Reproductive Health Care for Women With Disabilities

1
Reproductive Health Care for Women With
Disabilities
2
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

3
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, STIs, Skin examination

4
Tutorial Outline

• Part III - Medical considerations
• Module 1 Contraception
• Module 2 Abnormal uterine bleeding
• Module 3 Pregnancy and parenting issues
• Module 4 Diet, exercise and weight
• Module 5 Adolescent issues
• Module 6 Aging and osteoporosis
• Part IV Health issues specific to disability
  type
• Module 1 Mobility impairments
• Module 2 Developmental disabilities
• Module 3 Sensory disabilities

5
Tutorial Outline

• Part V Improving Access
• Module 1 Requirements and incentives
• Module 2 Sensitivity
• Module 3 Universal design
• Part VI Resources

6
Part I

• INTRODUCTION

7
Module 1

• SCOPE OF DISABILITY

8
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
9
Defining Health in Women with Disabilities (WWD)

• Challenge to the paradigm
• Disability ? sickness
• Medical definitions of health
• Perception of personal health among WWD
• WHO definition of health

10
WHO Definition of Health

• Health is the state of complete physical,
  mental, and social well-being and not merely the
  absence of disease or infirmity
• Source United Nations World Health Organization5
  

11
Glossary of Terms on Disability

• Impairment
• Instrumental Activities
• of Daily Living IADL
• People-first language
• Sensory disability
• Severe disability
• Universal design

• Accessibility
• Activities of Daily Living ADL
• Developmental disability
• Functional limitation - FL

12
Disability TypesU.S. 1997 ages 18
N 59,939
Source Diab and Johnston, 2004 8
13
Women Aged 16-64by Type of Impairment-

• 12 of all women aged 16-64 have one of these 3
  types of disabilities

N 11 million women
Source US Census Supplementary Survey 20009
14
Population of Women with DisabilitiesAge and
Severity

• 26 million American women have a disability
• 63 are severe
• 31 require assistance with ADLs
• Source US Census Bureau,
• American Community Survey 200210

15
Adult Women with Disabilities,by Race and
Severity
Source US Census Bureau, Survey of income and
program participation 1996-7 12
16
Education U.S. Women Ages 18-34
Source U.S. Census Bureau, Survey of income and
program participation 1996-7 12
17
EmploymentU.S. Women Ages 21 - 64
Source U.S. Census Bureau Supplementary Survey,
2000 9
18
Poverty Rate by Gender and Type of Disability
Source National Health Interview Survey 2005 13
19
Difficulty With Transportation
Source USDOT, Freedom to Travel, 200314
20
Unmet Need Among Working-Age SSI Recipients New
York, 1999-2000
Working age 18-64 yrs.
Source Coughlin TA, et al., Health Care Fin Rev,
2002 15
21
Unmet Health Care Needs

• Reasons for unmet health care needs
• Limited availability of providers
• Limited provider accessibility

22
Surgeon Generals 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

23
Summary

• 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

24
References

• 1. Americans with Disabilities Act of 1990 (ADA),
  42 USC 12102 (2) accessed at http//www.ada.gov/
  pubs/ada.htmAnchor-36876 on 12/10/07
• 2. Iezzoni LI, ODay 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/bull
  etin_board/83/ustun11051/en
• 2/20/07
• 6. U.S. Census Bureau. Disability definitions.
  Downloaded from www.census.gov/hhes/www/disabilit
  y/disab_defn.html. on
• 11/20/07
• 7. Carmona, R. Surgeon Generals 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/s
  ervlet/DTSubjectKeywordServlet?_ts215370183390
  Accessed on 12/10/07
• 10. US Census Bureau. American Community Survey
  Available at http//factfinder.census.gov/servle
  t/DatasetMainPageServlet?_programACS_submenuIdd
  atasets_1_langen_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 200224115-36

25
Module 2
SEXUALITY
26
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

27
Information About Sexuality Offered to Women with
Disabilities
Source Beckman 1989 1
28
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

29
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.

30
Womens Sexual HealthBarriers to Knowledge

• 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

31
Traditional Model of Sexual Response
Orgasm
Multiple Orgasm
Plateau
Resolution
Excitement
Source Masters Johnson 19663
32
Female Sexual Response Cycle
Emotional Intimacy
Motivates the sexually neutral woman
Emotional and Physical Satisfaction
to find/be responsive to
Spontaneous Sexual Drive Hunger
Sexual Stimuli
Psychological and biological factors govern
arousability
Arousal Sexual Desire
Sexual Arousal
Source Modified from Basson, 20015
33
Neurologic Pathways Involved in Female Sexual
Functioning

• Reflex vaginal lubrication mediated by
• Sacral parasympathetics
• Psychogenic thoracolumbar sympathetics and sacral
  parasympathetics
• Smooth muscle contraction of the uterus,
  fallopian tubes and paraurethral glands mediated
  by
• Thoracolumbar sympathetics
• Contraction of striated pelvic floor muscles,
  perineal and anal sphincter muscles mediated by
• S2 to S4 parasympathetics along the somatic
  efferents

Source Sipski, 1991 2 and Griffith 1975 6
34
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)

35
Medications Affecting Sexual Function

• Oncologic agents
• Psychotropics
• Sedative-hypnotics
• Stimulants
• Anti-androgens
• Decongestants
• Antivirals
• Antiarrhythmics

• Anti-hypertensives
• Lipid-lowering agents
• Diuretics
• Antidepressants
• Immunosuppressive agents
• Anticonvulsants
• Anticholinergics
• Antispasmodics

Source Nusbaum 20037
36
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)
37
Sexuality in 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

38
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

39
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 patients underlying
  condition(s)
• WWD are reluctant to bring up sexual concerns
  without HCP prompting
• HCP has a negative stereotyping of WWD

40
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

41
Taking a Sexual History (cont)

• Use open-ended and non-judgmental questions
• After meeting with the patient see patient and
  partner together

42
Strategies to Optimize Sexual Functioning in
Women with Disabilities

• General considerations
• Dietary issues
• Medication administration
• Environmental issues
• Psychological issues
• Advocacy Issues
• Other provider counseling suggestions

43
Strategies to Optimize Sexual Functioning in
Women with Disabilities

• General considerations
• 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

44
Strategies to Optimize Sexual Functioning in
Women with Disabilities

• Dietary
• 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
45
Strategies to Optimize Sexual Functioning in WWD

• Medication Administration
• 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
46
Strategies to Optimize Sexual Functioning in WWD

• Environmental 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
47
Strategies to Optimize Sexual Functioning in WWD

• Psychologic
• Patients should be encouraged to
• Keep a healthy attitude. A positive perspective
  is an important aspect of maintaining sexual
  health
• 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
48
Strategies to Optimize Sexual Functioning in WWD

• Advocacy
• Promote the availability and use of private space
  for couples and individuals
• Instruct caregivers and institutions on patient
  sexuality

49
Strategies to Optimize Sexual Functioning in WWD

• Provider Counseling Suggestions
• 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

50
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

51
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
• Urologist (Male partner Sexual Dysfunction)

52
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

53
Reference 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

54
Web References 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.femalesexuald
  ysfunctiononline.org
• Society for the Scientific Study of Sexuality
  www.sexscience.org
• International Society for the Study of Womens
  Sexual Health www.isswsh.org
• International Academy of Sex Research
  www.iasr.org

55
References

1. Beckmann CR, Gittler M, Barzansky BM, Beckmann
   CA. Gynecologic health care of women with
   disabilities. Obstet Gynecol. 19897475-9.
2. Sipski ML. Spinal cord injury What is the effect
   on sexual response? J Amer Paraplegia Soc
   199114(2)40-43
3. Masters WH, Johnson VE. Human Sexual Response.
   Reproductive Biology Research Foundation. Boston
   Little Brown 1966
4. 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.
5. Basson R. Female Sexual Response The role of
   drugs in the management of sexual dysfunction.
   Obstet Gynecol 200198350-353
6. Griffith ER, et al. Sexual functioning in women
   with spinal cord injury. Arch Phys Med Rehabil
   197556(1)18-21
7. Nusbaum MR, et al. Chronic illness and sexual
   functioning. Amer Fam Phys 200367(2)347-54
8. Nosek MA, et al.Sexual functioning among women
   with physical disabilities Arch Phys Med Rehab
   199677107-15
9. Cheng MM, Udry JR. Sexual behaviors of physically
   disabled adolescents in the United States.
   Journal of Adolescent Health 20023148-58
10. Suris JC, Resnick MD, Cassuto N, Blum RW. Sexual
    behavior of adolescents with chronic disease and
    disability. Journal of Adolescent Health
    199619124-31
11. Murphy N, Young PC. Sexuality in children and
    adolescents with disabilities. Dev Med Child
    Nerol 200547640-644
12. Drugs that cause sexual dysfunction an update.
    Medical Lett Drugs Ther 19923473-8

56
References (cont)

1. 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
2. Zorzon M. Sexual dysfunction in multiple
   sclerosis a case-control study. 1. Frequency and
   comparison of groups. Mult Scler 1999541827
3. Marinkovic S, Badlani G. Voiding and sexual
   dysfunction after cerbrovascular accidents. J
   Urol 2001165359-70
4. Saxton M. Reclaimimg sexual self-esteem peer
   counseling for disabled women. West J Med
   1991154630-31
5. Basson R. Sexual health of women with
   disabilities. Can Med Assoc J. 1998159359-362
6. Nusbaum MR, Hamilton C. The proactive sexual
   health inquiry key to effective sexual health
   care. Amer Fam Phys 2002661705-12
7. Sipski ML. Central nervous system based
   neurogenic female dysfunction Current status and
   future trends. Arch Sex Behav 200231(5)421-24
8. Nusbaum MR. Sexual Health Monograph No. 267, Home
   study self-assessment program. Leawood, Kan.
   American Academy of Family Physicians, 2001
9. Sipski ML. Sildenafil effects on sexual and
   cardiovascular responses in women with spinal
   cord injury. Urology 200055(6)812-815
10. Sipski MJ. A psychiatrists views regarding the
    report of the International Consensus Conference
    on female sexual dysfunction Potential concerns
    regarding women with disabilities. Sex Mar Ther
    200127215-6.

57
Female Sexual Dysfunction Classifications

• 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 Desire/Interest Disorder
Female Sexual Arousal Disorder

• Sexual Arousal Disorder (FSAD) (inability to
  attain or 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

• 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)

58
Module 3

• PSYCHOSOCIAL ISSUES

59
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

60
Depression
Percent responding yes
Impairment Depressed Stressed Strong fears
No disability 3.4 1.3 2.5
Blind or low vision 24.8 14.2 13.2
Deaf or hard of hearing 16.8 8.9 10.5
Major lower extremity mobility difficulty 33.6 20.3 17.4
Major upper extremity mobility difficulty 35.7 21.5 19.4
Source 1994-5 National Health Interview Survey
Disability Supplement , Adapted from Iezzoni,
2006 8
61
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 (see weight and exercise
  section).

62
Depression Medication Issues 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
63
Depression Medication Considerations
Concern Action
Weight gain Avoid mirtazapine and pareoxetine. Consider buproprion
Diarrhea Avoid sertraline
Sexual dysfunction Consider bupropion
Abnormal bleeding Consider tricyclics or bupropion
Source AHRQ 20079
64
Stress

• Women with physical disabilities report high
  levels of perceived stress.
• Those at highest risk include those limited by
• 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

65
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

66
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

67
Smoking Prevalence
Impairment Use tobacco
No Impairment 21.7
Blind or very low vision 32
Deaf or very hard of hearing 34.9
Major upper extremity mobility difficulty 38.3
Major lower extremity mobility difficulty 42.9
Mild to borderline developmental disability 30-37
Data source MEPS 2001 12 , Hymowitz, 1997 13
68
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.

69
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

70
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.

71
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

72
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

73
Issues Leading to Abuse of Women with
Disabilities

• Power and control by non-disabled people.
• Easy targets
• Belief that no harm is done or that the woman is
  not aware.
• Poverty, reliance on abusive caregivers.

74
Abuse Clues from Medical History

• Inconsistent description
• Injury to treatment time delay
• Accident-prone history
• Suicide attempts or depression
• Repeated psychosomatic complaints

75
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

76
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
• gt 50 of those sexually assaulted also receive
  physical injuries.24

77
Indicators of Sexual Assault

• Behavioral
• 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

78
Indicators of Sexual Assault

• Physical indicators
• Bleeding, bruising, infection, scarring or
  irritation of genitals, rectum, mouth or breasts
• Difficulty walking or sitting
• Ongoing, unexplained medical problems like
  stomachaches or headaches.

79
Indicators of Sexual Assault

• Caregiver behavior
• 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

80
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

81
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

82
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

83
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

84
Abuse Assessment Screen Disability (AAS-D)
 

• 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

   
85
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

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