Exploring experience of and engagement in coercive pregnancy behaviors among sexually active young men from five clinics in Baltimore, MD

Abstract

Objectives.

To explore young men’s perceived experience of coercive pregnancy behaviors by female partners, and engagement in and behavioral overlap of these occurrences in this sample.

Study design.

Heterosexually active young men aged 15–24 (n=39), recruited from three primary care and two sexually transmitted disease clinics in Baltimore, MD city over a two-week period, were surveyed on their perceived experience of and engagement in coercive pregnancy behaviors, attitudes about women, and background characteristics.

Results.

Of 130 invited, sixty-six (51%) agreed to participate, 39 of whom were heterosexual young men; 87% were non-Hispanic Black and 59% were aged 20–24. Eleven (28%) perceived one or more coercive pregnancy behaviors by a partner and nine (23%) engaged in one or more coercive behavior. Most (58%) agreed women are responsible for birth control decisions, but 55% believed women could not be trusted to tell the truth about contraceptive use and 68% believe women would like to get pregnant.

Conclusions.

Over one-third of young men in this sample perceived experience of coercive pregnancy behaviors by partners and/or engaged in these behaviors. Findings have implications for promoting healthy relationships among young people.

1. Introduction

Adolescence and young adulthood are important times of growth during which young people are developing romantic and interpersonal relationships. However, rates of unintended pregnancy and sexually transmitted diseases (STD) peak during this period [1, 2]. Past work demonstrates that contraception use is improved when partners are communicating about this together [3–7] and that young men often believe preventing pregnancy is a shared responsibility [8, 9]. However, engagement in coercive pregnancy behaviors within a relationship can result in the domination of one’s partners wishes and actions. Studies that have examined female adolescents’ perspectives of coercive pregnancy behaviors have described that male coercive pregnancy behaviors might influence the likelihood of pregnancy [10–12]. Although most studies suggest that coercion involving a male partner’s dominance over a female predominates, females may also engage in forms of coercion [13]. Examining young men’s perceived engagement in coercive pregnancy behaviors and their experience of these behaviors by their partners would contribute to a better understanding of this issue.

Past work, conducted among adult men, has examined some aspects of men’s perceived experience of coercive pregnancy behaviors by partners [14–17]. Two quantitative studies described that 10% of adult men perceived partners had ever tried to get pregnant when they did not want them to, 4% reported female partners refused to let them wear condoms when wanting to, and 8% perceived a partner had ever tried to interfere with their birth control use [14, 15]. Two qualitative studies described small samples of men discussed their female partners engaging in pregnancy-promoting behaviors, such as interfering with their contraceptive strategies or pressuring them to father children [16, 17].

Fewer studies have assessed from the adult male viewpoint reports of engagement in coercive pregnancy behaviors. Three qualitative studies described small samples of young men discussed engaging in coercive pregnancy behaviors (e.g., pressuring or deceiving partners into becoming pregnant, failing to withdraw as promised, damaging condoms before use) [16–18]. No men in these studies endorsed making a partner have sex without a condom or removing a condom during sex.

Limitations to past work include lack of inclusion of male adolescents and assessments of specific coercive pregnancy behaviors (e.g., assessing only whether men have pressured a partner to become pregnant rather than also assessing specific condom use, withdrawal, and birth control behaviors). This prior work has also not examined behavioral overlap of these occurrences (e.g., the degree to which young men perceived experience of and/or engagement in these behaviors). There is also a need to better understand young men’s attitudes about women’s contraception use decisions and responsibility to provide greater context to these behaviors [8, 9]. Developing and examining new measures of coercive pregnancy behaviors with young men does not negate or supersede women’s perceptions of, or experiences with, these behaviors.

Addressing these gaps, we explored sexually active young men’s perceived experience of coercive pregnancy behaviors by a partner, their engagement in these behaviors with a partner, and behavioral overlap in these reports. We also described young men’s attitudes about women and contraception.

2. Methods

2.1. Study Procedures and Sample

We analyzed data from the fifth and final round of data collection (from August 2017 through September 2017) in three primary care and two STD clinics in Baltimore, MD as part of a larger study focused on engaging young men in sexual and reproductive healthcare (SRHC) conducted from August 2014 through September 2017 [19]. Each data collection round, including the fifth round, was conducted with a convenience sample of male patients aged 15–24 who were able to understand or read English or Spanish that lasted for a 2-week period at each clinic. We had the opportunity to add questions about coercive pregnancy behaviors only in the fifth round of data collection. Adults provided consent and minors consent if visits were SRHC-related, or parental consent with minor assent if visits had another focus. Respondents completed an audio-assisted computer survey after their visit that lasted 10–15 minutes and received $5 remuneration. The Johns Hopkins Institutional Review Board approved this study.

2.2. Measures

2.2.1. Coercive pregnancy behaviors

We adapted items to measure coercive pregnancy behaviors among young men from relevant survey items used previously in studies of women [10, 20].

To assess young men’s perceived experience of coercive pregnancy behaviors, respondents answered yes/no whether they perceived a current/past sexual partner had “Ever tried to get pregnant when you did not want to” and perceived seven item-specific coercive pregnancy behaviors by a partner: Whether a current/past sexual partner ever tried to: “Take off condom during sex when you did not want to,” “Keep you from using condom when you wanted to,” “Damage condom on purpose,” “Keep you from pulling out when you wanted to,” “Lie about taking birth control or intentionally skipping pills,” “Lie about being on another type of birth control beside pills,” and “Pressure you to get partner pregnant.”

To assess young men’s engagement in coercive pregnancy behaviors, respondents answered yes/no whether they had “Ever tried to get current/past sexual partner pregnant when partner did not want to” and engaged in seven item-specific coercive pregnancy behaviors: Whether they had ever tried with a current/past sexual partner to: “Take off condom during sex when partner did not want you to,” “Damage condom on purpose,” “Convince partner to have sex without condom when they did not want to,” “Lie about pulling out,” “Ejaculate inside when partner thought you were going to pull out,” “Hide or destroy pills or anything else partner was using to prevent pregnancy,” and “Pressure her to get pregnant.”

To examine behavioral overlap, we created a combined measure coded as having ever perceived experience of any behaviors by a partner only, engaged in any behaviors with a partner only, perceived experience of and engagement in any behaviors, or neither.

2.2.2. Attitudes about women and contraception

Items measuring men’s attitudes about women and contraception were developed based on prior qualitative research [21, 22] and the item on gender responsibility for contraception was adapted from prior surveys [23]. Respondents answered on a 4-point scale (strongly disagree to strongly agree) whether: “Women can be trusted to tell the truth about whether they are using contraception;” “Some women want a baby so badly that they will lie about being on birth control so that they can get pregnant;” and “It should be a woman’s responsibility to make decisions about birth control” and coded as strongly disagree/disagree or agree/strongly agree.

2.2.3. Background characteristics

We assessed respondents’ age (15–19 or 20–24 years) and race/ethnicity (non-Hispanic Black, non-Hispanic white, or Hispanic), whether they were currently attending school, currently working, consistent condom use (most/all of the time) in the last 3 months, condom use and partner hormonal method use at last sex, history of ever having gotten someone pregnant and ever fathering a child, and clinic recruitment setting (STD or primary care).

2.3. Data analysis

We generated frequencies for study measures and behavioral overlap. Given the small sample size, we did not undertake conventional significance testing.

3. Results

3.1. Study response rate

Of the 226 young men approached, 42% did not meet the study’s inclusion criteria mainly due to their age. Of the 130 eligible young men, 51% (66) agreed to participate and completed the survey; the main reason for non-participation was time constraints based on research staff notes. The analytic sample for this analysis consists of 39 young men who reported ever having vaginal, oral, and/or anal sex with a female partner.

3.2. Background characteristics

The majority of young men were aged 20–24, non-Hispanic black, currently working and were recruited from primary care settings; about one-third currently attended school (Table 1). Over half of young men consistently used condoms in the last 3 months and at last sex, and one-quarter reported partner hormonal method use at last sex. Over half had ever gotten someone pregnant and under one-third had ever fathered a child.

Table 1.

Characteristics of respondents recruited from five Baltimore, MD clinics, 2017

	N=39	%
Age
15–19	16	41.0
20–24	23	59.0
Race/ethnicity
Non-Hispanic Black	34	87.2
Non-Hispanic White	4	10.3
Hispanic	1	2.6
Currently attending school1	23	59.0
Currently working	14	35.9
Contraception use
Consistent condom use (most/all of the time) in the last 3 months2	25	64.1
Condom use at last sex	21	53.8
Partner hormonal method use at last sex	10	25.6
History of ever gotten someone pregnant	22	56.4
History of ever fathering a child	12	30.7
Clinic recruitment setting
Sexually Transmitted Disease	13	33.3
Primary care	26	66.7
Attitudes about women and contraception (% agreed/strongly agreed)
Women can be trusted to tell the truth about whether they are using contraception1	17	44.8
Some women want a baby so badly that they will lie about being on birth control so that they can get pregnant	26	68.4
It should be a woman’s responsibility to make decisions about birth control	22	57.9

¹Missing value=1 case

²Missing value=4 cases

3.3. Ever perceived experience of coercive pregnancy behaviors by partner

Three young men (3/39, 8%) perceived a partner tried to get pregnant when not wanting her to (see Table 2). Eleven of 39 (28%) young men perceived experience of one (5/39, 13%) or more (6/39, 15%) item-specific behaviors by partner. The two most endorsed items included perceiving a partner tried to keep them from pulling out (reported by 18%) and a partner pressuring to get her pregnant (reported by 13%).

Table 2.

Young men’s perceived experience of coercive pregnancy behaviors by partner and engagement in these behaviors in five Baltimore, MD clinics, 2017

	N=39	%
Ever perceived experience of coercive pregnancy behaviors by partner
Sexual partner ever tried to get pregnant when you did not want her to	3	7.7
Item-specific questions about partner
Removed condom during sex when you did not want to (Item A1)	2	5.1
Kept you from using a condom when you wanted to (Item A2)	3	7.7
Intentionally damaged condom (Item A3)	0	-
Tried to keep you from pulling out when you wanted to (Item A4)	7	17.9
Lied about taking birth control or intentionally skipping pills (Item A5)	3	7.7
Lied about being on other forms of birth control (Item A6)	1	2.6
Pressured you to get her pregnant (Item A7)	5	12.8
Summary of item-specific questions about partner1
No report	28	71.8
% ever perceived experience 1 behavior by partner	52	12.8
% ever perceived experience 2 or more behaviors by partner	63	15.4
Ever engaged in coercive pregnancy behaviors
Ever tried to get sexual partner pregnant when she did not want you to	1	2.6
Item-specific questions
Removed condom during sex when partner did not want you to (Item B1)	2	5.1
Convinced partner to have sex without a condom when they did not want to (Item B2)	3	7.7
Intentionally damaged condom (Item B3)	0	-
Lied about pulling out (Item B4)	2	5.1
Ejaculated inside when partner thought you were going to pull out (Item B5)	5	12.8
Hid or destroyed pills or anything else she was using to prevent pregnancy (Item B6)	0	-
Pressured her to get pregnant (Item B7)	2	5.1
Summary of item-specific questions about partner1
No report	30	76.9
% ever engaged in 1 behavior	54	12.8
% ever engaged in 2 or more behaviors	45	10.3

¹Summary across 7 item-specific questions by partner or self-report, respectively

²N=1 reported Item A1; N=1 reported Item A2; and N=3 reported Item A4

³N=1 each reported Item A7 with Items A2, A4, or A5, respectively; N=1 each reported Items A4 and A5 with Items A6, or A7, respectively; and N=1 reported Items A1, A2, A4, and A7

⁴N=2 reported Item B1; N=2 reported Item B5; and N=1 reported Item B7

⁵N=1 each reported Item B2 with Items B5 or B7; N=1 reported Items B4 and B5; and N=1 reported Items B2, B4, and B5

3.4. Ever engaged in coercive pregnancy behaviors with partner

Although only one young man (1/39, 3%) answered more generally ever having tried to get a partner pregnant when she did not want to, 23% (9/39) responded to engaging in one (5/39, 13%) or more (4/39, 10%) item-specific pregnancy coercive behaviors. The two most endorsed items included ever ejaculating inside when their partner thought they were going to pull out (reported by 13%) and ever convincing their partner to have sex without a condom when their partner did not want to (reported by 8%).

3.5. Behavioral overlap in coercive pregnancy behaviors

Overall, one-third (14/39, 36%) of young men perceived experience of and/or engaged in any behaviors: 5 of 39 (13%) perceived experience of coercive pregnancy behaviors by partners only, 3 of 39 (8%) engaged in these behaviors only, and 6 of 39 (15%) reported both behaviors; twenty five of 39 reported no behaviors (64%).

3.6. Attitudes about women and contraception

The majority of young men agreed/strongly agreed it is a woman’s responsibility to make decisions about birth control (22/39, 58%) and that some women want a baby so badly that they will lie about being on birth control to get pregnant (26/39, 68%), and 55% (21/39) disagreed/strongly disagreed that women can be trusted to tell the truth about whether they were using contraception.

4. Discussion

Overall, we found that just over one-third of young men from a clinical convenience sample ever perceived experience of and/or engagement in coercive pregnancy behaviors with partners. Assessing for both perceived experience and behavioral engagement allowed for identifying young men who not only reported both but also one or the other occurrence. The coercive pregnancy behavior measures that young men were asked to report on in this study are new. We have demonstrated that young men can answer survey items about these types of sensitive issues that should be further tested and refined with future research. Findings highlight the need to include young men in research examining perceived experience of, and engagement in, coercive pregnancy behaviors to better understand why young people engage in these behaviors.

The overall prevalence of young men’s reported engagement in coercive pregnancy behaviors in this study was generally consistent with young women’s perceptions of reproductive coercion behaviors by their male partners estimated at 4–20% by females aged 14–29 in a recent systematic review [11]. Reproductive coercion has been defined as behavior that interferes with women’s autonomous decision-making with regard to reproductive health [10–12]. In the current study, young men most frequently reported not using withdrawal when one’s partner thought he would and convincing one’s partner to have condomless sex when not wanting to. Use of these behaviors have implications for both STD risk and unintended pregnancy, especially during emerging adulthood that coincides with the highest rates for these negative health outcomes. While an established literature describes the negative impact reproductive coercion has for women [11], the influence of similar perceived experiences for young men’s health has yet to be well-defined or investigated. Despite the fact that young men’s beliefs about women and contraception appeared to indicate a common distrust of women. Greater frequencies of young men had mistrustful attitudes about women’s contraception use and pregnancy desire than the proportion perceiving experience of coercive pregnancy behaviors by partners. More research is needed to understand this generalized distrust and its implications for gender relations within the context of partnered relationships.

Past research examining the context of reproductive coercion experiences among only women demonstrates these were associated with periods of intimate partner violence, increased pregnancy risk [20, 24] and among Black women in the context of more transient relationships and male partners’ impending incarceration [25, 26]. Although the current study did not assess the context of young men’s coercive pregnancy behaviors, one of the few studies that examined a community sample of nonproblem drinking adult men’s condom use resistance intentions, demonstrated resistance intentions were associated with past severe sexual aggression [27]. Other factors may also contribute to young men’s condom use resistance that partners may perceive as being coercive, including lack communicating goals related to seeking sexual pleasure or reproduction [28–30]. Future work is needed to gain a better understanding of the reasons why some young men engage in coercive pregnancy behaviors, partner-level concordance of coercive pregnancy behaviors using dyadic research methodology [31, 32], and coercive pregnancy behaviors within the context of other experiences of intimate partner violence.

The current study extends prior work by also assessing young men’s perceived experience of condom-, withdrawal-, and birth control-related coercive behaviors by their partners and the overlap of these perceived experiences with young men’s own use of these behaviors. When assessing alone, just under thirty percent of young men reported ever perceiving experience of one or more of these behaviors by a partner. When examining behavioral overlap with engagement in these behaviors, only thirteen percent ever perceived experiencing these behaviors by a partner and fifteen percent reported both perceived experience of and engagement in these behaviors. Future research is needed to examine the temporal order of these occurrences, whether they occurred in the same or different relationships, and the prevalence of more recent coercive pregnancy behavioral occurrences since this study assessed only lifetime behavioral recall [20, 33].

More young men responded to the item-specific coercive pregnancy measures than the more generally phrased “pressure to get pregnant” question. Use of item-specific measures may have assisted with young men’s behavioral recall about these specific occurrences. It is also possible that affirmative responses to some items (e.g., perceptions that partners prevented them from using withdrawal or doing it themselves or for convincing a partner to not use condoms when they did not want to) may not be directly related to males’ motivations for pregnancy and were instead due to other reasons (e.g., achieving greater sexual pleasure during sex act [29, 30]). Future work should aim to refine these measures for use by young men.

This study was limited by a small convenience sample recruited from primary care and STD clinics in one urban area. Future work should examine contextual factors that are associated with young men’s experience/engagement of coercive pregnancy behaviors and the settings where they may present. Measures of coercive pregnancy behaviors represented self-reports that may not include other forms of coercive pregnancy behaviors or other experiences of intimate partner violence. Examining perceptions of, and engagement in, coercive pregnancy behaviors by young men was not intended to set up equivalences of coercive experiences by young men and women, but rather an effort to describe a range of these experiences by young men.

Findings highlight the need for research to include young men in examining coercive pregnancy behaviors as well as developing strategies to support educational and clinical approaches to address young men’s role as partners in healthy contraceptive practices.

Implications.

This study found over one-third of young men perceived experience of coercive pregnancy behaviors by partners and/or engaged in these behaviors. Findings highlight the need for research to include young men in examining coercive pregnancy behaviors. Findings also highlight the need to develop strategies to support educational and clinical approaches to address young men’s role as partners in healthy contraceptive practices.

Abbreviations.

RC

Reproductive coercion

SRHC

sexual and reproductive health care

STD

sexually transmitted disease