Sexual assault prevention for women with intellectual disabilities: a critical review of the evidence

Systematic Review Overview: Violence Against Adults with Disabilities

This study aimed to conduct an overview of systematic reviews in the field of violence against adults with disability. Eight electronic databases as well as gray literature from January 2022 to April 2023 were searched to identify systematic reviews that focused on violence against adults with disabilities. A total of 13 high-quality systematic reviews were included in the overview. Findings show that adults with disabilities experience a higher rate of emotional and physical violence than the general population. Sociodemographic, financial, and cultural risk factors, prevention, and treatment approaches were discussed. Although the large body of studies on disability and violence have explored different aspects of the issue, there are some limitations and gaps in the literature that need further attention. The most important gap in the literature is the lack of attention to diversity. Accordingly, there is little knowledge about disability and violence in a variety of geographical locations. In addition, studies on violence based on ethnicity/race, age, gender identifications, and some types of disabilities such as hearing impairments or severe disabilities were scarce. There is a need to reach diverse populations of adults with disabilities, through employing a variety of data collection methods and qualitative research methodology. Prevention and treatment programs should be developed with attention to types of disability, and they should be culturally and linguistically sensitive.

A Systematic Review of Interventions Addressing the Primary Prevention of Violence Against Women With Disability

Women with disability experience significantly more violence and abuse than their nondisabled peers. Efforts to implement, evaluate, and scale-up strategies to prevent violence against women are rapidly expanding, but we know less about "what works" to prevent violence against women with disability. While secondary and tertiary prevention aim to identify violence early and prevent further occurrence, this review focuses on primary prevention. In the disability services sector, primary prevention is sometimes referred to as safeguarding and covers a range of activities that aim to address the underlying determinants of violence to prevent it from happening in the first place. The aim of this review is to identify and synthesize research on evaluated interventions addressing the primary prevention of violence against women with disability and explore evidence about their quality and effectiveness. A systematic search across the bibliographic databases of Medline, CINAHL, Embase, and PsychInfo for peer-reviewed literature published in English on or after January 1, 2010, yielded 483 papers of potential interest. Twelve studies met the inclusion criteria and were considered for review. Data were extracted and the quality of the studies was assessed using the Quality Assessment Tool for Quantitative Studies. Most studies reported outcomes from pre- and post-test research designs and received a weak rating of quality. Although interventions targeting awareness, knowledge, and skill development showed evidence of effectiveness, there is a distinct lack of program development that draws on known risk factors for violence such as the intersection of ableism and gender inequality.

Addressing sexual assault in Pakistan: Insights from an analysis of female survivors at Lahore General Hospital

BACKGROUND & OBJECTIVE

Rape is a severe kind of sexual violence that represents a significant violation of human rights. The objective was to investigate the demographic and clinical features of female survivors of sexual assault in Lahore, Pakistan.

METHOD

A retrospective study was conducted at the Department of Forensic Medicine of Lahore General Hospital, analysing records of female sexual assault survivors investigated by affiliated police stations from November 2020 to November 2022. Data were collected from medicolegal certificates and medical notes and analysed using SPSS software.

RESULT

282 female survivors reported to Lahore General Hospital's Forensic Medicine Department, aged 5-55 years, with a mean age of 22.74 ± 8.30. A significant proportion (50.4%) were aged 16-25 years. Most survivors were examined between 6 and 24 h (34%) and 2-7 days (37.9%) after the assault, with the majority (95%) exhibiting well-developed secondary sexual characteristics. Sexual assault and physical abuse were both reported in 56.4% of cases. In 77% of cases, the perpetrator was known, and in 36.5% of cases, a weapon was used. No external body injury was observed in 74.8% of cases, and 2.8% showed signs of fresh hymen rupture. The study identified 92.2% of cases lost to follow-up.

CONCLUSION

This study highlights the pressing need to implement effective measures to prevent and address rape in Pakistan. The findings emphasise the need for education, improved forensic infrastructure and policy reforms to address sexual assault effectively.

An Integrative Literature Review of Interventions to Protect People with Disabilities from Domestic and Family Violence

PURPOSE

While domestic and family violence against people with disabilities is an ongoing and crucial public health concern, and awareness of the extent of violence against people with disabilities is growing, research on the field is still limited. Thus, the present review aims to systematically identify and synthesize evidence and effectiveness from intervention strategies to increase the awareness and skills of those with disabilities to reduce and prevent domestic and family violence against them.

METHOD

PRISMA guidelines were followed to perform a systematic search of seven scientific databases to identify the peer-reviewed literature.

RESULTS

A total of 17 eligible studies were identified (14 evaluations and 3 descriptive studies), with most taking place in developed countries. Children and women are the most frequent victims, and they were therefore the most common target audience of the included studies. Sexual, physical, and verbal abuse were the most reported types of abuse, while financial abuse and neglect were studied less often. Interventions also focused on a diversity of disabilities, including learning, intellectual, mental, and physical impairments. Overall, the intervention strategies reflected a substantial homogeneity: focus on training and education as well as setting up channels and facilities for victims to seek help. Nine studies yielded significant positive outcomes using various strategies and techniques, while five studies had mixed results, and three studies only reported on the intervention strategies but did not evaluate the results.

CONCLUSIONS

This review confirms a significant gap in the literature on domestic and family violence against people with disabilities and how to prevent and address the violence through evidence-based interventions. Several recommendations to improve future research and practice are proposed.

The Right to Sexuality, Reproductive Health, and Found a Family for People with Intellectual Disability: A Systematic Review

Although sexuality, reproductive health, and starting a family are human rights that should be guaranteed for all citizens, they are still taboo issues for people with intellectual disability (ID), and even more so for women with ID. This paper systematically reviews the current qualitative and quantitative evidence on the rights of people with ID in regard to Articles 23 (right to home and family) and 25 (health, specifically sexual and reproductive health) of the Convention on the Rights of Persons with Disabilities (CRPD). A systematic review of the current literature, following PRISMA 2020, was carried out in ERIC, PsychInfo, Scopus, PubMed, ProQuest, and Web of Science. In all, 151 articles were included for review. The studies were categorized into six themes: attitudes, intimate relationships, sexual and reproductive health, sexuality and sex education, pregnancy, and parenthood. There are still many barriers that prevent people with ID from fully exercising their right to sexuality, reproductive health, and parenthood, most notably communicative and attitudinal barriers. These findings underline the need to continue advancing the rights of people with ID, relying on Schalock and Verdurgo's eight-dimensional quality of life model as the ideal conceptual framework for translating such abstract concepts into practice and policy.

Analysis of the Differential Efficacy of the Reduced Version Over the Extended Version of an Affective-Sexual Education Program for Adults with Intellectual Disabilities

Recently, with the increase in demand, multiple intervention proposals aimed at improving the sexual health of people with intellectual disabilities have emerged. Among them is the SALUDIVERSEX program, which takes a positive approach to sexuality. It has an extended version, consisting of 16 sessions and whose efficacy has already been proven, and a reduced version of 10 sessions. Thus, the present study aimed to test the differential efficacy of the two versions. A total of 208 participants (103 women and 105 men) aged between 19 and 67 years (M = 37.23, SD = 10.66) completed a battery of instruments before and after the intervention. Statistical analyses showed that users who participated in the reduced version of the program presented a significantly higher rate of improvement in their sexual behaviors compared to those who participated in the extended version (Sexual response: β₁₀ = - 0.46 ± 0.19, p = .034; Sex practices: β₁₀ = - 0.52 ± 0.23, p = .037; Use condoms: β₁₀ = - 1.56 ± 0.59, p = .017), as well as a significantly higher decrease in the risk of suffering sexual abuse (β₁₀ = 3.95 ± 0.64, p < .001). However, no statistically significant differences in sexuality knowledge were obtained with respect to the improvement between the two versions (β₁₀ = - 0.09 ± 1.21, p = .94). Meanwhile, the professionals who applied the program found that those who participated in the reduced version, although they presented a significantly greater increase in their knowledge about privacy (β₁₀ = - 0.48 ± 0.08, p < .001), did not improve their concerns about their inappropriate sexual behaviors as much as the users of the extended version (β₁₀ = - 1.35 ± 0.21, p < .001). Thus, although both versions were effective, the reduced version seems to do so to a greater extent and in a shorter time, which makes it the more recommendable option.

Validation of a Scale on Society's Attitudes towards the Sexuality of Women with Intellectual Disabilities-Survey Study

BACKGROUND

The main aim of this study was to design and validate a questionnaire in Spanish to acknowledge the perception of the sexuality of women with intellectual disabilities. We sought to cover specific spheres of sexuality, such as sexual capacity, decision-making capacity, sexual disinhibition, and sexual education and quality of life.

METHODS

A questionnaire was developed based on a literature review. Validation was performed using content validation through a panel of experts; construct validation was performed using exploratory and confirmatory factorial analyses; reliability tests were also performed, using Cronbach's Alpha and the two-halves test.

RESULTS

Two-hundred forty-four participants pilot tested the initial 34-item questionnaire. After content validation and exploratory factorial analysis, the resulting 10-item questionnaire showed four domains, with Cronbach's Alpha values between 0.69 and 0.82. Confirmatory factorial analysis confirmed the domains, and the model's goodness-of-fit tests were adequate.

CONCLUSIONS

The final ten-item scale developed in this research proved to be a valid and reliable instrument, as it has good psychometric properties of both validity and reliability. Thus, researchers interested in investigating the social perception of the sexuality of women with intellectual disabilities can use this tool. Future research can extend the validity of this scale to other languages and settings.

Sexual Violence Against Persons With Disabilities: A Meta-Analysis

A growing number of large-scale studies suggest that people with disabilities are at greater risk of sexual victimization than nondisabled individuals. However, certain results are inconsistent and whether potential moderators explain this variability in previous findings remain to be considered. This meta-analysis aimed to determine the magnitude of the difference in risk of being sexually victimized based on the presence of a disability. An additional objective was to evaluate the relative influence of gender, age, type of disability, type of sexual violence, and relationship with the perpetrator on the association between the presence of a disability and sexual victimization. Studies were searched using pertinent databases and retained if they included a group with a disability, provided data that quantify the occurrence of abuse, indicated the type of sexual violence, and was published between 1970 and 2018 in French or English. A total of 68 studies, allowing 84 independent samples and 12,427 participants, were included. Individuals with disabilities were at significantly higher risk of sexual victimization than persons without disabilities (odds ratio = 2.27). The risk of sexual victimization among individuals with a disability was significantly higher in adult participants compared with the risk in minor participants. Sensory impairment was the type of disability associated with the highest risk of sexual victimization. Odds of sexual victimization among individuals with a disability were significantly higher in African countries compared with all others, and odds in Western Europe were significantly lower than in the United States. No significant differences emerged across eras.

Formal and Informal Supports for Women With Intellectual and Developmental Disabilities During Pregnancy

This article explores the role of formal and informal supports for women with intellectual and developmental disabilities (IDD) throughout their pregnancy, childbirth, and postpartum experiences. Data from qualitative interviews with women with IDD (n = 16) were analyzed. Results showed that formal supports aided in planning, transportation, advocacy, and providing emotional support throughout pregnancy. Informal supports helped with errands, comfort, and emotional encouragement. The community surrounding these women facilitated communication with providers, self-empowerment regarding health choices, and increased preparedness for parenthood. Findings indicate the importance of encouraging and sustaining both formal and informal supports during pregnancy, childbirth, and postpartum to improve pregnancy and parenting experiences for women with IDD.

Knowledge hardly translates to reality-A randomized controlled trial on sexual abuse prevention for girls with intellectual disabilities

Objective

People with intellectual disabilities (ID) are at higher risk of being sexually abused and developing psychiatric disorders in consequence. The effects of behavior prevention programs for children with ID have rarely been investigated. Previous studies suffer from methodical weaknesses, such as the lack of a control group, small sample size, or invalid outcome measures. This study aimed at demonstrating the efficacy of a prevention program by overcoming these flaws.

Methods

A group prevention program was developed and evaluated. One hundred and six girls aged from 8 to 12 years with mild ID were enrolled in a randomized controlled study, comparing the training to a sham intervention. Effects were examined in a three-time follow-up design as individual changes in preventive knowledge (board game, verbal reports) and preventive behavior (role-play, in situ tests). Participants' behaviors were videotaped and rated by three blinded raters.

Results

Girls from the intervention group (n = 64) showed significant improvements in preventive knowledge compared with the control group (n = 39) but showed non-significant improvements for preventive behavior. In situ tests with realistic seduction situations revealed no improvement. The intervention proved to be safe, but several risks need to be considered.

Discussion

This is the first study that evaluates a behavioral prevention program on sexual abuse for children with ID on a high level of evidence. Group interventions empowering girls with ID to recognize abuse situations are suitable to enhance sexual preventive knowledge but are less suitable to enhance preventive behavior. Naturalistic settings are indispensable for providing evidence for preventive interventions in children with ID.

Peer Educators in the Facilitation of Sexuality and Respectful Relationship Education for People with an Intellectual Disability: A Scoping Review and Narrative Synthesis

A scoping review was conducted to identify how peer-education models are being used in sexuality and respectful relationship education for people with a disability. The search was conducted in August 2021 using the Joanna Briggs framework to scope and map the literature and research activity. Using strict criteria, 7 online databases, grey literature and reference lists were searched for resources written or published in the last 15 years (2006–2021). Relevant sources were shortlisted and assessed by the two authors. Six sources met the criteria for inclusion in this review. In total, four educational programs are described and discussed. The results identify four sexuality and respectful relationship programs that met screening criteria: (1) “Telling it like it is!”, (2) “Sexual Lives and Respectful Relationships”, (3) “Talking about sex and relationships: the views of young people with learning disabilities”, and (4) “Health, Safety & Sexuality Training for You & Me”. Peer-educators experienced increased confidence and feelings of empowerment, while people without an intellectual disability reported a greater understanding of the challenges and experiences of people with a disability. The use of peer educators to deliver sexuality and respectful relationship education for people with intellectual disability is a promising education model with multiple potential benefits for participants. However, more research is needed to understand the consequences and limitations of such programs.

Knowledge, perceptions and experiences of risk to sexual violence among adults with intellectual disabilities in Cape Town, South Africa

Background

People with intellectual disabilities are at high risk to sexual violence, yet minimal research has been conducted in South Africa to understand this phenomenon, especially seeking perspectives of people with intellectual disabilities themselves.

Objectives

This study aimed to explore and describe the knowledge and awareness of risk to sexual violence among adults with intellectual disabilities and to understand their perceptions and experiences of risk.

Method

An exploratory qualitative approach was appropriate as there is lack of literature on this subject. Focus group discussions were used as the method of data collection. The method of conducting focus group discussions and data collection instruments were adapted to suit the communication and cognitive abilities of the adults. Twenty-seven adults participated in the study and they were divided into six groups of four to five participants in each group.

Results

The adults’ responses revealed that they had some knowledge of risks to sexual violence, but they also had knowledge gaps and some erroneous knowledge and perceptions that could put them at high risk. The experiences they shared showed that the risk of sexual violence is high among women with intellectual disabilities.

Conclusion

Further research is needed to inform a community approach which includes people with intellectual disabilities, their families, services providers and community members as an intervention to empower and protect people with intellectual disabilities from sexual violence. To achieve this, we recommend an ecological framework as a guiding tool in both the research processes and the implementation of the outcomes.

Sexual Experiences and Perspectives of Adolescents and Young Adults With Intellectual and Developmental Disabilities

The purpose of this study is to understand the sexual experiences and perspectives of adolescents and young adults (AYA) with intellectual or developmental disabilities, how they are receiving sexual education, and how sexual education can be tailored to their needs. This qualitative study utilized semi-structured focus groups and interviews with eight AYA with intellectual or developmental disabilities from January 14 to May 7, 2019. Data were analyzed using a constant comparative approach. Participants reported a diverse range of sexual experiences and an interest in marriage and parenting in the future. Two themes emerged for how AYA are learning about sexual health information: through formal (school, doctors’ visits, or from caregivers) and informal education (peers, siblings, self-exploration, or Pop Culture). Sexual education can be tailored to this population by addressing educational gaps (pregnancy, contraception, sexually transmitted infections, intimacy, and sexual activity) and by implementing specific participant recommendations (proactive, inclusive education with real-life examples). With a growing emphasis on disability rights to sexual education among individuals with intellectual or developmental disabilities, it is vital to understand AYA’s experiences, perspectives, and current understanding of sexual health information so that we can design a program specifically tailored to meet their unique needs.

Disparities in Accessing Sexual and Reproductive Health Services at the Intersection of Disability and Female Adolescence in Tanzania

Despite at times having greater needs for sexual and reproductive health (SRH) services, adolescents with disabilities often face challenges when trying to access them. This inaccessibility is further exacerbated during female adolescence. The qualitative study examines how SRH services respond to the characteristics of Tanzanian adolescent females with disabilities. We used the method of empathy-based stories to investigate the perceptions of 136 adolescent females with disabilities of their access to SRH services in Tanzania. The study used thematic content analysis and the Levesque model of health care access was applied as an analytical framework. The results demonstrate that discrimination affects access at different phases of care-seeking, that affectionate behaviour of providers is a central enabler of access, and that for this population access relies on a collective effort. We propose that affection, as an enabler of access, is as an additional provider dimension of access to SRH services for adolescents with disabilities, serving as a “reasonable accommodation” to the health care systems in southern contexts and beyond.

"I really want people to use our work to be safe"…Using participatory research to develop a safety intervention for adults with intellectual disability

People with intellectual disability experience disproportionately high rates of interpersonal violence (IPV) due, in part, to disability-related risks that often can be minimized through targeted intervention. In this article, we describe using an academic and community participatory research approach to develop and test the feasibility of an accessible IPV prevention program for people with intellectual disability. The Safety Class, which is an interactive, structured, eight-session, weekly face-to-face group program, was found feasible for implementation in an efficacy study. Working in partnership with the intellectual disability community through all phases of the project helps ensure the relevance, inclusion, and accessibility of The Safety Class.

Evaluation of a Safety Awareness Group Program for Adults With Intellectual Disability

Using a participatory research approach, we enlisted 12 U.S. Centers for Independent Living (CILs) to recruit and enroll 170 adults with intellectual disability (ID) to be randomized to either The Safety Class, an abuse prevention group program, or usual care. Participants were asked to complete pre, post, and 3-month follow-up questionnaires. CIL staff members facilitated the eight-session, interactive program. Quantitative and qualitative findings suggest that participation in a brief safety program may improve safety protective factors among men and women with ID. The Safety Class serves as one model for delivering an abuse prevention and education intervention to adults with significant safety needs but extremely limited access to relevant community resources.

Minor sex trafficking of girls with disabilities

Purpose –

The purpose of this paper is to investigate the associations between minor women' (girls') disability status and victimization via minor sex trafficking.

Design/methodology/approach –

This investigation used data from the National Longitudinal Study of Adolescent to Adult Health, a large, nationally-representative sample of in-school adolescents in the USA that began in 1994. The analysis included bivariate associations between physical disability status or low cognitive ability and minor sex trafficking among female survey respondents (n = 5,430).

Findings –

Girls with any disability had a higher prevalence of minor sex trafficking than their peers without disabilities. Odds of minor sex trafficking were significantly higher for those with severe physical disabilities (5.83) and for those with low cognitive abilities (4.86) compared to the odds of their peers without their respective disabilities. Results for girls with mild or moderate physical disabilities were not statistically significant compared to peers without disabilities.

Social implications –

These nationally-representative survey data reinforce the trends present in smaller populations and case study research: female adolescents with disabilities are at a heightened risk for sex trafficking. On both a national and global scale, the human rights gaps in policy and practice must be addressed to adequately reach, intervene and protect this vulnerable population.

Originality/value –

Research about minor sex trafficking typically relies on small-scale surveys and/or convenience samples. This study used a nationally-representative survey to demonstrate the link between disability status and women's experiences with minor sex trafficking.

Using video vignettes in research and program evaluation for people with intellectual and developmental disabilities: A case study of the Leadership for Empowerment and Abuse Prevention (LEAP) project

People with intellectual and developmental disabilities (IDD) are often excluded from meaningful participation in research and program evaluation for various reasons, including protocols and measures that are inaccessible for people with varying cognitive and communication abilities. Emancipatory research models emphasize the importance of inclusive research practices. Video vignettes are a promising tool for research and program evaluation with people with IDD because they are standardized, they use visual imagery rather than relying on written or verbal communication, and they allow for distance from sensitive topics. The Leadership for Empowerment and Abuse Prevention (LEAP) project used video vignettes to evaluate a healthy relationship program for people with IDD. The authors discuss the process of piloting various protocols and measures, which then ultimately led to the use of video vignettes in the evaluation.

Making Connections and Building Confidence: A Study of Specialist Dating Agencies for People with Intellectual Disabilities

Dating agencies are a small, but growing sector of social care provision for people with intellectual disabilities. The research reported here is the first to explore, with 10 specialist agencies in the UK, why they were set up, how they operate, the barriers and problems they encounter and their success or otherwise in facilitating relationships for people with intellectual disabilities. A strong case is made for the proliferation of such services.

After Disclosure: A Research Protocol to Respond to Disclosures of Abuse and Sexual Violence in Research With Adults With Intellectual Disabilities

People with intellectual disabilities (ID) have high lifetime risk of abuse and assault, including sexual violence. As adults with ID participate in research, researchers must be prepared for disclosures of past or current abuse. In collaboration with our state's protective agency, we developed a protocol for responding effectively to disclosures of sexual violence from adult research participants with ID. We completed a literature review clarifying best practices for responding to disclosures of abuse by adults with ID. The literature focused on various professionals but we were unable to find evidence clarifying researchers' roles in responding to sexual violence. Working with our state protective services agency, we adapted these practices to develop protocols and an algorithm for responding to disclosure, as well as materials for participants. Our protocol for abuse reporting considers all members of the research team to be mandated reporters, emphasizes informed consent, and details specific steps for responding to disclosures of abuse in the context of research. It represents a collaboration between academic researchers and community partners. Research participation by people with ID may represent an opportunity for disclosure of past or current abuse, and therefore, it is imperative that researchers are equipped to respond effectively. Policy-level responses to prevent abuse and enable justice are also needed; however, ensuring that researchers respond systematically and effectively to disclosures is crucial to the ethical conduct of research with a vulnerable population. We anticipate that the frequency with which researchers will need to use this protocol will depend on the nature of their research. In practice, we recommend including this protocol as part of the overall study protocol and submitting it for Institutional Review Board (IRB) approval. Future research to test our protocol in the field is recommended.

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.

"It's When the Trees Blossom": Explanatory Beliefs, Stigma, and Mental Illness in the Context of HIV in Botswana

Mental illness is a common comorbidity of HIV and complicates treatment. In Botswana, stigma impedes treatment of mental illness. We examined explanatory beliefs about mental illness, stigma, and interactions between HIV and mental illness among 42 adults, from HIV clinic and community settings, via thematic analysis of interviews. Respondents endorse witchcraft as a predominant causal belief, in addition to drug abuse and effects of HIV. Respondents describe mental illness as occurring "when the trees blossom," underscoring a conceptualization of it as seasonal, chronic, and often incurable and as worse than HIV. Consequently, people experiencing mental illness (PEMI) are stereotyped as dangerous, untrustworthy, and cognitively impaired and discriminated against in the workplace, relationships, and sexually, increasing vulnerability to HIV. Clinical services that address local beliefs and unique vulnerabilities of PEMI to HIV, integration with peer support and traditional healers, and rehabilitation may best address the syndemic by facilitating culturally consistent recovery-oriented care.

Intimate Partner Violence among Women with Disabilities in Uganda

Violence against women with disabilities is pervasive, yet a paucity of research examines intimate partner violence (IPV) experienced by women with disabilities in low- and middle-income countries. The purpose of this study is to document the prevalence and consequences of IPV exposure among Ugandan women with disabilities. Cross sectional data from the 2011 and 2016 Uganda Demographic and Health Surveys (UDHS) were used to study married and/or partnered women aged 15⁻49 who answered specific questions about lifetime intimate partner violence (N = 8592). Univariate and multivariate logistic regression models were used to investigate the relationship between disability, IPV, and indicators of maternal and child health. Compared to women without disabilities, women with disabilities were more likely to experience lifetime physical violence (odds ratio (OR) 1.4, p < 0.01), sexual violence (OR = 1.7, p < 0.01), and emotional abuse (1.4, p < 0.01) after controlling for sociodemographic and household characteristics. Study findings suggest that women with disabilities in Uganda may experience increased risk for IPV compared to women without disabilities, with concomitant risks to their health and the survival of their infants. Further research examining the prevalence and correlates of IPV in low- and middle-income countries is needed to address the needs and rights of women with disabilities.

Pregnancy course, infant outcomes, rehospitalization, and mortality among women with intellectual disability

BACKGROUND

Pregnant women with intellectual disability (ID) may have greater levels of comorbidity and decreased care access, social support, or ability to monitor their status and communicate needs, but few studies have examined their pregnancy course and outcome, and little is known about their longer-term maternal and infant health.

OBJECTIVE

We compared pre-pregnancy characteristics, pregnancy outcomes, and rehospitalization <2 years after delivery among women with and without ID.

METHOD

We identified all women with ID and randomly selected a 10:1 comparison group of women without ID with singleton live birth deliveries in Washington State population-based linked birth-hospital discharge data 1987-2012. Multivariable regressions estimated adjusted odds ratios comparing pre-pregnancy characteristics. In cohort analyses, we estimated relative risks (RR) and 95% confidence intervals (CI) for outcomes.

RESULTS

Women with ID (N = 103) more often had gestational diabetes (RR 3.39, 95% CI 1.81-6.37), preeclampsia (RR 1.88, 95% CI 1.03-3.42), and inadequate prenatal care (RR 2.48, 95% CI 1.67-3.70). Their infants more often were small for gestational age (RR 1.78, 95% CI 1.10-2.89). Need for rehospitalization postpartum was not increased among women with ID or their infants.

CONCLUSION

Reasons for increased preeclampsia and gestational diabetes among pregnant women with ID are unclear. Barriers to inadequate prenatal care are multifactorial and warrant further study, with consideration that wellness during pregnancy and other times involves social, familial and clinical support systems responsive to each woman's needs.

Care of the Adolescent After an Acute Sexual Assault

Sexual violence is a broad term that encompasses a wide range of sexual victimizations. Since the American Academy of Pediatrics published its last policy statement on sexual assault in 2008, additional information and data have emerged about sexual violence affecting adolescents and the treatment and management of the adolescent who has been a victim of sexual assault. This report provides new information to update physicians and focuses on the acute assessment and care of adolescent victims who have experienced a recent sexual assault. Follow-up of the acute assault, as well as prevention of sexual assault, are also discussed.

Effectiveness of IMPACT:Ability to Improve Safety and Self-Advocacy Skills in Students With Disabilities-Follow-Up Study

BACKGROUND

Research shows that individuals with disabilities are more likely to experience abuse than their peers without disabilities. Yet, few evidenced-based abuse prevention interventions exist. This study examines whether positive outcomes identified previously in an evaluation of IMPACT:Ability were maintained 1 year later.

METHODS

A survey measuring safety and self-advocacy knowledge, confidence, and behaviors among special education high-school students was administered 12 months post-training. Paired samples t-tests were used to compare baseline to follow up and postsurvey to follow up and repeated measures analyses were conducted to test the effect of time across the 3 time points (baseline, post, and 1-year follow up) (N = 47).

RESULTS

Follow-up study participants had a range of disabilities, just over half were boys, and most were either black or Latino/Hispanic. Difference between scores at baseline and follow-up for all the measures of interest represented gains from baseline. Statistically significant post-training improvements in participants' safety and self-advocacy knowledge and confidence were maintained 1-year later.

CONCLUSIONS

These results provide additional support for the case that IMPACT:Ability is a promising safety and self-advocacy training program for diverse groups of students with disabilities.

Child protection services and parents with intellectual and developmental disabilities

BACKGROUND

Information about parents with intellectual and developmental disabilities (IDD) in the child protection system (CPS) continues to evolve. This study examined characteristics, experiences and representation of parents with IDD across three CPS decision points, as compared to parents with other disabilities and parents without disabilities in the United States.

METHODS

The sample consisted of 303,039 individuals: 2,081 were individuals identified as parents in a CPS investigation; 1,101 had children in out-of-home care (OHC); and 308 experienced termination of parental rights (TPR). Descriptive statistics, chi-square analysis, disparity indices and logistic regression were employed.

RESULTS

Parents with IDD were significantly more likely than parents without disabilities (but not significantly more likely than parents with other types of disabilities) to experience disproportionately representation.

CONCLUSIONS

Parents with IDD are generally over-represented within CPS; however, this representation is dependent upon the comparison group utilized and other risk factors. CPS system-level changes are necessary.

Randomized Controlled Trial to Evaluate an Abuse Prevention Curriculum for Women and Men With Intellectual and Developmental Disabilities

This study was designed (a) to assess the impact of the ESCAPE-DD curriculum on the decision-making skills of adults with intellectual and developmental disabilities (IDD) in hypothetical situations of abuse, (b) to examine the role of problem awareness, and (c) to identify factors associated with posttest decision-making performance. Fifty-eight women and men with IDD were randomly assigned to an intervention group or a wait-list control group. Participants who experienced ESCAPE-DD made significantly greater gains on measures of overall effective decision making and safe-now effective decision-making relative to participants in the control group. Problem awareness was related to decision making, but it did not improve as a result of the intervention. Implications of the findings for future curriculum-development efforts are discussed.

Effectiveness of the IMPACT:Ability program to improve safety and self-advocacy skills in high school students with disabilities

BACKGROUND

Individuals with disabilities experience higher rates of abuse than the nondisabled. Few evidence-based prevention interventions have been published despite a need for such work. This study evaluated

IMPACT

Ability, a safety and self-advocacy training for individuals with cognitive and/or physical disabilities.

METHODS

A quasi-experimental design was used to assess change in safety and self-advocacy knowledge, confidence, and behaviors among special education high school students in Boston, MA. Instruments were interviewer-administered at 3 time points. Analysis of covariance (ANCOVA) was used to compare change between the intervention (N = 21) and wait-list (N = 36) groups. Repeated measures analysis was used to test change in the complete sample (N = 57).

RESULTS

Students were diverse (58% males, 82% nonwhite) with a range of disabilities. Significantly greater improvement in key outcomes, including safety and self-advocacy knowledge, confidence, and behavior, were observed in intervention students compared to the wait-list group. Results in the complete sample showed evidence of further improvements in students' sense of safety and general self-efficacy.

CONCLUSIONS

These findings are encouraging given the effects were demonstrated in a heterogeneous urban population.

IMPACT

Ability may be an effective safety and self-advocacy training for students with disabilities. Further research will be required to determine effectiveness within particular subpopulations of students.

The demands of human dignity: Sexuality in the young person with intellectual disabilities

The topic of sexuality among the disabled is often ignored within Catholic seminaries; within pediatrics, it is treated as a "problem" where the best solution is contraception or sterilization. In this article, the authors argue for an approach to sexuality in disabled youth that is grounded in the inherent dignity of the person, borne out of Christ's own humanity. Because sexuality is a part of the human person in his or her totality, it cannot be ignored or obscured; on the other hand, it cannot also be the overriding "problem" which defines them. Rather, by friendship, love, and covenantal solidarity with the disabled person, we can begin to set an example for them and for society that there are goods to be strived for beyond the physical. The demands of dignity require practical changes in seminary and medical education and practice.

A systematic review of the effectiveness of interventions to prevent and respond to violence against persons with disabilities

Persons with disabilities make up some 15% of the world's population and are at higher risk of violence. Yet there is currently no systematic review of the effectiveness of interventions to prevent violence against them. Thus the aim of this review was to systematically search for, appraise the quality of, and synthesize the evidence for the effectiveness of interventions to prevent and mitigate the consequences of all the main forms of interpersonal violence against people with all types of disabilities. The method used consisted of searches of eleven electronic databases, hand searches of three journals, scanning of reference lists of review articles, contact with experts, appraisal of risk of bias using the Quality Assessment Tool for Quantitative Studies, and narrative synthesis of results. This resulted in 736 titles being identified, 10 of which met the inclusion criteria and 6 and 2 addressed people with intellectual disabilities and developmental disabilities, respectively. Only one was from a low- and middle-income country. All studies received a weak rating on the quality assessment tool and none could be considered effective after taking risk of bias into account. In sum, the current evidence base offers little guidance to policy makers, program commissioners, and persons with disabilities for selecting interventions. More and higher quality research is required, particularly from low- and middle-income countries and on other forms of disability such as physical impairments, sensory impairments, and mental health conditions.

A Safety Awareness Program for Women With Diverse Disabilities

Women with diverse disabilities ( N = 213), recruited through 10 centers for independent living (CILs), were randomly assigned to either a personal safety awareness program or usual care. The 8-week program, led by CIL staff, was designed to increase safety awareness, abuse and safety knowledge, safety skills, safety self-efficacy, social support, and safety promoting behaviors. All participants completed pre-, post-, and 6-month follow-up questionnaires. Results revealed that participation in a brief safety awareness program may improve safety protective factors among women with disabilities who vary widely in their experience with abuse. The program holds promise for enhancing safety among women with disabilities.

The role of learning disability nurses in promoting cervical screening uptake in women with intellectual disabilities: A qualitative study

Research suggests that the uptake of cervical screening by women with intellectual disabilities (commonly known as learning disabilities within UK policy frameworks, practice areas and health services) is poor compared to women without intellectual disabilities. The present study explored learning disability nurses' experiences of supporting women with intellectual disabilities to access cervical screening in order to examine their role in promoting attendance and elucidate potential barriers and facilitators to uptake. Ten participants recruited from a specialist learning disability service completed a semi-structured interview and data were analysed using experiential thematic analysis. Identified individual barriers included limited health literacy, negative attitudes and beliefs and competing demands; barriers attributed to primary care professionals included time pressures, limited exposure to people with intellectual disabilities and lack of appropriate knowledge, attitudes and skills. Attendance at cervical screening was facilitated by prolonged preparation work undertaken by learning disability nurses, helpful clinical behaviours in the primary care context and effective joint working.

Determinants of cervical cancer screening among women with intellectual disabilities: evidence from medical records

OBJECTIVE

We examined receipt of cervical cancer screening and determinants of screening for women with intellectual disabilities in one Southeastern state.

METHODS

Using medical records data from 2006 through 2010 for community-dwelling women with intellectual disabilities who were 18-65 years of age (n=163), we employed descriptive and bivariate statistics and a multivariate regression model to examine receipt of cervical cancer screening and the determinants of cervical cancer screening across women's sociodemographic and health-care provider characteristics.

RESULTS

Of women 18-65 years of age with intellectual disabilities, 55% received a Papanicolaou (Pap) test during 2008-2010, markedly below the Healthy People 2020 targets or rates of Pap test receipt of women without intellectual disabilities. Women with intellectual disabilities who lived in residential facilities, those who lived in rural communities, and those who had an obstetrician/gynecologist had higher rates of receipt of care than other women with intellectual disabilities.

CONCLUSIONS

Assertive measures are required to improve the receipt of cervical cancer screening among women with intellectual disabilities. Such measures could include education of women with intellectual disabilities, as well as their paid and family caregivers, and incentives for health-care providers who achieve screening targets.

A friendships and dating program for adults with intellectual and developmental disabilities: a formative evaluation

Meaningful relationships with others are often elusive for people with intellectual and developmental disabilities, but no less desired for their full inclusion and participation in society. It is well documented that people with disabilities are victims of interpersonal violence at higher rates than peers without disabilities. This article presents a formative evaluation of the Friendships and Dating Program (FDP). The FDP was designed to teach the social skills needed to develop healthy, meaningful relationships and to prevent violence in dating and partnered relationships. Thirty-one adults were recruited by 5 community agencies in Alaska to participate. The results showed the size of the participants' social networks increased and the number of incidents of interpersonal violence was reduced for participants who completed the FDP, and outcomes were maintained 10 weeks later.

Physical abuse around the time of pregnancy among women with disabilities

Women with disabilities are at greater risk for physical abuse than women without disabilities. However, no previous population-based studies have examined physical abuse against women with disabilities around the time of pregnancy, a critical period for mother and child. The objective of this study was to describe the prevalence of physical abuse before and during pregnancy among a representative sample of Massachusetts women with and without disabilities. Data from the 2007-2008 Massachusetts Pregnancy Risk Assessment Monitoring System (PRAMS) were analyzed in 2010. Disability prevalence was 4.9% (95% CI = 3.9-6.2) among Massachusetts women giving birth during 2007-2008. The prevalence of physical abuse during the 12-months before pregnancy among women with disabilities was 13.6% (95% CI = 7.2-24.0) compared to 2.8% for women without disabilities (95% CI = 2.1-3.7). Similarly, 8.1% (95% CI = 4.0-15.7) of women with disabilities compared to 2.3% (95% CI = 1.7-3.1) of women without disabilities experienced physical abuse during pregnancy. Multivariate analyses indicated that women with disabilities were more likely to report physical abuse before pregnancy (OR = 4.3, 95% CI = 1.9-9.7), during pregnancy (OR = 2.8, 95% CI = 1.1-7.1), or during either time period (OR = 3.2, 95% CI = 1.4-7.1) than women without disabilities while controlling for maternal age, education, race/Hispanic ethnicity, marital status and household poverty status. No difference was observed by disability status in the likelihood of prenatal-care providers talking to women about physical abuse. These analyses reveal disproportionate prevalence of physical abuse before and during pregnancy among women with disabilities. Screening for physical abuse and timely referral of women in need of assistance are critical to optimize health outcomes for both mother and child.