Seth J. Barishansky1, Periel M. Shapiro2, MaryEllen G. Pavone1, Angela K. Lawson1
1Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, 2Department of Psychiatry, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ
Definition, Prevalence, Risk Factors, Consequences
Intimate partner violence (IPV) is a common women’s health issue with serious consequences including physical and psychological trauma as well as poor health outcomes (1,2). It is therefore an issue that all physicians who treat women must be aware of, particularly obstetricians, gynecologists, and reproductive specialists. In 2015, the Centers for Disease Control (CDC) updated its consensus-derived definition of IPV to include psychological aggression and stalking by a current or former intimate partner, in addition to physical violence and sexual violence (2). Intimate partners include spouses, boyfriends or girlfriends, dating partners, or sexual partners. IPV effects both heterosexual and same-sex couples (1,2).
Although both men and women of any ethnic group can be a victim of IPV, ethnic minorities and women are disproportionately affected (1). In 2010, the CDC National Intimate Partner and Sexual Violence Survey (NISVS) began collecting United States prevalence data at both national and state level. The most recent report from 2017 provided an estimate that 37.3% of American women and 30.9% of American men face intimate partner sexual violence, physical violence, and/ or stalking in their lifetime, with state estimates ranging from 27.8% to 45.3% for women and 18.5% to 38.2% for men (3).
Psychological manifestations of IPV are also highly prevalent in the United States. The NISVS estimates that an alarming 47.1% of women and 47.3% of men experience IPV in the form of psychological aggression (3). Psychological aggression, which includes coercive acts as well as stalking and online harassment, is particularly relevant to reproductive-aged patients and those who are pregnant or attempting to become pregnant. Reproductive coercion (RC) is a prominent feature of psychological aggression that involves attempts by one partner to control the reproductive or sexual health behaviors of their partner, including the decision to terminate or maintain a pregnancy. A partner may attempt to force or terminate a pregnancy by threatening or enacting physical or psychological harm, such as infidelity or abandonment.
There are a myriad of physical and psychological health consequences of IPV. The most obvious is physical injury, often due to blunt force trauma to the head, face, and neck (3). In addition, female victims of IPV are at risk of poor obstetric outcomes, sexual dysfunction, and somatic pain syndromes. IPV survivors are also at increased risk for mental health issues such as mood disorders or post-traumatic stress disorder (3).
Guidance from Professional Medical Associations
Over the past three decades healthcare providers have begun to recognize the critical role that they play in identifying and responding to IPV. In 1985, Dr. C. Everett Koop, the 13th Surgeon General of the United States, recognized the need for public awareness and education of health professionals regarding IPV, producing the first policy recommendations for the prevention of domestic violence (4). Four years later, the American College of Obstetrics and Gynecology (ACOG) issued its initial bulletin on domestic violence, becoming the first national organization to formally recognize the need to educate physicians in the recognition, prevention and treatment of IPV (5) and has been a stalwart leader in their commitment to address IPV ever since. Most recently, in 2013, the U.S. Preventive Services Task Force (USPSTF) upgraded their 2004 IPV screening report from an “I” rating, or insufficient evidence for recommendation of a screen, to a “B” rating, which indicates that clinicians should screen all reproductive-age women (6). However, the World Health Organization (WHO) does not endorse universal screening for IPV in the healthcare setting. Nonetheless, the WHO does encourage screening in an antenatal setting in which providers are trained to ask questions appropriately and are able to initiate a first-line response, which includes referral to services (7).
The medical community continues to debate how to address IPV. Concerns exist regarding the efficacy of screening in the healthcare setting (8). Some fear that an IPV screen could distress patients without impacting health outcomes and may even aggravate abuse. Finally, a lack of a gold standard screening instrument has made it difficult for the medical community to adopt universal screening recommendations.
Many of these concerns have recently been addressed. In 2009, the MacMillan trial, one of the first large randomized controlled trials investigating IPV in clinical practice, sought to assess harms related to screening (8). While this study was flawed due to loss of follow up of more than 40% in both groups and fell short of spurring policy changes, one of the major findings was a lack of evidence for harmful secondary outcomes of screening, such as re-exposure to violence. Shortly after, in 2011, the Agency for Healthcare Research and Quality along with the Oregon Evidence-Based Practice Center conducted a new review that led to a reevaluation and update of the 2004 USPSTF recommendations (9). While this study did not lead to a gold standard screening tool, it demonstrated several tools with high diagnostic accuracy. This review also demonstrated that interventions are available which reduce exposure to abuse. USPSTF concluded that the benefits of screening women of childbearing age outweigh the minimal adverse effects. An effective patient-physician interaction can be an empowering motivator for change and a checkpoint in the vicious cycle of violence. Referral to intervention services following a positive screen can reduce a patient’s risk of IPV and thereby help them avoid consequent physical and emotional harm.
Given the evidence that clinicians can effectively screen and counsel for IPV (9), physicians have an ethical obligation to do their part in monitoring. Reproductive specialists are situated at an important juncture for IPV screening as both pregnancy and infertility are risk factors for IPV. Therefore, it is important for the reproductive science community to consider the presentation of IPV in the context of assisted reproduction.
Partner Violence and Reproductive Medicine
Reproductive endocrinologists must grapple with unique risk factors, consequences, and ethical issues related to IPV. The failure to conceive can be a life crisis that has broad social implications which threaten marital relationships and social status. Stellar et al. suggests that infertility may confound the relationship between multiple risk factors and IPV and may itself be a causal risk factor for violence and other forms of IPV (10). Specifically, infertility may engender or exacerbate other familial and economic risk factors for IPV identified by the WHO, including marital discord or divorce, economic stress, and social alienation (11).
While there are no studies to our knowledge investigating partner violence in the context of infertility care in the United States, there is a growing body of literature suggesting a relationship between infertility and IPV in those facing infertility internationally. Research from Egypt suggests that psychological violence, including reproductive coercion, is the most common type of partner violence that those with infertility face (12). Reports from Turkey suggest that from a third to over half of women with infertility face infertility related IPV (13). However, the populations in international studies often have a distinct socio-economic profile, including low income and education levels, which may limit the transferability of this data to women seeking infertility care in the United States. We can also glean useful information from the general population of Americans seeking care for family planning. Of 1300 young women seeking care in five family planning clinics in Northern California, 19% of all respondents reported reproductive coercion and approximately 75% of those women reported a lifetime history of IPV(14).
Infertility patients face serious economic, psychological, and physical stress, which increases the risk for IPV. Assisted reproductive technologies, even in states with mandated fertility coverage, carry a heavy financial burden. Interpartner tension or relationship strain is common (15). Women can become isolated from their support systems or develop dysfunctional coping mechanisms (15). Mental health disorders, such as depression and anxiety, are also prevalent in infertility patients, which may increase risk of IPV or compound the consequences of victimization (4).
Due to the often lengthy and emotional process of fertility counseling and treatment, the reproductive endocrinologist has extensive and intimate interactions with their patients. In addition, the antenatal period is a time in which victims may be more likely to come forward to their healthcare providers and seek care and counseling, driven by a desire to protect their unborn children from possible abuse by an intimate partner. The pregnant population is considered a highly motivated patient group, uniquely receptive to education about domestic violence. Those undergoing fertility treatment likely share this strong motivation to protect their future progeny and may be further enabled to seek help due to socioeconomic assets that are often present among those seeking ART. These patients are more likely to be married and to have a higher level of education and income (16).
REIs face unique ethical considerations relating to IPV. The issue of coercive sex-selection has historically been associated with the coerced abortion of female fetuses in the context of population restrictions in countries like China where male children were preferred. However, with the advent of pre-gestational genetic sex selection, new manifestations of coercive sex selection have come to the fore. Infertility specialists may feel pressured by financial incentive and patient demand, increasing the likelihood that they consider providing fertility services. Family coercion also plays a major role. In one study that interviewed 65 Indian immigrants in the United States who pursued fetal sex selection, 40% of the women interviewed had terminated prior pregnancies. The use of technology to select for a male embryo or terminate a pregnancy with a female fetus was associated with psychological pressure to produce a male child, including verbal and physical abuse by male partners and mothers-in-law (17).
Reproductive endocrinologists also face a more general ethical dilemma in deciding whether to provide fertility services to a couple that is predisposed to or actively experiencing IPV. In helping such couples achieve pregnancy, the physician may be further increasing their risk of partner violence, as pregnancy itself is a well-established risk factor for IPV (11). Providers must also consider how the stress of rigorous infertility treatments may exacerbate IPV.
Adherence to the behavioral and medication regimen required for fertility treatments may be another issue for those experiencing IPV. Hormone injections during an ART cycle are often administered out-of-office and require a high degree of patient autonomy and/or cooperation between partners. Injection administration is often time-sensitive, presenting a challenge in a home disrupted by domestic violence. Problems with medication adherence are well documented in cases of IPV victims who receive HIV prophylaxis retroviral therapy (17). Medication adherence issues stem from home discord; IPV victims are sometimes chased from the home or flee due to safety concerns, resulting in missed doses due to lack of access to their medication. The period of abstinence recommended during ART may not be possible in a home marked by sexual violence. Patients may also drop out of treatment entirely; psychosocial reasons, which include relationship discord, have been cited as the greatest factors contributing to patient dropout (19).
Patients who are not compliant with fertility treatment protocols or follow-up surveillance risk serious health consequences, including multifetal pregnancy, untreated OHSS, and deep venous thrombosis (20), as well as poor treatment outcomes (e.g., low numbers of oocytes at retrieval). Failure to adhere to ART medications and recommendations is associated with a 15% decreased chance of success (21). Finally, issues with medication compliance may be compounded by IVF-related mood disorder, which has also been linked to poor treatment compliance (22).
Non-compliance has financial consequences. Treatment that is terminated due to non-compliance or dropout can cost patients and clinics a significant sum of money without a positive outcome. Incomplete treatment cycles utilize resources that could otherwise be used for other patients. Thus, by addressing IPV-related noncompliance and dropout, providers may save money for their patients while ensuring careful utilization of highly specialized and limited ART resources.
Intimate partner violence is a serious preventable public health concern with unique risk factors and consequences for those seeking fertility treatments. Reproductive health providers are positioned to be strong advocates for patients facing IPV. Through familiarity with signs and symptoms of IPV, effective screening methods, appropriate clinical responses, and available community resources, fertility providers can play a critical role in the early prevention and reduction of IPV.
1. Smith SG, Chen J, Basile KC, Gilbert LK, Merrick MT, Patel N, Walling M, Jain, A. National Intimate Partner and Sexual Violence Survey: 2010-2012 State Report. Atlanta (GA): National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2017.
2. Breiding MJ, Basile KC, Smith SG, Black MC, Mahendra RR. Intimate Partner Violence Surveillance: Uniform Definitions and Recommended Data Elements, Version 2.0. Atlanta (GA): National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2015.
3. Black MC, Basile KC, Breiding MJ, Smith SG, Walters ML, Merrick MT, et al. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 Summary Report. Atlanta (GA): National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2011.
4. US Congress. Domestic Violence and Public Health - Hearing Before the Senate Subcommittee on Children, Family, Drugs and Alcoholism;1985 October 30; Washington, DC.
5. American College of Obstetricians and Gynecologists. ACOG Technical Bulletin no. 124: The Battered Woman. Washington, DC. 1989.
6. Moyer V. Screening for intimate partner violence and abuse of elderly and vulnerable adults: U.S. preventive services task force recommendation statement. Ann Intern Med. 2013; 158:478-486.
7. World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. Available at: https://apps.who.int/iris/bitstream/handle/10665/250796/9789241549912-eng.pdf;jsessionid=8E0D9FFEB36A1B07A5A6EF5BA33DB76E?sequence=1. Accessed August 3,2019.
8. MacMillan H, Wathen C, Jamieson E, Boyle M, Shannon H, Ford-Gilboe M, et al. Screening for intimate partner violence in health care settings: a randomized trial. JAMA 2009; 302:493-501.
9. Nelson H, Bougatsos C, Blazina I. Screening women for intimate partner violence: a systematic review to update the U.S. Preventive Services Task Force recommendation. Ann Intern Med 2012;156:796-808.
10. Stellar C, Garcia-Moreno C, Temmerman M, van der Poel S. A systematic review and narrative report of the relationship between infertility, subfertility, and intimate partner violence. Int J Gynaecol Obstet 2016; 133:3-8.
11. Butchart A, Garcia-Moreno C, Mikton C. Preventing intimate partner and sexual violence against women: taking action and generating evidence. Geneva (CH): World Health Organization; 2010.
12. Mansour F, Abdel Mohdy H. Intimate Partner Violence among Women with Female Infertility. Am J Nurs 2018; 6: 309-316.
13. Yildizhan R, Adali E, Kolusari A, Kurdoglu M, Yildizhan B, Sahin G. Domestic violence against infertile women in a Turkish setting. Int J Gynaecol Obstet. 2009; 104(2): 110- 112.
14. Miller E, Decker MR, McCauley HL, et al. Pregnancy coercion, intimate partner violence and unintended pregnancy. Contraception. 2010; 81: 316–322.
15. Patel A, Sharma PS, Narayan P, Binu VS, Dinesh N, Pai PJ. Prevalence and predictors of infertility-specific stress in women diagnosed with primary infertility: A clinic-based study. J Hum Reprod Sci 2016;9:28-34.
16. Kessler L, Craig B, Plosker S, Reed D, Quinn G. Infertility evaluation and treatment among women in the United States. Fertil Steril 2013;100(4):1025-32.
17. Puri S, Adams V, Ivey S, Nachtigall RD. "There is such a thing as too many daughters, but not too many sons": A qualitative study of son preference and fetal sex selection among Indian immigrants in the United States. Soc Sci Med 2011;72:1169-1176.
18. Roberts S, Haberer J, Celum C, Mugo N, Ware N, Cohen C, et al. Intimate Partner Violence and Adherence to HIV Pre-exposure Prophylaxis (PrEP) in African Women in HIV Serodiscordant Relationships: A Prospective Cohort Study. J Acquir Immune Defic Syndr 2016;73:313-322.
19. Rajkhowa M, McConnell A, Thomas GE. Reasons for discontinuation of IVF treatment: a questionnaire study. Hum Reprod 2006;21:358-363.
20. Mahajan N, Naidu P, Gupta S, Rani K. Deep venous thrombosis in a patient undergoing In-vitro fertilization with oocyte donation. J Hum Reprod Sci 2015;8:182-185.
21. Gameiro S, Verhaak CM, Kremer JA, Boivin J. Why we should talk about compliance with assisted reproductive technologies (ART): a systematic review and meta-analysis of ART compliance rates. Hum Reprod Update 2013;19:124-135.
22. Holley S, Pasch L, Bleil M, Gregorich S, Katz P, Adler N. Prevalence and predictors of major depressive disorder for fertility treatment patients and their partners. Fertil Steril 2015;103:1332-1339.