Reproductive Health Care
for Women With Disabilities
OBJECTIVES
To identify the characteristics of the population of
women with physical disabilities
To describe special considerations necessary in the
gynecological exam for women with physical
disabilities
To identify major health issues that are unique to
women with physical, developmental or sensory
disabilities.
To identify medical issues that require special
consideration for women with disabilities.
To increase awareness of those things which facilitate
access to health care for women with disabilities
To identify resources to support the OB-GYN treating
women with disabilities
Tutorial Outline
Part I: Introduction
Module 1: Scope of disability in women
Module 2: Sexuality
Module 3: Psychosocial issues
Part II: Routine GYN Health Care
Module 1: The GYN Examination
Module 2: GYN Health Screening : Breast and
cervical cancer, STI’s, Skin examination
Tutorial Outline
Part III - Medical considerations
Module 1: Contraception
Module 2: Menses and abnormal uterine bleeding
Module 3: Pregnancy and parenting issues
Module 4: Bladder and bowel considerations
Module 5: Diet, exercise and weight
Module 6: Adolescent issues
Module 7: Aging and osteoporosis
IV – Health issues specific to disability type
–Module 1: Mobility impairments
–Module 2: Developmental disabilities
–Module 3: Sensory disabilities
–Part
Tutorial Outline
Part V: Improving Access
Module 1: Requirements and incentives
Module 2: Disability Culture
Module 3: Universal design and Office
Solutions
Part VI: Resources
Module 1
SCOPE OF DISABILITY
Objectives –
Scope of Disability
At the conclusion of this module, the
participant will be able to:
1.
2.
3.
4.
Define “disability” as it relates to this program.
Have an increased awareness of the prevalence
of disabilities for women in the US by a variety
of demographics.
Identify 2 barriers to care for women with
disabilities
Identify 3 unmet health care needs for women
with disabilities
Part I
INTRODUCTION
Defining “Disability”
“A physical or mental impairment that
substantially limits one or more
major life activities.”
Source: Americans with Disabilities Act of 1990 (ADA)1
Defining Health in Women
with Disabilities
Challenge to the paradigm
Disability ≠ sickness
Medical definitions of health
Perception of personal health among
women with disabilities (WWD)
World Health Organization definition of
health
WHO Definition of Health
“Health is the state of complete
physical, mental, and social wellbeing and not merely the absence of
disease or infirmity”
Source: United Nations World Health Organization5
Glossary of Terms on Disability
Accessibility
Activities of Daily
Living – ADL
Developmental
disability
Functional
limitation - FL
Impairment
Instrumental Activities
of Daily Living – IADL
People-first language
Sensory disability
Severe disability
Universal design
Disability by Type
23%
18%
5%
13%
3%
3%
3%
9%
9%
6%
8%
N = 59,939
Source: Diab and Johnston,
2004 8
Back or Neck
Arthritis
Injury
Breathing
Walking
Heart
Mental
Vision
Diabetes
Medical
Other
Type of Impairment
Women Aged 16-64
N = 11 million women
12% of all
women
aged 16-64
have one of
these 3
types of
disabilities
Source: US Census Supplementary Survey 20009
30%
19%
51%
Physical
Mental
Sensory
Disability by Age of Woman
12
10
8
Num
6
(M)
4
2
0
15-24 25-44 45-64
Source: US Census Bureau,
American Community Survey 200210
Age (y)
65+
Race and Severity of Disability
Adult Women
Any disability
Severe disability
Percent
30
20
10
0
White
Black
Asian
Source: US Census Bureau, Survey of income and program participation 1996-7 12
Hispanic
Education and Disability
U.S. Women Ages 18-34
35
No Disability
With a Disability
30
Percent
25
20
15
10
5
0
< 12y
12y
Some College
College
Degree
Source: U.S. Census Bureau, Survey of income and program participation 1996-7 12
Professional
Employment and Disability
Percent
U.S. Women Ages 21 - 64
80
70
60
50
40
30
20
10
0
No Disability
With a Physical Disability
With a Self-care Disability
Employed
Source: U.S. Census Bureau Supplementary Survey, 2000 9
Employed full time for
past year
Poverty Rate by Gender and
Type of Disability
35
30
Percent
below
Poverty
Line
25
20
Men
Women
15
10
5
0
No Disability
Mental
Physical
Type of disability
Source: National Health Interview Survey 2005 13
Sensory
Transportation Difficulty
for People with Disabilities
Don't want to inconvenience others
No one I can depend on
Transportation is hard to use
No car
No or limited public transportation
0
5
10
15
20
25
Percent Reporting
Source: USDOT, Freedom to Travel, 200314
30
35
40
Unmet Need Among SSI Recipients:
New York, 1999-2000
50
Working age = 18-64 yrs.
Percent
40
30
20
10
0
Any Unmet
Need
Medical Care Doctor Care
or Surgery
Source: Coughlin TA, et al., Health Care Fin Rev, 2002 15
Prescription
Drugs
Special
Equipment
Unmet Health Care Needs
for People with Disabilities
Reasons for unmet health care needs:
Limited availability of providers
Limited provider accessibility
Surgeon General’s Call to Action
To Improve The Health And Wellness Of
Persons With Disabilities - 2005
Goals involve:
public
awareness,
health care
provider
knowledge,
personal
life style
change,
accessible
services
Summary – Scope of Disability
Disability does not mean sickness
Disabilities are prevalent: 12% of
women age 16 to 64 identify as having
a disability
WWD face educational and economic
barriers
WWD have unmet health needs
Scope of Disability
Module Quiz
True/False
1. A disability is a condition requiring
medical treatment.
2. Universal design is a theological term in
the context of this program.
3. Transportation is a major issue for people
with disabilities
4. Insufficient attention is paid by the health
care system to prevent secondary
conditions in persons with disabilities.
References
1. Americans with Disabilities Act of 1990 (ADA), 42 USC § 12102 (2) accessed at http://www.ada.gov/pubs/ada.htm#Anchor-36876 on
12/10/07
2. Iezzoni LI, O’Day BL. More Than Ramps. 2006 Oxford University Press, New York: p18
3. Ibid. p 20
4. Marks MB. More than ramps: Accessible health care for people with disabilities. CMAJ 2006; 175(4): 329
5. WHO. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New
York,19-22 June 1946, and entered into force on 7 April 1948. Accessed at
http://www.who.int/bulletin/bulletin_board/83/ustun11051/en
2/20/07
6. U.S. Census Bureau. Disability definitions. Downloaded from :www.census.gov/hhes/www/disability/disab_defn.html. on
11/20/07
7. Carmona, R. Surgeon General’s Call to Action To Improve The Health And Wellness Of Persons With Disabilities. U.S. Dept. of
Health and Human Services. 2005. Downloaded from http://www.surgeongeneral.gov/library/disabilities/calltoaction/index.html on
12/10/07
8. Diab ME, Johnston MV. Relationships between level of disability and receipt of preventive health services. Arch Phys Med Rehabil.
2004 May; 85(5): 749-57
9. US Census Bureau American 2000. (disability types) Available at
http://factfinder.census.gov/servlet/DTSubjectKeywordServlet?_ts=215370183390 Accessed on 12/10/07
10. US Census Bureau. American Community Survey Available at :
http://factfinder.census.gov/servlet/DatasetMainPageServlet?_program=ACS&_submenuId=datasets_1&_lang=en&_ts=
Accessed 12/10/07
11. McNeil JM. Americans with Disabilities: 1994-95, Washington DC: GPO, 1997
12. US Census Bureau. Survey of income and program participation 1996-97. Available at http://www.sipp.census.gov/sipp/
13. National Center for Health Statistics. Vital and Health Statistics, Series 10, No. 232: Summary and Health Statistics for U.S. Adults:
National Health Interview Survey, 2005. Centers for Disease Control and Prevention, Hyattsville MD, 2006.
14. U.S. Department of Transportation, Bureau of Transportation Statistics (2003b). Freedom to travel. BTS03-08. Washington, DC.
15. Coughlin TA, Long SK, Kendall SJ. Health care access use and satisfaction among disabled Medicaid beneficiaries. Health Care
Financing Review 2002;24:115-36
Module 2
SEXUALITY
Objectives - Sexuality
At the completion of this module, the
participant will be able to:
Have an improved understanding of the
sexual response cycle and neurological
pathways to response.
List 3 factors affecting sexuality in WWD
List 4 facilitators in taking a sexual history
Identify at least one strategy to improve
sexual functioning in these realms:
Diet, medication administration, environment,
psychosocial, advocacy.
Overview
Background information on the sexual
response cycle and neurological pathways
Factors affecting sexuality in women with
disabilities
Barriers for health care providers (HCP) in
talking about sexuality
Strategies for talking with and helping
patients and their partners with sexual issues
Sexual Dysfunction
Adolescent sexuality
% Agreeing
Information About Sexuality
Offered to Women with Disabilities
60
50
40
30
20
10
0
od
to
rs
de
Un
d
fie
d
re
tis
fe
Sa
Of
er
id
d
ov
ke
Pr
As
en
om
W
o
nf
tI
an
W
Source: Beckman 1989 1
Sexual Physiology
Sexual response mediated by nerve
roots T10-L2 and S2-S4
Vaginal lubrication involves S2-S4
Up to 50% of women with spinal cord
injury (SCI) can experience orgasm2
Most information is generalized based
on more thorough studies among men
with disabilities
Sources of Sexual Dysfunction
Primary:
impairment of
sexual feelings
or response
such as those
that may arise as
a result of the
disability
Secondary:
nonsexual
impairment that
affects sexuality
such as
emotional
response
Tertiary:
psychosocial or
cultural issues
that interfere
with sexual
experience such
as gender role
expectations.
Barriers to Knowledge
Women’s Sexual Health
Research in female sexual function and
dysfunction has lagged tremendously due to:
Inadequate funding of basic science research
Lack of basic science models of sexual response in
female animals
Limited research on sexuality and WWD
Professional training in sexual health remains
limited
Traditional Model of Sexual
Response
Orgasm
Source: Masters & Johnson 19663
Multiple
Orgasm
Female Sexual Response Cycle
Emotional
Intimacy
Emotional and
Physical
Satisfaction
Motivates the sexually
neutral woman
to find/be
responsive to
“Spontaneous”
Sexual Drive
“Hunger”
Sexual
Stimuli
Psychological and
biological factors
govern “arousability”
Arousal &
Sexual Desire
Source: Modified from Basson, 20015
Sexual
Arousal
Neurologic Pathways Involved in Female
Sexual Functioning
Reflex vaginal lubrication
mediated by:
Smooth muscle
contraction of the uterus,
fallopian tubes and
paraurethral glands
mediated by:
Contraction of striated
pelvic floor muscles,
perineal and anal
sphincter muscles
mediated by:
• Sacral parasympathetics
• Psychogenic thoracolumbar sympathetics
and sacral parasympathetics
• Thoracolumbar sympathetics
• S2 to S4 parasympathetics along the
somatic efferents
Source: Sipski, 1991 2 and Griffith 1975 6
Factors Affecting Sexual
Function in WWD
Physiologic or mechanical limitations
Misconceptions and social stereotypes
about ability to have and enjoy sex
Fear of the safety of having sexual relations
Concerns about body-image, self-esteem,
self-concept
Depression, stress and anxiety
Fatigue
Pain
Life experiences (i.e. abuse)
Medications
Affecting Sexual Function
Anti-hypertensives
Oncologic agents
Lipid-lowering agents
Psychotropics
Diuretics
Sedative-hypnotics
Antidepressants
Stimulants
Immunosuppressive agents
Anti-androgens
Anticonvulsants
Decongestants
Anticholinergics
Antispasmodics
Source: Nusbaum 20037
Antivirals
Antiarrhythmics
Sexuality in Adolescent Girls
With and Without Disabilities
Girls’ Experiences at Age 16 by Physical Disability Status
Physical Disability
Status
Never Had
Sex
All
Consensual
Been Forced
No disability
66.3
27.7
6.0
Minimal disability
48.2
40.9
10.9
Mild disability
63.7
23.4
12.9
Severe disability
57.9
31.0
11.1
1994-1995 Wave 1 Data from the National Longitudinal Study of Adolescent Health
Probability sample of adolescents in grades 7-12 in US Schools. N = 24,105
Disability severity index is set on a functional, self and parent defined scale at the time of
the survey
Source: Cheng and Udry, 2002 (9)
Sexuality Considerations
Adolescents with Disabilities
Need sexuality education and open
discussion
May lack knowledge /skills for safe
sex
Different disabilities affect puberty at
different rates
Societal attitudes hinder sexual
development more than their disability
Past sexual abuse likely to affect
sexual expression
Sexuality and Aging in Women
With and Without Disabilities
Common changes experienced by
menopausal women
Delayed orgasm
Vaginal dryness from vulvovaginal
atrophy
Unique factors affecting sexual
function in women with disabilities
Fatigue
Joint stiffness
Medication use
Reasons for Not Discussing
Sexuality
Health care providers (HCPs) may be reluctant
to discuss sexual health in WWD because:
•
•
•
•
•
Uncomfortable introducing the subject of
sexual health
Unaware of how to address sexual concerns
in WWD
Inquiry about sexual functioning is neglected
due to the complexity of the patient’s
underlying condition(s)
WWD are reluctant to bring up sexual
concerns without HCP prompting
HCP has a negative stereotyping of WWD
Taking a Sexual History
Initiating the discussion lets the
patient know that sexuality is an
important aspect of health
Be Direct – Use developmentally
appropriate language
Be Sensitive
Emphasize common concerns
about sexual functioning to ease
discomfort
Taking a Sexual History (cont’)
Use open-ended and nonjudgmental questions
After meeting with the patient
see patient and partner together
Strategies to Optimize Sexual
Functioning in WWD
General considerations
Dietary issues
Medication administration
Environmental issues
Psychological issues
Advocacy Issues
Other provider counseling suggestions
General Considerations to Optimize
Sexual Functioning in WWD
Educate woman and her partner on
issues particular to her disability
Take into account:
Baseline sexual function
Sexual history
Other possible causes for sexual
dysfunction
Dietary Strategies to Optimize Sexual
Functioning in WWD
Patients should be encouraged to:
Avoid tobacco
Limit alcohol intake
Delay sexual activity until 2 or
more hours after drinking
alcohol or eating
Source: Nusbaum 2003 7 and Nusbaum 2001 20
Medication Administration to Optimize
Sexual Functioning in WWD
Patients should be encouraged to:
Use analgesics (if needed) approximately 30 minutes
before sexual activity
Reduce or switch to alternative medications that
may not have as negative an impact on sexual
functioning
Try muscle relaxants if hip or lower extremity
spasticity interfere with enjoyment and/or
performance
Treat underlying depression
Use a water-based personal lubricant to
relieve vaginal dryness during sexual activity
Source: Nusbaum 2003 7 and Nusbaum 2001 20
Environmental Strategies to Optimize
Sexual Functioning in WWD
Patients should be encouraged to:
Plan sexual activity when energy level is highest (and when rested and relaxed)
Plan sexual activity for time of day when symptoms tend to be the least bothersome
Avoid extremes of temperature
Experiment with different sexual positions
Use pillows to maximize comfort
Maintain physical conditioning to highest possible level
If sphincter control has been lost, empty bladder & bowel before sexual activity
Source: Nusbaum 2003 7 and Nusbaum 2001 20
Psychological Strategies to Optimize
Sexual Functioning in WWD
Patients should be encouraged to:
Keep a healthy attitude.
Enhance sexual expression through use of the senses
Maximize use of nonsexual intimate touching
Communicate likes, dislikes, and needs to partner
Use self-stimulation as needed to reduce anxiety, help
with sleep, and provide general pleasure
Source: Nusbaum 2003 7 and Nusbaum 2001 20
Advocacy to Optimize Sexual
Functioning in WWD
Promote the availability and use of private
space for couples and individuals
Instruct caregivers and institutions on
patient sexuality
Provider Counseling to Optimize
Sexual Functioning in WWD
Target counseling to:
address body image, self-esteem,
social acceptance
adjustment to reality of physical limitations and
sexual functioning
foster mutual willingness of patient to have
open, honest discussions with partner on effect
of disability sexual functioning
Consider expert referral for sex therapy or
cognitive behavioral therapy
Strategies to Optimize Sexual
Functioning in WWD
Additional counseling tips:
Avoid assumptions
Assess needs
Tailor advice
Be creative
Involve partner
Explore involving other care givers
Evaluation of Sexual Dysfunction in
Women with Disabilities
Multi-disciplinary Approach is
KEY
Primary Health Care Provider and/or clinician
with expertise in Female Sexual Dysfunction
Psychiatrist
Sex Therapist
Physical Therapist
Social Worker
Summary - Sexuality
Women with disabilities have the need
and ability to express their sexuality
HCPs can provide education and
advocacy to support sexual expression
Most barriers can be overcome by
perseverance and creativity
Sexuality
Module Quiz
True/false
1.
2.
3.
4.
5.
Women with disabilities live in a protected environment
and have little opportunity or desire for sexual contact.
Women with spinal cord injuries and spina bifida are
unable to experience orgasm.
Muscle relaxants may help to reduce extremity spasticity
that can interfere with sexual performance.
An important approach to optimize sexual functioning for
WWD is creativity.
Adolescent girls with physical disabilities are much less
likely to have had sex than their peers.
Resources on Sexuality for
Women with Disabilities
Kroll K, Levy EL. Enabling romance: a guide to
love, sex and relationships for the disabled (and
the people who care about them). New York:
Harmony Books, 1992.
Journal of Sexuality and Disabilities – quarterly
journal published by Springerlink.
http://www.springerlink.com/content/104972/
www.sexualhealth.com
Web Resources on Sexual Health
for Health Care Providers
American Association of Sex Educators,
Counselors, and Therapists www.aasect.org
Educational resource on Female Sexual
Dysfunction for health professionals:
http://www.femalesexualdysfunctiononline.org
Society for the Scientific Study of Sexuality
www.sexscience.org
International Society for the Study of Women’s
Sexual Health www.isswsh.org
International Academy of Sex Research
www.iasr.org
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Beckmann CR, Gittler M, Barzansky BM, Beckmann CA. Gynecologic health care of
women with disabilities. Obstet Gynecol. 1989;74:75-9.
Sipski ML. Spinal cord injury: What is the effect on sexual response? J Amer
Paraplegia Soc 1991;14(2):40-43
Masters WH, Johnson VE. Human Sexual Response. Reproductive Biology Research
Foundation. Boston: Little Brown 1966
Kaplan HS. The New Sex Therapy, Vol 2. Disorders of Sexual Desire and other New
Concepts and Techniquesin Sex Therapy. New York: Brunner/Mazel 1979.
Basson R. Female Sexual Response: The role of drugs in the management of sexual
dysfunction. Obstet Gynecol 2001;98:350-353
Griffith ER, et al. Sexual functioning in women with spinal cord injury. Arch Phys Med
Rehabil 1975;56(1):18-21
Nusbaum MR, et al. Chronic illness and sexual functioning. Amer Fam Phys
2003;67(2):347-54
Nosek MA, et al.Sexual functioning among women with physical disabilities Arch Phys
Med Rehab 1996;77:107-15
Cheng MM, Udry JR. Sexual behaviors of physically disabled adolescents in the United
States. Journal of Adolescent Health 2002;31:48-58
Suris JC, Resnick MD, Cassuto N, Blum RW. Sexual behavior of adolescents with
chronic disease and disability. Journal of Adolescent Health 1996;19:124-31
Murphy N, Young PC. Sexuality in children and adolescents with disabilities. Dev Med
& Child Nerol 2005:47:640-644
Drugs that cause sexual dysfunction: an update. Medical Lett Drugs Ther 1992;34:73-8
References (cont)
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Foley FW, et al.Qualitative evaluation of obstacles facing multiple sclerosis
societies in addressing sexual dysfunction in MS. Int J MSCare 1999. Vol 1 Issue 1.
p. 64-68. Available at www.mscare.com
Zorzon M. Sexual dysfunction in multiple sclerosis: a case-control study. 1.
Frequency and comparison of groups. Mult Scler 1999:5:41827
Marinkovic S, Badlani G. Voiding and sexual dysfunction after cerbrovascular
accidents. J Urol 2001;165:359-70
Saxton M. Reclaimimg sexual self-esteem – peer counseling for disabled women.
West J Med 1991;154:630-31
Basson R. Sexual health of women with disabilities. Can Med Assoc J.
1998;159:359-362
Nusbaum MR, Hamilton C. The proactive sexual health inquiry: key to effective
sexual health care. Amer Fam Phys 2002;66:1705-12
Sipski ML. Central nervous system based neurogenic female dysfunction: Current
status and future trends. Arch Sex Behav 2002;31(5):421-24
Nusbaum MR. Sexual Health Monograph No. 267, Home study self-assessment
program. Leawood, Kan.: American Academy of Family Physicians, 2001
Sipski ML. Sildenafil effects on sexual and cardiovascular responses in women
with spinal cord injury. Urology 2000;55(6):812-815
Sipski MJ. A psychiatrist’s views regarding the report of the International
Consensus Conference on female sexual dysfunction: Potential concerns
regarding women with disabilities. Sex Mar Ther 2001;27:215-6.
Female Sexual Dysfunction – Classifications
Sexual
Desire/Interest
Disorder
 Hypoactive sexual desire disorder (deficiency of sexual
thoughts or desire for sex)
 May be due to psychological factors or secondary to
hormone deficiencies or surgical intervention
 Sexual aversion disorder (phobic aversion to and
avoidance of sexual contact)
 Usually psychological in origin, due to trauma
 Sexual Arousal Disorder (FSAD) (inability to attain or
Female Sexual
Arousal
Disorder
Orgasmic
Disorder
maintain sexual excitement expressed as a lack of
subjective excitement or lack of genital responses e.g.
lubrication, swelling)
May be psychological or physiological in origin
 Orgasmic Disorder (difficulty, delay or absence of
orgasm after sufficient stimulation)
Primary (never achieved orgasm) due to abuse or
medication
Secondary due to surgery, trauma or hormone
deficiencies
Pain Disorder
 Dyspareunia (genital pain associated with intercourse)
 Vaginismus (involuntary spasm of the musculature of
the outer third of the vagina)
 Non-coital sexual pain disorder (genital pain induced by
non-coital sexual stimulation)
Module 3
PSYCHOSOCIAL ISSUES
Objectives: Psychosocial
Issues
At the completion of this module, the participant will
be able to:
1.
2.
3.
4.
5.
Identify the risk factors and specific treatment
considerations for depression for women with disabilities
Have an improved understanding of the special risks of
substance abuse and smoking for women with disabilities
Describe the issues leading to the abuse of women with
disabilities
Identify the behavioral and physical indicators for sexual
assault in WWD
Become familiar with the disability specific abuse
assessment screen
Depression
Women with disabilities are at greater risk
for depression than women in general1
Those at risk for depression tend to be
younger and have:
Adult onset of disability 1
Chronic pain 1
Greater functional limitations 2
A low sense of mastery 2
Poor satisfaction with support 2
Women with lifelong disabilities tend to
have a lower prevalence of depression than
those with recently acquired disability.3
Depression By Disability
Impairment
Percent responding “yes”
Impairment
No disability
Depressed
Stressed
Strong fears
3.4
24.8
1.3
14.2
2.5
13.2
Deaf or hard of
hearing
Major lower extremity
mobility difficulty
16.8
8.9
10.5
33.6
20.3
17.4
Major upper extremity
mobility difficulty
35.7
21.5
19.4
Blind or low vision
Source: 1994-5 National Health Interview Survey Disability Supplement , Adapted from Iezzoni, 2006 8
Depression Treatment
Women with disabilities are less likely to
receive treatment for depression. 1
Depression treatment considerations:
Be aware of interactions and side effects of
medications, particularly if taking meds for
seizures or spasms.
Utilize social worker or case manager to assist in
finding appropriate depression counseling.
For some women, aerobic exercise may improve
depressive symptoms. 9
Depression Medication
Considerations for WWD
Tricyclic Antidepressants –
anticholinergic side effects
Urinary
retention
Constipation
Orthostatic
hypotension
SSRIs –side effects
Apathy
GI upset
Sexual dysfunction
and vaginal dryness
Weight gain
Agitation
Source: AHRQ 2007
Depression Medication
Choices
Concern
Weight gain
Diarrhea
Sexual
dysfunction
Abnormal
bleeding
Source: AHRQ 20079
Action
Avoid mirtazapine and
pareoxetine. Consider
buproprion
Avoid sertraline
Consider bupropion
Consider tricyclics or
bupropion
Stress
Those at highest
risk include
those limited by:
Women with
physical disabilities
report high levels of
perceived stress
• Pain
• Lack of family
and social
support
• Having
experience with
recent abuse
Stress leads to
the
development of
secondary
medical
conditions
Stress
management
such as web
based wellness
programs,
meditation and
water aerobics
may be helpful
Prescription Drug Abuse
Mind altering drugs prescribed for relief
of pain, anxiety, spasms, insomnia and
other ailments.
Combine with alcohol or other drugs
Share with friends
Abuse /overuse may be unintentional
Coordination with other HCPs needed
Substance Use Screening
and Treatment
Substance abuse puts user at risk for
increased impairment
Women with disabilities require the same
screening for substance use as all women
The ADA requires accessibility for
substance abuse treatment facilities.
SAMHSA treatment locator web site
http://dasis3.samhsa.gov
Smoking Prevalence
Impairment
Use tobacco
No Impairment
Blind or very low vision
21.7%
32%
Deaf or very hard of hearing
Major upper extremity mobility
difficulty
34.9%
38.3%
Major lower extremity mobility
difficulty
42.9%
Mild to borderline developmental
disability
Data source: MEPS 2001 12 , Hymowitz, 1997 13
30-37%
Smoking and Women With
Disabilities
Smoking can involve social
connection with others
Relieves stress associated with
anger, abuse, depression,
poverty, dependency
Interventions need to stress
reasonable substitution of
activities to replace smoking.
Pharmacotherapy for
Smoking Cessation
Increases smoking cessation rates by
50%.
Combine medications with QuitLine
counseling – 1-800-QUIT NOW
Considerations:
NRT patch – skin irritation and breakdown
Buproprion –
Contraindicated with seizure disorders
Use may deter weight gain
Also used as an antidepressant
Varenicline new effective alternative
Teen Smoking and Substance Use
Teens with disabilities who are at
greatest risk for smoking, alcohol
and/or marijuana use are those who:
Live away from their family of origin.
Have a mild to moderate learning
disability. 19
Girls use substances at about the
same rate as boys.
Teens with disabilities need tailored
health promotion programs about
drug, alcohol and tobacco use.
Case Study - Abuse
Woman age 40 with cerebral
palsy
Caregiver accompanies and
answers when questions posed
to patient
Poor nutritional state,
unexplained bruises and red
marks on buttocks and thighs
Patient fearful of abuse report
Domestic Abuse
Prevalence equal with women
without disabilities except:
Duration of abuse often longer
More often to occur by attendant or
health care providers
More difficulty resolving abusive
situations
Lack of accessible shelters
Fear of losing physical care assistance
Fear of losing children
Issues Leading to Abuse of
Women with Disabilities
Power and
control by
nondisabled
people.
“Easy
targets”
Belief that
no harm is
done or
that the
woman is
not aware.
Poverty,
reliance on
abusive
caregivers.
Abuse: Clues from Medical
History
Inconsistent description
Injury to treatment time delay
Accident-prone history
Suicide attempts or depression
Repeated psychosomatic complaints
Abuse: Clues from Medical
History (cont)
Alcoholism and/or drug abuse
Unexplained injuries
Poor nutrition and/or sleep
Other pregnancy-related problems
Post-traumatic stress disorder
Prevalence of Sexual Assault in
Women With Disabilities
Women with developmental disabilities have
an increased the risk for sexual assault.21
Often the offender is known and are support
providers.22
49% of these victims of sexual assault
experience 10+ incidents. Only 3% of cases
are reported and conviction is rare.23
> 50% of those sexually assaulted also
receive physical injuries.24
Behavioral Indicators of
Sexual Assault
Any significant change in behavior
Depression, withdrawal
Sleep disturbances
Sudden avoidance or fear of specific
people, specific genders or situations
Shying away from being touched
Hints about sexual activity and/or has a
new or detailed understanding of sexual
behavior
Physical Indicators of
Sexual Assault
Bleeding, bruising, infection, scarring
or irritation of genitals, rectum, mouth
or breasts
Difficulty walking or sitting
Ongoing, unexplained medical
problems like stomachaches or
headaches.
Caregiver Behavior
Indicators of Sexual Assault
Grooms or
massages
victims to get
them used to
personal
touch.
Giving special
gifts or treats.
Set up times
they can be
alone on a
regular basis
Sexual Abuse Prevention
Education
For Women with Developmental Disabilities
Keeping sex a secret does not protect them.
Learning needs:
Age appropriate sexual behavior
Sex knowledge and use of body parts
Relationship development
How to recognize sexual mistreatment and
how to avoid it.
Identifying opportunities for disclosure
Times for compliance and times for
assertiveness
Provider Response Messages
When responding to a victim of abuse
or sexual assault promote messages
such as:
I believe you
It is not your fault
You are not alone
I want to help you
Abuse Reporting/Response
Barriers
Fear- particularly if perpetrator is a family
member or personal care assistant
Non-accessible and untrained victims’
services
Lack of adequate disability care services
Reporting Requirements
Many states mandate the
reporting of known or
suspected abuse of people or
adolescents with disabilities
to the state department of
elder affairs or child
protective services. 29
Abuse Assessment Screen
Disability (AAS-D)
1.
2.
3.
4.
Within the last year, have you been hit, slapped,
kicked, pushed, shoved or otherwise physically
hurt by someone?
Within the last year has anyone forced you to
have sexual activities?
Within the last year, has anyone prevented you
from using a wheelchair, cane, respirator or other
assistive devices?
Within the last year, has anyone you depended
on refused to help you with an important
personal need, such as: taking your medicine,
getting to the bathroom, getting out of bed,
bathing, getting dressed, or getting food or
drink?
Source: Nosek 2001 30
Summary –
Psychosocial issues
All women with disabilities should be
screened for psychosocial issues as
frequently as the general population.
Some disability related modification
to screening questions and treatment
may be necessary
Psychosocial Issues
Module
Quiz
True/False
1.
2.
3.
4.
5.
6.
Most women with disabilities are depressed.
It is important to consider the side effects of
antidepressant medications when used for WWD
Smoking is particularly dangerous for people with
mobility disabilities
The prevalence of domestic abuse with WWD is
equal to that of women without disabilities.
If the patient is non-verbal it is not possible to
determine if she has experienced a sexual assault.
Screening for abuse and sexual assault for WWD is
similar to their peers without disabilities.
References
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4.
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8.
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