Hysterectomy and disability among U.S. women.

Approximately 600,000 hysterectomies are performed annually in the United States, and this surgery is the second most common—after cesarean section—among women of reproductive age.1 Hysterectomy is a major operation, involving the removal of the uterus, cervix, fallopian tubes or ovaries, and can lead to serious complications.2,3 Nevertheless, about 90% of hysterectomies are performed for elective reasons.*1 When reviewed by a panel of physician experts, about 70% of elective hysterectomies were found to carry at least as many risks as benefits.4 Hysterectomy receipt is socially patterned. Women with a high school education or less undergo hysterectomies at much higher rates than women with more education.5–7 In addition, women reporting relatively lower levels of income and those working in low-status occupations are far more likely to have hysterectomies than are their counterparts with higher incomes or better jobs.5–7 Whites and blacks have an identical risk of getting a hysterectomy, whereas Hispanics and women of other races or ethnicities have a lower risk of having one.5–8 The association between disability and having a hysterectomy has not been thoroughly considered in previous research. The health of women with disabilities in general has received relatively little attention,9,10 even though these women may be more vulnerable than others to adverse consequences of inadequate health care access.11–13 Indeed, they frequently face multiple forms of inequality that put them at a health disadvantage relative to other women—like low socioeconomic status and depression.14,15 Evidence suggests that women with varied types of disability are at heightened risk of having a hysterectomy, and that they may have a relatively high risk of hysterectomy at young ages. In 2001, Nosek and colleagues16 found that women with mobility limitations have hysterectomies at higher rates than women without such disabilities. Findings from their in-depth interviews suggest that some women with mobility limitations face pressure from family members and medical professionals to undergo elective hysterectomy, even if they wish to have children someday. Although the Nosek et al. study provides the best evidence to date on the relationship between disability and risk of hysterectomy, it has several shortcomings: Hysterectomy rates were calculated from a national convenience sample; the focus was exclusively on women with mobility limitations; and the analysis did not adjust for potentially confounding variables, like education and income. Historically, institutionalized women with disabilities and women with cognitive or multiple disabilities have been frequent targets of eugenics campaigns. The majority of women who involuntarily underwent hysterectomies at the height of the U.S. eugenics movement were institutionalized women who had disabilities.17–19 Medical ethics controversies in the past decade suggest that some young women with severe cognitive disabilities still have hysterectomies at the request of their parents to eliminate menstruation and ease caregiving burdens.20–23 This study sought to expand our understanding of the relationship between disability and hysterectomy in several ways. First, it used data from the National Health Interview Survey (NHIS), the only nationally representative survey to include retrospective measures of the timing and type of disability, as well as the timing of hysterectomy. Second, it employed multivariate regression analysis to explore the relationship between disability and having a hysterectomy, and to assess whether the risk of hysterectomy varies by disability type. Third, it used a series of event history regressions to investigate whether the risk of undergoing a hysterectomy faced by women with disabilities, and by women with multiple disabilities in particular, changes over the life course.