17.7 Intimate Partner Violence, Reproductive Coercion & Human Trafficking

Intimate Partner Violence & Human Trafficking

Universal Screening for Intimate Partner Violence (IPV)

The USPSTF and ACNM mandate universal screening of all adolescent and adult women for intimate partner violence (IPV) at routine primary care, well-woman, and obstetric visits.

• Strict Screening Protocol: Screening must occur in an entirely private, confidential clinical setting with NO partners, family members, or children older than 2 years present. Never utilize a partner or family member as a language interpreter.
• Validated Screening Instruments: HITS (Hurt, Insult, Threaten, Scream; score >10 is positive), WAST (Woman Abuse Screening Tool), or direct compassionate inquiry ("Because violence is so common in women's lives, I ask all my patients: Are you in a relationship with someone who hurts, threatens, or frightens you?").
• Trauma-Informed Care Principles: Ensure safety, transparency, peer support, collaboration, empowerment, and cultural respect. Validate the patient's experience without judgment: "You are not alone, you do not deserve to be treated this way, and there is help available."
• Lethality Assessment & High-Risk Flags: Screen specifically for firearms in the home, threats of homicide or suicide, increasing frequency of physical abuse, and history of non-fatal strangulation (choking). A history of non-fatal strangulation is associated with a 750% (7.5-fold) increased risk of subsequent completed homicide by an intimate partner!
• Safety Planning: Collaborate on an individualized safety plan: emergency contacts, hidden packed bag with essential medications and birth certificates/IDs, safe meeting places, and immediate connection to the National Domestic Violence Hotline (1-800-799-SAFE or text "START" to 88788).

Mandatory Reporting Legal Boundaries

A critical area of clinical and ethical confusion concerns state mandatory reporting statutes. Midwives must distinguish between adult IPV disclosure and other categories:

• Competent Adult IPV Disclosure: In the vast majority of U.S. jurisdictions, disclosure of domestic abuse by a competent adult patient with decision-making capacity is STRICTLY CONFIDENTIAL and does NOT trigger mandatory reporting to law enforcement without the patient's explicit consent. Breaching patient confidentiality by contacting police against the patient's wishes violates patient autonomy, shatters clinical trust, and significantly increases the immediate lethality risk to the victim.
• Mandatory Reporting Exceptions: State statutes legally mandate reporting to state authorities regardless of consent only in specific designated circumstances: (1) Suspected abuse, neglect, or exploitation of children; (2) Suspected abuse, neglect, or exploitation of vulnerable, incapacitated adults or elderly individuals; and (3) Injuries inflicted by deadly weapons (gunshot wounds, stab wounds).

Human Trafficking Red Flags

Human trafficking (commercial sexual exploitation or forced labor) frequently intersects with women's health settings. Midwives must recognize common red flags:

• Accompanied by a domineering, controlling individual who refuses to leave the exam room and insists on speaking, translating, or answering questions on the patient's behalf.
• Patient cannot produce identification, passport, or financial documents (documents held by another person).
• Scripted, rehearsed, or inconsistent medical histories.
• Commercial "branding" tattoos (barcodes, dollar signs, initials, names, or "property of" markings on the neck, chest, or pubic region).
• Recurrent, untreated sexually transmitted infections, multiple prior abortions, or advanced untreated trauma.
• Lack of knowledge of their current geographic location, city, or date; severe fear of law enforcement or authority figures.
• Midwifery Action: Separate the patient from the companion under the standard clinical protocol of obtaining a private urine specimen or private physical examination. Utilize professional, third-party telephonic medical interpreters. Offer contact info for the National Human Trafficking Hotline (1-888-373-7888 or text "HELP" to 233733).

Reproductive Coercion

Reproductive coercion is behavior intended to control a partner's reproductive decision-making. It overlaps heavily with intimate partner violence but can occur without physical violence, and it is missed unless asked about directly.

Three forms:

1. Pregnancy pressure and coercion — threats or pressure to become pregnant, or to stay pregnant.
2. Contraceptive sabotage — hiding, destroying, or flushing pills, puncturing condoms, non-consensual condom removal ("stealthing"), removing or pulling out IUD strings, or preventing the patient from getting to appointments.
3. Control of pregnancy outcomes — forcing continuation or forcing termination of a pregnancy.

Screen with concrete language rather than abstractions: "Has a partner ever tried to get you pregnant when you didn't want to be?" and "Has anyone ever messed with your birth control, or made you have sex without a condom?"

Clinical response:

• Offer a method a partner cannot detect or remove — DMPA injections, or an IUD with the strings trimmed very short or tucked into the fornix so they cannot be felt or pulled. Note that a subdermal implant is palpable in the arm.
• Provide advance emergency contraception to keep on hand.
• Ask whether the partner has access to the patient portal, phone, or mail, and document in a way that does not endanger her.
• Offer advocacy referral, safety planning, and a follow-up plan that does not require the partner's cooperation.

ACOG recommends screening for reproductive coercion in family planning and obstetric settings, in the same private conditions required for IPV screening.