**1. Introduction**

When someone has experienced spinal cord injury (SCI), the first question they often ask is, "Doctor, will I ever walk again?" The thought soon after—sometimes never verbalized—emerges with equal urgency: "Will I be able to have sex?" This question is not answered easily, although the slogan of the American Consortium for Spinal Cord Medicine [1] exhorts to believe that "No injury, no matter how serious, can take away your ability to have a relationship, experience love, and experience the attraction between two people" (p. 3). People with SCI face many difficulties to regain confidence in themselves and their ability to experience intimacy and affection [2]. These challenges do not just emanate from the genital dysfunction caused by the injury, including alterations or loss of genital sensation, or erection, ejaculation, lubricate, and orgasm [3, 4]. They also arise because they must rediscover a new way of pleasure to themselves and others by learning to

inhabit a body that in many ways is new and dissimilar and requires a different way of touching, caressing, and exploring themselves and their partner [4].

In addition to this difficult adjustment to changes, like many other people with disabilities, people with SCI have to battle with their own and societal attitudes and stereotypes that deny individuals with disabilities are sexual beings [4, 5]. Such attitudes and stereotypes are the results of two pervasive and interrelated misconceptions (myths), which very often influence human thinking and behavior: bodily perfection [6] and asexuality [7–10]. These two myths arise from a disability model that is often known as the medical model of disability [11, 12], whereby people are deemed disabled due to their medical condition or impairment [13, 14]. Therefore, disability is understood as an individual inability to conform to a standard of normality, namely when the abnormality occurs within the person [15], making him/ her different from the majority of people [16].

According to this (medical) disability model, people with SCI have a disability in sexual relations due to the limitation or lack (resulting from the injury) of ability to conduct sexual activity in the manner that is considered normal or ideal [17]. Here, the interrelation between bodily perfection and sexual activity is closely and precisely related. 'Abled' people have to see the person with SCI as asexual because the injury obviously has affected the capacity to perform the so-called normal sexual activity. Conceiving sexual activity by a person with a disability for a 'normal' population would mean admitting to imagine an abnormal (monstrous) sexuality [8, 18].

The myths of bodily perfection and asexuality of disabled persons are not mere social constructions that influence attitudes and stereotypes. Every cultural context and historical period encompasses an ideal of bodily beauty and sexual behavioral norms [19]. Therefore, we should find such myths as universal human convictions [20, 21] that emerged from psychological mechanisms that evolved to solve long-enduring adaptive problems characteristic of the ancestral human environment [22]. Mating with someone who is unhealthy could pose a range of adaptive risks to our ancestors, including transmitting communicable diseases or viruses, impacting survival and reproduction, infecting children, and jeopardizing the children's chances of survival and reproduction [23, 24]. Hence, human survival was guaranteed by an evolved psychological mechanism to avoid contact and sexual intercourse with persons with visible deformity [25, 26]. Park et al. [27] found that individual differences in disease perception predict immediate cognitive responses that connect physical disability to disease (medical model) and also predict behavioral avoidance (disgust) of people with physical disabilities. Meloni et al. [28] also found a relationship between an evolved disease avoidance mechanism and contemporary prejudices that affect individuals with physical disabilities.

It should be noted that the field of psychiatry has a specific term for the sexual attraction to the body of a person with a disability: devotism. This concept is considered suspect and, to a certain extent, pathological; it is classified as a paraphilia in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [29].

Another signal that the medical disability model might act as an innate psychological mechanism below the two cultural constructs of bodily perfection and asexuality, as a cognitive constraint [30], is the occurrence of disability explanation compatible with the medical model early in childhood [31–33], independent of parents' disability representations and explanations [13].

Like the nondisabled, most people with SCI have grown up believing that disability is deviance and that bodily perfection is the standard [34]. As Susan Wendell wrote in her famous autobiography book *The Rejected Body* [19], to identify oneself

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

as a disabled person requires a change in one's own personality and a radically new way of thinking about oneself. The SCI is almost always a devastating event with many life-changing consequences, all of which require a number of changes during their post-injury lives [35, 36]. Sexual adjustment to SCI is one of those problems that is closely related to body image [2], general psychological health, overall selfesteem [37, 38], and body attractiveness [10, 39].

In a male-centered patriarchal culture [40]—characterized by unequal relationships between men and women (polarization) and power distribution (androcentrism), and biological essentialism (i.e., gender and roles vary by nature) [41]—the sex most people get to know is totally phallocentric (penis centered). According to Freud [42], around the age of five, children become aware that they either possess a penis or do not possess a penis and that having a penis is "a proud possession" [43]. Conversely, for women, the absence of a penis makes them "victim to envy for the penis" [42]. The recognition that one has or does not have a particular set of genitals is, for Freud, tantamount to recognizing the gender to whom they belong. "I have a penis" means "I am a boy" and "I do not have a penis" means "I am a girl." In this system, the gender identity is a genital (penis-centered) identity. As Rubin [44] wrote,

*"The alternative presented to the child [to have a penis or to be castrated] may be rephrased as an alternative between having, or not having, the phallus. […] The presence or absence of the phallus carries the differences between two sexual statuses, 'man' and 'woman'."* (p. 191)

This penis orientation relates to the awareness that having and using erections has something to do with masculinity [45]. Therefore, "males are in constant danger of losing their manhood and their identities" [45] when the erectile functions are compromised. As testified by Tepper [9], a sexuality educator and counselor living with SCI, "[T]he man with erectile dysfunction, inhibited ejaculation, loss of sensation, or physical limitations might conclude that his sex life is over." (p. 45).

Extensive research on erectile functions and male sexuality has largely overlooked the female sexuality of women with SCI [39, 46, 47]. This phenomenon is not surprising within Judeo-Christian androcentrism that restricts the sexual role of a woman to a reproductive function within the family and the ability to stimulate and satisfy a man's own sexual appetite [41]. This view denies women the experience of sexual pleasure [48]. Given that SCI neither compromises the receptive function of female sexual organs nor a woman's reproductive capacity [1], the biggest issues for women after SCI is usually focused on the perceived attractiveness of their bodies [39], that is, as a function of male sexuality. In an androcentric, penis-centered sense of sexuality—that Tom Shakespeare [49] defined as the "fucking ideology": heterosexual and penetrative intercourse with a male on top of a female—characterizing Judeo-Christian androcentrism, loss of genital sensation does not compromise a woman's sexual role. The Austrian philosopher Otto Weininger, a Jew who converted to Christianity in 1902 and who became a real posthumous celebrity within the German-speaking cultural world of the early twentieth century and beyond, in his popular and influential book on sex and character [50] published in 1903, explained the difference between a mother and a prostitute, woman's polar attributes (*sic*), "The mother does not experience sexual intercourse any *less* than the prostitute, but *differently*. The mother's behaviour is mainly receptive and accepting, while the prostitute feels and savors the pleasure to the extreme" (p. 205; emphasis in the original). Far from it, the loss of genital sensation ensures the woman's virginal and chaste role [48] (see also the traditional

practice of female genital mutilation in Islamic cultures that involves more than 200 million girls and women in 30 countries worldwide: https://www.unicef.org/media/ files/FGMC\_2016\_brochure\_final\_UNICEF\_SPREAD.pdf). Alexander and Rosen [51] and Komisaruk and Whipple [52] provided other evidence of a different focus on the sexuality of women with SCI compared to men. Women are oriented to giving rather than receiving pleasure. As both studies found, the major sexual concern of women is the diminishing opportunity and ability to give their partner sexual fulfillment because the disability disfigured the beauty of their body. Moreover, according to Kettl et al. [39],

*"The biggest and most remarkable change [for women] after spinal cord injury in our study was the worsening in body image. This was far greater than any change in ratings of sexual practice or enjoyment."* (p. 294)

Given that the sexual role of a woman in patriarchal cultures is restricted to the attractiveness of their body as a function of male sexuality, in a reverse sense, this factor can also be their shame. In fact, a woman's attractiveness is perceived similarly to penis erection, that is, a sexual behavior: when a male finds an attractive body, then sex is allowed because the former is a function of the latter. As LaRocca and Kromrey [53] found, male students consider an event to be more harassing when the victim was unattractive (read, not sexually available) compared to when the victim was attractive (read, sexually available). This stereotype is certainly no less affecting in women's judgment, who consider an event as more harassing when the victim was attractive (if sexually available, why violence?) than when the victim was unattractive (because of sexual unavailability, male violence allowed). Thus, Golden reports [54] that an action by an attractive male directed toward an unattractive female is more likely to be identified as not harassing. From a recent survey conducted by the Italian National Institute of Statistics [55] on stereotypes on gender roles and the social image of sexual violence, the prejudice that blames the woman for their suffered sexual violence still persists. For instance, 23% (without gender differences) believe that women can cause sexual violence with their way of dressing (read, their attractiveness). Therefore, it is not surprising that the main sexual concern of women with SCI is to have a body that is no longer attractive, no longer capable, that is, of giving their partner the 'right' sexual pleasure, and run the risk of deserving violence. Still in a recent survey conducted in the United Kingdom, Thrussell et al. [56], in accordance with previous literature, reaffirm that for women with SCI.

*"satisfaction with body image was reduced. To look 'sexy' was difficult […]. Lacking confidence and feeling sexually unattractive during rehabilitation was common; support and opportunities to improve self-confidence, self-esteem, body image and social skills were identified as essential."* (pp. 1088–1091)

The aim of this chapter is to provide data for the Love & Life project that was collected from two interventional studies led by two growth groups. The project was performed in the Unipolar Spinal Unit of the '*S. Maria* della Misericordia' hospital in Perugia (USU-PG). This unit is one of the 22 spinal units that comprise the Italian National Health System, of which 9 are unipolar. Love & Life aims to enhance the psychological sexual health of USU-PG in- and outpatients and their partners. To achieve this goal, the project follows the biopsychosocial sexual health model of the World Health Organization [57, 58] and human functioning [59]. This positive, holistic, and comprehensive view states that sexual health is "a state

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

of physical, emotional, mental, and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction, or infirmity" ([58], p. 3). This view implies overcoming the reduction of the medical model and its socio-cultural products (myths, attitudes, stereotypes, and prejudices), which restrict sexuality to the physiological function of genitalia, phallocentric primacy of sexual pleasure, and attractiveness of only bodily perfection. The Love & Life initiative facilitates a psychological (emotional and behavioral) change, which increases self- and sexual esteem and satisfaction. By promoting a psychoeducational personal growth group [60], people with SCI and their partners can experience, express, and rework thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, roles, and relationships about sexuality [58].

This project was approved by the ethics committee of the Department of Philosophy, Social & Human Sciences, and Education, University of Perugia. The project information was disseminated both orally and in paper format. Written informed consent was recorded for each group member on a prepared form by participant signature.
