The use of contraception by women with intellectual disabilities

Centering disability visibility in reproductive health care: Dismantling barriers to achieve reproductive equity

Access to comprehensive and culturally competent reproductive health care is essential for individuals and communities to realize and achieve health and well-being, as one prefers. The disability community represents a diverse group of individuals with a wide spectrum of functional, physical, sensory, and/or neurodivergent abilities. Existing barriers to reproductive health care are a consequence of environmental and attitudinal barriers, not from the disabilities themselves. People with disabilities are also not frequently centered or included in discussions surrounding reproductive rights. This article reviews the intersection of the Disability Justice Movement and the history of discrimination in the United States against people with disabilities with a particular focus on reproductive oppression. We discuss the mechanisms of inequity and barriers to health care, including financial barriers, inaccessible medical facilities, provider discrimination and competency, and guardianship; as well as the importance of open access to contraception, menstrual health, and abortion for people with disabilities. Finally, we explore the intersection of the Disability Justice Movement and the Reproductive Justice Movement to better promote reproductive autonomy.

“It Gives Me, as her Caregiver, a Sense of Security.” Young People with Intellectual Disability and Their Experiences with Sexuality, Menstruation, Gynecological Treatment and Contraception: A Follow-up Analysis of Parents’ and Caregivers’ Perspectives

Background

Research shows that caregivers support but also impede people with intellectual disabilities from developing intimate relationships. People with intellectual disability experience coital sex later and less often compared to adolescents without disabilities. Caregivers often request hormonal contraception from gynecologists on their behalf. Their main motives are pregnancy avoidance (either as a result of consensual sex or sexual abuse) and menstrual suppression.

Method

The sample included 42 primary caregivers of young people with intellectual disability aged 14 to 25. Interviews were evaluated with qualitative content analysis.

Results

Nine of the main caregivers assumed that sexual intercourse had taken place. Half of the carers evaluated the importance of sexuality for the young people with intellectual disability as high. The main reason for seeing a gynecologist was the prescription of hormonal contraceptives; the outcome of which was arbitrary and dependent on the individual gynecologist. The majority of young women took general hormonal contraceptives as a preventive measure or due to heavy bleeding, regardless of sexual activity. One-fifth took hormone depots as a form of long-term contraception.

Discussion

A trusting relationship with the gynecologist favored the compliance and well-being of the young women. The administration of hormonal contraceptives seems to be controlled by third parties. Caregivers used hormonal contraceptives to simplify the regulation of menstruation and felt relieved by it. Carers view the sexual activities of the young women more critically because they fear a pregnancy and the responsibility for a potential grandchild. The use of hormonal contraceptives made carers clearly more tolerant of sexual activity.

Development and psychometric properties of a self-report instrument for the assessment of sexual behaviour and concerns of people with mild intellectual disabilities (SEBECOMID-S)

BACKGROUND

This paper presents a description of the development and psychometric properties of a self-report instrument for the assessment of sexual behaviour and concerns of people with mild intellectual disabilities (SEBECOMID-S).

METHODS AND PROCEDURES

The study included 281 people with mild intellectual disabilities. The psychometric properties were examined through exploratory factorial analysis, descriptive statistics, and reliability indices.

RESULTS

The exploratory factor analyses offered a structure with three factors: concern about the appropriateness of their sexual behaviour, sexual practices performed, and safe sex practices. The model presents an excellent fit (χ² /df = 1.10, RMSEA = 0.019, CFI = 0.997, TLI = 0.995, and SRMR = 0.065). General test reliability was good (α = 0.77, Ω = 0.76).

CONCLUSIONS

SEBECOMID-S is a valid and reliable tool to obtain objective information about the sexual behaviour and concerns of people with mild intellectual disabilities. The use of this instrument will make it possible to adjust their training to their real experiences, making it more effective.

Are Nepal's water, sanitation and hygiene and menstrual hygiene policies and supporting documents inclusive of disability? A policy analysis

PURPOSE

This study assesses the inclusion of disability in Nepal's policy and guidance relevant to water, sanitation and hygiene (WASH), and menstrual hygiene management (MHM) in comparison to gender. We investigated both policy formulation and implementation, using the Kavrepalanchok district as a case study.

MATERIALS AND METHODS

We used the EquiFrame framework, adapted for disability and gender, and focusing on WASH and MHM. Ten Nepali policies and guidance documents were reviewed and scored for quality against the framework, which included 21 core concepts of human rights. We also interviewed key informants to consider the inclusion of disability in the implementation of MHM interventions. We applied stratified purpose sampling to 12 government officials and service providers working in Kathmandu and the Kavrepalanchock district; conducted in-depth interviews and analysed data thematically using Nvivo 11.

RESULTS

Disability was inadequately covered within the policy documents, and MHM policy commitments for disability were almost non-existent. Participation of people with disabilities in policy development was limited; within Kavrepalanchok, policy commitments were not implemented as intended and disability service providers were unable to allocate government resources. Inadequate data on disability and MHM resulted in limited professional understanding of the issues, as service providers had no training. A narrow WASH infrastructure approach to improving MHM for people with disabilities was prioritised. MHM interventions were delivered in schools; these failed to reach children with disabilities who are often out of school. Finally, there were indications that some caregivers seek sterilisation for people with disabilities who are unable to manage menstruation independently.

CONCLUSION

Though the Constitution of Nepal enshrines gender equality and disability inclusion, there are consistent gaps in attention to disability and MHM in policies and practice. These omit and exclude people with disabilities from MHM interventions. Investment is required to generate evidence on the MHM barriers faced by people with disabilities, which would then be drawn on to develop training on these issues for professionals to improve understanding. Subsequently, policy makers could include more concepts of human rights against disability in relevant policies and service providers could implement policy commitments as intended.

Qualitative study exploring the barriers to menstrual hygiene management faced by adolescents and young people with a disability, and their carers in the Kavrepalanchok district, Nepal

BACKGROUND

Menstrual hygiene management (MHM) is a recognised public health, social and educational issue, which must be achieved to allow the realisation of human rights. People with disabilities are likely to experience layers of discrimination when they are menstruating, but little evidence exists.

METHODS

The study aims to investigate barriers to MHM that people with disabilities and their carers face in the Kavrepalanchok, Nepal, using qualitative methods. Twenty people with disabilities, aged 15-24, who menstruate and experience 'a lot of difficulty' or more across one or more of the Washington Group functional domains were included, as well as 13 carers who provide menstrual support to these individuals. Purposeful sampling was applied to select participants. Different approaches were used to investigating barriers to MHM and triangulate data: in-depth interviews, observation, PhotoVoice and ranking. We analysed data thematically, using Nvivo 11.

RESULTS

Barriers to MHM experienced by people with disabilities differ according to the impairment. Inaccessible WASH facilities were a major challenge for people with mobility, self-care and visual impairments. People with intellectual impairments had difficulty accessing MHM information and their carers despaired when they showed their menstrual blood to others, which could result in abuse. No support mechanisms existed for carers for MHM, and they felt overwhelmed and isolated. Menstrual discomfort was a major challenge; these were managed with home remedies, or not at all. Most participants followed menstrual restrictions, which were widespread and expected; many feared they would be cursed if they did not. As disability is often viewed as a curse, this demonstrates the layers of discrimination faced.

CONCLUSION

Issues related to MHM for people with disabilities is more complex than for others in the population due to the additional disability discrimination and impairment experienced. Research exploring these issues must be conducted in different settings, and MHM interventions, tailored for impairment type and carers requirements,should be developed. Attention to, and resourcing for disability inclusive MHM must be prioritised to ensure 'no one is left behind'.

Level of knowledge, attitude, and practice of family planning and associated factors among disabled persons, north-shewa zone, Amhara regional state, Ethiopia

Background

In Ethiopia, people with disabilities face socioeconomic disadvantages and they have a limited access to sexual and reproductive health information including family planning service. At present, however, there is a scarcity of research on the association between disability and family planning, and only limited data is available for disabled people in Ethiopia. Hence, this study assessed the level of knowledge, attitude, and practice of family planning and associated factors among disabled persons in North-shewa zone, Amhara regional state, Ethiopia.

Methods

A cross-sectional survey was conducted from June to October 2019. A total of 397 study participants were interviewed using a structured and pre-tested questionnaire. A multistage systematic sampling technique was employed to select study participants. Data were entered into Epi data and exported into Statistical Package for the Social Sciences (SPSS) version 21 for analysis. Logistic regression was performed to analyze the data. A significant association was declared at a p-value of less than 0.05.

Results

Forty-six percent of study participants were knowledgeable about family planning methods. The injectable was the most known method of modern contraception (74.8%) while withdrawal (18.1%) was the least known traditional family planning method. Fifty-five percent of our study participants had a good attitude about family planning methods and one-fourth (24.5%) of disabled persons currently utilized any method of family planning. Those having a good knowledge of family planning were 1.6 times more likely to utilize family planning methods than those having poor knowledge of family planning methods (AOR = 1.61, CI = 1.27, 16.24). Moreover, participants who completed college education were 7 times more likely to have a good knowledge of family planning methods than uneducated participants (AOR = 7.23; 95% CI = 2.28, 22.06).

Conclusions

In this study, the knowledge, attitude, and practice of disabled people about family planning methods were relatively low. Due attention should be given to ensure that disabled people are well informed about family planning methods through information, education, and communication activities.

How can sexual and reproductive health and rights be enhanced for young people with intellectual disability? - focus group interviews with staff in Sweden

BACKGROUND

Different types of staff support individuals with intellectual disability (ID) in their daily life, in schools, leisure activities and in special accommodations. This study aimed to gain a deeper understanding of experiences and perceptions regarding sexual and reproductive health and rights (SRHR) among staff.

METHODS

Data were collected in mid-Sweden in four focus groups with altogether 20 participants, 18 women and 2 men aged between 18 and 65 years. They had different professions and worked among youth and adults with ID aged 18-40 years in schools, accommodations and with leisure activities. Their working experience varied from 3 years to more than 20 years. Interviews were audio recorded, transcribed and analysed with content analysis.

RESULTS

The participants generally described positive attitudes towards sexuality for people with ID, both among themselves and in society. However, many situations such as ensuring privacy, balancing between waiting and acting, issues around contraception and reproduction were difficult to address and participants had hesitations about childbearing. They described different strategies such as showing respect, enhancing self-esteem and decision making ability and using interprofessional support to cope with frustrating situations. They lacked a clear mandate from managers as well as written guidelines and policies. They requested education and support from peers, supervisors and other professionals.

CONCLUSION

Participants in the study were generally open-minded and accepting towards sexuality among young people with ID. They thought it was difficult to deal with reproduction/parenthood and felt unprepared and frustrated in certain situations. The participants requested a clear mandate from managers, organizational guidelines, more education and inter-professional support. We believe these findings can inform the development of policy and support the implementation of SRHR related guidelines to support staff working with young people with ID.

Role of family caregivers regarding sexual and reproductive health for women and girls with intellectual disability: A scoping review

BACKGROUND

While people with intellectual disability (ID) face disparities relating to sexual and reproductive health (SRH) services, little is known about the role of family caregivers who assist women and girls with ID access SRH services. This scoping review examined the findings of studies to elucidate the role of family caregivers with regard to SRH for women and girls with ID.

METHOD

We used Arksey and O'Malley's six-stage scoping framework, with Levac, Colquhoun and O'Brien's revisions, to evaluate identified sources. We searched three electronic databases, six ID journals and reference lists in full-text articles. Inclusion criteria included (1) primary and secondary source research studies in peer-reviewed journals; (2) published in English; (3) all research methodologies (i.e. qualitative, quantitative, mixed methods and systematic reviews or commentaries); (4) published between 2000 and 2016; and (5) studies from any country.

RESULTS

The search yielded 2062 studies; 57 articles met inclusion criteria. Most studies employed purposive, convenience or criterion sampling. Participants included people with ID, family caregivers, paid caregivers and health-care professionals. Findings were summarised thematically: (1) menstruation and menopause; (2) vaccinations and preventive screenings; (3) supporting sexuality and healthy relationships; (4) coordinating with health-care providers and (5) contraception and sterilisation.

CONCLUSIONS

Findings from this scoping review underscore the need for more and better-quality research, including how family caregivers assist women and girls with ID access perinatal and preventive SRH services and sexual abuse education. Family caregivers, women and girls with ID and health-care providers need increased access to information about SRH.

Provision of Moderately and Highly Effective Reversible Contraception to Insured Women With Intellectual and Developmental Disabilities

OBJECTIVE

To estimate provision of moderately and highly effective reversible contraceptives to women with intellectual and developmental disabilities.

METHODS

We used data from the Massachusetts All-Payer Claims Database to identify women aged 15-44 years with and without intellectual and developmental disabilities who were continuously enrolled in a private commercial insurance plan, Medicaid, or Medicare in 2012. We calculated the percentage of women aged 15-44 years who were not medically or surgically sterile and were provided 1) highly effective, long-acting reversible contraception (LARC, the intrauterine device or subdermal implant); or 2) prescriptions for moderately effective methods (pill, patch, ring, shot, or diaphragm). Logistic regression models estimated the odds of LARC and moderately effective method provision by disability status, adjusted for age, income, and Medicaid receipt.

RESULTS

Among 915,561 women who were not medically or surgically sterile, 13,059 women (1.4%) had at least one intellectual and developmental disability. Women with intellectual and developmental disabilities were less likely to be provided LARC (2.1% vs 4.2%, P<.001, adjusted odds ratio [OR] 0.43, 95% CI 0.38-0.48, P<.001) and moderately effective methods (21.1% vs 29.9%, P<.001, adjusted OR 0.68, 95% CI 0.65-0.71, P<.001) than women without intellectual and developmental disabilities. The one exception was the progestin shot, which was provided more often to women with intellectual and developmental disabilities than women without these disabilities (14.7% vs 4.3%, P<.001). Among a subset of women who only received moderately effective methods or LARC (n=310,344), women with intellectual and developmental disability had lower odds of receiving LARC than moderately effective methods (adjusted OR 0.59, 95% CI 0.52-0.67).

CONCLUSION

The study findings raise concerns that the provision of LARC and moderately effective methods differs based on the presence of intellectual and developmental disabilities. Greater understanding is needed regarding factors that underlie lower provision of LARC in comparison with moderately effective methods, especially the progestin shot, among women with intellectual and developmental disabilities.

Systematic review of menstrual hygiene management requirements, its barriers and strategies for disabled people

BACKGROUND

One quarter of the global population is of menstruating age, yet menstruation is shrouded in discrimination and taboos. Disability also carries stigma, so disabled people may face layers of discrimination when they are menstruating. The objective of the review is to assess the menstrual hygiene requirements of disabled people, the barriers they face, and the available interventions to help them manage their menstruation hygienically and with dignity.

METHODS

Eligible studies, gathered across all countries, were identified by conducting searches across four databases (MEDLINE, PubMed, EMBASE, Global Health) in May 2017, with alerts set on each database to highlight new titles added until April 2018. Eligible studies incorporated analyses relevant to menstruating disabled people and/or how their carers provide support during their menstrual cycle.

RESULTS

The 22 studies included were published since 1976; the majority after 2010 (n = 12; 55%). One study was a quasi-experiment; all others were observational. Most studies (n = 15; 68%) were from high income countries and most (n = 17; 77%) focused on people with intellectual impairments, so the review findings focus on this group and their carers. Outcomes investigated include choice and preference of menstrual product, ability to manage menstrual hygiene and coping strategies applied. Barriers faced included a lack of standardised guidance for professional carers; a lack of menstruation training, information and support provided to people with intellectual impairments and their carers; a lack of understanding of severity of symptoms experienced by people with intellectual impairments, the high cost of menstrual products and lack of appropriate options for people with physical impairments. Few interventions were found, and strategies for menstrual hygiene management applied by carers of persons with intellectual impairments include limiting the disabled person's movements when menstruating and suppressing their menstruation.

CONCLUSIONS

Little evidence was identified on the requirements of disabled people and their carers in managing their menstruation, and only one intervention, but a range of barriers were identified. This gap in evidence is important, as the consequences of failing to meet menstrual hygiene needs of disabled people includes shame, social isolation, and even sterilisation.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095497.

Midwives' work and attitudes towards contraceptive counselling and contraception among women with intellectual disability: focus group interviews in Sweden

OBJECTIVES

Family planning counselling is an essential part of sexual and reproductive health care; however, health care professionals often fail to offer sexual and reproductive health services to women with intellectual disability (ID), based on a misconception of inactive sexuality. The aims of this study were to gain a deeper understanding of midwives' perceptions of sexual health and contraceptive use of women with ID, and of midwives' practices in providing contraceptive counselling to women with ID.

METHODS

Five focus group interviews were conducted with 19 midwives at five antenatal/family planning clinics in central Sweden between December 2016 and February 2017.

RESULTS

The findings are presented in a paradigm model comprising the following components: context, causal conditions for women with ID needing contraception, intervening conditions, action and interaction strategies based on the midwives' approach and performance during the consultation, and finally consequences. Midwives strived to enhance informed choice, whenever possible, and tried to maintain a neutral attitude during counselling. They wanted to provide the most suitable contraceptive method balanced against any risk of long-term use and possible side effects. Midwives raised the need for teamwork and inter-professional support to improve health care, security and access to other related services for women with ID.

CONCLUSIONS

Few women with ID request contraceptive counselling, which limits midwives' knowledge, experience and competence. Midwives, therefore, plan consultations carefully and strive to enable women with ID to make informed contraceptive choices. Increased teamwork could be a way to strengthen the role of midwives and thereby improve counselling.

Contraceptive Provision to Postpartum Women With Intellectual and Developmental Disabilities: A Population-Based Cohort Study

CONTEXT

Women with intellectual and developmental disabilities who experience pregnancy, like all women, require postpartum care that supports their contraceptive knowledge and decision making. Yet, little is known about the postpartum contraceptive care these women receive, or how it compares with care given to other women.

METHODS

A population-based study using linked health and social services administrative data examined provision of postpartum contraceptive care to women who had a live birth in Ontario, Canada, in 2002-2014 and were beneficiaries of Ontario's publicly funded drug plan. Modified Poisson regression was used to compare care between 1,181 women with and 36,259 women without intellectual and developmental disabilities. Outcomes were provision of any nonbarrier contraceptive in the year following the birth and type of method provided.

RESULTS

In the first year postpartum, women with intellectual and developmental disabilities were provided with contraceptives at a higher rate than were other women (relative risk 1.3); the difference was significant for both nonsurgical and surgical methods (1.2 and 1.8, respectively). The higher rate of nonsurgical contraceptive provision was explained by provision of injectables (1.9); there were no differences for pills or IUDs.

CONCLUSION

Nonbarrier contraceptives may be the most appropriate methods for some women with intellectual and developmental disabilities. However, future research should investigate why women with such disabilities are more likely than others to receive injectable contraceptives, which have possible negative side effects, and surgical contraception, which is irreversible. Research also should investigate how these women perceive their participation in contraceptive decision making.

The experience of sexuality in adults with intellectual disability

BACKGROUND

People with intellectual disability have the same sexual needs as those without any disability, yet their sexuality is often restricted by reluctant attitudes and/or fears based on irrational beliefs. The aim of this study is to describe and analyse different areas of sexuality in adults with mild or moderate intellectual disability.

METHOD

The sample consisted of 180 men and 180 women attending occupational centres. All the participants were administered a questionnaire about sexuality adapted to their characteristics.

RESULTS

Results show that 84.2% have had sexual relationships with another person, this percentage being higher in females and in people aged between 38 and 55 years old. Condoms are used by 41.4%. The most frequently used contraceptive methods are the pill (39.6%), transdermal patch (30.2%) and intrauterine device (6.7%). 9.4% of the women and 2.8% of the men has experienced sexual abuse.

CONCLUSION

In conclusion, there is a need to draw up educational programmes, differentiated according to gender and adapted to their reality, which include contents related with sexual health, sexual abuse and condom use.

Maternal attitude towards delaying puberty in girls with and without a disability: a questionnaire-based study from the United Arab Emirates

BACKGROUND

Parental anxiety about the impact of puberty/menses, particularly in girls with severe disability leads to seeking therapeutic pubertal suppression. We aim to explore maternal attitudes and reasons for seeking pubertal suppression.

METHODS

Mothers of girls receiving gonadotropin -releasing hormone analogue therapy in Mafraq hospital, Abu Dhabi were enrolled in the study. A semistructured interview was conducted to ascertain possible reasons for delaying puberty. The study group was divided into girls with a disability with central precocious puberty (CPP) or normal puberty and girls without a disability presenting with CPP.

RESULTS

42 mother-daughter pairs were enrolled and divided into two groups; group A: 15 girls with CPP with no disability; group B: 27 girls with disability (10 had CPP (group B1) and 17 had normal pubertal timing (group B2)). Mothers in group A aimed to delay puberty, while in group B, 13 (48%) mothers desired to halt puberty and 7 (26%) requested permanent surgical intervention. Fear of short stature (15, 100%), inability to cope psychologically (10, 67%) and fear of peer rejection (9, 60%) were the main concerns in group A. In group B, mothers were concerned about menstrual hygiene management (25, 92.5%), fear of child abuse or unwanted pregnancy (15, 55%) and fear of inability to express pain/discomfort with menstruation (8, 30%).

CONCLUSION

Mothers of girls with a disability commonly seek medical help to delay/halt puberty due to concerns about menstrual hygiene. Short final height was the main concern for girls without a disability. Culture and religion play an important role in puberty management in girls with a disability.

Contraceptive use at last intercourse among reproductive-aged women with disabilities: an analysis of population-based data from seven states

OBJECTIVE

To assess patterns of contraceptive use at last intercourse among women with physical or cognitive disabilities compared to women without disabilities.

STUDY DESIGN

We analyzed responses to 12 reproductive health questions added by seven states to their 2013 Behavioral Risk Factor Surveillance System questionnaire. Using responses from female respondents 18-50 years of age, we performed multinomial regression to calculate estimates of contraceptive use among women at risk for unintended pregnancy by disability status and type, adjusted for age, race/ethnicity, marital status, education, health insurance status, and parity.

RESULTS

Women with disabilities had similar rates of sexual activity as women without disabilities (90.0% vs. 90.6%, p=.76). Of 5995 reproductive-aged women at risk for unintended pregnancy, 1025 (17.1%) reported one or more disabilities. Contraceptive use at last intercourse was reported by 744 (70.1%) of women with disabilities compared with 3805 (74.3%) of those without disabilities (p=.22). Among women using contraception, women with disabilities used male or female permanent contraception more often than women without disabilities (333 [29.6%] versus 1337 [23.1%], p<.05). Moderately effective contraceptive (injection, oral contraceptive, patch, or ring) use occurred less frequently among women with cognitive (13.1%, n=89) or independent living (13.9%, n=40) disabilities compared to women without disabilities (22.2%, n=946, p<.05).

CONCLUSIONS

The overall prevalence of sexual activity and contraceptive use was similar for women with and without physical or cognitive disabilities. Method use at last intercourse varied based on presence and type of disability, especially for use of permanent contraception.

IMPLICATIONS

Although women with disabilities were sexually active and used contraception at similar rates as women without disabilities, contraception use varied by disability type, suggesting the importance of this factor in reproductive health decision-making among patients and providers, and the value of further research to identify reasons why this occurs.

[Sexual health and intellectual disability: a narrative literature review and its implications for nursing practice.]

Issues associated with affectivity and sexuality in the context of intellectual disability have recently been the subject of various interdisciplinary discussions in academia. In nursing, interventions in sexual health are supported with hesitation and those issues constitute a marginal field of nursing research. A narrative literature review was realized in order to establish a portrait of the knowledge produced on this topic in the last decade. This paper illustrates three specific research areas recently developed, namely issues related to sexual autonomy, contextual factors positively or negatively contributing to emotional and sexual life, and the experiences of people identified as having an intellectual disability in this regard. On the basis of these results, different issues related to sexuality and intellectual disability are discussed, including those associated with the negotiation process of affective and sexual life, parenthood as a mediator of emotional and sexual expression, and the inclusiveness issues of sexual diversity in health interventions. Implications for nursing are finally discussed in light of the recent development of its role in sexual health.

Disparities in receipt of family planning services by disability status: New estimates from the National Survey of Family Growth

BACKGROUND

A substantial and increasing population of US women of childbearing age live with disability. Disability-based disparities in access to family planning services have been previously documented, but few studies have used population-based data sources or evidence-based measures of disability.

OBJECTIVE

To determine population-based estimates of use of family planning services among women 15-44 years of age in the United States, and to examine differences by disability status.

METHODS

This is a secondary analysis of a cross-sectional survey, the 2011-2015 National Survey of Family Growth. These analyses include 11,300 female respondents between the ages of 15 and 44 who completed in-person interviews in respondents' homes.

RESULTS

Approximately 17.8% of respondents reported at least one disability in at least one domain. Women with disabilities were less likely than those without disabilities to receive services; the largest differences by disability status were seen among women with low education, low income, and those who were not working. Logistic regression analysis suggests that women with physical disabilities and those with poorer general health are less likely to receive services.

CONCLUSIONS

Women living with disabilities reported lower receipt of family planning services compared to women without disabilities, but the differences were small in some subgroups and larger among disadvantaged women. Physical disabilities and poor health may be among the factors underlying these patterns. Further research is needed on other factors that affect the ability of women with disabilities to obtain the services they need to prevent unintended pregnancy.

The sexuality of young women with intellectual and developmental disabilities: A neglected focus in the American foster care system

Youths with intellectual and developmental disabilities (ID/DD) are overrepresented in the American foster care system and experience heightened rates of pregnancy compared to their nondisabled peers. Yet limited information is known about sexually active or pregnant young women with ID/DD in foster care. Consequently, important healthcare needs of this population are not adequately addressed. This article explores sexuality education and sexual healthcare for female adolescents in foster care with ID/DD and recommends practice guidelines to support and prepare their emergent sexual development.

Endocrine problems in children and adolescents who have disabilities

The consequences of disability span almost all aspects of life, for families and for an affected individual. Endocrine aspects of disability cover disorders of hypothalamic pituitary dysfunction, bone health, puberty, fertility, sexual function and contraceptive needs. Adequate endocrine assessment for a child with a disability requires extensive and sensitive history to address social issues, general nutrition, vitamin D status, specific hypothalamic pituitary problems, together with parental concerns regarding puberty and contraception. Bone health assessment includes history of minimal trauma fracture, need for intervention or fitness for surgery. Strategic interventions to improve outcome include management of puberty, vitamin D status, biomechanical stimulation with vibration and standing and possible consideration for bisphosphonate in special circumstances. Both early and late puberty cause major family concerns. The paediatrician must be aware of a range of management options to improve outcomes for the child and family.

Concepts of contraception for adolescent and young adult women with chronic illness and disability

Sexual behavior is common in adolescents and young adults with or without chronic illness or disability, resulting in high levels of unplanned pregnancy and STDs. Individuals with chronic illness or disability should not receive suboptimal preventive health care. These individuals have a need for counseling regarding issues of sexuality and contraception. Sexually active adolescent and young adult women can be offered safe and effective contraception if they wish to avoid pregnancy. Women with chronic illnesses and disabilities who are sexually active should also be offered contraception based on their specific medical issues. Condoms are also recommended to reduce STD risks. Table 36 summarizes basic principles of contraception application for specific illnesses, which have been identified since the release of the combined OC in 1960. Clinicians should also consider the noncontraceptive benefits of this remarkable and life-changing technology that allows all reproductive age women to improve their lives, including those with chronic illnesses and disabilities.

Caring for a daughter with intellectual disabilities in managing menstruation: a mother's perspective

BACKGROUND

The concerns of mothers and their experiences while providing help to their daughters with intellectual disability (ID) and considerable support needs during menstruation have rarely been addressed. This qualitative study explored mothers' experiences and perceptions of managing their daughters' menstruation.

METHOD

Twelve Taiwanese mothers of 13 daughters with ID (1 mother had twins) were interviewed to explore their experiences of providing help to their daughters with high support needs during menstruation.

RESULTS

Support networks were limited and mothers developed their own strategies for managing their daughter's menstruation. Surgical hysterectomy or use of medication to cease or postpone menstrual bleeding was never considered by the mothers. The financial cost of menstrual pads and nappies was significant.

CONCLUSIONS

Both an appropriate allowance for families involved in the menstrual care of women with ID and access to appropriate support are needed. More information and educational programs need to be provided to relevant professionals and carers.

Relationships, sexuality and decision-making capacity in people with an intellectual disability

PURPOSE OF REVIEW

The current review attempts to summarize the current status of our knowledge and clinical practice in the complex and challenging area of relationships and sexuality for people with an intellectual disability.

RECENT FINDINGS

Although there has been an ideological shift within services for people with an intellectual disability towards person-centredness and inclusivity, this change has not manifested in an obvious way at the practice level in the area of relationships and sexual expression. Recent surveys of caregivers and service providers do show a greater awareness of the fact that sexuality is a central part of personal identity, yet generally restrictive or prohibitive attitudes prevail at both individual and organizational levels. These attitudes appear to reflect a fear of possible legal sanction as well as ethical and moral conflicts. The views and experiences of people with an intellectual disability generally confirm this impression that, whereas some small changes have taken place, the prevailing experience is of restriction. Whereas there is now an abundance of sexuality and relationship educational programmes available, they require more rigorous and systematic evaluation both in terms of their effectiveness for enhancing knowledge and, more importantly, for examining the impact of that education on behaviour and capacity to make sexuality-related decisions, which we know to be a fluid ability.

SUMMARY

There is a need for greater education of caregivers and a need for discussion of the complex issues regarding relationships and sexuality at a societal and policy level. The development of self-advocacy in disability services provides a vehicle to operationalize the changing service ideologies in a way that provides greater opportunities for enriching relationship experiences whilst also preventing undue risk of harm. However, successful self-advocacy requires organizational support, and this remains the greatest challenge for service providers.