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. Author manuscript; available in PMC: 2022 Mar 1.
Published in final edited form as: Womens Health Issues. 2020 Nov 18;31(2):157–163. doi: 10.1016/j.whi.2020.10.003

Birth Control Sabotage as a Correlate of Women’s Sexual Health Risk: An Exploratory Study

Tiara C Willie 1, Kamila A Alexander 2, Amy Caplon 3, Trace S Kershaw 4, Cara B Safon 5, Rachel W Galvao 6, Clair Kaplan 7, Abigail Caldwell 7, Sarah K Calabrese 8
PMCID: PMC8005431  NIHMSID: NIHMS1647621  PMID: 33218751

Abstract

Objective:

To explore associations between birth control sabotage, a form of reproductive coercion, and women’s sexual risk among women attending family planning health centers.

Study Design:

Data were collected from a 2017 cross-sectional online survey of 675 women who attended Connecticut Planned Parenthood centers. Participants reported birth control sabotage; sexual risk (i.e., inconsistent condom use during vaginal and anal sex in the past six months, lifetime STI diagnosis, lifetime exchange sex [trading sex for money, drugs, or other goods], and multiple sexual partners in the past six months); and socio-demographics. Bivariate and multivariable logistic regression models were used to examine associations between birth control sabotage and women’s sexual risk.

Results:

One in six women (16.4%, n=111) reported experiencing birth control sabotage. Women who reported birth control sabotage had greater odds of ever having an STI (adjusted odds ratio [95% confidence interval]=2.18 [1.31, 3.60]), p=.003), ever engaging in exchange sex (adjusted odds ratio [95% confidence interval]=2.77 [1.17, 6.53]), p=.020), and having multiple sexual partners in the past six months (adjusted odds ratio [95% confidence interval]=1.96 [1.21, 3.18]), p=.006).

Conclusions:

Our findings demonstrate increased engagement in sexual risk-taking among women who reported birth control sabotage compared with women did not.

Keywords: reproductive coercion, women, sexual risk

INTRODUCTION

Reproductive coercion is a direct violation of women’s sexual and reproductive rights. Reproductive coercion occurs when an intimate partner uses power and control to influence a partner’s reproductive health outcomes (American College of Obstetricians and Gynecologists, 2013; Miller et al., 2010). Extant research has identified two forms of reproductive coercion: birth control sabotage (i.e., direct acts to limit and prohibit use of contraception), and/or pregnancy coercion (i.e., coercive behaviors to promote pregnancy [American College of Obstetricians and Gynecologists, 2013; Miller et al., 2010]). Birth control sabotage can include behaviors such as intentionally damaging a condom; withholding or destroying oral contraceptives; and removing a condom during sex. Pregnancy coercion is more indirect and includes telling a partner to stop birth control use or limiting her ability to access birth control.

A growing body of research indicates that birth control sabotage and pregnancy coercion have important reproductive health implications for women such as unintended pregnancy (Miller et al., 2010, 2011; Miller et al., 2014). Birth control sabotage, in particular, may negatively shape women’s sexual health by heightening their engagement in sexual risk behaviors. For example, a controlling partner who tampers with condoms by putting holes in them or breaking them may directly lead to STI acquisition if the partner has an STI. Similarly, removing a condom during sexual intercourse in order to promote pregnancy can directly place her at risk for acquiring HIV and other STIs if her partner has an STI (Willie, Kershaw, Campbell, & Alexander, 2017a). Further, previous research indicates that women involved in relationships with unequal power dynamics, as is commonly the case in relationships involving intimate partner violence, are more likely to engage in sexual risk behaviors such as having multiple sexual partners (Mittal et al., 2013; Seth, Raiford, Robinson, Wingood, & DiClemente, 2010; Stockman, Hayashi, & Campbell, 2015; Stockman, Lucea, & Campbell, 2013a) and participating in exchange sex (Stockman et al., 2013b; Willie, Kershaw, & Callands, 2018). Extending this research, reproductive coercion is a potential manifestation of unequal power dynamics between romantic and intimate partners (Alexander, Volpe, Abboud, & Campbell, 2016; Park, Nordstrom, Weber, & Irwin, 2016; Willie et al., 2017b), and women who report reproductive coercion may also engage in sexual risk-taking (Capasso, DiClemente, & Wingood, 2019; Hill et al., 2019; Katz, Poleshuck, Beach, & Olin, 2015; Northridge, Silver, Talib, & Coupey, 2017). While these studies demonstrate an important growing body of research, extant research examining reproductive coercion and sexual risk-taking typically focus on the middle (Hill et al., 2019; Northridge et al., 2017) and/or late (Capasso et al., 2019; Katz et al., 2015) stages of adolescence. In order to inform the development of novel sexual health interventions addressing reproductive coercion for all women, it is important to analyze these associations among women across the lifespan who may be at risk for STI infections. Title X-funded providers such as Planned Parenthood offer affordable reproductive and sexual healthcare to family planning users from adolescence through middle adulthood.

The current study sought to explore associations between reproductive coercion—specifically reports of birth control sabotage—and sexual risk indicators among women engaged in care at Connecticut Planned Parenthood centers. We hypothesized that birth control sabotage would be associated with inconsistent condom use, having an STI, engaging in exchange sex, and having multiple sexual partners. Better understanding of the impact of birth control sabotage on women’s sexual risk indicators is critically important to inform sexual risk reduction interventions.

METHODS

Methods described below have also been reported elsewhere (Calabrese et al., 2018; Calabrese et al., 2019).

Procedures

Participants were recruited for an anonymous online survey through an email invitation distributed to 11,238 Planned Parenthood patients in February of 2017. A survey invitation was sent via email to patients 18 years of age or older who had recently engaged in care at Planned Parenthood centers in New Haven, Bridgeport, and Hartford—the three cities reporting the highest incidence of HIV infections in Connecticut (State of Connecticut Department of Public Health, 2017). Patients were defined as “recently engaged in care” if they had one or more visits documented in their medical record in the past 10 months, and the survey link was only sent to patients who had agreed to receive email communication from Planned Parenthood (77%). Interested patients followed a survey link in the recruitment email, completed an online consent form, and responded to survey questions (median completion time = 36 minutes). Participants were compensated with $10 gift cards. The study was closed after 973 participants had enrolled and initiated the survey to avoid exceeding the enrollment maximum of 1000 patients (additional patients had initiated the preliminary screening items). This equated to 8.7% of the 11,238 patients invited to participate. All procedures were approved by the Yale University Human Investigation Committee.

For the present study, we examined the sexual health correlates of women’s reports of birth control sabotage. As a result, we restricted the analytic sample to include only participants who identified as women and responded to all the birth control sabotage questions. The final analytic sample included 675 women (representing 69% of the original sample). Compared to the parent study sample, the analytic sample was not significantly different in regards to age, race and ethnicity, or employment (ps>.05).

Measures

Sociodemographic and partner characteristics included age, race and ethnicity (Non-Hispanic Black or African American; Non-Hispanic White; Hispanic; Non-Hispanic other racial group, which included Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native), education, and gender of sexual partners.

Birth control sabotage was measured using items from a measure developed by Miller et al. (Miller et al., 2011). For the current study, we assessed one domain of reproductive coercion: birth control sabotage. We focused on this domain of reproductive coercion rather than pregnancy coercion because behaviors related to birth control sabotage more directly threaten women’s sexual health. Birth control sabotage was assessed using five items. Participants were asked “Has someone you were dating ever: 1) taken off the condom while you were having sex so you would get pregnant?; 2) put holes in the condom so you would get pregnant?; 3) broken a condom on purpose while you were having sex so you would get pregnant?; 4) taken your birth control (like pills) away from you or kept you from going to the clinic to get birth control so that you would get pregnant?; and 5) made you have sex without a condom so you would get pregnant?” An affirmative response to any of the five items was coded as experiencing reproductive coercion.

Sexual risk indicators included inconsistent condom use during vaginal sex with a man (past six months), inconsistent condom use during anal sex with a man (past six months), having multiple male sexual partners (past six months), participating in exchange sex (lifetime), and having a STI diagnosis (lifetime). To assess inconsistent condom use during vaginal and anal sex, participants were asked how consistently they used condoms during these sexual acts in the past six months. The response options were Always, Mostly, Sometimes, Rarely, and Never. Responses of Never, Rarely, Sometimes, and Mostly were coded as inconsistent condom use during vaginal and anal sex. To assess multiple sexual partners, participants were asked how many different men they had vaginal and/or anal sex with in the past six months. Participants who reported two or more different men were coded as having multiple sexual partners. Two or more male partners during a 6-month period is consistent with the CDC’s definition for multiple sexual partners (Centers for Disease Control and Prevention, 2019) and also consistent with previous research on women’s sexual risk behaviors (Calabrese et al., 2019; Hill et al., 2019; Neblett, Davey-Rothwell, Chander, & Latkin, 2011; Santelli, Brener, Lowry, Bhatt, & Zabin, 1998; Willie & Kershaw, 2018). To assess exchange sex, participants were asked if they ever had sex in exchange for money, drugs, or other goods. An affirmative response was coded as engaging in exchange sex. To assess STI diagnosis, participants were asked if a healthcare provider ever told them they had an STI. This question was asked for HIV, Chlamydia, Gonorrhea, Syphilis, Genital Herpes, Trichomoniasis, HPV or Genital Warts, and other STIs. An affirmative response to any one of the nine items was coded as reporting an STI diagnosis.

Data Analysis

Basic descriptive statistics (frequencies, means) were performed to describe the characteristics of the study sample. Chi-square and t tests were used to describe bivariate associations and pairwise comparisons between sociodemographic characteristics and birth control sabotage. Bivariate and multivariable logistic regression models were conducted to examine associations between birth control sabotage and sexual risk indicators. Covariates were age, education, race and ethnicity, and gender of sexual partners, and they were chosen if they were significantly associated with sexual risk indicators at the p-value<.05 level or relevant based on previous research (Capasso et al., 2019; Hill et al., 2019; Katz et al., 2015; Northridge et al., 2017). Models were assessed for significance using odds ratios (OR), 95% confidence intervals (CI), and p-values<.05. All analyses were conducted using SAS 9.4(SAS Institute, 1990).

RESULTS

Sociodemographic Characteristics and Associations with Reproductive Coercion

In our sample of 675 women, the average age was 28 years (Table 1). Slightly less than one-fourth of women were Hispanic (23.3%). More than one-third of women self-identified as non-Hispanic Black or African American (35.6%), the majority of women had at least a high school education (96.6%), and 86% of women identified the gender of their sexual partners as men only.

Table 1.

Bivariate Associations of Demographics with Birth Control Sabotage (N=675)

Independent Variables Overall N (%) Birth Control Sabotage (+), N (%) Birth Control Sabotage (−), N (%) p
Overall 675 (100.0) 111 (16.4) 564 (83.6)
Age (years), M (SD) 28.2 (7.4) 29.6 (7.3) 27.9 (7.4) .020
Education .060
 Less than high school 23 (3.4) 5 (4.5) 18 (3.2)
 High school graduate/GED 147 (21.8) 28 (25.2) 119 (21.1)
 Some college 260 (38.5) 50 (45.1) 210 (37.2)
 College graduate or higher 245 (36.3) 28 (25.2) 217 (38.5)
Race and Ethnicity <.001
 Non-Hispanic Black or African American 240 (35.6) 58 (52.3) 182 (32.3)
 Non-Hispanic White 234 (34.7) 23 (20.7) 211 (37.4)
 Hispanic 157 (23.3) 21 (18.9) 136 (24.1)
 Non-Hispanic other racial group 44 (6.5) 9 (8.1) 35 (6.2)
Gender of sexual partners .178
 Men only 581 (86.1) 91 (82.0) 490 (86.9)
 Men and women 94 (13.9) 20 (18.0) 74 (13.1)
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Note. Column percentages rounded to the nearest tenth and may not equal 100. p-values are from t tests or χ2 test.

Bivariate associations revealed two significant associations between sociodemographic characteristics and birth control sabotage (Table 1). Women who reported birth control sabotage were slightly older than women who did not report birth control sabotage (29.6 years vs. 27.9 years). Additionally, a higher proportion of women who reported birth control sabotage identified as non-Hispanic Black or African American women versus women who did not report birth control sabotage (52.3% vs. 32.3%).

Reports of Birth Control Sabotage and Sexual Risk

Figure 1 displays the prevalence of sexual risk indicators among women with and without reports of birth control sabotage. One in six (16.4%, n=111) women reported birth control sabotage. Compared with women who did not report birth control sabotage, a higher proportion of women who reported birth control sabotage had a history of STI diagnosis (76.4% vs. 53.0%, p<.001), had engaged in exchange sex (10.5% vs. 3.8%, p<.003), and had multiple sexual partners (37.8% vs. 22.3%, p<.001).There were no significant differences in the prevalence of inconsistent vaginal condom use (89.6% vs. 90.1%, p=.866) and anal condom use (75.8% vs. 86.4%, p=.134) reported by women who did and did not report birth control sabotage, respectively.

Figure 1.

Figure 1.

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Prevalence of sexual risk by women’s reports of birth control sabotage.

Multivariable Associations between Birth Control Sabotage and Sexual Risk

After adjusting for age, education, race and ethnicity, and gender of sexual partners, birth control sabotage remained significantly associated with STI diagnosis (aOR [95% CI] = 2.18 [1.31, 3.60]), p=.003), exchange sex (aOR [95% CI] = 2.77 [1.17, 6.53]), p=.020), and multiple sexual partners (aOR [95% CI] = 1.96 [1.21, 3.18]), p=.006).

DISCUSSION

The current study explored associations between birth control sabotage and sexual risk indicators in a racially and ethnically diverse sample of women attending Connecticut family planning health centers. One in six women (16.4%) reported experiencing birth control sabotage in their lifetime. This prevalence estimate is almost double the prevalence of reproductive coercion among a nationally representative sample of adults in the United States (Black et al., 2011) but is similar to other studies among family planning patients (Miller et al., 2010) and patients attending OB/Gyn clinics (Clark, Allen, Goyal, Raker, & Gottlieb, 2014; Willie et al., 2017b). Further, our findings indicate a positive association between reports of birth control sabotage and elevated sexual risk. Reproductive coercion is an important correlate of women’s reproductive health such as unintended pregnancies (Miller & Silverman, 2010), and our findings support burgeoning research acknowledging its relevance for women’s sexual health as well (Capasso et al., 2019; Northridge et al., 2017), particularly among women seeking care in family planning programs.

Birth control sabotage was positively associated with reporting exchange sex, multiple sexual partners, and history of STI diagnosis among women receiving services at Connecticut family planning centers. There are some potential explanations for these findings. For example, birth control sabotage that compromise condoms’ effectiveness may directly facilitate the transmission of an STI if a sexual partner had an STI. Also, emerging research suggests that women who report reproductive coercion have greater odds of mental health conditions such as depression and posttraumatic stress disorder compared with women who do not (Alexander et al., 2019; McCauley, Falb, Streich-Tilles, Kpebo, & Gupta, 2014), which can make it difficult to engage in safer sex practices (Brawner, Gomes, Jemmott, Deatrick, & Coleman, 2012; Overstreet, Willie, Hellmuth, & Sullivan, 2015). Also while reproductive coercion can occur without accompanied intimate partner violence (Grace & Anderson, 2016; Miller et al., 2010), a number of studies illustrate a strong association between reproductive coercion and intimate partner violence (Clark et al., 2014; Katz et al., 2015; Willie et al., 2017a; Willie et al., 2017b). Abusive partners can restrict women’s economic resources (de Moraes, Marques, Reichenheim, de Freitas Ferreira, & Salles-Costa, 2016; Gupta et al., 2018; Postmus, Plummer, McMahon, Murshid, & Kim, 2011), which could increase women’s likelihood of engaging in economically-motivated relationships and exchange sex (Willie et al., 2018). Future studies should examine potential mechanisms linking reproductive coercion and women’s sexual risk-taking in order to inform the development of sexual risk reduction interventions.

Birth control sabotage may also co-occur and interact with other social determinants of sexual and reproductive health (e.g., economic status, social networks) that may relate to sexual risk-taking among women. For example, economic factors such as having less than a high school education, facing economic hardship, and needing to care for dependents are associated with economically-motivated sexual indicators such as exchange sex and having multiple sexual partners (Dunkle, Wingood, Camp, & DiClemente, 2010; Raiford et al., 2014). If birth control sabotage is present within the context of economic hardship and caregiving responsibilities, then it is possible that power dynamics of an economically-unbalanced relationship could further increase women’s sexual risk-taking. Similarly, structural factors such as high male incarceration rates contribute to the shortage of available male partners, which has been associated with multiple and concurrent sexual partners (Adimora et al., 2001; Dauria et al., 2015; Ferguson, Quinn, Eng, & Sandelowski, 2006) and possibly impedes women’s negotiations of mutual monogamous relationships (Adimora et al., 2013). One study found that Black women discussed incarceration as a factor motivating male partners’ efforts to promote pregnancy in order to secure emotional and economic security (Nikolajski et al., 2015).

Collectively, our findings suggest that birth control sabotage could potentially compromise women’s sexual health. They also point to promising directions for future research to further understand how birth control sabotage and other social determinants interact to increase women’s sexual risk-taking.

These findings should be interpreted in the context of several study limitations. The cross-sectional nature of the study design limits our ability to make causal inferences given the temporality of the associations. Further, the assessment of lifetime prevalence of some of the sexual risk outcomes limits the temporal ordering of the results. Future studies could use a longitudinal study design and causal inference statistical methods to address these limitations. Additionally, the analysis was based on self-report, which is susceptible to social desirability bias. Lastly, women were recruited from Planned Parenthood centers in Connecticut, and therefore may not be representative of women in other geographic areas or attending other types of healthcare settings. For example, our analytic sample was more diverse than the U.S. population in terms of race and ethnicity. Our analytic sample, compared to the general US female population, had a higher prevalence of Non-Hispanic Black women (35.6% vs. 13.7%) and Hispanic women (23.3% vs. 17.8%), and lower prevalence of Non-Hispanic White women (34.7% vs. 60.1%) (US Census Bureau, 2018). Future research should replicate our findings with a larger sample of women across multiple geographic areas and healthcare settings.

IMPLICATIONS FOR PRACTICE AND/OR POLICY

Notably, this study was conducted among a sample of women receiving health services at Connecticut family planning health centers. Over seven million women in the US receive reproductive health services from family planning health centers (Frost, Frohwirth, & Zolna, 2015) and these clinical settings tend to also provide sexual health services such as STI testing and treatment (Frost, Gold, & Bucek, 2012). Healthcare providers and other clinical staff are uniquely positioned to screen and identify women who may report reproductive coercion (Decker et al., 2017). Routine screening for reproductive coercion in these clinical settings could facilitate conversations about women’s sexual health and safety and link to community resources.

CONCLUSIONS

Reproductive coercion is an important public health issue threatening women’s sexual and reproductive health. Compared with those who do not report birth control sabotage, women who report birth control sabotage may be at greater risk for poor sexual health outcomes such as STIs due to increased engagement in sexual risk behavior. In family planning health centers, reproductive coercion screening could be made a priority and help to facilitate conversations around sexual health and safety.

Table 2.

Associations of Birth Control Sabotage with Women’s Sexual Risk

Unadjusted Model Adjusted Model
Outcomes OR (95% CI) p aOR (95% CI) p
Past Six Months Inconsistent Vaginal Condom Use 0.94 (0.46 – 1.93) .867 0.98 (0.45 – 2.16) .963
Past Six Months Inconsistent Anal Condom Use 0.49 (0.19 – 1.26) .140 0.63 (0.22 – 1.84) .405
Lifetime Exchange Sex 3.00 (1.40 – 6.43) .005 2.77 (1.17 – 6.53) .020
Lifetime STI Diagnosis 2.86 (1.79 – 4.58) <.001 2.18 (1.31 – 3.60) .003
Past Six Months Multiple Sexual Partners 2.12 (1.37 – 3.26) <.001 1.96 (1.21 – 3.18) .006
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Note. The adjusted model controlled for age, education, race and ethnicity, and gender of sexual partners.

ACKNOWLEDGEMENTS

The authors wish to thank the Connecticut Planned Parenthood patients who generously contributed their time and effort by participating in this study. We are grateful to Ms. Susan Lane, Director of Planning and Grants at Planned Parenthood of Southern New England, Inc., for her help with data collection and other facets of the study.

Funding: This work was supported by the Yale University Center for Interdisciplinary Research on AIDS and the National Institute of Mental Health (NIMH) [Grant Number P30-MH062294]. TCW was supported by the NIMH [Grant Number F31-MH113508 and R25-MH083620] and National Institute on Minority Health and Health Disparities (NIMHD) [Grant Number K01-MD015005]. Support for SKC was provided by the NIMH [Grant Number K01-MH103080].

The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH). The findings and conclusions in this article are those of the authors and do not necessarily reflect the views of Planned Parenthood Federation of America, Inc.

Conflicts of Interest and Sources of support: Authors declare no conflicts of interest. Funding for this research was provided by the Yale University Center for Interdisciplinary Research on AIDS and the National Institute of Mental Health (NIMH) via P30-MH062294. TCW was supported by the NIMH via F31-MH113508, R25-MH083620; and the National Institute on Minority Health and Health Disparities (NIMHD) via K01MD015005. Support for SKC was provided by the National Institutes of Mental Health via Award Number K01-MH103080.

Author Biographies

Tiara C. Willie, Ph.D, M.A. is an Assistant Professor at the Department of Mental Health at the Johns Hopkins Bloomberg School of Public Health. Her research examines how social and behavioral factors influence the etiology and health consequences of gender-based violence, both domestically and globally.

Dr. Kamila A. Alexander is an Assistant Professor at the Johns Hopkins School of Nursing. Her research focuses on prevention of sexual health outcome disparities and the complex roles that structural determinants such as intimate partner violence, societal gender expectations, and limited economic opportunities play in the experience of intimate human relationships.

Amy Caplon, MPH is a designated Presidential Management Fellow at the National Institutes of Health within the National Cancer Institute. Her research focuses on the intersections of intimate partner violence, harm reduction, women’s health, and pre-exposure prophylaxis use.

Trace Kershaw is Professor and Chair of Social and Behavioral Sciences at the Yale School of Public Health, the Director of the Development Core at the Center for Interdisciplinary Research on AIDS, and the Director of the Yale AIDS Prevention Training Program and the Research Education for Diverse Scholars Training Program.

Cara Safon is an AHRQ T32 Pre-Doctoral Fellow and PhD student in Health Services Research at Boston University School of Public Health. She is interested in applying mixed methods to study issues related to maternal and child health.

Rachel Galvao is a medical student at University of Pennsylvania Perelman School of Medicine. Rachel hopes to dedicate her career to improving women’s health. Recently, she contributed to research about HIV pre-exposure prophylaxis access and women’s preferences regarding PrEP.

Clair Kaplan, APRN, is the Director of Clinical Research at Planned Parenthood of Southern New England. A women’s healthcare nurse practitioner, she is interested in research that impacts the social determinants that disadvantage women’s reproductive lives and health.

Abigail Caldwell, ANP-C, WHNP-BC is an Adult and Women’s Health nurse practitioner and was formerly the Director of Primary Care at Planned Parenthood of Southern New England.

Sarah K. Calabrese, PhD, is an assistant professor in the Department of Psychological and Brain Sciences and the Department of Prevention and Community Health at George Washington University. Her research focuses on stigma, HIV prevention, sexual health promotion, and healthcare inequity.

Footnotes

Disclaimer: This article was prepared while Amy J. Caplon (or AJC) was a student at Yale University School of Public Health. The opinions expressed in this article are the authors’ own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States government. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health (NIH).

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