Women's Sexual Safety Strategies in the Context of Intimate Partner Violence: Towards Survivor-Informed Intervention Tools

Introduction: One in three U.S. women experience intimate partner violence (IPV; Black et al., 2011). Up to 68% of these victim-survivors also experience forced or coerced sex by an intimate partner (McFarlane et al., 2005). Links between IPV, forced and coerced sex, and HIV risk are well established (El-Bassel et al., 2000; Josephs & Abel, 2009). Yet, there is currently a limited understanding of the best strategies to address these risks. The purpose of this study is to understand and describe survivor’s sexual health strategies to inform interventions that are relevant to women’s lived experiences of IPV.

Methods:Semi-structured, in-person interviews were conducted with female IPV survivors (n = 28). A purposive sample was recruited from domestic violence shelters and community agencies. Interviews were audio-recorded and transcribed. Using qualitative description, data were analyzed through process coding (first cycle coding) and focused coding (second cycle coding). Detailed process notes, analytic memos, random coding checks, and the use of visual analytic displays were used to increase the trustworthiness of findings.

Results: Women reported sexual abuse, sexual coercion, and sexual assault in their intimate relationships. They also reported poor sexual health outcomes, including miscarriages, cervical cancer, and sexually transmitted infections. No women reported being HIV-positive.  In caring for their sexual health, participants described a common path to care: (1) being naïve, (2) discovering the truth, (3) worrying about risk, and (4) seeking services. At this final stage, they faced their fears to visit a sexual healthcare provider. In describing sex with a violent partner, women experienced sex as a weapon of power and control: It was a “double-edged sword” when partners required or withheld sex. On other occasions, women had to reconcile having enjoyable, consensual sex with partners who were sexually abusive: “People are like, ‘Why are you with that guy?’ And we did have good sex” (“Kelly”).  Regarding intervention components, women emphasized understanding dynamics of abuse, speaking up about violence, and focusing on non-romantic relationships. For sexual safety planning, women discussed defining what sex means, setting sexual expectations, and setting boundaries initially.

Conclusions:  HIV prevention efforts must address the complexities of survivors’ situations, such as experiencing “good” sex with someone who has also been sexually violent and coercive. This research is a fundamental step in developing sexual safety planning tools. Next steps include conducting survivor and provider focus groups to refine sexual safety planning tools before testing them for acceptability and feasibility.