Today, on National Women and Girls HIV/AIDS Awareness Day, we want to remind people about the links between HIV transmission and intimate partner violence. Studies have shown that women who are subjected to abuse, especially sexual abuse by intimate partners, are at greater risk of HIV infection. There are several ways in which coercion and violence make it more likely that a woman will contract HIV. Violence robs a woman of her ability to refuse sex with an infected partner or to insist on using condoms. Forced sex creates physical wounds that increase the opportunities for HIV to pass from one person to the other. And there is evidence that girls who suffer sexual abuse are more prone to risk-taking behaviors when they are older. But violence does not just pave the way for AIDS; the formula also works the other way around. Revealing her HIV status or even that she was tested may entail severe consequences for an abused woman.

The problems intensify if the woman is both HIV+ and pregnant. Women who are subjected to ongoing violence by an intimate partner tend to be isolated and can have a hard time getting medical help. According to Margo Kaplan of the Center for HIV Law and Policy, complicating factors include the fear that HIV treatment drugs will harm fetal development. A woman might fear that authorities will take away her child or children when they learn she is HIV+ and in a violent relationship. She might worry that the medical professionals who provide prenatal care will reveal her HIV+ status to a violent partner or hostile community. All of these factors are barriers that prevent a woman from getting the help she desperately needs.

One new resource is the publication of a guide by The Center for HIV Law and Policy, called “HIV and Pregnancy: Medical and Legal Considerations for Women and Their Advocates.” It can be downloaded here.

We have known for many years that violence and abuse are more closely associated with unintended pregnancy than with pregnancies that are intended. Forced sex, fear of violence if she refuses sex, and difficulties negotiating contraception and condom use in the context of an abusive relationship all contribute to increased risk for unintended pregnancy as well as for sexually transmitted infections including HIV. Newer research now also points to the influences of male control of contraception and pregnancy pressure on unintended pregnancy.

We are lead researchers of a new study, which appeared in Contraception online in late January. The research report, “Pregnancy coercion, intimate partner violence and unintended pregnancy,” highlights a phenomenon we labeled reproductive coercion to describe explicit male behaviors to promote pregnancy. Particularly for women with a history of partner violence, these behaviors are significantly linked with unintended pregnancy.

Such reproductive coercion takes many forms, but frequently involves a male partner’s direct interference with a woman’s use of contraception (‘birth control sabotage’). It includes removing condoms during sex to get her pregnant, intentional breaking of condoms, and preventing her from taking birth control pills.2,3

In addition, a male partner may utilize threats and coercion to pressure a woman to get pregnant (‘pregnancy coercion’), such as telling her not to use contraception and threatening to leave her if she doesn’t get pregnant.

Our previous qualitative research has pointed to a range of reasons that a man might engage in such behaviors including wanting to leave a legacy, desiring to keep a woman connected to him in some way, as well as need for control in the relationship. Clearly, much more research with men and boys needs to be done to understand male involvement in unintended pregnancies and how to positively engage men and boys in discussions of healthy relationships.

Our new study included English- and Spanish-speaking women ages 16 to 29 who sought health care at five reproductive health clinics in California. The reasons the women sought care included annual physical exams, contraception, pregnancy testing, and testing for sexually transmitted infections.

Participants completed a confidential computerized survey (with questions read to them via headphones) before their clinic visit; the clinic providers did not see the responses. More than half of the respondents (53 percent) reported experiencing physical or sexual violence from a male partner, or someone they were dating or going out with some time in their lives. A quarter (25 percent) reported that they had ever experienced ‘reproductive coercion,’ with 19 percent reporting pregnancy coercion and 15 percent reporting birth control sabotage. Women who reported experiencing both partner violence and reproductive coercion experienced a 100 percent increase in their risk for unintended pregnancy.

Unintended pregnancy is clearly a complex phenomenon. It can be caused by a number of factors including: a mismatch of intentions and behaviors for both males and females (i.e., not wanting to get pregnant, while not using contraception or a condom, often called ‘contraceptive and pregnancy ambivalence’); limited access to contraception; lack of knowledge about the range of contraceptive options; stigma associated with asking a partner to use a condom; as well as substance use such as alcohol accompanying intercourse.

Our study adds another important piece to this puzzle: Male partners interfering with women’s reproductive autonomy. Moreover, the effect of male partner reproductive coercion on unintended pregnancy is likely to be greater in the context of partner violence, given the clear threat of violence if she tries to resist her partner’s wishes.

There are many unanswered questions around the interrelationship between reproductive coercion, partner violence, and unintended pregnancy. Our study provides preliminary findings indicating a significant connection, but it was limited to lower income women seeking care in a particular type of family planning clinic in a particular region. We need to know the prevalence of reproductive coercion when women are seeking gynecologic care in other settings such as hospitals or primary care clinics, as well as how prevalent this is across the general population.How often does reproductive coercion occur in the absence of partner violence? Does partner violence precede effective attempts to control a woman’s pregnancy and the outcomes of that pregnancy? Or do men’s coercive behaviors regarding contraception and reproductive outcomes precede physical and sexual violence in the relationship? How do men recognize and understand reproductive coercion? And, perhaps most critically, why do men engage in such controlling behaviors, and what strategies will successfully engage men and boys in preventing partner violence and reproductive coercion?

Beyond answering such research questions, we need to identify effective strategies to increase awareness about reproductive coercion among both men and women. Women may perceive reproductive coercion and physical violence in a relationship as distinct issues, and may need support and information to connect the dots between this range of behaviors and their reproductive health needs. If family planning practitioners pay attention to and address reproductive coercion, they may be more successful at identifying clients at risk both for unintended pregnancy and for harm from partner violence.

Further, such identification is likely to improve the efficacy of family planning services, because knowledge of reproductive coercion can inform counseling about contraceptive adherence and choices (women at risk can be offered methods that are not easily detected by male partners and are not reliant on male partner consent). This knowledge that a woman is experiencing reproductive coercion can trigger more intensive use of prevention strategies that can reduce unintended pregnancies, including among adolescents, and promote a woman’s safety.

It also would be wise to consider incorporating efforts to reduce reproductive coercion into comprehensive sexuality education and pregnancy prevention programs. Making discussions of healthy relationships the foundation of sexuality education would be a good start. Then incorporating discussions of abusive behaviors and partner violence into curricula that discuss contraceptive negotiation would be particularly helpful in increasing a woman’s success at contraceptive negotiation and enhancing her reproductive autonomy. Prevention programs that engage men and boys in reducing unintended pregnancies should also offer opportunities to discuss masculinities, gender equity, and reproductive justice.

Finally, vehicles like the currently authorized Violence Against Women Act’s Health Provision could assist in supporting needed health research and innovations in practice related to intimate partner violence and reproductive coercion, including efforts to promote healthy relationships. We should encourage professional health care provider organizations to recognize and develop relevant standards and competencies. For instance, family planning standards can be updated to address issues of partner violence and reproductive coercion.

Many people were stunned and alarmed by the Guttmacher Institute’s January report on teen pregnancy rates in the United States. It noted a three percent increase in pregnancies among 15- to 19-year-olds from 2005 to 2006—the first increase in some 15 years. While teens and young women report the highest rate of unintended pregnancies, many adult women experience unintended pregnancies as well. Experts have been telling us for years that almost half of pregnancies in the United States are unintended (i.e., mistimed, unplanned, and/or unwanted).

The causes and mechanisms that underlie unintended pregnancy are numerous and complex, but one thing is clear. If we are serious about reducing unplanned pregnancies in this country, we must bridge the gap between efforts to reduce violence against women and girls and efforts to reduce unintended pregnancy. We need innovative programs for both young men and women that address both partner violence and healthy relationships.

1. Miller, E., M. R. Decker, et al. (2010 Epub ahead of print). “Pregnancy Coercion, Intimate Partner Violence, and Unintended Pregnancy.” Contraception.

2. Center for Impact Research. (2000). “Domestic Violence & Birth Control Sabotage: A Report from the Teen Parent Project.”

3. Miller, E., M. R. Decker, et al. (2007). “Male Partner Pregnancy-Promoting Behaviors and Adolescent Partner Violence: Findings from a Qualitative Study with Adolescent Females.” Ambulatory Pediatrics 7(5): 360-366.

4. Finer, L. B. and S. K. Henshaw (2006). “Disparities in rates of unintended pregnancy in the United States, 1994 and 2001.” Perspectives on Sexual & Reproductive Health 38(2): 90-96.

“Pregnancy Coercion, Intimate Partner Violence and Unintended Pregnancy” is the first quantitative examination of the relationship between intimate partner violence, reproductive coercion and unintended pregnancy. It finds that young women and teenage girls often face efforts by male partners to sabotage their birth control or coerce or pressure them to become pregnant - including by damaging condoms and destroying contraceptives. These behaviors, defined as “reproductive coercion,” are often associated with physical or sexual violence.

It also finds that among women who experienced both reproductive coercion and partner violence, the risk of unintended pregnancy doubled.

The study was conducted by researchers at the University of California Davis School of Medicine and the Harvard School of Pubic Health. From August 2008 to March 2009, researchers worked at five reproductive health clinics in Northern California, querying some 1,300 English- and Spanish-speaking 16- to 29-year-old women who agreed to respond to a survey about their experiences. They were asked about birth-control sabotage, pregnancy coercion and intimate partner violence.

Key findings include:

• Approximately one in five young women said they experienced pregnancy coercion and 15 percent said they experienced birth control sabotage;
• Fifty-three percent of respondents said they had experienced physical or sexual violence from an intimate partner; and
• Thirty-five percent of the women who reported partner violence also reported either pregnancy coercion or birth control sabotage.

“Those of us who work to stop dating, domestic and sexual violence have long known that many victims face threats, verbal demands and physical violence designed to interfere with their efforts to use birth control,” said Family Violence Prevention Fund (FVPF) President Esta Soler. ”It is a big part of the reason that women in abusive relationships are at higher risk for unintended pregnancy.  This very important study underscores the link between violence and abuse and unintended pregnancy - and the need for providers at reproductive clinics to screen female patients for violence, as well as for pregnancy coercion and birth control sabotage. If we are serious about reducing unintended pregnancy in this country, we have to do more to stop violence and abuse, and help victims.”

“This study highlights an under-recognized phenomenon where male partners actively attempt to promote pregnancy against the will of their female partners,” said lead author Elizabeth Miller, an assistant professor of pediatrics in the UC Davis School of Medicine and a practitioner at UC Davis Children’s Hospital. “Not only is reproductive coercion associated with violence from male partners, but when women report experiencing both reproductive coercion and partner violence, the risk for unintended pregnancy increases significantly.”

“We have known about the association between partner violence and unintended pregnancy for many years,” said Jay Silverman, the study’s senior author and an associate professor of society, human development and health in the Harvard School of Public Health. “What this study shows is that reproductive coercion likely explains why unintended pregnancies are far more common among abused women and teens.”

Rebecca Levenson, a Senior Policy Analyst in the FVPF’s Health Unit, is a co-author of the new study. It was conducted in collaboration with the FVPF and the Planned Parenthood Shasta Diablo Affiliate.

The FVPF’s KnowMoreSayMore initiative is creating a dialogue about birth control sabotage and reproductive coercion, which can result in unintended pregnancy, HIV/AIDS, sexually transmitted infections, miscarriage, infertility, coerced abortion, poor birth outcomes including preterm birth and low birth-weight babies, and other serious health problems.

“The teens in our study know what they want in a relationship, but they either don’t know how to get it or don’t believe it is realistic,” said Lina Guzman, Ph.D., lead author of the study.

Male and female teens identified respect, honesty, and trust as the main components of a healthy relationship.  But they were more likely to define “healthy” by what is not:  cheating, disrespect, and violence.

The researchers suggest that programs aimed at teens include more mentors who can share information and experiences about strong, healthy relationships and encourage positive behavior rather than just avoiding the negative.  ”Our findings suggest that both mentoring and teen pregnancy prevention programs may benefit from incorporating discussions and activities on how to build healthy romantic relationships,” they wrote.

Moreover, education about healthy relationships should start in the pre- and early-teen years. “[R]elationship habits, expectations, and behaviors formed in adolescence have implications for adult relationships,” the report says.  ”Adolescence may be a key window of time to help foster positive behaviors and curtail the cycle of intimate partner violence whose seeds are often planted early.”

The Family Violence Prevention Fund encourages dating violence prevention programs and sexuality education programs to integrate information about healthy relationships.

Secretary of State Hillary Rodham Clinton gave a powerful speech recommitting the United States to prioritizing women’s access to reproductive health services and programs as a path to better health and equality. The January 8 speech at the State Department commemorated the 15th anniversary of the International Conference on Population and Development (ICPD) – the first ever global forum to recognize the connection between women’s health, the quality of women’s lives and human progress.

The Secretary noted that 15 years after the landmark Cairo conference, vast inequities remain. “Too often, still today in 2010, women and girls bear the burdens of regional and global crises, whether it’s an economic downturn or climate change or political instability. They still are the majority of the world’s poor, unschooled, unhealthy, and underfed. They are rarely the cause of violent conflicts, but increasingly they bear the consequences of such conflicts. We’ve seen that from the Congo to Bosnia to Burma. And 15 years after the Cairo conference, far too many women still have little or no access to reproductive health services, including family planning and maternal health care,” she told the audience of State Department employees, advocates and experts.

“In societies where women’s rights and roles are denied,” she added, “girls are forbidden from attending school or they pay a very heavy price to try to do so. Few have the right to decide whether or when to get married or become mothers. Poverty, political oppression, and even violent extremism often follow.” 

The world has made measurable progress in improving the lives of women and girls – including a global increase in contraception use, greater access to neo-natal care and to medicines that prevent the spread of HIV from mother to child, increased child survival rates and a growing number of girls attending schools, she said. Yet today, some 215 million women worldwide lack access to modern forms of contraception, which leads to sexually transmitted diseases including HIV/AIDS, unintended pregnancy, abortion, infant mortality, and a range of maternal and child health problems.

“If we believe that human rights are women’s rights and women’s rights are human rights, then we cannot accept the ongoing marginalization of half the world’s population,” the Secretary warned. “In the Obama Administration, we are convinced of the value of investing in women and girls, and we understand there is a direct line between a woman’s reproductive health and her ability to lead a productive, fulfilling life. Therefore, we believe investing in the potential of women and girls is the smartest investment we can make. It is connected to every problem on anyone’s mind around the world today. So we are rededicating ourselves to the global efforts to improve reproductive health for women and girls.”

2015 is the target year for completing the goals set forth back in 1994 at ICPD. At that conference, 179 nations agreed on actions needed to achieve universal access to: education, especially for girls; reductions in infant, child and maternal mortality; and universal access to reproductive health over the next 20 years. Many United Nations conferences and international meetings have reaffirmed the Cairo Consensus, including the 1995 Fourth World Conference on Women, which established the Beijing Platform for Action, and the 2000 Millennium Summit, which established the Millennium Development Goals.

Secretary Clinton closed her speech by saying that achieving these goals to improve the health of women and children worldwide is in America’s best national security interests. She asked advocates to help “create institutional and structural change that does not get wiped away when the winds change.”

Secretary Clinton’s remarks are available here. For information on the International Conference on Population and Development and a video of the speech, please visit www.icpd2015.org/. Information on the international center the Family Violence Prevention Fund broke ground on the day Secretary Clinton gave her speech is here.   The Family Violence Prevention Fund’s statement on Secretary Clinton’s speech is here.
]]> http://www.knowmoresaymore.org/2010/01/access-to-reproductive-health-care-essential-for-women%e2%80%99s-health-and-progress-secretary-clinton-says/feed/ http://www.knowmoresaymore.org/2009/12/stupak-pitts-amendment/ http://www.knowmoresaymore.org/2009/12/stupak-pitts-amendment/#comments Wed, 09 Dec 2009 20:29:32 +0000 margaret http://www.knowmoresaymore.org/?p=274 The Family Violence Prevention Fund (FVPF) is concerned about the impact of the Stupak- Pitts Amendment on a woman who is in an abusive relationship. This amendment would effectively prohibit a woman from purchasing private health insurance that would coverage abortion care.  A growing body of evidence points to a much more complicated picture of unintended pregnancy and abortion than our politicians would like to admit.  For many years we have known that domestic and sexual violence are widespread in this country.  Nearly one-third of American women (31 percent) report being physically or sexually abused by a husband or boyfriend at some point in their lives.[i] We also know that domestic and sexual violence increase the risk of unintended pregnancy and abortion as well as STDs/HIV.  For instance:

• Women seeking an abortion are 3 times more likely to be the victim of intimate partner violence compared to women who were continuing their pregnancies.[ii]
• 1 in 5 women seeking a repeat abortion disclosed a history of physical IPV.[iii]
• Among women seeking a protection order, 20% had experienced a rape related pregnancy.[iv]

But recent research shows that abusive partners go beyond physical and sexual violence alone to more subtle behaviors that we have termed “sexual and reproductive coercion.”  These behaviors include: interfering with the couple’s birth control; attempting to impregnate a partner against her will; threatening or acting violent if a partner does not comply with the other partner’s wishes regarding sexual activity, contraception or the decision whether to terminate or continue a pregnancy; and intentionally exposing a partner to STIs.  We are learning that these behaviors are extremely common, rarely addressed and can have devastating consequences.

A pilot study conducted in a family planning clinic by the FVFP, UC Davis School of Medicine, and Harvard School of Public Health found:

• The lifetime prevalence of sexual and reproductive coercion by a partner was 25%.
• 1 in 5 women seeking family planning experience interference with their birth control;
• 1 in 6 experience pregnancy coercion[v]

So what do these facts mean in a real woman’s life?  Consider these stories of contraceptive coercion that lead to pregnancy:

“I was on the birth control, and he ended up getting mad and flushing it down the toilet, so I ended up getting pregnant.” [vi]

“…[O]r like when I had the pill, he used to act out and ask me why I am using them, [...] I am hiding to use it and stuff like that. Then, there was another time I started using the ring and he pulled it out of me. [...] I was like, “I thought I could actually hide this one, not knowing you will come up inside of me and pull it out of me.”[vii]

Or listen to why some men refuse to wear condoms:

“…if she’s saying no, she could leave… while you’re putting the condom on. So…you don’t have time…”[viii]

“…if she doesn’t want to [have sex], then she’ll leave if you’re trying to put a condom on and, you know, she doesn’t want to do it so you don’t want her to get away.” [ix]

Or this story of a boyfriend who intentionally got his 19 year old girlfriend pregnant - not because he wanted to be a father — but because he did not want her to leave him:

“I should just get you pregnant and have a baby with you so that I know you will be in my life forever.”[x]

For every statistic, there is a real woman with a real story.  Healthcare reform - something the FVPF strongly supports - should be about how we can support a woman’s health and safety.

The essence of health insurance is to plan for the unexpected.  No woman expects to have an unplanned pregnancy or to have an abortion.  No woman plans to be in an abusive relationship.  But if she is in such a situation, we can agree that she should have all of her options.

We need health policies that reflect the realities of a woman’s life, not someone’s political agenda.  At the FVPF, we know that domestic and sexual violence lead to unintended pregnancy and abortions.  When a woman is struggling to control her life the last thing she needs is to be denied all of her options.

[ii] Bourassa D, Berube J.  The Prevalence of Intimate Partner Violence Among Women and Teenagers Seeking Abortion Compared with Those Continuing Pregnancy.  Journal of Obstetrics & Gynaecology Canada. 2007;29(5):415-423.

[iii] Fisher WA, Sukhbir S, Singh SS, Shuper PA,  Carey M, Otchet F, MacLean-Brine D, Dal Bello D, Gunter J. Characteristics of Women Undergoing Repeat Induced Abortion.  CMAJ. 2005;172(5):637-641.

[iv] McFarlane J, Malecha A, Watson K, Gist J, Batten E, Hall I, Smith S.  Intimate Partner Sexual Assault Against Women: Frequency, Health Consequences, and Treatment Outcomes.  Obstetrics & Gynecology. 2005;105:99-108.

[v] Miller, E, personal communication, 2009

[vi] Miller, E et al. Male partner pregnancy promoting behaviors in adolescent partner violence: findings from a qualitative study with adolescent females. Ambulatory Pediatrics 2007: 360-66

[vii] Moore, A, Frohwirth, L, Miller, E, Personal communication, 2009

[viii] Silverman, J G et al. Social norms and beliefs regarding sexual risk and pregnancy involvement among adolescent males being treated for dating violence perpetration. Journal of Urban Health , 2006;83: 723-35

[ix] Silverman, J G et al Social norms and beliefs regarding sexual risk and pregnancy involvement among adolescent males being treated for dating violence perpetration. Journal of Urban Health , 2006;83: 723-35

[x] Moore, A, Frohwirth, L, Miller, E, Personal communication, 2009

A new study illustrates the strong link between partner violence and negative reproductive health outcomes. The study, published in this month’s issue of General Hospital Psychiatry, reveals that those who are in physically abusive relationships are at higher risk for HIV infection.

The study involved nearly 14,000 U.S. women ages 20 and older. The results showed that women who experience violence from their partners were more than three times as likely to have HIV as women who do not. Almost 12% of the HIV infection was due to intimate partner violence.

A news release on the study can be found here; the full article is here.

]]> http://www.knowmoresaymore.org/2009/06/new-study-those-in-abusive-relationships-have-higher-risk-for-hiv/feed/ http://www.knowmoresaymore.org/2009/06/senate-committee-hears-about-the-link-between-violence-and-unintended-pregnancy/ http://www.knowmoresaymore.org/2009/06/senate-committee-hears-about-the-link-between-violence-and-unintended-pregnancy/#comments Tue, 16 Jun 2009 21:27:50 +0000 margaret http://www.knowmoresaymore.org/?p=243 Ann Burke, R.N., M. Ed., testified last week at the U.S. Senate Judiciary Committee hearings on “The Continued Importance of the Violence Against Women Act (VAWA).”

As part of her testimony, Ms. Burke, who is president and founder of the Lindsay Ann Burke Memorial Fund in Rhode Island, cited Dr. Jay Silverman’s research on reproductive coercion.  She noted, “Recent research has found a strong connection between violence among young people and poor reproductive health outcomes. A study published in the Journal of the American Medical Association found that one in three U.S. high school girls who has been abused by a boyfriend has become pregnant. By reducing dating violence, we can reduce unintended teen pregnancies.”

To view a webcast of the hearings, click here.