The 'hidden violence' of reproductive coercion and abuse

New data from a ten-year Australian population study, and specific data screening study published in the MJA, show a significant need to screen for reproductive coercion and abuse (RCA) in Australia.

This story comes with a trigger warning for family violence and intimate partner violence. If you or someone else is experiencing abuse, you can call 1800 RESPECT.

New data shows reproductive coercion and abuse (RCA), along with intimate partner violence (IPV), is a significant issue Australia-wide.

RCA has been referred to as a “hidden form of violence against women,” and describes behaviours used to control a person’s reproductive autonomy, to either prevent or promote pregnancy.

The MJA published a study this month featuring an IPV and RCA screening program used at Sexual Health Quarters (SHQ) in Perth, Western Australia to collect data regarding patients’ experiences with IPV and RCA.

Also this month, the third Australian Study of Health and Relationships (ASHR3) presented preliminary data regarding IPV and RCA.

A closer look at reproductive coercion

Dr Cathy Brooker is a GP at the SHQ clinic that began researching a screening program for IPV and RCA in March 2019.

“We have two studies: one reports on the experience of introducing the program, and the other is the data we found” says Dr Brooker.

“We noticed that we probably weren’t picking up clients who might be experiencing IPV or RCA, because the number of clients reporting this to us was not as high as other prevalence studies would indicate,” said Dr Brooker.

“There weren’t any similar screening programs in services at that time, so, we created one,” said Dr Brooker.

“It’s one of the really challenging things when you’re a GP. You almost don’t want to ask patients about abuse because, how do you help the person in front of you?” said Dr Brooker, who said the clinic took a practical approach.

“We needed to create a full service with practicalities, such as: can someone get an emergency appointment with the counsellor if they need to,” said Dr Brooker.

“We already had a counselling service, so our counsellors were given specific training to look after people in that initial stage, and then work out where they might link into services,” she said.

“The exciting thing is that our screening program does seem to work, given the stats. We are picking up people who are experiencing abuse,” said Dr Brooker.

“Another finding was that if someone has experienced reproductive coercion, there is a very high chance that she has also experienced intimate partner violence. It’s important to know that and ask the questions,” said Dr Brooker.

If you don’t ask, you don’t know

Dr Brooker said the data highlights that patients generally only reported IPV and RCA when asked. Dr Brooker said that some women only reported the second time they were asked.

According to an earlier paper written about the same program, the reported lifetime prevalence rate of women experiencing IPV and RCA was 17% (which is similar to other studies). Of those who screened positive, the majority (61%) had already been patients at SHQ for at least one year. These patients only disclosed exposure to violence for the first time when directly asked through the screening program.

“At SHQ, we think we’re nice doctors, and we all think we’re good at listening to people and forming a relationship, and that people would tell us if they had something going on. But we didn’t pick it up until we had the screening program, and I think that is an important statistic. If you don’t ask, you don’t know,” she said.

The researchers also found that the data pointed at different demographics than they perhaps originally thought it would.

“You can’t pick it up from demographics. In our MJA paper, there were demographic surprises. Being Australian born was a risk factor, and being in a middle socio-economic group, not a lower socio-economic group. And being older, not younger,” said Dr Brooker.

“It says to us, you don’t just ask someone because they are from a perhaps historically presumed high-risk group. You’re going to be missing a lot of people,” said Dr Brooker.

The clinicians and other staff were also happy with the screening program.

“We looked at the level of concern and acceptability of the screening program amongst staff before and during. Certainly, the statistics moved from the staff having significant reservations to essentially thinking it was fantastic,” said Dr Brooker.

Dr Brooker said that the data was important in the fight against violence against women generally.

“People experiencing IPV, and reproductive coercion often have many health problems that aren’t necessarily a black eye. They also often have an increased number of presentations to GPs, about unrelated things. These forms of abuse are responsible for a lot of health problems. From a public health point of view that’s important, because if these forms of abuse can be addressed, then there will be fewer health problems,” says Dr Brooker.

A national perspective

Dr Allison Carter is a senior lecturer and group leader of the Sexual Health and Reproductive Equity (SHARE) research group at the Kirby Institute, UNSW Sydney.

Dr Carter presented preliminary findings at the 25th IUSTI World Congress Incorporating the Australasian Sexual & Reproductive Health Conference 2024, from the third Australian Study of Health and Relationships (ASHR3).

The ASHR3 is an Australian study conducted about every 10 years, providing a snapshot of the sexual reproductive health of Australians aged 16 to 69 years, with over 14 500 people surveyed.

Among women, the most prevalent form of RCA was forced abortion (4.9%) followed by contraceptive interference by a partner (3.9%), forced sterilisation/contraception (2.6%), and forced pregnancy (1.9%).

“This data comes from a nationally representative sample of Australian adults, and so it’s the first population-based evidence of the prevalence in the country,” said Dr Carter.

“We found that in all types of experiences, reproductive coercion was primarily perpetrated by partners. Although parents, other family members, and health professionals were also reported. And in fact, in the case of forced abortion, parents were a common source of pressure and coercion for women reporting that experience,” said Dr Carter.

Dr Carter said that most perpetrators are male, and most victim/survivors are female partners.

Dr Carter, like Dr Brooker, said that RCA is also associated with other health concerns for women.

“About 5% of Australians report reproductive coercion and abuse. Socio-economically marginalised communities were more likely to experience reproductive coercion and abuse. Members of the LGBTQ community were affected. We also found a high number of poor reproductive, sexual, physical, and mental health outcomes linked with reproductive coercion and abuse including poor general health, mental, psychosocial distress,” she said.

The study found increased odds of ever reporting an STI, and several reproductive outcomes like miscarriage, as well as a strong link with a history of experiencing sexual violence.

“There’s a critical need to better understand and respond to this health issue in people with diverse backgrounds and to engage them in the co-design of solutions.

Dr Carter says that, where sexual health clinics are at the coalface, and show higher prevalence rates, this is the first study showing that reproductive coercion is happening across a broader sample of Australians.

Politics and reproductive coercion

Reproductive health care is more visible globally since the Supreme Court of the United States overturned the Roe versus Wade ruling, limiting access to reproductive health care. Reproductive health care is now a political issue in some Australian states.

Dr Carter says that the way governments can restrict reproductive rights and health care is currently being discussed in terms like those of RCA.

“The scientific literature around reproductive coercion and abuse tends to frame it sort of at an individual and interpersonal level. They describe it as a form of intimate partner violence in which people enact coercive behaviours against another person to control or threaten their reproductive autonomy,” said Dr Carter.

“The literature tends to conceptualise structural issues, like laws, policies, as barriers or possibly facilitators to reproductive rights and reproductive choices. But there’s a lot of debate in the field, because we know that states and governments and medical institutions can mimic the dynamics of coercion and fear and control. And so, there are other scholars who would contend that what’s happening in the US is a very clear example of government controlling the reproductive autonomy of individual women,” said Dr Carter.

“I read a recent study that found reproductive coercion and abuse was a precursor to domestic homicide. And there is a lot of evidence to suggest that abuse can begin during pregnancy or intensify then. And so, it’s a critical time for women and for health care providers to be screening women. But we don’t yet have the systems in place to really support providers in that regard,” said Dr Carter.

“The behaviours can sometimes be quite subtle and difficult to kind of detect. There’s quite a lot of work that needs to be done in this space.”

If you or someone else is experiencing abuse, you can call 1800 RESPECT.

Subscribe to the free InSight+ weekly newsletter here. It is available to all readers, not just registered medical practitioners.