Pills Flushed Down the Sink: Recognizing Reproductive Coercion and Partner Violence at a Contraception Visit for a 26-Year-Old, and Building a Safety Plan She Can Use
[Student Name]
University of Phoenix
NRP/563: Management of Women's Health Issues
Week 1 Assignment
[Instructor Name]
[Date]
The patient is a composite written for a model paper.
Ms. R., a 26-year-old restaurant server, comes to our clinic asking for "a birth control he can't find." Her partner of two years has thrown her pills away twice and says he wants a baby "whether you're ready or not." She is not ready. Her partner drove her to the clinic and is in the waiting room. This paper describes how I responded.
Recognizing Reproductive Coercion
Miller et al. (2010), surveying young women at family planning clinics, found that 53% reported physical or sexual partner violence, 19% reported pregnancy coercion and 15% reported birth control sabotage, and that among women with partner violence, reproductive control was associated with unintended pregnancy. Ms. R.'s account, a partner destroying her contraception and pressuring pregnancy, is reproductive coercion, and it often occurs alongside other forms of abuse.
Creating a Safe Space
Because her partner is in the waiting room, privacy matters. Our clinic's policy is to see every patient alone for part of each visit, which avoids singling her out. I explain confidentiality and its limits, including mandatory reporting laws in our state, which do not require reporting partner violence against a competent adult except in specific circumstances such as certain injuries.
Screening for Partner Violence
Federal preventive guidance asks clinicians to ask every woman in her reproductive years about partner abuse and to connect anyone who discloses it with ongoing support (U.S. Preventive Services Task Force et al., 2018). I use a brief validated screening tool, asking whether her partner has hit, kicked or otherwise hurt her, insulted or talked down to her, threatened her or screamed and cursed at her. She says he has pushed her against a wall twice, controls her money and checks her phone.
She came for a contraceptive; what she needed was someone to notice why she was asking.
Assessing Danger
Campbell et al. (2003), in a case-control study of intimate partner femicide, identified risk factors including the abuser's access to a gun, previous threats with a weapon, estrangement, especially from a controlling partner, stalking, forced sex and abuse during pregnancy. These factors form the basis of the Danger Assessment. I ask Ms. R. about each. Her partner owns a handgun, has threatened to "make her sorry" if she leaves and has become more controlling in recent months. She has not tried to leave. His access to a gun and threats raise her risk considerably.
Responding to Her Request
For reproductive coercion, methods her partner cannot detect or interfere with offer protection. A copper intrauterine device or a hormonal IUD with strings trimmed short, an implant in the arm or an injection every three months are options. She chooses the injection, which leaves no device or pills to find, and receives it today after a negative pregnancy test. I also offer emergency contraception to keep, if she can do so safely.
Screening for Sexually Transmitted Infections
Reproductive coercion and forced sex increase the risk of sexually transmitted infections. With her consent, I test for chlamydia, gonorrhea, HIV and syphilis.
Safety Planning
Safety planning belongs to her. I ask what she has already done to stay safe, then discuss options: a code word with a friend, a packed bag with documents and money at a trusted person's home, safe places she could go and how to reach the national hotline and local advocates. I give her the hotline number in a way that will not be found, written on a small card for her shoe or saved under another name.
Referral
With her permission, I connect her by phone, from the exam room, with an on-call advocate from a local domestic violence program. Warm handoffs increase the chance that patients use services. She talks with the advocate for ten minutes and agrees to meet later.
Why Not Confront the Partner
It can be tempting to speak to the partner in the waiting room or to warn him. Doing so could increase her danger, since abusers often retaliate when they learn a victim has disclosed. My communication stays with Ms. R., and the visit ends as an ordinary contraception visit from his point of view. If he asks what happened, she can say she received a shot for birth control, which is true and gives him no reason for suspicion if she chooses to tell him.
Why an Injection and Not a Pill
Pills can be found and thrown away; an implant or IUD might be discovered or, in rare cases, forcibly removed. The injection leaves nothing to find and lasts three months. The tradeoff is the need to return every 12 weeks, which, for Ms. R., is also an advantage: it gives her a regular, unremarkable reason to see a clinician who knows her situation.
Children and Pregnancy
If Ms. R. becomes pregnant, the risk of violence may increase, since abuse during pregnancy is among the femicide risk factors (Campbell et al., 2003). Preventing an unwanted pregnancy is therefore part of protecting her safety as well as her reproductive autonomy.
Trauma-Informed Care
Throughout the visit, I explain each step, ask permission before examining and let her decide how much to share. Trauma-informed care recognizes that people who have experienced violence may feel powerless in medical settings, and that restoring small choices, such as whether the door is closed or who is present, helps rebuild trust.
Respecting Her Choices
She is not ready to leave. Leaving can be the most dangerous time, as the estrangement factor in the femicide study suggests (Campbell et al., 2003). My role is to offer information and support, not to insist on a decision, and to remain a safe contact.
Documentation
I document her statements in her own words, the screening results, the danger assessment findings, the method provided, the referral and the safety plan, without writing anything in the visit summary she will take home that could alert her partner. I note the gun and threats so that future clinicians understand her risk.
Her Phone
Because her partner checks her phone, I avoid sending portal messages or appointment texts that mention the topic, and I ask how she would like the clinic to contact her.
If She Returns Injured
If she comes back with injuries, the note will describe them precisely, with a body map and photographs if she consents, which can support her later if she seeks protection.
Follow-Up
I schedule her next injection visit in 12 weeks, a reason to return that her partner will accept, and invite her to call sooner.
Conclusion
Ms. R.'s request for a contraceptive her partner could not find revealed reproductive coercion and partner violence. Screening her alone, as recommended, and assessing danger with evidence-based risk factors showed high risk from her partner's gun and threats. An undetectable contraceptive, infection testing, a safety plan she designed and a warm handoff to an advocate respond to her needs while respecting her choices.
References
Campbell, J. C., Webster, D., Koziol-McLain, J., Block, C., Campbell, D., Curry, M. A., Gary, F., Glass, N., McFarlane, J., Sachs, C., Sharps, P., Ulrich, Y., Wilt, S. A., Manganello, J., Xu, X., Schollenberger, J., Frye, V., & Laughon, K. (2003). Risk factors for femicide in abusive relationships: Results from a multisite case control study. American Journal of Public Health, 93(7), 1089-1097. https://doi.org/10.2105/AJPH.93.7.1089
Miller, E., Decker, M. R., McCauley, H. L., Tancredi, D. J., Levenson, R. R., Waldman, J., Schoenwald, P., & Silverman, J. G. (2010). Pregnancy coercion, intimate partner violence and unintended pregnancy. Contraception, 81(4), 316-322. https://doi.org/10.1016/j.contraception.2009.12.004
U.S. Preventive Services Task Force, Curry, S. J., Krist, A. H., Owens, D. K., Barry, M. J., Caughey, A. B., Davidson, K. W., Doubeni, C. A., Epling, J. W., Jr., Grossman, D. C., Kemper, A. R., Kubik, M., Kurth, A., Landefeld, C. S., Mangione, C. M., Silverstein, M., Simon, M. A., Tseng, C.-W., & Wong, J. B. (2018). Screening for intimate partner violence, elder abuse, and abuse of vulnerable adults: US Preventive Services Task Force final recommendation statement. JAMA, 320(16), 1678-1687. https://doi.org/10.1001/jama.2018.14741
How this NRP 563 Week 1 example is structured
The NRP/563 Week 1 work usually presents an intimate partner violence case and asks for screening, assessment, documentation and response. This paper shows how a routine request can reveal abuse, how to ask safely, how to judge danger with evidence and how to respond without taking control away from the patient. Students search this week as NRP 563 Week 1, NRP563 Wk 1 or NRP/563 Wk 1; all three are the same assignment.
NRP/563 Week 1 questions, answered
What does NRP/563 Week 1 usually ask for?
Many sections open with a case study on intimate partner violence, asking students to screen, assess risk, document and respond with referrals and a safety plan.
What is reproductive coercion?
Behavior by a partner that interferes with a person's reproductive choices, such as pressuring them to become pregnant or sabotaging birth control by hiding or destroying pills or removing condoms.
Should clinicians screen for intimate partner violence?
Yes. The USPSTF recommends screening women of reproductive age for intimate partner violence and providing or referring those who screen positive to ongoing support services.
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