Reproductive and Sexual Coer- cion: The Role of Alcohol, Social and Demographic Conditions

Reproductive coercion is defined as partner behaviors that interfere with effective use of contraception. The contraception sabotage includes hiding, withholding and destroying of contraceptives in an attempt to induce pregnancy despite a female partner’s wishes to prevent the pregnancy. In the literature, contraception sabotage is usually discussed as an intentional act. It has been suggested to extend the definition by adding the reproductive coercion by negligence, in particular, the sabotage of agreed or presupposed method of contraception, which sometimes happens under the impact of alcohol. Five case histories are presented here. The social background and cause-effect relationships between certain behavioral stereotypes, alcohol consumption and heavy binge drinking are analyzed. The use of condoms is dependent on personal characteristics and the level of social development; however, alcohol consumption at sexual encounters and heavy binge drinking are potential risk factors for the non-use of condoms and other irresponsible behaviors. The sexual and reproductive coercion is sometimes used for the purpose of migration, to cement a relationship or to spread a certain genotype. Vasectomy may be a viable solution for some individuals incapable to control their behavior and consistently use condoms, although it does not eliminate the necessity of condoms to prevent sexually transmitted infections. to a systematic review and meta-analysis, consistent condom use was less prevalent among hazardous vs. regular drinkers in Russia [6]. Fortunately, both the abortion rate and alcohol consumption in Russia tend to decrease [7,8]. It seems that at different times there have been official or unofficial directives aimed at the birth rate elevation initially in conditions of the gender imbalance after the World War II. This resulted in a limited availability of contraceptives, unavailability of voluntary sterilization, and prohibition of abortions till 1955 along with the propagation of consumerist attitude to women: corresponding talks and behaviors have been quite usual. The official atheism obviously contributed to irresponsible and immoral behaviors [9]. In the meantime, the gender imbalance has reverted and global overpopulation has come to the fore; but fertility is stimulated now as before. For example, some popular TV series such as the “Sled” (Trace) and “Slepaia” (The Blind) regularly present unexpected and unintended pregnancies both in and out of wedlock as something natural and unavoidable while contraception is mentioned rarely. Remarkably, in the Episode 306 of the latter series (shown by TV3 on 10 November 2020) a gynecologist at a husband’s request surreptitiously replaced contraceptive pills by vitamins. This was presented by the filmmakers as a good deed as the husband wanted children but the wife did not. The risks associated with oral contraceptives are invented or exaggerated by mass media and some literature. Apparently, the propaganda follows policies aimed at the birth rate elevation. Among the background factors are the machismo ideation, disrespect for some laws and regulations, abundant violence and death on TV indirectly trivializing the child and elder abuse, sexual and reproductive coercion. In the author’s opinion, authorities should handle the neglectful and intentional contraception sabotage as offenses with infliction of bodily harm if an abortion or unintended pregnancy followed. Of note, a majority of studies on these topics have been performed in more developed countries, while dimensions of the problem in less open societies are difficult to assess. In particular, the rape myth, an ideology excusing sexual assault and/or blaming victims for their own sexual victimization, is widespread in some sociocultural settings [10,11]. The relatively high level of alcohol consumption is believed to be a factor contributing to the irresponsible sexual behavior and IPV. Five Introduction Reproductive coercion (RC) interferes with a woman’s decisionmaking regarding reproductive health; it may consist of contraception sabotage and/or pressure to either carry a pregnancy to term or to have an abortion [1]. The RC definitions include male partners’ attempts to promote pregnancy through verbal pressure and threats [2]. The contraception sabotage includes hiding, withholding or destroying contraceptives, deliberate tearing or removing of condoms or failing to withdraw in an attempt to induce pregnancy despite a female partner’s wishes to prevent the pregnancy [3]. Reproductive coercion is not always defined as such by the victim; in particular, intimate partner violence (IPV) may prevent a woman from naming certain behaviors as coercion [1]. In the literature, RC is usually discussed as intentional act. It has been suggested to extend the definition by adding the “RC by negligence”, in particular, the sabotage of agreed or presupposed method of contraception, which sometimes happens under the impact of alcohol [4]. Admittedly, it may be difficult to distinguish between the negligence, subconscious and conscious intentions. The abortion rate in the former Soviet Union (SU) has been the world highest [5], caused not only by the insufficient availability of modern contraception but also by an irresponsible behavior sometimes in conditions of excessive alcohol consumption. According J Addiction Prevention May 2021 Vol.:9, Issue:1 © All rights are reserved by Jargin SV. Avens Publishing Group Inviting Innovations Citation: Jargin SV. Reproductive and Sexual Coercion: The Role of Alcohol, Social and Demographic Conditions. J Addiction Prevention. 2021;9(1): 5. J Addiction Prevention 9(1): 5 (2021) Page 2 ISSN: 2330-2178 case histories are presented here followed by an overview of literature. Certain cases were reported to the authorities after a delay as the denunciation of illegal and immoral acts was unusual in the former SU especially of those committed by individuals from the privileged milieu (exemplified by Case 1).

to a systematic review and meta-analysis, consistent condom use was less prevalent among hazardous vs. regular drinkers in Russia [6]. Fortunately, both the abortion rate and alcohol consumption in Russia tend to decrease [7,8]. It seems that at different times there have been official or unofficial directives aimed at the birth rate elevation initially in conditions of the gender imbalance after the World War II. This resulted in a limited availability of contraceptives, unavailability of voluntary sterilization, and prohibition of abortions till 1955 along with the propagation of consumerist attitude to women: corresponding talks and behaviors have been quite usual. The official atheism obviously contributed to irresponsible and immoral behaviors [9]. In the meantime, the gender imbalance has reverted and global overpopulation has come to the fore; but fertility is stimulated now as before. For example, some popular TV series such as the "Sled" (Trace) and "Slepaia" (The Blind) regularly present unexpected and unintended pregnancies both in and out of wedlock as something natural and unavoidable while contraception is mentioned rarely. Remarkably, in the Episode 306 of the latter series (shown by TV3 on 10 November 2020) a gynecologist at a husband's request surreptitiously replaced contraceptive pills by vitamins. This was presented by the filmmakers as a good deed as the husband wanted children but the wife did not. The risks associated with oral contraceptives are invented or exaggerated by mass media and some literature. Apparently, the propaganda follows policies aimed at the birth rate elevation. Among the background factors are the machismo ideation, disrespect for some laws and regulations, abundant violence and death on TV indirectly trivializing the child and elder abuse, sexual and reproductive coercion. In the author's opinion, authorities should handle the neglectful and intentional contraception sabotage as offenses with infliction of bodily harm if an abortion or unintended pregnancy followed. Of note, a majority of studies on these topics have been performed in more developed countries, while dimensions of the problem in less open societies are difficult to assess. In particular, the rape myth, an ideology excusing sexual assault and/or blaming victims for their own sexual victimization, is widespread in some sociocultural settings [10,11]. The relatively high level of alcohol consumption is believed to be a factor contributing to the irresponsible sexual behavior and IPV. Five

Introduction
Reproductive coercion (RC) interferes with a woman's decisionmaking regarding reproductive health; it may consist of contraception sabotage and/or pressure to either carry a pregnancy to term or to have an abortion [1]. The RC definitions include male partners' attempts to promote pregnancy through verbal pressure and threats [2]. The contraception sabotage includes hiding, withholding or destroying contraceptives, deliberate tearing or removing of condoms or failing to withdraw in an attempt to induce pregnancy despite a female partner's wishes to prevent the pregnancy [3]. Reproductive coercion is not always defined as such by the victim; in particular, intimate partner violence (IPV) may prevent a woman from naming certain behaviors as coercion [1]. In the literature, RC is usually discussed as intentional act. It has been suggested to extend the definition by adding the "RC by negligence", in particular, the sabotage of agreed or presupposed method of contraception, which sometimes happens under the impact of alcohol [4]. Admittedly, it may be difficult to distinguish between the negligence, subconscious and conscious intentions.
The abortion rate in the former Soviet Union (SU) has been the world highest [5], caused not only by the insufficient availability of modern contraception but also by an irresponsible behavior sometimes in conditions of excessive alcohol consumption. According Page -2 ISSN: 2330-2178 case histories are presented here followed by an overview of literature. Certain cases were reported to the authorities after a delay as the denunciation of illegal and immoral acts was unusual in the former SU especially of those committed by individuals from the privileged milieu (exemplified by Case 1).

Case Series
(1) A 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 of a company that, apart from selling to foreigners of icons and silver coins (fartsovka: https://en.wikipedia.org/wiki/Fartsovka), involved adolescents in the binge drinking and teenage girls into sexual contacts e.g. with participants of international exhibitions in Moscow and foreign truck drivers. Individuals infected with N. gonorrheae and other sexually transmitted infections (STI) avoided the dermato-venereological prevention and treatment centers (so-called dispensaries), where the treatment was lengthy and unpleasant, and treated themselves with antibiotics [12]. Intramuscular injections of Hexestrol (Synoestrol) oil solution were used to induce abortions -a well-known method of self-induced abortions in the former SU. The case was reported to the authorities; the informer made no secret of that, later he underwent assault and battery. It is known that some sons of higher officers and functionaries were prone to promiscuity regarded as manly behavior. This case demonstrates that the society and its institutions factually permitted the spread of STI. Being informed of the lengthy and unpleasant treatments, high-risk groups avoided the governmental medical institutions, practiced self-treatment and/ or continued spreading STI. Some female patients, especially those seen as socially unprotected or "immoral", recollected harsh and painful gynecological examinations, abortions etc., whereas personal judgment and ideation of punishment have apparently played a role [12].
(2) A case of child abuse followed by alcohol overconsumption by the victim was reported previously [13]. The ethnic factor obviously played a role as the abuser was of Jewish descent while the victim was ethnic Russian. The history had a prequel. A 33-years-old single mother with a 5-year-old son was visiting at her relatives in one of the Baltic republics. The head of the inviting family was an officer; 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 offender married the victim pregnant at that time. Under conditions of the Soviet registration system, aimed to counteract a mass migration to the Capital, factual and fictive marriages were often used to obtain a residence permit (propiska) in Moscow. In the former SU, the registration and accommodation have been strong motives especially for the cities attracting immigrants. It is known that, in some cultural settings with a rape myth acceptance, sexual violence was a method of acquiring wives [14,15]. The fact that some victims married their rapists was erroneously seen as indication that women enjoy it; in fact, existing accounts demonstrate various degrees of trauma [15]. As mentioned above, high social positions held by offenders or their relatives generally impeded reporting. (3) The victim of child abuse was prone to alcohol consumption and binge drinking during his adolescence and early adulthood. Cause-effect mechanisms have been discussed previously [13]. At the age of 22 years he started relationship with a 7 years older woman coming from another Soviet republic. Having no accommodation in Moscow, she had a motive to maintain the relationship. This motive is known also in other countries, where individuals lacking affordable housing feel coerced to maintain unsafe relationships [16]. The female partner participated in the binge drinking taking smaller doses. The heavy binge drinking was occasionally accompanied by neglect of the agreed withdrawal method of contraception. During four years' cohabitation there was "only" one abortion induced by intramuscular injections of Hexestrol (Synoestrol). However, the neglectful stereotype has been repeated also with other partners, which resulted in two more abortions at least. This behavior was explicable within the scope of frontal lobe dysfunction (discussed below) and Klüver-Bucy syndrome after a childhood head trauma and prolonged alcohol intake with heavy binges: irresponsible behaviors, lack of concern about consequences and morals, loss of normal fear and anger responses, partial visual agnosia and amnesia [17]. Moreover, IPV sometimes occurred in connection with drinking binges. Apparently, it was an example of the intergenerational transmission [18] i.e. continuation of IPV practiced by the stepfather and mother, who both had been victims of physical abuse in their childhood.
(4) In the 7th class of a school (13-14 years old children) appeared two brothers from one of the Transcaucasian republics of the former SU, both early-ripening. It came out later that they had seduced or raped several girls, which resulted in one abortion at least. One of the girls recollected that it happened so quickly that she noticed it when it was too late: the boy was adroit; apparently, he had been instructed within his family. Sexual experiences with relatives are not unusual in certain environments [19]. In particular, mother-son and sisterbrother relationships may result in teenagers feeling themselves as men and acting as such when they deem it safe. It was reported that 49% of "child perpetrators" had been sexually abused prior to their own abusive behaviors [20].
(5) This case is a composite from different individuals; it summarizes the topic of date rape, which has rarely been recognized and prosecuted as such in the former SU, if not arranged as a trap. He invites her or vice versa, then she says "no"; there follows a more or less intensive resistance. Definitions of the non-consent and coercion are not always straightforward in such cases. Studies indicate that sexually aggressive acts often do not involve the condom use, while the offender's alcohol consumption and condom non-use tend to correlate [21]. The condom use is inconvenient in the settings of sexual violence but the withdrawal method of contraception can be applied. Alcohol may contribute to a misperception of intentions [22]. It has been assumed that alcohol impairs a woman's ability to recognize the sexual assault risk and to resist advances [23]. Although intoxication is not a prerequisite of the sexual violence, their cooccurrence suggests that alcohol sometimes plays a causative role [24]. Of note, a case is classified as rape if a victim is incapacitated by drugs or alcohol being unable to give valid consent. One rationale for the date rape is that women going into dates know that men expect sex; therefore, if a woman did not intend it, she should not agree to a date. By analogy with the informed consent in medicine, there can be no situations where a person gives up her or his right to say "no" to any kind of sexual activity [25]. It is important to mention that among ISSN: 2330ISSN: -2178 risk factors of the date rape and contraception sabotage is the hostility toward women [11,26], either to all of them or to a certain ethnic or another type. A direct association between misogynistic attitudes and coercion aimed at unprotected sex has been noticed [21]. This may be a conscious or subconscious "retaliation" for some true or imagined insults in the past while sexual encounters provide opportunities for revenge. Finally, the rape in marriage and partnership should be mentioned; which has often been regarded as norm [15]. As discussed above, the rape culture is an ideology supporting or excusing sexual assault [11]. Hopefully, today the matters are improving together with a decline in the alcohol consumption and heavy binge drinking in the former SU [7,8].

Discussion
An association between the alcohol consumption and negligent behavior is explainable within the framework of alcohol myopia theory. The cognitive capacity is impaired under the impact of alcohol, so that intoxicated individuals concentrate their attention on the cues that are momentarily significant for them. The immediate sexual engagement involves the limited cognitive resources, while more remote cues, such as the risk of STI or unintended pregnancy, are ignored [27,28]. Remarkably, inebriated persons may concentrate their attention on risks and display more prudent behavior if salient features of the encounter emphasize the risks [29]. For example, alcohol tended to enhance the condom use in women from certain ethnic backgrounds presumably through diminishing anxiety about proposing condoms [30]. The data that the condom use was relatively frequent among heavy episodic drinkers [31] agree with our observations: individuals with alcohol dependence and increased tolerance may preserve a high level of risk perception and behavioral skills in the state of intoxication. However, personality changes slowly progressing after a prolonged alcohol overconsumption and heavy binge drinking (discussed below) might sooner or later interfere with the risk perception and social skills. In addition, the heavy binge drinking is associated with severe hangovers, which are sometimes accompanied by depression that in turn is associated with unprotected sex [32].
Apart from immediate effects of the alcohol intake, consequences of a 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 the latter comprises consequences of head trauma, undernourishment, protein and vitamin (especially thiamine) deficiency, toxicity by substances other than ethanol in poor-quality beverages [33] that may contribute to the damage of neural structures and advancement of personality changes. Manifestations of alcohol-related dementia and frontal syndrome partly overlap, sharing the personal and social neglect, derangements of the cognitive capacity with impaired perception of risks, disinhibition, lack of concern about consequences and morals [34][35][36][37][38][39][40][41]. Aggressive behavior is known to occur in alcoholrelated dementia, which is beyond the scope of this review. Of note, aggression in alcoholics is sometimes intentionally provoked by female partners and/or other persons. The alcohol administration research demonstrated that people behave more aggressively when drinking; however, these effects are strongest in individuals predisposed to aggression. Overall, surveys indicated that personality characteristics, attitudes, and past experiences of sexual perpetrators who drink during the assault are similar to those who don't. Many perpetrators commit multiple sexual assaults, some of them when drinking and some when sober. Apparently, alcohol interacts with the personality and some aspects of the situation, enhancing the risk of perpetration among men already predisposed to aggression [24]. Domestic and sexual violence is often combined with the alcohol abuse, while the use of condoms in the context of violence is less probable [42]. There is also an opposing opinion that violence leads to an increased condom use, explained by a loss of trust and intimacy [43]. This may be true for milder cases, when the victim is not intimidated by her violent partner. In this connection, it is important to distinguish between the relationship dysfunction and violent entrapment or "battered woman syndrome" including the learned helplessness [44,45]. RC is regarded to be a form of IPV; it can lead to unintended pregnancy, abortion, poor pregnancy outcomes, STI, psychological trauma and depression [2,3,46,47]. Among potential contributing factors are disrespect for laws and regulations, impunity of some offenses and offenders, habitual display of death and violence on TV indirectly trivializing less spectacular phenomena such as the IPV, sexual and reproductive coercion.
Furthermore, relationships between the safer sex decision making and alcohol intake depend on the level of sociocultural development. Multiple studies performed in more developed countries did not unequivocally confirm the association between alcohol consumption and non-use of condoms [31,[48][49][50][51][52][53][54]. According to some research, only very high levels of alcohol intake reduce the probability of condom use [30]. On the contrary, all known studies performed in less developed or recently industrialized parts of the world confirmed the association of the alcohol intake with the non-use of condoms and other risky sexual behaviors [55][56][57][58][59][60][61][62]. It can be reasonably assumed that the social progress correlates with improvements of morality, so that distracting factors such as alcohol lose their significance. However, international migrations confound this scheme while the alcoholrelated negligence sometimes gives way to migration-related and geopolitical motives [63]. Fictive and temporary marriages have been used for obtaining the registration and accommodation in Moscow as well as in other cities attracting migrants. As exemplified by the Cases 2 and 4, the sexual and reproductive coercion are sometimes used intentionally for the purpose of migration, to cement a relationship and/or to spread a certain genotype. Cases are known when heritable disease in a perpetrator was concealed from the partner and then acquired by the offspring. Various methods are applied: persuasion and seduction, alcohol and drugs, sexual and reproductive coercion, intimidation and IPV. Considering the forthcoming globalization, women should be aware of these strategies.

Conclusion
Interventions for gender-based violence should include the screening for reproductive coercion and confidential counseling [64]. Vasectomy is a viable solution for some males incapable and/ or unwilling to control their behavior and consistently use condoms, although it does not eliminate the necessity of condoms to prevent STI. Admittedly, surgical sterilization can be seen as a violation of the bodily integrity. The same, however, can be said about sexual and ISSN: 2330ISSN: -2178 reproductive coercion. It should be stressed that vasectomy is a safe and efficient method of permanent contraception; it was reported to be 30 times less likely to fail and 20 times less likely to have postoperative complications than tubal ligation in women. Complications of vasectomy are rare and minor in nature [65,66]. Vasectomy is mentioned here because it is obviously preferable to the unintended pregnancy and abortion. As per the tubal ligation, its combination with cesarean section (CS), i.e. cesarean tubal ligation, should be generally considered for women not planning further pregnancies. Certainly, the latest delivery is not necessarily the last one, because circumstances may change after the delivery. The age and attitude of the male partner should be taken into account. However, CS on maternal request must be available also in the absence of contraindications for attempting vaginal delivery. This pertains also to Russia, where CS is usually not performed on a maternal request [67]. Certain authors reported that they had performed CS on maternal request whereas countrywide CS is performed more frequently when the procedure is paid on by patients [68]. Other experts insist that SC must be done only in accordance with indications. In the author's opinion, the worldwide increase in the percentage of deliveries performed by CS is a positive development. A more frequent use of the cesarean tubal ligation would be especially favorable for overpopulated regions with a gender imbalance; details and references are in [69].