**2. Study 1**

#### **2.1 Setting**

The inpatients were recruited from the USU-PG by the psychologist working in the unit between November and December 2017. All inpatients admitted to the USU-PG received a brochure with the goal of the Love & Life initiative, participation requirements, topics for the sessions on sexual life in the personal growth group, schedule of meetings, and leaders' names and phone numbers. The same content was also presented in a poster format in unit corridors and in other hospital departments. In the same time, IR also recruited outpatients from the USU-PG patient registry by phone. The personal growth group on sexual life met in the USU-PG wheelchair accessible rehabilitation room from December 2017 through May 2018.

#### **2.2 Participants**

The inclusion criteria for attending the Love & Life personal growth group on sexual life were the following:


We use 'participants' to refer to all those who attended the growth group on sexual life and 'patients' to refer to both inpatients and outpatients. Fourteen participants attended the growth group on sexual life from December 2017 to May 2018. Only 11 participants were included in the present study, as explained in Section 2.7 (the subsection 'Sample').

#### **2.3 Measurements and procedures**

A sociodemographic questionnaire and three outcome measures were selfadministered (see below) by participants and their partners who had provided voluntary written informed consent during the recruitment process. The outcome measures were administered again at the end of the last group meeting.

*Sociodemographic questionnaire*. This form was developed *ad hoc* to collect data on participants' age, gender, sexual orientation, type of SCI (para- or tetraplegia), civil status, children, education, employment, citizenship, political orientation, and religious beliefs. The sexual orientation was rated on the Kinsey scale [61], also called the Heterosexual-Homosexual Rating Scale. It ranges from 0 to 6, with '0' indicating exclusively heterosexual/opposite sex behavior or attraction and '6' indicating exclusively homosexual/same-sex behavior or attraction. Ratings 1–5 are for those who report varying levels of attraction or sexual activity with either sex. The sociodemographic questionnaire was administered to all participants once, before the start of the first group meeting.

*Sexual Interest and Satisfaction (SIS) scale*. This measure is a six-item scale designed to measure sexual adjustment after SCI [62]. It is used to assess interest in and satisfaction with sexuality before and after injury [63]. Partners of the participants with SCI were instructed to answer the questions by making reference to before and after their partners' injury. Participants are asked to give answers on a scale of 0 (non-existent/very dissatisfying) to 3 (increased/very satisfying). This sexuality scale is one of the few that has been used within the SCI population [64]. Only one study [62] reported validity and reliability properties of the scale on a sample of 73 SCI subjects (60 male; mixed injury types; SCI duration >1 year). The SIS scale showed a high correlation with age at injury and moderate-to-high correlation with quality of life, and a high internal consistency (Cronbach's α = 0.96).

*Beck Depression Inventory-II* (*BDI-II*). In its current version, the BDI-II is a 21-question multiple-choice self-report inventory that comprises items relating to symptoms of depression such as hopelessness and irritability, cognitions such as guilt or feelings of being punished, and physical symptoms such as fatigue, weight loss, and lack of interest in sex [65]. Scores for statements ranged from 0 (e.g., "I do not feel sad") to 3 (e.g., "I am so sad or unhappy that I can't stand it"). Higher total scores indicate more severe depressive symptoms. The reliability and validity of the BDI-II in the Italian population have been demonstrated [65].

*Beck Anxiety Inventory* (*BAI*). This measure was designed to differentiate anxiety from depression [66]. The respondents indicate how much they have been bothered by each of the 21 symptoms during the past week. Symptoms include the inability to relax and trembling hands. Respondents rated each symptom on a scale ranging from 'not at all' (0) to 'severely' (3). The reliability and validity of the Italian BAI have been demonstrated [67].

#### **2.4 Structure, content, and techniques of the psychoeducational intervention**

The personal growth group met every fortnight for a total of 12 meetings, each of which lasted for 2 h. The sessions were held by psychologists and psychotherapists with expertise in sexuality and disability. The group meetings were organized in two parts: informative and practical. The informative part covered six topics, each for two meetings: (i) Me and my new body, (ii) Affective-relational communication, (iii) Between identity and sexual orientation, (iv) Discovering pleasure, (v) Live sexual life, and (vi) Aids to pleasure. The contents were also transmitted through the projection of videos and sexually explicit images, starting from the assumption that observational learning has an informative and motivational

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

function [68–71]. The interactive practical part—dedicated to personal growth and body awareness—utilized cognitive-behavioral therapy, Gestalt therapy, and emotion-focused therapy techniques. Through the cognitive-behavioral therapy techniques (e.g., problem management, role-playing, imagery, and modeling) [72], Participants were driven by the cycle of creating thoughts and emotions associated with their own sexuality to address stereotypes and derogatory beliefs about sexuality and disability, masturbation, orgasm, pleasure, sexual fantasy, sexual identity, and the beauty and attractiveness of the body. This process included the identification of possible dysfunctional patterns of self that negatively influenced the relationship with their partners. This effort meant overcoming the reductionist view that stems from both the disability medical model, which limits sexuality to the physiological functions of genitalia and genital sensation as the only possibility for sexual experience and heterosexism. Through Gestalt therapy [73] and emotionfocused therapy techniques [74], the emergence of a new sexual concept has been reinforced by increasing awareness on bodily feelings, stressing the relationship and the cycle of reflection on exciting emotions to create new meaning. For example, we used an empty chair and the imagination of the participants to develop and direct dialogs to help them reconcile contrasting aspects of their experience, pay attention to the body and verbal language, concentrate on emotions and the here and now of the relationship with the therapist or other group members. See the Supplementary Material to [63], where two topic guides are provided as an example of two group meetings on sexual life.

#### **2.5 Apparatus**

During the personal growth group meetings, a computer (Lenovo, ThinkPad T560), projector (Epson EB-S05), and wireless speaker (JBL Clip 2) were used to watch educational videos and images and perform some psychology exercises (e.g., visualization and relaxation exercises).

#### **2.6 Data analysis**

All data were processed using IBM SPSS Statistics for Windows, Version 25 (Armonk, NY). Due to the small sample size, nonparametric statistical tests were used. Specifically, the Wilcoxon test for paired samples was used to compare preand post-intervention scores on the SIS, BDI-II, and BAI for the complete sample (participants) and the two sub-groups (patients and partners).

To determine the effect size of the intervention, *r* was used, which was calculated by dividing the *z* value by the square root of *N* (number of cases used in the analysis). The interpretation of *r* values for effect size is relatively similar to Cohen's *d* [75]. It was considered negligible if it was less than 0.10, small from 0.10 to 0.30, medium between 0.30 and 0.50, and high if it was greater than 0.50. Although we used nonparametric statistics for the analyses, means and standard deviations of the variables (instead of the median) were reported whenever possible. An independent sample Kolmogorov-Smirnov test was also used to compare the patients and partners groups and consider possible gender effects.

#### **2.7 Results**

*Sample.* Three out of fourteen male participants who signed the informed consent and participated in the group meetings did not complete the complete sociodemographic questionnaire and/or outcome measures. Therefore, they have been excluded from data analysis. Of the remaining 11 participants (female: *N* = 6, 54.5%; male: *N* = 5, 45.5%), 4 males had complete paraplegia, 1 female had complete tetraplegia, and 1 female and male each had incomplete paraplegia. All of them were outpatients during the group activity. For all participants, the cause of SCI was traumatic (years from injury: *M* = 38.1; min = 26; max = 50; *SD* = 9.44). All four partners of the participants with SCI were females. The 11 group participants included 4 couples (8 individuals). One female participant with SCI reported not having a romantic or sexual partner.

*Outcome measures*. All participants (*N* = 11) improved significantly on SIS scale item 5 ("How are your opportunity and your ability to enjoy sexuality yourself?"; *z* = −3; *p* < 0.01), SIS scale total score (*z* = −2.53; *p* < 0.05), and BAI scores (*z* = −1.99; *p* < 0.05). The effect size was high in all cases (*r* = 0.90, *r* = 0.76, and *r* = 0.60, respectively). There was no difference in the scores for the SIS general satisfaction after injury or BDI.

A significant effect was found on SIS scale item 5 ("How are your opportunity and your ability to enjoy sexuality yourself?") for both patients (*N* = 7; z = −2.24; *p* < 0.05) and partners (*N* = 4; *z* = −2; *p* < 0.05) with a high effect size (*r* = 0.84 and *r* = 1, respectively). There were no effects for the total score or general satisfaction after injury for the SIS scale, BDI-II, or BAI. Further, there were no significant differences between genders or patients and partners. See [63] for more details on the pilot data of Study 1.
