Among those who had sex in the previous 3 months, participants with recent reproductive coercion were more likely than those without to report hormonal contraceptive method use only (28.8% vs 18.6%, P=.045). Females without reproductive coercion exposure were more likely than those with exposure to report simultaneous hormonal methods and condom use (33.3% vs 24.2%, P=.045) (Table 2). Recent condom use did not differ significantly between those who reported reproductive coercion and those who did not (59.1% vs 69.4%, P=.126), neither did use of emergency contraception (12.1% vs 15.2%, P=.542) (Table 2). Individuals who had experienced both relationship abuse and reproductive coercion had significantly higher odds of reporting hormonal methods only (aOR 3.77, 95% CI 1.09–13.1) (Table 3). Furthermore, they also had higher odds of having two or more sexual partners recently (aOR 3.86, 95% CI 1.57–9.48) and a partner who was 5 or more years older (aOR 4.66, 95% CI 1.51–14.4) (Table 3).
Of the total sample, 5.6% of participants reported reproductive coercion only, 2.4% reported reproductive coercion and adolescent relationship abuse only, 2.0% reported reproductive coercion and nonpartner sexual violence only, and 2.0% reported all three. Of the total sample, 8.9% of participants reported relationship abuse only and 4.0% reported relationship abuse and nonpartner sexual violence only. Finally, 8.9% of participants reported nonpartner sexual violence only (Fig. 1). Compared with those who had not experienced reproductive coercion, participants who had reproductive coercion had higher rates of recent physical relationship abuse (22.7% vs 7.0%, P=.009), recent sexual relationship abuse (27.3% vs 9.1%, P=.019), and recent nonpartner sexual violence (33.3% vs 14.7%, P=.035) (Table 2). Among the participants who disclosed recent physical or sexual relationship abuse, we observed higher rates of nonpartner sexual violence (34.7% vs 13.2%, P=.009) compared with those who had not experienced relationship abuse. Similarly, among females who had sex in the previous 3 months, those who reported recent physical or sexual relationship abuse had higher rates of recent reproductive coercion compared with those who did not (27.0% vs 10.9%, P=.002) (Table 2). These results remained significant in adjusted models investigating the relationship between recent relationship abuse and reproductive coercion (Table 3). Females who had recent reproductive coercion had more than four times the odds of experiencing recent physical relationship abuse (aOR 4.32, 95% CI 2.12–8.79) and recent sexual relationship abuse (aOR 4.24, 95% CI 2.21–8.11), adjusting for race or ethnicity and grade level. Females who had recent relationship abuse had more than three times the odds of experiencing reproductive coercion (aOR 3.21, 95% CI 1.81–5.71). Both groups (those who had reported reproductive coercion and those who had reported relationship abuse) had higher odds of recent nonpartner sexual violence (reproductive coercion aOR 2.88, 95% CI 1.33–6.21, relationship abuse aOR 3.55, 95% CI 1.95–6.48) (Table 3).
These data indicate that reproductive coercion is common among adolescents and young women who are high school students and is associated with adolescent relationship abuse, yet there were no observed significant demographic differences or care-seeking patterns among participants with this exposure. The majority of females with recent reproductive coercion identified as black or Hispanic, similar to research with older women.7,13,22–25 Given persistent disparities in reproductive and sexual health among women and girls of color,26–28 further study is needed on the potential contribution of reproductive coercion to these disparities among adolescents and young women, specifically.
There were no observed differences in visit frequency between those with and without reproductive coercion or relationship abuse. Individuals reporting relationship abuse had higher odds of seeking STI testing or treatment, but not pregnancy testing, which may reflect ease of obtaining over-the-counter pregnancy tests. These data confirm previous studies while challenging others. Miller et al29 found that adolescents who experienced relationship abuse were more likely to have foregone health care (ie, not seeking care despite needing to do so),20 whereas another study noted that recent reproductive coercion and partner violence were positively associated with seeking pregnancy and STI testing.30 In school health centers where barriers to confidential care are minimized (eg, no cost, transportation, or reliance on a parent or guardian for transport), reproductive coercion may not be associated with differential care-seeking patterns.
Females who experienced both reproductive coercion and relationship abuse had higher odds of having a partner who was 5 or more years older. Providers should be aware of mandated reporting laws relevant to child sexual abuse (including partner age in sexual abuse definitions) and discuss these with patients before asking about relationships. Additionally, participants who experienced both exposures had higher odds of having two or more recent sexual partners. A patient's disclosure of unprotected intercourse or sexual activity with multiple partners could indicate previous or current reproductive coercion or relationship abuse.31–34
With contraceptive use, those exposed to reproductive coercion and relationship abuse had higher odds of using hormonal methods only, as opposed to hormonal methods and condoms. Condom manipulation (eg, damaging condoms, removing condoms during sex) is a critical dimension of reproductive coercion that is challenging to include in harm-reduction counseling as behaviors are driven by the perpetrator.10 In fact, research has documented that those experiencing partner violence may be less likely to negotiate condom use or fear the consequences of negotiating condom use with their sexual partners.32–34 Providers should consider discussions on how to safely negotiate condom use and make emergency contraception accessible for patients, as part of harm-reduction counseling to address reproductive coercion and relationship abuse.
Study limitations include the cross-sectional design, limiting causal inference. Our sample only included participants at school health centers in northern California and is not necessarily generalizable to stand-alone adolescent clinics or health settings in other areas. To be consistent with prior studies with older adolescent and young adult women, we focused on reproductive coercion and physical and sexual relationship abuse only. Effects of emotional and cyber abuse are detailed elsewhere.11 Finally, given that the study was not initially powered to detect group differences, our results do not provide definitive evidence of lack of demographic differences and associations with care-seeking behaviors.
Our study explicitly seeks to investigate demographic differences in reproductive coercion and the effects of harmful partner behaviors on care-seeking behaviors among adolescents and young women. Examining adolescent and young women–only populations is important, given how abusive behaviors can manifest differently in adolescence compared with adulthood.35 These findings underscore the need for universal education and assessment of harmful partner behaviors among female patients. Furthermore, although clinical guidelines exist to address reproductive coercion, adherence to these guidelines is not yet ubiquitous.15,16,36,37 By highlighting the relevance of reproductive coercion in adolescence, this study substantiates the urgent need for developmentally appropriate interventions.
There are several clinical practice implications of these findings: 1) reproductive coercion and relationship abuse are prevalent among high school–aged females and should be addressed during clinic visits; 2) multiple sexual partners and older partner age may elevate risk for reproductive coercion or relationship abuse, but there are few care-seeking characteristics to guide case identification; thus, providing education to all patients on healthy and unhealthy relationships and reproductive coercion is appropriate; and 3) harm-reduction counseling should go beyond hidden (or “invisible”) contraception7 and include discussions of condom manipulation as a form of abusive behavior. All patients who are adolescents and young women should receive information and resources about reproductive coercion and relationship abuse, and routine inquiry for these exposures can be integrated into every clinical encounter.
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