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A Call for Comprehensive, Disability- and LGBTQ-Inclusive Sexual and Reproductive Health Education

      See Related Article on p.255
      The study by Horner-Johnson et al. in this issue of the Journal of Adolescent Health concerning the sexual health experiences of high school students with disabilities is an important contribution to the literature, particularly in light of a growing body of literature on the reproductive and perinatal health of women with disabilities. Learning about the sexual experiences of youth with disabilities may help us understand their later sexual and reproductive health experiences and identify ways in which we might work to mitigate adverse outcomes (e.g., unintended pregnancies, sexual violence, sexually transmitted infections).
      Pregnancy is not uncommon among women with disabilities; recent studies conducted in both the U.S. and Canada have found that rates of pregnancy are slightly lower among those with physical disabilities and sensory disabilities than in those without disabilities, but the difference is small [
      • Brown H.K.
      • Chen S.
      • Guttmann A.
      • et al.
      Rates of recognized pregnancy in women with disabilities in Ontario, Canada.
      ,
      • Iezzoni L.I.
      • Yu J.
      • Wint A.J.
      • et al.
      Prevalence of current pregnancy among US women with and without chronic physical disabilities.
      ,
      • Horner-Johnson W.
      • Darney B.G.
      • Kulkarni-Rajasekhara S.
      • et al.
      Pregnancy among US women: Differences by presence, type, and complexity of disability.
      ]. From health administrative data in Ontario, Canada, my colleagues and I found that between 2003 and 2018, pregnancy rates slightly decreased among those without disabilities, increased among those with sensory disabilities and multiple disabilities, and stayed about the same for those with physical disabilities and intellectual and/or developmental disabilities (IDDs) [
      • Brown H.K.
      • Chen S.
      • Guttmann A.
      • et al.
      Rates of recognized pregnancy in women with disabilities in Ontario, Canada.
      ]. Of particular relevance to the findings of the study by Horner-Johnson et al. is our finding that, compared with women without disabilities, pregnancy rates were lower overall but higher among teenagers (aged 15-19 years) [
      • Brown H.K.
      • Chen S.
      • Guttmann A.
      • et al.
      Rates of recognized pregnancy in women with disabilities in Ontario, Canada.
      ]. My colleagues and I also found that women with disabilities of reproductive age (15-44 years) experience many health disparities, including higher rates of substance use disorders and assault, than those without disabilities [
      • Tarasoff L.A.
      • Lunsky Y.
      • Chen S.
      • et al.
      Preconception health Characteristics of women with disabilities in Ontario: A Population-based, Cross-Sectional study.
      ]. These and other health disparities were particularly pronounced among reproductive age women with IDD. Those with IDD were the youngest and most socioeconomically marginalized group.
      The findings from our Ontario-based research and from the study by Horner-Johnson et al. in this issue of the Journal of Adolescent Health, as well as their research documenting high rates of unintended pregnancy among women with disabilities [
      • Horner-Johnson W.
      • Dissanayake M.
      • Wu J.P.
      • et al.
      Pregnancy Intendedness by Maternal disability Status and type in the United States. Perspect sex Reprod health.
      ], underscore the need for a life course approach concerning the sexual and reproductive health of people with disabilities. For those with disabilities, sexual and reproductive health education should start early and include discussions about sexuality, sexual behavior, reproductive life plans (including the social, psychological, and physiological impact of pregnancy), consent, and healthy relationships [
      • Tarasoff L.A.
      • Lunsky Y.
      • Chen S.
      • et al.
      Preconception health Characteristics of women with disabilities in Ontario: A Population-based, Cross-Sectional study.
      ].
      In addition to demonstrating a need for interventions to ensure positive sexual health experiences for teens with disabilities, the study by Horner-Johnson et al. evokes many questions to explore. For instance, how do teens with disabilities, particularly those with physical (or mobility) disabilities and IDD (or cognitive disabilities), define sexual intercourse? In turn, how might we measure sexual activity among teens and adults with disabilities if sexual activity is defined and looks differently for them compared with those without disabilities?
      The study by Horner-Johnson et al. is also noteworthy because of the inclusion of nonbinary and sexual minority high school students with disabilities. It is vital that in sexual and reproductive health research, health promotion, and education, youth and adults with disabilities are not lumped together as a homogenous group with regard to sexual orientation and/or gender identity. Understanding the unique experiences of sexual and gender minority people with disabilities is key to developing relevant educational and health interventions, particularly with regard to sexual violence and victimization, as we know that sexual and gender minority teens and young adults, and especially those who are bisexual and trans, are at increased risk of sexual violence and victimization, including in school settings [
      • Kann L.
      • McManus T.
      • Harris W.A.
      • et al.
      Youth risk behavior Surveillance - United States, 2017.
      ,
      • Murchison G.R.
      • Agénor M.
      • Reisner S.L.
      • Watson R.J.
      School Restroom and Locker Room Restrictions and sexual assault risk among Transgender youth.
      ,
      • Griner S.B.
      • Vamos C.A.
      • Thompson E.L.
      • et al.
      The Intersection of gender identity and violence: Victimization experienced by Transgender College students.
      ,
      • Caputi T.L.
      • Shover C.L.
      • Watson R.J.
      Physical and sexual violence among Gay, lesbian, bisexual, and questioning Adolescents.
      ,
      • Walters M.L.
      • Chen J.
      • Breiding M.J.
      The National Intimate Partner and sexual violence Survey (NISVS): 2010 findings on victimization by sexual orientation.
      ].
      Related to the aforementioned query concerning definitions of sexual intercourse, how is sexual intercourse defined and what does it look like for teens with disabilities who identify as sexual and/or gender minorities? In addition, related to the issue of sexual violence, how does sexual violence play out in the context of disabled LGBTQ relationships? In addition to not being disability-inclusive, sexual health education in many places in the U.S. and elsewhere is not LGBTQ-inclusive. As Campbell et al. note, “the ableist and heteronormative assumptions embedded within the ‘hidden curriculum’ of many formal sex education programmes position sex as a heterosexual act and disabled people as non-sexual” [
      • Campbell M.
      • Löfgren-Mårtenson C.
      • Martino A.S.
      Cripping sex education.
      ].
      As my colleagues and I have found with regard to the sexual victimization experiences of young lesbian and bisexual people [
      • Flanders C.E.
      • VanKim N.
      • Anderson R.E.
      • Tarasoff L.A.
      Exploring potential determinants of sexual victimization disparities among young sexual minoritized people: A mixed-method study.
      ], I presume those with disabilities also typically learn about sexual violence only in the context of heterosexual interactions and relationships. As such, it may be difficult to recognize sexual violence within the context of same-gender relationships, for LGBTQ youth broadly and for those with disabilities, particularly those with cognitive and independent living/self-care disabilities (some of whom have adults in their lives, including adult caregivers, of the same gender).
      The study by Horner-Johnson et al. highlights many sexual health disparities among teens with disabilities that gravely need to be addressed. While it is of course important to consider the sexual experiences of youth with disabilities in the context of victimization and vulnerability, there is also a need for research, both quantitative and qualitative, exploring the positive sexual experiences of youth with disabilities. For instance, in addition to asking youth with disabilities about bad sexual experiences or experiences of violence and victimization, future research could explore how they might describe their best or a good sexual experience, as well as what they would like to know or resources that they feel would be helpful to make decisions about their sexual health and relationships. In addition to asking youth with disabilities about the barriers they encounter regarding their sexual health, asking youth with disabilities to identify what aspects of sexual health they deem important and what facilitates healthy relationships and sexual health may be vital to addressing the disparities they experience.

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