**3.4 Results**

*Sample*. One male and one female (out of nine participants) who signed the informed consent and participated in the group meetings did not complete the entire sociodemographic questionnaire and/or the outcome measures. Therefore, they were excluded from data analyses. Of the remaining 7 participants (female: *N* = 1), 2 males had complete paraplegia, 2 males had complete tetraplegia, 1 male had incomplete paraplegia, and 1 male had incomplete tetraplegia. Five of them were outpatients during the group activity. For 5, the cause of SCI was traumatic (years from injury: *M* = 8; min = 0.75; max = 11; *SD* = 3.03). The participating female was the partner of a male with SCI, the only couple in the group. Three male participants with SCI reported not having a romantic or sexual partner.

*Outcome measures*. Although not significant, there was an increase in the raw values for all participants (*N* = 7) on SIS scale item 5 ("How are your opportunity and your ability to enjoy sexuality yourself?"; *M* = 1.29–3.57), SIS scale total score (*M* = 10.86–13.14), and SIS scale general satisfaction after injury score (*M* = −1.57 to −2). The effect size was medium in all cases (*r* = 0.36, *r* = 0.46, and *r* = 0.60, respectively). There were no significant differences in the scores for BDI-II and BAI and between genders or patients and partners.


#### **Table 1.**

*Level of agreement between the two independent evaluators, as scored using Krippendorff's alpha.*

*Qualitative analysis assisted by Atlas.ti*. The findings resulted in the core category 'psychological sexual health after SCI' and identified the experience of evolving sexuality during the personal growth group. Three main themes were identified, supported by seven categories: (1) disabled sexuality, (2) influences of family and social environment, and (3) effects of psychoeducational intervention. As shown in the diagram below (**Figure 1**), the three themes can be assumed to represent three stages of the same process—each one inextricably influenced by the others—and resulting in the ultimate purpose of the intervention, namely to achieve sexual health after SCI.

**Theme 1—Disabled sexuality:** "I don't know how your body can react to my caress, it's not like before."

Participants expressed their experience of sexuality as influenced by their impaired body. They reported psychological experiences related to living with a disability or with a partner with a disability, a phenomenon that negatively influenced daily life and sexuality, compromised the possibility of giving and receiving sexual pleasure, and hampered the ability to experience intimacy and affection after SCI.

Disability was experienced as an element that leads to an imbalance in the life of the person with SCI and their family, causing anger, anxiety, depression, difficulties in self-regulation of emotional states, and caregivers' psychophysical exhaustion.

*It was better that I hadn't been saved from the accident [...] I would have felt nothing, and 11 years would have passed, that the people who love me wouldn't. (DM).*

There was a constant focus on past life, which was valued more positively than present life, often due to encountering difficulties in accepting disability (one's own or her or his partner's), discomfort, and negative self-perception. In fact, physical changes in sexual function and masturbation emerged.

*Initially, I had written only a couple of problems related to masturbation, which were those of lack of sensitivity, […] of not achieving orgasm as before and therefore this created small desire and small excitement, so small desire to masturbate. (DP).*

*I wouldn't feel pleasure if I touched myself or someone touched it [my penis]. (DM).*

*It often happens to me that it [my penis] thinks the way it thinks, and I think different from it [...] I can't see if I can put this [my penis] and this [my head] in synergy. (SF).*

#### **Figure 1.**

*Core categories resulted by the qualitative analysis assisted by Atlas.ti and their inter-relationship.*

*Related to masturbation before the accident and afterwards, it became almost completely absent for me, right? Because it doesn't give me, to this day, the same satisfaction that it did before. (DP).*

*Unfortunately, I haven't tried them [sensations] now, because I don't have the use of my hands and nothing, I can't even think about masturbating right now. (SA).*

*The participants presented common stereotypes about sexuality and consequent experiences with the topic: performance anxiety, sexual dissatisfaction, loss of interest, and perception of not being attractive.*

*I was the first one to call myself asexual or disabled (DP).*

*I can't… I couldn't, I mean, or I could more hardly woo a girl and then tell her to go get a pizza, and then I probably couldn't do what I was able to do when I was 30. (SP).*

*Finally, there were two opposing attitudes: sexual desire and fear.*

*I caress him (my partner with SCI) in the face and I feel something moving inside of me, but it doesn't go... it can't go any further. It can't... and then I think back to the past. And from there I get stuck. (GA).*

**Theme 2—Influences of family and social environment**: "I've seen them look at me differently."

Familial, social, and professional relationships influenced sexual dialog with current or future partners. The participants expressed that there were changes in relational experiences and reflections on the perceived level of support.

The participants reported role changes within the family and conflicts in relationships.

*At home I did everything, I was the fulcrum. (SA).*

*Now we talk to each other all the time with something… a little bit of anger, of... if he doesn't want to talk, shut up like he used to, and I'll raise my voice. (GA).*

Furthermore, the participants expressed difficulties in finding a romantic/ sexual partner, and disability was described as a cause of being discriminated.

*I believe, from a purely subjective point of view, that not all, I speak of the female counterpart, have a detail, that is 'patience'. About knowing problems of who is in a wheelchair and then get to normal sexual intercourse, or… develop fantasies about being in a wheelchair and whatever else. (FC).*

*There was someone I haven't seen in a long time. When he saw me, I felt like I had the worst disease in the world from the look on his face. (SF).*

*Many people always see only the wheelchair; they don't see the person, the wheelchair as an inanimate object. I just need it to carry that person… not that person, that pile of muscle, bones and whatever else from point A to point B. (FC).*

The participants also reported that they did not receive enough support (familial and institutional) in coping with the changes brought about by their disability. Others felt supported by family members and found the psychological support received in the rehabilitation process and in the personal growth group important.

*I am working a lot, swimming pool, gym, all private clearly, because it is useless, after 3 years I have seen them all. (SA).*

*Even my children, they can't understand my anger. (GA).*

*[My partner] is sincerely facing this sexuality on her part, this sexuality [...] in general, she is facing this problem with extreme naturalness, tranquillity, and positivity. (SF).*

*Thanks to you, professionals, who have been supportive along the way. (FC)*

**Theme 3—Effects of psychoeducational intervention**. "I have discovered that sexuality is not only physical, but there is also the more satisfying aspect, which is, really, that which goes beyond the physical part."

This theme includes the effects that the intervention had during personal growth. Starting from the expectations of the participants, there were moments in which the therapeutic environment proved to be effective in achieving its goals. At other moments, the group showed difficulties during the exercises.

The therapeutic environment was effective in changing the participants' state of activation. It provided relaxation and well-being and presented strategies and new perspectives that increased self-esteem.

*I feel that there are a lot of things to do, and it has given me a line, a direction. I was really looking for it. (SA).*

*I did a good job. I also felt some emotions, perhaps crossing the eyes of SA., or FA... [...] and it made me feel good emotions. (SF).*

*Maybe more self-esteem? That is, if I was on a certain level of self-esteem and courage [...], the encounters have given back a bit of lymph in being able to deal face-to-face this kind of topic with a person. (FC).*

*The exercises stimulated insight and introspection. Sharing within the group was considered by the participants as a means of enrichment.*

*I realize [...] how limiting was my past way of doing. I understand very well the potential of the mind and how restricted was the vision of sexuality that I had before with respect to what could be or is. [DP].*

*The most encountered difficulties concerned the expression of personal experiences or those related to the intimate sphere, exercises of imagination, and auto analysis, the latter for members in whom the exercises evoked thoughts related to the traumatic event and past life.*

*When we started talking about sexology, my head went haywire. (GA).*

*By doing this, in quotes, experiment happiness took my breath away. (DM).*

*Finally, the intervention stimulated motivation to recover sexual health after SCI, with an emphasis on the relational component rather than the physical component of the sexual experience. The participants demonstrated that they understood the importance of exploring the body and resources, as well as the possibility of developing compensatory mechanisms and sexual assistance.*

*With my partner every little sign that approaches sexuality is amplified, every caress, every word, every gesture enters me with amplified power. (SF).*

*My new sexuality can be a caress, a kiss, a "thank you", a word in need... this is sexuality for me now. The closeness, the awareness of being together and interacting, sometimes. Together. (GA).*

*To be aware that, sexuality is not something that just sits there. We talked about physicality, but it finds its own progression also through other... other forms of... sharing, of participation. (SP).*

*Let [the sexual assistant] help me or reveal some secrets, some little tricks so that I can interact with him. (GA).*
