Obstetricians and gynecologists should routinely screen teenagers and women during annual, new-patient, and obstetric visits for sexual and reproductive coercion, according to a new committee opinion from the American College of Obstetricians and Gynecologists.
Sexual and reproductive coercion – a pattern of physical violence or psychologically coercive behaviors intended to control a woman’s sexual decision-making, contraceptive use, or pregnancy – is an "under-recognized" problem, according to Dr. Eve Espey, associate professor of obstetrics and gynecology at the University of New Mexico, Albuquerque, and one of the opinion’s authors (Obstet. Gynecol. 2013;121:411-5).
Dr. Eve Espey
The coercion can play out as contraceptive sabotage, pressure to become pregnant unwillingly, or forcing a woman to continue or end a pregnancy against her will. "Some male partners go so far as to forcefully remove intrauterine devices and vaginal rings, poke holes in condoms, or destroy birth control pills. Repeated pressure to have sex, forcing sex without a condom, and intentionally exposing a partner to an STI are examples of sexual coercion," according to an ACOG written statement. Unintended pregnancies, sexually transmitted infections (STI), and HIV can be red flags.
Ob.gyns. "are in a unique position to address" the problem, the ACOG opinion states.
If women answer yes to screening questions such as, "Has your partner ever forced you to do something sexually that you did not want to do or refused your request to use condoms?" ob.gyns. should do the following:
• Offer hotline numbers and referrals to local domestic violence shelters and agencies, letting women use the office phone to make the calls.
• Offer long-acting methods of contraception less detectable to partners, such as IUDs, contraceptive implants, or injections.
• Trim IUD strings inside the cervical canal so they are undetectable and are harder for partners to remove, and send emergency contraceptive pills home in plain envelopes.
• Counsel these patients on harm-reduction strategies and safety planning.
The opinion by the ACOG Committee on Health Care for Underserved Women also suggests that ob.gyns. get more education about reproductive and sexual coercion and "include reproductive and sexual coercion and [intimate partner violence] as part of the differential diagnosis when patients are seen for STI testing, emergency contraception, or unintended pregnancies."
Other screening questions can be included: "Has your partner ever tried to get you pregnant when you did not want to be pregnant?" "Are you worried your partner will hurt you if you do not do what he wants with the pregnancy?" and "Does your partner support your decision about when or if you want to become pregnant?" the opinion noted. Additional questions can be found in "Addressing Intimate Partner Violence, Reproductive and Sexual Coercion."
"If a patient responds affirmatively ... the health care provider should validate her experience and commend her for discussing and evaluating her health and relationships. She should be reassured that the situation is not her fault, and further assessment of her safety should be elicited and discreet contraceptive options reviewed," according to the opinion.
"Anybody can be in this situation, but it disproportionally affects disempowered, underserved women," Dr. Espey said in an interview.
Sexual and reproductive coercion tends to travel with physical or sexual violence. In one study, 66% of battered adolescent mothers on public assistance reported birth control sabotage by their dating partner (School Nurse News 2006;23:38-40).
The opinion "is an expansion of ACOG’s long-standing work on intimate partner violence in general," said Dr. Espey, noting that the organization offers educational sessions on sexual and reproductive coercion at its annual meetings.
There is no specific ICD-9/ICD-10 code for screening for sexual and reproductive coercion. Because the physician initially will be performing a screening service, the contraceptive counseling codes would not be the most appropriate codes to report, according to ACOG’s coding department. Code V82.89 (Special screening for other conditions; Other specified conditions) would be a better bet for routine screening.
If coercion seems likely, counseling may be reported with code V65.49 (Other specified counseling) or code V62.89 (Other psychological or physical stress, not elsewhere classified; Other). Payer reimbursement policies will vary, according to ACOG.
Women wouldn’t have a copay for screening and counseling because sexual and reproductive coercion is a subset of intimate partner violence, which is a no-copay preventive care service under the Affordable Care Act.
The National Domestic Violence Hotline is 1-800-799-SAFE (7233); the Rape Abuse & Incest National Network Hotline is at 1-800-656-HOPE (4673). Several websites offer help and guidance as well, including Futures Without Violence, the National Coalition Against Domestic Violence, and the U.S. Department of Justice Office on Violence Against Women.