Sexuality and Sexual Education

Adolescents with special needs can have physical and/or developmental disabilities. They are often seen by society, including their families and care providers, as asexual, and therefore sexual education might not have been provided or considered necessary. Physically disabled teens are as likely to be sexually active as nondisabled teens. The care provider needs to assess the teen’s knowledge of anatomy and sexuality, her social knowledge of relationships, and her ability to consent to sexual activity. Education regarding HIV and other sexually transmitted infections (STIs), disease prevention, and contraception, including postcoital contraception, should be offered at a developmentally appropriate level. Teens with disabilities may be more at risk for isolation and depression during adolescence.

Abuse

The risk for sexual abuse in teens with disabilities is difficult to estimate. Studies show that teens with physical disabilities are just as sexually active as their nondisabled counterparts but that more of their activity is nonvoluntary. Screening for abuse is mandatory. Abuse prevention education can include the No! Go! Tell! model. For teens with limited verbal capacity or developmental delay, abuse may be very hard to detect. The care provider needs to be vigilant in looking for signs on physical exam, such as unexplained bruises or scratches, or changes in behavior that may be indications of sexual abuse in those adolescents (Chapters 37.1 and 113).

Pelvic Examination

A pelvic exam is rarely indicated in teens who are not sexually active, unless they have vulvar issues such as discharge, irregular bleeding, suspicion for abuse, or foreign body and an external inspection can be performed. A speculum exam is not performed, and if the vagina or cervix needs to be visualized, an exam under anesthesia by a gynecologist should be considered. Testing for STIs can be accomplished by urine testing or vaginal swabs (Chapter 114).

Menstruation

Irregular menstruation is common in teenagers, especially the first 5 years after menarche, due to immaturity of the hypothalamic-pituitary-ovarian (HPO) axis and subsequent anovulation (Chapter 110). Several conditions in teens with disabilities are associated with an even higher risk of irregular cycles. Teens with Down syndrome have a higher incidence of thyroid disease. There is a higher incidence of reproductive issues, including PCOS in teens with epilepsy and on certain antiepileptic drugs (AEDs) (Chapter 546). Antipsychotic medication can cause hyperprolactinemia, which can affect menstruation.

The main issue with menstrual cycles, whether they are regular, irregular or heavy, is the impact of menstruation on the patient’s life and her normal activities. The history should focus on this aspect, and menstrual calendars may be helpful to document the cycles, behavior, and the impact of treatments. Most adolescents who self-toilet can learn to use menstrual hygiene products appropriately.

The evaluation for abnormal bleeding is the same as for all teens. Areas requiring particular attention for the child with special needs are the possible need for menstrual suppression for hygiene or cyclical behavioral issues, like crying, tantrums, or withdrawal, and a request for birth control, especially coming from a caregiver and not from the teen, which requires an evaluation of the teen’s ability to consent and evaluate the safety of her environment.