Sexuality and Disability A Disability-Affirmative Approach to Sex Therapy CSL 6794.01 Class 6 Chapter 21

People with disabilities have become the largest minority group in the world, with the number of PWD increasing to approximately 10% of the world’s population. Clinicians see disability as a multicultural variable important in the assessment and treatment of sexual health. Understanding disability as a minority experience invites clinicians to utilize a cultural strengths-based model for working with PWD.

Culture of Disability Disability has historically been represented variously as a: Moral consequence Source of shame Medical anomaly Tragic condition associated with the need for rehabilitation

Social Model of Disability The Social Model of Disability emphasizes the strengths of PWD and identifies the physical and social barriers that obstruct PWD’s ability to thrive: Strengths of PWD’s: Humor Acceptance of variation Matter-of-fact orientation toward assistance Tolerance for unpredictability and ambiguity Flexible, adaptive approach to tasks

Social Model of Disability (cont’d) Once we begin to consider disability from a multiplicity of perspectives, both the importance and complexity of sexual expression for PWD become more visible. When the experiences of PWD are viewed from the perspective of healthy functioning and resilience, sexual expression begins to be seen as a right versus a privilege and barriers to sexual expression crystallize as problems rather than natural, expected sequelae of individual inadequacy

Sexual Health Care Accessing quality sexual healthcare is difficult for many PWD. Challenges to quality care include; Environmental and structural limitations that impede access to sexual and reproductive health care Attitude pool and informational barriers which may lead to miss conceptions and in sensitivities about clients needs Advocacy for appropriate and timely sexual healthcare may be a key role for sexual health clinicians. This can be accomplished by: Researching disability-informed resources in the local healthcare system Providing relevant information to PWD's (cont’d on next slide)

Empowering clients to advocate for their own care Educating providers on improving accessibility to clinical settings: Making architectural modifications Repositioning furniture Making materials available in a variety of formats

Assessment Considerations The Clinician must be mindful of their own potential for bias toward negative or dismissive attitudes about sexuality of PWD. The Clinician will maintain an empowering, sex- positive stance that will help to build rapport and guide assessment toward sources of resilience and creativity. Clinical tools specifically for assessment of sexuality among PWD have not been well developed.

Be sensitive to the PWD client’s readiness and comfort to talk about their sexuality. When conducting a comprehensive clinical interview, consider the unique physiological, behavioral, cognitive, psychological, socio- relational, and cultural aspects of sexuality and intimacy for the PWD.

Physiological Factors Although the physiological nature of a person's disability is relevant to her or his sexual experiences, it is important to note that its impact is not essentially negative and that it does not inherently inhibit the potential for sexual enjoyment. The willingness of PWD to look beyond traditional cultural emphasis on heterosexual penile-vaginal intercourse and instead focus on intimacy as mutual pleasure and enjoyment allows more PWD to experience thriving sexual lives, in the context of any challenges and sexual functioning that may occur secondary to disability

Differences in sexual functioning may occur throughout the sexual response cycle for PWD and may vary based on the specific nature of the individuals disability. Despite reductions in genital sensations in people living with SCI (spinal cord injury), most individuals continue to be able to experience orgasm in alternative ways, though the experiences may be different than it was pre-injury. Mobility limitations and pain must be assessed.

Psychological Factors Positive sexual experiences for PWD involve psychological factors related to self-image. Body image is of particular relevance to PWD, especially in light of our society’s devaluation of the disabled body, which may lead to internalized negative body images in PWD and even to lowered sexual desire. Sexual self-esteem encompasses cognitive, behavioral, and emotional facets of one’s sexuality and is a predictor of sexual adjustment.

Social and Relational Factors The sociocultural environment in the U.S. chronically exposes PWD to narrow definitions of attractiveness, virility, and beauty. It is a myth that PWD are asexual. Higher rates of poverty for PWD. Limitations in sexual activity by the “caregiver” due to fatigue. Increased risk of abuse or trauma for the PWD. WWD and individuals with intellectual disabilities are at risk of intimate partner violence

Diversity Factors Viewing disability as a minority cultural experience helps to conceptualize the context of clients’ sexual functioning concerns. Assessment should include Stigma and discrimination Access to or isolation from disability culture Degree of identification with values of disability culture (cont’d on next slide)

ASSESSMENT (mnemonic) Addressing highlights the need to attend to: Age Disability (Developmental) Disability (Acquired) Religion Ethnicity Socioeconomic status Sexual orientation Indigenous heritage National origin Gender

Emerging Psychosocial Approaches: Third-Wave CBTs Third-wave CBTs such as acceptance and commitment therapy (ACT) have emerged as effective treatments for various presenting problems. Mindfulness – purposeful and nonjudgmental attention to the present moment. Through practice it can aid in accepting anxious thoughts and reducing subsequent distress and avoidance behaviors during intimacy. ACT information can be found at www.contextualpsychology.org

Sensual Mindfulness Mindfulness may be particularly helpful for PWD. Integrating mindfulness with traditional techniques, such as sensate focus, can enhance and already effective strategy to include the ACT goal of experiencing something fully without defense.

Values Clarification Values for romantic and intimate relationships may include: Being intimate and honest Sharing similar interests Being trustworthy Experiencing new things Being physically affectionate

Sexual-expression values include: Being open in sexual communication Being focused on the present moment in sexual interactions Being able to satisfy a partner Prioritizing sexual expression in relationships Being willing to thing broadly about sex and intimacy