January 25, 2013
A man pulls off a condom during sex, or threatens a woman so she'll get an abortion. These are examples of "reproductive coercion," a major group of doctors for women says. The new statement comes from the American College of Obstetricians and Gynecologists (ACOG). Preventing a woman from making choices about birth control and pregnancy is a form of abuse, ACOG says. It says doctors should look out for such abuse and help patients avoid it. The statement cites a study of teens in abusive relationships. About 25% reported "birth control sabotage." So did 15% of physically abused women. Examples include destroying birth control pills or forcing a woman to have unprotected sex. Some men have even pulled out intrauterine devices (IUDs) and vaginal rings, ACOG says. The group urges doctors to screen patients and refer those who are abused to counseling. ACOG says doctors also can help by providing means of birth control that are harder to detect. They can even cut off the strings that are used to remove an IUD. The journal Obstetrics & Gynecology published the statement January 24. USA Today wrote about it.
By Mary Pickett, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
The American College of Obstetrics and Gynecology (ACOG) is advising doctors to ask female patients some direct questions. Doctors are being urged to ask women if they have experienced "birth control sabotage."
What does this mean? It could include being forced to have sex with no condom, or having a birth control method interrupted on purpose. For example, a partner might hide birth control pills, pull out an intrauterine device (IUD) or a vaginal ring, or put holes into a condom. ACOG says that 25% of teen girls with abusive partners and 15% of women who are physically abused report having a problem like this. Another name for it is reproductive or sexual coercion.
Some people do behave in surprising and cruel ways. As a doctor, I struggle at times with how many of these "warning" conversations to have with my patients. Should I ask about sexual safety, suicide thoughts, violence in the home, eating disorders? When and in what plain language should I take the time in our brief interactions to bring these dark horses into the room?
I have not come across many instances of birth control sabotage. But I have seen several cases of serious concern. There was a teen who was drugged by her boyfriend and subjected to an illegal abortion (not one performed by a doctor). One patient with HIV refused to wear condoms or to inform sexual partners of his infection. Another man asked to have his vasectomy reversed in order to get his girlfriend pregnant, but he did not want his wife to know.
I have also encountered cases that make me fearful that doctors do not always know the whole story. One example is a woman whose pregnancy occurred soon after she took steps toward leaving an abusive partner. The pregnancy caused her to stay in the relationship. She had been using what should have been reliable birth control.
These brief peeks into dark corners tell doctors that not all is well in some relationships. I don't think the ACOG is being extreme in recommending that doctors bring this topic up with their patients.
When I was a new doctor, I used to ask my patients, "Are you in a safe relationship?"
Almost all of my patients gave me a "yes" to that question. So I changed to a more specific question: "Have you ever been hit, slapped, punched, kicked, pushed, choked, forced into intimacy or sex or threatened by a partner?" People are much more likely to answer this one with examples of times they have felt vulnerable.
Beginning today, I may add a new question: "Have you ever felt bullied or controlled by a partner, in your choices for or access to birth control?"
What Changes Can I Make Now?
Your reproductive health needs to stay in your control. Your doctor can't choose relationships for you. However, he or she can talk with you about:
Your doctor is a good person to talk over concerns that you would like to keep confidential.
Teenagers are especially vulnerable to sexual coercion. They are also vulnerable to human error, when it comes to remembering pills. In many states, teens can get birth control from a doctor without having a parent's consent.
In 2011, ACOG named IUDs and contraceptive implants in the arm (Implanon) as the first choices of birth control for teen girls. IUDs are inserted in the uterus and prevent pregnancy for 5 or 10 years, depending on the IUD type. Implants (brand name Implanon) prevent pregnancy for 3 years. IUDs and Implanon are the most secure forms of birth control available.
If you have had sex without reliable birth control, a way to prevent pregnancy is emergency birth control. This is also known as the "morning after pill" or "Plan B." It is used within 72 hours (but preferably sooner) after sex. Emergency birth control can reduce the chance of pregnancy to between 1% and 3%.
In the United States, emergency birth control pills are available without prescription for women and men 17 and older. At least 9 states allow pharmacists to provide them directly to teens, even those who are too young to buy them over the counter. (Call any pharmacy to learn if this is true in your state).
Emergency birth control is a two-dose hormone treatment. It contains progesterone, either with or without estrogen. Here are examples when emergency contraception would be useful:
What Can I Expect Looking to the Future?
It is helpful to give names to forms of abuse, and to violations of human rights. I applaud ACOG for bringing birth control sabotage to public attention. By asking questions we can find ways to make women safer.