Sexual violence and coercion by intimate partners plays a critical role in unintended pregnancy, the spread of sexually transmitted infections, poor maternal outcomes and in abortion. The problems of violence, control, and contraceptive sabotage are so widespread that public-health advocates see teen pregnancy as a "canary in a coal mine" or one indicator of possible abuse.

Janey (not her real name) was 19 when she fell "head over heels" for a guy six years her senior.

He

moved in just weeks after their first date, which was before she

learned about the cheating. When she confronted him, repeatedly, he

raped her, repeatedly. When she told him to move out, he threatened her

with more violence. Meanwhile, condoms: not happening. Hormonal birth

control like the Pill, she says, made her sick.

"The first time

I got pregnant against my will, I had the baby," she says. Along with

several STDs. (He’d been her only partner.) After a stint in jail for

violating an ex’s order of protection, he was back, promising never to

hurt her, gushing about family happiness.

The — yes — second

pregnancy occurred when she’d run out of money for emergency

contraception, having purchased it more than 10 times before from her

college nurse. He refused to help her pay for an abortion. "He thought

another baby would keep me in his life forever," Janey says.

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Thankfully,

he was wrong. She finally secured an order of protection; he wound up

back in jail for separate reasons. Janey graduated from college, has a

good job and now lives in Arizona with two healthy children.

Media

attention to the Chris Brown-Rihanna saga, which technically ended

Monday when Brown pleaded guilty to felony assault, certainly got

people talking — for better or for worse — about teen dating abuse and intimate partner violence.

But

many violence and public-health experts agree that at least one major

issue was, and has for too long remained, missing from that

conversation. For girls like Janey, as you can see, partner violence

doesn’t show up in police photos as swollen bruises. Instead, the evidence might be their swollen, pregnant bellies.

Sexual

coercion and "reproductive control," including contraceptive sabotage,

are a common, and devastating, facet of dating and domestic abuse. A

growing number of studies, experts and young women

themselves are testifying to boyfriends demanding unprotected sex,

lying about "pulling out," hiding or destroying birth control —

flushing pills down the toilet, say — and preventing (or, in some

cases, forcing) abortion.

The implications for young women’s and public health are profound, among them unintended pregnancy,

miscarriage and STDs, including HIV. (Some STDs are cured easily — if

tested for and treated — while others can lead to chronic pelvic pain,

ectopic pregnancy, even infertility.) While this problem is not

brand-new, only now are we starting to understand its scope — and,

ideally, starting to learn from its consequences.

"Partner violence is not just about hitting," says Patti Giggans, executive director of Peace Over Violence,

noting how long it took to raise awareness that "partner violence"

occurs at all. Now another alarm must be sounded, she says: "Sexual

coercion is the most secretive part."

Secretive, and pervasive. In what is said to be the first study

in adolescent health literature "to document the role of abusive

partners in promoting teen pregnancy," Elizabeth Miller, M.D., Ph.D.,

assistant professor in pediatrics at the University of California,

Davis School of Medicine, found that among 61 racially and ethnically

diverse girls in Boston’s poorest neighborhoods, 53 were in were in

abusive and sexually active relationships at the time they were

interviewed — and 26 percent of them said their partners were

"actively trying to get them pregnant by manipulating condom use,

sabotaging birth control," or simply sweet-talking them about "making

beautiful babies" together. Several reported hiding their birth control

from their boyfriends; one girl told researchers her boyfriend "tried

to get me pregnant on purpose, and then made me have an abortion."

Jill A. Murray,

Ph.D., a leading author and expert on teen dating violence, does

counseling in high school teen-mother programs. Of one recent group,

she says, "every single one of the girls was in an abusive

relationship, of which the pregnancy or the child was a product."

The

problem is so widespread, in fact, that public-health advocates are

working to cast teen pregnancy in a whole new light: not as a measure

of "promiscuity," or a failure of cluefulness, but rather as a canary

in the coal mine of partner violence.

"We have to treat pregnancy

itself as a warning sign," says Murray. "I always tell other counselors

that I’m training, ‘When you see a pregnant teen girl, always, always

assess for an abusive relationship, because 99 percent of the time,

that will be the case.’ "

Of course, not all teenage girls are

100 percent averse to getting pregnant. But that doesn’t mean they’re

in healthy relationships.

"Teen pregnancy is likely emerging out

of unhealthy relationships," says Miller. "That’s not the only

mechanism for teen pregnancy, but it is an important one that we’ve

managed to miss for a very long time."

Miller, for her part,

has vowed not to miss it again. Nine years ago, she was working as a

volunteer physician in a teen health clinic in Boston when a

15-year-old girl asked her for a pregnancy test. It was negative. But

two weeks later, the girl wound up in the ER with a severe head injury.

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?"

Last week, a new study

revealed that while teen sex rates remain the same, teen contraceptive

use is down. Fingers were pointed — deservedly so, one imagines — at,

among other things, abstinence-only education that downright demonizes

condoms.

But even as a growing body of research underscores the

role male partners play in condom use and negotiation, no suggestion

was made that those stats might include some girls who are forgoing

condoms against their will, even those bolstered by condom-friendlier

sex ed.

"The person you’re ‘negotiating’ condom use with may not be interested in negotiation," says Miller.

"The

picture out there is ‘just get women birth control,’ " adds Esta Soler,

president of the Family Violence Prevention Fund, which has launched a

public awareness campaign

about reproductive abuse in relationships. "But, because of coercion or

sabotage, they may not have control over whether they use it."

And

it’s not just about pregnancy. Dr. Anne Teitelman, Assistant Professor

in the School of Nursing at the University of Pennsylvania, is an

expert on partner abuse and HIV risk. In her published review on this

link among adolescent girls, she found six studies

identified an association between intimate partner violence and

increased risk for HIV (as in condom non-use). Among adolescent girls,

survivors of partner abuse are significantly more likely than others to

be diagnosed with an STD.

Dr. Teitelman’s research findings also

indicate that verbal abuse, as well as physical abuse, is linked with

increased HIV risk among adolescent girls.

Teitelman, who is also

a Family Nurse Practitioner, observed this association firsthand,

before studies began to confirm the link.

"We’re giving teens all

this information about prevention in the clinic, and yet I see them

back all the time for STI testing," she says. So, she began to ask, "

‘What’s not working on our end? What are the obstacles in their lives

that are making this difficult for them?’ I was not a partner-abuse

researcher before, but I became one because that was one of the major

answers."

What drives young men to abuse in this way?

"It’s

clearly out-and-out control of a woman’s body. Control for control’s

sake," says Miller. It’s an urge that stems, experts say, from an

inability to manage their own fears and insecurities.

In one 2007

study, some boys acknowledged outright that they insisted on condomless

sex as a way to establish power over female partners. (There is

evidence of analogous male-on-male sexual violence, but it hasn’t been

studied in depth.)

Other research found that some men took a

woman’s request for a condom as an accusation of cheating, or an

admission that she had slept around or strayed. And for some, yes, the

goal is fatherhood — but not so much of the "involved"

variety; rather, it’s a desire — as with Janey’s ex — to mark one

woman as "mine" forever. Or, according to Patti Giggans, young men in

gangs say, "I’m not gonna be around forever. I’ve gotta leave my

legacy."

(Still, Jill Murray is quick to note, she sees this

problem in all classes, schools and neighborhoods she visits. "I don’t

want parents to think, ‘Oh, my kids’ aren’t in a gang, so they’re

safe.’ ")

And the girls: Why do they stay? Classic

domestic-violence pathology, say experts. In an unfortunate mix of

psychological circumstances, some girls take such intense control to

mean, "I’m really special to this person," says Giggans. Plus,

remember: Often, they have this guy’s kid.

Perhaps most

important is: what can be done? Some of the most essential work is

already under way: experts like Miller and Teitelman have not only

recognized pregnancies, STDs — or repeat requests for testing — as

warning signs and are working to train other teen health care providers

to do the same. (Janey’s 10 requests for Plan B should have sent up some sort of red flag.)

"Providers

need to be asking questions like, ‘Is this a pregnancy that you wanted?

Did your partner ever mess with your birth control?’ " says Miller.

Peace Before Violence is one of many organizations working specifically to educate boys about healthy relationships in programs that focus on the positive aspects of strength and masculinity.

Others

train boys’ coaches to talk to their athletes about calling out their

peers on violence against women and misogyny. Researchers,

including Teitelman, are also studying exactly how parents can best

educate their kids, not just about the birds and the bees, but also

about standing up to sexual coercion. (In one study, Teitelman found

teen girls whose mothers had talked to them about resisting sexual

pressure were twice as likely to delay sex, or use condoms during sex;

when fathers did the same, they were five times more likely to have

safe sex.)

And yes, we need to get even more dating-violence education into the schools. Though of course in this economy — which some

blame for a further rise in dating violence itself — "most schools are

barely doing sex ed and basic health," says Elizabeth Miller. Her

vision: stop "siloing" the issues that affect teen sexual health and

relationships.

"It doesn’t make sense to talk about substance

abuse use this week and pregnancy next week and STDs the following week

and then healthy relationships the week after that," she says. "We need

to be talking about how they’re all linked together."