IUD Use in Adolescents With Disabilities

Sexuality is an intrinsic aspect of human nature, and, like all adolescents, those with disabilities experience sexual development, romantic and sexual attractions, and sexual feelings, including desire and pleasure.⁴  Although the specific reproductive health needs vary among this group, they exist for all. For example, patients with intellectual disabilities may have more difficulty negotiating condom use within a relationship. Adolescents with physical disabilities may not be perceived to be sexually active or have sexual desire, presenting a barrier to reproductive health screening and contraceptive access. Yet adolescents with disabilities, whether intellectual or physical, have the same rights as all adolescents to sexual and reproductive health.⁴  Human rights approaches emphasize that adolescents with disabilities should have their preferences considered “on an equal basis with other children,” and to be provided with disability and age-appropriate assistance to realize that right.⁵ 

For adolescents with disabilities, contraceptives are commonly used for menstrual control, and this can be a more complex quality-of-life decision. Menstrual hygiene, dysmenorrhea, or heavy periods can disrupt schooling, services, and full participation in activities. Balancing medical risks and benefits must be considered. Levonorgestrel-containing IUDs do not contain estrogens, which have increased thrombotic risk, or have side effects like higher dose progestins, which lower bone density and may cause weight gain.⁶  Schwartz et al³  found IUDs effective in management of menstrual bleeding and acceptable to adolescents with disabilities.³  This large cohort experienced low rates of expulsion and malposition, no cases of perforation or infection, and high 1- and 5-year continuation rates. Smaller uterine sizes and younger ages among their cohort did not affect success rates of IUD insertions. The main risk was that almost all the IUDs were placed under general anesthesia. Schwartz et al³  mitigated this risk by placing nearly half at the same time as dental or other procedures that use anesthesia.

Clinicians should recognize that adolescents with disabilities have a range of decision-making capacities. For reproductive decision-making, adolescents have the right to be included to the best of their ability.⁵  However, adolescents with disabilities are often left out of reproductive decisions, with these decisions falling to their parents or guardians and providers. In a shared decision-making approach, providers, adolescents, and, when the adolescent chooses, parents share the best available data on contraceptive options, and the adolescent is supported by the provider to express their preferences.⁷  Shared decision-making can be done with adolescents with mild intellectual disability. For adolescents with more significant intellectual disability, supported decision-making can be employed. Supported decision-making involves the adolescent identifying a parent, family member, or caregiver whom they trust. This supportive adult helps the adolescent communicate their goals and understand the decision and assists the provider in communication with the adolescent.⁸  For those with more profound intellectual disability, risks of placement and use should be thought of in a similar manner as other procedures that are routinely done to improve quality of life.

Schwartz et al³  highlight the safety and acceptability of IUDs for adolescents with disabilities. As clinicians, it is up to us to highlight these adolescents’ abilities to exercise their rights to sexual and reproductive health.

IUD

intrauterine device