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Teen relationship abuse puts teens at risk
By Anita Brakman, MS,
Assistant Director of Education, Research, and Training
Physicians for Reproductive Choice and Health
New York City
and Melanie Gold, DO, FAAP, FACOP
Clinical Professor of Pediatrics
University of Pittsburgh School of Medicine
University of Pittsburgh Student Health Service
Four hundred thousand (1.6% of U.S. adolescents) experience serious physical and/or sexual dating violence each year.1 Within their lifetimes, 20% of U.S. female high school students report experiencing intimate partner violence.2
Unfortunately, intimate partner violence often goes unreported, and available data reveal a limited view of the range of abusive behaviors that can occur within adolescent dating relationships. Verbal and emotional abuse as well as other controlling behaviors might be better captured by using the term "adolescent relationship abuse" (ARA). ARA is defined as a pattern of repeated acts in which a person physically, sexually, or emotionally abuses another person whom they are dating or in a relationship with, whether of the same or opposite sex, in which one or both partners is under age 18.3 In addition to incidents of verbal abuse, physical, or sexual assaults, ARA can include many behaviors including but not limited to social isolation, cell phone monitoring, and controlling attendance at school or social activities.
Reproductive healthcare providers might find particularly concerning controlling behaviors related to reproductive and sexual health referred to as reproductive coercion. Attempts to impregnate a partner against her wishes; controlling pregnancy outcomes; hiding, withholding, or tampering with contraceptives; forcing sexual acts; and intentional exposure to sexually transmitted infections are all examples.
While reproductive coercion can occur in relationships without concurrent physical abuse, they often co-occur. Adolescent girls in physically abusive relationships are more likely to experience unintended pregnancy, fear the consequences of condom negotiation, and are less likely to use condoms consistently.4,5 In one recent study of women seeking care in family planning clinics, 18% of women ages 16-20 reported experiences with reproductive coercion, and 12% reported experiences with birth control sabotage specifically.6
Routine visits offer window
There are numerous routine visits when seeing adolescents that provide opportunities to identify reproductive coercion. Adolescents should be asked at health visits, especially annual and routine gynecologic visits, about how safe they feel in their relationship, and providers should confirm there is no intimate partner violence or coercion. When an adolescent requests a change in contraceptive methods, it might be helpful to ask how her partner(s) feel about the previous method to reveal information about sabotage. If an adolescent wants to avoid pregnancy but is nervous about sabotage, more hidden, private methods such as injectable, implantable, or intrauterine contraceptives might be preferable to pills, patches or rings. Adolescents seeking pregnancy testing might benefit from counseling where they are asked if their current partner desires a pregnancy. Repeat visits to request emergency contraception or sexually transmitted infection testing might also prompt acknowledgement of condom refusal, tampering, or episodes of coerced unprotected sex.
Providing routine education about healthy relationships and reproductive coercion normalizes the topics. Even if an adolescent is not ready to address abuse, the discussion opens the door to future conversations. For example, if an adolescent chooses to initiate contraceptive injection use after experiencing contraceptive sabotage, follow-up visits for injections provide additional opportunities to check in about the relationship and safety. Talking with adolescents who are not directly experiencing ARA or reproductive coercion also allows the information to be passed on to others in need because adolescents commonly share health-related information with peers. Finally, a universal approach allows providers to reach male adolescents and adolescents in same-sex relationships who often are overlooked by traditional dating violence assessments.
One ARA intervention evaluated through a randomized control trial found, over 24 weeks, that among a group of age 16-29 females experiencing intimate partner violence in the last three months, those who received education about healthy relationships and reproductive coercion were 60% more likely to end a relationship because it seemed unsafe or unhealthy.7 The intervention consisted of trained counselors providing enhanced intimate partner violence screening focused on reproductive coercion, harm reduction planning when intimate partner violence was disclosed, providing education about local intimate partner violence resources, as well as a distributing a patient pocket card to provide ongoing resources.
When assessing reproductive coercion, it is essential to discuss confidentiality rights, exceptions, and state reporting requirements at the beginning of the visit. If a disclosure of abuse or coercion is made, providers should ensure immediate safety and refer adolescents to local resources for violence prevention, counseling, and services. Making supported referrals where adolescents are directed to specific professionals known to your practice can make these sensitive services easier for teens to access.
The Family Violence Prevention Fund has developed several tools to facilitate discussions about healthy relationships, ARA and reproductive coercion. These include clinical guidelines, scripts for talking to patients about these topics, guidance on staff training, and materials to help adolescents assess their own relationship health. These and other materials are available at www.endabuse.org.