Lindsay Clark, M.D., couldn't figure out why her patients were getting pregnant. An obstetrics and gynecology resident in Rhode Island, she was treating women who very recently had been pregnant, or had come to her with the opposite intent. “I wondered why women were getting pregnant so soon after they came to me for birth control counseling,” she told the Cut. “I became interested in the idea that women might not have as much control over their birth control as they think.”
Surveying 641 women who received routine ob-gyn care at Providence’s Women and Infants Hospital, Clark found that 16 percent had received unwelcome pressure to get pregnant. Their boyfriends and partners made it hard for them to use birth control — poking holes in condoms or hiding their pills — or threatened to leave or harm them if they didn’t get pregnant.
If you don’t hear much these days about the stereotypical gold digger who lies about being on the pill to ensnare a man into marriage or eighteen years of child support payments, that may be because doctors are now being told to look for just the opposite: The woman whose partner sabotages her birth control. She’s not so hard to find.
Early this year, the American College of Obstetrics and Gynecologists (ACOG) issued a committee recommendation urging ob-gyns to screen patients for these behaviors, collectively known as reproductive coercion. Whether women were in for an annual exam, a pregnancy test, or a second trimester visit, it recommended asking questions like, “Does your partner support your decision about when or if you want to become pregnant?”
The ACOG’s strategy reflects a growing body of research that identifies reproductive coercion as a unique form of domestic or intimate partner violence, and offers an explanation for the high rates of unintended pregnancies among women in abusive relationships. Increasingly, birth-control sabotage is viewed as a tool not for baby-crazed female stalkers, but for a class of predominantly male abusers who want to exercise control over their partner’s body, make her dependent upon them, or secure a long-term presence in her life.
One of the subject’s leading experts, the Children’s Hospital of Pittsburgh's chief of adolescent medicine Elizabeth E. Miller, M.D., Ph.D., began looking into the phenomenon less than a decade ago, after seeing a 15-year-old patient who said her boyfriend only used condoms some of the time. Rather than asking whether the boyfriend refused her request to use condoms, she assumed the patient needed to be educated about birth control. Two weeks later, the girl was in the emergency room with a severe head injury. “Personally, it was incredibly destabilizing,” Miller recalled. “It was like, ‘How could I have missed this?” Later, she interviewed girls who were known to have been in violent relationships for a 2007 paper on the topic. “A quarter of them said, ‘He was trying to get me pregnant.'”
In Miller’s 2010 study, one of the largest on reproductive coercion to date, 15 percent of 1,300 women who visited federal- and state-subsidized California family-planning clinics had their birth control sabotaged. One in five had been urged by a boyfriend not to use birth control, or told by a boyfriend he would leave her if she wouldn’t get pregnant. A larger portion of respondents, 35 percent, who reported intimate partner violence (IPV) also reported birth-control sabotage.
Because Miller’s study examined low-income-friendly clinics — and because domestic violence disproportionately affects low-income women — some have conjectured that reproductive coercion is a classed issue. But Dr. Clark’s survey, which looked at a general population of patients, with and without private insurance, suggests birth-control sabotage and pregnancy coercion happen at a similar rate across socioeconomic and educational backgrounds. In her study, the single highest risk factor for reproductive coercion was being unmarried and sexually active.
Miller’s co-author Rebecca Levenson, a senior policy analyst for Futures Without Violence, said she expects more and diverse women will come forward as information about reproductive coercion spreads and women recognize it as a kind of abuse. “Naming something is powerful,” she said. But first, she hopes the research will inform the many doctors who are in a position to directly intervene and reduce the reproductive harm facing IPV victims — be it an unwanted pregnancy, an expensive abortion, or the unhappy extension of a bad relationship — but don’t know to ask. Harm-reduction strategies range from offering birth control or emergency contraceptives in plain packaging to switching women to a stealthier method, like Depo Provera hormone shots or an IUD with the strings clipped.
Levenson described a 17-year-old she interviewed whose boyfriend claimed the condom broke six times in a row before she sought out Depo Provera for herself. This was before reproductive coercion was widely discussed, she said, but “Imagine how powerful it would be if when she went to the clinic the clinician would say, ‘Hey, you’ve come in for emergency contraceptive three times. Are you at all worried about that?’”
When Futures Without Violence took their findings to Eve Espey, M.D., M.P.H., a professor of obstetrics and gynecology at the University of New Mexico and an author of the ACOG’s committee opinion, she was “totally embarrassed,” she said. “I’ve always asked patients about intimate partner violence, but I had not asked specifically about reproductive coercion,” she told the Cut. “I was amazed that a seasoned ob-gyn like I am was not aware of that as an entity.”
Once she became aware, she wasn’t surprised how common it was among her patients. In addition to the IUD and the shot, in some cases Espey recommends patients switch to a non-hormonal IUD because “there are some men who count the days of women’s periods,” which can be fewer if she’s on hormonal birth control. “When people have power and control needs, they will seek the information,” she explained.
Citing the high rate of response to her survey, Dr. Clark told the Cut that patients are equally quick to identify reproductive coercion once aware of its existence. “In my practice, they say, ‘Oh, I’ve never really thought about it like that, but, yeah, I do get pressure,'” she said. “Women want to talk about it.” Finally, they will have someone with whom they can.