CommentaryLooking back while moving forward: a justice-based, intersectional approach to research on contraception and disability
Introduction
It is estimated that 12% of US reproductive-age women have one or more disabilities, which include those with physical, sensory or cognitive disabilities that are associated with difficulty in self-care and independent living [1]. This heterogeneous population is comprised of individuals across a wide spectrum of functional ability. While individual variations based upon genetic and medical history exist, most women with disabilities are fertile and as likely to experience pregnancy as women without disabilities [2]. Based upon 12 reproductive health questions from the 2013 Behavioral Risk Factor Surveillance System in 7 states, Haynes and colleagues recently reported that the overall prevalence of sexual activity was similar for women with and without physical or cognitive disabilities [3]. Women with disabilities who do not desire pregnancy should receive counseling regarding and access to all available contraceptive methods.
In this commentary, we highlight recent US population-based analyses reporting that women who report having sex with men and have a disability are more likely to undergo female sterilization and less likely to use long-acting reversible contraception (LARC) than women without disabilities even after adjusting for age and other confounders. We summarize potential reasons for these differences and limitations of these analyses. To inform future research, we advocate for the application of intersectionality, a paradigm rooted in black feminist scholarship, to understand discrimination and inequities that arise from the intersection of multiple social and cultural identities [4].
Section snippets
An intersectional framework: stratified reproduction and ableism
We first propose an intersectional framework that blends the concepts of stratified reproduction and ableism, which are derived from a reproductive justice framework and disability theory, respectively. The reproductive justice framework originally developed by women of color is based upon the premise that women’s reproductive rights extend beyond the right to abortion only and should include the equally paramount right to pursue pregnancy and parenthood [5]. Stratified reproduction, as
The United Nations Convention on the Rights of Persons with Disabilities
Although this commentary is focused on US studies, it is critical to appreciate the global scope and impact of disability-based disparities on all spheres of life. Individuals with disabilities represent one in every six people worldwide [10] and constitute a population whose human rights — including equal rights and access to health, education, work and due process under the law — have been systematically neglected and violated [11]. Ratified in 2008, the United Nations Convention on the
Female sterilization and LARC trends in the United States
Female sterilization and LARC (the implant and intrauterine devices) are important options for women who desire highly efficacious and long-term contraception. From 2008 to 2014, LARC use among the general US population of reproductive-age women increased significantly, from 6% to 15% of all contraceptive users [14]. During the same period, there was a significant decrease in the percentage of contraceptive users who relied upon female sterilization, from 27% to 22% [14]. These changes in
Female sterilization and LARC use differs by disability status
Several recent population-based analyses from the National Survey of Family Growth (NSFG) have identified differences in LARC and female sterilization based upon disability status. Wu and colleagues reported that after adjusting for confounders including age, parity, smoking status and body mass index, the odds of LARC use were lower among women with physical and/or sensory disabilities than women without these disabilities [adjusted odds ratio (aOR) 0.55, 95% confidence interval (CI)
Patient-related factors
It is possible that women with disabilities and/or their advocates (e.g., family members, legal guardians, caseworkers) are simply more familiar with female sterilization than with LARC, leading to more requests for female sterilization. Unfortunately, population-based studies that assess contraceptive knowledge among US adult women with disabilities and their advocates are limited. However, one nationally representative study of adolescents [21], along with qualitative and small
A call for a justice-based, intersectional approach to contraception and disability research
The new body of research described in this commentary is a necessary but insufficient step towards understanding how to provide equitable contraceptive counseling and care for women with disabilities. First, a more robust body of evidence is necessary to understand why and how differences in contraceptive patterns between women with and without disabilities occur, and to what extent these differences reflect fully informed decisions and preferences versus inequities in contraceptive care.
Conclusions
The higher odds of sterilization among US women with disabilities relative to LARC use are a finding that demands further investigation. Factors that may contribute to these contraceptive patterns include incomplete contraceptive knowledge among patients and their advocates, inadequate provider training and lack of fully accessible health care facilities. We also posit that ableism and stratified reproduction are interrelated forms of discrimination that discourage and prevent people with
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Cited by (22)
Preconception health risks by presence and type of disability among U.S. women
2024, Disability and Health JournalContraception use among female youth with disabilities: Secondary analysis of a Canadian cross-sectional survey
2023, Disability and Health JournalPregnancy decision-making in women with physical disabilities
2022, Disability and Health JournalAbortion at the edges: Politics, practices, performances
2020, Women's Studies International ForumCitation Excerpt :Australian disability activist Nicole Lee (2019), who uses a wheelchair, writes of how her decision to have an abortion was, in a reversal to the stated norm, interrogated far less than her decision to become a mother. The stigma of disabled parenting can manifest in coercive practices, most notoriously in sterilisation, which women with disabilities continue to experience disproportionately compared to the able-bodied (Wu et al., 2019). Discourses of able-bodiedness also variegate abortion stigma.
Study support: Dr. Wu receives support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) under award number 1K23HD084744-01A1. Dr. Horner-Johnson was supported in part by award number K12HS022981 from the Agency for Healthcare Research and Quality (AHRQ) and award number 90DDUC0039 from the Administration on Community Living (ACL). The content is the responsibility solely of the authors and does not necessarily represent the official views of the NICHD, AHRQ or ACL. The funders had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review and approval of the manuscript; or decision to submit the manuscript for publication.