Contraception and Disability

Patients with physical, sensory, intellectual or psychosocial disabilities have the same right as others to information, a free choice of method and confidential care. They face stigma, inaccessible facilities, assumptions that they are not sexually active, and a higher risk of sexual violence. Care is built on supported decision-making and removing barriers, not on withholding services.

Assess capacity, not diagnosis. Capacity is decision-specific and assumed unless shown otherwise. Give information in an accessible format, allow time, repeat, use sign language, large print, pictures or easy-read material, and involve a trusted supporter only with the patient's agreement.

Assessment. Type of disability, mobility and transfers, communication, continence, spasticity or contractures, seizures, medicines (anticonvulsants, antipsychotics, muscle relaxants), bone health, venous thromboembolism risk, menstrual hygiene needs, sexual activity, abuse risk and the patient's own wishes.

Violence and abuse. Ask privately about coercion and abuse and offer emergency contraception and STI and HIV care when needed. Do not assume that contraception is requested by the carer for the patient's benefit.

Effectiveness. First-year pregnancies per 100 women with typical use: implants 0.05, intrauterine devices 0.2 to 0.8, injectables 3, combined pills 8.

Eligibility. The usual categories apply; disability alone is never a contraindication. Specific conditions that change categories:

• Wheelchair use or reduced mobility: not a contraindication to any method, but major surgery with prolonged immobilisation makes combined methods category 4.

• Epilepsy with enzyme-inducing medicines: combined pills and progestin-only pills category 3; implants and norethisterone enanthate category 2; DMPA and intrauterine devices category 1.

• Spinal cord injury: no restriction by category; additional precautions for autonomic dysreflexia at intrauterine insertion and for bone loss with DMPA.

• Intellectual disability: all methods by their usual categories; consent and assent rules apply.

Method comparison.

• Long-acting methods (implant, levonorgestrel device, copper device) suit patients who cannot manage daily pills or periodic injections, and the levonorgestrel device and implant often reduce bleeding and hygiene burden.

• DMPA suits patients who want amenorrhoea but affects bone density, a concern in non-ambulant patients.

• Combined pills, patch and ring need dexterity and carer support; thrombosis risk is higher with immobility.

• Condoms are added when there is STI risk.

Menstrual management. Contraception can also be used for menstrual suppression when the patient or supporter requests it; the patient's wishes decide.

Special groups. Adolescents with disabilities need the usual assent and consent process. Patients on antipsychotics may have hyperprolactinaemia and amenorrhoea that does not imply infertility.

Regimen lines.

• Etonogestrel 68 mg rod: 3 years; levonorgestrel two 75 mg rods: 5 years or 3 years by system; backup 7 days if inserted after day 7 of bleeding.

• Levonorgestrel 52 mg device: 5 years; copper T 380A: up to 12 years; insertion within 12 days of the start of bleeding or at any time if reasonably not pregnant; no backup.

• DMPA 150 mg intramuscularly every 13 weeks, up to 4 weeks late, or 104 mg subcutaneously every 13 weeks, up to 4 weeks late; supporter administration may be arranged with consent.

• Progestin-only pill: one tablet daily without a break; late window 3 hours for the traditional pill, 12 hours for desogestrel and 24 hours for drospirenone; backup 2 days after a late or missed pill.

• Levonorgestrel 1.5 mg single dose within 120 hours for emergency contraception.

Consent and permanent methods. Obtain informed consent from the patient with supported decision-making. Sterilisation is never done for convenience or on the request of a carer alone. Where capacity is absent, a substitute decision is made only as the law permits, after a documented capacity assessment and an independent second opinion.

Procedure adaptations. Offer an accessible couch or alternative positions, extra time, a trusted person present, analgesia, and sedation only when needed and safe.

Follow up. Arrange visits that match mobility and transport, offer home or outreach follow up, and review comfort, bleeding and satisfaction at each contact.

Autonomic dysreflexia. In spinal cord injury at the sixth thoracic level or higher, insertion or removal procedures can trigger severe hypertension, headache and sweating; sit the patient upright, remove the stimulus, check bladder and bowel, and give nifedipine 10 mg orally if blood pressure stays high.

Bone loss. DMPA in non-ambulant patients increases fracture risk; prefer an implant or intrauterine device, or give calcium and vitamin D with bone review.

Bleeding. Treat bothersome bleeding with ibuprofen 800 mg three times daily for 5 days when kidney function is normal; avoid oestrogen-containing treatment in immobility.

Abuse. Report and manage suspected abuse as the law and safeguarding duties require, and offer emergency contraception, HIV post-exposure prophylaxis and STI treatment.

Red flags. Disclosure of abuse, unexplained bleeding, pregnancy, signs of pelvic infection.

Referral and escalation. Refer capacity disputes, requests for sterilisation without consent, and safeguarding concerns to the appropriate legal and protection services.