Reproductive Coercion Module

Upon completion of this module, individuals will be able to…

• Define and explain the term reproductive coercion to patients

• Understand the patient’s current situation and needs

• Create a safe environment to permit disclosure of intimate partner violence and reproductive coercion

• Incorporate the patient’s priorities into medical decision making

• Prioritize the patient’s safety in considerations of reporting and seeking safety

• Advocate for patient safety

• Understand the negative impact of coerced pregnancy and denied abortions

Reproductive coercion is a form of sexual and gender-based violence rooted in power differentials where an abuser is in control of the reproductive decisions of an individual. It can be seen in various forms of sexual violence including within the framework of intimate partner violence.

Understanding reproductive coercion, its role in intimate partner violence, and the importance of the availability of abortion as a reproductive health care option in this context is crucial for physicians to effectively facilitate disclosure and allow for conversations with patients. By understanding the concepts below, medical professionals can be better equipped to support patients who express that they are experiencing reproductive coercion and are seeking abortions in situations where they do not want to continue a pregnancy.

This lesson presents an overview of intimate partner violence and its dynamic in reproductive healthcare. This is accompanied by a discussion of reproductive coercion and the effect of abortion restrictions on individuals experiencing this form of intimate partner violence.

Practitioners can utilize the following skills when treating a patient who is experiencing reproductive coercion

• Define and explain the term reproductive coercion to patients

• Understand the patient’s current situation and needs

• Create a safe environment to permit disclosure of intimate partner violence and reproductive coercion

• Incorporate the patient’s priorities into medical decision making

• Prioritize the patient’s safety in considerations of reporting, seeking safety, and pregnancy decisions

• Advocate for patient safety

• Understand the negative impact of coerced pregnancy and denied abortions

It should be noted that this module is meant to guide medical professionals in the care of adult patients (18 years old and over). In the case of intimate partner violence or any form of abuse for patients who are minors (under 18 years old), healthcare professionals are mandatory reporters and must inform the appropriate authorities based on the country or state in which they are located- laws may vary by country and state.

Intimate partner violence can be in the form of physical violence, sexual violence, psychological abuse, or stalking by current or previous partners. It involves a pattern of purposeful coercion and control through violence, intimidation, and abuse.

Reproductive coercion is a type of intimate violence in which an abuser uses reproduction and sexual health as a form of control. This can involve the abuser doing any of the following:

• Coercing or forcing an individual to have unprotected sex

• Tampering with contraceptive methods

• Lying about the use of contraceptive methods

• Forcing their pregnant partner to have an abortion or not have an abortion

Reproductive coercion is more commonly seen in the case of a male abuser towards a female due to the potential for pregnancy but can be seen in the case of a female abuser towards a male as well. The dynamic within which reproductive coercion exists makes it a form of sexual, emotional, and financial abuse of an individual. 

Reproductive Coercion Statistics 

Reproductive coercion is an ongoing problem, but there have been increased risks and reports since 2022 with the overturn of Roe v Wade. 

Between October and December 2023, the National Domestic Violence Hotline conducted a survey about reproductive coercion. Of the 3,431 responses: 

• 63% said their current or former partner pressured or forced them to have sex or other sexual activity when they didn’t want to

• 39% said their current or former partner threatened them if they said no to sex or other sexual activity

• 23% of respondents said their current or former partner pressured them into becoming pregnant

• 13% of respondents said their current or former partner used or threatened violence while they were pregnant, with the intention of ending the pregnancy

• 23% said their current or former partner knowingly exposed them to an STI/STD.

• 37% said their current or former partner refused to or prevented them from using condoms, diaphragms, or STI/STD prevention methods.

• 20% said their current or former partner prevented them from using birth control (pills, patches, rings, IUDs, etc.)

  • Using methods such as destroying, hiding, tampering with, or withholding contraception

Pregnancy and Intimate Partner Violence 

Pregnancy itself is very dangerous in the setting of intimate partner violence, as this can be associated with an increase in violence from an abuser. 

In the United States, homicide is the leading cause of death among pregnant women. In a study of 2008 to 2019 data on women ages 15 to 44 from the National Violent Death Reporting System, it was found that in the homicides that occurred against pregnant women, 71% of cases involved intimate partner violence. Suicide is also seen at higher rates among pregnant women experiencing intimate partner violence, with 45% of suicides among pregnant or post-partum individuals involving intimate partner violence.

Key Terms:

• Physical abuse: Abuse in the form of hitting, shoving, pushing, choking, punching, burning, etc. Physical abuse also involves the use of firearms or any weapon against an individual. Sexual abuse is a form of physical abuse

  • This is typically seen in the intimate partner violence situations in which reproductive coercion can occur.

• Sexual abuse: Unwanted or unconsented sexual contact with an individual 

  • This can be the cause of pregnancy in the case of intimate partner violence and reproductive coercion

  • This includes tampering with birth control, refusal to use protection, and knowingly transmitting an STI to someone without their knowledge

• Emotional/Psychological abuse: The use of name-calling, degradation, threats, coercion, and other methods to harm an individual emotionally and/or mentally as a form of demonstrating and maintaining control. Isolation or the removal of one’s support system can also be used as a tactic by abusers, whether geographically or by making claims that family/friends will not protect an individual from their abuse or do not care about them.

  • This can be seen in the context of reproductive coercion with what an abuser might say to an individual to force them to keep the pregnancy and remain in a violent situation.

• Financial abuse: Cutting off the ability for an individual to support themselves financially by taking away their access to money or preventing them from getting a job and making money themselves

  • This is seen in reproductive coercion because forcing an individual to become pregnant can allow an abuser to restrict their ability to work and have future disposable income that may have otherwise been used in a way to leave an unsafe situation.

Creating a safe environment where disclosure can occur begins with the patient entering a medical setting. In waiting rooms, including posters or flyers defining reproductive coercion can help as well as resources regarding seeking safe locations and the local hotline for intimate partner violence (In the US: 1-800-799-7233).

How can you be alert for Intimate Partner Violence in the Medical Setting? 

Whether in a clinic or hospital setting, a standard and regularly conducted intimate partner violence screening including questions regarding reproductive coercion for both pregnant and non-pregnant individuals is recommended. This could be with all new patient appointments and each annual visit or with every emergency visit for non-pregnant individuals and periodically during obstetric care for pregnant individuals. The American College of Obstetrics and Gynecology recommends that screening is given at the first prenatal visit, at least once per trimester, and at the postpartum check-up.

Validated Intimate Partner Violence Screening Tools 

• Abuse Assessment Screen

  • Assesses the occurrence of intimate partner violence based on: Emotional Abuse, Physical Abuse, Forced Sexual Activity, and Fear

• HITS Screening- Hurt, Insult, Threaten, Scream

  • Assesses the HITS areas to detect intimate partner violence

• Partner Violence Screen

  • 3 question screening regarding recent violent interactions and feelings of safety

• STaT Screening- Slapped, Things, and Threatened

  • Assesses the STaT areas to detect intimate partner violence

• WAST Assessment- Women Abuse Screening Tool

  • Evaluates tension in a relationship and asks how arguments are resolved in a relationship

More information about validated Intimate Partner Violence Assessments can be found at: https://www.cdc.gov/violenceprevention/pdf/ipv-prevention-resource_508.pdf 

Important Aspects of Intimate Partner Violence Screening 

Before the screening, it is important to highlight the mandatory reporting laws within your state or country to ensure that your patient is not blindsided by your role as a mandatory reporter in the event that they disclose certain information. Most states in the United States do not require health care providers to report intimate partner violence against adults (18 years and older) (See Section 3 of this module for more details).

Taking note of the individuals who accompany the patient to the medical facility is also important as a patient experiencing intimate partner violence and reproductive coercion may be accompanied by the abuser.

It is important to conduct this screening when the patient is alone and in a safe setting, such as in the patient room. A strategy to allow for this in the case of someone accompanying the patient to the office is to ask to see the patient in the patient room for an individual exam prior to the accompanying individual coming from the waiting room. If there is difficulty in getting a patient alone, one could use strategies such as having the accompanying individual retrieve an object from or give some forms to office staff.

Reproductive Coercion Screening 

The American College of Obstetrics and Gynecology recommends that screening for reproductive and sexual coercion is given at the same interval as an IPV screening with regular checkups and during pregnancy: first prenatal visit, at least once per trimester, and at the postpartum check-up. 

While validated IPV tools can detect reproductive and sexual coercion, physical abuse is more often the focus of the aforementioned tools. For this reason, ACOG recommends the inclusion of the following questions to all IPV screeners to also effectively and explicitly address reproductive coercion:

• Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?

• Has your partner ever tried to get you pregnant when you did not want to be pregnant?

• Are you worried your partner will hurt you if you do not do what he wants with the pregnancy?

• Does your partner support your decision about when or if you want to become pregnant?

Reproductive Coercion and Contraception 

Contraception can be a major aspect of focus for a patient experiencing reproductive coercion. For any patient who is seeking birth control refills more regularly than expected (For example, a patient who comes in after 2 months for a refill on birth control when they were given a 3 month supply) or asking for discrete forms of contraception, IPV and reproductive coercion screenings should be utilized. 

Once the screening is completed and reproductive coercion has been identified, the patient has options for contraception access that can be beneficial regardless of what they choose as their next steps. Discrete contraception methods available include IUDs with strings cut, implants such as Nexplanon, and injected Depo Provera. Depo Provera has a special utility in this situation since it is an intramuscular injection that can be given at the doctor’s office every 3 months. Use of Depo Provera has less risk of being discovered by the abuser because it is not a physical device and it can increase the patient’s interaction with medical professionals, allowing for more regular check ins on the patient’s safety and health. 

However, it should be noted that these methods of contraception do have side effects that can include increased bleeding, cramping, and injection or insertion site reactions that should be told to the patient due to the risk of the abuser noticing in the days following device insertion or injection administration. 

It is important to focus on the patient in all aspects of medical care, but that could not be of more importance in the case of intimate partner violence and reproductive coercion. Given the dynamic of intimate partner violence, it is likely that the individual experiencing reproductive coercion does not feel a sense of autonomy over their own body, much less in their medical care. As a medical professional, you should be able to encourage their decisions to leave an unsafe situation but talk them through their safety considerations and fears.

Mandatory Reporting Considerations 

Exceptions to this are in the case of mandatory reporting requirements for medical professionals, which should be considered for patients experiencing and disclosing intimate partner violence and reproductive coercion. It is for this reason that intimate partner violence screenings should begin with the restrictions a medical professional faces in that state and/or country to ensure that the patient is aware of situations when confidentiality may not be legally possible.

Although this is the law and should be followed by all medical professionals, studies have found that mandatory reporting laws in the case of intimate partner violence deter individuals from disclosing experiences of abuse. As a physician, it is important that regardless of disclosure laws, you consider the concerns of your patient in their situation. The next steps in the case of intimate partner violence may not be immediate and may require multiple days or weeks to prepare, whether with regards to securing a safe secure location, an escape method, finances, and/or personal documents until they are able to leave.

Facilitating Patient Decision Making 

Patients may not feel that they have the power to leave their partner even after disclosure of violence and discussing it with you. Often, patients may decide to leave in the months or years following disclosure. It is important to allow your patients to make that decision for themselves and continue to be a person of comfort and support. In the case of reproductive coercion, it is important to emphasize to your patient that they have autonomy over their body. Asking what they would like to do regarding whether or not they wish to be pregnant is a large step in protecting their self-interests and their safety in a situation of intimate partner violence.

A patient experiencing reproductive coercion may approach pregnancy in a variety of ways. Some may choose to carry a pregnancy to term and seek support to leave a violent situation to protect themselves and their child. Others may choose termination of the pregnancy, often with the understanding that carrying the pregnancy to term means being tied legally, socially, and financially to an abuser and potentially putting a child at risk as well. As a physician, it is important to understand both decisions and support whatever decision the patient makes regarding their pregnancy decisions. 

The Turnaway Study, the most comprehensive long term study of women who were denied abortions, found that 8% of women seeking abortions were facing intimate partner violence. For individuals denied an abortion, it was found that the individual was more likely to stay in contact with a violent partner and more likely to face physical abuse in the years following their denied abortion.

Effects of Being Denied versus Receiving Abortions 

It was also found that women denied abortions were more likely to ultimately become the sole parent for their child in the coming years with no partner or familial support, more likely to be in negative financial situations and more likely to live below the federal poverty line. Being denied an abortion also affects future child experiences, with poorer maternal bonding seen with the child who results from the pregnancy as well as poorer maternal bonding with future children.

Contrarily, women who received wanted abortion services had more positive financial outcomes, experienced greater employment progression, raised current children with more stability, and were more likely to have wanted pregnancies and children in the future.

An extension study from the Turnaway study also found that there was an association between having an abortion and a decrease in physical violence for individuals experiencing intimate partner violence. The association was not seen among women who were denied abortions.

This is an important context for reproductive coercion given that when an individual is experiencing this form of intimate partner violence and seeking an abortion, they often face the same fears as the individuals within the Turnaway Study. Refusal of abortion in this setting means that there is a similar outlook to those refused abortions in the Turnaway Study- they are most likely to stay in contact with an abusive partner, more likely to face physical abuse in the future, more likely to become the sole parent of the child, and more likely to be living under the federal poverty line. Additionally, their child is more likely to have worse developmental outcomes and poorer maternal bonding.

Abortion restrictions allow abusers to be more deliberate in their use of reproductive coercion to force an individual to remain in a violent relationship and in contact with a violent partner if they have a child together.

In the report of the survey conducted by the National Domestic Violence Hotline between October and December 2023, of the 3,431 responses, 

• 7% said their current or former partner prevented them from using medication abortion to have an abortion

• 23% of respondents said their current or former partner pressured them into becoming pregnant.

• 13% of respondents said their current or former partner pressured or forced them to terminate a pregnancy

• 13% of respondents said their current or former partner used or threatened violence while they were pregnant, with the intention of ending the pregnancy.

• 9% of the respondents said their current or former partner used or threatened violence if they wanted to or were trying to terminate a pregnancy.

Abortion in the United States (as of June 2024) 

In the United States, abortion was determined by the Supreme Court to be a constitutional right in the Roe v Wade Supreme Court Decision. Roe precluded state regulation of abortion in the first trimester but allowed limited types of state regulation in the second trimester and the ability to ban abortion after viability. This changed in June of 2022 with the Dobbs v Jackson Women’s Health Organization decision that overturned Roe v Wade. Under Dobbs, states may restrict or ban abortion at any point in pregnancy.

As of June 2024, 14 states in the United States have legislation in effect that has completely banned abortion with exceptions only in the case of maternal or fetal health risks, and 18 states have banned the use of public funds for abortions.

These restrictions have a variety of impacts on abortion providers and patients. In a study conducted in 2007, it was found that intimate partner violence was 3 times greater among women seeking abortions in comparison to those who continued their pregnancy. These restrictions make it more difficult for medical practitioners to provide abortions and more difficult for patients to access or pay for abortions in these unsafe scenarios.

States with Complete or Near-Complete Abortion Bans 

In states with complete abortion restrictions that require out-of-state travel as the only option, abortion funds have been able to support paying for abortions. However, there is still an undue burden on individuals from these states as they seek abortion services in states where abortion is legal, given the financial cost of leaving a job for the day and the safety risks for an individual experiencing intimate partner violence. Additionally, many states have gestational limits for seeking pregnancy services in their states, making it hard for individuals who may not know that they are pregnant until further along in a pregnancy to find states in which they can receive abortion services.

Updated Policies can be found at: https://www.guttmacher.org/state-policy/explore/overview-abortion-laws

State Policies Map: https://states.guttmacher.org/policies/?_gl=1*1sfplan*_ga*NTM0MDIwMDMxLjE2OTM3NDM0NTI.*_ga_PYBTC04SP5*MTY5Mzc0MzQ1Mi4xLjEuMTY5Mzc0Mzk5Ni4wLjAuMA..

Reproductive coercion in the case of an individual seeking an abortion is not considered a medical exception that would permit an abortion in any of the states with abortion bans. This makes out-of-state travel the only option for individuals in restricted states- a costly and risky situation for someone experiencing reproductive coercion.

Adoption and Intimate Partner Violence 

An additional barrier exists in the situation of the commonly proposed alternative option to abortion, adoption. This is not a realistic possibility in situations where one lives with an abusive partner and would be unable to conceal a pregnancy. Given that pregnancy is a particularly dangerous time for an individual experiencing intimate partner violence, this does not address the issues of concern. 

In cases of an individual who has left an abusive situation but is pregnant, there are considerations in the decision of adoption as an alternative to an abortion. Some states require notification of the father for adoption to move forward, making this an impossible option in the case of intimate partner violence because notifying the abusive partner can require reassociation and an escalation of violence. More state-specific information on adoption laws in the United States can be found at: https://adoptionnetwork.com/adoptee-resources/adoption-consent-laws-by-state/

Internationally, abortion restrictions have a similar impact to what is currently being seen in the United States. According to the World Health Organization, about 73 million abortions take place every year and studies have indicated that the lifetime prevalence of reproductive coercion can range between 8% and 30%, depending on the sampled population.

Why do Abortion Restrictions Exist? 

Historically, abortion restrictions were put in place for three reasons: dangers of performing abortions at the time, considerations of abortion as a sin and therefore enacting laws as a form of punishment for individuals seeking to commit such immoral actions, and the belief that fetuses are persons.

Today, these reasons have little medical and public health support. Medicine has advanced to make abortion an extremely safe procedure to the point that in the United States, induced abortion is safer than carrying a pregnancy to term. Medical understanding of pregnancy and the growth of an embryo to a fetus as well as the impact of pregnancy on an individual has increased understanding to a large extent. However, legal restrictions on abortion continue for the last two reasons, as abortion restrictions continue to be used as a form of punishment for individuals seeking to end a pregnancy and some individuals’ beliefs of fetal personhood, often with cultural and/or religious backing for these beliefs. 

Given that the last 2 reasons have little medical standing, it is largely agreed upon that these views should not be a part of medical practice. In countries (and states in the United States) with abortion restrictions, these reasonings are used largely outside of medical control or understanding and more in political reasoning. As a physician, there is advocacy and political involvement in these areas that support the overturning of these policies, as intimate partner violence and reproductive coercion is a major case in which one can advocate against abortion restrictions and advocate for the importance of protected abortion access.

Information about abortion restrictions by country can be found at: https://www.cfr.org/article/abortion-law-global-comparisons

Throughout the world, reproductive coercion is used as a tool by abusers. While the reality of reproductive coercion varies by country and may include both forced abortions and forced pregnancy, it is clear that restrictions to abortion have negative impacts. The lack of abortion accessibility is more likely to result in increased future violence for individuals experiencing intimate partner violence and serves to further allow control over women around the world.

Medical professionals are in a unique situation in which they can directly support pregnant individuals and screen for signs of reproductive coercion. Often one does not realize that they are experiencing reproductive coercion until it is too late or they may feel that they are not able to make a decision to leave a situation involving reproductive coercion. This is particularly true in situations where an individual does not want to be pregnant but is unable to get an abortion due to legal restrictions.

Using this module, medical professionals can normalize screening for reproductive coercion in every patient and support an individual who is experiencing reproductive coercion to encourage them to regain their autonomy on their own terms. It is important to understand that abortion restrictions are being used as a tool by abusers. As medical professionals, we have the ability to advocate for our patients and hope for a future in which pregnancy is no longer used as a form of control and perpetuation of intimate partner violence.

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