Impacts of the COVID-19 pandemic on access to sexual and reproductive health services for women and gender-diverse people with disabilities in Canada: a qualitative study.

The COVID-19 pandemic has had a detrimental impact on gender disparities in health as well as sexual and reproductive health and rights (SRHR) globally. 1 SRHR is contingent on the availability, accessibility, acceptability, and quality of sexual and reproductive health (SRH) services. SRH service provision, access, and use was disrupted by COVID-19 pandemic control measures and by the redirection of resources and staff away from SRH services and toward COVID-19 mitigation efforts, resulting in supply shortages, deferral of services deemed non-urgent, public messaging discouraging non-urgent care seeking, clinic closures, and limitations on in-person service provision. Growing evidence indicates the pandemic reduced access to contraceptives, abortion, sexually transmitted infection (STI) testing and treatment, reproductive cancer screening, gender-based violence supports, gender-affirming services, fertility services, perinatal health services, and routine child vaccinations. 2–10 Reduced access to SRH services can lead to poor health outcomes, and the pandemic is already known to have had negative SRH implications among the general population, including elevated rates of gender-based violence; compromised sexual health and wellbeing; changes in sexual behaviours, menstrual health, and pregnancy intentions; and worse maternal and fetal outcomes. 10–12 Yet, we know little about how the COVID-19 pandemic has impacted the SRHR of women and gender-diverse people with disabilities. 2 Research is needed on disabled people’s access to SRH services during the pandemic for the following reasons. First, there is a high global prevalence of disability, with an estimated one in seven people living with disability, and women are more likely to have a disability than men. 13 While data on the prevalence of disability among gender-diverse people is lacking, estimates suggest transgender people are more likely to have a disability than cisgender people. 14 Second, disabled people experienced significant SRHR disparities compared to non-disabled people pre-pandemic, including increased risk of STIs, gender-based violence, perinatal health complications, and child custody loss. 15–22 Third, people with disabilities have been disproportionately impacted by the COVID-19 pandemic, with higher rates of hospitalisation and mortality following COVID-19 infection, greater risk of psychological distress and social isolation, increased vulnerability to economic and food insecurity, and exacerbated accessibility barriers to health care services, that caused poor mental health and wellbeing outcomes. 23–25 The World Health Organization recognises the impact of emergency situations on SRHR for people with disabilities. 26 In 2021, a global United Nations Population Fund (UNFPA) report (based on data from Latin America, Asia-Pacific, Sub-Saharan Africa, Europe, Central Asia, and the Arab region) found that COVID-related barriers to SRH services increased for women with disabilities in ways similar to (e.g. supply shortages) and different from (e.g. restrictions to disability supports like support persons and sign language interpreters) women without disabilities. 27 A handful of quantitative studies found that, during the pandemic, people with disabilities (in Nepal) were more likely to report SRH service barriers; SRH service barriers increased in both number and type for people with disabilities assigned female at birth (in the United States); and the transition to telehealth improved SRH service accessibility for people with disabilities (in Australia). 19 , 28 , 29 Qualitative studies described SRH service barriers experienced by women with disabilities during the pandemic, including mobility and communication barriers, provider insensitivity, and lack of social support (in Turkey) and disability-related prejudice (in Zimbabwe). 30 , 31 This study contributes to the literature on this important topic by using a disability reproductive justice perspective to examine how the COVID-19 pandemic impacted access to SRH services for women and gender-diverse people with disabilities in a universal health care context. Developed by queer disabled women of colour and influenced by intersectional feminist, queer, and crip theories, disability justice conceptualises disability as a means of connecting people who inhabit non-normative bodyminds through impairment, illness, or Madness. It focuses on underlying reasons for systematic disability injustices that fail to account for the intersectional complexities of disabled lived experiences, and advocates to move beyond individualised disability rights to collective approaches to disability which recognise that justice for disabled people is inextricably linked to combating racism and other forms of oppression. 32–36 Disability justice has been overlooked in global SRHR movements, despite disability communities experiencing significant SRHR violations like gender-based violence and the denial of sexual and reproductive decision-making. 37–39 A disability reproductive justice perspective is especially relevant in the context of the COVID-19 pandemic, which has worsened systemic ableism, SRHR violations, and reproductive injustices disproportionately for underserved communities. 40 , 41

This qualitative study is part of a larger mixed-methods, community-engaged research project examining the impacts of the COVID-19 pandemic on the SRHR of women and gender-diverse people with disabilities in Canada. The study’s community-engaged methodology centred lived experiences and incorporated input from disability communities through an Advisory Committee that included members from the DisAbled Women’s Network of Canada and ASE Community Foundation for Black Canadians with Disabilities, and a research team that included peer researchers from the disability community. Members from racialised, gender-diverse and queer disability communities were also represented on the research team and Advisory Committee. Ethics approval was received from the University of Toronto Research Ethics Board (Protocol Number 42194, approved January 21st, 2022). We understand disability to be an ambiguous and unstable experience, identity, and sociopolitical category that encompasses a range of bodily, cognitive, and sensory differences, abilities, and capacities that are produced by a nexus of bodily, social, and environmental factors. This study uses disability inclusively to refer to people who self-identify as disabled (including those who have not been officially recognised as disabled by medical or legal systems) and people living with disability-related impairments who may not identify as disabled for various reasons, such as ableism (the belief that disabled people are inferior to non-disabled people), identification with specific communities (e.g. Deaf, Mad, neurodivergent), or tensions about disability identity within communities experiencing multiple forms of oppression. 36 We also recognise disability and d/Deafness has a complex relationship: not all people who identify as Deaf (stylised “Deaf”) identify as disabled and not all people who experience deafness as hearing impairment (stylised “deaf”) identify with Deaf culture. We use the stylisation “d/Deaf” to reflect these fluid identities. 42 We use both person-first language (e.g. “people with disability”) and identity-first language (e.g. “disabled people”) to reflect diverse community language preferences. 43 We used purposeful sampling of group characteristics, including homogenous sampling of people with disabilities and maximum variation sampling within this subgroup. 44 To reflect diversity within the community, we recruited people with a range of disabilities and SRH experiences (broadly inclusive, e.g. contraception; abortion; sexual health and wellness; gynaecological and menstrual health; gender-based violence; gender-affirming health; perinatal/parental health; and health of young children). We distributed recruitment flyers and a video in English through email and social media to disability-related organisations. We also recruited participants through research team and Advisory Committee networks. We screened interested individuals for eligibility and selected participants based on relevant sociodemographic positionalities (e.g. age, race, geography) to maximise the variation and diversity of the sample. To participate, individuals had to self-identify as disabled or be identified as disabled, a person with a disability, and/or d/Deaf; identify as a woman or gender-diverse person (i.e. cisgender and transgender women, transgender men, Indigenous Two-spirit persons [i.e. a queer gender, sexual, and spiritual identity culturally-specific to Indigenous people across Turtle Island including Canada], and non-binary, genderqueer, gender non-conforming, or gender-questioning persons [i.e. fluid identification with both or neither masculine and feminine identities]); be 18 years of age or older; and live and receive health care in Canada. We relied on participants’ self-reported information for all inclusion criteria. The research team developed a semi-structured interview guide with input from the Advisory Committee; this was a flexible guide and changing document that was refined by the research team based on input from participants and disability community partners. Between May 2022 and March 2023, peer researchers and a medical anthropologist facilitated interviews by Zoom videoconferencing platform (with video and audio, or audio only) or telephone. Before interviews, we acquired verbal or written informed consent and documented verbal consent in writing. The option of written or verbal consent accommodated participant preferences and needs. We asked participants with intellectual disabilities additional questions to determine capacity to consent (e.g. What will you be doing if you take part in the study?), specifying that learning was permitted in this process. 45 We asked if participants needed interview accommodations or support (e.g. support person, interpreter). We conducted brief socio-demographic questionnaires (age, gender, sexuality, marital status, race/ethnicity, level of education, employment status, and locality/geography). Interviews were conducted in English, audio-recorded, and typically 60 minutes in length. American Sign Language (ASL) interpreters facilitated two interviews with Deaf participants. We asked open-ended questions about disability and SRH history; experiences accessing, trying to access, or thinking about accessing SRH services during the COVID-19 pandemic (defined as March 2020 to the date of interview); and recommendations for improving SRH services. We provided a CA$ 40 gift card and a list of resources to participants after interviews. One week after interviews, we contacted participants to see if they had any questions or additional thoughts. Interviews were transcribed by a professional transcription service and verified and deidentified by interviewers. All names are pseudonyms. Our analysis used a constructivist qualitative approach. This exploratory, data-driven, and reflexive method conceptualises data to represent socially constructed realities and theory as emergent constructions grounded in data interpretation. 46 We used a hybrid approach, coding transcripts both deductively (using preidentified thematic codes informed by the literature) and inductively (identifying new thematic codes based on the data) using NVivo 12. Several steps were taken to ensure rigour and credibility of data analysis. 47 First, interviewers debriefed and wrote field notes to capture key points after interviews. Second, negative cases (i.e. outlier narratives that did not fit within broader patterns) were examined, as well as unexpected findings. Third, we triangulated sources, analysts, and perspectives by having two analysts code transcripts and by regularly conducting Advisory Committee consultations to refine themes and ensure that multi-disciplinary and community perspectives informed our interpretations. Fourth, we recruited a relatively large and diverse sample to enhance the transferability and applicability of the results. Our reporting adheres to the Standards for Reporting Qualitative Research guidelines. 48

We interviewed 61 people with disabilities ( Table 1 ). About half of the participants had multiple disabilities ( n  = 31). The most reported disability was physical (67%), followed by mental health (44%), cognitive (43%), and sensory (10%). The mean age was 36 years (range 18–63 years). Participants included women (80%) and/or gender-diverse people (25%), who identified as straight or heterosexual (59%) or with one or multiple queer sexualities including lesbian, gay, bisexual, pansexual, and asexual (41%). About half of the sample was single (52%) and the other half partnered. Participants identified as white (65%); Black, Afro-Caribbean, Afro-Indo Caribbean, African (21%); Asian, East Asian, South Asian, Pacific Islander, Middle Eastern (15%); and Indigenous (5%). Most lived in Ontario (74%) and urban areas of cities with a population of 100,000 or more (77%). The majority had completed postsecondary education (80%) and were employed full-time (46%) or part-time (21%). Table 1. Socio-demographic characteristics of study participants ( n  = 61) Socio-demographic characteristic N (%) Disability a,b    Cognitive 26 (43%)  Mental health 27 (44%)  Physical 41 (67%)  Sensory 6 (10%) Age range (years)    18–29 18 (29%)  30–39 20 (33%)  40–49 17 (28%)  50+ 6 (10%) Gender a    Women (cisgender, cisgender and genderqueer or gender-questioning, and transgender women) 49 (80%)  Gender-diverse people (genderqueer, gender-questioning, non-binary, transmasculine, transgender men, transgender women, and Two-spirit Indigenous persons) 15 (25%) Sexuality    Straight (heterosexual) 36 (59%)  Queer (including lesbian, gay, bisexual, pansexual, asexual) 25 (41%) Race a    Asian, East Asian, South Asian, Pacific Islander, Middle Eastern 9 (15%)  Black, Afro-Caribbean, Afro-Indo Caribbean, African 13 (21%)  Indigenous 3 (5%)  White 40 (65%) Relationship status    Partnered (married, common-law, long-term relationship) 29 (48%)  Single (never married, separated, widowed, divorced) 32 (52%) Highest level of education    Secondary (high school diploma) 12 (20%)  Postsecondary (college/trade diploma, undergraduate degree, graduate degree) 49 (80%) Employment status    Employed full-time 28 (46%)  Employed part-time/freelance 13 (21%)  Student 5 (8%)  Unemployed (looking for employment, on permanent disability leave, volunteering, caring for family) 15 (25%) Province    Atlantic Canada 2 (3%)  British Columbia 6 (10%)  Ontario 45 (74%)  Prairies 7 (11%)  Quebec 1 (2%) Locality    Small town (between about 1000 and 29,999 people) 6 (10%)  Medium-sized city (between about 30,0000 and 99,999 people) 8 (13%)  Big city (between about 100,000 and 499,999 people) 22 (36%)  Very big city (more than 500,000 people) 25 (41%) a. Participants reported multiple disabilities, gender, and racial identities; therefore, the sum of these categories exceeds n  = 61 (100%). b. Examples of disabilities represented in the sample include (but were not limited to) paraplegia, cerebral palsy, spina bifida, fibromyalgia, endometriosis, multiple sclerosis (physical disabilities); post-traumatic stress disorder, mood disorder, obsessive compulsive disorder, personality disorder, depression, and anxiety (mental health disabilities); autism, fetal alcohol spectrum disorder, attention-deficit/hyperactivity disorder, and learning disabilities (cognitive disabilities); vision loss, hearing loss, and identifying as d/Deaf (sensory disabilities). Socio-demographic characteristics of study participants ( n  = 61) a. Participants reported multiple disabilities, gender, and racial identities; therefore, the sum of these categories exceeds n  = 61 (100%). b. Examples of disabilities represented in the sample include (but were not limited to) paraplegia, cerebral palsy, spina bifida, fibromyalgia, endometriosis, multiple sclerosis (physical disabilities); post-traumatic stress disorder, mood disorder, obsessive compulsive disorder, personality disorder, depression, and anxiety (mental health disabilities); autism, fetal alcohol spectrum disorder, attention-deficit/hyperactivity disorder, and learning disabilities (cognitive disabilities); vision loss, hearing loss, and identifying as d/Deaf (sensory disabilities). We identified four major themes with twelve sub-themes. First, we describe COVID-related changes to SRH service delivery and disability-related health effects. Second, we examine COVID-related changes to SRH service accessibility. Third, we explain the disability-related SRHR implications of COVID-related social changes. Fourth, we synthesise participant recommendations for improving people with disabilities’ SRHR. COVID-19-related changes to health service delivery (i.e. supply shortages, clinic closures, staffing shortages, redeployment of resources, pauses to non-essential services) disrupted access to SRH services in community, outpatient, and inpatient settings, and had disability-related health implications. In community and outpatient settings, participants reported delayed access to contraception, abortion care, STI testing and care, menstrual care and products, gynaecological care, cervical and breast cancer screening, gender-based violence services, gender-affirming services, pregnancy-related care, and health care services for young children. Public health messaging that deprioritised non-urgent care seeking, pandemic-related stress, and limited privacy at home for telehealth appointments were factors that discouraged participants from seeking care. Disability-related health concerns about COVID-19 exposure compounded barriers. “ I found it hard to get a hold of the birth control patches when [the pandemic] started. [Pharmacies] were only giving out one [month supply at a time]. Every month I had to go back, [and] I had panic attacks if people got too close to me.” Jamie (white cisgender woman, cognitive/physical disabilities) “ I got the [letter] saying, ‘it’s time for you to go in for a mammogram.’ [Every] time I have to go to the hospital, I could be at risk. I don’t want to expose myself [to COVID]. I won’t go for my mammogram unless I really have to. I shouldn’t be that afraid [but] 30 years [of chronic health issues] inform how I look at that letter.” Winona (white/Indigenous cisgender woman, cognitive/physical/sensory disabilities) “[Delayed abnormal cervical cell treatment] makes me paranoid [and] affects my depression [and] my Crohn’s [disease] because it causes me stress [and] more flare-ups.” Melissa (white cisgender woman, cognitive/physical/mental health disabilities) “Waiting for top surgery—no exaggeration—almost took my life.” Avery (Black/Mixed non-binary trans man, physical/mental health disabilities) “I wanted to take the [intrauterine contraceptive device] out, so I did. The messaging was basically, urgent care only.” Lilian (white cisgender/genderqueer woman, cognitive/physical disabilities) “[Pandemic delays to STI testing] shifted the way that I was able to do [sex work] and do my work safely.” Jody (Black/Afro-Caribbean non-binary person, cognitive/mental health disabilities) “Public transportation was suspended in my town during the pandemic [so] you’re looking at a $50 [taxi] trip just to get [to the local hospital] and back. [When I had a genital infection], I [asked my friend], ‘come look [and] tell me, do you think I should be going to the hospital?’ I shouldn’t need [a friend] to come evaluate me before I go see a doctor.” Sarah (cisgender white woman, cognitive disabilities) “Getting things like tampons, pads, and panty liners is an issue. The cost is ridiculous. They increased in price during the pandemic. [Sometimes] I wasn’t able to afford it. I had to go without or be very strategic. It’s frustrating. [Condoms are] free at the community centre but those are closed.” Kassie (Black cisgender woman, cognitive/mental health disabilities) Delays to SRH services produced anxiety and stress that exacerbated physical disabilities (e.g. chronic pain and illness flare-ups) and mental health disabilities (e.g. post-traumatic stress disorder, suicidality). Because of delays, some participants took SRH into their own hands. “ I found it hard to get a hold of the birth control patches when [the pandemic] started. [Pharmacies] were only giving out one [month supply at a time]. Every month I had to go back, [and] I had panic attacks if people got too close to me.” Jamie (white cisgender woman, cognitive/physical disabilities) “ I got the [letter] saying, ‘it’s time for you to go in for a mammogram.’ [Every] time I have to go to the hospital, I could be at risk. I don’t want to expose myself [to COVID]. I won’t go for my mammogram unless I really have to. I shouldn’t be that afraid [but] 30 years [of chronic health issues] inform how I look at that letter.” Winona (white/Indigenous cisgender woman, cognitive/physical/sensory disabilities) “[Delayed abnormal cervical cell treatment] makes me paranoid [and] affects my depression [and] my Crohn’s [disease] because it causes me stress [and] more flare-ups.” Melissa (white cisgender woman, cognitive/physical/mental health disabilities) “Waiting for top surgery—no exaggeration—almost took my life.” Avery (Black/Mixed non-binary trans man, physical/mental health disabilities) “I wanted to take the [intrauterine contraceptive device] out, so I did. The messaging was basically, urgent care only.” Lilian (white cisgender/genderqueer woman, cognitive/physical disabilities) “[Pandemic delays to STI testing] shifted the way that I was able to do [sex work] and do my work safely.” Jody (Black/Afro-Caribbean non-binary person, cognitive/mental health disabilities) “Public transportation was suspended in my town during the pandemic [so] you’re looking at a $50 [taxi] trip just to get [to the local hospital] and back. [When I had a genital infection], I [asked my friend], ‘come look [and] tell me, do you think I should be going to the hospital?’ I shouldn’t need [a friend] to come evaluate me before I go see a doctor.” Sarah (cisgender white woman, cognitive disabilities) “Getting things like tampons, pads, and panty liners is an issue. The cost is ridiculous. They increased in price during the pandemic. [Sometimes] I wasn’t able to afford it. I had to go without or be very strategic. It’s frustrating. [Condoms are] free at the community centre but those are closed.” Kassie (Black cisgender woman, cognitive/mental health disabilities) Experiences of SRH service delays were exacerbated by experiences of oppression (i.e. ableism, racism, sexism, cissexism/transphobia, classism, ageism, and anti-fatness/fatphobia). Amplified financial barriers negatively impacted access to SRH services and products (e.g. condoms, tampons, and sanitary pads). Providers discharged some participants early or attempted to refuse them admission to hospital during the pandemic. Racialised women with disabilities reported early discharge following significant SRH events. Early hospital discharges were followed by poor health outcomes for two racialised women (Angela’s rehabilitation was compromised and Pauline suffered from a blood-borne infection for weeks before receiving necessary treatment). “[A dilation and curettage procedure following a pregnancy miscarriage affected my ability to walk during the pandemic. At the rehabilitation hospital, a nurse said], ‘you’re not ready to be kicked out yet—other people walking better are still able to be here, you can barely walk, and they’re kicking you out.’ There was another Black woman, it was happening [to her too]. I can barely get down the hallway, I’m learning to walk. If I go home, how am I supposed to manage? They hadn’t solidified consistent [home care]. [After discharge, outpatient occupational therapists] were like, ‘oh my gosh, you really are not walking yet.’ I’m like, ‘and yet they kicked me out because of COVID.’” Angela (Black cisgender woman, physical/cognitive disabilities) “[After my hysterectomy procedure] I said, ‘can you keep me in one more day, I feel like hell.’ But I had to go. It was because of the beds being required for COVID that I wasn’t able to recuperate in the normal amount of time that you should have had to for a complete hysterectomy. […] I think it was my age, my disability, and my race that impacted my care. Not enough to take it to court, but enough to know that it was there.” Pauline (Indigenous cisgender woman, physical disabilities) White women with disabilities described varying degrees of success advocating to remain in hospital care before and after giving birth. “[The urologist was] going to come see me [on labour and delivery]. After the baby’s born, they’re like, ‘now it’s outpatient.’ [They discharged me]. I begged for extra days, and they wouldn’t. COVID was picking up again. [After discharge] I did manage to stay there in one of the parent rooms [while my infant was in intensive care].” Brittany (white cisgender woman, physical disability) “ They were trying to send me home because I was in early labour, but not early enough to be normally [admitted]. [Emergency] doctors didn’t see in the chart that my doctor didn’t want me to go into labour. My husband had to argue with them. Then they decided, yes, they were going to do the [caesarean] early.” Andrea (white cisgender woman, physical/cognitive disabilities) “[A dilation and curettage procedure following a pregnancy miscarriage affected my ability to walk during the pandemic. At the rehabilitation hospital, a nurse said], ‘you’re not ready to be kicked out yet—other people walking better are still able to be here, you can barely walk, and they’re kicking you out.’ There was another Black woman, it was happening [to her too]. I can barely get down the hallway, I’m learning to walk. If I go home, how am I supposed to manage? They hadn’t solidified consistent [home care]. [After discharge, outpatient occupational therapists] were like, ‘oh my gosh, you really are not walking yet.’ I’m like, ‘and yet they kicked me out because of COVID.’” Angela (Black cisgender woman, physical/cognitive disabilities) “[After my hysterectomy procedure] I said, ‘can you keep me in one more day, I feel like hell.’ But I had to go. It was because of the beds being required for COVID that I wasn’t able to recuperate in the normal amount of time that you should have had to for a complete hysterectomy. […] I think it was my age, my disability, and my race that impacted my care. Not enough to take it to court, but enough to know that it was there.” Pauline (Indigenous cisgender woman, physical disabilities) “[The urologist was] going to come see me [on labour and delivery]. After the baby’s born, they’re like, ‘now it’s outpatient.’ [They discharged me]. I begged for extra days, and they wouldn’t. COVID was picking up again. [After discharge] I did manage to stay there in one of the parent rooms [while my infant was in intensive care].” Brittany (white cisgender woman, physical disability) “ They were trying to send me home because I was in early labour, but not early enough to be normally [admitted]. [Emergency] doctors didn’t see in the chart that my doctor didn’t want me to go into labour. My husband had to argue with them. Then they decided, yes, they were going to do the [caesarean] early.” Andrea (white cisgender woman, physical/cognitive disabilities) SRH service accessibility was directly impacted by COVID-19 preventative measures. In-person accessibility barriers were exacerbated, new in-person accessibility barriers were introduced, and the transition to telehealth (virtual) SRH services amplified, and mitigated, accessibility barriers. Pre-existing in-person physical and communication barriers to SRH services were exacerbated. For instance, reduced public transportation availability made it difficult to physically access appointments. Inaccessible clinics and hospital infrastructures became more difficult to navigate. “I’ve had to put off [cervical cancer screening]. There’s no lift in [my] doctor’s office. My husband usually lifts me [onto the inaccessible examination table, and] it’s been hard to manage [our] different schedules amidst COVID.” Cynthia (white cisgender woman, physical/mental health disabilities) Deaf participants said communication barriers worsened because ASL interpreters became more difficult to book, and hospitals became more reluctant to book them. “The hospital keeps cancelling [my gynecology appointment] because there’s no interpreter. [Why have I] been waiting two years? There’s no communication, no support. [The fibroids are] growing. There’s been no appointments because of COVID.” Lena (white cisgender Deaf woman, sensory disability) Participants with cognitive disabilities struggled to access information and answers to their questions, and they felt emotionally unsupported. “[Fertility] doctors [and] nurses didn’t show compassion, like I was just another number. [I asked] the nurse, ‘can you hold my hand?’ Just to have that support. She didn’t even hold my hand. […] I felt my questions were not answered. I felt that I wasn’t supported during that time of COVID.” Olivia (white cisgender woman, cognitive disabilities) “I’ve had to put off [cervical cancer screening]. There’s no lift in [my] doctor’s office. My husband usually lifts me [onto the inaccessible examination table, and] it’s been hard to manage [our] different schedules amidst COVID.” Cynthia (white cisgender woman, physical/mental health disabilities) “The hospital keeps cancelling [my gynecology appointment] because there’s no interpreter. [Why have I] been waiting two years? There’s no communication, no support. [The fibroids are] growing. There’s been no appointments because of COVID.” Lena (white cisgender Deaf woman, sensory disability) “[Fertility] doctors [and] nurses didn’t show compassion, like I was just another number. [I asked] the nurse, ‘can you hold my hand?’ Just to have that support. She didn’t even hold my hand. […] I felt my questions were not answered. I felt that I wasn’t supported during that time of COVID.” Olivia (white cisgender woman, cognitive disabilities) COVID-19 preventative measures produced new in-person physical and communication barriers to SRH services. Partitions and obstructions in clinics (to encourage physical distancing) created accessibility challenges for participants with sight loss. Masking led to new communication barriers for Deaf people. Clinic closures made it difficult for participants with disabilities to communicate with providers and access information, resources, and support. “I was told [pregnancy] wasn’t going to be an option for me. Then I was told there was a doctor that specialises in patients who have kidney transplants having children [at hospital A]. But trying to find out who she was and [how to] access her, especially through the pandemic, was very difficult. [I called] information, I [said], ‘I have a disability. I have a kidney transplant. I’m diabetic. I’ve heard there’s a doctor that deals with transplants and pregnancy.’ They had no idea what I was talking about. I left a message on a voicemail and never got a phone call back. I called back, and they put me through to another voicemail. [It was difficult to get] information [and] help. [My kidney doctors] didn’t seem to know of any other [pregnancy supports]. My husband and I decided that our time for kids wasn’t going to happen.” Anika (South/East/Southeast Asian/Caribbean cisgender woman, sensory disability) COVID-19 preventative measures prohibiting outside devices and support persons from health care facilities created new barriers to SRH services. “You can’t bring [support people to prenatal appointments], but [they ask] ‘Why can’t you transfer onto the table?’ [In labour and delivery postpartum, the nurses said], ‘we can’t transfer your baby every time you ask us. We’re busy. Postpartum is about independence. How can we send you home if you’re not picking up your baby?’ I was like, ‘you can send me home when I’m better because I will pick up my baby at an accessible bassinette that the hospital said I couldn’t bring because of infection prevention control measures. […] I already told you, it’s dangerous, I’m not dropping my kid in this hospital.’ These are the same people who would call [child protection services] if I dropped my kid.” Alisha (white cisgender woman, physical/cognitive/mental health disabilities) Several white cisgender women successfully advocated to have support persons. Even with these accommodations, access could be challenging. “[Our obstetrician] was fantastic, he actually managed to get my husband into the majority of [prenatal appointments]. Once we were able to access the care it was great care, it was just a fight to get what we needed. […] Sometimes my husband would be purposely pushing [my wheelchair] to make it look like I needed more assistance than I did, to make it less of a fight.” Andrea (white cisgender woman, physical/cognitive disabilities) Racialised participants consistently reported being denied accommodations to have support persons. “[Our baby] was really sick [and non-emergency telephone services] advised us to go to the hospital. [The hospital] would only allow [one parent, i.e.,] my partner to be there. ‘I’m the mom, I can’t carry him, but I have to nurse him, it’s going to be overnight, we need to be there together.’ ‘No.’ There was no exception, no, ‘I’m going to talk to someone.’ That upset me so much. I felt so powerless and so horrible I couldn’t provide safe health care for my son.” Tanya (Indigenous Two-Spirit person, physical/mental health disabilities) “I was told [pregnancy] wasn’t going to be an option for me. Then I was told there was a doctor that specialises in patients who have kidney transplants having children [at hospital A]. But trying to find out who she was and [how to] access her, especially through the pandemic, was very difficult. [I called] information, I [said], ‘I have a disability. I have a kidney transplant. I’m diabetic. I’ve heard there’s a doctor that deals with transplants and pregnancy.’ They had no idea what I was talking about. I left a message on a voicemail and never got a phone call back. I called back, and they put me through to another voicemail. [It was difficult to get] information [and] help. [My kidney doctors] didn’t seem to know of any other [pregnancy supports]. My husband and I decided that our time for kids wasn’t going to happen.” Anika (South/East/Southeast Asian/Caribbean cisgender woman, sensory disability) “You can’t bring [support people to prenatal appointments], but [they ask] ‘Why can’t you transfer onto the table?’ [In labour and delivery postpartum, the nurses said], ‘we can’t transfer your baby every time you ask us. We’re busy. Postpartum is about independence. How can we send you home if you’re not picking up your baby?’ I was like, ‘you can send me home when I’m better because I will pick up my baby at an accessible bassinette that the hospital said I couldn’t bring because of infection prevention control measures. […] I already told you, it’s dangerous, I’m not dropping my kid in this hospital.’ These are the same people who would call [child protection services] if I dropped my kid.” Alisha (white cisgender woman, physical/cognitive/mental health disabilities) “[Our obstetrician] was fantastic, he actually managed to get my husband into the majority of [prenatal appointments]. Once we were able to access the care it was great care, it was just a fight to get what we needed. […] Sometimes my husband would be purposely pushing [my wheelchair] to make it look like I needed more assistance than I did, to make it less of a fight.” Andrea (white cisgender woman, physical/cognitive disabilities) “[Our baby] was really sick [and non-emergency telephone services] advised us to go to the hospital. [The hospital] would only allow [one parent, i.e.,] my partner to be there. ‘I’m the mom, I can’t carry him, but I have to nurse him, it’s going to be overnight, we need to be there together.’ ‘No.’ There was no exception, no, ‘I’m going to talk to someone.’ That upset me so much. I felt so powerless and so horrible I couldn’t provide safe health care for my son.” Tanya (Indigenous Two-Spirit person, physical/mental health disabilities) The transition to telehealth during the COVID-19 pandemic both impeded and facilitated SRH service accessibility for people with disabilities. Pregnant participants and new parents with physical disabilities found perinatal telehealth inaccessible; they needed in-person support, for example, to help practise swaddling or positioning a baby for breastfeeding. Deaf participants said it was difficult accessing telehealth services that would facilitate ASL interpretation. “[Lactation consultants] wanted to do virtual breastfeeding visits. How do you, with no hands, manipulate a screen and a newborn? I couldn’t do it by myself. I was like, ‘I can’t do this appointment.’” Megan (white cisgender woman, physical disability) “[Clinics] hang up because they can’t communicate with me, they don’t like it when the interpreter connects. [My SRH] has struggled because there aren’t in-person services.” Lena (white cisgender Deaf woman, sensory disability) Participants with cognitive or mental health disabilities, including autistic people and persons with autism spectrum disorder, characterised telehealth as cold, impersonal, and rushed. Many were frustrated that some providers offered telephone calls but not videoconferencing, which has features like closed captioning and can better facilitate nonverbal communication, such as the reading of body language and facial expressions. “[Lactation consultants] wanted to do virtual breastfeeding visits. How do you, with no hands, manipulate a screen and a newborn? I couldn’t do it by myself. I was like, ‘I can’t do this appointment.’” Megan (white cisgender woman, physical disability) “[Clinics] hang up because they can’t communicate with me, they don’t like it when the interpreter connects. [My SRH] has struggled because there aren’t in-person services.” Lena (white cisgender Deaf woman, sensory disability) Several participants, particularly those with physical disabilities and/or chronic health concerns, found telehealth more accessible because they could attend appointments from home. Cancellations of telehealth and exclusive returns to in-person care were characterised inaccessible. “I love telehealth [and I’m] happy that that option became available. People with disabilities have been wanting this for so long. Yet we’re not listened to until non-disabled people need access to it. It’s been wonderful to have the option because sometimes it’s really hard to get out of the home.” Cynthia (white cisgender woman, physical/mental health disabilities) “I love telehealth [and I’m] happy that that option became available. People with disabilities have been wanting this for so long. Yet we’re not listened to until non-disabled people need access to it. It’s been wonderful to have the option because sometimes it’s really hard to get out of the home.” Cynthia (white cisgender woman, physical/mental health disabilities) COVID-related social changes, including lockdowns, social isolation, COVID infections, and COVID-related ableism, affected SRHR. Lockdowns and stay-at-home measures exacerbated gender- and disability-based violence, social isolation amplified SRH issues like menopause and worsened mental health disabilities, and COVID infections could aggravate disability-related SRH concerns. “[My ex-husband’s abuse] escalated [during lockdown]. I couldn’t leave the house because of COVID. [He] wouldn’t let me lock the [bathroom] door [or] be by myself. [He] was very controlling [physically, financially, emotionally, sexually]. [He] talked about what he wanted, that’s the only time he would sign [with ASL].” – Lena (white cisgender Deaf woman) “My skin disorder affected the vaginal area. I [had] to go to emergency services [for] incision and drainages because they are boils, [and] I believe COVID might have caused that flare up.” Stacey (white cisgender woman, physical disabilities) “[My ex-husband’s abuse] escalated [during lockdown]. I couldn’t leave the house because of COVID. [He] wouldn’t let me lock the [bathroom] door [or] be by myself. [He] was very controlling [physically, financially, emotionally, sexually]. [He] talked about what he wanted, that’s the only time he would sign [with ASL].” – Lena (white cisgender Deaf woman) “My skin disorder affected the vaginal area. I [had] to go to emergency services [for] incision and drainages because they are boils, [and] I believe COVID might have caused that flare up.” Stacey (white cisgender woman, physical disabilities) COVID-related ableism exacerbated structural ableism and intersected with other forms of discrimination, compromising SRHR. “The government has to be interested in letting us live. Then I think they [could] have a conversation about reproductive health [for people with disabilities]. The government isn’t ready for a conversation about reproductive rights of people with disabilities because they haven’t recognized our right to be alive.” Alisha (white cisgender woman, physical/cognitive/mental health disabilities) “If you’re just a disabled old Indian woman with a uterus no longer there, where are you on the pecking order? [With COVID] you get triaged. I don’t know if my body would have been on the ‘save’ list [and] that’s not a very comfortable thought to live with.” Pauline (Indigenous cisgender woman, physical disabilities) “[SRH services] got worse over COVID. [Providers] don’t see us as people with disabilities, they see us as problems and exaggerators. [Our] access was severely limited [during the pandemic], even more than it was already. [It] became very clear that it’s anti-Black racism, it’s ableism.” Alanna (Black cisgender woman, physical/mental health disabilities) “The government has to be interested in letting us live. Then I think they [could] have a conversation about reproductive health [for people with disabilities]. The government isn’t ready for a conversation about reproductive rights of people with disabilities because they haven’t recognized our right to be alive.” Alisha (white cisgender woman, physical/cognitive/mental health disabilities) “If you’re just a disabled old Indian woman with a uterus no longer there, where are you on the pecking order? [With COVID] you get triaged. I don’t know if my body would have been on the ‘save’ list [and] that’s not a very comfortable thought to live with.” Pauline (Indigenous cisgender woman, physical disabilities) “[SRH services] got worse over COVID. [Providers] don’t see us as people with disabilities, they see us as problems and exaggerators. [Our] access was severely limited [during the pandemic], even more than it was already. [It] became very clear that it’s anti-Black racism, it’s ableism.” Alanna (Black cisgender woman, physical/mental health disabilities) Participants recommended ways of improving SRH services for disability communities during and beyond the COVID-19 pandemic. Participants said the government must increase health and social service funding to improve SRHR for people with disabilities in the wake of the pandemic. They recommended investing in free prescription medications (universal pharmacare), accessible services (e.g. accessible health care infrastructures, mobile and home care, ASL interpreters, longer appointment times, health service navigators), accessible public transportation, affordable housing, income supports (i.e. better disability benefits and universal basic income), and community-based supports. They also recommended investing in more research and education about SRHR for people with disabilities. “The government needs to see that disability support is necessary. […] People shouldn’t have to live in poverty and struggle every day to function and thrive because they’re receiving so little funding. […] It would help if there was funding set aside to make sure that access to reproductive health care is accessible.” Cameron (white genderqueer person, mental health disabilities) “The government needs to see that disability support is necessary. […] People shouldn’t have to live in poverty and struggle every day to function and thrive because they’re receiving so little funding. […] It would help if there was funding set aside to make sure that access to reproductive health care is accessible.” Cameron (white genderqueer person, mental health disabilities) Participants recommended better disability-related education for providers (medical and administrative staff) to improve SRH services; specifically, training on how to provide anti-ableist and disability-affirming care that is intersectional and trauma-informed, in addition to training on disability-related care needs (e.g. patient lift and transfer training). However, participants cautioned against developing training efforts in silos (e.g. investing in provider education without investing in human resources). “I want [providers] to go through sensitivity training. But if you give sensitivity training to someone who is burnt out, is the only person on the floor, [they don’t have] time to be empathetic and listening.” Ava (white genderqueer non-binary person, cognitive/physical/mental health disabilities) “I want [providers] to go through sensitivity training. But if you give sensitivity training to someone who is burnt out, is the only person on the floor, [they don’t have] time to be empathetic and listening.” Ava (white genderqueer non-binary person, cognitive/physical/mental health disabilities) Participants identified the need for disability-inclusive sex education, improved accessibility and diversification of public health communications, better interprofessional communication, and more integrated health information systems. “More information out of government, resources about sexual health, [and] posters and information in plain language.” Logan (Asian transgender man, cognitive disabilities) “More information out of government, resources about sexual health, [and] posters and information in plain language.” Logan (Asian transgender man, cognitive disabilities) Participants recommended the provision of disability accommodations, including during a pandemic, through accessible public health pandemic mitigation measures; for example, by allowing support persons in health facilities, providing both in-person and telehealth options, and prioritising equity in service delivery. “Do not separate people from their support person.” Emily (white cisgender woman, cognitive/mental/physical disabilities) “Do not separate people from their support person.” Emily (white cisgender woman, cognitive/mental/physical disabilities) Participants recommended enhancing disability representation and comprehensive community engagement, and emphasised the need for broader systemic change. “[Providers should] listen to disabled people more because [we were] speaking about and asking for [telehealth] prior to the pandemic, because we live in unique and beautiful ways [and] access the world differently. We have ideas and suggestions that improve things. [Service] providers and government [should] have more disabled people on their teams—include us in conversations and strategizing.” – Cynthia (white cisgender woman, physical/mental health disabilities) “[Providers should] listen to disabled people more because [we were] speaking about and asking for [telehealth] prior to the pandemic, because we live in unique and beautiful ways [and] access the world differently. We have ideas and suggestions that improve things. [Service] providers and government [should] have more disabled people on their teams—include us in conversations and strategizing.” – Cynthia (white cisgender woman, physical/mental health disabilities)

We found that the COVID-19 pandemic disrupted access to SRH services for people with disabilities, with disability-related health implications that were intensified by intersecting identities and experiences. COVID-19 preventative measures compromised in-person SRH service accessibility by amplifying pre-existing physical and communication barriers and introducing new barriers, and the transition to telehealth services had positive and negative effects on service accessibility. COVID-related social changes amplified structural ableism and intersected with other forms of discrimination to compromise disabled people’s SRHR. To improve SRH services, participants recommended increasing funding to make services accessible, training providers in disability-affirming care, improving information and communication, providing disability accommodations, and enhancing community representation and engagement for systemic change. Like previous studies on SRHR impacts of the COVID-19 pandemic for the general population, we found reduced access to a range of SRH services; increased risk of gender-based violence; changes in menstrual health and pregnancy intentions; and compromised sexual health and wellbeing. 2–9 , 11 , 12 Our findings are in line with research on barriers to SRH services for people with disabilities before the COVID-19 pandemic; like these studies, we found access to SRH services for people with disabilities was negatively impacted by physical and communication barriers, experiences of stigma and discrimination, and lack of supports. 20–22 Our results are similar to research on COVID-related disruptions to general health care access for people with disabilities causing negative mental health impacts. 25 Consistent with prior research on COVID-related SRH experiences of people with disabilities, we found delayed access to SRH services, with delays exacerbated by disability-related health and safety concerns and intersectionality (e.g. economic barriers); amplified accessibility barriers (e.g. partitions, reduced public transport, restrictions to support persons and devices, sign language interpreter shortages, information barriers); and experiences of ableism and discriminatory provider attitudes. 27 , 30 , 31 Differing from prior research that found telehealth improved SRH service accessibility, 29 we found telehealth both improved and compromised accessibility. This study contributes to the existing literature in several ways. First, our study indicates that pandemic response efforts were not disability-inclusive in the context of a high-income country with universal health care. Disability-inclusive pandemic responses must ensure safe and accessible physical spaces and communication, and equitable access to SRH services, free from discrimination. 49 While SRH services were disrupted for the general population, we found unique disability-related impacts. Disability-related health and safety concerns about COVID-19, early discharges from care, amplified accessibility barriers, and new accessibility barriers led to increased delays, compromised SRH service quality, and poor physical and mental health outcomes. Based on these findings, we argue that SRH service disruptions intensified systemic ableism during the COVID-19 pandemic and obstructed disability reproductive justice. Second, our study demonstrates that women and gender-diverse people with disabilities experienced SRHR violations in the form of disability- and gender-based discrimination (ableism and sexism) when seeking SRH services during the COVID-19 pandemic. The 2006 UN Convention on the Rights of Persons with Disabilities recognises the SRHR of people with disabilities and the World Health Organization (WHO) designated reproductive health service continuation during the COVID-19 pandemic as “high priority”. 50 Our findings indicate SRHR and the continued provision of SRH services were not ensured for women and gender-diverse people with disabilities during the COVID-19 pandemic. Notably, transgender participants with disabilities reported delayed access to gender-affirming care (e.g. hormone replacement therapy, surgeries) that caused significant negative mental health outcomes (including suicidality). The intersection between ableism and cissexism/transphobia in SRHR requires further attention. Third, our study documents that intersecting forms of oppression exacerbated SRH service disruptions, including delays to services, early discharges from care, access to disability accommodations (support persons), and experiences of amplified structural ableism. For example, following significant SRH events (dilation and curettage abortion care following miscarriage, hysterectomy) during the pandemic, two Black and Indigenous women with disabilities related their early discharge from care and negative physical and mental health consequences to intersecting forms of oppression (ableism, racism, sexism, and ageism). In contrast, white women with disabilities described varying degrees of success advocating to remain in care during the pandemic (before and after giving birth). There was a similar pattern with the provision of COVID-related disability accommodations: white women with disabilities described some success advocating for support persons, and racialised women and an Indigenous Two Spirit person with disabilities were denied similar accommodations, including for gynaecological and perinatal services, and health care for their young children. The failure to ensure accommodations for people with disabilities accessing SRH services during the pandemic exemplifies disability reproductive injustice with disproportionate impacts for racialised people with disabilities. The intersection between ableism and racism in SRHR requires further attention. Our study has several strengths and limitations. The cross-disability inclusion criterion broadens the scope of the study; however, the heterogeneity of the sample restricts the applicability of our recommendations for specific disability communities. Persons with negative experiences of SRH services during the pandemic may have been more inclined to participate. We recruited a diverse sample; yet, there are underrepresented communities in our study, including people with sensory disabilities, cognitive disabilities who have high support needs or live in residential care, people living in diverse, rural, and remote regions of Canada (i.e. outside the urban context of southern Ontario), Indigenous people and other racialised communities including Asian people and Latin American people, and immigrant populations. These communities may not be adequately represented in our findings, and more research is needed to examine the SRH experiences of underrepresented communities with disabilities. Our study is inclusive of diverse SRH service experiences. However, stigmatised services like abortion and gender-based violence support were typically discussed in the context of SRH histories and not often in the context of the pandemic. More research is needed on disabled people’s experiences with these services during the COVID-19 pandemic. Changes to SRH service delivery and accessibility during the pandemic perpetuated systemic disability reproductive injustice by failing to provide disability accommodations and ensure accessible and equitable access to care. Service providers, health care educators, clinic directors and managers, and policymakers should urgently address ableism in SRH service delivery by scaling-up staff training in anti-ableist and disability-affirming care delivery. Training programmes should be developed through comprehensive engagement with disability communities. At the policy level, future pandemic control measures must include accessibility provisions, for example, by providing accommodations for people with disabilities to access health facilities with support persons, more accessible telehealth services (e.g. with videoconference options), and in-person services if telehealth is inaccessible to them. Future pandemic control measures should consider health equity when restricting non-urgent SRH services, such as cervical cancer screening; priority access should be restored first for underserved communities like disabled people. Government actors and policymakers should ensure disability communities are represented among decision-makers and that comprehensive engagement with disability communities continually informs policy-making processes.

COVID-related impacts on access to SRH services compromised disability reproductive justice. Practice and policy development must include comprehensive disability community engagement to inform accessible and inclusive SRH services for women and gender-diverse people with disabilities during and beyond pandemic emergencies.