JOGNN
RESEARCH
Reproductive Coercion and Partner Violence among College Women Melissa A. Sutherland, Heidi Collins Fantasia, and Holly Fontenot
Correspondence Melissa A. Sutherland, PhD, RN, FNP-BC, Boston College, William F. Connell School of Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467. [email protected]
ABSTRACT
Keywords reproductive coercion intimate partner violence college women
Methods: An e-mail invitation to participate in an electronic survey was sent to undergraduate and graduate female students. A web link to the informed consent and inclusion criteria were provided. Students who affirmed they met inclusion criteria could proceed to the survey. Completion of the survey implied consent.
Objective: To examine reproductive coercion and partner violence among college women. Design: Cross-sectional, descriptive. Setting: A large public university in the Northeast United States. Participants: Inclusion criteria were college women age 18 to 25, enrolled either full- or part-time, English speaking, and screened positive for relationship. Data from 972 women were analyzed.
Results: Nearly 8% of participants (n = 76) reported reproductive coercion, including pregnancy coercion, birth control sabotage, or both. Women reported more pregnancy coercion (6.8%) than birth control sabotage (3.9%). Being told not to use any birth control was the most commonly reported act (6.8%, n = 62). Of women reporting reproductive coercion (n = 76), 57% also screened for positive relationship violence (95% confidence interval [CI] [2.74, 7.29]). Conclusion: Pregnancy coercion and birth control sabotage occur among college women, and higher rates were reported among women with histories of partner violence. In addition to screening and counseling for partner violence, college health providers should assess for reproductive coercion and tailor contraceptive counseling discussions accordingly.
JOGNN, 44, 218-227; 2015. DOI: 10.1111/1552-6909.12550 Accepted October 2014
Melissa A. Sutherland, PhD, FNP-BC, is a certified family nurse practitioner and an assistant professor at the William F. Connell School of Nursing, Boston College, Chestnut Hill, MA. Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an assistant professor in the College of Health Sciences, School of Nursing, University of Massachusetts Lowell, Lowell, MA, and a nurse practitioner for Health Quarters, Beverly, MA.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
218
ntimate partner violence (IPV) is a major public health issue among women living in the United States. Approximately one third of women report being abused by an intimate partner (current or former boyfriend, girlfriend, spouse) in their lifetimes, and 3% to 12% in the past year (Centers for Disease Control and Prevention [CDC], 2008; Plichta & Falik, 2001). Adolescents and young adult women are at high risk for IPV, with the highest rates among college-age women (Black et al., 2011; Catalano, 2007; Davis, 2008). The United States has 20 million students enrolled in higher education, approximately 5.7% of the total population; 14.6 million are full-time students and approximately half are women (U.S. Census Bureau, 2010). An estimated 43% of college women report experiencing physical, sexual, verbal, or controlling abuse from an intimate partner and 20% to 25% of college women report experiencing a completed or attempted rape during their college career (Fisher, Cullen, & Turner, 2000).
I
The CDC (2014a) defines IPV as a pattern of coercive control of one intimate partner by the other that includes physical and sexual violence, threats of physical or sexual violence, and emotional abuse in the context of physical and sexual violence. Among women experiencing IPV, an increased risk for sexually transmitted infections (STIs) has been demonstrated across different populations and settings (Allsworth, Anand, Redding, & Peipert, 2009; Champion, Piper, Holden, Korte, & Shain, 2004; Coker, 2007; Seth, Raiford, Robinson, Wingood, & DiClemente, 2010; Stockman, Campbell, & Celentano, 2010). Numerous researchers have also supported an association between IPV and unintended pregnancy (Hathaway et al., 2010; Lang, Salazar, Wingood, DiClemente, & Mikhail, 2007; O’Donnell, Agronick, Duran, Myint, & Stueve, 2009). The link between IPV and unintended pregnancy has been attributed to compromised sexual decision making (McFarlane et al., 2005; Silverman
C 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
RESEARCH
Sutherland, M. A., Fantasia, H. C., and Fontenot, H.
et al., 2011), difficulty negotiating condom use with partners (Sales et al., 2008; Silverman et al., 2011; Teitelman, Ratcliffe, Morales-Aleman, & Sullivan, 2008; Wingood & DiClemente, 1997), and fear related to condom negotiation (Sales et al., 2008; Wingood & DiClemente, 1997). However, researchers have identified reproductive coercion as an important mechanism linking IPV and unintended pregnancy (Gee, Mitra, Wan, Chavkin, & Long, 2009; Miller et al., 2010; Moore, Frohwirth, & Miller, 2010; Stockman et al., 2010; Thiel de Bocanegra, Rostovtseva, Khera, & Godhwani, 2010).
The aim of this study was to describe reports of reproductive coercion among college women.
lege women, a disproportionately at-risk group for IPV. Therefore, the aim of this study was to describe reports of reproductive coercion among college women.
Methods Study Design
Reproductive coercion, a form of IPV, is a man’s behavior that interferes with a woman’s ability to make independent decisions about reproduction. Reproductive coercion includes pregnancy coercion (e.g., verbal demands/threatening to harm a woman physically or psychologically if she does not become pregnant) and birth control sabotage, such as direct acts that ensure a woman cannot use contraception (Chamberland & Levenson, 2012). Women experiencing reproductive coercion may not be able to negotiate for effective contraception and/or condom use, possibly resulting in unintended pregnancy and STIs (Moore et al., 2010; Thiel de Bocanegra et al., 2010) that are associated with adverse health outcomes, including pelvic inflammatory disease, infertility, ectopic pregnancy, and perinatal infections (CDC, 2011; Hosenfeld et al., 2009). Unintended pregnancy is associated with delayed prenatal care, poor maternal mental health, reduced quality of the mother-child relationship, and poor developmental outcomes for children (Hoffman & Maynard, 2008; U.S. Department of Health and Human Services, 2015). Researchers who analyzed results from the National Intimate and Sexual Violence Survey (2010) found that approximately 9% of women in the United States (or 10.3 million) reported having an intimate partner who tried to get them pregnant when they did not want to or refused to use a condom (Black et al., 2011). Among family planning patients, researchers reported reproductive coercion prevalence rates from 16% to 25% (Clark, Allen, Goyal, Raker, & Gottlieb, 2014; Miller et al., 2010). Adolescents and young women seeking health care services at specialized clinical settings such as family planning clinics, obstetrics/gynecology clinics, or domestic violence shelters have been the focus of prior research (Clark et al., 2014; Gee et al., 2009; Miller et al., 2010; Thiel de Bocanegra et al., 2010). To date, however, reproductive coercion has not been studied in col-
JOGNN 2015; Vol. 44, Issue 2
This study was based on a secondary analysis of data from a sample of enrolled graduate and undergraduate college women from one large public university (N = 5,900). The parent study focused on sexual health of a sample of college men and women and explored the association between forced sex and consent attitudes, beliefs, and behaviors among the sample (Fantasia, Fontenot, Lee-St. John, & Sutherland, unpublished data). In this analysis we describe the reproductive coercion reported by college women in the sample from the parent study. In the parent study, Institutional Review Board (IRB) approval was obtained from the participating university and an online survey was sent to all currently enrolled female students. The online data collection occurred during the fall semester of 2012 using SurveyMonkey. With permission from the Office of Institutional Research and Reporting, the students were sent an introductory e-mail that described the study and overall purpose and provided a link to the informed consent document. Upon consenting electronically, students received the survey questions. All responses were anonymous. At the end of the study, all participants received information about web-based, community, and campus resources and referrals on IPV and sexual assault. For their participation, students could opt to access a separate webpage to enter a raffle to win one of two Apple iPod Touch devices. The raffle webpage was not linked to the survey responses.
Sample Inclusion criteria were currently or previously sexually active, age 18 to 25, enrolled full- or part-time at the university, and able to read and understand English. The introductory e-mail invitation was sent to approximately 5,900 women, and 1,180 arrived at the survey welcome page, reviewed the consent, and agreed to participate representing
Holly Fontenot is an assistant professor at the William F. Connell School of Nursing, Boston College, Chestnut Hill, MA and a nurse practitioner at the Fenway Health/Sidney Borum Health Center, Boston, MA.
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RESEARCH
Reproductive Coercion and Partner Violence among College Women
Nearly 8% of the college women reported reproductive coercion, and more than one -half of these women experienced some form of relationship violence during their lifetimes.
a response rate of 20%. Complete data from 972 participants were available for this analysis.
Measures
ical variables) were used to examine differences between women who reported reproductive coercion and those who did not on the variables of age, race/ethnicity, year in school, history of abortion, unintended pregnancy, condom use, and contraception. Logistic regression was used to estimate adjusted odds ratios and 95% CI for the prevalence of IPV among women reporting reproductive coercion. All calculated p values were 2-sided and p < .05 was considered statistically significant.
Demographic characteristics included age, race/ethnicity, living situation, and year in school.
Results Sexual health. Sexual and reproductive health were measured using an adapted questionnaire from the CDC (2009, 2013; Groves, Mosher, Lepkowski, & Kirgis, 2009). The questions used for this study included pregnancy and abortion history, relationship status, and contraceptive methods. Intimate partner violence. IPV was measured using two items adapted from the Abuse Assessment Screen (Soeken, McFarlane, Parker, & Lominak, 1998). Participants were asked if they had ever been abused (physical, sexual, emotional, or threats of abuse or violence) by a partner/significant other or forced to have sex when they didn’t want to. A positive history of IPV was considered an answer yes to either of these two questions. Reproductive coercion. The Reproductive Coercion Scale (10 items) was used to measure pregnancy coercion (five items) and birth control sabotage (five items) by male partners (Miller et al., 2010; Moore et al., 2010). For each of the items, respondents indicated yes or no. A positive response to any of the items was coded as reproductive coercion. In a previous study, the alpha coefficient of the Reproductive Coercion Scale was 0.76 (Miller et al., 2010). We added an additional pregnancy coercion item to this scale: “Does your partner refuse to pay for birth control because he wants or desires you to become pregnant?” See Table 2 for all items. The alpha coefficient for the revised scale in this sample of college women was 0.66.
Reproductive Coercion and IPV Reports of a history of reproductive coercion were associated with reports of IPV, and IPV was reported by 20.6% (n = 201) of the respondents. Of the college women who reported reproductive coercion (n = 76), 57% also screened positive for IPV (95% CI [2.74, 7.29]). Specifically, 67.9% of the women who reported birth control sabotage and 59.1% of the women reporting pregnancy coercion also reported IPV (see Table 2).
Descriptive analysis was conducted with Statistical Package for the Social Sciences (SPSS) version 20 to determine the rates of pregnancy coercion, birth control sabotage, and overall reproductive coercion and to describe characteristics of the sample. Independent sample t tests (continuous variables) or chi-squared analyses (categor-
Almost 8% of the college women (n = 76) reported an act of reproductive coercion (pregnancy coercion or birth control sabotage). Nearly 82% (62/76) of women who reported reproductive coercion were told not to use birth control and 26% (20/76) of the women were forced to have sex without a condom or other birth control method (birth control sabotage). Being told not to use any birth
JOGNN, 44, 218-227; 2015. DOI: 10.1111/1552-6909.12550
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Data Analysis
220
Sample Characteristics The mean age of the participants was 20.6 (SD = 2.0) years. Consistent with the demographics of the university, the participants were predominately White (75.3%; n = 701). Participants were evenly distributed across year in college except for graduate students (11.2%, n = 105 of the sample). A majority of students reported living at home with parents, 36.8% (n = 345) or living in the residence hall, 33.3% (n = 312). Approximately two thirds of the women reported being in a mutually monogamous relationship during the previous year (n = 645). Other relationship types included one-time sexual encounters with acquaintances (12.1%), repeated sexual encounters with the same people without the expectation of a relationship (15.7%), and one-time sexual encounters with strangers (5.7%). Almost 8% (n = 74) of the sample reported having ever been pregnant and 6.6% (n = 65) reported an unintended pregnancy (see Table 1). Most pregnancies were unintended (65 out of 74).
RESEARCH
Sutherland, M. A., Fantasia, H. C., and Fontenot, H.
Table 1: Demographic Characteristics of Study Sample Characteristic Age, y (n = 941), M (SD)
20.6
Table 2: Prevalence of Intimate Partner Violence (IPV) among Women Reporting Reproductive Coercion, Pregnancy Coercion, or Birth Control Sabotage (n = 76)
2.0 Positive history of IPV
n
%
Race/Ethnicity (n = 931) Hispanic Black/African American White
96 45 701
n
%a
95% CI
Reproductive coercion
44
57.9
[2.74, 7.29]
b
19
67.9
[2.75, 13.93]
39
59.1
[2.73, 7.75]
10.3 4.8 75.3
Birth control sabotage b
Asian
89
9.6
Year in School (n = 940) Freshman
177
18.8
Sophomore
213
22.7
Junior
234
24.9
Senior
211
22.4
Grad student
105
11.2
At home w family
345
36.8
In a residence hall
312
33.3
Apartment w roommates
162
17.3
Living situation (n = 938)
In home/apt alone
23
2.5
In home/apt w a partner
96
10.1
Mutually monogamous
645
66.4
Repeated sexual encounters
153
15.7
118
12.1
62
6.4
55
5.7
Relationship statusa (n = 972)
with the same person without commitment One-time sexual encounters with acquaintance(s) Non-monogamous long term sexual relationship One-time sexual encounters with stranger(s) Note. a Categories are not mutually exclusive.
control was the most common act of pregnancy coercion (n = 62) reported. A greater number of pregnancy coercion acts than acts of birth control sabotage were reported. Nearly 14% (11/76) of women who reported reproductive coercion had partners take off condoms during sex (see Table 3). Bivariate chi-squared analysis indicated differences in race/ethnicity between women who reported reproductive coercion compared with those who did not, with Hispanic women having
JOGNN 2015; Vol. 44, Issue 2
Pregnancy coercion
Note. CI = confidence interval. a Row percentages are reported. b Variables are not mutually exclusive.
higher rates. Although the numbers were small, women (n = 4) who experienced reproductive coercion were more likely to use an injectable birth control method (p = .001) (Table 4). Additionally, women who experienced reproductive coercion were also more likely to report a history of pregnancy (p < .001), abortion (p < .001), and unintended pregnancy (p < .001) (Table 4).
Discussion This study documents the prevalence of partner violence and reproductive coercion among a sample of nearly 1,000 female college students from a large public university. To date, this is the first known description of reproductive coercion (pregnancy coercion, birth control sabotage, or both) among college women in the literature. Our findings highlight that nearly 8% of the college women reported reproductive coercion, and more than one half of these women experienced some form of relationship violence during their lifetimes. Previous researchers have reported higher rates of reproductive coercion in other samples of women using family planning clinics and gynecology services. Miller et al. (2010) found that 19% of the participants experienced pregnancy coercion and 15% experienced birth control sabotage. Similarly, Gee et al. (2009) found that women with a lifetime history of IPV were more likely to report reproductive coercion. Most recently, Clark et al. (2014) found reproductive coercion with cooccurring IPV prevalent among women seeking obstetric/gynecologic care. It is interesting to note that women in this study reported more subtle acts of coercion, such as pressure to not use contraception, than overt acts, such as sabotaging the
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RESEARCH
Reproductive Coercion and Partner Violence among College Women
Table 3: Reproductive Coercion Among College Women (N = 972) Reported acts of reproductive coercion
n
%
Reproductive coercion Any act of pregnancy coercion or birth control sabotage
76
7.8
66
6.8
Told you not to use any birth control (like the pill, shot, ring, etc.)
62
6.4
Tried to force or pressure you to become pregnant
13
1.3
Pregnancy coerciona
Told you he would have a baby with someone else if you did not get pregnant
4
0.4
Said he would leave you if you did not get pregnant
3
0.3
1
0.1
8
0.8
28
3.9
Made you have sex without a condom or other birth control method so you would get pregnant
20
2.1
Taken off the condom while you were having sex so that you would get pregnant
11
1.1
3
0.3
Broken a condom on purpose while you were having sex so you would get pregnant
3
0.3
Put holes in the condom so you would get pregnant
1
0.1
Hurt you physically because you did not agree to get pregnant a
Refuse to pay for birth control because wanted/desired pregnancy a
Birth control sabotage
Taken birth control (like pills) away from you or kept you from going to the clinic to get birth control so you would get pregnant
a
Note. Not mutually exclusive items; investigator developed for the study.
contraceptive method, that were reported by previous researchers (Miller et al., 2010). The reason for this is not clear and should be explored in future work. It is not known if subtle pressure from partners to avoid contraception increases pregnancy risk or if women are able to maintain adequate contraception despite pressure from their partners. This study supports the findings of previous researchers and similarly showed an occurrence of reproductive coercion among sexually active reproductive-age women and an association between relationship violence and reproductive coercion (Clark et al., 2014; Gee et al., 2009; Miller et al., 2010; Moore et al., 2010; Thiel de Bocanegra et al., 2010). Our findings also add to the current knowledge regarding reproductive coercion by describing this form of coercion among a sample of college women.
Several limitations deserve consideration. Because we did not ask detailed partner history questions in the original study, the results must be viewed in terms of those limitations. Specifically, the survey did not include questions about the specific acts of partner violence and the sever-
Finally, the response rate of the survey was less than reported by other researchers using online survey methodology (Sutherland, Amar, & Laughon, 2013). However, this online survey was launched just prior to a major weather event with widespread and prolonged power outages in the area of the university, which may have contributed to the response rate. Underreporting of a sensitive issue may also explain the lesser response rate. Despite these limitations, this study had notable
JOGNN, 44, 218-227; 2015. DOI: 10.1111/1552-6909.12550
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Limitations
222
ity and timing of the violence within relationships. Additionally, the alpha coefficient of the Reproductive Coercion Scale in this study was marginal and lower than reported in earlier studies. Previously the scale was used with samples of women from family planning and obstetric/gynecologic offices. Further instrument testing among college samples is needed. Future investigators should also examine the construct of unintended pregnancy in more detail. Pregnancy intention is multifaceted, and use of a dichotomous measure does not capture the complexity surrounding the dynamics of decisions to avoid or attempt pregnancy. Additionally, this sample was largely homogenous, and the results may not be reflective of women from all races and ethnicities or those at other public or private universities in the United States.
RESEARCH
Sutherland, M. A., Fantasia, H. C., and Fontenot, H.
Table 4: Demographic and Reproductive Variables by Reproductive Coercion and Intimate Partner Violence (IPV) Status Positive history reproductive coercion
Variables
%a
n
p
Positive history of IPV
%a
n
p
Age, y 18–20
42
8.7
101
27.1
21–23
24
6.8
71
24.5
24–25
10
9.8
29
35.8
0.48
0.13
Race/Ethnicity Hispanic
16
16.7
167
28.6
7
15.6
5
17.9
White
46
6.6
22
28.2
Asian
6
6.7
7
14.9
Black/African American
0.002∗
0.14
Year in school Freshman
18
10.2
38
30.4
Sophomore
13
6.1
46
27.5
Junior
27
11.5
53
27.3
Senior
15
7.1
48
27.6
3
2.9
16
19.5
Graduate School
∗
0.54
0.04 Living situation At home with family
29
8.4
75
27.5
In a residence hall
29
9.3
70
29.4
Apartment w roommates
5
3.1
26
20.0
In a home/apt alone
1
4.3
6
30.0
12
12.5
24
30.0
In a home/apt w partner
0.06
0.35
Relationship status Monogamous
59
9.1
586
77.6
Non-monogamous
10
28.6
52
5.8
Hook up w acquaintance
17
14.4
31
30.1
Hook up w stranger
11
20.0
19
38.0
Friends w benefits
20
13.1
50
36.8
0.25
0.13 ∗
Ever pregnant
17
22.4
0.001
33
16.5
Ever had abortion
12
15.8
RESEARCH
Reproductive Coercion and Partner Violence among College Women Melissa A. Sutherland, Heidi Collins Fantasia, and Holly Fontenot
Correspondence Melissa A. Sutherland, PhD, RN, FNP-BC, Boston College, William F. Connell School of Nursing, 140 Commonwealth Avenue, Chestnut Hill, MA 02467. [email protected]
ABSTRACT
Keywords reproductive coercion intimate partner violence college women
Methods: An e-mail invitation to participate in an electronic survey was sent to undergraduate and graduate female students. A web link to the informed consent and inclusion criteria were provided. Students who affirmed they met inclusion criteria could proceed to the survey. Completion of the survey implied consent.
Objective: To examine reproductive coercion and partner violence among college women. Design: Cross-sectional, descriptive. Setting: A large public university in the Northeast United States. Participants: Inclusion criteria were college women age 18 to 25, enrolled either full- or part-time, English speaking, and screened positive for relationship. Data from 972 women were analyzed.
Results: Nearly 8% of participants (n = 76) reported reproductive coercion, including pregnancy coercion, birth control sabotage, or both. Women reported more pregnancy coercion (6.8%) than birth control sabotage (3.9%). Being told not to use any birth control was the most commonly reported act (6.8%, n = 62). Of women reporting reproductive coercion (n = 76), 57% also screened for positive relationship violence (95% confidence interval [CI] [2.74, 7.29]). Conclusion: Pregnancy coercion and birth control sabotage occur among college women, and higher rates were reported among women with histories of partner violence. In addition to screening and counseling for partner violence, college health providers should assess for reproductive coercion and tailor contraceptive counseling discussions accordingly.
JOGNN, 44, 218-227; 2015. DOI: 10.1111/1552-6909.12550 Accepted October 2014
Melissa A. Sutherland, PhD, FNP-BC, is a certified family nurse practitioner and an assistant professor at the William F. Connell School of Nursing, Boston College, Chestnut Hill, MA. Heidi Collins Fantasia, PhD, RN, WHNP-BC, is an assistant professor in the College of Health Sciences, School of Nursing, University of Massachusetts Lowell, Lowell, MA, and a nurse practitioner for Health Quarters, Beverly, MA.
(Continued)
The authors report no conflict of interest or relevant financial relationships.
218
ntimate partner violence (IPV) is a major public health issue among women living in the United States. Approximately one third of women report being abused by an intimate partner (current or former boyfriend, girlfriend, spouse) in their lifetimes, and 3% to 12% in the past year (Centers for Disease Control and Prevention [CDC], 2008; Plichta & Falik, 2001). Adolescents and young adult women are at high risk for IPV, with the highest rates among college-age women (Black et al., 2011; Catalano, 2007; Davis, 2008). The United States has 20 million students enrolled in higher education, approximately 5.7% of the total population; 14.6 million are full-time students and approximately half are women (U.S. Census Bureau, 2010). An estimated 43% of college women report experiencing physical, sexual, verbal, or controlling abuse from an intimate partner and 20% to 25% of college women report experiencing a completed or attempted rape during their college career (Fisher, Cullen, & Turner, 2000).
I
The CDC (2014a) defines IPV as a pattern of coercive control of one intimate partner by the other that includes physical and sexual violence, threats of physical or sexual violence, and emotional abuse in the context of physical and sexual violence. Among women experiencing IPV, an increased risk for sexually transmitted infections (STIs) has been demonstrated across different populations and settings (Allsworth, Anand, Redding, & Peipert, 2009; Champion, Piper, Holden, Korte, & Shain, 2004; Coker, 2007; Seth, Raiford, Robinson, Wingood, & DiClemente, 2010; Stockman, Campbell, & Celentano, 2010). Numerous researchers have also supported an association between IPV and unintended pregnancy (Hathaway et al., 2010; Lang, Salazar, Wingood, DiClemente, & Mikhail, 2007; O’Donnell, Agronick, Duran, Myint, & Stueve, 2009). The link between IPV and unintended pregnancy has been attributed to compromised sexual decision making (McFarlane et al., 2005; Silverman
C 2015 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
http://jognn.awhonn.org
RESEARCH
Sutherland, M. A., Fantasia, H. C., and Fontenot, H.
et al., 2011), difficulty negotiating condom use with partners (Sales et al., 2008; Silverman et al., 2011; Teitelman, Ratcliffe, Morales-Aleman, & Sullivan, 2008; Wingood & DiClemente, 1997), and fear related to condom negotiation (Sales et al., 2008; Wingood & DiClemente, 1997). However, researchers have identified reproductive coercion as an important mechanism linking IPV and unintended pregnancy (Gee, Mitra, Wan, Chavkin, & Long, 2009; Miller et al., 2010; Moore, Frohwirth, & Miller, 2010; Stockman et al., 2010; Thiel de Bocanegra, Rostovtseva, Khera, & Godhwani, 2010).
The aim of this study was to describe reports of reproductive coercion among college women.
lege women, a disproportionately at-risk group for IPV. Therefore, the aim of this study was to describe reports of reproductive coercion among college women.
Methods Study Design
Reproductive coercion, a form of IPV, is a man’s behavior that interferes with a woman’s ability to make independent decisions about reproduction. Reproductive coercion includes pregnancy coercion (e.g., verbal demands/threatening to harm a woman physically or psychologically if she does not become pregnant) and birth control sabotage, such as direct acts that ensure a woman cannot use contraception (Chamberland & Levenson, 2012). Women experiencing reproductive coercion may not be able to negotiate for effective contraception and/or condom use, possibly resulting in unintended pregnancy and STIs (Moore et al., 2010; Thiel de Bocanegra et al., 2010) that are associated with adverse health outcomes, including pelvic inflammatory disease, infertility, ectopic pregnancy, and perinatal infections (CDC, 2011; Hosenfeld et al., 2009). Unintended pregnancy is associated with delayed prenatal care, poor maternal mental health, reduced quality of the mother-child relationship, and poor developmental outcomes for children (Hoffman & Maynard, 2008; U.S. Department of Health and Human Services, 2015). Researchers who analyzed results from the National Intimate and Sexual Violence Survey (2010) found that approximately 9% of women in the United States (or 10.3 million) reported having an intimate partner who tried to get them pregnant when they did not want to or refused to use a condom (Black et al., 2011). Among family planning patients, researchers reported reproductive coercion prevalence rates from 16% to 25% (Clark, Allen, Goyal, Raker, & Gottlieb, 2014; Miller et al., 2010). Adolescents and young women seeking health care services at specialized clinical settings such as family planning clinics, obstetrics/gynecology clinics, or domestic violence shelters have been the focus of prior research (Clark et al., 2014; Gee et al., 2009; Miller et al., 2010; Thiel de Bocanegra et al., 2010). To date, however, reproductive coercion has not been studied in col-
JOGNN 2015; Vol. 44, Issue 2
This study was based on a secondary analysis of data from a sample of enrolled graduate and undergraduate college women from one large public university (N = 5,900). The parent study focused on sexual health of a sample of college men and women and explored the association between forced sex and consent attitudes, beliefs, and behaviors among the sample (Fantasia, Fontenot, Lee-St. John, & Sutherland, unpublished data). In this analysis we describe the reproductive coercion reported by college women in the sample from the parent study. In the parent study, Institutional Review Board (IRB) approval was obtained from the participating university and an online survey was sent to all currently enrolled female students. The online data collection occurred during the fall semester of 2012 using SurveyMonkey. With permission from the Office of Institutional Research and Reporting, the students were sent an introductory e-mail that described the study and overall purpose and provided a link to the informed consent document. Upon consenting electronically, students received the survey questions. All responses were anonymous. At the end of the study, all participants received information about web-based, community, and campus resources and referrals on IPV and sexual assault. For their participation, students could opt to access a separate webpage to enter a raffle to win one of two Apple iPod Touch devices. The raffle webpage was not linked to the survey responses.
Sample Inclusion criteria were currently or previously sexually active, age 18 to 25, enrolled full- or part-time at the university, and able to read and understand English. The introductory e-mail invitation was sent to approximately 5,900 women, and 1,180 arrived at the survey welcome page, reviewed the consent, and agreed to participate representing
Holly Fontenot is an assistant professor at the William F. Connell School of Nursing, Boston College, Chestnut Hill, MA and a nurse practitioner at the Fenway Health/Sidney Borum Health Center, Boston, MA.
219
RESEARCH
Reproductive Coercion and Partner Violence among College Women
Nearly 8% of the college women reported reproductive coercion, and more than one -half of these women experienced some form of relationship violence during their lifetimes.
a response rate of 20%. Complete data from 972 participants were available for this analysis.
Measures
ical variables) were used to examine differences between women who reported reproductive coercion and those who did not on the variables of age, race/ethnicity, year in school, history of abortion, unintended pregnancy, condom use, and contraception. Logistic regression was used to estimate adjusted odds ratios and 95% CI for the prevalence of IPV among women reporting reproductive coercion. All calculated p values were 2-sided and p < .05 was considered statistically significant.
Demographic characteristics included age, race/ethnicity, living situation, and year in school.
Results Sexual health. Sexual and reproductive health were measured using an adapted questionnaire from the CDC (2009, 2013; Groves, Mosher, Lepkowski, & Kirgis, 2009). The questions used for this study included pregnancy and abortion history, relationship status, and contraceptive methods. Intimate partner violence. IPV was measured using two items adapted from the Abuse Assessment Screen (Soeken, McFarlane, Parker, & Lominak, 1998). Participants were asked if they had ever been abused (physical, sexual, emotional, or threats of abuse or violence) by a partner/significant other or forced to have sex when they didn’t want to. A positive history of IPV was considered an answer yes to either of these two questions. Reproductive coercion. The Reproductive Coercion Scale (10 items) was used to measure pregnancy coercion (five items) and birth control sabotage (five items) by male partners (Miller et al., 2010; Moore et al., 2010). For each of the items, respondents indicated yes or no. A positive response to any of the items was coded as reproductive coercion. In a previous study, the alpha coefficient of the Reproductive Coercion Scale was 0.76 (Miller et al., 2010). We added an additional pregnancy coercion item to this scale: “Does your partner refuse to pay for birth control because he wants or desires you to become pregnant?” See Table 2 for all items. The alpha coefficient for the revised scale in this sample of college women was 0.66.
Reproductive Coercion and IPV Reports of a history of reproductive coercion were associated with reports of IPV, and IPV was reported by 20.6% (n = 201) of the respondents. Of the college women who reported reproductive coercion (n = 76), 57% also screened positive for IPV (95% CI [2.74, 7.29]). Specifically, 67.9% of the women who reported birth control sabotage and 59.1% of the women reporting pregnancy coercion also reported IPV (see Table 2).
Descriptive analysis was conducted with Statistical Package for the Social Sciences (SPSS) version 20 to determine the rates of pregnancy coercion, birth control sabotage, and overall reproductive coercion and to describe characteristics of the sample. Independent sample t tests (continuous variables) or chi-squared analyses (categor-
Almost 8% of the college women (n = 76) reported an act of reproductive coercion (pregnancy coercion or birth control sabotage). Nearly 82% (62/76) of women who reported reproductive coercion were told not to use birth control and 26% (20/76) of the women were forced to have sex without a condom or other birth control method (birth control sabotage). Being told not to use any birth
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Data Analysis
220
Sample Characteristics The mean age of the participants was 20.6 (SD = 2.0) years. Consistent with the demographics of the university, the participants were predominately White (75.3%; n = 701). Participants were evenly distributed across year in college except for graduate students (11.2%, n = 105 of the sample). A majority of students reported living at home with parents, 36.8% (n = 345) or living in the residence hall, 33.3% (n = 312). Approximately two thirds of the women reported being in a mutually monogamous relationship during the previous year (n = 645). Other relationship types included one-time sexual encounters with acquaintances (12.1%), repeated sexual encounters with the same people without the expectation of a relationship (15.7%), and one-time sexual encounters with strangers (5.7%). Almost 8% (n = 74) of the sample reported having ever been pregnant and 6.6% (n = 65) reported an unintended pregnancy (see Table 1). Most pregnancies were unintended (65 out of 74).
RESEARCH
Sutherland, M. A., Fantasia, H. C., and Fontenot, H.
Table 1: Demographic Characteristics of Study Sample Characteristic Age, y (n = 941), M (SD)
20.6
Table 2: Prevalence of Intimate Partner Violence (IPV) among Women Reporting Reproductive Coercion, Pregnancy Coercion, or Birth Control Sabotage (n = 76)
2.0 Positive history of IPV
n
%
Race/Ethnicity (n = 931) Hispanic Black/African American White
96 45 701
n
%a
95% CI
Reproductive coercion
44
57.9
[2.74, 7.29]
b
19
67.9
[2.75, 13.93]
39
59.1
[2.73, 7.75]
10.3 4.8 75.3
Birth control sabotage b
Asian
89
9.6
Year in School (n = 940) Freshman
177
18.8
Sophomore
213
22.7
Junior
234
24.9
Senior
211
22.4
Grad student
105
11.2
At home w family
345
36.8
In a residence hall
312
33.3
Apartment w roommates
162
17.3
Living situation (n = 938)
In home/apt alone
23
2.5
In home/apt w a partner
96
10.1
Mutually monogamous
645
66.4
Repeated sexual encounters
153
15.7
118
12.1
62
6.4
55
5.7
Relationship statusa (n = 972)
with the same person without commitment One-time sexual encounters with acquaintance(s) Non-monogamous long term sexual relationship One-time sexual encounters with stranger(s) Note. a Categories are not mutually exclusive.
control was the most common act of pregnancy coercion (n = 62) reported. A greater number of pregnancy coercion acts than acts of birth control sabotage were reported. Nearly 14% (11/76) of women who reported reproductive coercion had partners take off condoms during sex (see Table 3). Bivariate chi-squared analysis indicated differences in race/ethnicity between women who reported reproductive coercion compared with those who did not, with Hispanic women having
JOGNN 2015; Vol. 44, Issue 2
Pregnancy coercion
Note. CI = confidence interval. a Row percentages are reported. b Variables are not mutually exclusive.
higher rates. Although the numbers were small, women (n = 4) who experienced reproductive coercion were more likely to use an injectable birth control method (p = .001) (Table 4). Additionally, women who experienced reproductive coercion were also more likely to report a history of pregnancy (p < .001), abortion (p < .001), and unintended pregnancy (p < .001) (Table 4).
Discussion This study documents the prevalence of partner violence and reproductive coercion among a sample of nearly 1,000 female college students from a large public university. To date, this is the first known description of reproductive coercion (pregnancy coercion, birth control sabotage, or both) among college women in the literature. Our findings highlight that nearly 8% of the college women reported reproductive coercion, and more than one half of these women experienced some form of relationship violence during their lifetimes. Previous researchers have reported higher rates of reproductive coercion in other samples of women using family planning clinics and gynecology services. Miller et al. (2010) found that 19% of the participants experienced pregnancy coercion and 15% experienced birth control sabotage. Similarly, Gee et al. (2009) found that women with a lifetime history of IPV were more likely to report reproductive coercion. Most recently, Clark et al. (2014) found reproductive coercion with cooccurring IPV prevalent among women seeking obstetric/gynecologic care. It is interesting to note that women in this study reported more subtle acts of coercion, such as pressure to not use contraception, than overt acts, such as sabotaging the
221
RESEARCH
Reproductive Coercion and Partner Violence among College Women
Table 3: Reproductive Coercion Among College Women (N = 972) Reported acts of reproductive coercion
n
%
Reproductive coercion Any act of pregnancy coercion or birth control sabotage
76
7.8
66
6.8
Told you not to use any birth control (like the pill, shot, ring, etc.)
62
6.4
Tried to force or pressure you to become pregnant
13
1.3
Pregnancy coerciona
Told you he would have a baby with someone else if you did not get pregnant
4
0.4
Said he would leave you if you did not get pregnant
3
0.3
1
0.1
8
0.8
28
3.9
Made you have sex without a condom or other birth control method so you would get pregnant
20
2.1
Taken off the condom while you were having sex so that you would get pregnant
11
1.1
3
0.3
Broken a condom on purpose while you were having sex so you would get pregnant
3
0.3
Put holes in the condom so you would get pregnant
1
0.1
Hurt you physically because you did not agree to get pregnant a
Refuse to pay for birth control because wanted/desired pregnancy a
Birth control sabotage
Taken birth control (like pills) away from you or kept you from going to the clinic to get birth control so you would get pregnant
a
Note. Not mutually exclusive items; investigator developed for the study.
contraceptive method, that were reported by previous researchers (Miller et al., 2010). The reason for this is not clear and should be explored in future work. It is not known if subtle pressure from partners to avoid contraception increases pregnancy risk or if women are able to maintain adequate contraception despite pressure from their partners. This study supports the findings of previous researchers and similarly showed an occurrence of reproductive coercion among sexually active reproductive-age women and an association between relationship violence and reproductive coercion (Clark et al., 2014; Gee et al., 2009; Miller et al., 2010; Moore et al., 2010; Thiel de Bocanegra et al., 2010). Our findings also add to the current knowledge regarding reproductive coercion by describing this form of coercion among a sample of college women.
Several limitations deserve consideration. Because we did not ask detailed partner history questions in the original study, the results must be viewed in terms of those limitations. Specifically, the survey did not include questions about the specific acts of partner violence and the sever-
Finally, the response rate of the survey was less than reported by other researchers using online survey methodology (Sutherland, Amar, & Laughon, 2013). However, this online survey was launched just prior to a major weather event with widespread and prolonged power outages in the area of the university, which may have contributed to the response rate. Underreporting of a sensitive issue may also explain the lesser response rate. Despite these limitations, this study had notable
JOGNN, 44, 218-227; 2015. DOI: 10.1111/1552-6909.12550
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Limitations
222
ity and timing of the violence within relationships. Additionally, the alpha coefficient of the Reproductive Coercion Scale in this study was marginal and lower than reported in earlier studies. Previously the scale was used with samples of women from family planning and obstetric/gynecologic offices. Further instrument testing among college samples is needed. Future investigators should also examine the construct of unintended pregnancy in more detail. Pregnancy intention is multifaceted, and use of a dichotomous measure does not capture the complexity surrounding the dynamics of decisions to avoid or attempt pregnancy. Additionally, this sample was largely homogenous, and the results may not be reflective of women from all races and ethnicities or those at other public or private universities in the United States.
RESEARCH
Sutherland, M. A., Fantasia, H. C., and Fontenot, H.
Table 4: Demographic and Reproductive Variables by Reproductive Coercion and Intimate Partner Violence (IPV) Status Positive history reproductive coercion
Variables
%a
n
p
Positive history of IPV
%a
n
p
Age, y 18–20
42
8.7
101
27.1
21–23
24
6.8
71
24.5
24–25
10
9.8
29
35.8
0.48
0.13
Race/Ethnicity Hispanic
16
16.7
167
28.6
7
15.6
5
17.9
White
46
6.6
22
28.2
Asian
6
6.7
7
14.9
Black/African American
0.002∗
0.14
Year in school Freshman
18
10.2
38
30.4
Sophomore
13
6.1
46
27.5
Junior
27
11.5
53
27.3
Senior
15
7.1
48
27.6
3
2.9
16
19.5
Graduate School
∗
0.54
0.04 Living situation At home with family
29
8.4
75
27.5
In a residence hall
29
9.3
70
29.4
Apartment w roommates
5
3.1
26
20.0
In a home/apt alone
1
4.3
6
30.0
12
12.5
24
30.0
In a home/apt w partner
0.06
0.35
Relationship status Monogamous
59
9.1
586
77.6
Non-monogamous
10
28.6
52
5.8
Hook up w acquaintance
17
14.4
31
30.1
Hook up w stranger
11
20.0
19
38.0
Friends w benefits
20
13.1
50
36.8
0.25
0.13 ∗
Ever pregnant
17
22.4
0.001
33
16.5
Ever had abortion
12
15.8
