Practical Approaches to Supporting Young Women With Intellectual Disabilities and High Support Needs With Their Menstruation

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.

Menstrual hygiene management strategies used by women who are blind or have low vision

BACKGROUND

Menstrual hygiene management is a global public health issue that requires local and individualized support to reduce activity limitations and enable safe, independent task performance for people with impaired body functions.

AIM

How do women with blindness or low vision self-manage their menstrual hygiene to promote independence, and what do they recommend occupational therapists incorporate in education for young women when working in this field?

METHODS

Phenomenological design revealing lived experience expertise. Semi-structured interviews were conducted with six women who are blind or have low vision aged 16-70 in Australia. The resulting data transcripts were coded and analyzed thematically using the Person-Environment Occupation Performance Model as an organizing framework.

RESULTS

Participants reported a range of personal (touch) and organizational strategies relying on environmental cues such as regular times for changing sanitary items, lining up pads using underwear seams and wearing dark clothing to disguise leaks. Participants suggested that group occupational therapy education sessions be used to promote self-management.

CONCLUSIONS AND SIGNIFICANCE

The lived experience of women who successfully self-manage menstrual hygiene with blindness or low vision has generated evidence to inform the development of therapist-mediated interventions and resources that could be applied with women across a range of clinical populations.

'Flower of the body': menstrual experiences and needs of young adolescent women with cerebral palsy in Bangladesh, and their mothers providing menstrual support

Background

This study offers voice to young adolescent women with cerebral palsy (CP) in Bangladesh as they describe their menstrual experiences and needs, and their mothers providing menstrual support.

Method

Semi-structured focus groups with adolescents with CP, and separately their mother. Data was analysed using a material discursive framework and drawing on feminist disability theory. Participants were recruited from the Bangladesh CP Register (BCPR); a population-based surveillance of children and adolescents with CP in rural Bangladesh.

Results

Participants were 45 women including 12 female adolescents with CP and 33 female caregivers. Participants reported a wide range of experiences and needs; menarche acted as a gateway to menstrual information although for some a discourse of silence prevailed due to exclusion from peer and familial networks. Menstruation was discursively constructed as a sign of ‘female maturation’ marked by an expectation of ‘independence’, required for acceptance into socially valued adult roles, and was positioned alongside increased vulnerability to sexual abuse. Young adolescent women with CP were expected to ‘quietly endure’ the material aspects of menstruation although unmanaged pain and distress were described. Mothers reported an imperative for meeting their adolescent’s menstrual needs however this role was discursively positioned as ‘painful’, ‘irritating’ and ‘shameful’, in part due to an absence of affordable, functional menstrual resources.

Conclusion

The findings of the present study provide motivation for disability services in Bangladesh to account for the menstrual needs of young adolescent women with CP within service delivery through strategies such as providing menstrual education and by embedding value in constructs such as ‘interdependence’. Moreover, interventions focused on alleviating menstrual pain among young adolescent women with CP as well as those targeted to alleviate distress among mothers providing menstrual care are required. Finally, policy responses are required to ensure that ‘inclusive development’ considers the needs of menstruating women with disability.

Systematic review on the outcomes of poller screw augmentation in intramedullary nailing of long bone fracture

Various technical tips have been described on the placement of poller screws during intramedullary (IM) nailing; however studies reporting outcomes are limited. Overall there is no consistent conclusion about whether intramedullary nailing alone, or intramedullary nails augmented with poller screws is more advantageous.

We conducted a systematic review of PubMed, EMBASE, and Cochrane databases. Seventy-five records were identified, of which 13 met our inclusion criteria. In a systematic review we asked: (1) What is the proportion of nonunions with poller screw usage? (2) What is the proportion of malalignment, infection and secondary surgical procedures with poller screw usage? The overall outcome proportion across the studies was computed using the inverse variance method for pooling.

Thirteen studies with a total of 371 participants and 376 fractures were included. Mean follow-up time was 21.1 months. Mean age of included patients was 40.0 years. Seven studies had heterogenous populations of nonunions and acute fractures. Four studies included only acute fractures and two studies examined nonunions only.

The results of the present systematic review show a low complication rate of IM nailing augmented with poller screws in terms of nonunion (4%, CI: 0.03–0.07), coronal plane malunion (5%, CI: 0.03–0.08), deep (5%, CI: 0.03–0.11) and superficial (6%, CI: 0.03–0.11) infections, and secondary procedures (8%, CI: 0.04–0.18).

When compared with the existing literature our review suggests intramedullary nailing with poller screws has lower rates of nonunion and coronal malalignment when compared with nailing alone. Prospective randomized control trial is necessary to fully determine outcome benefits.

Cite this article: EFORT Open Rev 2020;5:189-203. DOI: 10.1302/2058-5241.5.190040

Management of contraceptives and menstrual complaints in patients with Down syndrome

Enhanced health care for patients with Down syndrome (DS) results in improved overall quality of life and longer life expectancy. The main gynecologic complaints of patients with DS and their caregivers relate to menstrual cycles, hygiene and reproductive issues. Certain aspects, such as age of menarche, menstrual cycles, internal genitalia, and hormone profile are similar to those observed in the general population. However, individuals with DS may have a higher incidence of other disorders related to menstruation, such as hypothyroidism, epilepsy and use of anticonvulsants. Contraceptive measures for individuals with DS can be used for both contraception and control of menstrual symptoms. The physician must be to make an individualized recommendation aimed at offering the most efficient and least invasive method with the fewest side effects. Among medical options are oral contraceptives, quarterly injectable medroxyprogesterone acetate, oral progesterone, a levonorgestrel-releasing intrauterine system, transdermal patch and vaginal rings. Surgical methods, including hysterectomy, endometrial ablation, or tubal ligation, are rarely considered because they raise ethical and legal questions. This article reviews the literature and basic guidelines to assist physicians who attend adolescent girls and women with DS to provide guidance on the appropriate management of the main gynecologic complaints of this population.

Hysterectomy for the Management of Menstrual Hygiene in Women With Intellectual Disability. A Systematic Review Focusing on Standards and Ethical Considerations for Developing Countries

Background: Menstruation poses particular challenges for women with intellectual disability (ID). In low-and middle-income countries, where these women do not have access to facilities and resources for adequate menstrual care, hysterectomy could be considered as an ethically acceptable procedure. We conducted the first systematic review to identify what constitutes best practice for menstrual hygiene in women with ID and explored the perspectives of actors involved in the hysterectomy decision.

Methods: Theory-informed mixed-method thematic systematic review with theory development.

Results: Eleven ethical guidelines and 17 studies were included. Respect for autonomy and the patient's best interest were the criteria to determine what constitutes best practice. The actors' values and attitudes expressed some dimensions of existing inequities. In low-and middle-income countries, the main concern of parents was the difficulty to train their daughters about menstrual hygiene. Parents (mothers in particular) also expressed the feeling of being excessively burdened, and complained about the limitations of their support networks. Doctors perceived hysterectomy as a safe procedure and a solution for women with ID, whose menstrual hygiene is problematic. In general, the more severe or profound the level of ID, the more likely the interested parties advocated for a hysterectomy. The women with ID perceived their menstruation as a negative experience. Hence, the three parties supported hysterectomy for menstrual hygiene. Parents and doctors considered informed consent or assent (from the women with ID) as necessary and achievable.

Conclusion: The international ethical guidelines suggest that non-therapeutic hysterectomy in women with ID should not and ought not to be recommended as routine and appropriate method to cope with menstrual hygiene even if it is technically safe. Although hysterectomy to cope with menstrual hygiene is still a live issue in high-, middle-, and low-income countries, in high income countries it is performed with authorization from the Court; whilst in low-and middle-income countries there is not an active involvement of the State, or financial or training support for women with ID and their carers. Hence, in low-and middle-income countries there is an urgent need to develop and enact policies and statutes in this area of public health and clinical practice.

Menstrual and reproductive issues in adolescents with physical and developmental disabilities

Most obstetrician-gynecologists will encounter adolescents with disabilities in their practice, because developmental and physical disabilities are common in young patients (8.4%). Reproductive health issues such as puberty, sexuality, and menstruation can be more complicated for teenagers with disabilities and their families as a result of concerns surrounding menstrual hygiene, abuse risk, vulnerability, changes in seizure pattern, and altered mood. Teenagers with disabilities have gynecologic health care needs similar to those of their peers as well as unique needs related to their physical and cognitive issues. The gynecologic health visit for a teenager with disabilities should include an evaluation of the teenager's reproductive knowledge as well as an assessment of her abuse and coercion risk and her ability to consent to sexual activity. The menstrual history is focused on the effects of menstrual cycles on her daily life. Diagnostic testing is not different from other adolescents. Hormonal treatment is often requested by the patient and her family to alleviate abnormal bleeding, cyclic mood changes, dysmenorrhea, or a combination of these, to assist with menstrual hygiene, and to provide contraception. Menstrual manipulation can be used to induce complete amenorrhea, regulate cycles, or decrease regular menstrual flow. However, treatment risks and side effects may have a different effect on the lives of these adolescents. The comfort level of health care providers to respond to the special concerns of adolescents with disabilities is low, and several barriers exist. This review addresses the complex issues of puberty, menstruation, sexuality, abuse, and safety highlighting the distinctive needs of this population. The options and decisions around menstrual manipulation are highlighted in detail.