General aspects of sexual health of people with

physical disabilities

INTRODUÇÃO À SEXOLOGIA – MESTRADO INTEGRADO EM PSICOLOGIA

RAQUEL PEREIRA
10 E 11 DE NOVEMBRO DE 2020
Topics:
1st Part – General Concepts of Disability
1. Definition and characterization
2. Models of Disability: (a) individual models; (b) social models;; (c) biopsychosocial model

2nd Part – Sexual health: research and intervention

3. The state of art regarding sexuality and disability
4. Main approaches for intervention: (a) Sexual rehabilitation; (b) the PLISSIT and the Recognition
Model
5. Strategies and resources
1 part
st
“What are disabilities”

Vídeo: https://www.youtube.com/watch?v=3F4Hp0N_A1Q
1.1 Definition and characterization

CATEGORIES

Mental Disability
Physical Disability
◦ Motor (e.g. paraplegia, tetraplegia, amputation, etc.)
◦ Sensorial (e.g. visual or earing impairment)
◦ Neurological (e.g. multiple sclerosis, cerebral palsy, etc.).
◦ …
1.1 Definition and characterization

ONSET OF DISABILITY

Congenital
Adquired
◦ By disease
◦ By accident
◦ …
 1.2 Models of Disability
“language not only mirrors but creates reality” (Olkin, 2002, cit. in Loja, 2012)

Theoretical models of disability help to understand the cultural background where

individuals experience disability.

Theoretical models
influence the nature of
rights that are recognized
to people with disabilities

Theoretical models influence Theoretical models influence

how people with disabilities how people with disabilities
are treated (e.g. kind of are integrated/included in
services available) society
1.2 Models of Disability

Historical Evolution: From individual to social models

Civil rights
movements in USA
Enlightment and UK – 60’s and 70’s
Period (sec. XX)
Biomedical Social models
Classical Era and Model
Middle Age
Moral Model
Individual models

Disability is regarded as personal tragedy, as a deficit and a burden to society. The focus of
treatment is to cure the pathology and restore normality.

 Despite social evolution, this is still the most prevalent view of disability in our society.
Individual models
MORAL MODEL
Disability is regarded as a sin, a symbol of impurity or holy punishment.
Ambivalent attitudes:
 Discrimination
Charity

“God gives us only what we can bear” / “There is a reason why I was chosen to have this
disease”
ADVANTAGES DISADVANTAGES

Use of faith and spirituality to cope with Feelings of shame, isolation and ostracism
disability
The need to conceal and beg.
Individual models
BIOMEDICAL MODEL
Disability is regarded as the result of an objective and biological pathology.
 The model seeks the natural and individual cause of the impairment.
The model brings the possibility of “cure” or rehabilitation
ADVANTAGES DISADVANTAGES

Less stigmatization. Paternalistic view, as the treatment goals are

defined by the doctor.
Better technology that promote better quality
of life. The person with disability assumes a passive
attitude.
 Social Models
Disability is socially constructed.

“Nothing for us without us” / “Civil rights, not charity”

Social Models
 These models have in common the rejection of an
individualistic view of disability.
 The problem is on society, and the process of stigmatization
and discrimination.
 These models emphasize that disability does not exist per
se, but it is constructed through social mechanisms.
These models seek to promote self-determination and self-
definition as a way of empowerment.
These models are at the Foundation of disability rights
movements and Disability Studies.
ADVANTAGES DISADVANTAGES

Depathologization and blurring of the It totally ignores the impairment

diferences between people with and without
disability It deepens barries between people with and
without disability.
Promotion of equality and social inclusion.
Biopsychosocial Model

Part 1:
Individual factors

Part 2:
Contextual factors

Figure 1. Disability model from the International Classification of Functionality (ICF), adapted from Simeonsson e Lollar (2006)
 Biopsychosocial Model
DISABILITY/ INCAPACIDADE
IMPAIRMENT/ DEFICIÊNCIA
DISABLEMENT/ INCAPACITAÇÃO

Exclusively medical and Interactive processes

individual aspects of body between the person and
function and structure – the context
negative conotation
2 part
nd
“Vivir y otras ficciones”

Vídeo: https://www.youtube.com/watch?v=totfzL5sQR0
 Attitudes and myths towards disability

People with disabilities

don’t develop sexual needs
or sexual expression Assexuality People with disabilities
Hipersexuality are not capable of
controlling their sexual
impulses

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Attitudes and myths
People with disabilities are less actractive and unable to find a partner.

People with disabilities can’t have a “normal sexuality”.

People with disabilities can’t and shouldn’t have children.

 Body
Body stigma
stigma
Lack
Lack of
of sexual
sexual
Lack
Lack of
of privacy
privacy education
education

Internalized
Internalized
Socio-sexual
Socio-sexual norms
norms and
and
isolation
isolation models
models

Kind
Kind of
of Lack
Lack of
of
impairment
impairment Sexuality empowerment
empowerment

(Ahumuzza,
(Ahumuzza, Matovu,
Matovu, Ddamulira,
Ddamulira, &
&
Muhanguzi,
Muhanguzi, 2014; García &
2014; García & Álvarez,
Álvarez,
2011;
2011; Vaughn,
Vaughn, Silver,
Silver, Murphy,
Murphy,
Ashbaugh,
Ashbaugh, &
& Hoffman,
Hoffman, 2015)
2015)
6 challenges in sexuality
Problems in sexual
functioning

Changes in the
Difficulties of
physical and
psychosexual
emotional
development
experience

Difficulties
Changes/difficulties
adapting to
in the couple
changes

Secondary
problems (fatigue,
spams, urinary
system)

Adaptado de Pieters, Kedde & Bender (2018)

Sexual Health

Tertiary causality Social and psychological impact

Secondary
Pain, fatigue, medication effects
causality

Primary causality Direct impact of the disease

(Lew-Starowicz & Rola, 2013).

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Sexual Functioning
People with physical disabilities show difficulties with: (a) having and maintaining and erection;
(b) ejaculating; (c) lubricating. They also presente decreased orgasmo and sensitivity (Altuntug,
Ege, Akin, Kal, & Salli, 2014; Basson, 2000; McCabe & Taleporos, 2003).
 Regarding gender, research shows higher prevalence of sexual dysfunctions in disabled
women (between 65.7% and 72.8%) than men (between 64.4% and 65.9%) (Amidu, 2010a,
2010b; Owiredu, 2015).
 As for age of onset, there is lower frequency of sexual activity and sexual satisfaction for
people with more severe and congenital/early-onset disabilities (DeHaan & Wallander, 1988;
McCabe & Taleporos, 2003).
 The majority of couples report a decrease in sexual activity after diagnosis, although this
tends to improve with the duration of disability.(Cardoso, 2006; Taleporos & McCabe, 2004)
Sexual Satisfaction
 Decreased sexual satisfaction after the diagnosis (McCabe &
Taleporos, 2003; Taleporos & McCabe, 2003).
 Higher levels of satisfaction in relationships initiated after the
diagnosis (Crewe and Krause, 1988; (Kreuter, Sullivan, & Siosteen, 1994)
 Sexual satisfaction associated with higher sexual-esteem, body
esteem and better body image (e.g. McCabe & Taleporos, 2003;
Taleporos & McCabe, 2001; 2002; Vanteensvegen, Jans, & Revell, 2003;
Hassouneh-Phillips & McNeff, 2005; Lease, Cohen, & Dahlbeck, 2007;
Taleporos & McCabe, 2002; DeHaan & Wallander, 1988; Kedde & van
Berlo, 2006; Moin, Duvdevany, & Mazor, 2009; Salehi, Tavakol, Shabani,
& Ziaei, 2015; Taleporos & McCabe, 2002).
 Sexuality and Functional Diversity in
Portugal
 Recent mediatic attention – “Yes, we fuck!” activist
group

 Little research in mental disability and spinal cord injury

(e.g. Jorge Cardoso, Ana Garrett, Manuel Marques)

Little intervention – sexological consultation in Alcoitão,

psychoeducation…
Understanding the challenges…
Family:
• High dependency
• Overprotection
• Unbalanced roles (informal carer)

Professionals:
• Lack of specific knowledge
• Unconfortable approaching the subject
• Possible myths

Instituitions:
• Contexts which do not favour autonomy, privacy of self-determination
• Lack of multidisciplinar work
Good principles

Respect
Disabled
for confidentiality
person as the and
protagonist
intimacy
Professionals as Focus
mediators
Engaging on capacities
partnersand
andsupport
family figures

Adapted from Machado e Meireles,

2017
Sexual Rehabilitation
Sexual Exploring a Specific
(In)formation
response new sexuality therapies

Sex Positions: side

by side; support on
Sexual and Masturbation and Sexual and couples
the wall or using
reproductive health self-exploration therapy
hospitalar bed;
using pillows…

Specific information
Tecnical aids: oral or Exploring new
regarding the
intravenous therapy; erogenous áreas:
impact of the health Sexual assistance…
vacum pump; penile nipples, neck;
condition on
prothesis; lubricants mouth
sexuality

Exploring sexual
stimuli: erotic clips,
texts, sounds…
The PLISSIT Model

In 1976, Jack Annon, an american

psychologist, developed na
intervention model based on the fact
that the majority of people facing
sexual problems undergoing primary
health care don’t need intensive
therapy.

14-03-2016 ENA - ESCOLA DE NEGÓCIOS E ADMINISTRAÇÃO 32

The PLISSIT Model
Allowing the patients to share their
Permission concerns and feelings regarding
sexuality

Giving information about their

Limited condition and their new possibilities
information

Suggesting techniques and exercises

Specific that may improve the sexual activity
Sugestions

14-03-2016 ENA - ESCOLA DE NEGÓCIOS E ADMINISTRAÇÃO 33

Permission
Rafael (false name) has 37 years old and is married for 3 years. Almost a year ago he suffered a
complete spinal cord injury of the Segment S2. In the past few months he has been at the
Hospital, completing Physical Rehabilitation. He has adapted to the manual wheelchair and he
has mastered the training for bowel and bladder self-control. Soon he will have hospital
discharge and he will return home to his wife.

E.g.:
•People with the same condition as you suffer some changes in terms of sexual life. Do you
want to share your feelings regarding this part of your life in the future?
• Most people need some medical help for their sexual functioning. How is your situation?
• It is very common to feel some inhibition in talking about your sexual concerns, but this is a
safe place to do so.
Limited information
Rafael (false name) has 37 years old and is married for 3 years. Almost a year ago he suffered a
complete spinal cord injury of the Segment S2. In the past few months he has been at the
Hospital, completing Physical Rehabilitation. He has adapted to the manual wheelchair and he
has mastered the training for bowel and bladder self-control. Soon he will have hospital
discharge and he will return home to his wife. So he finally opened up with his doctor about
something that worried him for months: “How will my sexual life be from now on?” Particularly,
he wanted to know if he would still be able to satisfy his wife and conceive a child.

E.g.:
• There are several resources in order to improve your sexual life.
• What kind of information do you have so far?
• Do you know you can still be a father through medical technology?
Specific suggestions
Rafael (false name) has 37 years old and is married for 3 years. Almost a year ago he suffered a
complete spinal cord injury of the Segment S2. In the past few months he has been at the
Hospital, completing Physical Rehabilitation. He has adapted to the manual wheelchair and he
has mastered the training for bowel and bladder self-control. Soon he will have hospital
discharge and he will return home to his wife. He knows that with his lesion, despite not having
much sensitivity, he can have a psychogenic erection not always sufficient for intercourse. He also
knows that he keeps his reproductive function. However, he would like to keep a satisfying sexual
life with his wife and have kids in the future, so he is curious on techniques to improve sexual
activity in his situation.
E.g.:
• These are erogenous areas commonly identified by people with your condition that you can
ask your partner to stimulate more persistently.
 The Recognition Model

5. Referring
(when
necessary)
2. Promotion of 3. Exploration of
1. Recognition of
sensitive the
the person as a
strategies of problema/concer
sexual being
permission n

4. Resolution of
the issue within
the team
Sugestions and resources
WEBSITES

Sexual Health and Disability Alliance - http://shada.org.uk/wp2/

Sexuality and Disability - http://www.sexualityanddisability.org/
European Platform Sexual Assistance - http://www.epseas.eu/en/page/181
Enhance the UK - http://enhancetheuk.org/enhance/
The Outsiders Club – Disabled Dating - http://www.outsiders.org.uk/outsidersclub/
Tandem Team - https://www.tandemteambcn.com/
Sugestions and resources
FILMES E SÉRIES
Some resources
Sex positions for women with paralesis:
https://www.youtube.com/watch?v=vjx00AC0Hl
w

Sex positions for men with spinal injury:

https://www.youtube.com/watch?v=HatRXFL1Tx
Q

Adaptation devices:
https://www.youtube.com/watch?v=-T5sB_mw2Mw
&has_verified=1
Some resources

◦ Sex Furniture (www.liberator.com)

◦ Intimate Rider

◦ Sex Toys (vibrators Eva e Rumble)

Sugestions and resources
BOOKS

Owens, T. & Than, C. (2015). Supporting

disabled people with their sexual lives: A clear
guide for health and social care professional.
London and Philadelphia: Jessica Kingsley
Publishers
 Where you can find me?

https://www.facebook. https://www.faceb https://www.facebook.

com/sexlab.fpceup/ ook.com/sex.disab/ com/psi.arlpereira

https://www.fpce.up.pt/sexlab/ https://raquel-pereira53.webnode.pt/
Get in touch…

arlpereira.rp@gmail.com
psi.arlpereira@gmail.com

+351 91 252 05 34
Bibliography
Ahumuza, S. E., Matovu, J. K., Ddamulira, J. B., & Muhanguzi, F. K. (2014). Challenges in accessing sexual and reproductive health services
by people with physical disabilities in Kampala, Uganda. Reproductive Health, 11(59). doi: 10.1186/1742-4755-11-59
Cardoso, J. (2006). Sexualidade e deficiência. Coimbra: Quarteto
Cole, T. M. (1975). Sexuality and physical disabilities. Archives of Sexual Behavior, 4(4), 389-403.
Cole, S., & Cole, T. (1993). Sexuality, Disability, and Reproductive Issues through the Lifespan. Sexuality and Disability, 11(3), 189-205.
Couldrick, L., Sadlo, G., & Cross, V. (2010). Proposing a new sexual health model of practice for disability teams: the Recognition Model.
International Journal of Therapy and Rehabilitation, 17(6), 290-299.
Esmail, S., Darry, K., Walter, A., & Knupp, H. (2010). Attitudes and perceptions towards disability and sexuality. Disability &
Rehabilitation, 32(14), 1148-1155. doi: 10.3109/09638280903419277
Masala, C., & Petretto, D. R. (2008). From disablement to enablement: Conceptual models of disability in the 20th century.
Disability and Rehabilitation, 30(17): 1233-1244. doi: 10.1080/09638280701602418
McCabe, M. P., & Taleporos, G. (2003). Sexual esteem, Sexual satisfaction, and Sexual behavior among people with physical disability.
Archives of Sexual Behavior, 32(4), 359-369. doi: 0004-0002/03/0800-0359/0
Pieters, R., Kedde, H., & Bender, J. (2018). Training rehabilitation teams in sexual health care: A description and evaluation of a
multidisciplinary intervention. Disability and Rehabilitation, 40, 732-739. doi: 10.1080/09638288.2016.1271026