National Partnership for Women & Families

Monthly Women's Health Research Review

Analysis assesses intimate partner violence as issue of sexual, reproductive health and rights

Summary of "Understanding intimate partner violence as a sexual and reproductive health and rights issue in the United States," Kinsey Hasstedt/Andrea Rowan, Guttmacher Policy Review, July 6, 2016.

"Intimate partner violence (IPV) is undeniably a public health crisis in this country -- one that disproportionately affects women and has profound implications for their sexual and reproductive health and autonomy," according to Kinsey Hasstedt, senior public policy manager at the Guttmacher Institute, and Andrea Rowan, a public policy associate at Guttmacher.

Citing research underscoring "the importance of understanding and addressing IPV as a critical component of sexual and reproductive health and rights (SRHR) in the United States," Hasstedt and Rowan wrote that "there is much to be gained if SRHR advocates and service providers were to better understand key policies and programs addressing IPV aimed at impacting health service provision."

IPV and SRHR

Using CDC's definition of IPV, the researchers explained that "IPV encompasses acts of stalking, psychological aggression, physical violence or sexual violence -- behaviors and tactics through which an intimate partner seeks to establish and maintain power over another."

Noting that several "negative sexual and reproductive health outcomes have been linked to IPV," Hasstedt and Rowan wrote that IPV encompasses both sexual violence and reproductive control. The researchers outlined multiple negative health outcomes for an individual experiencing IPV, including "a particularly high risk of experiencing an unintended pregnancy."

They explained that "IPV is most prevalent among women of reproductive age," with women ages 18-24 most at risk for both IPV and unintended pregnancy. According to the researchers, "The risk of unintended pregnancy is especially salient for women experiencing male reproductive control or sexual violence," as such behaviors can "directly impede a woman's ability to properly use her preferred method of contraception and compromise her ability to avoid a pregnancy she does not want."

The researchers wrote that while "abortion rates specific to women who experience an unintended pregnancy resulting from IPV are unknown, many women may be highly motivated to terminate these pregnancies." Further, the researchers noted that "male reproductive control may manifest as pressure to terminate a pregnancy when the woman does not want to do so," and that prior research "has found a link between women seeking repeat abortions and having been subjected to physical or sexual violence."

According to the researchers, IPV also "has a negative impact on the health of pregnant and postpartum women and their infants." They wrote that IPV is linked to multiple pregnancy complications, including postpartum depression, a lower likelihood of accessing early prenatal care and an increased likelihood of preterm labor, low-birthweight infants and stillbirth.

Further, the researchers wrote that women experiencing IPV are also at increased risk of sexually transmitted infections (STI), through rape by an intimate partner or via "male reproductive control behaviors includ[ing] refusing to use condoms." Noting that women experiencing IPV might be blocked by an abusive partner from accessing health care services for HIV or other STIs, the researchers wrote, "Untreated STIs can lead to additional negative sexual and reproductive health outcomes, including pelvic inflammatory disease, infertility, cancer and possible pregnancy complications."

Federal policies addressing IPV

Given research showing "that IPV is inextricably tied to sexual and reproductive health and autonomy," Hasstedt and Rowan wrote that "understanding where these two issue areas intersect at the federal policy level is critical to better addressing the needs of those experiencing IPV and to better supporting safety-net providers in doing so."

The researchers outlined the "[t]hree major policy initiatives [that] form the core of the national response to violence and sexual assault: the Family Violence Prevention & Services Act (FVPSA) [PL 98-457], the Victims of Crime Act (VOCA) and the Violence Against Women Act (VAWA)." According to the researchers, the Affordable Care Act (ACA) [PL 111-148] and public funding for family planning also "explicitly and directly address the health care needs of women experiencing IPV."

FVPSA, first authorized in 1984, "remains the main federal source of support for direct services and assistance to IPV survivors and their families," the researchers wrote. The program allocates grants to "states, territories and tribes, and state domestic violence coalitions, many of which then allocate funding to local outreach programs and shelters." The researchers noted that while "70% of an individual state's FVPSA formula grant must go toward sheltering survivors and families, and related programming and services ... FVPSA funds cannot reimburse the provision of any actual health services."

According to the researchers, "VOCA established the Crime Victims Fund (CVF)," which uses money from criminal fines and forfeited bail bonds to reimburse survivors "for various out-of-pocket costs related to the crime when other compensation, including private insurance, will not cover their expenses" and to "supplemen[t] state funds to assist survivors in obtaining needed services and support." The researchers added, "Safety-net family planning centers are particularly well-positioned to serve women experiencing IPV, which makes them natural -- and important -- participants in this grant program."

The researchers wrote that VAWA, the "keystone federal policy addressing violence against women in the United States, ... focuses on law enforcement and legal responses to violence, and emphasizes the importance of a coordinated community response and the inclusion of myriad stakeholders -- including health care professionals -- in developing local support systems." However, the researchers wrote that health care services are "not generally a focus of VAWA ... and efforts to address survivors' health needs have thus far been largely deprioritized and underfunded." The researchers explained that while VAWA has made efforts to address rape and STIs, "other health needs related to sexual assault remain unaddressed," such as access to abortion care and emergency contraception.

Meanwhile, according to the researchers, "the ACA's coverage expansions include provisions to help ensure that individuals experiencing IPV are able to obtain affordable health insurance coverage." For example, "the ACA established a special enrollment period for individuals experiencing domestic violence and their dependents." In addition, the law enables a woman who has left or been abandoned by a spouse to apply for marketplace coverage as an "unmarried" individual. The researchers also point to the ACA's contraceptive coverage requirements and a preventive health services provision that "requires that screening and brief counseling for IPV be covered and provided without cost-sharing."

The researchers also highlighted the Title X family planning program, which requires that "any health center receiving Title X funding ... ensure confidentiality for all of their family planning clients." According to the researchers, "These protections are particularly important given the sensitive nature of sexual and reproductive health services supported by Title X grants, and they are intended to protect the privacy of especially vulnerable groups of safety-net family planning clients," including women experiencing IPV. The researchers also cited recent guidance from CDC and the U.S. Office of Population Affairs that emphasizes the importance of confidentiality for all family planning providers, not only those receiving Title X funding. The guidance also advises that providers refer women experiencing IPV for additional care and consider IPV when recommending birth control methods.

An integrated approach

Citing the increased risk women experiencing IPV have "for multiple negative sexual and reproductive health outcomes," Hasstedt and Rowan wrote that women experiencing IPV require "confidential and affordable" access to "the full range of sexual and reproductive health services, including contraceptive supplies and counseling, STI testing and treatment, maternity care and abortion."

The researchers expressed concerns about the Hyde Amendment, which "blocks federal Medicaid funds from being used to cover abortion in all but the most limited circumstances," as well as the multiple states that "bar abortion coverage in at least some private health plans." Nonetheless, the researchers wrote that "the Hyde Amendment and many of the state restrictions on private insurance do provide exceptions for cases of rape and incest (as well as cases when the wom[a]n's life is endangered by the pregnancy), which makes this coverage of potential use for some women experiencing IPV."

Hasstedt and Rowan also pointed to the increasing use of "trauma-informed care," an approach in which medical providers "tak[e] into account the many considerations -- health or otherwise -- that arise when a patient is experiencing IPV or another form of trauma." Such an approach "can include helping a woman to protect her sexual and reproductive health and autonomy in a way that also takes her safety into account, ensuring her care remains confidential and connecting her to resources that can help her address broader needs," the researchers wrote.

The researchers added that according to advocates, "[a]chieving this type of approach to caring for those experiencing IPV requires collaboration on many levels among IPV and SRHR service providers." Hasstedt and Rowan highlighted the unique position of safety-net family planning providers "to confidentially meet survivors' particular family planning needs and to connect them to broader resources, especially if they have received appropriate training and have mutual referral relationships with IPV experts in their communities." The researchers wrote that further research into IPV-response guidance and family planning guidelines "will offer opportunities to identify and incorporate systemic changes that more inclusively address the sexual and reproductive health and autonomy of women experiencing IPV."

Nonetheless, the researchers also acknowledged ongoing "barriers to effective collaboration." For instance, the researchers cited the "intense and negative politics of abortion," which can deter "many in the IPV community [from] overtly mak[ing] the natural policy connections between IPV and SRHR." Meanwhile, "advocates focused on SRHR may lack an understanding of IPV policy, and safety-net family planning providers may feel they lack sufficient guidance, support or experience to fully engage with a client on her experiences with IPV," the researchers wrote. The researchers conclude "that overcoming these barriers is imperative to being able to holistically serve individuals experiencing IPV, including addressing their need for sexual and reproductive health care."