Violence & Coercion

Practitioners who support people presenting with who are pregnant are often in a unique position to screen for domestic violence and reproductive coercion, but sometimes feel they don’t have the specific skills or knowledge to do this effectively and sensitively.  

There is a clear link between pregnancy and domestic violence. Women subjected to domestic violence are more likely to face an pregnancy and more likely to have a pregnancy of higher gestation at the time of presentation to a service.  

‘Domestic violence’ is an umbrella term used to describe a range of behaviours to exert power and control over a partner. This behaviour may manifest in a number of physical, sexual, emotional, financial, or psychological ways.  

Reproductive coercion is a relatively new term in Australia but is used to describe interference with reproductive autonomy that denies a woman or person who can become pregnants decision-making and access to options. These behaviours range from birth control sabotage, where contraception is deliberately thrown away or tampered with, to threats and use of physical violence if a woman or person with the ability to become pregnant insists on condoms or other forms of contraception, to emotional blackmail coercing themto have sex or to fall pregnant, or to have an abortion, to forced sex and rape. In these circumstances, pregnancy can be used as a tool of control, and a sign to a perpetrator of violence that they have power over their partner’s body. Reproductive coercion is an easy and effective and cowardly way of manipulating and controlling a woman or person with the ability to become pregnant, by limiting their autonomy over their fertility and reproductive health and choices.  

Women and people with the ability to become pregnant can experience coercion from a partner to either become pregnant or progress with a pregnancy they do not want, or to terminate a pregnancy they wish to continue. It usually occurs within the context of relationships which are violent in other ways, as an additional tool used by perpetrators of violence. This behaviour may be deliberate or indirect and can include a coerced abortion. 

Coerced pregnancy is both a form of and consequence of reproductive coercion, where a pregnancy is deliberately intended or used by the perpetrator as a tool of control over the woman or pregnant person, and any decision-making regarding the pregnancy outcomes are removed from the pregnant person. 

Violence may begin or escalate in pregnancy and patterns of violence may shift. It is also worth noting that violence may decrease during pregnancy – usually not out of a shift in the partner’s concern for the pregnant person, but a reflection that the pregnancy itself is the control strategy and so other tactics are not needed at that time. 

Contraceptive use is often compromised for people living with violence.

Contraceptive options that are safe and appropriate for one woman may not work for another. If you’re working with a person experiencing violence, it’s important to explore each persons unique circumstances and draw on her/their own knowledge to assess the degree of comfort and safety with their contraceptive options.

Important factors to consider include whether the perpetrator is likely to:

• Monitor the persons Medicare or prescription records through her MyGov account;
• Restrict or monitor access to health care professionals;
• Monitor menstruation and fertility patterns;
• Engage in severe physical assaults;
• Be actively searching for the use of contraceptive drugs or devices; and/or
• Engage in rape and other forms of sexual assault.

Below is a great resource that provides a starting point for thinking further about which contraceptive options might be safest and most appropriate given an individual patients or clients circumstances.

The following provides an overview of the types of questions practitioners might use to identify if violence is present in a patient’s or client’s life. Our thanks to Debbie McCarthy (Flinders Medical Centre) and the Pregnancy Advisory Centre for allowing us to reproduce their material here.

Violence Screening Questions

Some potential screening questions for your practice may be along the lines of:

Because domestic violence is increasingly common, we ask everyone about it as part of our consultation. Are you safe in your relationship, or is there violence present? What forms of violence are present now or have been in the past?

Has a partner or significant other ever made you feel afraid? Caused you to feel worried about the safety of other people in your household? Hurt you physically or thrown objects? Constantly humiliated or put you down? Do you want help with any of this now?

Was the sex that led to the pregnancy consensual? Has there been any forced or coerced sex? Has there been any forced or coerced decision-making?

If questioning reveals violence is present, check their vulnerability level (i.e. age, living arrangements, financial control, social isolation, language barriers, disability, etc) and provide referrals where appropriate.

Remember to:

1. Ask alone
2. Be supportive
3. Call on resources
4. Document
5. Encourage safety

Points to note 

If a woman or pregnant person discloses domestic violence or it is picked up by staff, they may not want to report it. Staff need to respect this, and not force them to seek support they’re not wanting at the time.

It may be an option to provide some normalising, e.g. “One in three women experience domestic violence at some time in their lives” OR “We see at least one pregnant person every day here who shows signs that someone is perpetrating violence against them.”) Validation of their experience may also be helpful, irrespective of whether woman or pregnant person would like to take any steps at that time. E.g. “What you are experiencing is not okay. Everyone has a right to be safe.” and “It is not your fault. Violence is the responsibility of the perpetrator.”

Referrals 

1800 Respect have a directory of domestic violence support services in Queensland, and also has information on domestic violence, safety strategies, and seeking protection.

Domestic violence red flags

Red flags: Indicators of domestic violence in a woman or pregnant person presenting at your clinic or service

The woman or pregnant person may not disclose domestic violence during intake (written or verbal). However, clinic staff may observe indicators during physical/clinical intake that the woman or pregnant person has experienced/may be experiencing violence. The following is a list of indicators that domestic violence is being perpetrated on the woman or pregnant person. This is not an exhaustive list but a select list of things most likely to be observed or revealed in an abortion clinic setting.

The woman or pregnant person may:

• Appear nervous, ashamed or evasive;
• Describe their partner as controlling or quick to anger;
• Seem uneasy in the presence of their partner;
• Have a partner who may insist on following them throughout the clinic visit;
• Have a partner who does most of the talking when they are together;
• Have physical signs of violence such as bruising on the breast and abdomen, multiple injury sites and small cuts;
• Give an unconvincing explanation of current injuries;
• Have recently separated;
• Have a more advanced pregnancy;
• Show signs of alcohol and/ or other drug use;
• Identify having mental health issues;
• Have other gynaecological problems such as chronic pelvic pain, have suffered previous miscarriages or unplanned pregnancies; or
• Present with signs of neglect.

Violence and control can take many forms and can lead to unwanted and mistimed pregnancies, and unwanted abortions as well. While unplanned pregnancy and abortion are common they are even more common for women and people who can become pregnant who experience violence and control.

Sometimes experiences of violence and control can make it hard for women and people who can become pregnant to feel safe about talking to their sexual partner about contraception or asking them to use a condom.

• Are you afraid to talk to your sexual partner about contraception?
• Does he/your sexual partner support you using birth control?

Some types of contraception needed to be talked about or agreed upon each time you have sex, like condoms, diaphragms, withdrawal and fertility awareness methods (not having unprotected penis-in-vagina sex when you are fertile). If you are worried or afraid to talk to your sexual partner about contraception then there may be other types of contraception that would help you take control of your body without having to talk to your sexual partner about it each time sex might happen.

All women and people who can become pregnant should have the right to decide if and when they become pregnant. You could choose a contraceptive that gives you control over your own body, and reduce your risk of unwanted or mistimed pregnancies. Types of contraception that give you more control include implants, injections and IUDs. You can read about your contraceptive options over on this page.

Some violent and controlling people see getting a person pregnant and making them have child as a way of keeping them under control. This is called reproductive coercion and is a form of domestic violence. They may put pressure on a person to become pregnant when they do not want to be or do not feel right about it. The violent partner may mess with their contraception in order to get them pregnant and they may try to stop them from having an abortion when they wants one, or pressure them to have one when they don’t want to.

• Do you feel okay talking to your partner about if or when you might want to get pregnant?
• Has he/anyone ever hurt you, or threatened you or made you feel bad because you didn’t agree to get pregnant?
• Has your sexual partner tried to mess with your birth control, for example has he thrown away or hidden your contraceptive pills or thrown away or damaged a contraceptive device, such as condoms or your diaphragm?
• Have you ever felt you needed to hide contraception from your sexual partner so he wouldn’t get you pregnant?
• Has anyone ever made you feel afraid or threatened you if you didn’t do what they wanted you to with a pregnancy – either to end it or to continue it against your will?

Every woman and person who can become pregnant should have the right to decide if and when they becomes pregnant. You may be able to choose a type of contraceptive you feel safe with, that others will not know you are using and cannot mess with. Explore your options here.

If you’re pregnant now and are trying to make a decision about whether to end or to continue that pregnancy, you might find it useful to visit our Making a decision page, which includes some questions around violence and control. If you’re in Queensland, you can also get in touch with us to talk over your options with a qualified counsellor.

The relationship between domestic violence and poor reproductive health outcomes is well established. As well as the other outcomes of domestic violence for women, pregnant people, and children, it has a particular reproductive health context.

The World Health Organization reports that intimate partner violence may lead to a host of negative sexual and reproductive health consequences for women and pregnant people, including unintended and unwanted pregnancy, abortion and unsafe abortion, and pregnancy complications.

There is evidence that unintended pregnancies are up to two or three times more likely to be associated with intimate partner violence than planned pregnancies. Reproductive coercion may be one mechanism that helps to explain the known association between intimate partner violence and unintended pregnancy. Reproductive coercion refers to a range of male partner pregnancy-controlling behaviours. See our fact sheet on reproductive coercion for more information.

It is important to note that some women and pregnant people in violent relationships will experience coerced abortion; although there is some available evidence relating to poor mental health outcomes for women and pregnant people in these circumstances, there is little data on the prevalence of coerced abortion in Australia, and what exists is largely anecdotal.

Children by Choice is a pro-choice service and under no circumstances supports a pregnancy termination without the express wish and consent of the pregnant woman or pregnant person themselves. Coerced abortion is abhorrent.

Types of Violence

Women and pregnant people may experience a range of different types of violence during pregnancy, including physical, sexual and emotional violence, by a variety of people. For the purposes of this fact sheet, the following describes the types of violence women and pregnant people report to us:

Domestic violence: behaviour within an intimate partner relationship that is used to entrench power and control over the other person. This behaviour may manifest in a number of physical, sexual, emotional, financial, or psychological ways.

Sexual violence: forced or coerced sex, or rape, either within an intimate partner relationship or by another person. This includes sex which was coerced using emotional violence and manipulation, threats or use of physical violence, and situations where a woman or pregnant person was unable to properly consent to sex due to the influence of alcohol or drugs or due to an intellectual or cognitive disability or extreme youth.

Reproductive coercion: interference with reproductive autonomy that denies a woman or pregnant person’s decision-making and access to options. This behaviour may be deliberate or indirect, and can manifest in a number of different ways.

Prevalence of Violence in Pregnancy

Many women and pregnant people face an increased risk of intimate partner abuse during pregnancy [4], and unintended pregnancy occurs more commonly for women and pregnant people in abusive relationships [5].

Data also shows that using medical contraception to control fertility is often complicated for women and pregnant people in abusive relationships [6].

National data exists to show one in three women has experienced physical violence and one in five has experienced sexual violence [7], although there is not a lot of information about women and pregnant people who experience both physical and sexual violence by an intimate partner.

Our service data

In 2014-15, 30.5% of contacts to our counselling and information service in Queensland disclosed violence (domestic violence, sexual assault, and/or reproductive coercion). In 2009-10, this figure was 6%.

7.5% of all our contacts in 2014-15 reported both sexual and domestic violence, highlighting the prevalence of forced sex within ongoing relationships which are also abusive in other ways.

Our client data also shows that women and pregnant people reporting violence are over-represented in later gestation presentation, which has repercussions no matter which pregnancy option they choose: if they wish to continue the pregnancy, they will have missed vital early antenatal care and testing, while if they would prefer to terminate the pregnancy, abortion procedures are more costly and harder to access in the second trimester. For more information on our clients and their experience of violence, you can read our latest Annual Report here.

D, 22, was brought to Australia by her 50 year old boyfriend after an online relationship lasting some years. He told her he would help her go to university in Australia and after her parents died, she had no family left at home to support her.

When she arrived in Australia her boyfriend took her to a caravan park in a regional Queensland town – her new home. Far from sending her to university and supporting her to find work, he locked her in the caravan and wouldn’t allow her out except to go to church and the store. The only money she had was what he gave her.

He made her have sex with him every day, even though she told him she didn’t want to. He refused to use contraception and she had no access to any, but even so he told her if she became pregnant he would send her back home to her poverty-stricken country, where her extended family wanted her to undergo female genital circumcision against her will. When she became pregnant she was too afraid to tell him in case he ‘hurt’ her.

A friend from church gave her our number and we helped her financially and logistically to figure out how she was going to access the abortion she needed – the first step to escaping her relationship.

She’s now in Brisbane receiving the help of specialist services for survivors of violence who are also helping navigate her immigration status.

Impacts on Women and Pregnant People of Violence During Pregnancy

The Turnaway Study being conducted by the University of Southern California examines the impact of being denied abortion for women in the United States. This longitudinal study shows that women who seek and are denied an abortion are more likely to remain in violent relationships than women who are granted access [8]. There is no reason to suggest the results would be different in an Australian study of the same type, although no local data exists.

Pregnancy and co-parenting may impact on a woman or pregnant person’s capacity or willingness to leave the relationship due to:

• a fear they may lose their children in a custody battle, or that their partner will then have court-ordered unsupervised contact time with them without them to intervene and potentially protect the children from physical violence or worse;
• a fear that he may carry out threats to harm them, the children or himself if they leave;
• a concern that they won’t be able to take care of themselves and the children alone, either economically or psychologically after being subjected to the perpetrator’s emotional abuse undermining their belief in themselves and their abilities;
• an awareness that they will need to find accommodation suitable for children, and financially support themselves; and
• a belief that children need two parents.

Consequently, a pregnancy can be an impetus to end or leave an abusive relationship when considering the possibility of a child being exposed to his violence and control, or inform a decision to terminate when considering the life-long connection that a child would create between them.

What Do Women and Pregnant People Experiencing Violence Tell Us?

A pregnancy in the context of a violent relationship which is unwanted by the pregnant woman or pregnant person themselves can be extremely distressing. Certain themes are recurring in the conversations we have with clients who report violence:

Overall strain and distress as a result of the violence: women and pregnant people say they are ‘at breaking point’. The children they have are as much as they can handle given what they have been through.

Child Safety involvement as a result of the violence: women and pregnant people report that they can’t handle the mental health impact of having another child removed like they did the last one, due to violence in the relationship.

A desire to escape a relationship due to violence: women and pregnant people see ending the pregnancy as another strategy for cutting ties with the man involved, and of being less likely to subjected to further violence if there is no child connecting them.

In these circumstances a termination may be the preferred option of the pregnant woman or pregnant person directly as a result of the violence they experience, in terms of not wanting to parent with the perpetrator and therefore expose a child to potential violence also, or wanting to make their ability to disentangle from the perpetrator easier. Continuing a pregnancy to become ‘co-parents’ can further entrench a connection between the women or pregnant person and the perpetrator, which may continue regardless of the context of the relationship itself and can become a tool for further manipulation through family court proceedings.

Given this, access to and affordability of termination procedures can be entwined with a woman or pregnant person’s ability to escape domestic violence. Issues that are so often present in violent relationships, including surveillance, manipulation, and financial or other control, further restrict a woman or pregnant person’s capacity to access a termination, even if they are doing so to attempt greater safety for themselves and any existing children.

As co-parents in a domestic violence context, a woman or pregnant persons ability to ever be safe from that perpetrator’s violence against them and/or their children is significantly compromised. If women and pregnant people choose to access abortion in the context of domestic violence, it needs to be available.

References

1. C Garcia-Moreno, A Guedes and W Knerr (2012)Understanding and addressing violence against women: Intimate partner violenceWorld Health Organisation Department of Reproductive Health. Available online at http://apps.who.int/iris/bitstream/10665/77432/1/WHO_RHR_12.36_eng.pdf?ua=1 or download at http://www.who.int/reproductivehealth/topics/violence/vaw_series/en/.
2. E Miller, R Decker, H McCauley, D Tancredi, R Levenson, J Waldman, P Schoenwald and JSilverman Pregnancycoercion, intimate partner violence and unintended pregancy’ Contraception 2010 Volume 81 Issue 4. Online at http://www.contraceptionjournal.org/article/S0010-7824(09)00522-8/abstract.
3. American Psychological Association, Task Force on Mental Health and Abortion. (2008).Report of the Task Force on Mental Health and Abortion. Washington, DC. Available online athttp://www.apa.org/pi/wpo/mental-health-abortion-report.pdf
4. KChibberet al, ‘The Role of Intimate Partners in Women’s Reasons for Seeking Abortion’ (2014) 24(1) Women’s Health Issues e131; Lynn Meuleners et al, ‘Maternal and foetal outcomes among pregnant women hospitalised due to interpersonal violence: A population based study in Western Australia, 2002-2008’ (2011) 11(70) BMC Pregnancy and Childbirth.
5. E Miller, B Jordan, R Levenson and J Silverman, ‘Reproductive Coercion: Connecting the Dots Between Partner Violence and Unintended Pregnancy’ (2010) 81Contraception457; Available online at https://www.arhp.org/publications-and-resources/contraception-journal/june-2010.
6. C Williams, U Larsen, and L McCloskey, ‘Intimate Partner Violence and Women’s Contraceptive Use’ (2008) 14Violence Against Women1382. Online at http://vaw.sagepub.com/content/14/12/1382.abstract.
7. See the Our Watch website for an overview of Australian data around violence against women and children:http://www.ourwatch.org.au/Understanding-Violence/Facts-and-figures
8. S Roberts, M Biggs, KChibber, H Gould, C Rocca, D Greene Foster, ‘Risk of violence from the man involved in the pregnancy after receiving or being denied an abortion’BMC Medicine 2014, 12:144. Available online at https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-014-0144-z.

 August 2016 saw the commencement of our new domestic violence project “Screening to Safety”, funded by the Samuel and Eileen Gluyas Charitable Trust managed by Perpetual. The project centres on the intersection of domestic violence, pregnancy decision making and abortion and iwas completed in April 2018. 

The main aim of the work has been on increasing the capacity of private abortion providers to identify and respond to the needs of women and pregnant people experiencing domestic violence who attend for abortion care, with special focus on the issue of reproductive coercion. A parallel but more limited process has been carried out in the domestic violence and broader women’s sector. 

Since the commencement of the project we have: 

Resourced clinics to develop a clinic environment that is supportive of disclosure through practical support (eg posters on domestic and sexual violence in waiting areas, signage indicating patients will be seen on their own, which you can download here)

Developed domestic and family violence screening tools for abortion provision settings that incorporate screening questions about coerced pregnancy. This is further explored in the section on screening below. 

Reviewed clinic and intake and admissions processes to offer advice on changes to tools and procedures. The focus of this review looked at the information routinely collected in abortion care settings and how this might inform which women and pregnant people were most likely to be experiencing violence, for example previous termination or miscarriage is an indicator of risk for violence. 

Developed and distributed a tailored resources for guiding health care practitioners and others in their contraceptive counselling of women and pregnant people subjected to reproductive coercion, which you can download from our resources page. 

Updated our website in-line with project learnings. Check out our updated contraception section and tips for decision making in the context of violence. The project is encouraging other abortion providers and broader sexual and reproductive health services to consider including information about discrete contraception options (can it be detected, can it be tampered with) alongside mainstream contraceptive information provision. 

Developed a series of posters aimed at awareness raising, with funding from the Queensland Government and the YWCA Queensland for Women’s Week 2018, which you can download from our resources page. 

Provided training to clinic staff on the intersection between domestic violence and abortion, identifying and responding to the needs of women and pregnant people experiencing coerced pregnancy and coerced abortion. In some settings this involved nursing staff and some administration staff but not doctors. It was noted that most effective systems changes came about in clinic where doctors were actively involved in the training and discussion. 

Developed three short online video training modules. With provision of medication abortion through GP providers, it was important that the project be able to reach these providers through its initiatives. These videos are made available to GP providers of medication abortion through MS Health, and publicly available through our Youtube channel:  

• The intersection of domestic violence and unplanned pregnancy (6:56min); 
• Reproductive coercion and forced pregnancy (8:44min);  

• Reproductive coercion and forced abortion (5:47min).  

Established the Screening to Safety LARC Access Fund, which enables women and pregnant people experiencing violence, including reproductive coercion to access suitable cost-subsidised LARC at time of TOP through our ten partnering private abortion providers. Clinics are reimbursed for associated costs by the Screening to Safety LARC Access Fund, administered by Children by Choice. Since July 2016 this fund has supported 84 women and pregnant people, with 13 of these women and pregnant people directly supported by the clinic. Women and pregnant people experiencing domestic violence and reproductive coercion take up the option of LARC at time of TOP when financial barriers are removed. 

Collaborated with the domestic violence sector: Training on the intersection of domestic violence, reproductive coercion, pregnancy decision making, and abortion has been provided to seven different domestic violence and women’s health services, and four regional, cross agency training events have been held.  Issues papers and posters have been presented at four relevant conferences. As a result of these combined initiatives, some specialist domestic violence services have now incorporated reproductive coercion screening and safety planning into their safety and risk tools, and have indicated that they will include unplanned pregnancy risk assessment and pregnancy testing as part of domestic violence refuge intake and admissions processes. 

Provided education and information to a wider range of health care providers through collaboration with TRUE Relationships and Reproductive Health (formally known as Family Planning Queensland) to develop, and trial, a full day training package for health care practitioners which includes a focus on reproductive coercion, and presenting to partitioners through the Brisbane South Primary Healthcare Network. 

Raised awareness of reproductive coercion at a national level through participation in roundtables on contraception and reproductive coercion, and presenting on this issue at our Children by Choice national conference in August of 2017. 

We continue to appreciate Queensland’s private abortion providers and their desire to do the best for the women and pregnant people experiencing violence and control through compassionate care, and abortion and contraception access for Queensland’s more vulnerable women and pregnant people. It reaffirms for us the important role that health care practitioners can play in intervening in the sexual and reproductive health impacts of domestic and sexual violence. 

We are buoyed by the capacity and willingness of Queensland’s domestic violence and women’s sector in stepping up to the challenge of responding to issues of reproductive justice through the provision of holistic responses to women and pregnant people’s needs in the face of constant and complex workload pressures.