Reproductive coercion involves behavior that interferes with contraceptive and pregnancy choices of women and occasionally men. This includes birth control sabotage (intentional destruction of a woman’s chosen method of contraception), pregnancy pressure (behaviors to coerce pregnancy against one’s wishes), and pregnancy coercion (threats to direct the outcome of a pregnancy). All are associated with serious reproductive consequences including unintended pregnancy, abortion, sexually transmitted infections, poor pregnancy outcomes, and psychological trauma. This article presents an overview of the recent literature surrounding reproductive coercion and how it relates to the reproductive health outcomes of women, adolescents, and the lesbian, gay, bisexual, and transgender community. Men’s experience with reproductive coercion will also be discussed. Clinical implications and evidence-based strategies for assessment and intervention will be identified.
Reproductive coercion (RC) is a type of intimate partner violence (IPV) that involves exerting power and control over contraceptive and/or pregnancy choices and outcomes. This can occur either in conjunction with or independent of physical or sexual violence. The most common forms of RC include birth control sabotage, pregnancy pressure, and pregnancy coercion. The magnitude of the problem has been demonstrated in several large studies, with a prevalence ranging from 15% to 25%, depending on the vulnerability of the population. Higher rates of RC have been found in those with previous or concurrent history of IPV.
Although the predominant form of RC involves a male partner’s dominance over a woman, RC may also occur as women’s pregnancy coercion over men, in same-sex relationships, and in some cultures, within intergenerational relations (ie, parents or in-laws). RC is a serious public health issue; however, it often goes unrecognized by providers and even by women who suffer from this form of IPV. Reproductive health providers are in a unique position to screen, intervene, and prevent RC to decrease associated physical and emotional consequences.
Definitions
Birth control sabotage involves any deliberate act that interferes with or inhibits a woman’s ability to obtain contraception. This includes hiding or destroying oral contraceptive pills; removing vaginal rings, contraceptive patches, or intrauterine devices (IUDs) without a partner’s permission; removing or intentionally breaking condoms; or not withdrawing when that was the agreed-upon method of contraception.
Pregnancy pressure refers to pressuring a female partner to become pregnant when she does not wish to become pregnant, such as threatening to leave or hurting a partner who does not agree to become pregnant. Conversely, pregnancy coercion includes threats or acts of violence if a woman fails to comply with the partner’s wishes concerning the decision to terminate or continue an existing pregnancy, such as forcing a partner to carry a pregnancy against her wishes, forcing a partner to terminate a pregnancy against her wishes, or injuring a partner with the intent to cause a miscarriage.
This article summarizes the existing literature surrounding RC and how it relates to heterosexual, same-sex, and adolescent relationships. It explores the clinical implications of birth control sabotage and pregnancy coercion and the poor reproductive outcomes associated with IPV. Finally, evidence-based strategies and interventions suggested for screening and assessment to reduce negative health consequences will be examined. By increasing awareness, screening for coercive behaviors, and promoting healthy relationships, providers can empower women to take control of their reproductive decision making and have a positive impact on this public health burden.
Prevalence of the problem
Women, domestic
In 2010, Miller et al reported the prevalence of RC in the United States. In this cross-sectional survey of more than 1200 female clients aged 16–29 years in 5 Northern California family-planning clinics, 15% reported birth control sabotage and 19% reported pregnancy coercion. Three quarters of women who reported a history of RC also acknowledged suffering from IPV. The prevalence of IPV in this sample was higher (53%) compared with the national average of 24% reported by the Centers for Disease Control and Prevention.
Further exploring the link between IPV and RC, Moore et al reported findings from 71 women from 3 sites in large metropolitan cities: a domestic violence shelter, a free-standing abortion clinic, and a family-planning clinic. Nearly 75% of respondents reported experiencing one of the following: (1) pregnancy coercive behavior, such as threats to force a pregnancy or refusing to pay for birth control; (2) intentional impregnation, despite the women’s protests, by sabotaging birth control attempts; or (3) postconception attempts at influencing the outcome of the pregnancy, whether aimed at continuing or terminating the pregnancy.
Similarly, in a study of more than 1400 surveys collected at 2 Planned Parenthood centers in Pennsylvania, 17% of the women reported not using contraception because either their partner was unwilling or because their partner wanted the respondent to become pregnant. The prevalence of IPV was 21% in this population, and women were more likely to report RC if they had experienced IPV, although it is unclear whether IPV occurred in the same relationship as the RC.
In 2011, the first national survey to explore RC, released by the Family Violence Prevention Fund and the National Domestic Violence Hotline, reported that 25% of more than 3000 callers to the Domestic Violence Hotline reported some form of RC. The prevalence of RC may be higher than these initial findings suggest because some callers were not included in this survey because of their need for immediate referral.
The aforementioned studies recruited highly vulnerable women: those seeking care for reproductive health issues such as sexually transmitted infections or unwanted pregnancies or those with a history of IPV from domestic violence shelters or helplines. However, RC has been shown to affect women from all demographics. In a cross-sectional survey of 641 women, aged 18–44 years, presenting for routine care at a large urban clinic in Rhode Island, 16% reported current or prior RC, with a third of these affected women reporting a concurrent exposure to IPV. In this study, single women (those who did not identify a primary partner) were at higher risk for RC, suggesting that either single women were more vulnerable to coercion or single women who experienced past coercion were less likely to engage in committed relationships. Better understanding of the current risk for single women should be explored, although clearly RC is pervasive in both high- and low-risk women.
Many reproductive health providers screen for IPV as part of routine preventative health services, as outlined by the Institute of Medicine in 2011. The high prevalence of IPV and associated RC in these studies demonstrate the need for providers to probe further into coercion when IPV is identified or vice versa. This could guide contraceptive counseling, sexually transmitted infection (STI)/human immunodeficiency virus (HIV) risk assessment, and patient education that may dramatically affect reproductive health outcomes.
Adolescents/teens
Adolescents may be more susceptible to physical, psychological, or sexual abuse in relationships than their adult counterparts. The vulnerability of adolescent girls to physical and sexual violence has been demonstrated in multiple, nationally representative surveys. In one survey of more than 42 million women, of 36% of US women who reported IPV, the majority (69%) reported their first violent experience before age 25 years. Almost half of those who reported ever being raped had suffered the assault before age 18 years.
A study of 64 adolescent girls, living in poor urban areas, participated in focus groups while seeking care at reproductive health clinics. More than half (53%) reported unwanted, unprotected intercourse, and 25% indicated they were unable to discuss condom use with their partner because of fear of physical or emotional abuse or partners equating non–condom use as a symbol of commitment and fidelity in the relationship. In a sample of 356 adolescents seeking reproductive health services in the Greater Boston area, 19% reported they had previously been coerced into not using condoms, with 12% reporting fear of requesting condom use or a previous negative experience when requesting condom use. Negative experiences included physical abuse, accusations of infidelity by the partner, or partner infidelity.
Pregnancy-coercive behaviors and birth control sabotage has been suggested as a possible mechanism linking adolescent pregnancy and IPV. Miller et al noted that 26% of 61 adolescents with a history of IPV surveyed perceived their male partners were actively seeking pregnancy (ie, using the pregnancy and subsequent child as a means of control in the relationship).
These findings indicate that clinicians treating teens affected by pregnancy, STIs, or other consequences of condom or contraceptive nonuse should explore victimization by RC in addition to baseline screening for IPV. Contraceptive options may then be tailored to promote discrete methods not easily discovered by partners (ie, IUDs, subdermal implant, or depot medroxyprogesterone injection).
Prevalence of the problem
Women, domestic
In 2010, Miller et al reported the prevalence of RC in the United States. In this cross-sectional survey of more than 1200 female clients aged 16–29 years in 5 Northern California family-planning clinics, 15% reported birth control sabotage and 19% reported pregnancy coercion. Three quarters of women who reported a history of RC also acknowledged suffering from IPV. The prevalence of IPV in this sample was higher (53%) compared with the national average of 24% reported by the Centers for Disease Control and Prevention.
Further exploring the link between IPV and RC, Moore et al reported findings from 71 women from 3 sites in large metropolitan cities: a domestic violence shelter, a free-standing abortion clinic, and a family-planning clinic. Nearly 75% of respondents reported experiencing one of the following: (1) pregnancy coercive behavior, such as threats to force a pregnancy or refusing to pay for birth control; (2) intentional impregnation, despite the women’s protests, by sabotaging birth control attempts; or (3) postconception attempts at influencing the outcome of the pregnancy, whether aimed at continuing or terminating the pregnancy.
Similarly, in a study of more than 1400 surveys collected at 2 Planned Parenthood centers in Pennsylvania, 17% of the women reported not using contraception because either their partner was unwilling or because their partner wanted the respondent to become pregnant. The prevalence of IPV was 21% in this population, and women were more likely to report RC if they had experienced IPV, although it is unclear whether IPV occurred in the same relationship as the RC.
In 2011, the first national survey to explore RC, released by the Family Violence Prevention Fund and the National Domestic Violence Hotline, reported that 25% of more than 3000 callers to the Domestic Violence Hotline reported some form of RC. The prevalence of RC may be higher than these initial findings suggest because some callers were not included in this survey because of their need for immediate referral.
The aforementioned studies recruited highly vulnerable women: those seeking care for reproductive health issues such as sexually transmitted infections or unwanted pregnancies or those with a history of IPV from domestic violence shelters or helplines. However, RC has been shown to affect women from all demographics. In a cross-sectional survey of 641 women, aged 18–44 years, presenting for routine care at a large urban clinic in Rhode Island, 16% reported current or prior RC, with a third of these affected women reporting a concurrent exposure to IPV. In this study, single women (those who did not identify a primary partner) were at higher risk for RC, suggesting that either single women were more vulnerable to coercion or single women who experienced past coercion were less likely to engage in committed relationships. Better understanding of the current risk for single women should be explored, although clearly RC is pervasive in both high- and low-risk women.
Many reproductive health providers screen for IPV as part of routine preventative health services, as outlined by the Institute of Medicine in 2011. The high prevalence of IPV and associated RC in these studies demonstrate the need for providers to probe further into coercion when IPV is identified or vice versa. This could guide contraceptive counseling, sexually transmitted infection (STI)/human immunodeficiency virus (HIV) risk assessment, and patient education that may dramatically affect reproductive health outcomes.
Adolescents/teens
Adolescents may be more susceptible to physical, psychological, or sexual abuse in relationships than their adult counterparts. The vulnerability of adolescent girls to physical and sexual violence has been demonstrated in multiple, nationally representative surveys. In one survey of more than 42 million women, of 36% of US women who reported IPV, the majority (69%) reported their first violent experience before age 25 years. Almost half of those who reported ever being raped had suffered the assault before age 18 years.
A study of 64 adolescent girls, living in poor urban areas, participated in focus groups while seeking care at reproductive health clinics. More than half (53%) reported unwanted, unprotected intercourse, and 25% indicated they were unable to discuss condom use with their partner because of fear of physical or emotional abuse or partners equating non–condom use as a symbol of commitment and fidelity in the relationship. In a sample of 356 adolescents seeking reproductive health services in the Greater Boston area, 19% reported they had previously been coerced into not using condoms, with 12% reporting fear of requesting condom use or a previous negative experience when requesting condom use. Negative experiences included physical abuse, accusations of infidelity by the partner, or partner infidelity.
Pregnancy-coercive behaviors and birth control sabotage has been suggested as a possible mechanism linking adolescent pregnancy and IPV. Miller et al noted that 26% of 61 adolescents with a history of IPV surveyed perceived their male partners were actively seeking pregnancy (ie, using the pregnancy and subsequent child as a means of control in the relationship).
These findings indicate that clinicians treating teens affected by pregnancy, STIs, or other consequences of condom or contraceptive nonuse should explore victimization by RC in addition to baseline screening for IPV. Contraceptive options may then be tailored to promote discrete methods not easily discovered by partners (ie, IUDs, subdermal implant, or depot medroxyprogesterone injection).
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