Detecting Reproductive Coercion: Teen Pregnancy as a Red Flag
By Erin Liotta
When a teenage girl – pregnant for the second time – walks into a family planning clinic, what assumptions will the clinician make about the girl’s reproductive choices? Perhaps he assumes that no one educated her on the proper use of contraception. He may believe that the girl didn’t have money to buy condoms. He could assume that she and her partner were simply too apathetic to bother with birth control. But does he wonder whether her partner is abusing her? If the professionals who interact with adolescent girls do not see a red flag when the girl becomes pregnant, new research suggests they may be overlooking a critical piece of how to ensure her health and safety.
Many years later, Dr. Elizabeth Miller can still vividly describe the exact moment when she realized she had been asking the wrong questions. While volunteering at a teen clinic in Boston, she treated a 15-year-old girl who had come in for a pregnancy test.1 Miller asked whether the girl wanted to get pregnant and whether she was using any form of birth control. When the girl answered “no” to both questions, Miller listed off various contraceptive options and sent her on her way with a handful of condoms. Two weeks later, the girl returned—this time to the emergency room, after her boyfriend pushed her down a flight of stairs. Miller calls this her “most destabilizing experience as a clinician” as she realized she had failed to identify abuse as a factor in her patient’s reproductive health choices.2 Since then, Miller, currently Associate Professor of Pediatrics at the University of Pittsburgh School of Medicine, has devoted much of her work to pioneering research in the field of what is now known as reproductive coercion—when a man attempts to force his girlfriend or wife to become pregnant against her wishes.
Spurred in part by Miller and her colleagues’ research, the health care field is taking a more active stance toward the role that providers should play when treating a girl or woman who may be involved in an abusive relationship. President Obama’s health care reform law, the Patient Protection and Affordable Care Act of 2010 (ACA), now requires health insurance plans to provide female patients with screening and counseling on intimate partner violence without cost-sharing.3 In the first two months of 2013, two major bodies, the U.S. Preventive Services Task Force and the American College of Obstetricians and Gynecologists, issued recommendations that practitioners screen girls and women for intimate partner violence, including reproductive coercion.4 This article will review these and other recent developments in the health care arena, with the ultimate question of whether there are lessons that could benefit professionals working in other child-serving systems.
Reproductive Coercion and Intimate Partner Abuse
The hallmark of reproductive coercion is a pattern of controlling behavior by which a male attempts to coerce his female partner into getting pregnant. This may take on either subtle or overt forms of coercion, from a partner trying to sweet-talk his girlfriend into having his baby to the use of physical force or threats to kill her if she does not get pregnant. Miller and her colleagues separate reproductive coercion into two subcategories of behavior: (1) birth control sabotage, in which the male actively interferes with the girl or woman’s ability to use birth control; and (2) pregnancy coercion, in which he makes threats or uses force to try to make her get pregnant.
Research has shown that reproductive coercion is closely linked to intimate partner violence. Indeed, the main motivation driving the coercer often echoes that of the perpetrator of emotional or physical abuse: the desire to have and maintain power and control over one’s partner.5 In one study, young men who prevented a partner from using condoms plainly admitted that they did so in order to exert power over her.6 Although researchers aren’t clear about which comes first—whether reproductive coercion is an early predictor that a relationship will become abusive or whether it emerges from an already abusive relationship—the strong correlation between the two is clear.7 In a study of nearly 1300 young women ages 16 to 29 who visited family planning clinics in northern California, three-quarters of the women who reported having experienced reproductive coercion also reported experiencing intimate partner violence.8 Those in violent relationships were twice as likely to have had an unplanned pregnancy.9
What Does Reproductive Coercion Look Like?
Futures Without Violence defines reproductive and sexual coercion as “behaviors to maintain power and control in a relationship related to reproductive health by someone who is, was, or wishes to be involved in an intimate or dating relationship with an adult or adolescent.”
Examples include a male partner engaging in any of the following in order to impregnate his female partner against her wishes:
BIRTH CONTROL SABOTAGE
- Flushing her birth control pills down the toilet or otherwise hiding them
- Poking holes in a condom
- Removing a condom during intercourse
- Breaking a condom on purpose
- Forcing her not to use a condom
- Preventing her from going to a clinic to obtain birth control
- Tearing off her birth control patch
- Pulling out her IUD
- Telling her not to use birth control
- Threatening to leave her if she doesn’t get pregnant
- Threatening to have a baby with someone else if she doesn’t get pregnant
- Physically hurting her for not agreeing to get pregnant
Adolescents Are Especially Vulnerable
One of the disturbing revelations of the above study was that many of the girls and women who experience reproductive coercion experienced it before the age of 21. 19 percent of the total sample population reported having experienced pregnancy coercion; the reporting rate among 16-to-20-year-olds was already at 18 percent.10 15 percent of those studied reported having experienced birth control sabotage; the reporting rate among 16-to-20-year-olds was 12 percent.11 Finally, when asked about intimate partner violence, 53 percent of all study participants reported lifetime exposure to such violence; more than half of the 16-to-20-year-olds reported already having survived such abuse.12
Indeed, adolescents experience particularly high rates of dating violence and sexual assault. One in five adolescent girls reports having been in a violent relationship.13 Other studies place the figure closer to one in four.14 The Centers for Disease Control and Prevention has found that, of women who were raped in their lifetimes, nearly 80 percent were raped by the age of 24; 42 percent had been raped by the age of 17.15 These figures become even more striking when bearing in mind that researchers widely believe adolescents underreport rates of victimization.16
For providers and advocates who want to learn to identify the signs of dating violence, teen pregnancy and reproductive coercion hold a major clue. Up to two-thirds of teen pregnancies occur within the context of an abusive relationship. Girls who are victims of dating violence are 3.5 times more likely to become pregnant than girls in non-violent relationships.17 That’s not surprising given that girls who experience dating violence are nearly three times more likely to be afraid of negotiating condom use with their partners and are 2.6 times more likely to be fearful of even raising the topic of contraception.18
In the eyes of researchers and clinicians like Miller, the tendency of adolescent girls to underreport combined with their heightened vulnerability as young people mean that screening and intervention for this age group are especially crucial. As the National Conference of State Legislatures reminds us, teen dating violence “can lead to life-long unhealthy relationship practices, may disrupt normal development, and can contribute to other unhealthy behaviors in teens that, if left unchecked, can lead to problems over a lifetime.”19 Helping girls recognize early on that reproductive coercion is not, as they might believe, a sign of love or “normal” behavior can empower them to avoid similar situations in the future. In the worst-case scenarios, failure to recognize the warning signs can put the girl’s very life in danger: most homicides involving pregnant women are committed by an intimate partner.20 For advocates who work with adolescent girls, unplanned pregnancy should therefore be an automatic red flag for potential dating violence.
The Promise of Screening and Intervention
In the past several years, the health care field has made important strides toward mitigating the problems of teen dating violence and reproductive coercion. These advances rely heavily on clinician screening and counseling, approaches that initial research has shown to be efficient and effective. The first reproductive coercion intervention study, published in 2011, involved roughly 900 females ages 16 to 29.21 Advocates, clinicians, and researchers jointly developed and tested a three-step model intervention: (1) screening and education around reproductive coercion and intimate partner violence; (2) working with patients to identify harm-reduction strategies, such as using a form of birth control that a partner cannot tamper with; and (3) helping the patient link up with resources and services related to intimate partner violence.22 Although all this may appear time-intensive, the participating clinicians reported that following the steps within the context of a family planning visit actually helped “streamline” the appointment.23 The third step, for instance, required less than a minute.
The results were promising. Three to six months after their clinic visits, women and girls who had initially reported intimate partner violence and who received the three-step intervention reported a seventy-one percent reduction in pregnancy coercion as compared with similar women in the control group.24 Across all study participants, more women in the intervention group reported ending a relationship because it was unhealthy or unsafe.25 Other findings suggested that the improved outcomes for the intervention group were traceable primarily to the education and harm-reduction components of the intervention strategy.26
A number of provider organizations, and now federal law, are moving in the direction of screening and education around both intimate partner violence and, more recently, reproductive coercion. Given the ACA’s emphasis on preventive services, the U.S. Department of Health and Human Services (DHHS) tasked the Institute of Medicine (IOM) with putting forward recommendations related to preventive health services, including services specific to women. The resulting IOM report recommended that health care practitioners screen women and adolescent girls for, and counsel them on, intimate partner violence. According to the report, “[s]creening and counseling involve elicitation from women and adolescents about current and past violence and abuse in a culturally sensitive and supportive manner to address current health concerns about safety and other current or future health problems.”27
The Health Resources and Services Administration, an agency of DHHS, has adopted the IOM’s recommendations, now requiring as part of the ACA that providers cover annual “[s]creening and counseling for interpersonal and domestic violence” without cost-sharing.28 At this time, the mandate applies to female patients only. The guidelines could also benefit from further clarification, as they currently do not define what it means for a patient to receive “counseling,” and as Miller’s reproductive coercion intervention study shows, the type of counseling provided will impact its efficacy.
While additional guidance is needed to ensure maximum effectiveness of the ACA requirement, other groups have taken up the mantle. In January 2013, the U.S. Preventive Services Task Force reversed the stance it took in 2004, when it found no direct evidence of improved outcomes following intimate partner violence screening. In issuing its new recommendations, the Task Force cited Elizabeth Miller’s intervention study in its section on “Effectiveness of Early Detection.”29 The Task Force now recommends that “clinicians screen women of childbearing age [ages 14-46] for intimate partner violence . . . and provide or refer women who screen positive to intervention services . . . . .”30 This February, the American College of Obstetricians and Gynecologists issued a Committee Opinion urging providers to screen women and adolescent girls at regular intervals for intimate partner violence as well as for reproductive and sexual coercion.31 Given the early indicators of success discussed above, these screening measures are likely to dramatically improve the lives of girls and women facing reproductive coercion.
Moving Beyond the Health Care Context
The recommendations that drove the ACA’s intimate partner violence screening requirements stemmed in part from a finding that “[p]hysicians are in a unique position to identify women and adolescents experiencing abuse or neglect . . . .”32 But professionals in other fields, including those working in child welfare and juvenile justice, are similarly positioned to identify reproductive coercion. For years, studies have shown that those who have been abused as children are more likely to be affected by intimate partner violence later in life.33 And many at-risk youth are likely to have as much or more contact with non-health care systems as they have with their doctors. For instance, while an adolescent girl in foster care may see her doctor only once a year or during an acute crisis, she will see her caseworker once a month.
Broader reproductive coercion screening and counseling could also prove to be an effective strategy to reduce juvenile delinquency. For a girl in the juvenile justice system, such screening could help identify some of the root causes of her behavior. A juvenile court judge who does not know that a girl is in an abusive relationship cannot be expected to then understand how the dynamics of that relationship might be perpetuating her offending behavior.
This is not to suggest, however, that judges, attorneys, or other advocates should immediately start questioning girls about their reproductive and sexual histories. Effective intervention outside of the health care context will likely require further research and training. Miller’s intervention study, with its focus on education and harm reduction, demonstrates that simply asking the questions will not suffice to create change. Advocates need to be prepared to go further and to educate adolescents, both girls and boys, about healthy behaviors. Asking these questions in the private confines of a doctor’s office, moreover, is a far cry from asking them in a courtroom setting in front of attorneys, social workers, probation officers, and/or the youth’s parents.
Those who work in and with child-serving systems need to be made aware of the nature, causes, and effects of reproductive coercion. We must widely acknowledge the phenomenon of reproductive coercion before we can take the step of implementing systematic screening and other initiatives. Until we do so, we will be missing an important piece in the larger puzzle of keeping young people healthy and safe.
Erin Liotta is a staff attorney at NCYL. Her Comment on the incarceration of battered women will appear in the upcoming fourth edition of Domestic Violence Law, due out this summer from West Publishing Company.
- Conversation: Lynn Harris & Elizabeth Miller on Reproductive Coercion (The Nation on Grit TV broadcast July 28, 2010).
- Health Res. & Serv. Admin., U.S. Dep’t of Health & Human Serv., Women’s Preventive Services: Required Health Plan Coverage Guidelines (2011), www.hrsa.gov/womensguidelines/.
- Virginia A. Moyer, Screening for Intimate Partner Violence and Abuse of Elderly and Vulnerable Adults: A U.S. Preventive Services Task Force Recommendation Statement, Annals of Internal Med. 1 (2013); Comm. on Health Care for Underserved Women, Am. Coll. of Obstetricians & Gynecologists, Committee Opinion No. 554: Reproductive and Sexual Coercion (2013).
- Linda Chamberlain & Rebecca Levenson, Futures Without Violence, Addressing Intimate Partner Violence, Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic and Reproductive Health Care Settings 12 (2d ed. 2012).
- Lynn Harris, When Teen Pregnancy Is No Accident, The Nation, May 24, 2010, available at www.thenation.com/article/when-teen-pregnancy-no-accident (last visited Feb. 13, 2013). The gender pronouns used here are not intended to imply that intimate partner violence only occurs in the context of a male perpetrator and female victim. At this time, however, little information is available on reproductive coercion as experienced by males or by people in same-sex couples. Futures Without Violence currently defines reproductive coercion as “limited to heterosexual relationships.” Chamberlain & Levenson, supra.
- Reproductive coercion may occur in the absence of other sexual, physical, or emotional abuse, but this scenario occurs with far less frequency. In this study, 15 percent of the women reported reproductive coercion but no intimate partner violence, as compared with 35 percent of women who had experienced both. Elizabeth Miller et al., Pregnancy Coercion, Intimate Partner Violence and Unintended Pregnancy, 81 Contraception 316, 319 (2010).
- Miller, supra.
- Id. at 320.
- Id. at 318.
- Elizabeth Miller et al., Reproductive Coercion: Connecting the Dots Between Partner Violence and Unintended Pregnancy, 81 Contraception 457 (2010).
- National Conference of State Legislatures, Teen Dating Violence, www.ncsl.org/issues-research/health/teen-dating-violence.aspx (last visited Feb. 12, 2013).
- Michele C. Black et al., Centers for Disease Control & Prevention, The National Intimate Partner and Sexual Violence Survey: 2010 Summary Report 25 (2011).
- See, e.g., Elizabeth Miller et al., Male Partner Pregnancy-Promoting Behaviors and Adolescent Partner Violence: Findings from a Qualitative Study with Adolescent Females, 7 Ambulatory Pediatrics 360, 364 (2007).
- Timothy A. Roberts et al., Intimate Partner Abuse and the Reproductive Health of Sexually Active Female Adolescents, 36 J. of Adolescent Health 380 (2005).
- Futures Without Violence, The Facts on Adolescent Pregnancy, Reproductive Risk and Exposure to Dating and Family Violence (2012), www.knowmoresaymore.org/know/.
- National Conference of State Legislatures, supra.
- Am. Coll. of Obstetricians & Gynecologists, supra.
- Elizabeth Miller et al., A Family Planning Clinic Partner Violence Intervention to Reduce Risk Associated with Reproductive Coercion, 83 Contraception 274, 275, 276 (2011).
- Id. at 275.
- Id. at 278.
- Of women who experienced intimate partner violence, 29.2 percent in the intervention group reported ending a relationship for these reasons at follow-up, versus 20 percent in the control group. Id. at 278-79.
- Id. at 279.
- Comm. on Preventive Serv. for Women, Inst. of Medicine of the Nat’l Academies, Clinical Preventive Services for Women: Closing the Gaps 123 (2011).
- Health Res. & Serv. Admin., supra. For more information on the women’s preventive services guidelines, see Erin Armstrong, Nat’l Health Law Program, Q & A on Preventive Services for Women Coverage Requirements (2012), http://www.healthlaw.org/….
- Moyer, supra.
- Id. at 1, 3.
- Am. Coll. of Obstetricians & Gynecologists, supra. (“Because of the known link between reproductive health and violence, health care providers should screen women and adolescent girls for intimate partner violence and reproductive and sexual coercion at periodic intervals such as annual examinations, new patient visits, and during obstetric care (at the first prenatal visit, at least once per trimester, and at the postpartum checkup). Interventions include education on the effect of reproductive and sexual coercion and intimate partner violence on patients’ health and choices, counseling on harm-reduction strategies, and prevention of unintended pregnancies by offering long-acting methods of contraception that are less detectable to partners”).
- Inst. of Medicine of the Nat’l Academies, supra.
- See, e.g., David M. Fergusson et al., Childhood Sexual Abuse, Adolescent Sexual Behaviors and Sexual Revictimization, 21 Child Abuse & Neglect 789 (1997). Boys who are exposed to physical or sexual abuse or who observed domestic violence in their homes are also more likely to later impregnate their teenage partners. Futures Without Violence, supra