OB-GYN group calls on doctors to screen for sexual coercion

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It's not uncommon for abusive men to sabotage their female partners' birth control as a way of exerting power over them, according to the American College of Obstetricians and Gynecologists. Male partners have been known to poke holes in diaphragms or condoms, hide birth control pills or even forcibly remove patches and intrauterine devices.

In response to a growing body of research on the subject -- some of it conducted by Elizabeth Miller, chief of adolescent medicine at Children's Hospital of Pittsburgh of UPMC -- the College wants doctors to offer abused women and girls more long-acting methods of contraception that cannot be easily detected, such as implants, injections or IUDs with the strings cut short so they won't be noticed.

It also wants them to screen patients more effectively and frequently for coercion and refer them for help in leaving abusive relationships, something that not all OB-GYNs do.

The new opinion by the College's Committee on Health Care for Underserved Women will be published in the February 2013 issue of the journal Obstetrics & Gynecology and went online Wednesday afternoon at acog.org.

Sexual coercion is a known link to intimate partner violence. It includes explicit attempts to impregnate a woman or adolescent against her will, dictating pregnancy outcomes by forcing either a continuation or an abortion, coercing a partner to have unprotected sex and thus exposing her to disease as well as pregnancy, and interfering with contraceptive methods, according to ACOG.

"It's incredibly useful to have a large organization like ACOG recognize the critical importance of intimate partner violence and coercion in women's health," said Dr. Miller, whose team is in the midst of a large randomized study on the topic in Western Pennsylvania, funded by the National Institutes of Health. An earlier pilot project in northern California found that of 1,000 females coming into clinics, a quarter were living with reproductive coercion and half with intimate partner violence.

"It was astonishing," Dr. Miller said. "One of two women walking into family planning clinics were experiencing violence at the hands of a partner. That population is primarily [ages] 16 to 24 and they had a lot of concerns about pregnancy and infection.

"Clearly, those of us on the front lines of caring for young women have to prepare clinicians for asking about violence and coercion and offering meaningful intervention."

The College's opinion cites a number of studies and findings that informed the new recommendations:

• Homicide is a leading cause of pregnancy-associated deaths in the United States, the majority of those committed by intimate partners.

• One quarter of adolescent females reported abusive male partners trying to get them pregnant by interfering with planned contraception, forcing them to hide their contraceptive methods.

• In one study of family planning clinic patients, 15 percent of women experiencing physical violence also reported birth control sabotage.

• Among adolescent mothers on public assistance who experienced partner violence, 66 percent also dealt with sabotaged birth control.

• In 2007, the prevalence of intimate partner violence was nearly three times greater for women seeking an abortion compared with those continuing pregnancy.

• Males who perpetrated violence in the past year were more likely to report inconsistent or no condom use as well as forced intercourse without a condom, increasing the likelihood of unintended pregnancy.

"It's hard to say what the exact prevalence is because sexual violence and coercion aren't openly discussed," said Elizabeth Howell, vice chair of the College's Committee on Health Care for Underserved Women.

"But there is mounting concern based on clinical and anecdotal evidence. We need to not only screen for intimate partner violence, but go one step further to look at coercion in terms or contraceptive use and pregnancy."

Some doctors don't know how to talk about the issue, noted Dr. Howell, who is associate professor of obstetrics, gynecology and reproductive science at Icahn School of Medicine at Mount Sinai in New York City.

"If you don't start with the right questions and language, you'll never find out."

For example, she said, it's best to use the phrase "forced sex" instead of "rape," because many patients think rape is only by a stranger.

"The main message is raising awareness that we as physicians need to address this issue," Dr. Howell said. "If a woman keeps coming in with unintended pregnancies you want to ask about the context in which she lives. This would be part of that discussion."

Dr. Miller, of Children's Hospital, also is looking at the issue from another angle; she is studying a prevention program called "Coaching Boys into Men," which trains high school coaches to talk to their male athletes about stopping violence against women. That study is funded by the Centers for Disease Control and Prevention.

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Sally Kalson: skalson@post-gazette.com or 412-263-1610.


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