:

“We are learning more about how relationships affect women’s health and want all the women who we care for to have this information. If it’s safe to take with you, please take this card and some extra to share with friends or family members.”

Targeted assessment in the context of reproductive health visits

IPV and RC have profound consequences for women’s reproductive health, including unintended pregnancy and STIs. Frequent requests for pregnancy or STI testing and for emergency contraception (EC) are red flags that should prompt further assessment.

Other signs of RC may include a patient not using any contraception although she does not desire a pregnancy, missing appointments for depot medroxyprogesterone acetate injections, and “losing” birth control pills, the patch, or ring. Targeted assessment involves addressing the specific reproductive health concern:

“I see you are here for a pregnancy test, and you’ve told me that you don’t want to be pregnant right now. We are hearing from women that their male partners pressure them to get pregnant, mess with their birth control, and refuse to use condoms. Is this something that could be going on for you?”

Harm-reduction strategies in the reproductive health setting

In the clinical setting, healthcare providers can offer additional harm-reduction strategies. These may include placement of an IUD (which is less likely to be sabotaged), use of injectable or implantable contraceptives, and access to EC. Providers also can discuss how to negotiate condom use.

Notably, for women whose partners are monitoring their menstrual cycles, the copper IUD is the most discreet and least vulnerable to partner influence. To reduce the chance of removal by a partner, offer the option of cutting the strings in the endocervical canal at the time of placement.

Implants and depot medroxyprogesterone injections are less likely to be influenced by partners than are oral contraceptives, the vaginal ring, patch, or condoms, but assess whether a partner is also monitoring a woman’s menstrual cycle before offering these options.

Specific harm-reduction strategies include:

--Offering a copper IUD and cutting strings so the partner cannot feel or remove the device

--Recommending that the patient keep EC hidden in a small envelope (rather than the large product box)

--Offering to notify a partner anonymously about an STI diagnosis and need for treatment

--Discussing LARCs as methods less vulnerable to partner influence

--Offering use of the office phone to place a call to a victim service advocate so the call doesn’t show up on a woman’s cell phone

Responding to disclosures and making warm referrals

The goals of integrating IPV/RC assessment are to support women experiencing such abuse, validate their experiences, reduce their sense of shame and isolation, and provide information about advocacy services. Pushing a woman to disclose abuse is not the goal of assessing for IPV and RC. Rather, the message should be that that she is not alone, that she can get support and help, and that the clinical office is a caring, safe space.

Because abuse is profoundly demoralizing and isolating, a validating statement from a healthcare provider such as “You deserve to be treated with respect” or “No one deserves to be hurt or afraid of the people who are supposed to love them” can be life-changing. Women whose healthcare providers discuss IPV during the visit are more likely to use victim services.

When disclosures happen, providers can offer supportive statements like “I know it took a great deal of courage to share that with me. Thank you for sharing your story.”

Even after an IPV/RC disclosure, it is crucial to respect the patient’s autonomy. Women have said that an unintended negative consequence of disclosing IPV was losing their ability to choose what happened next or having yet another person tell them what they needed to do.²⁹ After a validation statement, a provider may then inquire, “What can I do to help you?” or “What would be most helpful to you?”

If a woman says that she is uncertain about the provider’s ability to help, the provider can then ask permission to offer suggestions: “May I offer some thoughts about how I might be helpful?” or “Can I share some ideas that other women have found useful?”

Providers should be prepared to make a “warm referral” to an advocate. This means assisting the patient in making contact with an advocate immediately. Some larger clinical sites have on-site victim service advocates. For most offices, advocates are off site but may be willing to come to an office to meet with a client (it may be easier for a woman to say to a partner that she is going to the clinical site for a health concern and meet with an advocate there than to go to a domestic violence agency).

If the client is willing, allowing her to use an office phone to talk to a victim service advocate during her visit can help. If the client is unwilling, providing hotline numbers, particularly the easy-to-memorize National Domestic Violence Hotline number (1-800-799-SAFE) allows her to use resources when or if she feels ready.

An advocate can also assist the client in making a safety plan, particularly if she is not yet ready to make any changes in her situation. Safety plans are strategies to prepare for another episode of violence. The National Coalition Against Domestic Violence has an example of a safety plan at www.ncadv.org/protectyourself/SafetyPlan.php.

To reinforce that a patient is not alone and that she has support regardless of what she is ready or able to do, providers should offer follow-up and schedule a return visit.

Assessing safety around pregnancy diagnosis

Providers also have an obligation to ask about a woman’s safety once a pregnancy is diagnosed. A question such as “How might the person who got you pregnant react if he were to know about your positive pregnancy test?” can reveal conflict around pregnancy intentions and can be helpful in guiding pregnancy counseling.

In some situations, a positive pregnancy test could lead to escalation of violence, forced continuation of the pregnancy, or threats to kill her if she doesn’t do what a partner expects regarding the pregnancy.

Summary

Healthcare providers are in a unique position to educate all women about IPV and RC, to offer harm-reduction strategies, and to build a link to victim advocates in a supportive and empowering way.

Providers should nurture close collaborations with on-site social workers (where available) and advocates to connect women to violence victimization-related resources.

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