Disability and women's health

Contraceptives are used by women with intellectual disabilities for various reasons, including pregnancy prevention, menstrual suppression, and management of teratogenic medications.[19] Women with intellectual disabilities are more likely to use contraceptives or request a hysterectomy to manage menstruation.[20][21] Different types of contraception are available to women with disabilities, but the prescription of a specific type of birth control is based on the type of disability and the associated side-effects.[21]

Menstrual cycles are sometimes affected by different types of disabilities, such as rheumatoid arthritis.[21] In addition, women who become disabled later in life sometimes experience transient menstrual disorders.[21]

Healthcare professionals are less likely to refer women with disabilities for various gynecological screenings.[22] This could be due to the healthcare provider's unfamiliarity with disability or the assumption that women with disabilities are asexual in nature.[23] Women who have a spinal cord injury above the T6 vertebra can have autonomic dysreflexia during a pelvic exam which can be life-threatening.[24] Women with intellectual disabilities are less likely to receive Pap smears because the process may be upsetting to the patient.[25][26]

In the case that the examination table cannot be lowered during a Pap smear, women with physical disabilities can use alternative examination positions during the procedure, such as knee-chest position, diamond-shaped position, M-shaped position and V-shaped position.[27] These alternative procedures can accommodate women who are unable to position their feet into stirrups or need greater body support.[27] In addition, lithotomy stirrups can be used for additional comfort.[28] The Welner table, designed by American obstetrician-gynecologist and disability rights activist Sandra Welner, is an examination table designed with a wider range of adjustments and positions to facilitate accessibility for both patients and doctors with physical disabilities.[29] Welner also compiled the handbook, Welner's Guide to the care of women with disabilities.[30]

A study conducted in 1989 found that 19% of women with physical disabilities had been counseled on sexuality in a medical setting and were rarely offered information about contraceptives.[6] Women with intellectual disabilities often lack both education about sexual health and the ability to learn about it informally.[31] In addition, their medical providers are less likely to discuss contraception with them.[20] Women with intellectual disabilities can use supported decision-making with family members or other support persons to determine their preferred contraceptive option.[32]

In Zimbabwe, people with disabilities are often treated as second-class citizens. Women in Zimbabwe face increased barriers when accessing services for sexual health.[33] The National Reproductive Health Policy implemented in 2006 did not address the needs of women with disabilities.[34] Zimbabwean women with disabilities faced negative attitudes about their reproductive health, such as those of female nurses who expressed the idea that "sex was not meant for the disabled."[35]

Women with intellectual disabilities have been advised to become sterilized to possibly prevent sexual assault or because doctors may consider them unfit to become mothers.[36][37] In the United States, a 1927 Supreme Court case, Buck v. Bell, allowed the forced sterilization of women with intellectual disabilities.[38] In Singapore, the Voluntary Sterlisation Act (VSA) was passed in 1970 and which allowed any spouse, parent or guardian of persons who are "afflicted with any hereditary form of illness that is recurrent, mental illness, mental deficiency or epilepsy" to consent to the sterilization on their behalf.[39] In Brazil, many healthcare providers and individuals with disabilities both see sterilization as the only option for contraception.[22]

Some studies have highlighted potential obstacles for pregnant women with disability. For example, a 1996 study discovered that over 50% of United States hospitals lacked the necessary infrastructure to cater to the needs of physically disabled pregnant women, which rendered their facilities inaccessible.[40] These barriers may include lack of adjustable examination tables, wheelchair compatible features, and accessible weight scales.[41]

A study published in the Journal of Applied Research in Intellectual Disabilities demonstrated that pregnant women and mothers with intellectual disabilities benefit from the inclusion of a doula both before and after they gave birth.[42] This approach contrasts with "crisis driven" services that are more often given to parents who have intellectual disabilities.[43] Participants in one small study felt that they gained a trusting relationship with their doulas and that helped them stay calm both during labor and after.[44] Additionally, the women felt that they were able to make better, more informed choices about their own care because of the information and support they received from their doulas.[44]

Expectant mothers with intellectual disabilities may need more specialized training and guidance in regards to childcare after they give birth.[45] Important themes in training may include consistent formal obstetric training and education for both providers and mothers.[45]

Many women with a disability do not regularly receive or are not regularly referred for breast cancer screenings.[46] Women with some physical disabilities may need to be referred to special mammography centers because most equipment is not designed to accommodate women who are unable to stand.[21][47] Some women with disabilities may be unable to receive breast cancer screening due to financial concerns.[47] Clinical depression is also a complication involved in whether or not women with disabilities get annual mammograms.[48] There is also potential concern that ionizing radiation applied to the spine too early on in life may cause an increased risk of developing breast cancer.[21] This is of particular concern for those women and girls who experienced disabilities relating to the spine from a young age.[21]

Standards of successful aging may be different for those experiencing disabilities and they may require additional support as they age.[49] Older women are more likely to be disabled than younger women.[21] The most common disability affecting elderly women worldwide is osteoarthritis.[50] Older women who have disabilities that affect their mobility are at risk of losing contact with their communities and may experience degraded life outcomes associated as a result.[51]

Women with physical disabilities are at a greater risk of having lower bone mass and are at risk for osteoporosis.[52] Women with ID and Down syndrome often go through menopause at an earlier age than other women.[53] Women with various disabilities sometimes show different symptoms from decreased estrogen levels during menopause.[21]

Loss of estrogen after menopause can also lead to a greater likelihood of urinary incontinence[21] Treatment and therapy interventions for incontinence have not been tested or modified for women with disabilities.[54]

• Right to health
• Sexual and reproductive health and rights
• Sexuality and disability