About half of all pregnancies in the U.S. are unintended. While it would be easy to assume in these cases that birth control failed, or that people were simply careless, research on abusive relationships shows that a minority of these unintended pregnancies are the result of reproductive coercion.
Reproductive coercion is a specific type of intimate partner violence in which one partner forces unprotected sex in order to increase the chances that the other partner will get pregnant against her will.
Defining this kind of abuse is important for both healthcare providers and women, explained Heather McCauley, a social epidemiologist and an assistant professor of human development at Michigan State University, who studies the phenomenon.
Reproductively coercive acts include threatening to leave unless the woman becomes pregnant, threatening to have a baby with someone else if she doesn't comply, physically abusing a woman because she does not agree to pregnancy and tampering with birth control to deliberately cause pregnancy. Forcing a woman to either carry a pregnancy to term or have an abortion against her wishes also constitutes reproductive coercion.
Birth control tampering and pregnancy coercion, in particular, is the focus of McCauley's latest research.
“The thing about reproductive coercion is that many women still don't recognize this behavior as abuse,” McCauley said. “If you were to ask them if they experienced abuse or coercion in their relationship, they would probably say no.”
We spoke to McCauley to learn more about reproductive coercion, and how to recognize the signs of a coerced pregnancy.
How did you first realize that reproductive coercion was actually part of a pattern of abuse in intimate relationships?
I was working with a team in Boston that was focused on violence against women, and I was focused mostly on physical and sexual intimate partner violence. Dr. Elizabeth Miller, who at the time was at the University of California at Davis and is now at the University of Pittsburgh, had identified reproductive coercion in her work.
It wasn't called that at the time, but it was a phenomenon where she found women were describing their partners messing with their birth control and breaking condoms on purpose. So she approached our research team, and we were able to team up to better understand what this phenomenon was.
Then I began to understand that violence against women includes more than physical and sexual violence, but also this coercive control, specifically, control around women's reproduction. I was pulled into this work in 2008.
Since this team's paper defining reproductive coercion in 2010, what has changed in terms of how doctors deal with the issue?
That first paper was the first time we were able to document that reproductive coercion was a phenomenon and it was happening to women more often than we even knew. Since then, we've partnered with Futures Without Violence, a national nonprofit based in San Francisco, to develop intervention materials to help clinicians have conversations with their patients about reproductive coercion. The team produced palm-sized safety cards with the title, “Did you know your relationship affects your health?”
The purpose of this card is for clinicians to have the conversation with their patients. It helps [patients] make the link between what's going on in their relationship and the reason they're seeking care.
What are the signs of reproductive coercion, both in women who aren't pregnant and in women who are? Are there clues in the way that she acts during a doctor's appointment, or in her medical history, that can tip doctors off to reproductive coercion?
We're finding that one clinical red flag is if you have a patient who comes in frequently for pregnancy testing or sexually transmitted infections. That is one sign that should tip the doctor off. This work is supposed to change providers' perceptions about why that might be the case. So if the patient is coming in frequently, instead of making assumptions about why they're seeking care, perhaps thinking about how violence and coercion could be impacting the reason why they could be in need of these services.
What about a medical history of several abortions?
That's absolutely another red flag.
Let's talk more about the two distinct modes of coercion that you outline in your most recent study. It seems like one of them involves deception, in that a man can tamper with condoms or remove a condom during sex without his partner's knowledge. But the other one is an explicit threat, and one that we'd more readily link to abuse.
Exactly. And that's one of the important reasons we conducted this research and published this paper ― to understand that there are two very distinct things going on. One is coercive, whether that includes pregnancy pressure ― an abusive partner might use threats to leave if a woman doesn't get pregnant, for example. And then the other part is that physically abusive manipulation of condoms to promote a pregnancy.
Are there scientifically backed ways to get the partner to stop doing reproductive coercion?
Our team was the first to develop an intervention around reproductive coercion, but it was geared toward women seeking care in a reproductive health clinic. There aren't interventions geared toward men. There's a lot of room for research around men's intentions and why this behavior is happening in the first place.
The work with men in this area is very new, so I'm not sure we're at the point of interventions yet. I think we still need to understand why reproductive coercion is happening from the man's perspective.
What are the interventions for reproductive coercion with just the woman in the clinic?
The first component is universal education. Providers are talking to all patients that walk into the door about relationships. The point there is to help create a safe space within the clinical setting, so that we become comfortable sharing our experiences in our relationships with our health care providers.
The second important goal with universal education is making sure that every patient who steps into the clinic is getting some sort of information about violence and reproductive coercion.
The second piece is more a direct assessment. If a provider notices some of those clinical red flags that I mentioned, like a patient coming in frequently for pregnancy testing, or coming in frequently to change her birth control option - if that is going on, then a provider can do a more direct assessment using these questions to ask women about their experiences.
The third component is connecting women to resources. I don't expect health care providers to be experts in violence and reproductive coercion, but I expect them to know who the domestic violence advocates are in their community.
Other research on reproductive coercion indicates that a significant percentage of women who experience this are also in physically abusive relationships. But can reproductive coercion happen in an otherwise loving relationship, or does it happen in an abusive relationship, of which reproductive coercion is just one aspect of abuse?
We see both situations. We know that in some [cases], women who experience reproductive coercion are also experiencing physical or sexual intimate partner violence. But it's not necessarily the case. Women can experience reproductive coercion by itself.
We know that regardless of whether they're experiencing one, the other or both, that exposure to coercion and violence in their relationship has a direct link to their reproductive health. So they're more likely to experience unintended pregnancy, regardless of whether there's that overlap between reproductive coercion and intimate partner violence.
Can reproductive coercion happen to a man? Can he be part of a relationship and a pregnancy against his will, or in spite of his efforts to use contraception?
That's certainly something I hear when I'm out giving lectures on the topic, or when I'm in the community talking about this. That's the first question people ask me. And sure, men can experience reproductive coercion, but that hasn't been the focus of this work. I'm much less familiar with studies that have documented it quite like this.
So are you saying that it's possible, but that research hasn't documented this?
I'm saying anecdotally, it's possible. It's something that I hear. Research hasn't documented it in the same way. So I can't speak definitively about it, but it's certainly the first question I get when people talk to me about this. The consequences are quite different for men and women with this behavior.
What else should we know about reproductive coercion?
This work has been done in clinical settings, and while I'm doing a lot of trainings with health care providers, I'm also interested in working with parents to help them play a role in having conversations with their adolescents about healthy relationships. We are seeing in our work that this is happening to our adolescent patients in particular, and it's something for us to be thinking about when talking to our teens about sexuality and relationships.
This interview has been lightly edited and condensed for clarity.
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