Findings from research on persons with disabilities’ sexual and reproductive health in Cambodia
Men and women with disabilities care for and support others as husbands and wives, mothers and fathers, sons and daughters. Research shows that they can realize their sexual and reproductive health rights and aspirations if health workers are willing to engage with them and know how to provide some practical support.
Theavy, a 34 year old woman with a mobility impairment, is married with two children. When her husband asked to marry her she replied:
“’Ask your parents’. He did and when they agreed to our marriage, so did I…but I told him I am a person with disability, you shouldn’t marry someone like me. I even fall over when I try to walk but he told me that he would do everything for me. I have never carried water once, he does everything for me. I only wash the clothes.”
Theavy’s husband supports her to get to the health centre if and when she needs to see the doctor. When she was pregnant he drove her to the health centre for pre- and post-natal check-ups and gave her money to cover medical expenses.
Panya is a 25 year old married man. He and his wife both have hearing impairments. His wife is heavily pregnant. Panya explains how they came to marry:
“I met my wife at the organisation where I work and told my parents that we wanted to get married. They went to visit her. My Mum was surprised that I wanted to get married but they arranged our marriage.”
When Panya and his wife go to visit the health centre a speaking and sign literate staff member from Panya’s work accompanies them. With a translator Panya and his wife are easily able to converse with the midwife during their consultation and to understand the information shared.
Exploring persons’ with disabilities’ intimate worlds
Heavy’s and Panya’s stories show that persons with disabilities can have fulfilled marital and sexual lives, and that they are able to access the health services they need for this if the appropriate support is available to them. Yet for many other persons with disabilities this is not yet the case. In most developing countries they still encounter a range of barriers to sexual and reproductive health information and services.
The Cambodian Improving Maternal and Newborn Care Project – implemented by Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of the German Ministry for Economic Cooperation and Development – recognized these challenges and in July 2015 commissioned research to investigate persons’ with disabilities sexual and reproductive health care (“The intimate worlds of men and women with disabilities in Cambodia”, A. Gartrell for GIZ, 2016). This article gives an overview of the key barriers the study identified and recommends how the health programme in Cambodia, and communities and health service providers in similar settings, can begin to address them.
Barrier 1: Mobility impairments
Men and women with disabilities who are unable to move independently rely upon others to assist them to travel. The availability spouses, children, siblings, parents, relatives and /or friends to accompany them to the health centre is critical to their access to health services. Women with disabilities however, are less likely than men with disabilities to marry and many are without a spouse to call upon for assistance. Women with disabilities who never marry find asking others to help them difficult; they feel family members are too busy working to help them. In the absence of others to support their travel, women with disabilities stay at home and buy medicine from local sellers or take traditional herbs when they are sick. They delay seeking help at the centre health and may only go in an emergency.
Barrier 2: Poverty
Persons with disability are more likely than other population groups to live in poverty. Women with disabilities in particular, struggle to access financial resources to cover the costs of medical care and transportation to help them to a health centre. They are thus unable to make their own decisions regarding their sexual and reproductive health and in a household context of poverty, low social status and dependence upon others for their livelihood, health and particularly sexual and reproductive health needs are not a priority. Some women with disabilities have never attended a health centre at all. In contrast, this study found that men with disabilities were either married or living with parents and were able to secure the support they needed to get to the health centre if and when they required.
Barrier 3: Difficulties in communicating with health workers
Without sign language interpreters and visual communication aids, men and women with hearing impairments found consultations with health centre staff confusing. They gained little information of their sexual and reproductive health from health centre staff who did not know how to appropriately approach, interact and communicate with them. Health centre staff thus tended to communicate with hearing others typically parents or spouses who may have accompanied them to the health centre. Some men and women with hearing impairments had such negative experiences, they decided not to return to the health centre again.
Barrier 4: Gender-related vulnerabilities
In this study women with disabilities were more likely to remain single and never marry than men with disabilities. As unmarried women they are exposed to compound vulnerabilities associated with poverty, gender, disability, living alone and being childless. Despite these barriers, they are likely to have greater unmet health needs than other women as they are more at risk of physical and sexual violence and abuse, and have few sources of support to call upon.
Steps toward inclusive health services
In their work with health centre staff in the field, the GIZ advisors in Cambodia recognized that health workers need greater exposure to persons with disabilities to increase their confidence to engage with and appropriately support them. To assist health centre staff to share information and communicate with persons with hearing impairments, for example, GIZ developed visual communication boards. They also learnt that the recruitment of persons with disabilities as health centre staff or as volunteers can help to ensure that services and information are inclusive.
GIZ is also working with disabled people’s organizations and their members to promote health education of persons with disabilities. A local NGO Epic Arts has been engaged to conduct theatrical performances and produce a video on disability awareness, sexual and reproductive health knowledge (see video below).
The performances aim to raise awareness for the fact that persons with disabilities are sexually capable beings just like everyone else. Their central message to persons without disabilities is simple and clear: “My needs are the same as yours.”
Theavy and Panya’s experiences are evidence that persons with disabilities can claim their sexual and reproductive health rights, access the health services they need for this and have fulfilling intimate loving relationships when the people around them and health care providers know how to appropriately support them. By working with disabled people’s organisations’ and health centre staff, health programmes like the one GIZ supports in Cambodia can help create awareness, build confidence of service providers and service users and facilitate the introduction of tools and approaches needed for inclusive healthcare provision.
Alexandra Gartrell
November 2016