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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, 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



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 Challenge to the paradigm Disability sickness Medical definitions of health Perception of personal health among WWD WHO definition of health Defining Health in Women with Disabilities (WWD)

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 Organization 5

11 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

12 Disability Types U.S ages 18+ Source: Diab and Johnston, N = 59,939

13 Women Aged by Type of Impairment- 12% of all women aged have one of these 3 types of disabilities N = 11 million women Source: US Census Supplementary Survey

14 Population of Women with Disabilities Age and Severity 26 million American women have a disability 63% are severe 31% require assistance with ADLs Source: US Census Bureau, American Community Survey

15 Adult Women with Disabilities, by Race and Severity Source: US Census Bureau, Survey of income and program participation

16 Education U.S. Women Ages Source: U.S. Census Bureau, Survey of income and program participation

17 Employment U.S. Women Ages Source: U.S. Census Bureau Supplementary Survey,

18 Poverty Rate by Gender and Type of Disability Source: National Health Interview Survey

19 Difficulty With Transportation Source: USDOT, Freedom to Travel,

20 Unmet Need Among Working-Age SSI Recipients: New York, Source: Coughlin TA, et al., Health Care Fin Rev, Working age = yrs.

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 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 § (2) accessed at on 12/10/07 2. Iezzoni LI, ODay BL. More Than Ramps Oxford University Press, New York: p18 3. Ibid. p Marks MB. More than ramps: Accessible health care for people with disabilities. CMAJ 2006; 175(4): 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 Accessed at 2/20/07 6. U.S. Census Bureau. Disability definitions. Downloaded from 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 Downloaded from on 12/10/07 8. Diab ME, Johnston MV. Relationships between level of disability and receipt of preventive health services. Arch Phys Med Rehabil May; 85(5): US Census Bureau American (disability types) Available at Accessed on 12/10/ US Census Bureau. American Community Survey Available at : Accessed 12/10/ McNeil JM. Americans with Disabilities: , Washington DC: GPO, US Census Bureau. Survey of income and program participation Available at 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, Centers for Disease Control and Prevention, Hyattsville MD, U.S. Department of Transportation, Bureau of Transportation Statistics (2003b). Freedom to travel. BTS 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

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 orgasm 2 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 Health Barriers 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 Resolution Multiple Orgasm Excitement Plateau Orgasm Traditional Model of Sexual Response Source: Masters & Johnson

32 Female Sexual Response Cycle Sexual Stimuli Sexual Arousal Arousal & Sexual Desire Emotional and Physical Satisfaction Emotional Intimacy Motivates the sexually neutral woman to find/be responsive to Psychological and biological factors govern arousability Spontaneous Sexual Drive Hunger Source: Modified from Basson,

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, and Griffith

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 Anti-hypertensives Lipid-lowering agents Diuretics Antidepressants Immunosuppressive agents Anticonvulsants Anticholinergics Antispasmodics Oncologic agents Psychotropics Sedative-hypnotics Stimulants Anti-androgens Decongestants Antivirals Antiarrhythmics Source: Nusbaum

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 Minimal disability Mild disability Severe disability 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 and Nusbaum

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 and Nusbaum

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 and Nusbaum

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 and Nusbaum

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, Journal of Sexuality and Disabilities – quarterly journal published by Springerlink. /

54 Web References on Sexual Health for Health Care Providers American Association of Sex Educators, Counselors, and Therapists Educational resource on Female Sexual Dysfunction for health professionals: Society for the Scientific Study of Sexuality International Society for the Study of Womens Sexual Health International Academy of Sex Research

55 References 1. Beckmann CR, Gittler M, Barzansky BM, Beckmann CA. Gynecologic health care of women with disabilities. Obstet Gynecol. 1989;74: Sipski ML. Spinal cord injury: What is the effect on sexual response? J Amer Paraplegia Soc 1991;14(2): Masters WH, Johnson VE. Human Sexual Response. Reproductive Biology Research Foundation. Boston: Little Brown Kaplan HS. The New Sex Therapy, Vol 2. Disorders of Sexual Desire and other New Concepts and Techniquesin Sex Therapy. New York: Brunner/Mazel Basson R. Female Sexual Response: The role of drugs in the management of sexual dysfunction. Obstet Gynecol 2001;98: Griffith ER, et al. Sexual functioning in women with spinal cord injury. Arch Phys Med Rehabil 1975;56(1): Nusbaum MR, et al. Chronic illness and sexual functioning. Amer Fam Phys 2003;67(2): Nosek MA, et al.Sexual functioning among women with physical disabilities Arch Phys Med Rehab 1996;77: Cheng MM, Udry JR. Sexual behaviors of physically disabled adolescents in the United States. Journal of Adolescent Health 2002;31: Suris JC, Resnick MD, Cassuto N, Blum RW. Sexual behavior of adolescents with chronic disease and disability. Journal of Adolescent Health 1996;19: Murphy N, Young PC. Sexuality in children and adolescents with disabilities. Dev Med & Child Nerol 2005:47: Drugs that cause sexual dysfunction: an update. Medical Lett Drugs Ther 1992;34:73-8

56 References (cont) 13. Foley FW, et al.Qualitative evaluation of obstacles facing multiple sclerosis societies in addressing sexual dysfunction in MS. Int J MSCare Vol 1 Issue 1. p Available at 14. Zorzon M. Sexual dysfunction in multiple sclerosis: a case-control study. 1. Frequency and comparison of groups. Mult Scler 1999:5: Marinkovic S, Badlani G. Voiding and sexual dysfunction after cerbrovascular accidents. J Urol 2001;165: Saxton M. Reclaimimg sexual self-esteem – peer counseling for disabled women. West J Med 1991;154: Basson R. Sexual health of women with disabilities. Can Med Assoc J. 1998;159: Nusbaum MR, Hamilton C. The proactive sexual health inquiry: key to effective sexual health care. Amer Fam Phys 2002;66: Sipski ML. Central nervous system based neurogenic female dysfunction: Current status and future trends. Arch Sex Behav 2002;31(5): Nusbaum MR. Sexual Health Monograph No. 267, Home study self-assessment program. Leawood, Kan.: American Academy of Family Physicians, Sipski ML. Sildenafil effects on sexual and cardiovascular responses in women with spinal cord injury. Urology 2000;55(6): 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 2001;27:215-6.

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 Orgasmic Disorder Pain 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 (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 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)


59 Depression Women with disabilities are at greater risk for depression than women in general 1 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 Impairment DepressedStressedStrong fears No disability Blind or low vision Deaf or hard of hearing Major lower extremity mobility difficulty Major upper extremity mobility difficulty Source: National Health Interview Survey Disability Supplement, Adapted from Iezzoni, Percent responding yes

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 ConcernAction Weight gainAvoid mirtazapine and pareoxetine. Consider buproprion DiarrheaAvoid sertraline Sexual dysfunction Consider bupropion Abnormal bleeding Consider tricyclics or bupropion Source: AHRQ

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

67 Smoking Prevalence ImpairmentUse tobacco No Impairment21.7% Blind or very low vision32% Deaf or very hard of hearing34.9% Major upper extremity mobility difficulty 38.3% Major lower extremity mobility difficulty 42.9% Mild to borderline developmental disability 30-37% Data source: MEPS , Hymowitz,

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 – 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 % 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

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) 1. Within the last year, have you been hit, slapped, kicked, pushed, shoved or otherwise physically hurt by someone? 2. Within the last year has anyone forced you to have sexual activities? 3. Within the last year, has anyone prevented you from using a wheelchair, cane, respirator or other assistive devices? 4. 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

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

86 References 1. Hughes RB, Robinson-Whelen S, Taylor HB, Petersen NJ, Nosek MA. Characteristics of depressed and non-depressed women with physical disabilities. Archives of Physical Medicine & rehabilitation 2005;86: Jang Y, Borenstein AR, Chirlboga DA, Mortimer JA. Depressive symptoms among African American and white older adults. Journal of Gerontology Series B – Psychological Sciences and Social Sciences 2005;60: McDermott S, Moran R, Platt T, Issac T, Wood H, Dasari S. Depression in adults with disabilities, in primary care. Disability and Rehabilitation: an international multidisciplinary journal. 2005;27: Iezzoni LI, ODay, BL. More than ramps: A guide to improving health care quality and access for people with disabilities. Oxford University Press, New York p Kinne S, Patrick DL, Doyle DL. Prevalence of secondary conditions among people with disabilities. AJPH 2004;94: Nosek, MA, Hughes, RB, Swedlund N, Taylor HB, Swank P. Self-esteem and women with disabilities. Social Science & Medicine 2002;56: Niemeier J, Kennedy R, McKinley W, Cifu D. The Loss Inventory: preliminary reliability and validity data for a new measure of emotional and cognitive responses to disability. Disability & Rehabilitation 2004;26: Iezzoni LI, ODay BL. More than ramps: a guide to improving health care quality and access for people with disabilities. Oxford University Press, New York, NY 2006, pgs

87 References 9. Agency for Healthcare Research and Quality. Choosing antidepressants for Adults: Clinician Summary Guide. AHRQ Effective Health Care Program Reports accessed at Accessed 10/19/2007) 10. Meijerr WEE, Heerdink ER, Nolen, WA, Herrings RMC, Leufkens HGN, Egberts ACG. Association of risk of abnormal bleeding with degree of serotonin reuptake inhibition by antidepressants. Arch Intern Med 2004;164: ) 11. Hughes RB, Robinson-Whelen S, Taylor HB, Petersen NJ, Nosek MA. Stress and women with physical disabilities: identifying correlates. Womens Health Issues 2005;15: Medical Expenditure Panel Survey (MEPS) Accessed at 13. Hymowitz N, Jaffe FE, Gupta A, Feuerman M. The importance of smoking education in preventive health stragegies for people with intellectual disability. Journal of Intellectual Disability Research. 1997;41: Chevarley FM, Thierry JM, Gill CJ, Ryerson AB, Nosek MA. Health, preventive health care and health care access among women with disabilities in the National Health Interview Survey, supplement on Disability. Womens Health Issues 2006;16: Fiore MC, Bailey WC, Cohen SJ, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville MD. US Dept. of Health and Human Services (USDHHS), Public Health Service (PHS) Hollis JF, McAfee, TA, et al. The effectiveness and cost effectiveness of telephone counseling and the nicotine patch in a state tobacco quitline. Tobacco Control 2007:16 (suppl. 1):53-9.

88 References 17. Peters MJ and Morgan LC. The pharmacotherapy of smoking cessation. Medical Journal of Australia 2002;176: Tonstad S, Tonnesen P, Hajek, et al. Effect of maintenance therapy with Varenicline on smoking cessation: a randomized controlled trial. JAMA 2006;296: Steele CA, Kalnins IV, Rossen BE, Biggar DW, Bortolussi, JA, Jutai JW. Age- related health risk behaviors of adolescents with physical disabilities. Sozial-und Praventivmedizin. 2004;49: Nosek MA. Howland CA, Rintala DH, Young EM, Chanpong GF. National study of women with physical disabilities: Final report. Sexuality and Disability 2001, 19: Sobsey D, Doe T. Patterns of Sexual Abuse and Assault. Journal of Sexuality and Disability 1991;9(3): Sobsey, D. Violence and abuse in the lives of people with disabilities: The end of silent acceptance? Baltimore, MD: Paul H. Brooks Publishing Co Abramson WH. Promoting violence-free relationships: Disability Services ASAP. Impact, published by the Institute on Community Integration, University of Minnesota 2000;13(3) 24. Cox-Lindenbaum D, Watson S. Sexual assault against persons with developmental disabilities in Ethical Dilemmas: Sexuality and Developmental Disabilities NADD Press, Kingston NY. Pgs

89 References 25. Mitra M, Brawarsky P, Wilber N, Walker DK. Sexual assault against women with disabilites in Massachusetts: Results from the Massachusetts Behavioral Risk Factor Surveillance System ( ). Paper presented at the annual meetin gof the American Public Health Assoc., San Francisco CA Nannini A. Sexual assault patterns among wimen with and without disabilities seeking survivor services. Womens Health Issues 2006;16: Valenti-Hein D, Schwartz L, The sexual abuse interview for those with developmental disabilities. James Stanfield Company. Santa Barbara: California Touch and My Body: A Guide for Teens with Developmental Disabilities to Discuss with a Caring Adult. Developed by Tri-County Council on Domestic Violence and Sexual Assault Inc. in Rhinelander, WI. Accessed at 29. Brandt B. Mandatory reporting of elder abuse: implications for domestic violence advocates. Natonal Clearinghouse on Abuse in Later Life/Wisconsin Coalition Against Domestic Violence Downloaded at Accessed 5/21/ Center for Research on Women with Disabilities with funding from the Centers for Disease Control and Prevention, (UHSP RO4/CCR614142), Nosek MA, Principal Investigator. Accessed at 31. Nosek MA, Hughes RB, Taylor HB, Violence Against Women With Physical Disabilities: Final Report, Center for Research on Women with Disabilities, Baylor College of Medicine. Dept. of Physical medicine and Rehabilitation, Houston,Texas, 2002.

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