The second webinar in a series on maternal health discussed the need to address and contextualize intimate partner violence (IPV) when treating women’s sexual and reproductive health. “Maternal Health Series: Intimate Partner Violence” was hosted by the Health Resources and Services Administration (HRSA) Office of Women’s Health (OWH) whose mission is to advance health and wellness for women across the lifespan by leading and promoting innovative sex and gender-responsive public health approaches.

IPV is the physical, sexual, and/or psychological abuse and stalking by an intimate partner. Although all genders are affected by IPV, the prevalence rates of violence against women and the co-occurrence of women’s health issues require a gendered framework. During the webinar, Meredith Bagwell-Gray, Ph.D., MSW, highlighted these intersections between IPV and women’s health risks.

Dr. Bagwell-Gray is an assistant professor in the School of Social Welfare at the University of Kansas with an emphasis on health equity research. She studies the impact of gender-based violence on women’s health and safety and is currently designing and testing trauma-informed approaches to promoting sexual health. Her research aims to facilitate post-traumatic growth and prevent cervical cancer amongst survivors of intimate partner violence.

Barriers to Care

According to the Centers for Disease Control and Prevention’s (CDC) 2015 National Intimate Partner and Sexual Violence Survey, about one in four women – compared with one in ten men – experienced violence or stalking by an intimate partner and reported an IPV-related impact during their lifetime. Of these women, those who discussed their abuse with a health care provider were four times more likely to use an intervention and 2.6 times more likely to exit the abusive relationship.

However, many women in violent and abusive relationships are kept from accessing health care services. Partner-related barriers to health care, such as preventing someone from attending OB-GYN appointments, is a form of coercive control. Coercive control theory is a framework developed by award-winning sociologist Evan Stark whose work helped shift the perception of violence from incident-based, such as the number and severity of physical hits, to a systematic deprivation of freedom. “To really understand IPV and what is happening, we have to understand it with a new lens,” Dr. Bagwell-Gray said. “It’s really a human rights issue because someone is being denied their freedom.”

According to Dr. Bagwell-Gray, abusive partners are one possible link between IPV and women’s sexual health concerns, especially sexually transmitted infections (STIs). “Abusive partners or partners who use violence are also more likely to engage in other high-risk behaviors associated with toxic masculinity: having sex with multiple partners, having unprotected sex with partners, forcing and coercing unwanted sex with a primary partner and with other partners, etc. That risk-taking means that within the woman’s relationship, she’s at higher risk of direct infection from her partner.”

Women with sexually abusive partners and partners who restrict their access to OB-GYN services and birth control are at similarly increased risk of STIs. “Without control over their own sexual decision-making and autonomy, forced or coerced sex can be a direct pathway to infections,” Dr. Bagwell-Gray said. A partner’s coercive control over contraception may lead to women being afraid to request the use of a condom, leading to increased risk of pregnancy as well.

IPV and Trauma

The traumatization of women in abusive, controlling, and violent relationships over time can have negative cognitive effects such as low self-esteem, low self-efficacy, sexual risk taking, and substance use. “That constellation of risk factors can lead to an STI or other negative sexual health outcomes,” said Dr. Bagwell-Gray. “We also know now that trauma over time can change your immune system and make your body more at risk for disease.”

Women who have experienced trauma, especially surrounding sexual assault or OB-GYN care, may avoid seeking care out of fear of triggering painful memories. “After doing group sessions with women, I’ve heard stories after stories of providers engaging in a way that is not trauma-informed,” Dr. Bagwell-Gray said. “This hurts the survivor and leaves them feeling further victimized by their providers. There’s also mistrust of providers and a concern about a lack of understanding of what the provider is communicating.”

Helping Women Heal

According to Dr. Bagwell-Gray, the unique risk factors that increase women’s likelihood of STIs create a need for specialized sexual health services and programs that address women’s experiences of IPV. Her proposed ideal solutions include a trauma-informed sexual safety planning program featuring collaborations between health care providers and social services. Any solutions should focus on survivor strengths and rebuilding self-worth; Dr. Bagwell-Gray’s work is informed by women who described their healing from IPV as a journey.

HRSA OWH focuses on four priorities to address IPV: train the public health workforce, raise awareness of IPV, increase access to IPV-informed health care services, and address gaps in knowledge about IPV risks, impacts, and interventions. Learn more about the OWH’s efforts and resources to combat IPV:

Watch the recorded webinar and register for the next session, “Maternal Health Series: Focus on Racial Equity,” on August 12.