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Health Disparities, Healthcare, Justice, Justice System, Politics, Public Health, Public Policy, Social Justice, Uncategorized, Women's Health

Reproductive Coercion: The Facts, Stats, and Scary Reality of This Growing Problem

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Reproductive coercion is one of the least discussed forms of intimate partner violence, and many are unaware that it even exists or that it is a type of abuse. Despite the lack of awareness, reproductive coercion is shockingly common, and many women who experience it are also victims of other forms of intimate partner violence such as physical and psychological abuse. Unfortunately, our justice system does not treat reproductive coercion as a crime like they do other forms of intimate partner violence, but many domestic violence advocates are working to change that.

 What is Reproductive Coercion?

The Family Violence Fund defines reproductive coercion as “threats or acts of violence against a partner’s reproductive health or reproductive decision-making.” Explaining the link between reproductive coercion and other forms of intimate partner violence, the American College of Obstetricians and Gynecologists’ (ACOG) 2013 Committee Opinion on reproductive coercion says that “reproductive and sexual coercion involves behavior intended 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.”

According to the ACOG, examples of reproductive coercion include hiding, withholding, or destroying a partner’s birth control pills; intentionally breaking condoms or removing a condom during sex; not withdrawing during intercourse when that was the agreed upon method of contraception; removing contraceptive patches, rings, or IUDs; attempting to force/ coerce a partner to have an abortion against their will; controlling abortion-related decisions; refusing to wear a condom when a partner wants to use one; pressuring someone to do sexual things when they don’t want to; and threatening to end a relationship if a partner doesn’t have sex.

Elizabeth Miller, MD, PhD., Beth Jordan, MD, Rebecca Levenson, MA, and Jay Silverman, PhD, were among the first researchers to identify and highlight the problem of reproductive coercion.  They explain that reproductive coercion can include a variety of “explicit male behaviors to promote pregnancy [that is] unwanted by the women.” Most commonly, these behaviors include “’birth control sabotage’” (interference with contraception) and/or ‘pregnancy coercion,’ such as telling a woman not to use contraception and threatening to leave her if she doesn’t get pregnant.”

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How Common Is Reproductive Coercion?

According to the National Crime Victimization Survey, approximately 1 in 5 adolescent girls and young women have experienced pregnancy coercion and one in seven have experienced active interference with contraception. In another study, researchers found that 16% of women ages 18-44 had experienced reproductive coercion, and one-third of reproductive coercion victims were also victims of other forms of intimate partner violence.

The prevalence of reproductive coercion is much higher among women in abusive relationships. According to one study, young women in abusive relationships are five times as likely to be forced into not using a condom and eight times more likely to be pressured to become pregnant. In a nationwide survey of over 30,000 callers to the National Domestic Violence Hotline, researchers at the Family Violence Prevention Fund found that more than 1 in 4 women had experienced birth control sabotage and pregnancy coercion. The researchers say that the rate of reproductive coercion is likely even higher than their findings showed because some callers who experienced this form of control were not included in the survey because they needed to be referred to help immediately. As a result of this study, the National Domestic Violence Hotline introduced new training for Hotline employees and volunteers to help them identify and support callers who experience reproductive coercion.

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The Relationship Between Reproductive Coercion and Other Forms Of Intimate Partner Violence

Researchers, health care professionals, domestic violence agencies, and legal experts agree that reproductive coercion is a type of domestic violence/intimate partner violence (IPV). Domestic violence is characterized by the use of physical violence, coercion, threats, intimidation, isolation, stalking, or emotional, sexual or economic abuse to gain or maintain power and control over another partner in an intimate relationship, and includes any behaviors that intimidate, manipulate, humiliate, isolate, frighten, terrorize, coerce, threaten, blame, hurt, injure, or wound someone. Given that coercion is explicitly mentioned in the definition of domestic violence, reproductive coercion certainly meets the criteria for abuse.

 According to a 2012 briefing issued by the California Law Review:

“[reproductive coercion] may take the form of direct interference or may be acted out through indirect coercion by threatening to harm a victim if she utilizes contraception.”

Similar to other types of abuse, reproductive coercion includes a wide variety of abusive and manipulative behaviors, and is often characterized by insidious tactics used to gain power and control over the victim.

The law review says that “male perpetrators use the possibility of pregnancy as a means to control their female victims in hopes of dominating them and precluding them from partaking in any alternate romantic pursuits. Additionally, a woman’s lack of power to negotiate contraceptive use and her partner’s refusal to pay for contraception hinders her ability to avoid an unwanted pregnancy.”

In addition to controlling, manipulating, and/or suppressing women’s reproductive decisions, abusers may also engage in other forms of IPV to gain more power and further diminish women’s autonomy. Creating isolation is one of the most common ways abusers gain control over their victims. For example, a woman’s partner may use threats, intimidation, and/or physical violence to prevent her from seeking employment, spending time with family and friends, or even using the telephone or driving a vehicle. Another common tactic is restricting the victim’s access to financial resources, thereby forcing the victim to become financially dependent on her abuser. According to the National Network to End Domestic Violence, “financial abuse is one of the most powerful methods of keeping a victim in an abusive relationship and deeply diminishes her ability to stay safe after leaving an abusive relationship.” The effects of economic abuse may be further intensified in situations involving women who become pregnant as a result of reproductive coercion.

In an interview with the Daily Beast, Katie Ray-Jones, president of the National Domestic Violence Hotline, describes two cases of reproductive coercion that highlight the connection with other forms of relationship violence:

“We had a woman who had seven children,” said Ray-Jones. Her husband “would impregnate her back to back so she wouldn’t be able to get a job, she’d always have an infant to care for and wouldn’t have any financial stability.” Though the husband was physically abusive, Ray-Jones recalled, “It was an extra challenge for us because it was hard to find a shelter that would take seven kids.” Even more harrowing, she said, was “another caller [who] told us [her partner] would get her pregnant, then force her to go get an abortion and began to punch her when she refused to get one.”

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Reproductive Coercion and Women’s Health

Intimate partner violence, including reproductive coercion, has significant implications for women’s health. IPV victims have a higher risk of many negative health outcomes including mental illness, chronic pain, substance use, gynecological problems, unintended pregnancy, and sexually transmitted infections. Among pregnant women, abuse is associated with unsafe abortion, miscarriage, stillbirth, low birth weight, and neonatal mortality. Further, victims of abuse are more likely to be unaware of their pregnancy and thus may be unable to access safe abortion services due to restrictive abortion legislation.

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Many experts believe that reproductive coercion may partially account for the increased rates of sexually transmitted infections (STI) among victims of IPV, who are almost three times as likely to have an STI than women in the general population. Reproductive coercion may also be a mechanism that helps to explain the known association between IPV and unintended pregnancy. Young women and adolescents who are victims of IPV are 4-6 times more likely than non-abused women to become pregnant, and 40% of abused pregnant women report that their pregnancy was unintended, compared to just 8% of non-abused pregnant women.

Victims of reproductive coercion have over twice the risk of unintended pregnancy than women in the general population. As a result, women who experience reproductive coercion are significantly more likely to use emergency contraception or abortion services to terminate an unwanted pregnancy from their abuser. Among women seeking abortions, the prevalence of IPV – including reproductive coercion – is three to four times that of the general population. In two separate studies, researchers found that 40% of women and teenage girls seeking termination of pregnancy had experienced physical and/or sexual abuse.  Restricting women’s access to these services makes it even harder for victims to escape abusive relationships and further diminishes their ability to control their own reproductive health.

Responding To The Crisis

Women’s health experts say that health care providers – particularly obstetricians and gynecologists – should routinely assess reproductive-age women for reproductive coercion and IPV in order to tailor family planning discussions and recommendations to each woman’s needs. Dr. Lindsay Clark, a lead investigator for several studies on reproductive coercion, says that mounting evidence highlights the public health impact of reproductive coercion. “Reproductive coercion may lead to unprotected intercourse and thus could have significant implications for health care providers’ efforts to promote reproductive health and family planning,” says Clark. “With improved understanding, [ob-gyns] will be better equipped to identify affected female patients and offer them options to help interrupt the cycle of birth control sabotage, male power over pregnancy decision making, and unwanted pregnancies.”

Elizabeth Miller, MD, PhD., Beth Jordan, MD, Rebecca Levenson, MA, and Jay Silverman, PhD, some of the first researchers to identify and highlight the problem of reproductive coercion, offer recommendations for improving the health care response to victims of reproductive coercion:

“Reproductive coercion provides a new lens on contraceptive decision-making and counseling women regarding pregnancy prevention options. This evidence linking partner violence, male influences on contraceptive decision-making, and unintended pregnancies underscores the need to strengthen connections between family planning practices and policies with efforts to reduce intimate partner violence. Reproductive health care providers should receive specific tools to assess for reproductive coercion, and strategies to help affected clients. These tools and strategies include safety cards and posters that educate clients about reproductive coercion and methods of contraception that partners cannot interfere with (i.e., intrauterine devices, injectable contraceptives); policies that ensure clients have access to emergency contraception as well as longer acting and hidden forms of contraception; and training for providers on how to offer referrals to domestic violence hotlines and shelter resources. Planned Parenthood Federation of America has been working in tandem with the Family Violence Prevention Fund to implement these tools and strategies.”

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What’s Next?

Last month, the Supreme Court of Canada convicted a man of sexual assault after he admitted to poking holes in condoms to get his girlfriend pregnant in an effort to prevent her from ending the relationship. In the U.S., current sexual assault and domestic violence laws make it nearly impossible to prosecute reproductive coercion – even though a person can be prosecuted for forcing a woman to end a pregnancy.

In a 2012 policy analysis, the Guttmacher Institute concluded that forcing a woman to become pregnant is no different than forcing a woman to terminate a pregnancy:

“Each case violates women’s basic human rights: the right to decide freely whether and when to bear a child and the right to have that decision respected by the government.”

However, only one of these is crime.

Although domestic violence is against the law, reproductive coercion is not yet recognized as a crime in the U.S. criminal justice system. Depending on the circumstances surrounding the abuse, some cases of reproductive coercion could be covered under the provisions of a legal statute – for example, several states have specific personal injury claims that may apply if a woman’s partner knowingly exposes to her to a sexually transmitted disease during the commission of reproductive coercion (which could happen if a man pokes holes in a condom). However, legal experts agrees that current statutes make it very unlikely that reproductive coercion could be successfully prosecuted in the U.S., and most professional organizations and domestic violence advocates say that reproductive coercion should be included under the law as another form of intimate partner violence, thereby greatly increasing women’s legal protection from abusive partners.

In a 2012 legal briefing, the California Law Review urged state legislatures to “act quickly to criminalize” reproductive coercion, saying that the evidence “linking reproductive coercion and domestic violence provide a sufficient justification for labeling [reproductive coercion] as an intentional” unlawful act. They contend that reproductive coercion is a form of domestic violence that constitutes an attack on female autonomy and independence. Noting the difficulty of prosecuting reproductive coercion under existing legal statutes, the law review says that “legislatures would be wise to create an independent criminal cause of action for birth control sabotage” and other forms of reproductive coercion. Further, the briefing also discusses the important implications of criminalizing reproductive coercion in an effort to prevent other types of domestic abuse:

“Recent scholarship has failed to recognize the important intersection of reproductive coercion and domestic violence even though reproductive coercion occurs at a significantly higher rate in violent intimate partner relationships than in other relationships. The increasingly apparent relationship between reproductive coercion and violence demonstrates the imminent need to reevaluate how reproductive coercion may fit into existing family law and domestic violence civil liability schemes; this correlation also underscores the importance of criminalizing reproductive coercion as a deterrent to other ongoing violence.”

Politicians and health care professionals also have a role in protecting the rights of victims. According to family planning expert Dr. Colleen McNicholas, in the past two years “at least two states have proposed or enacted legislation that allows physicians to withhold information from a woman about her pregnancy if they feel the information would result in her choosing to terminate, essentially permitting reproductive coercion by the physician,” which Dr. McNicholas calls a “universally deplorable form of violence against women.” For victims of reproductive coercion, being able to terminate an unwanted pregnancy resulting from birth control sabotage may be the only way for a woman to permanently escape an abusive relationship and regain control over her body and reproductive health. In a nationwide longitudinal study investigating women who were denied abortions because of restrictive state policies, researchers found that women who were turned away after seeking an abortion were more than twice as likely as women who were not turned away to experience domestic violence in the next 6 months and to remain in abusive relationships. The researchers say that these women were already in abusive relationships prior to seeking abortion services, and those who were denied coverage likely felt pressured to stay with or unable to leave the father of the baby, while those who were able to terminate their pregnancy had more control over leaving their abusive partners and ending the relationship.

Recent attempts to limit women’s access to birth control and abortion services may serve to perpetuate abuse and further disempower victims of reproductive coercion by denying them the right to full reproductive choice. States like Texas, which recently enacted new legislation resulting in the closure of over one-third of the state’s family planning and abortion clinics, make it nearly impossible for women in abusive relationships to access critical health care including screening and treatment for STI’s, emergency contraceptives, and abortion services. Restricting women’s reproductive choices has significant long-term consequences for the woman and baby, particularly in the context of an abusive relationship. Further, there is no evidence that abortion bans lead to lower abortion rates; rather, women who live in areas with restrictive abortion policies are more likely to turn to unsafe, illegal abortions. As a result, an estimated 47,000 women die each year from unsafe abortions, making up 13 percent of all maternal deaths.

For women who cannot access abortion services or are denied the option, forcing them to carry an unwanted pregnancy to term is the ultimate injustice. Amanda Marcotte of RH Reality Check, a reproductive justice organization, writes, “Forcing an abuse victim to have a baby against her will by her abuser is doing the abuser’s work for him.” Shockingly, some anti-choice groups advise their counselors to try to talk women out of having an abortion, even when the woman is clearly in an abusive relationship and was forced or manipulated into becoming pregnant. In one instance, an anti-choice counselor actually suggested that having a baby would bring an end to the abuse. Marcotte points out that, in reality, forcing an abused woman to carry an unwanted pregnancy from her abuser baby often makes the abuser “feel like they can get away with more abuse, because the child makes it that much harder for a woman to escape,” and in many instances, domestic abuse actually escalates during pregnancy. Homicide at the hands of an intimate partner is one of the leading causes of death for pregnant women.

Many health professionals and legal experts say that forcing a woman to carry an unwanted pregnancy to term is a form of reproductive coercion in itself – and a violation of their human rights. This is an issue that affects all women, not just victims of reproductive coercion. As Think Progress wrote earlier this week,

Unfortunately, the women who experience reproductive coercion aren’t necessarily the only example of Americans who are forced to be pregnant against their will. Record-breaking numbers of state-level abortion restrictions have created a world in which many women must carry an unwanted pregnancy for longer than they would prefer. For instance, even though nearly 90 percent of women are “highly confident” about their desire to have an abortion when they first approach a doctor, 26 states require them to wait at least 24 hours before having the procedure anyway. In South Dakota, that wait can stretch on for up to six days. And low-income women, who typically have to delay having an abortion while they save up the money for it, often run out of time and go on to have unintended births. The women who end up giving birth against their will are more likely to slip deeper into poverty and struggle with long-term mental health issues.”

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