Access to legal abortion has eroded significantly since the June 2022 Dobbs v. Jackson Women's Health Organization Supreme Court ruling, which reversed the previously acknowledged constitutional right to abortion (Rader et al., 2022Rader B. Upadhyay U.D. Sehgal N.K. Reis B.Y. Brownstein J.S. Hswen Y. Estimated travel time and spatial access to abortion facilities in the US before and after the Dobbs v Jackson women’s health decision.JAMA. 2022; 328: 2041-2047Google Scholar). Since then, threats to abortion access have continued with state and federal court and legislative challenges (Cohen et al., 2023Cohen D.S. Donley G. Rebouché R. The new abortion battleground.Columbia Law Review. 2023; 123: 1-100Google Scholar). Researchers, policy makers, and practitioners have focused on how restrictions disproportionately harm the most vulnerable, including minors, people living in poverty, immigrants, racialized people, and people with disabilities (Hassan et al., 2023Hassan A. Yates L. Hing A.K. Hirz A.E. Hardeman R. Dobbs and disability: Implications of abortion restrictions for people with chronic health conditions.Health Serv Res. 2023; 58: 197-201Google Scholar; Kozhimannil et al., 2022Kozhimannil K.B. Hassan A. Hardeman R.R. Abortion access as a racial justice issue.New England Journal of Medicine. 2022; 387: 1537-1539Google Scholar; Ogbu-Nwobodo et al., 2022Ogbu-Nwobodo L. Shim R.S. Vinson S.Y. Fitelson E.M. Biggs M.A. McLemore M.R. Mangurian C. Mental Health Implications of Abortion Restrictions for Historically Marginalized Populations.New England Journal of Medicine. 2022; 387: 1613-1617Google Scholar). This shift is noteworthy given the missteps of the past; reproductive health and rights frameworks have historically failed to center these populations in both clinical decision-making and policy (Nourse, 2011Nourse V. Buck v. Bell: A constitutional tragedy from a lost world.Pepp. L. Rev. 2011; 39: 101Google Scholar). In a post-Dobbs world, as modes of care and access change and transform, equity conscious stakeholders can and should re-define what justice-informed reproductive health care is, how it is operationalized, and who it empowers. Building off our Health Services Research article, entitled “Dobbs and Disability: Implications of Abortion Restrictions for People with Chronic Health Conditions” (Hassan et al., 2023Hassan A. Yates L. Hing A.K. Hirz A.E. Hardeman R. Dobbs and disability: Implications of abortion restrictions for people with chronic health conditions.Health Serv Res. 2023; 58: 197-201Google Scholar), we discuss further opportunities to mitigate structural ableism and its effects across the reproductive health lifespan. We define structural ableism as the cumulative and reinforcing ways in which willful or unconscious discrimination manifests in policy and institutions, threatening the survival and success of people with disabilities in favor of an able-bodied status quo. This definition is informed by the disability justice framework, developed in 2005 by queer and disabled activists of color Patty Berne, Mia Mingus, and Stacey Milbern (Invalid, 2017Invalid S. Skin, tooth, and bone–the basis of movement is our people: a disability justice primer.2017https://bjs.ojp.gov/content/pub/pdf/capd0914st.pdfGoogle Scholar). Disability justice is described by poet and writer Naomi Ortiz, 2012Ortiz N. Disability justice framework. Disability justice.http://disabilityj.blogspot.com/Date: 2012Date accessed: March 6, 2023Google Scholar:“Disability justice is the cross-disability (sensory, intellectual, mental health/psychiatric, neurodiversity, physical/mobility, learning, etc.) framework that values access, self-determination and an expectation of difference. An expectation of difference means that we expect difference in disability, identity and culture. To be included and part of society is about being able to be our ‘whole self ’ (all of our identities together)” (Ortiz, 2012Ortiz N. Disability justice framework. Disability justice.http://disabilityj.blogspot.com/Date: 2012Date accessed: March 6, 2023Google Scholar, 2012). Similar to disability justice, reproductive justice—the human right to bodily autonomy, to have a child, not have a child, and to parent in safe and sustainable communities (Ross et al., 2001Ross L.J. Brownlee S.L. Diallo D.D. Rodriquez L. Roundtable L. The" SisterSong Collective": women of color, reproductive health and human rights.American Journal of Health Studies. 2001; 17: 79-88Google Scholar)—was coined in reaction to the exclusion of marginalized people with intersectional perspectives from the mainstream rights movement and discourse (Ross, 2017Ross L.J. Reproductive justice as intersectional feminist activism.Souls. 2017; 19: 286-314Google Scholar). In considering the objectives of these two frameworks, we believe that they provide a powerful approach to retrofitting, reforming, and reimagining (McLemore, 2022McLemore M.R. Using retrofit, reform, and reimagine to advance toward health equity.The Journal of Perinatal & Neonatal Nursing. 2022; 36: 99-102Google Scholar) an equity-centered reproductive movement (Table 1). Nearly one in four people live with a physical or developmental disability (Courtney-Long et al., 2015Courtney-Long E.A. Carroll D.D. Zhang Q.C. Stevens A.C. Griffin-Blake S. Armour B.S. Campbell V.A. Prevalence of disability and disability type among adults—United States, 2013.Morbidity and Mortality Weekly Report. 2015; 64: 777Google Scholar); therefore, providing disability-inclusive reproductive care, education, services, and research is key. Further, it is critical to enact policies that ensure access to care, and to acknowledge historical and ongoing harms rooted in various systems of oppression. Although there are no easy solutions, the combination of these tangible activities supports a vision of bodily autonomy necessary to achieve a world where reproductive freedom is a lived reality for all.Table 1Reproductive and Disability FrameworksFrameworkReproductive HealthDisability InclusionReproductive RightsDisability RightsReproductive JusticeDisability JusticeObjectiveProvide direct health services to patients seeking careAdvocate for opportunities for people with disabilities to participate fully in societySupport the legal right to reproductive health careEstablish the civil rights of people with disabilitiesAffirm bodily autonomyAffirm the right to have or not have children, and the right to parent children in safe communitiesSelf-determination, celebrates all bodies as unique and essentialApproachExpand opportunity by opening more services and care, training, and educationFocused on “access”Lawsuits, political organizing, advocacy, lobbying for legal expansion of civil rightsFocused on “choice”Rectifying injustices, coalition building, centering the most marginalized/historically excluded, intersectionalityFocused on “autonomy” Open table in a new tab Fundamentally, reproductive bodily autonomy cannot orbit solely around the legal right to abortion care. In line with upstream public health approaches designed to address root causes, medically accurate and judgment-free reproductive counseling must begin early in the lifecourse, not just at the discovery of an unwanted pregnancy. Having providers and educators who recognize people with disabilities as whole individuals with reproductive and sexual lives, goals, and futures is a significant and impactful change that can be championed in several ways. To start, much can be gained from providing expansive and inclusive sex education that recognizes the sexual experiences and needs of differently abled people. People with disabilities often go through the U.S. education system without adequate sex education in part due to the persistent myth that disabled people are asexual or are incapable of intimacy (Sinclair et al., 2015Sinclair J. Unruh D. Lindstrom L. Scanlon D. Barriers to sexuality for individuals with intellectual and developmental disabilities: A literature review.Education and training in autism and developmental disabilities. 2015; 50: 3-16Google Scholar). This is especially problematic given that people with disabilities are disproportionately more likely to encounter sexual violence in their lives (Harrell, 2016Harrell E. Crime against persons with disabilities, 2009-2014-statistical tables. U.S Department of Justice, Bureau of Justice Statistics., Washington, DC2016Google Scholar). Providing accessible, medically accurate, and pleasure-inclusive sex and sexuality education can help people with disabilities achieve their own bodily autonomy and maintain satisfying intimacy. In addition, supporting access to a broad spectrum of contraceptive options is a necessary and equitable approach to care. Some people living with chronic health conditions and disabilities may need to use certain prescription contraceptive methods (ACOG Practice Bulletin No, 2019ACOG Practice Bulletin No206: use of hormonal contraception in women with coexisting medical conditions.Obstetrics & Gynecology. 2019; 133: e128-e150Google Scholar; Kaplan, 2006Kaplan C. Special issues in contraception: caring for women with disabilities.J Midwifery Womens Health. 2006; 51: 450-456Google Scholar). It is important that patients have access to all forms of contraception on the market, and that those methods are available at low or no cost. Importantly, when long-acting reversible contraception (LARC) is counseled, information on self-removal—including the benefits and risks in doing so—should be provided when clinically appropriate and efficacious. For many forms of LARC, such as intrauterine devices, self-removal guidance is increasingly being incorporated into contraception counseling protocol (Fay et al., 2023Fay K.E. Traore F. Amico J.R. Intrauterine device self-removal practices during the COVID-19 pandemic among family planning clinics.Contraception. 2023; 118: 109889Google Scholar). The inclusion of this practice is especially useful for people with disabilities because self-removal counseling can work to uplift reproductive autonomy and patient control (Broussard and Becker, 2021Broussard K. Becker A. Self-removal of long-acting reversible contraception: A content analysis of YouTube videos.Contraception. 2021; 104: 654-658Google Scholar). People with disabilities may experience unwanted pregnancy in their lives, and therefore having access to different modes of abortion care is vital to ensure this essential care is an affirming and accessible experience. Accommodating abortion in various supportive settings, including medication by telemedicine, is fundamental for people with mobility or transportation barriers. Patients seeking abortion care may also benefit from disability-informed full-spectrum doulas to support abortion patients inside and outside the clinic setting. Clinic policies that provide options for people with disabilities to be accompanied by caregivers and advocates, not just guardians, during appointments further supports abortion accessibility. When providing in-person care, reproductive health care clinics must prioritize accessible facilities and resources, such as adaptive exam tables, which serve as both a tangible and metaphorical sign of inclusion. An inclusive reproductive future must support medical training and employment of people with lived experiences with disability. Medical school, nursing school, and other clinical training programs have long been exclusionary for people with disabilities (Meeks and Moreland, 2021Meeks Lisa M. Moreland C. How Should We Build Disability-Inclusive Medical School Admissions?.AMA J Ethics. 2021; 23: E987-E994Google Scholar). Significant work is needed to reassess the accessibility and inclusion practices of teaching hospitals and clinics. A seat at the table for trainees living with disability provides a unique perspective on care provision for disabled patients that cannot otherwise be replicated. Professional societies can support the expansion of provider training and education by developing comprehensive justice-based professional guidelines inclusive of disability-informed recommendations. People who have lived experience with disability and/or chronic conditions often rely on subspecialties for illness-related support, treatment, and monitoring. Disease-specific information can be lost between specialists who are treating different dimensions of the same disease (Hirz, 2023Hirz A.E. Psychosocial Factors Contributing to Pregnancy Decisions among Women with Lupus: A Qualitative Study. [Unpublished Doctoral Dissertation]. University of California, Los Angeles2023Google Scholar; Panchal et al., 2013Panchal S. Khare M. Moorthy A. Catch me if you can: a national survey of rheumatologists and obstetricians on the use of DMARDs during pregnancy.Rheumatol Int. 2013; 33: 347-353Google Scholar; Thorne et al., 2020Thorne I. Sriskandarajah K. Mouyis M. Obstetric rheumatology training is an unmet educational need within the rheumatology community.Rheumatology Advances in Practice. 2020; 4: rkaa025Google Scholar). Therefore, reproductive and disability justice cannot reside only with reproductive care providers. Developing strong cross-specialty guidelines centering patient autonomy and self-determination can serve to decrease subjective discordance between providers and care recommendations. For example, many providers, such as rheumatologists, prescribe teratogenic medications and counsel their disabled patients on family planning; these clinicians would benefit from disability and reproductive justice guidelines when providing care. Guidelines should be disability-informed and flexible to accommodate the evolving needs of patients with lived experience with seen or unseen disabilities across their reproductive lifecourse. Ensuring access to care is essential to helping people with chronic conditions and disabilities live healthy lives. Congress has passed some landmark legislation that has improved access. For example, the Americans With Disabilities Act prohibits discrimination against people with disabilities and requires business and communities to ensure appropriate accommodations and infrastructure designs for people with a variety of disabilities (Anonymous, 1990Americans with disabilities act of 1990, 42 U.S.C. § 12101 et seq.https://www.ada.gov/law-and-regs/ada/Date: 1990Date accessed: March 6, 2023Google Scholar). The Affordable Care Act also prevents insurers from denying coverage or raising costs based on a preexisting condition (US Department of Health and Human Services, 2017US Department of Health and Human ServicesHealth insurance coverage for Americans with pre existing conditions: The impact of the Affordable Care Act. ASPE Issue Brief.https://aspe.hhs.gov/reports/health-insurance-coverage-americans-pre-existing-conditions-impact-affordable-care-actDate: 2017Date accessed: March 6, 2023Google Scholar). These laws have helped millions of Americans living with disabilities and chronic health issues access health care; however, other recommended policies that would improve the health and wellbeing of people with disabilities, such as the Reproductive Health Care Accessibility Act (Anonymous, 2022Reproductive health care accessibility act, S.4764, 117th cong.https://www.congress.gov/bill/117th-congress/senate-bill/4764Date: 2022Date accessed: March 6, 2023Google Scholar), have not been enacted. Nearly a dozen states have yet to expand Medicaid coverage, leaving 2.2 million people in the coverage gap (Garfield et al., 2021Garfield R. Damico A. Rudowitz R. Taking A Closer Look At Characteristics of People in the Coverage Gap. KFF, Kaiser Family Foundation, 2021Google Scholar). These U.S. adults have incomes that are higher than their states’ Medicaid eligibility levels, but below the poverty limit, meaning they do not qualify for marketplace subsidies. Approximately one of six people in the coverage gap have a physical or cognitive disability affecting their activities of daily living or how they navigate their communities (Garfield et al., 2021). State policies expanding coverage would help ensure that some uninsured people with disabilities or chronic conditions access preventive care and receive ongoing treatment and support for their medical conditions. In addition to policies ensuring access to family planning, legislative bodies should enact policies to protect and secure access to various fertility methods. Women and birthing people with disabilities are more likely to experience infertility (Ha and Martinez, 2021Ha S. Martinez V. Associations between disability and infertility among U.S. reproductive-aged women.Int J Environ Res Public Health. 2021; 18: 3202Google Scholar), and therefore may need to postpone pregnancy or use alternative methods to create the families they want. This includes the use of fertility preservation services, such as egg and embryo freezing, and the use of assisted reproductive technology (ART). Equitable distribution and access to fertility preservation services is necessary for people with disabilities to choose when to become pregnant on a timeline that fits their personal circumstances. Many insurers do not cover fertility preservation except in cases in which preservation is considered “medically necessary,” almost exclusively where chemotherapy and/or radiation treatments are used (Weigel et al., 2020Weigel G. Ranji U. Long M. Salganicoff A. Coverage and Use of Fertility Services in the US. KFF, Kaiser Family Foundation.https://www.kff.org/womens-health-policy/issue-brief/coverage-and-use-of-fertility-services-in-the-u-s/Date: 2020Date accessed: March 6, 2023Google Scholar). Institutional policies and insurers should expand access and guarantee coverage for fertility preservation in the absence of gonadotoxic treatments. Further, providers who care for people who can or want to get pregnant should self-educate on available fertility preservation services so that they can give timely and patient-centered recommendations to patients interested in fertility preservation (Ethics Committee of the American Society for Reproductive Medicine, 2018Ethics Committee of the American Society for Reproductive MedicineFertility preservation and reproduction in patients facing gonadotoxic therapies: an ethics committee opinion.Fertility and sterility. 2018; 110: 380-386Google Scholar). The Dobbs decision also created a complex landscape for ART (Heidt-Forsythe et al., 2022Heidt-Forsythe E. Kalaf-Hughes N. Mohamed H.S. Roe is gone. How will state abortion restrictions affect IVF and more? The Washington Post.https://www.washingtonpost.com/politics/2022/06/25/dodds-roe-ivf-infertility-embryos-egg-donation/Date: 2022Date accessed: March 6, 2023Google Scholar). State policies should explicitly protect these methods so that people living with chronic conditions and disabilities can select the most appropriate treatment for their type of infertility. One way we can start reckoning with our eugenic legacy as a society is to acknowledge its continued impact on reproductive self-determination. The United States has a history of limiting the reproductive autonomy of people with disabilities. The practice of eugenics widely promoted compulsory sterilization of disabled and racialized people during the 20th century (National Human Genome Research Institute, 2022National Human Genome Research InstituteEugenics and scientific racism. Genome.gov.https://www.genome.gov/about-genomics/fact-sheets/Eugenics-and-Scientific-RacismDate: 2022Date accessed: March 6, 2023Google Scholar). Eugenics imposes a hierarchy on who can reproduce by placing value on bodies; in turn, that value is often equated to a person's inheritable character (Winfield, 2010Winfield A.G. Instituting a hierarchy of human worth: eugenic ideology and the anatomy of who gets what.https://docs.rwu.edu/sed_fp/10Date: 2010Date accessed: March 6, 2023Google Scholar). Government- and state-sanctioned programs aimed to limit reproduction to control undesirable “character traits'' through the compulsory sterilization of disabled and racialized people in service of growing nativism and nationalism (Farber, 2008Farber S.A. U.S. scientists' role in the eugenics movement (1907-1939): a contemporary biologist's perspective.Zebrafish. 2008; 5: 243-245Google Scholar; Manian, 2020Manian M. “Immigration Detention and Coerced Sterilization: History Tragically Repeats Itself.” ACLU, American Civil Liberties Union.https://www.aclu.org/news/immigrants-rights/immigration-detention-and-coerced-sterilization-history-tragically-repeats-itselfDate: 2020Date accessed: March 6, 2023Google Scholar; Ordover, 2003Ordover N. American Eugenics: Race, Queer Anatomy, and the Science of Nationalism (NED-New edition). University of Minnesota Press, Minneapolis, MN2003Google Scholar Price et al., 2020Price G.N. Darity Jr., W. Sharpe R.V. Did North Carolina Economically Breed-Out Blacks During its Historical Eugenic Sterilization Campaign?.American Review of Political Economy. 2020; 15: 1-21Google Scholar). The practice of eugenics is not “in the past” (Stern, 2020Stern A. Forced sterilization policies in the US targeted minorities and those with disabilities – and lasted into the 21st Century. University of Michigan Institute for Healthcare Policy and Innovation, Ann Arbor, MI2020Google Scholar). Compulsory sterilization is still legal at the federal level, and 31 states as well as the District of Columbia have laws on the books legalizing the practice (National Women’s Law Center, 2021National Women’s Law CenterForced sterilization of disabled people in the United States.https://nwlc.org/wp-content/uploads/2022/01/%C6%92.NWLC_SterilizationReport_2021.pdfDate: 2021Date accessed: March 6, 2023Google Scholar). Today, eugenic practices often happen “behind closed doors.” Disabled women and pregnant people report not fully consenting to sterilization procedures, in some cases by gynecologists immediately after giving birth (National Women’s Law Center, 2021National Women’s Law CenterForced sterilization of disabled people in the United States.https://nwlc.org/wp-content/uploads/2022/01/%C6%92.NWLC_SterilizationReport_2021.pdfDate: 2021Date accessed: March 6, 2023Google Scholar). Trusted caregivers can legally decide to sterilize disabled people regardless of their stated reproductive desires (Ne’eman, 2018Ne’eman A. “Washington State may make it easier to sterilize people with disabilities.” ACLU, American Civil Liberties Union.https://www.aclu.org/news/disability-rights/washington-state-may-make-itDate: 2018Date accessed: March 6, 2023Google Scholar; National Women’s Law Center, 2021National Women’s Law CenterForced sterilization of disabled people in the United States.https://nwlc.org/wp-content/uploads/2022/01/%C6%92.NWLC_SterilizationReport_2021.pdfDate: 2021Date accessed: March 6, 2023Google Scholar). The incidence of forced sterilizations of disabled people is likely to be grossly underestimated due to fear of or inability to report abuse (Medosch, 2021Medosch E. Not just ice: forced sterilizations in the United States.Immigration and Human Law Review. 2021; (Available:)https://lawblogs.uc.edu/ihrlr/2021/05/28/not-just-ice-forced-sterilization-in-the-united-states/#post-276-footnote-ref-41Google Scholar; National Women’s Law Center, 2021National Women’s Law CenterForced sterilization of disabled people in the United States.https://nwlc.org/wp-content/uploads/2022/01/%C6%92.NWLC_SterilizationReport_2021.pdfDate: 2021Date accessed: March 6, 2023Google Scholar). Women and pregnant people should be empowered to report provider misconduct and not fear loss of care, retaliation, or denial of grievances. Professional association and insurer barriers to reporting should be removed and patients should be given information and supportive guidance for reporting reproductive abuse. Societally, we have yet to truly reckon with ableism as a health equity issue, and the dearth of research to understand the intersections of disability, race, and gender severely limits evidence-based and culturally competent interventions for the people most impacted by structural ableism. Funding this research must become a priority for grantmaking institutions interested in an equitable future. Disabled researchers and scholars should be supported in conducting this research. Many scholars who are disabled or have chronic conditions are apprehensive to disclose their health circumstances for fear of limited opportunities and stunted career growth (Brown and Leigh, 2018Brown N. Leigh J. Ableism in academia: where are the disabled and ill academics?.Disability & Society. 2018; 33: 985-989Google Scholar; Inckle, 2018Inckle K. Unreasonable adjustments: the additional unpaid labour of academics with disabilities.Disability & Society. 2018; 33: 1372-1376Google Scholar). Supporting disabled researchers can develop a culture of belonging and decrease the disability stigma common in capitalist societies that correlates human value with work productivity (Brown and Ramlackhan, 2022Brown N. Ramlackhan K. Exploring experiences of ableism in academia: a constructivist inquiry.Higher education. 2022; 83: 1225-1239Google Scholar; Shinohara et al., 2021Shinohara K. McQuaid M. Jacobo N. The burden of survival: how doctoral students in computing bridge the chasm of inaccessibility.in: Proceedings of the 2021 CHI Conference on Human Factors in Computing Systems. 2021: 1-13Google Scholar).
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