SOJ Neurology and Neuroscience

In June 2022, the U.S. Supreme Court issued its landmark decision to cease federal protections for individuals seeking an abortion in the Dobbs v. Jackson Women's Health Organization legal proceedings. The Court’s decision in Dobbs’ case effectively overruled Roe v. Wade (1973) and Planned Parenthood of Southeastern Pennsylvania v. Casey (1922), which originally conferred the constitutional right to an abortion. By removing such federal protections, the Dobbs’ decision allows for abortion regulation only on a state-level, posing danger for women of reproductive ages, as many states have sought to criminalize and restrict abortion access. As stated by Kaufman,¹ thirteen states had trigger laws that went into immediate effect after the overruling of Roe v. Wade (1973) to automatically ban abortions, in almost all circumstances, without further legal contemplation. Currently, fourteen states have enacted a near-complete abortion ban, and two states have enacted an abortion ban at six weeks of gestation affecting over twenty-two million women of reproductive age.²

With abortion access severely restricted in many states, individuals have increased difficulty in seeking their appropriate healthcare, and this difficulty is especially heightened for disadvantaged and marginalized communities. Intellectually-disabled (ID) adolescents represent one such marginalized sub-group which faces a disproportionate burden from the restriction of abortion regulation. Individuals with disabilities often endure multiple hurdles at the interposition of their medical and social care that is convoluted with structural barriers and inequities.

Per Harrell,³ adolescents with disabilities are three times more likely to face victimization, including sexual violence, than those without disabilities, which leads to the discussion of how disabled individuals are at higher risk of reproductive coercion with a need of safe abortion access. Already in adolescents without intellectual disabilities, sexual offenses may occur either by targeting in person⁴ or online.⁵ Found that adolescents aged 13-17 were highly vulnerable to online sexual abuse, including online grooming by adults in over 5% of this population.

However, adolescents with intellectual disability are a population at heightened risk for both grooming and physical sexual assault. One study of over 2,000 children with and without learning disabilities (LD) found that the prevalence of intercourse among girls with LD was 8%, higher than 3% of girls without an LD.⁶ There are further unique factors within the population of adolescent girls with intellectual disability which may increase their vulnerability to sexual assault. For instance, girls with more profound disabilities who live in group homes are at risk for assaults from employees.⁷ If non-verbal, they may not be able to report these attacks. Additionally, those with physical disabilities and limited mobility have added vulnerability to physical attack.

Contraception usage is still relatively low compared to typically-developing adolescents, despite general tendencies for caregivers to have adolescents started on hormonal contraceptives.⁸ Specifically, post-pubescent girls with ID have lower rates of long-acting reversible contraceptives (LARCs) and moderately/highly effective reversible contraception usage as compared with their typically-developing counterparts.⁹

There may be unique medical considerations in this population that may decrease rates of medical contraceptive use. Estrogen-containing birth control medications may have pharmacological interactions with other medications which may decrease the effect of other needed medications for the patient.¹⁰ Additionally, girls with significant physical disabilities that are immobile may be at heightened risk of bony fractures when taking non-estrogen-containing birth control,¹¹ but then also at risk for thromboembolism with estrogen-containing compounds due to immobility.¹² Likely for these reasons, Wu ⁹ did find that adolescents with ID are provided with progestin-only birth control injection at higher rates than adolescents without ID.

There are several factors that may decrease the ability of patients and caregivers of this population to recognize pregnancy in its early stages, and hence seek out an earlier stage abortion if needed. For one, adolescents with ID may have decreased language abilities, making it difficult for them to express early pregnancy symptoms. Adolescents in general may have irregular menstrual cycles,¹³ making it difficult to ascertain if a menstrual period is late. Hence, the difficulties that exist in this population to identify pregnancy in early stages present a barrier to early-stage abortion, which may be more accessible in some states.

Pregnancies themselves in this population may be high-risk for a number of factors. For one, young age itself is a risk, with pregnancies in teenagers presenting obstetric complications to the mother, including eclampsia and postpartum hemorrhage, as well as risks to the infant, including low birth weight.¹⁴ Young women with disabilities, including neurological and intellectual disabilities, may be less likely to have live births and more likely to have miscarriages if mobility impairments are significant.¹⁵ In some adolescents with ID, the etiology of their neurological impairment may be from a genetic disorder,¹⁶ that, if autosomal dominant,¹⁷ may be directly passed onto their offspring, and these genetic disorders may present their own medical risks to the pregnancy and health of the infant.

Adolescents with epilepsy comorbid with ID may be on seizure medications with teratogenicity,¹⁸ which may further cause medical complications in the infant. Further, there is evidence for gaps in reproductive healthcare specifically for adolescents with epilepsy and ID,¹⁹ with parents and guardians of these patients expressing the need for more frequent discussions of reproductive health with their neurologists.²⁰

For adult women with intellectual and physical disabilities Horner-Johnson¹⁵ reported no significant difference in rates of seeking elective abortion compared to women without disabilities. However, no direct findings have been reported for the specific age group of adolescents. Childbearing in adolescence has been decreasing over the years, likely as the result of safe and confidential abortion access and contraceptive use. Thereby, one can also presume that this trend applies to adolescents with intellectual disabilities as well.

However, with restrictions to elective abortion access in many states, there have been noted increases in birth rates to adolescent mothers,²¹ and the continued abortion restrictions will likely affect both typically-developing as well as intellectually-disabled adolescents with unwanted pregnancies. In addition to recent legislation that restricts access to abortion healthcare, young women with ID may face additional barriers to accessing elective abortions. For instance, many women are traveling across state lines to obtain elective terminations in states with legal abortion access, but this travel may be cost-prohibitive for many young women with ID, who may experience higher rates of unemployment compared to non-disabled counterparts.²²

Both young maternal age as well as the neurodevelopmental disabilities of adolescent mothers with ID may impact health and quality of life for their infants. Young maternal age is associated with challenges for infants, including higher rates of preterm delivery, decreased educational levels, increased likelihood of single motherhood in these children, and higher rates of incarceration among male children.²³

In conclusion, the Dobbs decision may disproportionately affect adolescents of childbearing potential with ID. Increased rates of sexual assault and grooming, delayed recognition of early pregnancy in non-verbal adolescents, and medical issues complicating contraception use may contribute to unplanned pregnancies in this population. Then, barriers to reproductive healthcare access may be associated with births in younger mothers with ID, and their infants may experience unique medical and social challenges. Hence, girls with ID are a marginalized population that may experience outsized effects from legislation restricting abortion access, and advocacy is needed to help this population gain access to reproductive healthcare.

The authors would like to give thanks to the Planned Parenthood of Greater New York for their support.

This Mini Review received no external funding.

Regarding the publication of this article, the authors declare that they have no conflict of interest.

1. 1. Kaufman R, Brown R, Martínez Coral C, et al. Global impacts of Dobbs v. Jackson Women's Health Organization and abortion regression in the United States. Sex Reprod Health Matters. 2022;30(1):2135574.
2. 2. Kirstein M, Dreweke J, Jones RK, et al. 100 days Post-Roe: At least 66 clinics across 15 US states have stopped offering abortion care. Guttmacher Institute. 2022.
3. 3. Harrell E. Crime Against Persons with Disabilities, 2009-2014 - Statistical Tables. U.S. Department of Justice. 2016.
4. 4. Farahi N, McEachern M. Sexual Assault of Women. Am Fam Physician. 2021;103(3):168-176.
5. 5. Finkelhor D, Turner H, Colburn D. Prevalence of Online Sexual Offenses Against Children in the US. JAMA Netw Open. 2022;5(10):e2234471.
6. 6. Helton JJ, Gochez Kerr T, Gruber E. Sexual Abuse of Children with Learning Disabilities. Child Maltreat. 2018;23(2):157-165.
7. 7. Strand M, Benzein E, Saveman B. Violence in the care of adult persons with intellectual disabilities. Journal of Clinical Nursing. 2004;13(4):506-514.
8. 8. Retznik L, Wienholz S, Höltermann A, et al. “It gives me, as her caregiver, a sense of security.” young people with intellectual disability and their experiences with sexuality, menstruation, Gynecological treatment and contraception: A follow-up analysis of parents’ and caregivers’ perspectives. Sexuality and Disability. 2022;41: 97-116.
9. 9. Wu J, Zhang J, Monika M, et al. Provision of Moderately and Highly Effective Reversible Contraception to Insured Women With Intellectual and Developmental Disabilities. Obstetrics & Gynecology. 2018;132(3):565-574.
10. 10. King A, Gerard EE. Contraception, fecundity, and pregnancy in women with epilepsy: an update on recent literature. Curr Opin Neurol. 2022;35(2):161-168.
11. 11. Cromer BA, Scholes D, Berenson A, et al. Depot Medroxyprogesterone acetate and bone mineral density in adolescents-The black box warning: A position paper of the society for adolescent medicine. Journal of Adolescent Health. 2006;39(2):296-301.
12. 12. Quint EH, O'Brien RF; COMMITTEE ON ADOLESCENCE; North American Society for Pediatric and Adolescent Gynecology. Menstrual Management for Adolescents With Disabilities. Pediatrics. 2016;138(1):e20160295.
13. 13. American Academy of Pediatrics Committee on Adolescence; American College of Obstetricians and Gynecologists Committee on Adolescent Health Care; Diaz A, Laufer MR, Breech LL. Menstruation in girls and adolescents: using the menstrual cycle as a vital sign. Pediatrics. 2006;118(5):2245-2250.
14. 14. Todhunter L, Hogan Roy M, Pressman EK. Complications of Pregnancy in Adolescents. Semin Reprod Med. 2022;40(1-2):98-106.
15. 15. Horner-Johnson W, Kulkarni Rajasekhara S, Darney BG, et al. Live birth, miscarriage, and abortion among U.S. women with and without disabilities. Disabil Health J. 2017;10(3):382-386.
16. 16. Gupta N. Deciphering Intellectual Disability. Indian J Pediatr. 2023;90(2):160-167.
17. 17. Daoud H, Luco SM, Li R, et al. Next-generation sequencing for diagnosis of rare diseases in the neonatal intensive care unit. CMAJ. 2016;188(11):E254-E260.
18. 18. Velez-Ruiz NJ, Pennell PB. Issues for Women with Epilepsy. Neurol Clin. 2016 May;34(2):411-25, ix.
19. 19. Kirkpatrick L, Collins A, Harrison E, et al. Pediatric Neurologists' Perspectives on Sexual and Reproductive Health Care for Adolescent and Young Adult Women With Epilepsy and Intellectual Disability. J Child Neurol. 2022;37(1):56-63.
20. 20. Vasudevan G, Filipink R, Gaesser J, et al. Preferences and experiences of parents/guardians of youth with epilepsy and intellectual disability on reproductive health counseling. Epilepsy Behav. 2024;152:109658.
21. 21. Texas & Harris County Reproductive Health Update: 2022 Fertility Rates, post 2021 Six-Week Abortion Ban. (Briefing 2401). By The University of Houston Institute for Research on Women, Gender & Sexuality. 2024.
22. 22. Bureau of Labor Statistics Persons with a Disability: Labor Force Characteristics. 2023.
23. 23. American Academy of Pediatrics Committee on Adolescence. The Adolescent's Right to Confidential Care When Considering Abortion. Pediatrics. 2022;150(3):e2022058780.