**4. Discussion**

The two studies provided pilot data on the effectiveness of a psychoeducational intervention for the sexual life of two groups of in- and outpatients and their partners performed at the USU-PG. We would like to emphasize that the first noteworthy outcome of this project (Love & Life) was the realization of an initiative aimed at promoting the sexual life of people with SCI in an Italian public health facility. As far as we know, this project was the first in Italy to tackle the issue of improving sex life and not just treating sexual dysfunction of people with SCI. Given the novelty of the initiative, we have had to battle with deep psychological, cultural, and religious reluctance to accepting the treatment of sexuality as an inherent aspect of personal well-being that no trauma can eradicate. Breaking the resistance of people (disabled and non-disabled, patients and partners, health workers and laypeople) even to consider that people with SCI also have the capacity to have relationships, experience love, and experience sexual and romantic attraction was a big deal. Having said that, 23 people's involvement is already reflective of the effectiveness of our initiative.

### **4.1 Sex, education, religion, and other characteristics of the participants**

Although the composition of the personal growth groups on sexual life was not defined in any way by the criterion of representativeness of the Italian population to the SCI, some of the characteristics of the sample tend to be compatible with the main SCI data. For instance, the prevalence of males with SCI in the group reflected the worldwide male-to-female ratio (4:1) [81, 82]. Only one participant (Study 2) has reached a master's degree level, only one a bachelor's degree (Study 1), and six a high school diploma (Studies 1 and 2). This finding is consistent with another key fact: SCI is associated with lower rates of school enrolment [83].

Except for one patient (Study 2), the cause of SCI was traumatic. The mean age when the traumatic event occurred was 37.2 years, data that are consistent with Pagliacci et al. [81] on the Italian SCI population (38.5 years). Ten participants declared that they were Roman Catholic, five from Study 1 and five from Study 2. Two of them (Study 1) were a lesbian couple with a civil union. The remaining participants declared themselves non-religious. In the two samples studied, the Catholic affiliation was lower than the national average—74.4% according to Ipsos Public Affairs [84]. Dealing with a sexually explicit topic seems to attract more people who do not have a religious affiliation or an orthodox view (e.g., lesbian couples in civil unions) because religions have specific sex teachings that can condemn masturbation or sexual relations outside of a heterosexual marriage [1, 19, 45, 49, 85–87].

#### **4.2 Outcome measures and effect size**

The effectiveness of the psychoeducational intervention was clearly apparent, denoted by a high (Study 1) or medium (Study 2) effect size in improving sexual interest and satisfaction as well as the opportunity and ability to enjoy sexuality. Anxiety was also reduced for all participants in Study 1 but not Study 2, although this outcome may not have been related to the psychoeducational intervention. Conversely, the intervention did not appear to significantly reduce levels of depression in patients or partners (Studies 1 and 2). This result might be clarified by the fact that the level of anxiety reported at the beginning of the first group meeting may be influenced by the context of novelty and sensitivity of the topic. When the re-test was carried out at the conclusion of the last group meeting, the climate was more friendly and the issue of sexuality less concerning. Hence, the decreased levels of anxiety could be more due to an intervening variable (anxiogenic context) than to treatment effectiveness. This potential fact could also explain why there has been no improvement in the levels of depression, which usually tends to positively correlate with anxiety [66, 88]. Indeed, the personal growth group on sexual life was primarily focused on improving awareness of sexuality conveyed by sexually explicit videos and therapy techniques focused on feelings and social relationships. Anxiety and depression might be determined by many other factors [88] that affect the quality of life of the patients and, consequently, their partners, besides sexual function, interest, and satisfaction. In addition, an efficacious psychotherapeutic treatment for observing reduced anxiety and depression might require more than 12 meetings over a period of 3 months [89, 90]. However, our findings correspond to the study by Harrison et al. [91] in which anxiety and depression were experienced by the same individuals, and anxiety—but not depression—was related to the sexual dysfunction of a woman with SCI.

#### **4.3 Qualitative data (study 2)**

The effectiveness of the psychoeducational intervention also clearly emerged from the qualitative analysis because it has promoted a path of self-confidence ("The encounters have given back a bit of lymph in being able to deal face-to-face this kind of topic") and it shattered prejudices about sexuality ("I understand very well the potential of the mind and how restricted was the vision of sexuality that I had before").

The three themes that emerged from the qualitative analysis are consistent with those elements highlighted in the Introduction. Sexuality emerged as closely linked to one's own and other's perception of the functioning and image of the body. A disabled body has disabled sexuality [92]. Recovering sexual health involves regaining the image of one's body and confidence that one can still give and receive pleasure [2, 4].

It is also clear from the qualitative analysis that stereotypes do not only concern nondisabled people toward people with disability; they also affect the people with disability themselves ("I was the first one to call myself asexual or disabled") [4, 5]. Finally, the adjustments that every person with SCI must tackle to regain their sexual health inevitably pass from the quality of social relationships ("Many people always see only the wheelchair"), ranging from the recovery of intimacy with the partner to trust in their own attractiveness.

### **5. Conclusions**

Several studies [5, 9, 93–96] and guides [1, 4, 68] urge that adequate education [96] and psychological support [97] be provided to people with SCI in order to

*Psychological Sexual Health of People with Paraplegia DOI: http://dx.doi.org/10.5772/intechopen.91854*

facilitate successful participation in sexual activities. These studies also highlight the need to involve intimate partners in discussions related to sexuality during the rehabilitative process [96] in an inclusive approach that gives women—in the same way as for males—the opportunity to talk with peers with SCI about sexual health during the initial rehabilitation and after returning home [98]. The first and greatest achievement of the Love & Life project was to develop, in Italy, an environment where a psychoeducational intervention could meet the needs of people with SCI, provide adequate education and psychological support, include partners, and create a space for peer-to-peer interaction. The intervention effectiveness also offers strong, clear evidence of the validity of the accepted biopsychosocial model that overcomes a reductionist view that restricts sexuality to the function/dysfunction of genitalia, phallocentric primacy of sexual pleasure, and attractiveness of only perfect body. We do not believe we have solved the complexity of the sexual lives of women [99] and men with SCI and their partners, but we hope that the Love & Life initiative will lead to a new way forward to address this complexity.
