Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic, Reproductive Health Care Settings Third Edition By Linda Chamberlain, PhD, MPH and Rebecca Levenson, MA Our vision is now our name. Formerly Family Violence Prevention Fund PRODUCED BY Futures Without Violence, formerly the Family Violence Prevention Fund. ©2013, 3rd edition. FUNDED BY U.S. Department of Health and Human Services’ Office on Women’s Health (Grant #1 ASTWH110023-01-00) and Administration on Children, Youth and Families. (Grant #90EV0414) With Special Thanks to: Nancy C. Lee, MD Director Office on Women’s Health Aleisha Langhorne, MPH, MHSA Health Scientist Administrator Office on Women’s Health Marylouise Kelley, PhD Director, Family Violence Prevention & Services Program Family and Youth Services Bureau Administration for Children and Families Futures Without Violence Wishes to Especially Thank the Following for their Contribution: Elizabeth Miller, MD, PhD Chief, Division of Adolescent Medicine Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center Jeffrey Waldman, MD Medical Director Planned Parenthood Shasta Pacific Phyllis Schoenwald, PA Vice President of Medical Services Planned Parenthood Shasta Pacific Vanessa Cullins, MD, MPH, MBA Vice President of Medical Affairs Planned Parenthood Federation of America Laurie Weaver Chief, Office of Family Planning California Department of Public Health Jacquelyn C. Campbell, PhD, RN, FAAN Anna D. Wolf Chair and Professor School of Nursing, Johns Hopkins University Funding for this project was made possible in part by the Department of Health and Human Services (HHS) Office on Women’s Health. The views expressed in written materials or publications and by speakers and moderators at HHS co-sponsored activities, do not necessarily reflect the official policies of the U.S. Department of Health and Human Services; nor does the mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government. This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The recommendations do not dictate an exclusive course of treatment or of practice. Variations taking into account the needs of the individual patient, resources, and information unique to the institution or type of practice may be appropriate. Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic, and Reproductive Health Care Settings CONTENTS PART 1: INTRODUCTION . 3 Background Definitions Magnitude of the Problem PART 2: REPRODUCTIVE HEALTH EFFECTS . 11 General Reproductive Health Effects of Abuse Contraceptive Use and Birth Control Sabotage Condom Use Teen Pregnancy The Role of Pregnancy Pressure in Unintended Pregnancies The Role of Pregnancy Coercion in Women Terminating or Continuing Their Pregnancies, Sexually Transmitted Infections (STIs) and HIV PART 3: GUIDE FOR RESPONDING TO IPV AND REPRODUCTIVE COERCION IN THE HEALTH CARE SETTING . 17 Preparing Your Clinic/Program Integrated Assessment and Intervention Supported Referral Document and Follow-up Promoting Prevention PART 4: POLICY IMPLICATIONS AND SYSTEMS RESPONSE . 33 APPENDICES . 37 Appendix A: National Consensus Guidelines, (Excerpts from pages 14-19) Health and Safety Assessment, Interventions, Documentation, Follow-up Appendix B: Reproductive Health, Intimate Partner Violence (IPV), and Reproductive and Sexual Coercion: Quality Assessment/Quality Improvement Tool Appendix C: Intimate partner violence . Committee Opinion No . 518 . American College of Obstetricians and Gynecologists . Obstet Gynecol 2012;119:412–7 FUTURESFUTURES WITHOUT WITHOUT VIOLENCE VIOLENCE 1 1 Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic, and Reproductive Health Care Settings 2 FUTURES WITHOUT VIOLENCE Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for Reproductive Health and Partner Violence Guidelines Obstetric, Gynecologic, and Reproductive Health Care Settings PART 1: INTRODUCTION utures Without Vioence (Futures), formerly the Family Violence Prevention Fund, is a leading advocate for addressing intimate partner What is Trauma- F violence (IPV)—also referred to as domestic violence in the health care Informed Care? setting. Futures produces numerous data-informed publications, programs, Information provided on the and resources to promote routine assessment and effective responses by health Substance Abuse and Mental care providers. Health Services Administration (SAMSHA) website indicates that most individuals seeking The American College of Obstetricians and Gynecologists (the College), a public behavioral health national medical organization representing over 56,000 members who provide services and many other public health care for women, is dedicated to the advancement of women’s health services—such as homeless and through continuing medical education, practice, research and advocacy. The domestic violence services—have College was the first national medical organization to formally recognize the histories of physical and sexual abuse and other types of trauma- problem of domestic violence over 25 years ago and continues to address this inducing experiences (http:// problem through its Guidelines for Women’s Health Care, Guidelines for www .samhsa .gov/nctic/trauma .asp). Perinatal Care, Committee Opinions, and slide lecture kits. Its most recent These experiences often lead to opinion on intimate partner violence was published in February 2012 (See mental health and co-occurring Appendix C for Committee Opinion). disorders such as chronic health conditions, substance abuse, eating disorders, and HIV/ This new resource, Addressing Intimate Partner Violence Reproductive and AIDS as well as contact with the Sexual Coercion, cobranded by the College, focuses on the crucial role of criminal justice system. the health care provider in identifying and addressing IPV and reproductive coercion. FUTURES WITHOUT VIOLENCE 3 Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for Obstetric, Gynecologic, and Reproductive Health Care Settings Background Over the past two decades, a growing body of research has recognized the connection between relationship violence and poor reproductive health care outcomes for women. More hidden and often undetected forms of victimization involving coercive behaviors that interfere with reproductive health have emerged from this research. Health care visits provide a window of opportunity to address IPV and coercive behaviors related to patients’ reproductive health. The goal of this resource is to reframe the way in which health care systems respond to IPV and reproductive and sexual coercion. The health care provider is the hub of a wheel in a trauma-informed, coordinated health care response that includes universal education and prevention. This guide highlights research that demonstrates how a brief intervention using a safety card to educate female patients about reproductive and sexual coercion can improve reproductive health outcomes and promote healthy, safe, and consensual relationships. Safety cards and other resources for integrating and sustaining a trauma-informed, coordinated response to IPV and reproductive and sexual coercion are included in this publication. In 2011, the Institute of Medicine (IOM) issued guidelines for preventive health services for women that recommend routine domestic violence (intimate partner violence) screening. The guidelines endorsed by Department of Health and Human Services require that new health insurance plans cover domestic violence screening as part of women’s preventive services. Under the Affordable Care Act, new health plans must reimburse domestic violence screening and counseling as part of preventive health care services at no additional cost. Addressing Intimate Partner Violence Reproductive and Sexual Coercion Guide expands the scope of routine screening for IPV to include assessment for reproductive and sexual coercion. A trauma-informed, comprehensive approach to relationship violence that includes behaviors that interfere with patients’ reproductive health can improve the quality of care and reproductive health outcomes including higher contraceptive compliance, fewer unintended pregnancies, preventing coerced and repeat abortions, and reducing sexually transmitted infections (STIs)/HIV and associated risk behaviors. Key components of addressing IPV and reproductive and sexual coercion in the health care setting include: • Promoting healthy, safe, and consensual relationships • Strengthening harm reduction behaviors • Providing services that are the safest, most effective options given the patient’s personal circumstances • Offering patients information and resources that will empower them to have more reproductive control and be safer The Guide includes: • Definitions of IPV, adolescent relationship abuse, reproductive coercion and related terminology • A brief overview of the prevalence of IPV and reproductive and sexual coercion • The latest research on the impact of IPV and reproductive and sexual coercion on women’s and girls’ reproductive health • Strategies for addressing reproductive and sexual coercion with patients seeking reproductive health care services 4 FUTURES WITHOUT VIOLENCE Addressing Intimate Partner Violence Reproductive and Sexual Coercion:Part 1: Introduction A Guide for Obstetric, Gynecologic,