The Nation: When teen pregnancy is no accident - by Lynn Harris

Excellent piece from the Nation on how abusers coerce their partners into getting pregnant, or otherwise sabotage their birth control efforts--all as a way of exerting long-lasting control over their partners' lives. It's an issue known as "reproductive coercion."

http://www.npr.org/templates/story/story.php?storyId=127209931

The Nation: When Teen Pregnancy Is No Accident
by Lynn Harris

New studies suggest that many partners of young women are coercing pregnancy, or sabotaging attempts at prevention.

May 27, 2010

Leyla W. couldn't figure out where her birth control pills kept going. One day a few tablets would be missing; the next, the whole container. Her then-boyfriend shrugged and said he hadn't seen them. She believed him — until she found them in his drawer. When she confronted him, he hit her. "That was his way of shutting me up," says Leyla, who is in her mid-20s and living in Northern California. (For her safety, Leyla wishes to withhold her last name and hometown.) He also raped her and, most days, left her locked in a bedroom with a bit of food and water while he went to work. (A roommate took pity and let her out until he came home.) Thanks to the missed pills, she got pregnant twice, the second time deciding against abortion.

Despite his role in getting her pregnant, when Leyla decided she did not want to have an abortion, her boyfriend did a 180, screaming at her belly that he didn't want the baby to live, threatening to "kick the baby out" of her stomach and even, one day, pushing her down a flight of stairs. Her pregnancy was "hell," says Leyla. Perhaps mercifully, it ended at thirty-seven weeks — the baby arriving three weeks early, her doctor speculated, because of his mother's profound stress. (Her doctor was aware, to some degree, of the abuse, and told Leyla the best thing she could do was leave.)

Leyla eventually did just that, getting herself out of her abusive relationship and into a support group. "I do ask every day why I stayed with him for seven years," she says (though she now says that witnessing her father abuse her mother corrupted her sense of what counts as "normal" in a relationship). She married a "wonderful" man last November who is, she says, "a great father" to her son, Eddie, now 2.

Leyla's story turns a modern fable on its head: that of the woman — call her the femme fertile — who conspires to get pregnant, perhaps by "forgetting" to take her birth control pills, as a way to "trap a man" and force marriage — or at least keep him in her life. In reality, experts researchers on dating violence and unintended pregnancy say, it's Leyla's version of that story is all too common. Two new studies have quantified what advocates for young women's health have observed for years: the striking frequency with which it is in fact young men who try to force their partners to get pregnant. Their goal: not to settle down as family men but rather to exert what is perhaps the most intimate, and lasting, form of control. ("Control" may also include attempts to force both pregnancy and abortion, even in the same relationship.) Together with earlier small-scale studies and reports by those in the field, the new figures help fill out the picture of a long-known, but under-addressed, phenomenon now referred to as "reproductive coercion," in which abusive partners subject young women already at risk of violence to the additional health risks of pregnancy and sexually transmitted infections. The new data confirm that we must expand not only our assumptions about who's forcing whom to get pregnant but also our understanding of the meaning and causes of "unwanted" pregnancy. "If we are serious about stopping unplanned pregnancy in this country, we simply must address the sexual violence and reproductive control that often cause it," says Esta Soler, president of the Family Violence Prevention Fund, which has been a leading advocate on the issue.

A new study has found that among 71 women aged 18-49 with a history of intimate partner violence, 74 percent reported having experienced some form of reproductive control, including forced unprotected intercourse, failure to withdraw as promised or sabotaging of condoms. Women who became pregnant were coerced to proceed in accordance with the wishes of their partners, who in some cases threatened to kill them if they had an abortion. Study authors Ann Moore, Lori Frohwirth and Elizabeth Miller, MD, recommend that service providers in women's health clinics ask questions designed to identify women who may be experiencing reproductive coercion, and should be aware that some women may need birth control (such as IUDs) that can be hidden from partners.

In the largest study of this phenomenon to date, "Pregnancy Coercion, Intimate Partner Violence and Unintended Pregnancy," published in the January issue of the journal Contraception, lead researcher Elizabeth Miller and others surveyed nearly 1,300 16- to 29-year-old women who'd sought a variety of services at five different Northern California reproductive health clinics. Among those who had experienced intercourse, i.e. who could be at risk of unintended pregnancy, not only did 53 percent of respondents say they'd experienced physical or sexual violence from a partner, but one in five said they had experienced pregnancy coercion; 15 percent said they experienced birth control sabotage, including hiding or flushing birth control pills down the toilet, intentional breaking of condoms and removing contraceptive rings or patches. These figures were consistent from clinic to clinic.

Three years ago, Miller, now assistant professor of pediatrics at the University of California, Davis, School of Medicine and a practitioner at UC Davis Children's Hospital, published what is said to be the first study in adolescent health literature to document the role of abusive partners in promoting teen pregnancy. The study was based on interviews with a racially and ethnically diverse group of sixty-one girls from Boston's poorest neighborhoods, all with histories of intimate-partner violence. Fifty-three of them were in abusive and sexually active relationships at the time of the interview; of those girls, 26 percent reported that their partners were "actively trying to get them pregnant" by manipulating condom use, sabotaging birth control" — many reported trying to hide their birth control from boyfriends — or simply sweet-talking them about "making beautiful babies" together. One girl reported that her boyfriend deliberately got her pregnant, and then made her have an abortion.

"Pregnancy is an extremely contested area of human relationships," says Miller. "It's likely that there are women who try to get pregnant on purpose in order to maintain or change a relationship. But now we can also say that there is another part of this story that we have not paid enough attention to: men's direct role in promoting pregnancy against women's wishes. It's not the only cause of teen pregnancy, but it's one that we'd managed to miss for a very long time."

The new data is both alarming and promising. While it adds wrinkles to the often-linked problems of unwanted pregnancy and intimate partner violence, it may also provide new clues as to how to address them.

What we now know about reproductive coercion could begin, for one thing, to shine some light onto recent upticks in rates of teen pregnancy and abortion. In January, the Guttmacher Institute reported that between 2005 and 2006 the pregnancy rate among girls ages 15 to 19 had jumped for the first time since 1990, by a factor of 3 percent. "There are a multitude of reasons for the recent increase in teen pregnancy," says Miller. "Reproductive coercion may be one piece of the puzzle."

Longitudinal studies are needed, Miller says, along with further exploration of the well-documented but puzzling phenomenon of "pregnancy ambivalence," a term those in the field use to describe sexually active women who say they don't want to get pregnant, yet who don't try consistently to prevent it. "We need further research to find out if part of what we've been addressing as 'ambivalence' is in fact male-partner influence on women's reproductive health and autonomy," explains Miller.

A better understanding of reproductive coercion also offers a new — though not always sufficiently early — warning system for intimate partner violence. Unwanted pregnancy should not be considered just a fait-accompli consequence of a series of individual and societal failures. Rather, Miller and others say, healthcare providers should treat unplanned pregnancy (or repeat pregnancy or STD testing) as a potential red flag for relationship abuse. (This is something Miller began to suspect a decade ago when, while working as a volunteer counselor in a Boston clinic, she gave a 15-year-old girl a pregnancy test — negative — and sent her on her way with the usual information about birth control; two weeks later, the girl wound up in the ER when her boyfriend pushed her down a flight of stairs.) In fact, Miller's latest, still-unpublished research has shown that when counselors at family planning clinics are trained to ask questions designed to reveal unhealthy relationships — "Did your partner ever mess with your birth control or try to get you pregnant when you didn't want to be?" — not only are they able to detect cases of relationship violence that might otherwise have fallen through the cracks but the young women at risk are also significantly more likely to get themselves safely out.

Of course, protecting and educating women is only half — if that — of the equation. Why do men abuse in this way in the first place? In one 2007 study, some young men said outright that they'd insisted on condomless sex as a way to establish power over female partners. (There is some evidence of analogous male-on-male violence, but no in-depth studies exist.) Other research shows that men consider a request for a condom an accusation — or admission — of cheating. Advocates such as Patti Giggans, executive director of Peace Over Violence, also hear male gang members say things like "I'm not gonna be around forever. I've got to leave my legacy." (That said, anecdotal evidence — to say nothing of wide reports that even philandering celebrities and politicos eschew condoms — shows that the phenomenon is not limited to the most economically depressed classes.)

According to Miller and Giggans, innovative, male-focused violence prevention programs are popping up all the time. But Miller says that recent research demonstrates that there's a clear need for relationship violence prevention to be integrated into pregnancy prevention and sexual health curricula, and vice versa. Given her findings, after all, preventing unwanted pregnancy appears to be about more than making contraception available, accessible, and acceptable. Never mind abstinence-only education, which would be irrelevant, to say the least, to someone experiencing sexual coercion — even the most comprehensive, medically accurate sex ed — or all the free condoms in all the fishbowls in the world — won't deter a sexually abusive partner, and won't magically protect a girl from a partner who deliberately damages a condom or suddenly removes it mid-intercourse. "Ideally, we'd discuss healthy relationships as a foundation for sex ed before we discuss mechanics," Miller says. Given how embattled sex ed already is, that will be a slow, state by state, curriculum by curriculum process. In fact, some dating violence educators, Miller says, are a bit resistant to tie the issue too explicitly to pregnancy prevention, for fear that too much discussion of sex could jeopardize the inclusion of their entire curriculum.

But changes are already beginning to take place — at least ten states have passed laws requiring (or at least "urging," though not necessarily funding) dating violence education — and teen advocacy groups are generally on board with the notion of broadening pregnancy prevention curricula to include coercion. Members of Miller's team, for example, have been working with the writers of the California pregnancy prevention curriculum to add a vignette in which a girl asks a guy to use a condom but then he removes it during sex. (Right now, Miller says, "that kind of conversation is just not happening.")

As important as it is to address the dangers of coercion, experts agree with Miller that the best big-picture approach is to educate young men and women alike about healthy relationships. "It's imperative that we teach kids comprehensive sex ed that includes awareness of violence and coercion. The more we can help them understand what constitutes a good relationship and where you go for help when something's not good, the more they have a fighting chance," says Debra Hauser, executive vice president of Advocates For Youth.

On the upside, there is at least one sense in which talk of sex-ed innovation is not pie in the sky: there may actually be some money for it. For all the warranted concern about reappropriation of funds for abstinence-only education, in December 2009 President Obama signed into law a $114.5 million teen pregnancy prevention initiative based on medically accurate, research-based information. While $75 million is reserved for programming already proven effective, at least $25 million is earmarked for research and testing of innovative new approaches.

The increasing awareness of the interpersonal complexities of unintended pregnancy — plus the potential funding — make Sarah Brown, executive director of The National Campaign to Prevent Teen and Unplanned Pregnancy, "uncharacteristically optimistic," she says. "Sex ed has mainly been focused on reproduction, not relationships. But people in the field have been beginning to understand that — while there is a role for specific pregnancy prevention and harm reduction — it's all part of a larger picture that also includes substance abuse and overall life planning. It's not just about body parts or pathogens or the mechanics of contraception; it's about what constitutes a respectful, warm relationship. If it weren't for the money, I wouldn't be so sanguine, but five years from now we'll have seen many more efforts to talk about the particular sex and safety topics within the larger context of healthy lives and relationships."

And, of course, school isn't the only place where prevention and intervention can take place — or be improved. The Family Violence Prevention Fund, in collaboration with the Office on Women's Health of the US Department of Health and Human Services, has just launched a $3 million violence-prevention initiative called Project Connect, which is designed to find new ways to identify and respond to domestic and sexual violence, including reproductive coercion, in public health settings. Working with ten state health departments and violence-prevention advocacy groups nationwide, the fund will train staff at family planning, adolescent health, home visitation and other maternal child health programs to understand domestic violence and reproductive coercion so that they recognize it when they see it and know how to help.

Given what we know now — and can do about — the link between violence and pregnancy prevention, there's hope for steps forward. "My dream is that we'll see a comprehensive public health response to domestic violence and reproductive coercion in the way we've seen for smoking cessation and HIV prevention," says Lisa James of the Family Violence Prevention Fund, director of Project Connect. "We're starting with just ten sites, but we know this will become the national standard."