Seven years ago, Elizabeth Miller was a volunteer physician in a community-based clinic in Boston, Mass., which offered confidential services to teens.

She is still haunted by the memory of a 15-year old girl who asked her for a pregnancy test. It was negative, but two weeks later the girl was treated for a severe head injury in a nearby emergency room. The girl's boyfriend had pushed her down a flight of stairs.

"I assumed all she needed was to be educated about her contraceptive options," Miller recalled. "Later, I wondered what I had missed. Could I have asked a question that would have identified that she was in an abusive relationship?"

That nagging question inspired Miller, now a pediatrician with UC Davis Children's Hospital, to dedicate her career to trying to understand the unique characteristics of adolescent partner violence.

In a new qualitative clinical study published in the September-October issue of the journal Ambulatory Pediatrics, Miller and her research colleagues report that a quarter of the teenage girls interviewed for the study -- all of whom had histories of abusive relationships -- say their partners were actively trying to get them pregnant. The study is the first in the general adolescent health literature to document the role of abusive partners in promoting teen pregnancy.

"Physicians are trained to think about domestic violence in adult terms," said Miller, a physician trained in both adult and pediatric medicine who specializes in treating adolescents. "Our study suggests that health-care providers who come in contact with teens, especially those seeking pregnancy testing and emergency contraception, should ask about the possibility of abuse in the relationship and specifically whether the young woman's partner may be trying to get her pregnant."

Miller's study is based on interviews with 61 girls from a variety of racial and ethnic backgrounds with a known history of intimate partner violence living in the poorest neighborhoods in Boston. The analysis included 53 girls between the ages of 15 and 20 who reported being sexually active and involved in relationships that included recurring patterns of physical, sexual or emotional abuse from a male partner. Twenty-six percent of these girls reported that their partners were actively trying to get them pregnant by manipulating condom use, sabotaging birth control use and making explicit statements about wanting them to become pregnant.

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"We were floored by what these girls told us," Miller recalled. "You think of forced sex as an aspect of abusive relationships, but this takes that abuse a step further to reproductive control of a young woman's body."

Despite the small sample size, Miller describes the current study as a critically important first step toward understanding the nuances of control in intimate relationships and its role in teen pregnancy.

"Our study suggests that those providing care, especially reproductive care, to adolescent girls need to ask questions that reveal the complexities of partner violence, specifically whether a partner is actively trying to get her pregnant when she doesn't want to be," Miller said. "Historically, assessments in clinical settings have focused on physical and sexual violence -- and for good reasons. However, our data argues for including questions, for instance, about whether a boyfriend is flushing birth control pills down the toilet or saying he used a condom when he didn't. And pregnancy prevention programs should include discussions about reproductive control as a form of abuse in relationships."

"This study demonstrates for the first time that abusive boys and men often actively promote pregnancy including contraceptive nonuse in their relationships," said Jay Silverman, director of Violence Preventions Programs for the Harvard School of Public Health and senior author on the study. "The implications are clear -- when we see girls who cannot consistently use contraception, who are requesting frequent emergency contraception or who seek repeat pregnancy testing, we need to be asking very directly about abuse from male partners and find ways to support them and promote their safety."

Miller added that she and her colleagues will next look at the phenomenon of reproductive control in a larger study and at the population level. They just completed a clinic-based survey of 825 youth in the Boston area designed to address the prevalence of intimate partner violence and related behaviors among boys and girls seeking confidential care, and they are in the process of designing a national study to address these same issues.

Miller has also designed a study that would test interventions for partner violence in family planning clinics among women ages 16 to 24 years, and she is planning a study of dating violence intervention to be conducted in school-based clinics in California and Massachusetts. These interventions involve identifying intimate partner violence through screening questions and include a protocol for providing referrals to appropriate resources, such as advocacy groups, shelters, counseling and agencies that can address safety.

"Our work is aimed at documenting the severity and prevalence of intimate partner violence in teens," Miller said. "Ultimately, we want to reduce teen pregnancy and the devastating effects of partner violence."

The current study was supported by grants from the National Center for Injury Prevention and Control/CDC and the William T. Grant Scholars Program.