This article presents a continuation of report series on alcohol abuse, reproductive coercion and intimate partner violence. Abortion rate in the former Soviet Union has been the highest in the world, caused not only by the insufficient availability of modern contraception but also by irresponsible behavior. The overconsumption of alcohol is generally perceived as a contributing factor. Currently there is an improvement tendency. The social background of certain behavioral stereotypes such as reproductive coercion and binge drinking are discussed. The conclusion is that use of condoms is dependent on personal traits and the level of social development; however, alcohol consumption at sexual encounters and heavy binge drinking are risk factors for the non-use of condoms and other irresponsible behaviors.

Sexual coercion; Contraception; Alcoholism; Alcohol-related dementia

Reproductive Coercion (RC) includes direct or indirect partner behaviors that interfere with effective use of contraception. RC compromises women’s autonomous decisions and increases the risk for adverse outcomes such as Sexually Transmitted Infections (STI) and unintended pregnancy. RC is defined e.g. as male partners’ attempts to promote pregnancy through verbal pressure and threats (pregnancy coercion), direct interference with contraception (birth control sabotage), threats and coercion related to pregnancy continuation or termination (control of pregnancy outcomes) [1]. Contraception sabotage includes hiding, withholding, destroying, or removing female-controlled contraceptives or deliberately breaking or removing a condom during sex or failing to withdraw in an attempt to promote pregnancy despite a female partner’s wishes to prevent pregnancy [2]. In the literature, RC is usually discussed as an intentional activity [3]. It is proposed here to extend existing definitions by adding RC by negligence, in particular, sabotage of agreed or presupposed withdrawal method of contraception, which sometimes happens under the impact of alcohol intoxication. Admittedly, it may be difficult to distinguish between negligence, subconscious and conscious intentions.

It is known that RC is associated with the Intimate Partner Violence (IPV); half of the women who reported RC also reported partners’ physical violence [4]. The risk of unintended pregnancy doubled among women reporting both IPV and RC [5]. More specifically, in a large survey of women in the United States, 8.6% of them reported ever having an intimate partner who tried to get them pregnant when they did not want to [6]. It should be noted that a majority of studies on these topics have been conducted in more developed countries, while dimensions of the problem in less open societies can only be conjectured; phenomena discussed in this report can persist without publicity, being regarded as norm by a part of the society. In particular, the “rape culture” is an ideology excusing or supporting sexual assault [7]. Furthermore, alcohol consumption is associated with IPV [8,9]. Here are presented four case histories on alcohol abuse, reproductive coercion and IPV, a continuation of the series of reports started previously [10-13]. All cases are from the late Soviet era. Certain cases were reported to the authorities after a delay as the Soviet-time morality generally disapproved reporting of illegal and immoral acts especially if committed by people from the privileged milieu.

son of a higher officer awarded himself a next rank every time he was infected with gonorrhea. In this way he became a “generalissimo” illustrating irresponsibility-the patient was proud of his “career”. He was one of the informal leaders in a company that involved adolescents in binge drinking and teenage girls in sexual contacts e.g. with foreign truck drivers coming to international exhibitions in Moscow. Intramuscular injections of Hexestrol (named Synoeshtol in Russia) oil solution were used to induce abortions-a well-known method in the former SU [14]. Some patients, especially those who could be regarded as socially unprotected or “immoral”, reported on harsh and painful gynecological manipulations, abortions etc. whereas personal judgment and ideation of punishment have apparently played a role. Being aware also of lengthy and unpleasant treatments of STI at prevention-and-treatment centers (so-called dermatovenereological dispensaries) [11], high-risk groups avoided medical institutions, practiced self-treatment or continued spreading STI.

A case of child abuse followed by alcoholism in the victim was reported previously together with discussion of cause-effect relationships [13]. The case history had a prequel. A 33-year-old single mother with her 5-year-old son was visiting by relatives in another Soviet republic. The head of the inviting family was an officer from another Soviet republic; there had been violence in his family. The officer had a 20-years-old son, who (together with his friend) sexually assaulted the visiting mother’s cousin. Two years later the officer’s son married the victim, who was pregnant at that time. Under conditions of the Soviet registration system, aimed to counteract mass migration to the capital, factual and fictive marriages were used to be registered in Moscow. It is known that one of the reasons for women to remain with their assailants can be shortage of community resources such as the legal assistance and social support [15]. In the former SU, the registration and accommodation have been strong motives especially for Moscow and other cities attracting migrants. In some less developed societies with a widespread rape myth acceptance, sexual violence was a way of acquiring wives [15,16]. The fact that some victims married rapists was seen as indication that women enjoy it; in fact, however, existing accounts demonstrate various degrees of trauma [16]. High social positions held by sexual offenders or their relatives sometimes impede reporting [15]. Later on, the stepfather physically abused his stepson, while the mother sometimes participated in battering.

The victim of child abuse described in the Case 2 was prone to the alcohol consumption and binge drinking during his adolescence and early adulthood: up to 500 ml of vodka with beer or 1.5 l of fortified (around 18 % of alcohol by volume) wine at one sitting. Potential cause-effect mechanisms were discussed in [10,17]. At the age of 22 years he entered relationship with a 7 years older woman coming from another Soviet republic; having no affordable accommodation in Moscow, she had a motive to maintain the relationship. An alternative of the cohabitation was a dormitory, where a room was shared with 2 other women. This motive is known also in other countries, where individuals lacking affordable housing may feel coerced to maintain unsafe relationships [18]. The female partner participated in binge drinking taking lower doses. The heavy binge drinking was in some, albeit rare, cases associated with neglectful sabotage of the agreed withdrawal method of contraception. In the course of the 4-year-long cohabitation there was “only” one abortion induced by intramuscular injections of Hexestrol (Synoestrol). However, the neglectful stereotype has been repeated by the male partner also with other partners, which resulted in 2 more abortions at least. The neglectful behavior was apparently reinforced by symptoms of impairment of the frontal lobe function (discussed below) caused by the prolonged alcohol intake with heavy binges: irresponsible behavior, lack of concern about consequences or morals, misdemeanors and hooliganism, drunk driving etc. Besides, IPV was practiced by the male partner (slapping in the face, pulling the hair), sometimes but not always in connection with the drinking binges. Today, he sincerely regrets his misbehavior. In the author’s opinion, the propensity to IPV was a continuation of the “family tradition” i.e. abuse by the stepfather and mother, who both had been victims of physical abuse in their own childhood.

This case illustrates an immediate, “mechanistic” cause-effect-relationship between the binge drinking on one hand, IPV and RC on the other hand, against the background of child abuse in the perpetrator’s family history. This mechanism is rarely discussed in the literature, where intentional RC-related behaviors are emphasized, e.g. “a male partner told you not to use any birth control, said he would leave you if you did not get pregnant, told you he would have a baby with someone else if you didn’t get pregnant” etc. [4]. The neglectful sabotage of the withdrawal method of contraception associated with the binge drinking is not mentioned in this and similar lists. At the same time, the pattern of IPV and RC described in the Case 3 has been widespread in the former SU against the background of the limited availability of modern contraception, being one of the causes of the high abortion rate [19].

This case summarizes numerous similar experiences of date rape [20], which was often not regarded as such in the former SU, if not arranged as provocation. He invites her or she him, they sit on a sofa and drink wine, and then she says “no”; there follows a more or less intensive resistance. Studies indicate that sexually aggressive acts often do not involve condom use, whereas offender’s alcohol consumption and condom non-use correlate significantly [21]. Obviously, thecondom use is inconvenient in the settings of sexual violence even if resistance is weak and insincere. However, the withdrawal method of contraception can be applied, its sabotage always being a neglectful or intentional act. Definitions of the non-consent and coercion in conditions of a date are not always straightforward [22-24], which is beyond the scope of this report.

As illustrated by the Case 4, the date rape aggravated by neglect of contraception sometimes amounts to RC and leads to an abortion, while alcohol may be a contributing factor. Alcohol supposedly enhances the misperception of intentions in such cases, which may increase the risk of sexual aggression, although some males believe that coercion they commit is merely seduction [25]. On the other hand, it is assumed that alcohol impairs a woman’s ability to recognize the sexual assault risk and to resist advances [26]. Although intoxication is not a prerequisite of the sexual violence, their frequent co-occurrence suggests that alcohol may play a causative role in some cases [27].

Furthermore, one of the risk factors of contraception sabotage is hostility toward women [7,28], either towards all of them or to a certain ethnic or another type. Hostile attitudes toward women and alcohol intoxication are known risk factors for sexual coercion and non-use of condoms [28]. A direct association between men’s misogynistic attitudes and the use of coercion to obtain unprotected sex was reported [21]. RC or IPV may be a conscious or subconscious “revenge” for some true or imagined insult in the past, while a date or cohabitation may provide opportunities for that.

The abortion rate in the former SU has been the highest in the world caused not only by the insufficient availability of modern contraception but also by irresponsible behavior [19]. Fortunately, both the abortion rate and alcohol consumption (heavy binge drinking in particular) in Russia tend to decrease [29-33]. It should be also mentioned that rape in marriage was widespread in the former SU [16]. At the same time, the incidence of HIV infection is growing [34], which is another argument in favor of the condom use. The “consumerist” attitude to women has been widespread in the former SU. Atheism, propagated during the Soviet era, contributed to the irresponsibility in marriage and immoral behavior. In particular, fictive and half-fictive (temporary) marriages were broadly used for obtaining registration and accommodation in large cities attracting migrants. For example, a well known professor and scientist publicly reproached a postgraduate student from Siberia that he didn’t marry to stay in Moscow [35]. Children from such marriages may become victims of maltreatment as their mothers remarry a migrant (Case 2). Apparently, there was an unofficial directive behind such attitude aimed at the birth rate elevation initially in conditions of the gender imbalance after the World War II. In the meantime, the gender imbalance has reverted and global overpopulation has come to the fore. The male-to-female ratio is growing worldwide due to sex-selective abortions, used increasingly in certain regions, and international migrations [36].

The association between alcohol consumption and negligent behavior is explicable within the framework of the alcohol myopia theory [37,38]. Under the impact of alcohol, the cognitive capacity is impaired, so that intoxicated individuals concentrate their attention on the stimuli that are most significant for them. Less salient cues, needing more cognitive resources, tend to remain out of the vision field. Under such conditions, immediate sexual engagement involves the already restricted cognitive resources, while more remote cues such as the risk of STI or unintended pregnancy remain out of the vision field [37]. Remarkably, inebriated persons may concentrate their attention on the risks and display more prudent behavior if the salient features of the sexual encounter emphasize the risks [39]. For example, under the impact of alcohol, “partner pressure decreased condom-decision abdication” i.e. intoxicated women negotiated for condom more decisively [40], which is also explicable within the framework of the alcohol myopia theory. There is even the opinion that alcohol increases the probability of condom use in women of certain ethnic background by lowering anxiety about proposing the condom use [41].

The relationship between safer sex decision making and alcohol intake depends on the stage of sociocultural development. Some studies conducted in more developed countries did not unequivocally confirm the correlation between the alcohol consumption and non-use of condoms [41-48]. According to some research conducted in more developed countries, only high levels of drunkenness reduce the probability of condom use [41]. On the contrary, all known studies conducted in less developed or recently industrialized countries, did confirm the association between alcohol intake and non-use of condoms [49-55]. It can be reasonably assumed that the social progress correlates with the improvement of morality, so that distracting factors such as alcohol lose their force. Apparently, migrations contribute to the leveling of international differences.

Apart from immediate effects of the alcohol intake, the consequences of prolonged alcohol overconsumption and heavy binge drinking should be taken into account. The term “alcoholic dementia” used in the former SU does not exactly correspond to the term “alcohol-related dementia”, used in other countries because head trauma, old hematomas, malnutrition, deficiency of proteins and vitamins (especially thiamine) may contribute to the damage of the nervous system and advancement of personality changes [56-58]. Frontal lobe syndrome is considered to be a hallmark of chronic alcohol abuse. Post mortem studies demonstrated a lower average weight of brains in alcoholics, particularly of the frontal lobes, while the neuron density tends to decline under the impact of repeated alcohol intoxications [59-64]. Manifestations of the frontal syndrome and alcohol-related dementia are largely overlapping and include personal and social neglect, emotional disinhibition, derangements of the cognitive capacity with impaired perception of risks, lack of concern about consequences or morals, irresponsible behavior such as the non-use of condoms [61-66], exemplified here by the Case 3. The topic of violence in alcohol-related dementia is beyond the scope of this report; however, aggression does occur in such patients [67,68]. Finally, it should not be forgotten that aggression in alcoholics and individuals with alcohol-related dementia is sometimes provoked by their partners, relatives and other persons [69].

It is known that women who experience IPV are at a higher risk of unintended pregnancy. There is a correlation between RC and IPV [3]; RC is even classified as one of the forms of IPV, thus being comparable with violent crime. RC and sexual coercion may lead to unintended pregnancy, abortion, STI, unfavorable pregnancy outcomes, and psychological trauma [70,71]. Among the predisposing social factors, currently becoming more conspicuous in Russia, are militarist and machismo ideology [72], whereas promiscuity is sometimes seen as an attribute of “manliness”, impunity of some misdemeanors, display of death and violence on TV, which tends to distract public attention from violence in families, child and elder abuse, sexual coercion and RC.

In conclusion, the use of condoms in relation to the alcohol drinking is largely dependent on individual features and the level of sociocultural development; but alcohol at sexual relations and heavy binge drinking enhances the risk of the non-use of condoms and sabotage of the withdrawal method of contraception. Analogously, experiments with alcohol administration demonstrated that people behave more aggressively when drinking; but these effects are stronger in people who are already predisposed to aggression [27]. Overall, survey research indicates that the personality characteristics of sexual offenders who drink alcohol during the assault are similar to those who do not drink during the assault [27]. As discussed previously, survey data from Russia are of limited value as this research tool has been discredited by obtrusive proposals to answer various questionnaires, often asking for private information [10]. Moreover, some people generally mistrust authorities because of nonobservance of some laws and regulations. Future effort should be aimed at strengthening mutual trust between authorities and the population, which would contribute to the elaboration of efficient preventive measures. Potential benefits of IPV and RC screening by health care providers include assisting women in naming certain behaviors as coercive and enabling them to seek help [3]. Interventions and publications promoting awareness of RC as well as preventive and overcoming strategies are of importance for reducing unintended pregnancy and abortion rate [73].