The marital status of disabled women in Canada: a population-based analysis

Surprisingly little population-based data exist on the marriage and relationship patterns of disabled women. This study investigated the formation and dissolution of marriage and common-law relationships involving disabled women in Canada. A secondary data analysis of the 2009 Canadian Community Health Survey was undertaken. The effective sample size for the study was 41,650 women, 18 – 59 years, including 9450 disabled women. The ﬁ ndings suggest that disabled women in Canada are less likely to be married or in a cohabiting relationship, although it appears that most will marry at some point. Among disabled women, those with early onset conditions, cognitive impairment, mobility limitations and lower levels of educational attainment are more likely to remain single, that is, never having entered into a cohabiting relationship. A plausible explanation for the observed differences in marital status is that disabled women have less opportunity to meet potential partners and form lasting cohabiting relationships.


Introduction
Any meaningful definition of full inclusion or equal access to ordinary life chances for disabled persons must include the opportunity to meet potential partners and form lasting relationships. Yet there is a dearth of data on the partnering patterns of disabled men and women, including relationship formation and dissolution. The limited available data suggest that disabled persons are, in general, more likely to remain single than their non-disabled peers (Charles and Stephens 2004;Clarke and McKay 2014;Liu and Zhang 2013;Nosek et al. 2001;Taleporos and McCabe 2003). Further, there is some evidence that married disabled persons are at increased risk of separation and divorce, although conflicting data have been reported (Charles and Stephens 2004;Clarke and McKay 2014;Jans and Stoddard 1999;Liu and Zhang 2013;Parish, Rose, and Andrews 2009;Singleton 2012).
Disabled persons face a number of barriers to relationship formation. Many are brought up to believe that intimacy, love and marriage are not for them (Kallianes and Rubenfeld 1997;Nemeth 2000;O'Toole 2002). Crawford and Ostrove (2003) observe 'even in childhood, disabled persons are discouraged from seeing themselves as viable relational partners' (183). Further, many disabled men and women live circumscribed lives, and their chances of meeting a potential mate may be further under-cut by negative social representations of disability (Crawford and Ostrove 2003;Parish, Rose, and Andrews 2009). Disabled women, for example, may be 'selected out' as potential marriage partners due to the uninformed yet pervasive belief that they are asexual, dependent and unfit for motherhood (Gill 1996;Lesseliers and Van Hove 2002).
It is unclear whether, and if so how the partnering patterns of disabled men and women vary with impairment type, level of functioning (e.g. physical, cognitive, social, emotional) and onset of condition. However, women with cognitive impairment may face more barriers than most to meeting a potential mate, forming a lasting cohabiting relationship, and starting a family of their own (Ali et al. 2012;Emerson 2007;Hall et al. 2005;Kijak 2013;Lesseliers and Van Hove 2002;MacInnes 2011;Young, Gore, and McCarthy 2012). Historically, many women with cognitive impairment were institutionalized and forcibly sterilized to prevent them from forming relationships and having children (Aunos and Feldman 2002). Today, women with cognitive impairment in highincome countries do not face such overt barriers, but they continue to run up against opposition. Such opposition may come from well-meaning family members and/or professionals, and be driven by a faulty assumption of inherent incompetence (Aunos and Feldman 2002;Bernert 2011;Booth and Booth 1994;Lesseliers and Van Hove 2002;Mayes, Llewellyn, and McConnell 2006).
The purpose of this study was to investigate the association between (non ageing-related) disability and marital status within a large and representative sample of Canadian women, 18-59 years of age, controlling for between-group differences in age, ethno-racial composition and socio-economic status. The extent to which variation in the marital status of disabled women may be explained by onset (i.e. acquired or existed at birth/genetic), functioning (i.e. cognitive, speech and mobility) and socio-economic factors is also examined. Our principal hypotheses were: disabled women are (1) more likely to be 'single: never married', and (2) more likely to be 'single: separated/divorced/ widowed', by comparison with non-disabled women.

Method
The method was secondary analysis of the Canadian Community Health Survey (CCHS). The CCHS collects cross-sectional data related to health status, health care utilization and health determinants for the Canadian population. CCHS data is representative of approximately 98% of the Canadian population aged 12 and over. The effective sample size for this study is 41,650 women, 18-59 years of age. The data were collected between January 2009 and December 2010. Both in-person computer assisted personal interviewing and computer assisted telephone interviewing were employed. Data collection also allowed for proxy respondents for participants who were unable to complete the survey in person or over the phone. Full details of the design, instruments and sampling procedure have been presented elsewhere (Statistics Canada 2011).

Disability and functioning
Consistent with the International Classification of Functioning, Disability and Health (WHO 2001), women were identified as 'disabled' if they responded 'yes, sometimes' or 'yes, often' to any of the following four questions: 'Does a long-term physical condition or mental condition or health problem, reduce the amount or the kind of activity you can do … ': (Q1) 'at home?' (Q2) 'at school?' (Q3) 'at work?' and (Q4) 'in other activities, for example, transportation or leisure?'** Three measures of functioning were included in the study, including measures of cognitive impairment, speech trouble and mobility limitations. These measures are derived from the Health Utility Index (HUI, Horsman et al. 2003). Cognitive impairment is measured on a scale ranging from 1 = 'no cognitive issues' to 6 = 'unable to remember or unable to think or solve problems'. Cognitive impairment is operationally defined as a score of 5 ('very forgetful or great deal of difficulty thinking and solving problems') or 6 on this scale. Speech trouble is measured categorically, with 1 = 'no speech problems' and 2 = 'partially or not understood'. Mobility limitation is measured on a **4-point scale, with 1 = 'no mobility problems' and 4 = 'requires help/cannot walk'.
A dichotomous measure of onset (i.e. acquired disability vs. existing from birth or genetic) was created based on an item asking respondents about the 'cause' of their condition or health problem: Which one of the following is the best description of the cause of this condition: (accident at home, motor vehicle accident, accident at work, other type of accident, existed from birth or genetic, … , or use of alcohol or drugs)?

Marital/relationship status
Three categories of marital/relationship status were created including 'single: never married', 'currently married or in a common-law relationship' and 'single: separated/divorced/widowed'. It is important to note that single women in this study could have been in a non-cohabiting relationship at the time of reporting. Further, the CCHS does not collect data on re-marriage.

Socio-economic indicators and ethno-racial group
Three indicators of socio-economic status were included: educational attainment, workforce participation (i.e. worked for pay in the past 12 months) and annual personal income from all sources. In the absence of more satisfactory information, a dichotomous measure of ethno-racial group derived by Statistics Canada was also included in the study, with respondents categorized as either 'white' or 'visible minority'.

Statistical analysis
The analyses were conducted using SPSS v.21. Normalized sample weights based on Statistics Canada computations were used in all calculations. There were less than 2.5% missing data for all variables except annual personal income, for which values were missing in 16% of cases. To investigate the association between disability and marital status, we employed multinomial logistic regression (MLR) analysis with 'currently married/ living in a common-law relationship' as the reference group. Odds ratios (OR) adjusted for between-group differences in age, ethno-racial composition, educational attainment and workforce participation are reported. A total of 6.5% of the sample were excluded from this analysis due to missing data. MLR was also employed to investigate variation among women with disability in marital status, with age, ethno-racial composition, educational attainment and workforce participation, onset of condition, cognitive impairment, speech trouble and mobility limitations included in the model. In this analysis, 7.5% of cases were excluded due to missing data.

Results
In total, 22.7% (n = 9450) of the women in the sample reported activity limitations associated with a long-term condition or health problem. One per cent of all women in the sample (n = 424) reported disability and cognitive impairment. The vast majority of disabled women completed all CCHS items independently, either by phone or in person (98%). Disabled women with cognitive impairment were more likely to utilize a 'person most knowledgeable' (PMK) proxy (8.7%).
Disabled women were, on average, older than non-disabled women (see Table 1). They also reported lower levels of educational attainment, workforce participation and annual personal income. Specifically, disabled women were less likely to have completed high school (88.7% vs. 92.5%); less likely to have worked for pay in the past 12 months (77% vs. 84.9%); and, they were more likely to report low annual personal incomes of less than CAN$20,000 (40.9% vs. 32.9%). A total of 18.3% of disabled women, 23.8% of disabled women with cognitive impairment, and 24.7% of women with no reported disability were categorized as a visible minority. The observed between-group difference in ethno-racial composition may be attributable, in part, to the 'healthy immigrant' effect (Ng 2011). Specifically, that Canadian newcomers arrive with better reported health and lower reported disability than the general population.
Overall, and in every age bracket, a greater proportion of disabled women were 'single: never married' (see Table 2). However, although cross-sectional, the data suggest that most disabled Canadian women, including those with cognitive impairment, will likely enter marriage at some point (see Figure 1). The trend suggests that disabled women may enter into marriage or a common-law union later than non-disabled women. For instance, among women in their thirties, 24.2% of those with disability and 17% of those without disability reported continuous singlehood. Among women in their fifties, the difference between disabled and non-disabled women was less than 2%.
Notwithstanding, among women in their fifties, disabled women were more likely to be approaching their senior years un-partnered: 30% of disabled women and almost 50% of disabled women with cognitive impairment were single in their fifties, compared with less than 25% of non-disabled women. A higher rate of marital dissolution may partially explain why a proportionally larger number of disabled women are single in their fifties. Notably, disabled women with cognitive impairment were more than twice as likely as non-disabled women to report being 'single: separated/ divorced/widowed'.
Results of the MLR analysis, presented in Table 3, show that the odds of being 'single: never married', and the odds of being 'single: separated, divorced or widowed' (vis-à-vis currently married or living common-law) were, respectively, 1.37 times and 1.47 times greater for disabled women, and 3.77 times and 3.16 times greater for disabled women with cognitive impairment, compared with non-disabled women, adjusting for between-group differences in age. Controlling for between-group differences in age, ethno-racial composition, educational attainment and workforce participation did not attenuate the strength of the association between disability and being 'single: never married', and between disability and being 'single: separated/divorced/widowed'.
The results of the MLR analysis investigating within-group variation in the marital status of disabled women are presented in Table 4. The results suggest that early onset (condition present at birth or genetic), cognitive impairment, mobility limitations and lower levels of educational Not mutually exclusivewomen are a subset of those with any reported disability. attainment are all associated with a higher 'risk' for disabled women of being 'single: never married'. Cognitive impairment, mobility limitations and lower levels of educational attainment were also associated with higher risk of being 'single: separated/divorced/widowed', together with low workforce participation. Notably, the women with acquired conditions were no more likely than the women with early onset conditions to be 'single: separated/divorced/widowed'.

Discussion
Forming a cohabiting relationship is a matter of choice bounded by opportunity. The results of this secondary data analysis suggest that disabled women in Canada are either more inclined to choose to remain single (i.e. not enter into a cohabiting relationship), and/or have less opportunity to meet a potential mate and form a marital bond. Earlier studies have found that most young disabled women, including those with cognitive impairment, have normative expectations: they expect and want to enter into a cohabiting relationship and start a family of their own (Arnold and Chapman 1992;Bernert 2011;Emerson, Honey, and Llewellyn 2008;IASSID Special Interest Research group on Parents and Parenting 2008;Nosek et al. 2001). It is therefore unlikely that the observed differences in the marital status of disabled Canadian women and their non-disabled peers reflect differing choices. Therefore, a more likely explanation is that disabled women have fewer opportunities to meet potential mates and form lasting cohabiting relationships. Women with disability may, for  example, have less opportunity to meet a potential partner due to socially engendered participation restrictions, and negative social valuation based on social constructions of disability and the feminine ideal (e.g. the beauty myth).
Opportunity for disabled women to form intimate partner relationships may also be constrained by the internalization of the disablist belief that they are not viable relational partners (Crawford and Ostrove 2003;Gerschick 2007;Kallianes and Rubenfeld 1997;Nemeth 2000;O'Toole 2002). The effect of internalized disablism on the life opportunities and experiences of disabled men and women is receiving increased research attention: Internalized disablism has been linked to lower self-efficacy, optimism and social support, as well as an increased expectation of rejection resulting in the loss of employment opportunities (Ali et al. 2012;Link 1987;Link et al. 1997;Livingston and Boyd 2010;Scheid 2005). There is however a dearth of research exploring the nexus between internalized disablism and the relationship patterns of disabled women.
There is a well-documented association between being in a positive long-term relationship (e.g. a 'healthy' marriage) and a wide range of health measures. For example, in comparison to single individuals, people who are married or living common law tend to report lower levels of depression and better health in general (Kim and McKenry 2002;Pienta, Hayward, and Jenkins 2000;Waite and Gallagher 2000;Wilson and Oswald 2005;Wood, Goesling, and Avellar 2007). The health and other benefits (e.g. economic) associated with positive partner relationships may be greatest for older people. The results of this study, which suggest that disabled women are more likely to be entering their senior years un-partnered, are therefore noteworthy. Without positive partner support these women may be at increased risk of health decline and early admission to long-term care facilities.
Disabled women may be more likely to be single in their fifties for a number of reasons. The data suggest that they are more likely to remain 'single: never-married', although in this regard, the difference between disabled and non-disabled women in their fifties was small. Another possible reason is a higher rate of separation and divorce. Our findings suggest that disabled women are more likely to be single: separated/divorced/widowed. However, because the CCHS does not collect data on number of marriages and common-law unions, we could not determine whether disabled women face an increased risk of separation and divorce, or are instead less likely to re-marry.
There are reasons for suspecting that the rate of divorce or relationship dissolution may be higher among disabled women. One is that disabled women are more likely to experience social and economic hardships, as documented in this and other studies, which are significant risk factors for relationship conflict and dissolution (Amato 2010;Clark and Crompton 2006;Kalmijn and Poortman 2006;Lyngstad and Jalovaara 2010). Another reason is that when disabled women enter into a cohabiting relationship, this may be scuttled by family opposition or by marriage penalties (i.e. the withdrawal of benefits and services) which threaten to cast their partner into what he or she may perceive as a constricting care giving role (Fiduccia 2000;Gill 1996). However, some studies have found that disabled women do not face an increased risk of relationship dissolution (Charles and Stephens 2004;Clarke and McKay 2014). Further research, ideally utilizing longitudinal data, is clearly needed to determine whether there are disability-based disparities in the longevity of cohabiting relationships. The analysis of within-group variation in marital status revealed that disabled women were more likely to be 'single: never married' if their condition was present at birth or genetic; they had cognitive impairment, mobility limitations, and/or lower levels of educational attainment and workforce participation. These may all be indicators of, or proxies for, impairment severity. While severity may be a contributing factor, caution is warranted with respect to causal inferences, and not merely because the CCHS was cross-sectional in design. Women with more severe impairments may face additional social barriers, or opportunity constraints, including for example, greater external control over their everyday routine, and perhaps, greater stigma associated with their impairment/ condition.
The primary strength of this secondary data analysis is the large and representative sample, permitting strong generalization. The primary limitation is the cross-sectional design of the CCHS. Children born in the 1990s are unlikely to have the same marriage and cohabitation patterns as their parents or grandparents (i.e. those represented by the 50-59 age-group in this study). In other words, by the time the youngest cohort in this study reach their forties, fifties or sixties, the proportion married or living common-law could be quite different. In addition, the CCHS does not contain all of the variables that we would have liked to include, such as information on the number of marital-type unions and romantic partnerships without cohabitation. Further, while the operational definition of disability used in this study was inclusive and not atypical for population-based studies (e.g. Brault 2012;Lasser, Himmelstein, and Woolhandler 2006), a more restrictive operational definition may have resulted in different, presumably larger observed disparities in the marital status of disabled and non-disabled women.
In conclusion, and limitations notwithstanding, the results of this study suggest that the marital patterns of disabled and non-disabled Canadian women are different. It appears, for example, that although the vast majority of women with disability will marry or enter into a common-law union, they tend to do so a little later in life. This and other findings of this study would be bolstered by replication, ideally utilizing longitudinal, population-based datasets. In addition, research is needed to advance understanding of how disablism, including externally imposed constraints, internalized stigma and what Thomas (1999) has called the socially engendered undermining of their psychoemotional well-being, may limit opportunity for disabled women and men to meet potential partners and form lasting cohabiting relationships.

Disclosure statement
No potential conflict of interest was reported by the authors.