The National Domestic Violence Hotline this year fielded 30 percent more calls, chats, and texts compared to the same period in 2017. Hotline chief executive Katie Ray-Jones told the New York Times, “We think #MeToo is part of that.”

But before #MeToo, intimate partner violence (IPV) was a deadly undercurrent for millions of women and men. About one in four women and one in ten men will experience a form of partner violence and report its impact, according to the National Intimate Partner and Sexual Violence Survey. A recent poll of IPV survivors by the Institute for Women’s Policy Research found four in ten said a partner had tried to get them pregnant against their will or stopped them from using birth control—what’s known as reproductive coercion.

Now, updated recommendations issued by the U.S. Preventive Services Task Force (USPSTF), an independent panel, advise health-care providers to screen patients for IPV, and to refer them to counseling and support services. The guidelines, appearing in the October issue of the Journal of the American Medical Association, renew the focus on identifying the signs of partner violence in health-care settings.

The reproductive health community has long understood the intersections between IPV, reproductive coercion, and health. Decades of research have linked relationship violence and lasting health issues among women. Less is known about the effects on male survivors.

“As a health care provider, I see firsthand how IPV harms individuals and can threaten their reproductive health and well-being,” Courtney Benedict, associate director of medical standards implementation at Planned Parenthood Federation of America, said in a statement.

‘How Can We Get Our Patients Alone’

Partner violence can jeopardize a person’s economic stability, physical safety, and overall wellness. Reproductive coercion is linked to IPV, but is less discussed, and in some instances, wrongly discounted as a joke.

In a recent poll of IPV survivors who experienced reproductive coercion, more than 80 percent said they had become pregnant against their will. The abuse takes a toll. Studies have found pregnant survivors experienced more mental health symptoms after delivery. Babies exposed to IPV were 31 percent more likely to be born prematurely or underweight, experience respiratory problems, or need hospitalization.

In 2012, Planned Parenthood was the nation’s first to begin routine screening for reproductive coercion throughout its network of hundreds of health centers, adopting a version of guidelines crafted by Futures Without Violence. Tammi Kromenaker, clinic director with Red River Women’s Clinic in North Dakota, said abortion care providers have long watched for the warning signs of IPV and reproductive coercion.

Partner violence can make pregnancy deadly. A literature review of 44 studies on pregnancy-associated deaths advised practitioners to “understand that homicide is a leading cause of pregnancy-associated death, most commonly as a result of partner violence.”

The exam room, Kromenaker noted, is one of the few places where pregnant people can count on being alone.

“These are things that abortion providers think about,” Kromenaker told Rewire.News. “I mean, we think about these things: How can we get our patients alone—so that they feel safe and they can tell us what their actual story is, and what their actual needs are—whether it’s from an intimate partner, a parent, a roommate.”

‘Easy to Implement’ Evidence-Based Screening

The updated guidelines advise health-care practitioners to ask women of reproductive age during appointments if they have experienced violence at the hands of someone they know. The USPSTF suggests certain screening tools, such as Woman Abuse Screening Tool (WAST); Humiliation, Afraid, Rape, Kick (HARK); Hurt, Insult, Threaten, Scream (HITS); Extended–Hurt, Insult, Threaten, Scream (E-HITS); and Partner Violence Screen (PVS). With the focus on women, the USPSTF admitted that more evidence-based tools are need to help male IPV survivors.

To avoid feelings of stigma, advocates suggest starting with nonthreatening questions. Futures Without Violence offers training and toolkits that spell out how to appropriately ask about IPV and reproductive coercion, to understand the limits of state patient privacy laws, and to advise patients of those limits—before asking about partner violence.

For survivors who need help, Lisa James, director of health at Futures Without Violence, said evidence-based interventions are “easy to implement” in a clinic setting. One program cut the rate of reproductive coercion by 70 percent, she noted, “by simply talking about violence and reproductive coercion, offering birth control strategies that can’t be interfered with, and connections to local domestic violence programs.”

“We know that for reproductive health providers this is particularly important because reproductive health settings see a lot of survivors in their practice,” James added.

Kromenaker, the clinic director, recalled a recent patient who revealed in a moment of privacy that her husband had taken her phone and passport. Kromenaker said they educated the woman on her rights, and provided her with resources in the North Dakota town where she lived. Then with WhatsApp, the woman called her family in her home country.

“I think if she’d been in any other setting where you don’t routinely speak with the patient alone, those kinds of things aren’t coming out,” Kromenaker observed. “I think there’s a chance you’re not getting the full picture and you’re not giving that person the opportunity to be with a trusted, safe person that you can confide in.”