Written by Michael A. Belmonte
Intimate partner violence (IPV), a cycle of controlling behaviors committed by an intimate or dating partner, affects more than 1 in 3 women* in the US.¹ These behaviors range from screaming, threatening, insulting, physical and sexual abuse, as well as “progressive isolation, stalking, deprivation, intimidation, and reproductive coercion.”¹
Patients experiencing IPV are often also experiencing reproductive coercion. Reproductive coercion is when an abusive partner aims to control the reproductive health of their partner as a method of maintaining power and control in the relationship. It can often manifest as forcing a partner to either carry or terminate a pregnancy against their will or even birth control sabotage, such as poking holes in condoms, switching or misplacing birth control pills, or simply forcing someone to use or not use birth control. Between 14-25% of women* seen at abortion clinics have experienced physical and/or sexual IPV in the past year.² When providing abortion or early pregnancy loss care to a patient, it is important to take additional steps to safeguard a patient’s reproductive autonomy.
Recommendations to incorporate into practice:
- Incorporate screening into intake forms.
- Room the patient alone to allow for screening in a private and safe setting where you cannot be interrupted or overheard.²
- Use professional language interpreters and not someone associated with the patient.
- Use a framing statement to show that screening is done universally (“We’ve started talking to all of our patients about safe and healthy relationships because it can have such a large impact on your health”).¹
- Integrate trauma-informed care into your patient interactions and workplace.
- Inform patients of the confidentiality and mandated reporter requirements in your jurisdiction, so that patients can disclose, if and when they feel ready, and on their terms.
- Establish and maintain relationships with community resources.²
- The domestic violence coalition in your state
- Local domestic violence advocates
- The violence prevention program in your state health department²
- Keep printed take-home resources.
- Display posters and other educational materials, such as safety cards, throughout visible areas that describe IPV and sexual and reproductive coercion; have these available in a variety of different languages.²
- Ensure staff receives regular training.
- Counsel patients being seen for a medication abortion with concerns about privacy to put the misoprostol pills inside their cheeks or under their tongue, instead of inserting the pills vaginally; this way, there will be no pill fragments left behind that can be discovered by a patient’s partner.
- Provide information on safe self-management abortion to patients that prefer to manage their abortion outside of a clinic setting; you can counsel patients on what the medications are, how to take them, what to expect, and when/where to seek help if needed.
Screening should not include “do you feel safe at home (and in your relationship)?” While these questions have high specificity (few false positives), they have extremely low sensitivity ( many false negatives or that we are missing out on the opportunity for disclosure and connection with resources).³
While there are many different methods for screening, such HITS, WAST, PVS, AAS (and more),⁴ HITS is an easy-to-use acronym: Hurt, Insult, Threaten, and Scream.
The questions to ask are:
- How often does your partner physically hurt you?
- How often does your partner insult or talk down to you?
- How often does your partner threaten you with physical harm?
- How often does your partner scream or curse at you?
While HITS has traditionally been used to assess frequency using a 5-point Likert scale response, these questions can be adapted to yes/no questions with any yes response triggering further screening and conversation. Additionally, to assess for reproductive coercion, you can add “How often does your partner force you to have sexual activities?”
Lastly, it is important to approach all patients as if they have experienced trauma, even if they aren’t ready to disclose.⁵ By doing so, you can avoid retraumatizing the very people you are trying to help. Simply creating the space and asking the questions can make it easier for someone to disclose in the future, when they are ready.
Footnote: Screening for IPV in women* of reproductive age is recommended by the U.S. Preventive Services Task Force [Grade B], the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) [Grade A]1,6,7
*The surveys cited in this Insights use the term “women.” RHAP recognizes that this language is not inclusive of all people experiencing intimate partner violence. A person’s biology does not determine their gender.
2. Chamberlain L, Levenson R. Addressing Intimate Partner Violence Reproductive and Sexual Coercion. Reproductive Health Guidelines. https://www.futureswithoutviol
3. Peralta RL, Fleming MF. Screening for intimate partner violence in a primary care setting: the validity of “feeling safe at home” and prevalence results. J Am Board Fam Pract. 2003;16(6):525-532. doi:10.3122/jabfm.16.6.525
5. Clinician Guide for Trauma-Informed Care. National Clinical Training Center for Family Planning. https://www.ctcfp.org/clinicia
6. Intimate partner violence, elder abuse, and abuse of vulnerable adults: Screening. Recommendation: Intimate Partner Violence, Elder Abuse, and Abuse of Vulnerable Adults: Screening | United States Preventive Services Taskforce. https://www.uspreventiveservic
Pharma-free: The Reproductive Health Access Project does not accept funding from pharmaceutical companies. We do not promote specific brands of medication or products. The information in the Insights is unbiased, based on science alone.