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Reproductive Health Care for Women With Disabilities

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

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Reproductive Health Care for Women With Disabilities

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  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, STI’s, 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. Accessibility Activities of Daily Living – ADL Developmental disability Functional limitation - FL Glossary of Terms on Disability • Impairment • Instrumental Activities • of Daily Living – IADL • People-first language • Sensory disability • Severe disability • Universal design

  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 ADL’s 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 1996-712

  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 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

  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.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

  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. Women’s 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 Excitement Resolution 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. Anti-hypertensives Lipid-lowering agents Diuretics Antidepressants Immunosuppressive agents Anticonvulsants Anticholinergics Antispasmodics Oncologic agents Psychotropics Sedative-hypnotics Stimulants Anti-androgens Decongestants Antivirals Antiarrhythmics Medications Affecting Sexual Function Source: Nusbaum 20037

  36. Sexuality in Adolescent Girls With and Without Disabilities Girls’ Experiences at Age 16 by Physical Disability Status 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 patient’s 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 EnvironmentalPatients 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

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