Addressing Intimate
Partner Violence,
Reproductive andSexual Coercion:
A Guide for Obstetric, Gynecologic andReproductive Health Care Settings
Second 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. ©2012, 2nd 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 HealthMarylouise Kelley, PhD
Director, Family Violence Prevention & Services Program
Family and Youth Services Bureau
Administration for Children and Families
Futures Without Violence Wishes to EspeciallyThank 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 PacificPhyllis Schoenwald, PA
Vice President of Medical Services
Planned Parenthood Shasta PacificVanessa 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 theindividual 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

CONTENTSPART 1: INTRODUCTION .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  .  . 3BackgroundDefinitions
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
FUTURES
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PART 1: INTRODUCTION

F

utures Without Violence (Futures), formerly the Family ViolencePrevention Fund, is a leading advocate for addressing intimate partner
violence (IPV)—also referred to as domestic violence in the health caresetting. Futures produces numerous data-informed publications, programs,
and resources to promote routine assessment and effective responses by healthcare providers.
The American College of Obstetricians and Gynecologists (the College), a
national medical organization representing over 56,000 members who provide
health care for women, is dedicated to the advancement of women’s healththrough continuing medical education, practice, research and advocacy. The
College was the first national medical organization to formally recognize theproblem of domestic violence over 25 years ago and continues to address thisproblem through its Guidelines for Women’s Health Care, Guidelines for
Perinatal Care, Committee Opinions, and slide lecture kits. Its most recent
opinion on intimate partner violence was published in February 2012 (SeeAppendix C for Committee Opinion).
This new resource, Addressing Intimate Partner Violence Reproductive andSexual Coercion, cobranded by the College, focuses on the crucial role ofthe health care provider in identifying and addressing IPV and reproductive
coercion.

What is TraumaInformed Care?
Information provided on the
Substance Abuse and Mental
Health Services Administration(SAMSHA) website indicatesthat most individuals seeking
public behavioral healthservices and many other public
services—such as homeless anddomestic violence services—have
histories of physical and sexual
abuse and other types of traumainducing experiences (http://
www.samhsa.gov/nctic/trauma.asp).
These experiences often lead tomental health and co-occurring
disorders such as chronic healthconditions, substance abuse,eating disorders, and HIV/AIDS as well as contact with thecriminal justice system.

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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 healthhave emerged from this research.
Health care visits provide a window of opportunity to address IPV and coercive behaviors related topatients’ 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 andpromote healthy, safe, and consensual relationships. Safety cards and other resources for integrating andsustaining 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 thatrecommend 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 healthplans must reimburse domestic violence screening and counseling as part of preventive health careservices 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, andreducing 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 healthcare services

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Obstetric, Gynecologic, and Reproductive Health Care Settings• Safety cards to use as a brief intervention to ask and educate patients about reproductive and sexual coercion• An overview of preparing your practice or program and keys for success including developing
relationships with local domestic violence advocates and community programs• A quality assessment/quality improvement tool to implement and sustain a trauma-informed,
coordinated response to IPV and reproductive and sexual coercion• Policy implications and recommendations
The information provided in this document focuses on the link between reproductive health andviolence against women. Additional information on assessing and responding to IPV in the healthcare setting is provided in the National Consensus Guidelines on Identifying and Responding toDomestic Violence Victimization in Health Care Settings.1 For more information on the College’s
IPV Committee Opinion: see Appendix C.
This guide is applicable, but not limited to, the following settings:• Family planning clinics• HIV prevention programs• OB/GYN and women’s health care settings• Adolescent health clinics and programs• Prenatal care programs• Abortion clinics and services• STI/HIV clinics• Any provider or setting that offers
reproductive health services• Title X clinics

Definitions
One of the challenges in the field of family violence research has been a lack of standardized definitions.
A working definition for IPV is provided in the National Consensus Guidelines.1 The Guidelines,
which were developed in collaboration with national experts and approved by the Agency for HealthCare Research, are widely accepted in research and practice. Adolescent relationship abuse (also known
as dating violence) is included in the definition of IPV. Experts in the field have noted that while many
aspects of adolescent relationship abuse are similar to IPV, there are also distinct characteristics relative
to the age of the victim and/or perpetrator and different patterns of abusive behaviors. For this reason, adefinition for adolescent relationship abuse is included below.
Intimate Partner Violence

Intimate partner violence is a pattern of assaultive and coercive behaviors that may include inflicted
physical injury, psychological abuse, sexual assault, progressive isolation, stalking, deprivation,
intimidation, and threats. These behaviors are perpetrated by someone who is, was, or wishes tobe involved in an intimate or dating relationship with an adult or adolescent, and are aimed at
establishing control by one partner over the other.2
Adolescent Relationship Abuse

Adolescent relationship abuse refers to 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 a minor. Similar to adult IPV,the emphasis on the repeated controlling and abusive behaviors distinguishes relationship abuse from

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isolated events (e.g. a single experience of sexual assault
occurring at a party where two people did not know eachother). Sexual and physical assaults occur in the context
of relationship abuse, but the defining characteristic isa repetitive pattern of behaviors that aim to maintainpower and control in a relationship. For adolescents, such
behaviors include monitoring cell phone usage, tellinga partner what she/he can wear, controlling whether thepartner goes to school that day, as well as manipulating
contraceptive use.
The intersections between IPV, reproductive and sexual
coercion, and reproductive health have enhanced ourunderstanding of the dynamics and health effects ofabusive adult and teen relationships. This has led to
expanded terminology to describe forms of abuse andcontrolling behaviors related to reproductive health. For
the purpose of this guide, working definitions for key terms
are provided below.
Reproductive and Sexual Coercion

Reproductive and sexual coercion involves behaviors to maintain power and control in a relationshiprelated to reproductive health by someone who is, was, or wishes to be involved in an intimate or
dating relationship with an adult or adolescent.
Most forms of behavior used to maintain power and control in a relationship that impact reproductive
health disproportionately affect females; however, there are some forms of reproductive and sexual
coercion that males experience that are included in the definitions below.
Reproductive Coercion

Reproductive coercion is related to behaviors that interfere with contraception use and/or pregnancy.
Reproductive coercion is limited to heterosexual relationships. Two types of reproductive coercion, birthcontrol sabotage and pregnancy pressure and coercion, are described below.
Birth Control Sabotage

Birth control sabotage is active interference with a partner’s contraceptive methods. Examples ofbirth control sabotage include:• Hiding, withholding, or destroying a partner’s birth control pills• Breaking or poking holes in condoms on purpose or removing a condom during sex in an
explicit attempt to promote pregnancy• Not withdrawing when that was the agreed upon method of contraception• Pulling out vaginal rings• Tearing off contraceptive patches• Pulling out an IUD/IUC

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Pregnancy Pressure and Coercion

Pregnancy pressure involves behaviors that are intended to pressure a female partner to become
pregnant when she does not wish to become pregnant. Pregnancy coercion involves coercive
behaviors such as threats or acts of violence if she does not comply with her partner’s wishes
regarding the decision of whether to terminate or continue a pregnancy. Examples of pregnancy
pressure and coercion include:• Threatening to hurt a partner who does not agree to become pregnant• Forcing a female partner to carry a pregnancy to term against her wishes through threats or actsof violence• Forcing a female partner to terminate a pregnancy when she does not want to• Injuring a female partner in a way that she may have a miscarriage
Sexual Coercion

All experiences of sexual violence are devastating and clearly impact sexual and reproductive healthand there has been a lot of work in the field to address sexual assault in the health care settings. To
further support that work, this guide also examines a narrowed focus of interest: sexual coercion.
Sexual coercion includes a range of behaviors that a partner may use related to sexual decision-making topressure or coerce a person to have sex without using physical force. Examples of sexual coercion, which
may occur in heterosexual or same sex relationships, include:• Repeatedly pressuring a partner to have sex when he or she does not want to• Threatening to end a relationship if a person does not have sex• Forced non-condom use or not allowing other prophylaxis use• Intentionally exposing a partner to a STI or HIV• Threatening retaliation if notified of a positive STI result
Males and Reproductive andSexual Coercion

Adolescent and adult males may also
experience reproductive and sexual
coercion. A recent national survey on
intimate partner and sexual violencein the United States provided thefirst population-based data on males’
experiences with reproductive andsexual coercion.3 Research on theimpact of reproductive and sexual
coercion on men’s reproductive
health is urgently needed. This
research is essential to inform thedevelopment and evaluation ofevidence-based interventions formales who experience reproductive
and sexual coercion.

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What Messages Do We Want to Share with Adolescent and Adult Males?

Male patients need to hear the same messages about the importance of healthy relationships,
consensual sex, and consensual contraception to prevent unwanted pregnancies as female patients.
Strategies for assessment, harm reduction, and intervention described in this guide can be adapted formale patients. As research evidence is being accumulated, clinical experience will help to inform bestpractices for male patients.

Magnitude of the Problem
IPV and reproductive and sexual coercion are health issues that disproportionately affect women.
Women are at significantly higher risk than men of experiencing IPV, of sustaining serious injuries, andbeing killed by an intimate partner.4,5• Approximately 1 in 4 women have been physically and/or sexually assaulted by a current orformer partner4• Nearly half (45.9%) of women experiencing physical abuse in a relationship also disclose forced
sex by their intimate partner6• In a nationally representative sample, 1 in 4 women reported lifetime coerced sex; among womenreporting coerced sex, more than one-third were 15 years old or younger at the time of their firstcoerced sexual experience7
Several studies have examined the prevalence of sexual coercion among adolescents and young adults.
• 19.6% of female and 8.2% of male undergraduate students reported unwanted sexual contact
in the past six months8• 23% of female college students and 7% of male college students reported one or moreexperiences of unwanted sexual intercourse9• A survey of 10th and 11th graders revealed that over half of girls and 13.1% of boys had
been victims of sexual coercion, defined as sexual behaviors involving verbal coercion, threats offorce, or use of drugs or alcohol 10• Females were more likely than males to report that their perpetrator used physical force during
coerced sex8,9
As previously noted, reproductive coercion is limited to heterosexual couples while sexual coercion
may occur in heterosexual or same sex couples. Recent research provides some insight into gay andbisexual males’ experiences with sexual coercion. In a survey with gay and bisexual men, 18.5%
reported unwanted sexual activity.11 Qualitative data from interviews with gay and bisexual men
suggest that many of the factors underlying sexual coercion are related more to masculine sexuality
versus gay sexuality and that society’s response to same sex relationships leads to circumstances such as
marginalization that increases vulnerability to sexual violence.12
Studies on the prevalence of IPV and sexual victimization among female patients seen in the health caresettings underscore the need for routine assessment and trauma-informed care.
• Two in five (40%) of female adolescent patients seen at urban adolescent clinics had experienced
IPV; 21% reported sexual victimization13• More than one-half (53%) of women seen at family planning clinics reported physical orsexual IPV14

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This guide focuses on partner violence as a health disparity issue for women and girls with aparticular focus on how men interfere with and limit their female partners’ ability to make choices
about their reproductive health. This guide provides an overview of recent research on the impactof relationship violence on family planning, abortion services, and STIs/HIV. Since the relationshipbetween IPV and poor pregnancy outcomes is well documented elsewhere, this document does notaddress the impact of IPV on maternal, fetal, and infant health.
Health care providers have an essential role in prevention of IPV and reproductive and sexual coercion
by discussing healthy, consensual, and safe relationships with all patients. Some of the screening andintervention strategies described in this guide can be adapted for male patients. It is anticipated that
future research will provide more information on how to better serve men, same sex couples, and otherat-risk populations.

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PART 2: REPRODUCTIVE HEALTH EFFECTS

General Reproductive Health Effects of AbuseT

here is a substantial body of research describing the dynamics and effects of IPV on women’s
and adolescents’ health. Abusive and controlling behaviors range from sexual assault and forced
sex, to more hidden forms of victimization that interfere with a partner’s choices about sexual
activities, contraception, safer sex practices, and pregnancy. In a systematic review of the impact of IPV
on sexual health, IPV was consistently associated with sexual risk taking, inconsistent condom use,
partner non-monogamy, unplanned pregnancies, induced abortions, STIs and sexual dysfunction.15

IPV can be a barrier to women and teens accessing reproductive health care.

In one study, adolescent girls who experienced IPV were nearly 2½ times more likely to have forgone health care in the past
12 months compared to non-abused girls.13
Sexual victimization increases the likelihood of adolescent risk behaviors and other health concerns.

Population-based data indicates that adolescents who
experienced forced sexual intercourse were more likely to engage
in binge drinking and attempt suicide.16

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Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings“It got so bad, I tried to kill myself. I tried jumping off
the bridge, and stuff like that; ’cause I just couldn’t
deal with it anymore. I couldn’t deal with it. I stopped
talking to all my friends. I had a ton of friends from [myhometown], and I wasn’t allowed to talk to any of them.” 17Contraceptive Use andBirth Control Sabotage
Women who have experienced IPV are more likely to report a lack of birthcontrol use because of a partner’s unwillingness to use birth control or desire
for pregnancy.18 Abused women are also more likely to have not used birthcontrol due to affordability and are more likely to have used emergency
contraception when compared to nonabused women.18 Similar to otherforms of controlling behavior in abusive relationships, partners interfere withwomen’s birth control use as a means to control them.
Recent research conducted by the Harvard School of Public Health,
University of California at Davis School of Medicine, and Futures indicatesthat a significant portion of women and adolescent girls seeking reproductive health care services haveexperienced some form of IPV and/or reproductive and sexual coercion. In family planning clinics, 15%of female patients with a history of physical and/or sexual IPV reported birth control sabotage.14
Birth control sabotage has been documented in the following studies:• Among teen mothers on public assistance who had experienced recent IPV, 66% disclosed birthcontrol sabotage by a dating partner19• The odds of experiencing interference with attempts to avoid pregnancy was 2.4 times higher
among women disclosing a history of physical violence by their husbands compared to nonabused women20• Among women with abusive partners, 32% reported that they were verbally threatened when they
tried to negotiate condom use, 21% disclosed physical abuse, and 14% said their partners threatened
abandonment21

Condom Use
Numerous studies have linked IPV victimization with inconsistent condom use or a partner refusing touse a condom.23,24,25,26,27 In a literature review on relationship violence, condom use and HIV risk among
adolescent girls, physical partner violence was routinely associated with inconsistent or non-condom
use.28 Adolescent boys who perpetrate dating violence are less likely to use condoms, particularly insteady relationships,29 while girls experiencing dating violence are half as likely to use condoms consistently
compared to non-abused girls.30 The connection between IPV and not using condoms is not limited
to physical violence. In a national study of adolescents, girls’ current involvement in verbally abusive
relationships was associated with not using a condom during the most recent sexual intercourse.31

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Obstetric, Gynecologic, and Reproductive Health Care Settings“Like the first couple of times, the condom
seems to break every time. You know what I
mean, and it was just kind of funny, like, thefirst 6 times the condom broke. Six condoms,
that’s kind of rare, I could understand 1 but
6 times, and then after that when I got on thebirth control, he was just like always saying,
like you should have my baby, you shouldhave my daughter, you should have my kid.” 22– 17 year old female who started
Depo-Provera without partner’s knowledge

Teen Pregnancy
Adolescent relationship abuse (also referred to as teen dating violence) increases the risk of teen
pregnancy.
• Adolescent girls who are currently involved in physically abusive relationships are 3.5 times more
likely to become pregnant than non-abused girls31• Adolescent mothers who experience physical partner abuse within three months after delivery
were nearly twice as likely to have a repeat pregnancy within 24 months32• In a qualitative study of adolescent girls who experienced dating violence, one-quarter (26.4%)
reported that their partners were trying to get them pregnant22

Connecting Pregnancy Pressure and Unintended Pregnancies
While there is limited body of research demonstrating a connection between IPV and unintended
pregnancies, a review of U.S. and international research identified several studies that have shownthat women who experience IPV are more likely to become pregnant when they did not intend
to be pregnant.33 A number of studies describe women’s experiences of being pressured to become
pregnant, which helps to explain why IPV may be associated with an increased risk of unintended
pregnancies.
• Among female patients seen at family planning clinics, 1 in 4 women who had experienced
physical or sexual IPV also reported pregnancy pressure14• Women with unwanted pregnancies are 4 times more likely to experience physical violence by ahusband or partner compared to women with intended pregnancies34• A survey conducted by the National Hotline on Domestic Violence found that 25% of womensaid that their partner or ex-partner had tried to force or pressure them to become pregnant35

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The Role of Pregnancy Coercion in Women Terminating orContinuing Their Pregnancies
The relationship between violence and continuing or terminating a pregnancy is bidirectional. Women
who want to continue their pregnancies may not be allowed to. Partners may also coerce women who do
not want to terminate their pregnancies into having an abortion.

“He really wanted the baby—he wouldn’t let me have—he always said, ‘If I
find out you have an abortion,’ you know what I mean, ‘I’m gonna kill you,’and so I was forced into having my son. I didn’t want to; I was 18. […] I
was real scared; I didn’t wanna have a baby. I just got into [college] on a fullscholarship, I just found out, I wanted to go to college and didn’t want to have ababy but I was really scared. I was scared of him.” 36- 26 year old female“My boyfriend was trying to push me to have an abortion… He said, ‘you won’t
keep that thing,’ and he threatened to kill me. Then he said he would kill thechild… Several times I felt like I wanted to kill myself. I felt like if I had an
abortion, I would have to kill myself… When we first met, he said he wanted afamily, wanted to marry me, then he changed his mind after I was pregnant.” 37
A significant proportion of women seeking abortions have a history of lifetime or current IPV.
Reproductive and sexual coercion behaviors such as forced sex, insisting on unprotected sex, and/or
refusing to allow a woman to use birth control may result in several unintended pregnancies followed bymultiple coerced abortions.
• Among women seen at abortion clinics, 14% to 25.7% have experienced physical and/or sexual
IPV in the past year38,39,40,41• Women and teens who seek abortions are nearly 3 times more likely to have been victimized by an
intimate partner in the past year compared to women who continue their pregnancies41• Women presenting for a third or subsequent abortion were more than 2.5 times as likely as thoseseeking a first abortion to report a history of physical abuse by a male partner or a history of sexual
abuse/violence42

Sexually Transmitted Infections (STIs) and HIV
Experiencing IPV and/or childhood sexual abuse dramatically increase the risk of STIs and HIV
among women and girls.43,44,45 According to the American Foundation for AIDS Research, violence
is both a significant cause and a significant consequence of HIV infection in women.46 A history
of IPV is a common denominator in studies of women who are HIV-positive.47,48,49 In a review study

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Obstetric, Gynecologic, and Reproductive Health Care Settingsof U.S. and international research on the intersection between IPV and HIV/AIDS, the increased
risk of HIV/AIDS related to IPV among women and adolescents was related to several mechanisms
including compromised negotiation of safer sex practices, forced sex with an infected partner, andincreased sexual risk-taking behaviors.50 The following studies demonstrate the complex relationshipbetween STIs/HIV and victimization:• Women experiencing physical abuse by an intimate partner are 3 times more likely to have a
STI, while women disclosing psychological abuse have nearly double the risk for a STI compared
to non-abused women51• More than one-half (51.6%) of adolescent girls diagnosed with a STI/HIV experience dating
violence52• Women who are HIV-positive experience more frequent and severe abuse compared to HIVnegative women who are also in abusive relationships53• Qualitative research with adolescent girls who were diagnosed with STIs and disclosed a history ofabuse suggests that the powerlessness they feel leads to a sense of acceptance that STIs are an
inevitable part of their lives, stigma, and victimization54
IPV perpetration and victimization are associated with a wide range of sexual risk behaviors. Druginvolved male perpetrators of IPV are more likely to have multiple intimate partners, buy sex, not use
condoms, use drugs, and coerce their partners into having sex.55
For women, being in an abusive relationship increases the likelihood of:• Her having multiple sex partners25• Inconsistent or nonuse of condoms25,49• Unprotected anal sex46• Having a partner with known HIV risk factors25• Exchanging sex for money, drugs, or shelter49• Alcohol or drug use before sex57“The guy I was going out with introduced me to drugs. He had me out there selling mybody to get all the drugs and stuff for us, you know? He got to beating on me because I
didn’t want to get out there no more in the streets doing it, and that’s when he broke mycheekbone and everything. That’s when I got infected [with AIDS] by him because he kept
forcing me to have sex.” 56
Important Considerations for Safe Partner Notification
Patient-initiated partner notification for treatment of STIs/HIV can compromise a patient’s safety if she
is in an abusive relationship. Women experiencing physical or sexual IPV are more likely to be afraid
to notify their partners of a STI.57 In a study with a culturally diverse sample of women seeking care atfamily planning clinics, female patients exposed to IPV were more likely to have partners who responded
to partner notification by saying that the STI was not from them or accusing her of cheating.59 Some of
the women reported threats of harm or actual harm in response to notifying their partner of an STI.

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Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

PART 3: GUIDE FOR RESPONDING
TO IPV AND REPRODUCTIVE ANDSEXUAL COERCION IN THE
HEALTH CARE SETTING{

PREPARING YOUR PRACTICE/PROGRAMASSESSMENT, HARM REDUCTION AND INTERVENTIONSUPPORTED REFERRALDOCUMENTATION AND FOLLOW-UP

PREPARING YOUR PRACTICEPROVIDER TIP:

Create a Safe Environment for Assessment and Disclosure

It is essential to find out,prior to asking questions
about IPV and reproductive
and sexual coercion,
whether a patient has sex
with men, women, or bothso you can focus assessment
on questions that are
relevant to the patient. For
example, for a woman who
is engaging only in samesex relationships, questions
would focus on IPV andsexual coercion and it
would not be necessary to
ask questions about birthcontrol sabotage.

There are several important steps you can take to create a safe and supportive
environment for asking patients about IPV and reproductive and sexual coercion.
These steps include:• Having a written policy and providing training on IPV and reproductive
and sexual coercion including the appropriate steps to inform patients about
confidentiality and reporting requirements• Having a private place to interview patients alone where conversations cannot be
overheard or interrupted• Displaying educational posters addressing IPV, reproductive and sexual coercion,and healthy relationships that are multicultural and multilingual in bathrooms,
waiting rooms, exam rooms, hallways, and other highly visible areas• Having information including hotline numbers, safety cards, and resource cards on
display in common areas and in private locations for patients such as bathrooms
and exam rooms

FUTURES WITHOUT VIOLENCE

17

Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings
Futures (www.FuturesWithoutViolence.org) has a culturally diverse selection of posters, educational
brochures, and safety cards.
¿Quién controla las decisiones de EMBARAZO?
Pregúntese. Mi pareja:✔ ¿Ha intentado presionarme o forzame para que me embarace?
✔ ¿Me ha lastimado amenazado porque no estoy de acuerdo enembarazarme?
Si alguna vez he estado embarazada:✔ ¿Mi pareja me ha dicho que me lastimaría si no hacía lo que elquería con el embarazo (en cualquier dirección, continuar con elembarazo o aborto)
Si respondió SÍ a cualquiera de estas preguntas, no esta sola y merece
tomar sus propias decisiones sin tener miedo.

Who controls PREGNANCY decisions?
Ask yourself. Has my partner ever:✔ Tried to pressure or make me get pregnant?

✔ Hurt or threatened me because I didn’t agree to get pregnant?
Obteniendo Ayuda
If I’ve ever been pregnant:✔ Si su pareja revisa su teléfono celular o textos, hable con su proveedor✔ Has my partner told me he would hurt me if I didn’t do what hede atención médica acerca de cómo usar su teléfono para llamar a losservicios de violencia doméstica, para que su pareja no pueda verlo enwanted with the pregnancy (in either direction—continuing the
pregnancy or abortion)?
su registro de llamadas.

✔ Si tienen una enfermedad de transmisión sexual (ETS) y teme que su pareja
If you answered YES to any of these questions, you are not alone andla lastime si le dice, hable con su proveedor de atención médica acerca deyou deserve to make your own decisions without being afraid.
cómo estar más segura y como ellos le pueden decir a su pareja de la
infección sin usar su nombre.
✔ Estudios muestran que educar a sus amigos y familiares sobre el abuso puede ayudarles a tomar pasos para estar más seguros—dándoles esta tarjeta
puede hacer una diferencia en sus vidas.
Getting Help
✔ If your partner checks your cell phone or texts, talk to your healthTodas estas líneas nacionales puedencare provider about using their phone to call domestic violenceservices—so your partner can’t see it on your call log.
conectarla a recursos locales ybrindarle apoyo. Para obtener ayuda✔ If you have an STD and are afraid your partner will hurt you if you
24 horas al día, llame al:tell him, talk with your health care provider about how to be safer andhow they might tell your partner about the infection without using
Línea Nacional Sobre la Violencia Doméstica
1-800-799-SAFE (1-800-799-7233) your name.
TTY 1-800-787-3224✔ Studies show educating friends and family about abuse can help
www.thehotline.org
them take steps to be safer—giving them this card can make a
Formerly Family Violence Prevention Funddifference in their lives.
Línea Nacional de Maltrato entre
FuturesWithoutViolence.org¿Qué hay del respeto?
Novios Jóvenes
1-866-331-9474
La persona
con quien estás (ya sea hablando, saliendo, o conectándote) debe:
www.loveisrespect.org
Funded in part by the U.S. Department of Health
Línea sentir
de Crisis
Nacional
de Abuso
andSexual
Human Services’ Office on Women’s HealthAll these national hotlines can connect
segura(o)y cómoda(o).
• Hacerte©2011 Futures Without Violence and American(Grant #1 ASTWH110023-01-00) and1-800-656-4673
you to your local resources and provideNo
presionarteotratardeemborracharteodrogartepara•
College of Obstetricians and Gynecologists.
Administration
on Children,
Youthtenerand Families.
support:(Grant #90EV0414)
All rights reserved.
sexowww.rainn.org
contigo.
• Respetar tus límites y preguntar si puede tocarte o besarte (oFor help 24 hours a day, call:
cualquier otra cosa).
National Domestic Violence Hotline
1-800-799-SAFE (1-800-799-7233)¿Cómo te gustaría que tu mejor amiga(o), o tu hermana(o) fuera
TTY 1-800-787-3224
tratada(o) por la persona con quien está Formerly
saliendo?
Pregúntate si la
Family Violence Prevention Fund
www.thehotline.org
persona que tú estás viendo te trata con respeto y si
FuturesWithoutViolence.org
tú le tratas con respeto.
National Dating Abuse Helpline
1-866-331-9474
www.loveisrespect.org
National Sexual Assault Hotline
1-800-656-HOPE (1-800-656-4673)©2011 Futures Without Violence and American
Cómo AyudaraUn(a)Amiga(o)College of Obstetricians and Gynecologists.
www.rainn.org
All rights reserved.
2_fvpf_pregwheel_2008.qxd¿Crees que alguna(o) de tus amigas(os) está en una relación que no es buena
para ella (él)?
Funded in part by the U.S. Department of Healthand Human Services’ Office on Women’s Health(Grant #1 ASTWH110023-01-00) and
Administration on Children, Youth and Families.
(Grant #90EV0414)¿Sabía Que
Su Relación
Afecta Su
Salud?

Sigue estos pasos para ayudarle:

Did You
Know Your
Relationship
Affects Your
Health?

• Dile a tu amiga(o) que lo que has visto en su relación te preocupa.
• Habla con tu amiga(o) en privado, y no le cuentes a otras(os) amigas(os) lo
que platicaron.

• Muéstrale www.loveisrespect.org y dale una copia de esta tarjeta.
• Si tú o alguien que tú conoces se siente tan triste que planea hacerse daño odesea morirse—busca ayuda. Red Nacional de Prevención delSuicidio: 1-800-273-8255

Si tú o alguien que tú conoces quisiera hablar
acerca de su situación con personas que ofrecen
apoyo, llama a estos números. Todas estas líneas
directas son gratis y confidenciales, y puedes
hablar con alguien sin tener que dar tu nombre.

Formerly Family Violence Prevention Fund

FuturesWithoutViolence.org©2011 Futures Without Violence.
All rights reserved.

A Train the Trainers Curriculum on
Domestic Violence, Reproductive
Coercion and Children Exposed

Hablemos acerca del embarazo

Pregúntese. Mi pareja alguna vez:
¿Me ha dicho que me lastimaría si no hacía lo que él quería con el embarazo (en cualquier dirección, continuar con el embarazo o aborto)?
✔ Si respondió SÍ a cualquiera de estas preguntas, no está sola ymerece tomar sus propias decisiones sin tener miedo.

8/28/08

3:10 PM

Page 1✔ Si su pareja revisa su teléfono celular o textos, hable con su
proveedor de atención médica acerca de cómo usar su teléfono parallamar a los servicios de violencia doméstica, para que su pareja no
pueda verlo en su registro de llamadas.

Who controls PREGNANCY decisions?
Ask yourself. Has my partner ever:Told me he would hurt me if I didn’t do what he wanted with the

Did you know...

By Linda Chamberlain, PhD, MPH

and Rebecca
Levenson,MA
Controlling and violent relationships
come inmany
forms including unwanted or mistimed pregnancies?
103853_Wheel

8/28/08

2:32 PM

Page 1pregnancy (in either direction-continuing the pregnancy or abortion)?
Tomando el Control

Referencias Pueden Ayudar
Buscando apoyo para usted y sus hijos le puede ayudar a avanzar hacia ✔ If you answered YES to this question, you are not alone and you
un futuro más saludable—aún el paso más poqueño es algo para celebrar. deserve to make your own decisions without being afraid.
Mientras que programas de la violencia doméstica locales y nacionales ✔ If you need help, talk to your health care provider about using theirphone to call domestic violence services—so your partner can’t see it on
pueden ayudar con su plan de seguridad y pueden proporcionarle con referencias a refugios seguros, también ofrecen servícios para mujeres que no your call log.
quieran, o no están listas para irse al refugio. Muchos programas ofrecen:✔ grupos de apoyo para mujeres y programas para niños.
✔ clases para fomentar su confidencia, planear para su futuro, yapoyarle en la crianza de sus hijos—llame a su programa local para
averiguar lo que está disponible.
Funded in part by the U.S. Department of Healthand Human Services’ Office on Women’s Health(Grant #1 ASTWH110023-01-00) and
Administration on Children, Youth and Families.
(Grant #90EV0414)

Red Nacional de Prevención del Suicidio
1-800-273-8255
Línea Directa Para Jóvenes que Huyen de Casa
(National Runaway Switchboard)
1-800-621-4000

Taking Control Back

Referrals Can Help

Si se siente frustrada o enojada con susGetting
hijos support for yourself and your children can help you move towarda healthier future—even the smallest step is something to celebrate.
y sencillamente necesita hablar...
Para recibir asistencia confidencial llame
a: local and national domestic violence programs can help with safety
Whileplanning and provide referrals to safe shelters, they also provide services for
Ayuda para niños
women who may not want or be ready to go to a shelter. Many programs have:
1-800-422-4453
Si su pareja está haciéndole daño usted✔
no Drop-in support groups for women and programs for children.
tiene la culpa. Para recibir asistencia llame a:

Red Nacional de Violación, Abuso, Incesto (RAINN)
1-800-656-Hope (1-800-656-4673)

Formerly Family Violence Prevention Fund

en
c re

FuturesWithoutViolence.org

DVs

Funded by the Administration on Children,
Youth and Families, U.S. Department of
Health and Human Services and the Officeon Women’s Health, U.S. Department of
Health and Human Services.

Línea Nacional sobre el Abuso de Novios
Adolescentes
1-866-331-9474
o platica/chatea (Chatroom) en Internet
www.loveisrespect.org

Healthy Moms,
Happy Babies:✔ Classes to build confidence, plan for the future and support your

Línea Directa Nacional para la Atención de laparenting—call your local program to findViolencia Domésticaout what is available.

1-800-799-7233

3rd

TTY 1-800-787-3224©2012 Futures Without Violence and American
College of Obstetricians and Gynecologists.
All rights reserved.

Línea Directa para la Atención de Casos
dein part by the U.S. Department of HealthFundedViolencia Sexualand Human Services’ Office on Women’s Health
1-800-656-4673(Grant #1 ASTWH110023-01-00) and
Administration on Children, Youth and Families.
(Grant #90EV0414)

If you are feeling frustrated or angry
with your child and just need to talk...
For confidential help call:

D

V

e
scr

1st

en

Child Help
1-800-422-4453

een
scr

2 nd

DV

¿Saliendo o Conectando?

If you are being hurt by a partner,
it is not your fault. For help, call:

Formerly Family Violence Prevention Fund

FuturesWithoutViolence.org

National Domestic Violence Hotline
1-800-799-7233
TTY 1-800-787-3224©2012 Futures Without Violence and American
College of Obstetricians and Gynecologists.
All rights reserved.

Ask
allpregnant
women:“Was your partner trying to get you pregnant
when you didn’t want to be?”“Does your partner hurt you or make you afraid?”

Hogares Seguros,
Hijos Seguros:

Sexual Assault Hotline
1-800-656-4673

Creando Futuros Sin Violencia

Safe Homes,
Safe Babies:
Creating Futures Without Violence

Develop Referral Lists and Partner with Local/Regional Resources
There is a range of referrals and resources available for victims of abuse in many communities. Contact
the following entities to find out contact information for a referral list and to have resources available atyour facility:• The domestic violence coalition in your state (for a listing go to: nnedv.org/resources/coalitions.html)• Meet with local domestic and sexual violence program professionals to understand the services they
provide. Arrangements can often be made so that staff can call a domestic violence advocate foradvice and discuss a scenario hypothetically, if needed, to understand how to best meet the needs ofa patient who is experiencing abuse• The violence prevention program in your state health department

Training on IPV and Reproductive Coercion
Core training on IPV and on reproductive and sexual coercion will be most effective if all clinic staff
that has contact with patients are trained. When possible, training should include staff from domestic
violence and sexual assault programs.
Ongoing training opportunities should be available for new hires and staff who want to repeat the training.
Refresher training is important to introduce advances in the field and offer opportunities for staff to
discuss progress, challenges, and opportunities.

18

FUTURES WITHOUT VIOLENCE

Intimate
Partner
Violence Reproductive
and Sexual
Coercion:
A GuideforPart 3: GuideAddressing
for Responding
to IPVand Reproductive
and Sexual Coercion
in theHealth Care
Setting
Obstetric, Gynecologic, and Reproductive Health Care Settings

WHO should receive training on IPV and reproductive and sexual coercion?

• Physicians• Social workers• Nurses and Nursing Practitioners• Medical interpreters• Medical and nursing assistants• Mental health professionals• Midwives• Sex therapists• Physician Assistants• Clergy• Public health professionals• Health educators

Training on IPV is often extended to other support staff such as security guards, parking lot attendants, andhousekeepers who may observe abusive and/or threatening behaviors and have safety concerns for patients.

Training Resources
Making the Connection: Intimate Partner Violence and Public Health is a free resource developedby Futures that can be used for self-directed training and to provide training to your staff and students(download at www.futureswithoutviolence.org/section/our_work/health/_making_connection). The toolkit consistsof a PowerPoint presentation, speakers’ notes, and an extensive bibliography. The following reproductive
health-related topics are addressed in the toolkit:• IPV and Family Planning, Birth Control Sabotage, Pregnancy Pressure, and Unintended Pregnancy• IPV and Sexually Transmitted Infections/HIV• IPV and Women’s HealthFree eLearning Activity: Online education opportunities on violence and reproductive and sexual
coercion with free CME are also available. Go to www.FuturesWithoutViolence.org/health for
information on new training opportunities as they become available.

FUTURES WITHOUT VIOLENCE

19

Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings

ASSESSMENT, HARM REDUCTION AND INTERVENTION
Getting Started: Always Discuss the Limits of Confidentiality Prior toAssessment
Mandatory reporting requirements are different in each state and territory. Consider contacting thefollowing organizations for information and resources specific to your state/region:• Child protection/child welfare services in your state for information about reporting requirements forminors experiencing and/or exposed to violence• The domestic violence coalition and sexual assault coalition in your state may have legal advocates or otherexperts that provide information and training on reporting requirements for IPV. For a complete list
go to www.nnedv.org/resources/coalitions.html
Many forms of reproductive and sexual coercion described in this guide are not included in most legal
definitions of IPV. Some forms, however, such as forced sex, may be included the legal definition of
IPV. In addition to IPV laws, teen dating violence can also raise questions about mandatory childabuse reporting requirements and statutory rape laws.
In addition, providers need to be familiar with relevant state privacy laws and federal regulations
regarding the confidentiality of health information. Make sure that you have accurate and up-to-date
information about mandatory reporting laws for your state.
Always disclose limits of confidentiality prior to doing any assessment with patients. The script
below is an example of how to disclose limits of confidentiality with a patient before doing assessment
for IPV and reproductive coercion.
Sample Script to Inform Client About Limits of Confidentiality:“I’m really glad you came in today (fill in the blank for visit type). Before we get started I want you
to know that everything you share with me is confidential, unless (fill in state law here—likely thisscript will look very different for an adolescent than an adult) you have been injured by a weapon,
forced to have sex by someone, or are suicidal—those things I would have to report, ok?”

Verbal Assessment is Essential
While assessment questions for IPV may be embedded in selfadministered medical history forms, asking questions about IPV andreproductive and sexual coercion also needs to be part of the face-to-faceassessment between the provider and the patient.
The patient’s responses to these questions will help inform the provider
about the best way to proceed relative to the treatment plan, potential
complications, compliance considerations, other health risks, andsafety concerns. This informed approach will ultimately save time andenhance the quality of care and reproductive health outcomes.

20

FUTURES WITHOUT VIOLENCE

Intimate
Partner
Violence Reproductive
and Sexual
Coercion:
A GuideforPart 3: GuideAddressing
for Responding
to IPVand Reproductive
and Sexual Coercion
in theHealth Care
Setting
Obstetric, Gynecologic, and Reproductive Health Care Settings

Brief, Evidence-based Assessment and Intervention with Safety Card
Tear out this sample card and fold it to wallet size.
To order additional free cards for your practice go
to: www.FuturesWithoutViolence.org/health

The Safety Card for Reproductive Health, developed by
Futures and co-branded by the College, is a wallet-size
card that includes self-administered questions for IPV
and reproductive and sexual coercion, harm reduction
and safety planning strategies, and information about
how to get help and resources. Providers can use thesafety card to facilitate screening and educate patients
about the impact of IPV and reproductive and sexual
coercion on reproductive health.

The safety card can bereviewed with a patient inless than one minute.

Who controls PREGNANCY decisions?
Ask yourself. Has my partner ever:✔ Tried to pressure or make me get pregnant?
✔ Hurt or threatened me because I didn’t agree to get pregnant?
If I’ve ever been pregnant:✔ Has my partner told me he would hurt me if I didn’t do what hewanted with the pregnancy (in either direction—continuing the
pregnancy or abortion)?
If you answered YES to any of these questions, you are not alone andyou deserve to make your own decisions without being afraid.

FOLD >

Getting Help

In a randomized controlled trial, women seen atfour family planning clinics were asked questions
about IPV and reproductive and sexual coercion andreviewed the safety card with their providers. The timerequired to review the safety card with a patient varied
from less than a minute to longer discussions when IPV
and/or reproductive and sexual coercion were disclosed.
Among women who reported IPV in the past threemonths at the time of initial assessment and received
the safety card intervention, there was a 71% reductionin the odds of pregnancy pressure and coercion at
the follow-up, 12 to 24 weeks later.58 Women who
received information about safety were more likely toreport ending a relationship because the relationship was
unhealthy or because they felt unsafe regardless of whether
they had disclosed a history of IPV. This intervention isbased on more than two decades of research, including
other randomized controlled trials, which has shown thatassessment combined with a small safety card can reduce
violence and improve safety behaviors among female
patients disclosing IPV.59,60,61,62
Women who received information about
safety were more likely to report ending
a relationship because the relationshipwas unhealthy or because they felt unsafe
regardless of whether they had disclosed ahistory of IPV.

✔ If your partner checks your cell phone or texts, talk to your healthcare provider about using their phone to call domestic violenceservices—so your partner can’t see it on your call log.
✔ If you have an STD and are afraid your partner will hurt you if you
tell him, talk with your health care provider about how to be safer andhow they might tell your partner about the infection without using
your name.
✔ Studies show educating friends and family about abuse can help
them take steps to be safer—giving them this card can make adifference in their lives.
FOLD >

Funded in part by the U.S. Department of Healthand Human Services’ Office on Women’s Health(Grant #1 ASTWH110023-01-00) and
Administration on Children, Youth and Families.
(Grant #90EV0414)

Formerly Family Violence Prevention Fund

FuturesWithoutViolence.org

FOLD >©2011 Futures Without Violence and American
College of Obstetricians and Gynecologists.
All rights reserved.

All these national hotlines can connect
you to your local resources and provide
support:For help 24 hours a day, call:National Domestic Violence Hotline
1-800-799-SAFE (1-800-799-7233)
TTY 1-800-787-3224
www.thehotline.org
National Dating Abuse Helpline
1-866-331-9474
www.loveisrespect.org
National Sexual Assault Hotline
1-800-656-HOPE (1-800-656-4673)
www.rainn.org

Did You
Know Your
Relationship
Affects Your
Health?
FUTURES WITHOUT VIOLENCE21

FUTURES WITHOUT VIOLENCE
Ask yourself:

22

Regardless of whether a patient discloses abuse, assessment
is an opportunity to educate patients about how abusive andcontrolling behaviors in a relationship can affect her reproductive
health. The safety card provides information that helps women
to make the connection between unhealthy relationships andreproductive health concerns such as unintended pregnancies.
Asking about IPV and reproductive and sexual coercion lets
patients know that they are not alone and that you are a safe
person to talk to. The safety card includes information about
safety strategies and referrals a patient can refer to after her visit.
The safety card was designed as a small, easy to conceal card basedon strategies used by domestic violence advocates who are expertson safety concerns and safety planning with IPV victims. It is
important to remember that it may not be safe for some patients
who are currently experiencing abuse to leave the clinic with thesafety card.
Some patients may not feel safe or comfortable disclosing IPV or
reproductive and sexual coercion when asked. Research also showsthat cultural stereotypes about rape and sexual assault influencea woman’s perceptions of sexually coercive experiences. Coerced
sex by an intimate partner may not be perceived as a real sexualassault or rape. Sexual coercion by a dating partner, especiallywhen alcohol is involved, may be minimized due to culturalstereotypes.63

How can using the safety card help withscreening given many women choose not todisclose what is happening to them?

Are you in a HEALTHY relationship?

✔ Is my partner kind to me and respectful of my choices?
✔ Does my partner support my using birth control?
✔ Does my partner support my decisions about if or when I want to havemore children?

If you answered YES to these questions, it is likely that you are in ahealthy relationship. Studies show that this kind of relationship leads tobetter health, longer life, and helps your children.

Are you in an UNHEALTHY relationship?

Ask yourself:✔ Does my partner mess with my birth control or try to get me pregnant
when I don’t want to be?
✔ Does my partner refuse to use condoms when I ask?
✔ Does my partner make me have sex when I don’t want to?
✔ Does my partner tell me who I can talk to or where I can go?

If you answered YES to any of these questions, yourhealth and safety may be in danger.

Is your BODY being affected?
Ask yourself:✔ Am I afraid to ask my partner to use condoms?
✔ Am I afraid my partner would hurt me if I told him I had an

STD and he needed to be treated too?

✔ Have I hidden birth control from my partner so he wouldn’t getme pregnant?

✔ Has my partner made me afraid or physically hurt me?

If you answered YES to any of these questions, you may be atrisk for STD/HIV, unwanted pregnancies and serious injury.
Taking Control:Your partner may see pregnancy as a way to keep you in his life and stayconnected to you through a child—even if that isn’t what you want.
If your partner makes you have sex, messes or tampers with yourbirth control or refuses to use condoms:✔ Talk to your health care provider about birth control you can control(like IUD, implant, or shot/injection).
✔ The IUD is a safe device that is put into the uterus and prevents pregnancy
up to 10 years. The strings can be cut off so your partner can’t feel them.
The IUD can be removed at anytime when you want to become pregnant.
✔ Emergency contraception (some call it the morning after pill) can betaken up to five days after unprotected sex to prevent pregnancy. It canbe taken out of its packaging and slipped into an envelope or empty pillbottle so your partner won’t know.

Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings

Intimate
Partner
Violence Reproductive
and Sexual
Coercion:
A GuideforPart 3: GuideAddressing
for Responding
to IPVand Reproductive
and Sexual Coercion
in theHealth Care
Setting
Obstetric, Gynecologic, and Reproductive Health Care Settings

Remember before you ask—always discuss limits of confidentiality
How Often Should You Ask?
At least annually.
When Should You Ask?
During any reproductive health appointments—(Pregnancy tests, STI/HIV tests,
initial and annual visits, abortions, birth control options counseling).
Where Should You Ask?
In a private setting such as the exam room and only when the patient is by herself
without parents, partners, or friends present.

SAFETY TIP

PROVIDER TIP

One key recommendation for clinics or providers in private practiceis to develop a sign for your waiting room that says: In this clinic,
we respect a patient’s right to privacy and always see patientsalone for some portion of their visit. Having a clearly statedpolicy like this helps the staff normalize the experience of seeing thepatient alone without a friend or family member there—especially
if there is an established pattern allowing partners or family
members in during the entire visits. Displaying the policy on a signin the waiting room takes the burden off the patient needing to ask
to be seen alone, while allowing the staff member to point to thesign if there is any opposition from the patient’s partner.

Asking questions about
IPV and reproductive andsexual coercion will help
you develop a patient’s
treatment plan, identify
potential complications andcompliance considerations,and assess other health risks
and safety concerns. Thisapproach will save time andimprove outcomes.

Making the link between violence and reproductive health uncovers risk factors that arecompromising a patient’s reproductive health and allows providers to offer interventions that are themost likely to succeed.
For example, research has shown that women with high STI knowledge under high levels of fear of abuse
were more likely to use condoms inconsistently than non-fearful women with low STI knowledge.64 More
HIV education without addressing the role of abuse is unlikely to lead to safer sex practices in this scenario.
Using the safety card integrates assessment with patient education. This integrated approach informs
patients about the increased risk of contracting STIs/HIV in abusive relationships, teaches condom
negotiation skills within the context of abusive relationships, and offers less detectable, femalecontrolled protective strategies that can lead to improved reproductive health outcomes and enhanced
quality of care.
Examples of scripts that demonstrate how to counsel a patient about harm reduction strategies when IPV
and/or reproductive and sexual coercion is disclosed, including sample scripts for different types of visits
and clinical scenarios, are shown below.

FUTURES WITHOUT VIOLENCE

23

Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings
Strategic Safety Card Use: Promoting Prevention, Assessment andIntervention for IPV, Reproductive and Sexual Coercion
Select relevant panels of the card based on the type of visit for assessment and offer
visit-specific harm reduction strategies when problems are identified.

Part of patient education is talking about healthy, safe, and consensual relationships. Health careproviders can also play an important role in preventing abuse by offering education and anticipatory
guidance about what a healthy relationship looks like, particularly for adolescent girls—but this is true
for adult women too.
The following sample script provides more messaging about healthy, safe, and consensual relationshipsthat can be shared with every patient.

Sample Script:“We have started talking to all of ourpatients about how you deserve to
be treated by the people you go out
with and giving them this card—It’skind of like a magazine quiz—Are
you in a HEALTHY relationship?”

Birth Control Options Counseling:

PROVIDER TIP:

Ask yourself:

Are you in a HEALTHY relationship?

✔ Is my partner kind to me and respectful of my choices?
✔ Does my partner support my using birth control?
✔ Does my partner support my decisions about if or when I want to havemore children?

If you answered YES to these questions, it is likely that you are in ahealthy relationship. Studies show that this kind of relationship leads tobetter health, longer life, and helps your children.

Are you in an UNHEALTHY relationship?
Are you in a HEALTHY relationship?
Ask yourself:
Ask yourself:✔ Does my partner mess with my birth control or try to get me pregnant
when
don’t want✔ Is
my Ipartner
kindtotobe?
me and respectful of my choices?
✔ Does my partner refuse to use condoms when I ask?
✔ Does my partner support my using birth control?
✔ Does my partner make me have sex when I don’t want to?
✔ Does my partner support my decisions about if or when I want to have
✔ Does my partner tell me who I can talk to or where I can go?
more children?

Before spending valuable time counseling a patient about various contraceptive methods, assess if she
is at risk for reproductive coercion. By changing the pronouns in the self-quiz found in the safety card,
If you answered YES to any of these questions, yourIf you answered
tobepatientthesequestions,
it is likely that you are in aproviders use the questions to facilitate face-to-face assessment
encounter.
healthandduringsafetyYES
maya
in danger.
healthy relationship. Studies show that this kind of relationship leads tobetter health, longer life, and helps your children.

Sample Script:“Before I review all of your birthcontrol options, I want to understandif your partner is supportive of yourusing birth control. Has your partner
ever tampered with your birth control
or tried to get you pregnant when you
didn’t want to be?”Harm Reduction Strategy:

Is your BODY being affected?
Ask yourself:
Are you in an UNHEALTHY relationship?
AskAm
yourself:✔
I afraid to ask my partner to use condoms?

✔ Does my partner mess with my birth control or try to get me pregnant
whenand
I don’twant totobe?
STD
he needed
be treated too?
✔ Does my partner refuse to use condoms when I ask?
✔ Have I hidden birth control from my partner so he wouldn’t getme pregnant?
✔ Doesmy partner make me have sex when I don’t want to?
✔ Am I afraid my partner would hurt me if I told him I had an

✔ Has
mewho
afraidor physicallyhurt me?
Doesmymypartner
partnermade
tell meI cantalk to or where
I can go?
If you answered YES to any ofof these
these questions,questions, you
yourmay be atriskforandSTD/HIV,
unwantedpregnancies and serious injury.
healthsafety may
be in danger.

Taking Control:Your partner may see pregnancy as a way to keep you in his life and stayconnected to you through a child—even if that isn’t what you want.
Is yourorBODY
being
affected?
If your partner makes you have sex, messes
tampers
with
your
birth
control or refuses to use condoms:
Ask yourself:✔
your tohealthcarepartner
providerbirth control you can control✔ TalkAm Itoafraid
ask myto about
use condoms?

(like IUD, implant,or shot/injection).
If her answer is yes, talk with her about contraceptive
optionsthat
areless Ivulnerable
Am IUD
I afraid
would
hurt
methe
if Iuterus
told him
had an pregnancy✔ The
is amysafepartner
device thatis putintoand prevents
STD
he needed
to be treated
too?off so your partner can’t feel them.
up
to and10 years.
The strings
can be cut
to being tampered with.
The IUDcan bebirth
removedat anytime
when
you want
become getpregnant.
✔ HaveI hiddencontrolfrom mypartnerso hetowouldn’t✔ Emergency
contraception (some call it the morning after pill) can beme pregnant?

taken up to five days after unprotected sex to prevent pregnancy. It can24

FUTURES WITHOUT VIOLENCE✔ Has
my partner
mademe afraid
physicallyme?
be takenout of its
packagingandorslipped
intohurt
an envelope
or empty pillbottle so your partner won’t know.
If you answered YES to any of these questions, you may be atrisk for STD/HIV, unwanted pregnancies and serious injury.

Taking Control:Your partner may see pregnancy as a way to keep you in his life and stayconnected to you through a child—even if that isn’t what you want.
If your partner makes you have sex, messes or tampers with yourIs your BODY being affected?
Ask yourself:✔ Am I afraid to ask my partner to use condoms?

Part 3: GuideAddressing
for Responding
to IPVand
Reproductive
andSexualCoercion
Health Care
Setting
Intimate
Partner
Violence
Reproductive
andCoercion:
A Guidefor✔
Am
I afraid
my partner would
hurt meif I told him
I hadSexual
an in theSTD and he needed to be treated too?
Gynecologic,
andsoReproductive
Health Care Settings✔ Obstetric,
Have I hidden birthcontrol from my partner
he wouldn’t getme pregnant?

✔ Has my partner made me afraid or physically hurt me?

If you answered YES to any of these questions, you may be atrisk for STD/HIV, unwanted pregnancies and serious injury.

Sample Script:“I’m really glad you told me about what
is going on. It happens to a lot of womenand it is so stressful to worry about getting
pregnant when you don’t want to be. I
want to talk with you about some methodsof birth control your partner doesn’t haveto know about—take a look at this sectionof the safety card called “Taking Control”.

Taking Control:Your partner may see pregnancy as a way to keep you in his life and stayconnected to you through a child—even if that isn’t what you want.
If your partner makes you have sex, messes or tampers with yourbirth control or refuses to use condoms:✔ Talk to your health care provider about birth control you can control(like IUD, implant, or shot/injection).

✔ The IUD is a safe device that is put into the uterus and prevents pregnancy

up to 10 years. The strings can be cut off so your partner can’t feel them.
The IUD can be removed at anytime when you want to become pregnant.
✔ Emergency contraception (some call it the morning after pill) can betaken up to five days after unprotected sex to prevent pregnancy. It canbe taken out of its packaging and slipped into an envelope or empty pillbottle so your partner won’t know.

Ask yourself:

Are you in a HEALTHY relationship?

✔ Is my partner
Clinical protocols regarding the use intrauterine devices (IUDs)
in kind to me and respectful of my choices?
Are
you incontrol?
a HEALTHY
relationship?
nulliparous women and adolescent girls need to be updated
to myreflect✔ Doespartner support my using
birth
SAFETYFIRST!
Ask yourself:current evidence. Recent recommendations clearly state that
IUDs
offer
a my decisions✔ Doesmy partner
supportif or when I want to have
It is about
important✔ Is
my children?
partner kind to me and respectfulof my choices?to be aware that some controllingmore
safe and appropriate option for nulliparous women and teens.
In 2011, thepartners may monitor bleeding patterns andIf you
YESsupport
to thesemyquestions,
it iscontrol?
likely that you are in a
Doesanswered
my partner
using birth
cycles. leads
Forto these women, the safest
American College of Obstetricians and Gynecologists (the✔healthy
College)issuedrelationship.
Studies show thatmenstrual
this kind of relationshipbetterhealth,longer
life,
and
helps
your
children.
✔
Does
mypartner
supportmydecisionsabout
if or bewhen
I wantto haveT IUD as it does not
65
optionmay
theCopperThere
are noa Practice Bulletin supporting IUDs for these populations. morechildren?
change their cycle.
studies that have demonstrated an increased risk of pelvic Ifinflammatory
you answered YES to these questions, it is likely that you are in ahealthy relationship. Studies show that this kind of relationship leads todisease (PID) in nulliparous IUD users and there is no evidence
IUD
better health,that
longer life,and helps your For
children.
IUD users, it is also recommended to discuss
use is associated with subsequent infertility. In fact, IUDs may be the best Are you
cutting
the stringsrelationship?
short in the cervical canal so thein an UNHEALTHY
yourself: whocontraceptive method for those experiencing reproductiveAsk
coerciondevice cannot be felt or detected by her partner.
✔ Does my partner mess with my birth control or try to get me pregnant
want to prevent or defer pregnancy.
when I don’t want to be?

Arecondoms
you in an
UNHEALTHY✔ Does my partner refuse to use
when
I ask? relationship?
Ask yourself:✔ Does my partner make me have sex when I don’t want to?
✔ Does my partner mess with my birth control or try to get me pregnant✔ Doespartnerwhen myI don’twanttell
to mebe?who I can talk to or where I can go?

When Condoms Are the Preferred Contraceptive Method

If youYESrefuse
to anytoofuse
thesequestions,✔
Doesanswered
my partner
condoms
whenyourI ask?

andsafety may bein danger.
Ask the patient if she is comfortable asking her partner to✔healthuse
condomsandif her partner is supportive
Does my partner make me have sex when I don’t want to?
of her choice.
✔ Does my partner tell me who I can talk to or where I can go?

Sample Script:“Anytime someone tells me they use
condoms as their main method ofcontraception—I always ask if using
condoms is something that you are able totalk with him about? Does he ever get madat you for asking? Do they break often?”

If you answered YES to any of these questions, yourhealth and safety may be in danger.
Is your BODY being affected?
Ask yourself:✔ Am I afraid to ask my partner to use condoms?

BODY
affected?
✔ Am I afraid my partner would hurt meIsifyour
I toldhim being
I had an
STD and he needed to be treated too?
Ask yourself:✔ Have I hidden birth control from my partner so he wouldn’t get✔ Am
I afraid to ask my partner to use condoms?
me pregnant?
✔
afraidmy partner
would
me if I told
himme?
I had an✔ Am
Has Imypartnermade meafraidhurt
or physicallyhurt
STD and he needed to be treated too?
If you answered YES to any of these questions, you may be at✔
I hidden birthcontrolpregnancies
from my partner
so he injury.
wouldn’t get
riskHavefor STD/HIV,
unwantedand serious
me pregnant?

✔ Has my partner made me afraid or physically hurt me?
Taking Control:
If you answered YES to any of these questions, you may be atYourforpartner
may seeunwanted
pregnancy as
a way to keepyouin his injury.
life and stayrisk
STD/HIV,
pregnancies
andserious
What to do if you get a “yes” to difficulty negotiating
connected to youcondoms:
through a child—even if that isn’t what you want.

Sample Script:‘I have had a lot a patients tell me theyare (fill in blank) uncomfortable asking,worried about breakage or not sure what
to do when he gets mad. There is anothermethod you might consider that doesn’t
have hormones that doesn’t depend upon
him using condoms”

If your partner makes you have sex, messes or tampers with your
Taking Control:
birth control or refuses to use condoms:
Your
partnermayhealthsee pregnancy
as a wayabout
to keepbirth
you inhis lifeyou
andcanstaycontrol✔ Talkto yourcare provider
controlconnected
to you implant,
through a orchild—even
if that isn’t what you want.
(like IUD,
shot/injection).
✔your
The IUDis a safe
deviceis putthe uterus
and prevents
Ifpartnermakes
youthathave
sex,into
messesor tampers
withpregnancy
yourupcontrol
to 10 years.
The strings
cancondoms:
be cut off so your partner can’t feel them.
birth
or refuses
to useThe IUD can be removed at anytime when you want to become pregnant.
✔ Talkto yourcontraception
health care provider
about
birth
controlafter
you pill)
can control
Emergency(some callit themorning
can be(likeshot/injection).
takenIUD,
up toimplant,
five daysorafter
unprotected sex to prevent pregnancy. It can✔ The
IUD isa safedevicethat is andput into
the uterus
prevents
be takenoutof itspackagingslippedinto anandenvelope
orpregnancy
empty pillup
to 10
The strings
be cut off so your partner can’t feel them.
bottleso years.
your partner
won’tcanknow.
The IUD can be removed at anytime when you want to become pregnant.
✔ Emergency contraception (some call it the morning after pill) can betaken up to five days after unprotected sex to prevent pregnancy. It canbe taken out of its packaging and slipped into an envelope or empty pillbottle so your partner won’t know.

FUTURES WITHOUT VIOLENCE

25

✔ Does my partner mess with my birth control or try to get me pregnant
when I don’t want to be?
✔ Does my partner refuse to use condoms when I ask?

Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings
Emergency Contraceptive Visit✔ Does my partner make me have sex when I don’t want to?
✔ Does my partner tell me who I can talk to or where I can go?

If you answered YES to any of these questions, yourhealth and safety may be in danger.

Is your BODY being affected?
Ask yourself:✔ Am I afraid to ask my partner to use condoms?

Am I afraid
my partner
would hurt
me if morning
I told him I had
an
Whenever someone comes in for Emergency Contraception ✔(EC),often
described
as theafter
STD and he needed to be treated too?
pill, there are key questions to ask and patient education to provide
tohelp
determinewhetherthesex✔ Have I hidden birth control from my partner so he wouldn’t getme pregnant?
was consensual or if any contraceptive tampering may be occurring.
Because some patients may not feel
✔ Has my partner made me afraid or physically hurt me?
comfortable disclosing what is happening to them—it is helpful
toreview
the harm reduction portion of the
If you answered YES to any of these questions, you may be atfor STD/HIV,
unwantedpregnancies and serious injury.
card so that all EC patients know about this strategy whetherrisk
theydiscloseor not.

Sample Script:“Was the sex you had consensual, something
you wanted to do? Are you at all concernedthat a partner may be trying to get you
pregnant when you don’t what to be?
Sometimes women have to worry about
someone else finding your emergency
contraception and throwing it away. If that is
an issue for you it may useful for you to try
out some of the strategies listed on the card.”

Taking Control:Your partner may see pregnancy as a way to keep you in his life and stayconnected to you through a child—even if that isn’t what you want.
If your partner makes you have sex, messes or tampers with yourbirth control or refuses to use condoms:✔ Talk to your health care provider about birth control you can control(like IUD, implant, or shot/injection).

✔ The IUD is a safe device that is put into the uterus and prevents pregnancy

up to 10 years. The strings can be cut off so your partner can’t feel them.
The IUD can be removed at anytime when you want to become pregnant.

✔ Emergency contraception (some call it the morning after pill) can betaken up to five days after unprotected sex to prevent pregnancy. It canbe taken out of its packaging and slipped into an envelope or empty pillbottle so your partner won’t know.

Harm Reduction Strategy:
Emergency contraception is often packaged in a large box with bold labelingand could easily be discovered in a purse or a backpack by an abusive partner.
Consider offering harm reduction strategies such as giving a patient anenvelope so that she can remove the EC from the packaging and then conceal itin the envelope so it is less likely to be detected by her partner.

Pregnancy Test Visits
The panel, “Who controls PREGNANCY Decisions?” of the safety card should be reviewed withpatients for all positive or negative pregnancy test results. Pregnancy options counseling should also
include these key assessment questions.
Sample Script:“Because this happens to so many women,
we ask all of our patients who come infor a pregnancy test if they are able to
make decisions about pregnancy and birthcontrol without any threats or fear from apartner. Who makes these decisions in yourrelationship?”Who controls PREGNANCY decisions?
Ask yourself. Has my partner ever:✔ Tried to pressure or make me get pregnant?
✔ Hurt or threatened me because I didn’t agree to get pregnant?
If I’ve ever been pregnant:✔ Has my partner told me he would hurt me if I didn’t do what hewanted with the pregnancy (in either direction—continuing the
pregnancy or abortion)?
If you answered YES to any of these questions, you are not alone andyou deserve to make your own decisions without being afraid.

Getting Help

Additional information about responding to IPV
in partner
healthare✔ If yourchecks careyour cell settingsphone or texts, talkto your healthcare provider about using their phone to call domestic violence
outlined in the National Consensus Guidelines on Responding
Domestic
services—so your topartner
can’t see it onViolence
your call log.

Victimization in Health Care Settings.1

26

FUTURES WITHOUT VIOLENCE✔ If you have an STD and are afraid your partner will hurt you if you
tell him, talk with your health care provider about how to be safer andhow they might tell your partner about the infection without using
your name.
✔ Studies show educating friends and family about abuse can help
them take steps to be safer—giving them this card can make adifference in their lives.

Funded in part by the U.S. Department of Healthand Human Services’ Office on Women’s Health(Grant #1 ASTWH110023-01-00) and
Administration on Children, Youth and Families.
(Grant #90EV0414)

All these national hotlines can connect
you to your local resources and provide
support:Ask yourself:

Are you in a HEALTHY relationship?

✔ Isandmy partner
kind to me andrespectfulof my choices?
Intimate
Partner
Violence
Reproductive
and Sexual
Coercion:
A GuideforPart 3: GuideAddressing
for Responding
to IPV
Reproductive
andSexualCoercionin theHealth Care
Setting✔ Does my partner support my using birth control?
Obstetric, Gynecologic, and Reproductive Health Care Settings✔ Does my partner support my decisions about if or when I want to havemore children?

If you answered YES to these questions, it is likely that you are in ahealthy relationship. Studies show that this kind of relationship leads tobetter health, longer life, and helps your children.

Harm Reduction Strategy:
If a patient discloses that she is afraid of her partner, follow up by offering
you inabout
an UNHEALTHY
referrals to local domestic violence programsAskand
remindingAreher
therelationship?
National
yourself:
Domestic Violence Hotline shown on the back
of my
the
safety✔ Doespartnermess withcard.
my birth control or try to get me pregnant
when I don’t want to be?

✔ Does my partner refuse to use condoms when I ask?

Testing for Sexually Transmitted Infections(STIs)✔ Does mypartner make me have sex when I don’t want to?
✔ Does my partner tell me who I can talk to or where I can go?

If you answered
YES to any of these
your the patient is
Because STI/HIV is highly correlated with abusive relationships
it is importantto questions,
make sure
health and safety may be in danger.
safe and able to make decisions about condoms.

Sample Script:“Anytime patients come in for STI/HIV testing,
we always ask if they feel comfortable talking totheir partners about using condoms.”“Are you afraid to ask your partner to use
condoms or does he ever get mad at you for
asking?”Is your BODY being affected?
Ask yourself:✔ Am I afraid to ask my partner to use condoms?
✔ Am I afraid my partner would hurt me if I told him I had an

STD and he needed to be treated too?

Whodecisions?
✔ Have I hidden birth control frommycontrols
partner PREGNANCY
so he wouldn’t
getmeyourself.
pregnant?Has my partner ever:
Ask

✔✔Has
mytopartner
mademe afraidor physicallyTriedpressureor makeme getpregnant? hurt me?

If✔youanswered
YES to meanybecauseof theseIquestions,
youtomayat
Hurtor threatened
didn’t agree
get bepregnant?
risk for STD/HIV, unwanted pregnancies and serious injury.
If I’ve ever been pregnant:✔ Has my partner told me he would hurt me if I didn’t do what heTaking Control:
wanted with the pregnancy (in either direction—continuingtheabortion)?
Yourpregnancy
partner mayorsee
pregnancy as a way to keep you in his life and stayconnected
to you throughif that
isn’t what
If you answered
YES atochild—even
any of thesequestions,
youyouarewant.
not alone anddeserveto makewithout
being afraid.
Ifyou
your
partnermakesyour
youownhavedecisions
sex, messes
or tampers
with yourbirth control or refuses to use condoms:

Positive STI Test Result—Seeking Treatment for STI Exposure
Harm Reduction Strategy:✔ Talk to your health care provider about birth control you can control(like IUD, implant, or shot/injection).

✔ The IUD is a safe device that is put into the uterus and prevents pregnancy“I want to go over the “Getting Help”
up to 10 years. The strings can be cut off so your partner can’t feel them.
The IUD can be removed at anytime when you want to become
pregnant.
GettingHelppanel of the safety card with you …
✔ Emergency contraception (some call it the morning after pill) can be✔ takenIf youruppartner
yourunprotected
cell phone sex
or texts,
talk topregnancy.
your healthto five checks
days after
to prevent
It canI know this isn’t a perfect answer,
care
providerusing theirto callviolencebetaken
out ofabout
its packaging
andphoneslippedintodomestic
an envelope
or empty pill
services—sopartnersee it on your call log.
bottleso youryour
partner
won’tcan’tknow.
but often controlling partners have
✔ If you have an STD and are afraid your partner will hurt you if you
multiple sex partners and it is possible
tell him, talk with your health care provider about how to be safer andhow they might tell your partner about the infection without usingthat the STI notification call could
your name.
be about someone other than you—
✔ Studies show educating friends and family about abuse can help
them take steps to be safer—giving them this card can make athis may reduce the likelihood thatdifference in their lives.
you would be hurt by your partner
when he finds out he has an STI. We
Funded in part by the U.S. Department of Healthand Human Services’ Office on Women’s HealthAll these national hotlines can connect
can have someone call your partner(Grant #1 ASTWH110023-01-00) andyou to your local resources and provide
Administration on Children, Youth and Families.
support:(Grant#90EV0414)
anonymously from the health department saying that someone
he has slept withhelp 24 hours a day, call:in the past year has (name of STI) and he needs to come and For
betreated.”National Domestic Violence Hotline
Formerly Family Violence Prevention Fund

FuturesWithoutViolence.org
If the patient says she is afraid of how her partner may react
if she notifies
him about the STI, consider calling the partner yourself, especially ifasking your health department to make the call is not an option.

©2011 Futures Without Violence and American
College of Obstetricians and Gynecologists.
All rights reserved.

ALWAYS FOLLOW UP POSITIVE DISCLOSURES OF REPRODUCTIVE
COERCION WITH ADDITIONAL IPV QUESTIONSDid You

Any positive disclosure of reproductive or sexual coercion should be
Know Your
followed up by questions about other abuse in her relationship.

Relationship
Affects Your
Health?

1-800-799-SAFE (1-800-799-7233)
TTY 1-800-787-3224
www.thehotline.org
National
Dating Abuse
Helpline
Promising
Practice:
1-866-331-9474
www.loveisrespect.org
Some of the staff who work with STIs at the
National Sexual Assault Hotline
Virginia Department
of Health ask their
1-800-656-HOPE(1-800-656-4673)
www.rainn.org
colleagues in another county with a different

area code to make the call to notify an abusive
partner about exposure to an STI. This harm
reduction strategy makes it less likely that theabusive partner will associate the STI exposure
with their current partner who may be seeking
services at a local clinic/program.

FUTURES WITHOUT VIOLENCE

27

Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings

Sample Script:“What you are telling me about your relationship makes me wonder if there are other things thatmake you uncomfortable. Has there ever been a situation where he has hurt you or made you havesex when you didn’t want to?”SUPPORTED REFERRAL
Another integral part of reproductive health care is called supported referral and is a strategy foraddressing reproductive and sexual coercion and IPV. By offering support to facilitate the referral process,providers can increase the likelihood that a patient follows through with a referral. Two key strategies
for supported referral are acknowledging a patient’s safety concerns and offering options. Additionally,
offering a patient use of a phone at the clinic to call a domestic violence hotline or an advocate can be asafer strategy that increases access to services.
A key step in developing supported referral is to connect with existing support services for IPV in thecommunity. Making this connection is mutually beneficial.
• Domestic violence and sexual assault advocates from shelters/advocacy programs are an excellent
resource for training and advocacy• Domestic violence and sexual assault advocates will become more aware of what reproductive healthservices are available for women experiencing IPVHealth care providers will become more familiar with what services for IPV are available locally and havea specific name/person to contact when referring patients.

28

FUTURES WITHOUT VIOLENCE

Part 3: GuideAddressing
for Responding
to IPVand Reproductive
and Sexual Coercion
in theHealth Care
Setting
Intimate
Partner
Violence Reproductive
and Sexual
Coercion:
A Guidefor
Obstetric, Gynecologic, and Reproductive Health Care Settings

Supported Referral Using the Futures Safety Card
The safety card can also be used to discuss safety planning and resources that are available for patients
who are experiencing IPV and/or reproductive and sexual coercion. A sample script for how to use thesafety card as an intervention tool is provided below.
Who controls PREGNANCY decisions?
Ask yourself. Has my partner ever:✔ Tried to pressure or make me get pregnant?

Sample Script:✔ Hurt or threatened me because I didn’t agree to get pregnant?
If I’ve ever been pregnant:“I want you to know that on the back of this safety card ✔there
are national hotline numbers withHas my partner told me he would hurt me if I didn’t do what hewith thepregnancy(in either
direction—continuing
folks who are available 24/7 if you want to talk. They can wanted
connectyouto localshelter
services ifthepregnancy or abortion)?
you need more urgent help. Also, I know (insert name ofIf you
local
advocate)
who
I
can
put
the
answered YES to any of these questions, youyou
are noton
alone
and
you
deserve
to
make
your
own
decisions
without
being
afraid.
phone with right now if you would like to talk to her.”
HARM REDUCTION STRATEGY:

Getting Help

Abusive partners often monitor phones and ✔
text
socellitphone
is orimportanttoIf yourmessages
partner checks yourtexts, talk to your healthcare provider about using their phone to call domestic violence
offer use of a private phone in the clinic to a patient
sopartner
she can’tcantheservices—so yoursee make
it on your calllog. call to ashelter or advocacy program without the number
being
tracedbypartner
herwillpartner.
✔ If you havean STD and
are afraid yourhurt you if you

Respect Her Answer

tell him, talk with your health care provider about how to be safer andhow they might tell your partner about the infection without using
your name.

✔ Studies show educating friends and family about abuse can help

them take steps to be safer—giving them this card can make a
If she says yes to relationship problems but doesn’t disclose morevague:
differencethan
in theirsomething
lives.

Sample Script:“You mentioned things are sometimes
complicated in your relationship. I justwant you to know that sometimes things
can get worse. I hope this is never the case,but if you are ever in trouble you can comehere for help. I am also going to give you acard with a hotline number on it. You cancall the number anytime. The hotline staff
really get how complicated it can be when
you love someone and sometimes it feels
unhealthy or scary. They have contact withlots of women who have experienced thisor know about it in a personal way.”

Funded in part by the U.S. Department of Healthand Human Services’ Office on Women’s Health(Grant #1 ASTWH110023-01-00) and
Administration on Children, Youth and Families.
(Grant #90EV0414)

Formerly Family Violence Prevention Fund

FuturesWithoutViolence.org©2011 Futures Without Violence and American
College of Obstetricians and Gynecologists.
All rights reserved.

All these national hotlines can connect
you to your local resources and provide
support:For help 24 hours a day, call:National Domestic Violence Hotline
1-800-799-SAFE (1-800-799-7233)
TTY 1-800-787-3224
www.thehotline.org
National Dating Abuse Helpline
1-866-331-9474
www.loveisrespect.org
National Sexual Assault Hotline
1-800-656-HOPE (1-800-656-4673)
www.rainn.org

Did You
Know Your
Relationship
Affects Your
Health?

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Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings

Who controls PREGNANCY decisions?
Ask yourself. Has my partner ever:✔ Tried to pressure or make me get pregnant?
✔ Hurt or threatened me because I didn’t agree to get pregnant?
If I’ve ever been pregnant:✔ Has my partner told me he would hurt me if I didn’t do what hewanted with the pregnancy (in either direction—continuing the
pregnancy or abortion)?
If you answered YES to any of these questions, you are not alone andyou deserve to make your own decisions without being afraid.

What to say when she says: “No, this isn’t happening to me.”Sample Script:“I’m really glad to hear nothing likethis is going on for you. We are giving
this card to all of our patients so thatthey will know how to help a friend ora family member having difficulties intheir relationship.”

Getting Help
✔ If your partner checks your cell phone or texts, talk to your healthcare provider about using their phone to call domestic violenceservices—so your partner can’t see it on your call log.
✔ If you have an STD and are afraid your partner will hurt you if you
tell him, talk with your health care provider about how to be safer andhow they might tell your partner about the infection without using
your name.
✔ Studies show educating friends and family about abuse can help
them take steps to be safer—giving them this card can make adifference in their lives.

Funded in part by the U.S. Department of Healthand Human Services’ Office on Women’s Health(Grant #1 ASTWH110023-01-00) and
Administration on Children, Youth and Families.
(Grant #90EV0414)

All these national hotlines can connect
you to your local resources and provide

Trauma Informed Reporting When Mandated Reporting is Required
support:for a Positive
For help 24 hours a day, call:
Disclosure

What is Trauma Informed Reporting?

Formerly Family Violence Prevention Fund

FuturesWithoutViolence.org

National Domestic Violence Hotline
1-800-799-SAFE (1-800-799-7233)
TTY 1-800-787-3224
www.thehotline.org
National Dating Abuse Helpline
1-866-331-9474
www.loveisrespect.org
National Sexual Assault Hotline
1-800-656-HOPE (1-800-656-4673)
www.rainn.org

Trauma-informed reporting provides a foundation for trauma-informed care. As described in the firstsection of this guide, becoming trauma-informed means looking at all aspects of services through a trauma
lens that increases awareness of how service delivery and policies can exacerbate trauma and vulnerabilities
among trauma survivors. This comprehensive approach includes the actual process of making a mandated
report to minimize the risk of further trauma or danger as a result of a report being made.
©2011 Futures Without Violence and American
College of Obstetricians and Gynecologists.
All rights reserved.

Did You

Trauma-informed reporting begins recognizing that a report
madeYouragainst a patient’s wishes may leadKnow
to feelings of helplessness. Providers should inform patients about the process of reporting, help them
Relationshipto understand what to expect, and involve them in making the report. These actions can minimize
Your through the process. For
untoward effects of reporting and give a patient more of aAffects
sense of control
Health?
example, if a female teen patient is upset about the need toreport, one way to support her and showrespect to what she is saying is to ask her if she would like to have input in the reporting process. Sample
scripts to facilitate trauma-informed reporting are provided below.
Always Acknowledge Patients’ Feelings:“I really hear that you don’t want me to do the report, and I am sorry but I am required by law to doso…”
Offer Ways to Involve Patients in the Reporting Process:Sample Script for Adolescent Patient:“I do have to make the report, but you are welcome to listen as I call in the report so you know what
is being said and there are no surprises. I can also put in the report any concerns you have about
what will happen when your parents are told about what happened or the best ways to inform them(place, time, one parent over the other etc).”

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Part 3: GuideAddressing
for Responding
to IPVand Reproductive
and Sexual Coercion
in theHealth Care
Setting
Intimate
Partner
Violence Reproductive
and Sexual
Coercion:
A Guidefor
Obstetric, Gynecologic, and Reproductive Health Care Settings

DOCUMENTATION AND FOLLOW-UP
The following information should be routinely documented in patients’ charts:• Confirmation that the patient was screened for IPV and reproductive and sexual coercion or thereason why screening could not be done and any plans or follow-up actions to ensure that thepatient will be screened• Patient response to screening• Documentation of resources provided such as Safety Cards• Any referrals provided
In addition to offering appropriate referrals and assistance when a patient discloses victimization, ask thepatient if a follow-up appointment can be scheduled at this time. It is also helpful to ask the patient forcontact information, such as a phone number where it is safe to contact her, so that any future contact
will be done in a way that minimizes risk to the patient.
Refer to the National Consensus Guidelines provided in Appendix A for additional information on
documentation and follow-up for IPV. This resource provides practical strategies for documentationsuch as the importance of using the patient’s own words to describe what happened and avoiding
judgmental statements such as “patient refuses help.”

What about boys and men?
The opportunities for screening, education, and prevention with male patients are similar to thosedescribed for female patients. Share pro-active messages with all male patients that emphasize theimportance of healthy, safe, and consensual relationships. Counseling about safe sex and STI prevention
should include messaging on how condom use can prevent unintended pregnancies and STIs. Malepatients need to understand how victimization such as sexual coercion may impact their reproductive
and sexual health and risk-taking behaviors.
Find out what resources are available for male patients by contacting local domestic violence and sexualassault programs/shelters or the National Hotline. Learn about innovative programs and practices forboys and men such as the Planned Parenthood Program described here.
Planned Parenthood:
THE NATIONAL ADOPTION OF THE INTERVENTIONPROMISING PRACTICE
The Planned Parenthood Association of Hidalgo County, Texas offers programs for male teens andadults. The teen program educates young males and first-time fathers about healthy relationships
and links youth to community resources. Another program at Planned Parenthood reaches out tomen who have been incarcerated, are in half-way houses, or substance abuse programs to help themtransition back into their lives, relationships, and families. Meeting in groups, the men discuss awide range of issues related to healthy relationships and fatherhood including manhood, sexuality,communication, and family violence. Participants are also connected to health care services.

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Addressing Intimate Partner Violence Reproductive and Sexual
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Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

PART 4: POLICY IMPLICATIONS AND
SYSTEMS RESPONSE

System-wide changes regarding practices will only be implemented and sustained when there
are tangible changes in policies and the infrastructure to support these changes. A formalized
protocol is an essential step to institutionalizing a trauma-informed, coordinated response that
addresses IPV and reproductive and sexual coercion.

All health care settings should have a written protocol for identifying
and responding to IPV that includes reproductive and sexual coercion.
For organizations that already have a protocol for IPV, the protocol should
be reviewed and expanded to address reproductive and sexual coercion.
Consider including the following elements:
1. Training requirements for staff
a. Content of training
b. Staff proficiencies for knowledge and skills
2. Confidentiality procedures and mandated reporting requirements
3. Assessment strategies including setting, frequency, and cultural and language considerations
4. Harm reduction counseling for patients disclosing IPV and/or reproductive and sexual coercion
5. Follow-up and supported referral strategies
6. Documentation

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Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings
Protocols need to be reviewed, updated, practiced, and supported by top-level management. As
described in the National Consensus Guidelines on Identifying and Responding to Domestic Violence
Victimization in Health Care Settings, 70% of providers complied with an IPV protocol when there
was strong administrative support and monitoring after a protocol was adopted; however, provider
compliance was only 30% when there was minimal administrative support and monitoring during thefirst year of implementing the protocol.1 Institutionalizing changes in practices and policies requires asystemic approach where screening and responding to IPV and reproductive and sexual coercion are
integrated into routine practive and health program design, implementation, and evaluation.66
In a study comparing approaches in two different healthcare settings (an obstetrics and gynecology clinic
and a general medicine clinic), the following elements were positively associated with providers’ comfort
level and confidence in addressing IPV67:• Systemic prioritization of IPV and resources• On-site resources• Adequate time
• Focused IPV training• Team approach

Creating Change and Helping Staff Exposed to Violence
The following strategies provide a framework for institutionalizing a trauma-informed, coordinatedresponse to IPV and reproductive and sexual coercion, while creating a safer and more supportive working
environment for staff that experience victimization. More information on workplace policies for IPV andreproductive and sexual coercion can be found at another Futures website: www.workplacesrespond.org
1. Implement and routinely update workplace policies to:a. Include language on ensuring a violence-free workplaceb. Offer support for staff exposed to violence including services through employee assistanceprograms

c. Describe plans for how to address stalking and workplace harassment by an abusive partner
2. Promote awareness that life experiences of the staff may influence their comfort level andeffectiveness with addressing IPV and reproductive and sexual coercion with patients

3. Examine opportunities for reimbursement strategies that allow compensation for addressing IPV

and reproductive and sexual coercion in the health care setting

4. Create a network of clinicians within your organization who have expertise on this issue and willchampion the cause

5. Develop program quality improvement goals that address IPV and reproductive coercion

through a consensus process with staff and monitor your organization’s progress

6. Celebrate successes and set aside specific times to discuss difficult cases

Futures has developed a quality assurance/quality improvement (QA/QI) tool (See Appendix B) for
family planning clinics, that may be adapted for physicians in private practice. This tool was developedfor implementing and evaluating a trauma-informed, coordinated response to IPV and reproductive andsexual coercion in the reproductive health care setting. The QA/QI tool, which uses a checklist format,
can help clinics and reproductive health programs to identify their goals and monitor their progress.

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Addressing Intimate Partner Violenceand Sexualand
Coercion:
Guide for
PartReproductive
4: Policy Implications
SystemsA Response
Obstetric, Gynecologic, and Reproductive Health Care Settings

The following topics are addressed in the QA/QI tool:• Assessment methods• Intervention strategies• Networking and training• Self care and support• Data and evaluation• Education and prevention• Environment and resources

This section closes with examples of promising practices:
1. Application of this guide system-wide in more than 800 reproductive health clinics serving morethan 3.5 million clients annually

2. A system-wide approach to implementing a trauma-informed, coordinated response to IPV andreproductive and sexual coercion in family planning clinics through public health partnerships

3. A cost-effective family planning initiative that has been instrumental in decreasing teenage

pregnancy rates

PROMISING PRACTICE: SYSTEM-WIDE PUBLIC HEALTH RESPONSE
By March 2012, Planned Parenthood affiliates will integrate reproductive and sexual
coercion screening into their reproductive health care services by implementing an adapted
version of Addressing Intimate Partner Violence Reproductive and Sexual Coercion. Futures
was approached by Planned Parenthood to adapt the guide for their providers, making
their organization the first to require routine screening for reproductive and sexual coercion
throughout their network of nearly 800 health centers serving three million women, men,and young people nationwide.
FUTURES WITHOUT VIOLENCE

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Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings

PROMISING PRACTICE: FAMILY PACT OF CALIFORNIAThe Guttmacher Institute recently published their national findings about teen pregnancy rates
in the United States. The State of California’s Family PACT (Family Planning, Access, Care, and Treatment)
program was shown to be the most successful model in the U.S.
• California Family PACT provides free family planning and contraceptive methods to womenand men at or below 200% of the poverty level• Family PACT serves one million women per year and 100,000 men per year
• California’s teen pregnancy rate declined by 52% between 1992 and 2005, the steepest drop
registered by any state during that period—far exceeding the national decline of 37%• Public health experts credit this record decline to California’s comprehensive and evidence-basedteen pregnancy prevention efforts dating back to the 1990’s• This coordinated effort has saved millions in tax dollars each year through the prevention of
unintended pregnancy among adolescents
In October 2010, Family PACT co-branded reproductive and sexual coercion safety cards with
Futures and sent samples to 3,200 Family PACT providers throughout the state of California. The
safety cards and posters, available in Spanish and English, are featured in Family PACT’s catalog ofmaterials and provided at no cost to service providers and patients statewide.

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FUTURES WITHOUT VIOLENCE

Addressing
Addressing
Intimate
Intimate
PartnerPartner
Violence
Violence
Reproductive
Reproductive
andandSexualSexualCoercion:
Coercion:A AGuide
Guideforfor
Obstetric,
Obstetric,Gynecologic,
Gynecologic,andandReproductive
ReproductiveHealth
HealthCare
CareSettings
Settings

APPENDIX A
Source: Family Violence Prevention Fund. National Consensus Guidelines on Identifying and Responding toDomestic Violence Victimization in Health Care Settings. Referencing sections of the Danger Assessment
tool by Jacquelyn C. Campbell, Ph.D., R.N. Copyright 1985, 1988. Pages 38-39.
Information in this appendix is adapted from the following resource: Family Violence Prevention Fund. National
Consensus Guidelines on Identifying and Responding to Domestic Violence Victimization in Health Care
Settings. Pages: 14-19

Health and Safety Assessment
The goals of the assessment are to a) create a supportive environment in which the patient can discuss theabuse, b) enable the provider to gather information about health problems associated with the abuse, andc) assess the immediate and long-term health and safety needs for the patient in order to develop andimplement a response.
What should assessment include?

For the patient who discloses current abuse, assessment should include at a minimum:
ASSESSMENT OF IMMEDIATE SAFETY• “Are you in immediate danger?”• “Is your partner at the health facility now?”• “Do you want to (or have to) go home with your partner?”• “Do you have somewhere safe to go?”• “Has the violence gotten worse or is it getting scarier? Is it happening more often?”
ASSESSMENT OF THE PATTERN AND HISTORY OF CURRENT ABUSE• “How long has the violence been going on?”• “Have you ever been hospitalized because of the abuse?”• “Can you tell me about your most serious event?”

Interventions with Victims of IPVInterventions will vary based on the severity of the abuse, the patient’s decisions about what s/he wants
for assistance at that time and if the abuse is happening currently. It is important to let the patient knowthat you will help regardless of whether s/he decides to stay in or leave the abusive relationship. For all
patients who disclose current abuse providers should:
Respond to safety issues:

Offer the patient a brochure about safety planning and go over it with her/him• Review ideas about keeping information private and safe from the abuser• Offer the patient immediate and private access to an advocate in person or via phone• Offer to have a provider or advocate discuss safety then or at a later appointment

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Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings• If the patient wants immediate police assistance, offer to place the call
• Reinforce the patient’s autonomy in making decisions regarding her/his safety• If there is significant risk of suicide, the patient should be kept safe in the health setting until
emergency psychiatric evaluation can be obtained

Documentation
Providers should document the patient’s statements and avoid pejorative or judgmental documentation(e.g. write “patient declines services” rather than “patient refuses services”, “patient states” rather than“patient alleges”).
Document relevant history:• Record details of the abuse and its relationship to the presenting problem• Document any concurrent medical problems that may be related to the abuse• For current IPV victims, document a summary of past and current abuse including:• Social history, including relationship to abuser and abuser’s name if possible• Patient’s statement about what happened, as opposed to what lead up to the abuse (e.g.

“boyfriend John Smith hit me in the face” not “patient arguing over money”)• Include the date, time, and location of incidents where possible• Patient’s appearance and demeanor (e.g. “tearful, shirt ripped” not “distraught”)• Any objects or weapons used in an assault (e.g. knife, iron, closed or open fist)• Patients accounts of any threats made or other psychological abuse• Names or descriptions of any witnesses to the abuse
Document results of physical examination:• If there are injuries, (present or past) describe type, color, texture, size, and location• Use a body map and/or photographs to supplement written description• Obtain a consent form prior to photographing patient. Include a label and date
Document laboratory and other diagnostic procedures:• Record the results of any lab tests, x-rays, or other diagnostic procedures and their relationship to thecurrent or past abuse
Document results of assessment, intervention and referral:• Record information pertaining to the patient’s health and safety assessment including yourassessment of potential for serious harm, suicide and health impact of IPV• Document referrals made and options discussed• Document follow-up arrangements

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Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

If patient does not disclose IPV victimization:• Document that assessment was conducted and that the patient did not disclose abuse• If you suspect abuse, document your reasons for concerns: i.e. “physical findings are not congruent
with history or description,” “patient presents with indications of abuse”

Follow-Up and Continuity of Care for Victims
At least one follow-up appointment (or referral) with a health care provider, social
worker or DV advocate should be offered after disclosure of current or past abuse:• “If you like, we can set up a follow-up appointment (or referral) to discuss this further”• “Is there a number or address that is safe to use to contact you?”• “Are there days/hours when we can reach you alone?”• “Is it safe for us to make an appointment reminder call?”At every follow up visit with patients currently in abusive relationships:• Review the medical record and ask about current and past episodes of IPV• Communicate concern and assess both safety and coping or survival strategies:• “I am still concerned for your health and safety”• “Have you sought counseling, a support group or other assistance?”• “Has there been any escalation in the severity or frequency of the abuse?”• “Have you developed or used a safety plan?”• “Told any family or friends about the abuse?”• “Have you talked with your children about the abuse and what to do to stay safe?”• Reiterate options to the patient (individual safety planning, talking with friends or family, advocacy
services and support groups, transitional/temporary housing, etc.)
For current and previous victims of IPV:

• Ensure that patient has a connection to a primary care or OB/GYN provider• Coordinate and monitor an integrated care plan with community based experts as needed, or other
health care specialists, trained social workers or mental health care providers as needed
If patient does not disclose current or past IPV victimization:• Document that assessment was conducted and that the patient did not disclose abuse• If you suspect abuse, document your reasons for concern: i.e. “ Findings are not congruent w/
history or description”, “patient presents with indicators of violence”

FUTURES WITHOUT VIOLENCE

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Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings

APPENDIX B
Reproductive Health, Intimate Partner Violence (IPV),and Reproductive and Sexual Coercion:
Quality Assessment/Quality Improvement Tool

Name/Title:
Clinic/Program Name:
Date:
1. Assessment Strategies
Does your clinic/program have a written protocol that addresses screening andintervention for the following types of relationship violence*:*Refer to Addressing Intimate Partner Violence Reproductive and Sexual Coercion for definitions.

Yes

No

N/A

Don’t Know

Intimate partner violence (IPV)
Reproductive Coercion
Sexual Coercion
Adolescent Relationship Violence
Does your clinic/program protocol include a description of trauma-informed care forpatients who have experienced IPV and/or reproductive and sexual coercion?

Yes

No

N/A

Don’t Know

Which of the following strategies are used at your clinic/program to screen patientsfor intimate partner violence (IPV)?

Yes

No

N/A

Don’t Know

Patients answer questions on a medical/healthhistory form
Staff review the patient’s completed medical/
health history form and ask additional and/or
follow-up questions as needed
Staff ask questions during face-to-face assessmentwith patients
Screening occurs in a private place
Staff explain to patients why they are being
screened for IPV
Staff inform patients about confidentiality andany mandated reporting requirements prior to
doing any assessment for IPV
Staff use safety cards to facilitate assessment for
IPV** Refer to Addressing Intimate Partner Violence Reproductive and Sexual Coercion for sample safety cards.

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Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

Which of the following strategies are used at your clinic/program to screen patientsfor reproductive and sexual coercion?

Yes

No

N/A

Don’t Know

N/ADon’t Know

Patients answer questions on a medical/healthhistory form
Staff review the patient’s medical/health history
form and ask additional and/or follow-up
questions as needed
Staff ask questions during face-to-face assessmentwith patients
Screening occurs in a private place
Staff explain to patients why they are being
screened for reproductive and sexual coercion
Staff inform patients about confidentiality andany mandated reporting requirements prior to
doing any assessment
Staff use safety cards to facilitate assessment for
reproductive and sexual coercion
2. Resources to Facilitate Assessment
Do your staff have:

Yes

No

Sample scripts and questions on assessment forms
that staff can use to ask patients about IPV
Sample scripts and questions on assessment
forms that staff can use to ask patients about
reproductive and sexual coercion
Sample scripts on how to inform patients about
limits of confidentiality
Instructions/protocol on how to do a mandated
report using a trauma-informed approach thatminimizes danger and trauma for patients who
have experienced relationship violence
Safety cards that can be used to facilitate
assessment and educate patients about the impact
of IPV and reproductive and sexual coercion on
their reproductive health

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Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings

Place an “X” to indicate whether screening occurs for the different types ofrelationship violence at the following patient visits:

Intimate Partner
Violence

Reproductive
Coercion

Sexual Coercion

Initial visit
Annual/comprehensive visit
Birth control counseling visit
EC visit
STI visit
HIV counseling and testing visit
Pregnancy test visit
Prenatal visit
Which staff person is primarily responsible for screening patients for IPV andreproductive and sexual coercion? Place an “X” in the box for the primary staff
person who is usually responsible for screening at each type of patient visit.

PhysicianNurse/NP/
CNM/PA

MedicalAssistantCounselor/
Health
Educator

Initial visit
Annual/comprehensive visit
Birth control counseling visit
EC visit
STI visit
HIV counseling and testing visit
Pregnancy test visit
Prenatal visit
3. Integrated Assessment and Intervention
Birth Control Options Counseling

Yes

No

N/A

Don’t Know

Yes

No

N/A

Don’t Know

Patients are routinely screened for birth control
sabotage (i.e. Has their partner ever interferedwith their birth control method?)
If a patient discloses birth control sabotage, theprovider talks with the patient about contraceptive
options that are less vulnerable to partnerinterference
Emergency Contraceptive (EC) Visit

Patients are routinely asked if the sex they hadleading to the EC visit was consensual
Patients are offered options to help them conceal
the EC such as asking if she would like to takeit out of the package and take it home in an
envelope

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Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

Pregnancy Test Visit

Yes

No

N/A

Don’t Know

Yes

No

N/A

Don’t Know

Patients are routinely asked if they are able to
make decisions about whether they want to bepregnant without threats or fear from a partner
STI/HIV Testing

Patients are routinely asked if they feel comfortable
talking with their partner about using condoms
Patients who test positive for a STI/HIV are
asked if they are concerned or afraid of how theirpartner may react to being notified about the STI/HIV
Patients who disclose concerns about how theirpartner may respond to partner notification abouta STI/HIV are offered harm reduction strategies
such as the provider notifying the partner or
having the health department make contact
4. Resources for Integrated Assessment and Intervention
Do your staff have:

Yes

No

N/A

Don’t Know

Yes

No

N/A

Don’t Know

Scripted tools/instructions on how to do safety
planning with clients who disclose current IPV
and/or reproductive and sexual coercion
Safety cards to give all patients with hotline
phone numbers and information on the impact of
unhealthy relationships on reproductive health
Instructions for how to do trauma-informed
reporting if mandated reporting is required due toa patient’s disclosure
An on-call advocate or counselor who can provide
on-site follow-up with the client who discloses
IPV and/or reproductive and sexual coercion
A safe place at your clinic/program where apatient can use a phone to talk to a violenceadvocate/services
Are there resource lists at your clinic/
program that:

Identify referrals/resources such as shelters or legal
advocacy for patients who disclose IPV
Identify referrals/resources for patients who
disclose sexual assault
Identify referrals/resources for perpetrators of IPV
Include a contact person for each referral agency
There is a designated staff person responsible for
updating these lists annually
Resource lists are updated at least once a year

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Addressing Intimate Partner Violence Reproductive and Sexual
Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings

5. Networking and Staff Support
Within the last year has your clinic staff had contact with representatives fromany of the following agencies (contact means called for assistance with a patient,called for information about services, or other direct contact with an agency
representative)?

Yes

No

N/A

Don’t Know

Yes

No

N/A

Don’t Know

Yes

No

N/A

Don’t Know

No

N/A

Don’t Know

Domestic violence advocates/shelter staff
Rape crisis center staff/advocatesChild protective services
Batterer’s intervention group
Legal advocacy/legal services
Law enforcement
There is someone on staff who is especially
comfortable with screening and intervention for
IPV with patients
There is someone on staff who is especially
comfortable with screening and intervention forreproductive and sexual coercion with patients
We have a protocol that advises staff on what to
do if they do not feel comfortable or adequately
skilled to help a patient who discloses IPV and/or
reproductive and sexual coercion
We have someone on staff who participates in a local
domestic violence task force or related subcommittee
We have a buddy system or internal referralfor staff to turn to for assistance when they
are overwhelmed or uncomfortable addressing
violence with a patient
6. Training

YesYour staff receives annual training on IPVYour staff has received training on reproductive
and sexual coercion in the past two years
Your staff has received training on traumainformed care in the past two years
Newly hired staff receive training on IPV
Newly hired staff receive training on reproductive
and sexual coercion
Domestic violence advocates are invited to yourclinic/program to network and/or provide training
at least once a year

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Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

7. Self Care and Support
Does your clinic/program staff have:

Yes

No

N/A

Don’t Know

N/ADon’t Know

A protocol for what to do if a staff person isexperiencing IPV and/or reproductive and sexual
coercion
A protocol for what to do if a perpetrator is onsite and displaying threatening behaviors or trying
to get information
Individual clinical supervision for staff to discuss
any concerns/discomfort relating to screening for
IPV and reproductive and sexual coercion
Other types (group supervision, case presentation)of opportunities for staff to discuss any concerns/
issues relating to cases involving IPV andreproductive and sexual coercion
An employee assistance program (EAP) that
staff can access for help with current or pastvictimization
8. Documentation and Follow-up
Does your clinic/program:

Yes

No

Record the number of patients screened for IPV
Record the number of patients who disclose
reproductive and sexual coercion
Record the number of patients screened for
reproductive and sexual coercion
Record the number of patients who disclose
reproductive and sexual coercion
Record use of longer-acting contraceptives among
patients
Annually review all clinic protocols relating torelationship violence (both client and staff related)
Include questions on patient satisfaction surveys
soliciting their opinions about assessment andintervention strategies for IPV and reproductive
and sexual coercion

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Addressing Intimate Partner Violence Reproductive and Sexual
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9. Prevention
Does your clinic/program:

Yes

No

N/A

Don’t Know

Provide information to patients on healthy
relationships
Sponsor any patient or community education totalk about healthy relationships or indicators ofrelationship violence
Offer parenting classes that address how
relationship violence can affect parenting
10. Preparing Your Clinic/Program
Does your clinic/program have:

Yes

No

N/A

Don’t Know

Yes

No

N/A

Don’t Know

Brochures/information about IPV for patients
Brochures/information about reproductive andsexual coercion
Posters/displays about IPV
Posters/displays about reproductive and sexual
coercion
Adolescent-focused brochures/information aboutadolescent relationship violence
Brochures/information about LGBTQ
relationship violence
Are brochures/information/posters placed in easily
visible locations such as waiting rooms and private
areas such as bathrooms and exam rooms?
Have these resource been reviewed by underserved
communities for inclusivity and linguistic andcultural relevance?
Additional Comments and Observations:46

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Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

APPENDIX C
The American College ofObstetricians and Gynecologists
WOMEN’S HEALTH CARE PHYSICIANSCOMMITTEE OPINION
Number 518 • February 2012
Committee on Health Care for Underserved WomenThis information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

Intimate Partner Violence
ABSTRACT: Intimate partner violence (IPV) is a significant yet preventable public health problem that affects
millions of women regardless of age, economic status, race, religion, ethnicity, sexual orientation, or educational
background. Individuals who are subjected to IPV may have lifelong consequences, including emotional trauma,
lasting physical impairment, chronic health problems, and even death. Although women of all ages may experience
IPV, it is most prevalent among women of reproductive age and contributes to gynecologic disorders, pregnancy
complications, unintended pregnancy, and sexually transmitted infections, including human immunodeficiency
virus (HIV). Obstetrician–gynecologists are in a unique position to assess and provide support for women who
experience IPV because of the nature of the patient–physician relationship and the many opportunities for intervention that occur during the course of pregnancy, family planning, annual examinations, and other women’s healthvisits. The U.S. Department of Health and Human Services has recommended that IPV screening and counselingshould be a core part of women’s preventive health visits. Physicians should screen all women for IPV at periodic
intervals, including during obstetric care (at the first prenatal visit, at least once per trimester, and at the postpartum checkup), offer ongoing support, and review available prevention and referral options. Resources are available
in many communities to assist women who experience IPV.

Intimate partner violence (IPV) is a pattern of assaultive
behavior and coercive behavior that may include physicalinjury, psychologic abuse, sexual assault, progressive isolation, stalking, deprivation, intimidation, and reproductive coercion (1). These types of behavior are perpetrated
by someone who is, was, or wishes to be involved in an
intimate or dating relationship with an adult or adolescent, and is aimed at establishing control of one partner
over the other (1). It can occur among heterosexual orsame-sex couples and can be experienced by both men
and women in every community regardless of age, economic status, race, religion, ethnicity, sexual orientation,or educational background. Individuals who are subjected to IPV may have lifelong consequences, including
emotional trauma, lasting physical impairment, chronic
health problems, and even death.
More than one in three women in the United States
have experienced rape, physical violence, or stalking by an
intimate partner in their lifetime (2). In the United States,
women experience 4.8 million incidents of physical orsexual assault annually (3). However, the true prevalenceof IPV is unknown because many victims are afraid todisclose their personal experiences of violence. Intimate

partner violence caused 2,340 deaths in 2007; of thisnumber, 1,640 were female and 700 were male (4).

Patterns of Intimate Partner Violence
Intimate partner violence encompasses subjection of apartner to physical abuse, psychologic abuse, sexual violence, and reproductive coercion. Physical abuse can
include throwing objects, pushing, kicking, biting, slapping, strangling, hitting, beating, threatening with any
form of weapon, or using a weapon. Psychologic abuseerodes a woman’s sense of self-worth and can include
harassment; verbal abuse such as name calling, degradation, and blaming; threats; stalking; and isolation. Often,
the abuser progressively isolates the woman from family and friends and may deprive her of food, money,
transportation, and access to health care (5). Sexual violence includes a continuum of sexual activity that covers
unwanted kissing, touching, or fondling; sexual coercion;and rape (6). Reproductive coercion involves behavior used
to maintain power and control in a relationship related
to reproductive health and can occur in the absence ofphysical or sexual violence. A partner may sabotage efforts
at contraception, refuse to practice safe sex, intentionally

Used with permission. Intimate partner violence. Committee Opinion No. 518. American College of Obstetricians and Gynecologists.
Obstet Gynecol 2012;119:412-7

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expose a partner to a sexually transmitted infection (STI)or human immunodeficiency virus (HIV), control theoutcome of a pregnancy (by forcing the woman to continue the pregnancy or to have an abortion or to injure
her in a way to cause a miscarriage), forbid sterilization,or control access to other reproductive health services(1).
Approximately 20% of women seeking care in familyplanning clinics who had a history of abuse also experienced pregnancy coercion and 15% reported birth control sabotage (7). In addition to unintended pregnancy
risk, there are also risks specific to partner notificationof an STI, which should be taken into account especiallywhen considering expedited partner treatment. Women
experiencing physical or sexual IPV are more likely to beafraid to notify their partners of an STI. In a study with aculturally diverse sample of women seeking care at familyplanning clinics, clients exposed to IPV were more likely
to have partners who responded to partner notification
by saying that the STI was not from them or accusing herof cheating (8). Some women reported threats of harmor actual harm in response to notifying their partnersof an STI (9). Expedited partner therapy is only recommended after a health care provider has assessed for andconfirmed that there is no risk of IPV associated withpartner notification. It is also not intended for childabuse, sexual assault, or any situation where there is aquestion of safety.

Consequences of Intimate Partner
Violence
Some women subjected to IPV present with acute injuries
to the head, face, breasts, abdomen, genitalia, or reproductive system, whereas others have nonacute presentations of abuse such as reports of chronic headaches, sleep
and appetite disturbances, palpitations, chronic pelvic
pain, urinary frequency or urgency, irritable bowel syndrome, sexual dysfunction, abdominal symptoms, andrecurrent vaginal infections. These nonacute symptoms
often represent clinical manifestations of internalized
stress (ie, somatization). This stress can lead to posttraumatic stress disorder, which is often associated withdepression, anxiety disorders, substance abuse, and suicide. Research confirms the long-term physical and psychologic consequences of ongoing or past violence (10).
Approximately 324,000 pregnant women are abused
each year in the United States (11). Although more
research is needed, IPV has been associated with poor
pregnancy weight gain, infection, anemia, tobacco use,
stillbirth, pelvic fracture, placental abruption, fetal injury,
preterm delivery, and low birth weight (11–14). In addition, the severity of violence may sometimes escalate
during pregnancy or the postpartum period (15, 16).
Homicide has been reported as a leading cause of maternal mortality, with the majority perpetrated by a current
or former intimate partner (14). High rates of birth

2

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control sabotage and pregnancy pressure and coercion
in abusive relationships are correlated with unintended
pregnancies (1, 7).
The societal and economic effects of IPV are profound. Approximately one quarter of a million hospital
visits occur as a result of IPV annually (17). The cost of
intimate partner rape, physical assault, and stalking totals
more than $8.3 billion each year for direct medical andmental health care services and lost productivity frompaid work and household chores (17, 18). Additional
medical costs are associated with ongoing treatment of
alcoholism, attempted suicide, mental health symptoms,
pregnancy, and pediatric-related problems associated withconcomitant child abuse and witnessing abuse. Intangible
costs include women’s decreased quality of life, undiagnosed depression, and lowered self-esteem. Destruction of
the family unit often results in loss of financial stability orlack of economic resources for independent living, leading
to increased populations of homeless women and children (19). Efforts to control health care costs should focus
on early detection and prevention of IPV (18).

Special Populations
Adolescents
Approximately one out of ten female high-school students in the United States reported experiencing physicalviolence from their dating partners in the previous year(20). Of those who reported ever having had sexual intercourse, one out of five girls experienced dating violence.
These girls were also more likely to have experienced
pregnancy and STIs, including HIV, and to report tobacco
use and mental health problems, including suicide
attempts (20). It is important for adolescents to be awareof behavior that aims to maintain power and control in a
relationship such as monitoring cell phone usage, digital
dating abuse (including posting nude pictures against her
will, stalking her through social networks, and humiliating her through social networks), telling a partner what towear, controlling whether the partner goes to school thatday, as well as manipulating contraceptive use (1). Early
recognition is critical in this population because adolescent violence can be associated with partner violence inadult life.
Immigrant Women
Women from different backgrounds may have different
perceptions about IPV and need culturally relevant carethat is sensitive to language barriers, acculturation, accessibility issues, and racism. Immigrant women may behesitant to report IPV because of fears of deportation. It is
important to increase awareness that a U Nonimmigrant
Visa allows immigrants who have been subjected to substantial physical or mental abuse caused by IPV or othercrimes to legally remain in the United States if it is justified on humanitarian grounds, ensures family unity, or isotherwise in the public interest (21).

Committee Opinion No. 518

Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

Women With Disabilities
Women with physical and developmental disabilities usually are less able to care for themselves and are more reliant on their partners or caregivers for help. This sets up adangerous dynamic where abusers may be in a position tophysically abuse their victims by withholding medication,
preventing use of assistive equipment such as canes or
wheelchairs, and sabotaging other personal service needs
such as help with bathing, bathroom functions, or eating.
Also, many violence shelters do not accept women withdisabilities or are not trained to respond adequately to theneeds of women with disabilities.
Older Women
An estimated 1–2 million U.S. citizens aged 65 years
or older have been injured, exploited, or mistreated bysomeone caring for them (22). For the obstetrician–gynecologist, the importance of elder abuse relates tothe increasing number of older women in the population (23). Older women seek care for pelvic floor relaxation, sexual dysfunction, breast and reproductive tract
cancer, and other problems. Elder abuse can occur inthe patient’s home, the home of the caregiver, or in a
residential facility in which the patient is residing. Thereis no typical victim of elder abuse. Elder abuse occurs
in all racial, social, educational, economic, and cultural
settings. Victims of elder abuse know their perpetrator 90% of the time (24). Approximately two thirds ofabusers are adult children or partners (24). Abuse canbe physical, sexual, and psychologic and includes neglect(refusal or failure to fulfill caregiving obligations), abandonment, and financial exploitation (illegal or improper
exploitation of funds or other assets through undue
influence or misuse of power of attorney). For more
information go to: http://www.acog.org/About_ACOG/
ACOG_Departments/Violence_Against_Women/Elder_
Abuse__An_Introduction_for_the_Clinician.aspx.

Role of Health Care Providers
The medical community can play a vital role in identifying
women who are experiencing IPV and halting the cycleof abuse through screening, offering ongoing support,
and reviewing available prevention and referral options.
Health care providers are often the first professionals tooffer care to women who are abused. The U.S. Department
of Health and Human Services has endorsed the Instituteof Medicine’s recommendation that IPV screening andcounseling be a core part of women’s health visits (25).
Adequate training and education among health care providers will provide the skills and confidence they need towork with patients, colleagues, and health care systems tocombat violence and abuse (26). Obstetrician–gynecologists are in the unique position to provide assistance forwomen who experience IPV because of the nature of thepatient–physician relationship and the many opportunities for intervention that occur during the course ofannual examinations, family planning, pregnancy, andCommittee Opinion No. 518

follow-up visits for ongoing care. Screening all patients
at various times is also important because some women
do not disclose abuse the first time they are asked. Healthcare providers should screen all women for IPV at periodic intervals, such as annual examinations and newpatient visits. Signs of depression, substance abuse, mental
health problems, requests for repeat pregnancy tests when
the patient does not wish to be pregnant, new or recurrent STIs, asking to be tested for an STI, or expressing
fear when negotiating condom use with a partner should
prompt an assessment for IPV. Screening for IPV during
obstetric care should occur at the first prenatal visit, atleast once per trimester, and at the postpartum checkup.
Studies have shown that patient self-administered orcomputerized screenings are as effective as clinician interviewing in terms of disclosure, comfort, and time spentscreening (27, 28). Screening for IPV should be done
privately. Health care providers should avoid questions
that use stigmatizing terms such as “abuse,” “rape,” “battered,” or “violence” (see sample questions in Box 1) anduse culturally relevant language instead. They should use
a strategy that does not convey judgment and one withwhich they are comfortable. Written protocols will facilitate the routine assessment process:• Screen for IPV in a private and safe setting with thewoman alone and not with her partner, friends, family, or caregiver.
• Use professional language interpreters and not someone associated with the patient.
• At the beginning of the assessment, offer a framing
statement to show that screening is done universally and not because IPV is suspected. Also, informpatients of the confidentiality of the discussion andexactly what state law mandates that a physician must
disclose.
• Incorporate screening for IPV into the routine medical history by integrating questions into intake forms
so that all patients are screened whether or not abuse
is suspected.
• Establish and maintain relationships with community resources for women affected by IPV.
• Keep printed take-home resource materials suchas safety procedures, hotline numbers, and referral information in privately accessible areas such as
restrooms and examination rooms. Posters and othereducational materials displayed in the office also canbe helpful.
• Ensure that staff receives training about IPV and thattraining is regularly offered.
Even if abuse is not acknowledged, simply discussing
IPV in a caring manner and having educational materials
readily accessible may be of tremendous help. Providing
all patients with educational materials is a useful strategy
that normalizes the conversation, making it acceptable
for them to take the information without disclosure.

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Addressing Intimate Partner Violence Reproductive and Sexual
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Box 1. Sample Intimate Partner Violence Screening Questions ^While providing privacy, screen for intimate partner violence during new patient visits,
annual examinations, initial prenatal visits, each trimester of pregnancy, and the postpartum
checkup.
Framing Statement“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.”*Confidentiality“Before we get started, I want you to know that everything here is confidential, meaning that
I won’t talk to anyone else about what is said unless you tell me that…(insert the laws in yourstate about what is necessary to disclose).”*Sample Questions“Has your current partner ever threatened you or made you feel afraid?”(Threatened to hurt you or your children if you did or did not do something, controlled who
you talked to or where you went, or gone into rages)†“Has your partner ever hit, choked, or physically hurt you?”(“Hurt” includes being hit, slapped, kicked, bitten, pushed, or shoved.)†For women of reproductive age:
“Has your partner ever forced you to do something sexually that you did not want to do, or
refused your request to use condoms?”*“Does your partner support your decision about when or if you want to become pregnant?”*“Has your partner ever tampered with your birth control or tried to get you pregnant when
you didn’t want to be?”*For women with disabilities:“Has your partner prevented you from using a wheelchair, cane, respirator, or other assistive device?”‡“Has your partner refused to help you with an important personal need such as taking your
medicine, getting to the bathroom, getting out of bed, bathing, getting dressed, or getting
food or drink or threatened not to help you with these personal needs?”‡*Family Violence Prevention Fund. Reproductive health and partner violence guidelines: an integrated response to intimate partner violence and reproductive coercion. San Francisco (CA): FVPF;
2010. Available at: http://www.futureswithoutviolence.org/userfiles/file/HealthCare/Repro_Guide.pdf.
Retrieved October 12, 2011. Modified and reprinted with permission.
†
Family Violence Prevention Fund. National consensus guidelines on identifying and responding todomestic violence victimization in health care settings. San Francisco (CA): FVPF; 2004. Available
at: http://www.futureswithoutviolence.org/userfiles/file/Consensus.pdf. Retrieved October 12, 2011.
Modified and reprinted with permission.
‡
Center for Research on Women with Disabilities. Development of the abuse assessment screendisability (AAS-D). In: Violence against women with physical disabilities: final report submitted to
the Centers for Disease Control and Prevention. Houston (TX): Baylor College of Medicine; 2002.
p. II-1–II-16. Available at http://www.bcm.edu/crowd/index.cfm?pmid=2137. Retrieved October 18, 2011.
Modified and reprinted with permission.

Futures Without Violence and the American College ofObstetricians and Gynecologists have developed patient
education cards about IPV and reproductive coercion for
adults and teens that are available in English and Spanish.
For more information visit http://fvpfstore.stores.yahoo.
net/safetycards1.html.
If the clinician ascertains that a patient is involvedin a violent relationship, he or she should acknowledge the trauma and assess the immediate safety of thepatient and her children while assisting the patient in thedevelopment of a safety plan. Risk factors for intimate
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partner homicide include having experienced previous
acts of violence, estrangement from partner, threats tolife, threats with a weapon, previous nonfatal strangulation, and partner access to a gun (29). Patients should beoffered information that includes community resources(mental health services, crisis hotlines, rape relief centers,
shelters, legal aid, and police contact information) andappropriate referrals. Clinicians should not try to force
patients to accept assistance or secretly place information in her purse or carrying case because the perpetrator
may find the material and increase aggression. To assist
Committee Opinion No. 518

Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settingsclinicians in responding to IPV, a local domestic violence
agency is often the best resource. It is important to notethat when abuse is identified, it is very useful to offer aprivate phone for the patient to use to call a domestic
violence agency. Controlling partners often monitor cell
phone call logs and Internet usage. Offering a private
phone to call the National Domestic Violence hotline
is a simple but important part of supporting a victim ofviolence. The National Domestic Violence hotline is amultilingual resource that can connect a patient to local
domestic violence programs, help with safety planning,and provide support. A protocol with all the informationneeded to perform an IPV assessment should be kept onsite. Futures Without Violence also provides educational
materials, IPV assessment and safety assessment tools(including scripts for clinical assessment of IPV andreproductive coercion), and free technical assistance specifically for health care providers and settings. For more
information, visit www.futureswithoutviolence.org/section/our_work/health.
Reporting of the abuse of children is mandatory;
however, reporting IPV, particularly mandatory reporting, is controversial. Although the intent of mandatory
reporting is to identify and protect individuals before
the next act of violence, the individual’s safety, in fact,
may be jeopardized (30). Most states do not mandate
reporting of IPV or only mandate reporting in certain
circumstances (31). To ensure compliance with statelaws and federal regulations, it is important to contact
the local law enforcement or domestic violence agency
to become familiar with the laws in a specific jurisdiction. A summary of state laws can be found at: www.
futureswithoutviolence.org/userfiles/file/HealthCare/
MandReport2007FINALMMS.pdf. All fifty states and theDistrict of Columbia have laws in effect authorizing
the provision of adult protective services in cases of
elder abuse or the abuse of individuals with disabilities, although the laws vary significantly between states.
Physicians generally are mandated to report abuse inthese instances. A current listing of state laws on elder
abuse can be found at: www.ncea.aoa.gov/NCEAroot/
Main_Site/Find_Help/State_Resources.aspx.
Documentation of the clinical interaction provides
important evidence for any future legal proceedings.
Accurate reflection of the patient’s condition, including any pertinent photographs or body maps, should be
included with direct and specific quotations. The healthcare provider should review with the patient in advance
what form of future communication is best because
medical bills and follow-up phone calls may prompt
retaliation from the abuser. Despite encountering violence, a patient may deny her circumstances based on fearof retaliation from her partner, fear of involvement withlaw enforcement and the justice system, embarrassment,or shame. Even if women do not reveal violence to their
physicians, hearing validating messages and knowingthat options and resources may be available could help
prompt them to seek help on their own in the future.
Committee Opinion No. 518

Conclusion
Based on the prevalence and health burden of IPV among
women, education about IPV; screening at periodic intervals, including during obstetric visits; and ongoing clinical care can improve the lives of women who experience
IPV. Preventing the lifelong consequences associatedwith IPV can have a positive effect on the reproductive,
perinatal, and overall health of all women.

Intimate Partner Violence National
Resources
Hotlines• National Domestic Violence Hotline
1-800-799-SAFE (7233)• Rape Abuse & Incest National Network (RAINN)
Hotline
1-800-656-HOPE (4673)
Web Sites• Futures Without Violence (previously known as
Family Violence Prevention Fund)
www.futureswithoutviolence.org• National Coalition Against Domestic Violence
www.ncadv.org• National Network to End Domestic Violence
www.nnedv.org• National Resource Center on Domestic Violence
www.nrcdv.org• Office on Violence Against Women(U.S. Department of Justice)www.usdoj.gov/ovw

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2007FINALMMS.pdf. Retrieved October 7, 2011. ^Copyright February 2012 by the American College of Obstetricians
and Gynecologists, 409 12th Street, SW, PO Box 96920, Washington,
DC 20090-6920. All rights reserved. No part of this publication may
be reproduced, stored in a retrieval system, posted on the Internet,
or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Requests for authorization to makephotocopies should be directed to: Copyright Clearance Center, 222
Rosewood Drive, Danvers, MA 01923, (978) 750-8400.
ISSN 1074-861X
Intimate partner violence. Committee Opinion No. 518. American
College of Obstetricians and Gynecologists. Obstet Gynecol 2012;
119:412–7.

Committee Opinion No. 518

Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

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Addressing Intimate Partner Violence Reproductive and Sexual Coercion: A Guide for
Obstetric, Gynecologic, and Reproductive Health Care Settings

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Coercion: A Guide for Obstetric, Gynecologic, andReproductive Health Care Settings

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