Rehabilitation Psychology 2014, Vol. 59, No. 2, 236-241
© 2014 American Psychological Association 0090-5550/14/$ 12.00 DOI: 10.1037/a0035916
BRIEF REPORT
Attitudes Toward the Sexuality of Persons With Physical Versus Psychiatric Disabilities Ilanit Hasson-Ohayon, Ifat Hertz, Noa Vilchinsky, and Shlomo Kravetz Bar-Ilan University
Objective: Research has shown that attitudes toward different disabilities form a hierarchy, with observers exhibiting more positive attitudes toward persons with physical disabilities than toward persons with psychiatric disabilities. In addition, investigations of attitudes toward persons with a disability indicate that they are often perceived as asexual. The current study examined whether involvement of persons with either a physical or psychiatric disability in a sexual relationship moderates the relation between their type of disability and attitudes toward them. Method: After reading one of six randomly assigned vignettes, university students (IV = 195) filled out a semantic differential-based attitude scale (Katz & Shurka, 1977; Kravetz, Katz, & Albez, 1994). The six vignettes consisted of a male with a physical disability/with a psychiatric disability/without a disability, who was either involved/not involved in a sexual relationship. Results: An interaction between type of disability and involvement in a sexual relationship was found for two subscales of the attitudes scale, occupation and intelligence. Involvement in a sexual relationship was found to generate more positive attitudes when the target person had a physical disability but more negative attitudes when he had a psychiatric disability. Conclusions: Involvement in a sexual relationship seems to work in favor of persons with a physical disability because of the association of such a relationship with normality and adaptation. However, attributing such a relationship to persons with a psychiatric disability seems to be stigmatic. Keywords: attitudes, disability, sexuality
bilitation and social integration (Chan, Tarvydas, Blalock, Strauser, & Atkins, 2009), the investigation of putative factors that may en hance or moderate these attitudes is important.
Impact and Implications • The current study adds to the rehabilitation psychology liter ature by uncovering the moderating role of sexuality. Involvement in a sexual relationship generates more positive attitudes when the target person has a physical disability but more negative attitudes when he has a psychiatric disability. • Educational efforts aimed at reducing the social stigma of various disabilities should take into account the role that attitudes toward involvement in an intimate relationship play.
• Based on the findings that persons with disabilities are con sidered a priori asexual (Shakespeare, 1999), in the current study, we explored the impact of knowledge regarding the sexual activity of persons with either a physical or a psychiatric disability on attitudes toward these persons.
Attitudes Toward Persons With Disabilities and Toward These Persons’ Sexuality
Introduction Studies in the area of rehabilitation psychology have consis tently produced evidence of negative attitudes toward persons with both physical and psychiatric disabilities (e.g., Antonak & Livneh, 2000; Brodwin & Orange, 2002; Vilchinsky et ah, 2010; Wang, Thomas, Chan, & Cheing, 2003). Because attitudes toward persons with disabilities have a substantial negative impact on their reha-
Studies have identified a number of variables associated with negative attitudes toward persons with disabilities. In their thor ough reviews, Livneh (1988), and more recently Chan et al. (2009), provided social and psychological explanations of the negative attitudes toward persons with disabilities. Among these explanations are the fear of death, which is evoked when meeting a person with a disability, and the sociocultural conditioning that culminates in the stigmatization of persons who deviate from the cultural norm of “wholeness.” In addition, the authors differenti ated between variables that are observer related (e.g., age, gender, childhood influences) and variables that are related to the person with the disability— the target (e.g., type of disability) (Chan et ah, 2009; Livneh, 1988). Of note, an exaggerated “prodisabled” ori entation has also been found to be related to negative attitudes
This article was published Online First April 7, 2014. Ilanit Hasson-Ohayon, Ifat Hertz, Noa Vilchinsky, and Shlomo Kravetz, Department of Psychology, Bar-Ilan University. Correspondence concerning this article should be addressed to Ilanit Hasson-Ohayon, PhD, Department of Psychology, Bar-Ilan University, Ramat-Gan 5290002, Israel. E-mail: [email protected]
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toward persons with a disability (Weisel, Kravetz, Florian, & Shurka-Zernitsky, 1988). Type of disability appears to be the most substantial targetrelated variable that influences attitudes toward persons with a disability. Attitudes toward persons with physical disabilities are more positive than attitudes toward persons with psychiatric dis abilities (Chan et a l, 2009; Cook, 1998; Livneh, 1982; Tsang, Chan, & Chan, 2004; Wong, Chan, Cardoso, Lam, & Miller, 2004). Chan et al. (2009) provide a sociocognitive explanation of this hierarchy of preference. This explanation is based on Weiner’s social-cognitive attribution theory (Weiner, 1995). Accordingly, two dimensions of perceived causality account for the preference of types of disability. These dimensions are onset controllability (the disability resulted from own fault or by accident) and stability (the level of stability and improvability of the disability’s causes). Corrigan et al. (2000) showed that persons with psychiatric dis abilities are perceived as having more control over their disability than are persons with physical disabilities. Furthermore, persons with psychiatric disabilities are often perceived as dangerous and unpredictable and, in terms of disorder changeability, their disabil ity is considered to be more stable than is a physical one (Corrigan et al., 2000; Corrigan & Watson, 2002). This more intense stig matization of persons with psychiatric disabilities might color the way in which persons without disabilities perceive their sexuality. Persons with different kinds of disabilities overall have been considered asexual even to the extent of being conceived as a “third gender” (Juergens & Miller-Smedema, 2009a; Juergens, Miller-Smedema, & Berven, 2009b; Sakellariou, 2006; Shake speare, 1999). According to Juergens et al. (2009b), this miscon ception is the product of the three following beliefs: (1) that sex cannot be a high priority in the lives of persons with disabilities (Kaufman, Silverberg, & Odette, 2007); (2) that due to limited opportunities for sexual gratification, persons with disability do not develop a need for sex (Milligan & Neufeldt, 2001); and (3) that persons without disabilities perceive people with disabilities as helpless and childlike and therefore as asexual (Kaufman et al., 2007). Indeed, in their comprehensive review on attitudes toward disability and sexuality, Juergens et al. (2009b) reported that persons with disabilities were more accepted as coworkers and casual friends than as marital or dating partners (e.g., Olkin & Howson, 1994; Yoshida, 1994). Vilchinsky, Werner, and Findler (2010) also showed that interpersonal shyness and embarrassment that typically arises between people of the opposite sex on a first casual meeting, disappears when one of them is presented as having a disability.
The Current Study Based on the above-mentioned negative conceptions of the sexuality of persons with disabilities, and the established knowl edge regarding the hierarchy of preference of disabilities, the current study examined the attitudes of persons without disabilities toward persons with physical and psychiatric disabilities. In addi tion, it explored whether the involvement of the person with the disability in a sexual relationship would result in a more negative attitude, especially if that person had a psychiatric disability. Accordingly, this study’s hypotheses were as follows: (a) attitudes toward a person with a psychiatric disability will be more negative than attitudes toward a person with a physical disability, while
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attitudes toward the latter will be more negative than attitudes toward a person without any disability; and (b) type of disability will interact with involvement in a sexual relationship. Conse quently, attitudes toward persons without disability will not be moderated by sexual involvement, whereas attitudes toward per sons with either a psychiatric or a physical disability will be moderated by their sexual involvement. The attitudes toward per sons with a disability who are sexually active will be more nega tive than the attitudes toward those who are not sexually active. Furthermore, the expected negative impact of sexual involvement on attitudes toward persons with a disability will be greater for persons with a psychiatric disability than for persons with a phys ical disability.
Method Participants The study population was defined as university students; 209 potential participants were invited to take part in the study. Refusal and drop-out rates were low with only 10 students declining to participate in the study and an additional six who did not complete the questionnaires. Data analyses were carried-out on a sample of 195 participants. All participants provided informed consent. Ap proximately half of the sample was women (56.4%). The mean age for the total sample was 32.64 {SD = 9.53); 13.8% of the sample reported being acquainted with a person with a psychiatric disabil ity, and 16.9% reported being acquainted with a person with a physical disability.
Measures Sociodemographic questionnaire. This questionnaire con sisted of questions regarding the participants’ age, gender, educa tion, religiousness and acquaintance with persons with a disability. Vignettes. Six vignettes were specifically designed for the current study. In all six, a young man was presented as having a relationship with a young woman. Information regarding his age, education, and past events was provided. Alternating the catego ries of the independent variables (type of disability, involvement in a sexual relationship) resulted in the following six conditions: (a) a description of the couple having a platonic relationship where neither the man nor the woman had a disability; (b) a description of the couple having an intimate sexual relationship where neither the man nor the woman had a disability; (c) a description of the couple having a platonic relationship where the man was described as using a wheelchair due to paraplegia; (d) a description of the couple having a platonic relationship where the man was described as having schizophrenia and living in the community; (e) a de scription of the couple having an intimate sexual relationship where the man was described as using a wheelchair due to para plegia; and (f) a description of the couple having an intimate sexual relationship where the man was described as having schizo phrenia and living in the community. A semantic differential-based attitudes scale (Katz & Shurka, 1977; Kravetz et al., 1994). This scale was used to evaluate the attitude toward the person in each vignette. It consisted of 31 items that referred to five characteristics of the young men portrayed in the vignettes: personality (six items;
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e.g., self-confidence), sociality (seven items; e.g., friendly), occupation (six items; e.g., productivity at work), intelligence (six items; e.g., talented), and ethics (six items; e.g., decency). Each item consisted of a pair of adjectives that referred to the aforementioned personal characteristics. In keeping with the semantic differential technique, each one of the pair of adjec tives was placed at one end of a bipolar graphic scale with the positive adjective (e.g., careful at work) at one end and the negative adjective at the other end (i.e., careless at work). Lower scores on this scale represented more negative attitudes. Previous studies (Katz & Shurka, 1977; Kravetz et al., 1994) have uncovered high internal consistency for this scale. Cronbach’s alpha for the overall scale in the current study was .90. Cronbach’s alpha for the subscales ranged from .55 to .82.
Procedure After the Bar-Ilan University Review Board approved the re search protocol, the research questionnaires were administered to the research participants either in groups during classes or indi vidually. The participants were randomly assigned to one of the six conditions of the study, and participants were informed that they were taking part in an assessment of the validity of a new measure that was being developed by the department of psychology.
Results Correlations Among Attitudes Toward Persons With Disabilities and Sociodemographic Variables Correlations were calculated between participants’ background characteristics (sociodemographics and acquaintance) and the at titudes scale scores. The only background variable that was sig nificantly related to the total attitude scale and subscales scores was acquaintance with a person with a physical disability (r ranging from —.16 to —.17). Therefore, this variable was treated as covariate in subsequent analyses. In addition, no significant difference in the frequency of any of the background variables was detected for the two conditions of involvement in sexual relations (yes/no) or between the three conditions of disability (no disability/psychiatric disability/physical disability).
Type of Disability, Involvement in a Sexual Relationship, and Attitudes Toward People With Disabilities In order to assess the contribution of type of disability (no disability/psychiatric disability/physical disability) and sexual in volvement (yes/no) to the attitudes scale total score, a two-way (3 X 2) Analysis of Variance (ANOVA) was carried out. A twoway (3 X 2) Multivariate Analysis of Variance (MANOVA) was also conducted in order to assess the contribution of the same independent variables to the attitude scale’s different subscales scores. When the dependent variable was defined as the total score, no significant main or interactions effects were found. Also, when the five attitude subscales scores were analyzed, significant overall effects were not found for disability, sexuality, or their interaction. However, the following separate ANOVAs for each subscale re
vealed a significant main effect for type of disability for subscales of attitudes regarding personality and attitudes regarding sociality (F = 3.87, d f = 2,188, p < .05, partial p.2 = 0.04; F = 3.41, d f = 2.188, p < .05, partial p.2 = 0.04; respectively). According to post hoc analyses (Scheffé), participants expressed more positive atti tudes in these two domains toward a person with a physical disability (M = 3.62, SD = .53; M = 3.40, SD = .60, for personality and sociality respectively) or without any disability (M = 3.53, SD = .53; M = 3.37, SD = .55, for personality and sociality respectively) compared to a person with a psychiatric disability (M = 3.36, SD = .56; M = 3.16, SD = .55, for personality and sociality respectively). In addition, significant interaction effects between type of dis ability and involvement in sexual relationship were found for the occupation and intelligence attitudes subscales (F = 3.85, d f = 2.188, p < .05, partial fx2 = 0.04; F = 3.08, d f = 2,188, p < .05, partial p,2 = .03; respectively). As can be seen in Table 1, when the person in the vignette was described as having a psychiatric disability, participants expressed more negative attitudes regarding both his occupation and intelligence when he was involved in a sexual relationship than in the condition where he was not. An opposite picture emerged when the fictitious person was described as having a physical disability. This time participants expressed more positive attitudes toward this person’s occupation and intel ligence when he was allegedly involved in a sexual relationship than in the condition where he was not. No differences were found between the two levels of the sexual relationship domain among persons without a disability. Figure 1 and Figure 2 portray these results. The same trend was detected with regard to the other attitude subscales although the differences on these subscales were not statistically significant.
Discussion The main goal of the current study was to assess the putative moderating effect of being involved in a sexual relationship on the association between type of disability and attitudes toward persons with a disability. Based on the existing data in the field, our a priori assumptions were that sexual relationship involve ment would generate more negative attitudes toward people with both psychiatric and physical disabilities with a greater effect for psychiatric disabilities. Results, however, revealed that the difference between psychiatric disabilities and physical disabilities was more complex. It was found that involvement in a sexual relationship generated more positive attitudes when the target person had a physical disability but more negative attitudes when he had a psychiatric disability. Though limited empirical studies have been carried out on attitudes toward the sexual behavior of persons with a psychi atric disability, the assumption that the sexual behavior of such person is considered less legitimate is consistent with studies on attitudes toward the sexual behavior of persons with such other chronic neurological conditions as mental retardation. These stud ies show that the sexual activity of persons with mental retardation was judged as less appropriate than the sexual activity of persons without any disability (Scotti, Slack, Bowman, & Morris, 1996; Wolfe, 1997). Similarly, the present study shows that associating sexual activity with a psychiatric disability strengthens the stigma elicited by the latter disability. Since one source of psychiatric
ATTITUDES TOWARD SEXUALITY AND DISABILITY
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Table 1 Means and Standard Deviations of the Attitudes Scores by Disability Type and Sexual Relationship
Attitude No sexual relationship Sexual relationship Total Personality3* No sexual relationship Sexual relationship Total Sociality3* No sexual relationship Sexual relationship Total Occupation0* No sexual relationship Sexual relationship Total Morals No sexual relationship Sexual relationship Total Intelligence“* No sexual relationship Sexual relationship Total 3 Main effect of disability. *p < .05.
Persons without a disability M (SD)
Persons with a physical disability M (SD)
Persons with a psychiatric disability M (SD)
3.46 (.47) 3.40 (.39) 3.42 (.42)
3.41 (.45) 3.55 (.49) 3.47 (.47)
3.36 (.47) 3.24 (.48) 3.29 (.48)
3.56 (.60) 3.51 (.50) 3.53 (.53)
3.53 (.53) 3.73 (.53) 3.62 (.53)
3.40 (.64) 3.34 (.48) 3.37 (.57)
3.46 (.59) 3.31 (.51) 3.37 (.55)
3.39 (.56) 3.40 (.65) 3.40 (.60)
3.26 (.59) 3.10 (.50) 3.16 (.55)
3.34 (.51) 3.36 (.45) 3.35 (.47)
3.28 (.51) 3.52 (.54) 3.39 (.53)
3.35 (.59) 3.10 (.54) 3.21 (.57)
3.57 (.79) 3.49 (.53) 3.49 (.64)
3.50 (.62) 3.64 (.69) 3.56 (.64)
3.52 (.67) 3.45 (.61) 3.48 (.64)
3.40 (.48) 3.43 (.41) 3.42 (.44)
3.50 (.54) 3.64 (.62) 3.56 (.57)
3.53 (.52) 3.24 (.57) 3.38 (.60)
b Interaction effect between sexuality and disability.
related stigma consists of viewing persons with a psychiatric disability as dangerous and unpredictable (Corrigan et al., 2000), narratives that depict such persons as being sexually active may automatically elicit stereotypical attributions of poor judgment, unsafe sex, promiscuity or abuse. The findings of the present study suggest that the spread effect (Wright, 1983) of the sexuality of
persons with a psychiatric disability may be so strong that it affects attitudes toward such different personal characteristics as intelli gence and occupation— characteristics not necessarily related to sex. Sexuality in the context of physical disability, on the other hand, apparently gave rise to the opposite effect. Following the
■ Sexual involvement
■ Sexual involvement
■ No sexual involvement
■No sexual involvement
3 .6 -----------------------------------------------------------------------------
3.7 — ----------------------------------------------------------------------
Without disability
Physical disability Psychiatric disability
Figure 1. The results of the interaction between type of disability and involvement in a sexual relationship in the occupation domain of attitude.
Without disability
Physical disability Psychiatric disabflity
Figure 2. The results of the interaction between type of disability and involvement in sexual relationships in the intelligence domain of attitude.
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HASSON-OHAYON, HERTZ, VILCHINSKY, AND KRAVETZ
model of Juergens et al. (2009b), the current findings suggest that persons with a physical disability who are presented as sexually active convey a message that, (a) they are not that absorbed by their impairments to the degree that sex becomes irrelevant to them; (b) they have opportunities for sexual rela tions; and (c) they are not helpless, childlike, or asexual. Thus, the existence of sexual activity seems to work in favor of people with a physical disability by strengthening their appearance of normality and adaptation, whereas it marginalized persons with a psychiatric disability. Several limitations of the current study should be taken into consideration. First and foremost, the vignettes used only con sisted of a fictitious male. Therefore, no conclusions can be derived from the current finding regarding gender differences. Second, the study sample consisted of only students, further limiting generalizability. Third, the attitudes scale used as sessed attitudes toward functioning in different life domains, but it did not capture such attitudinal dimensions as affect, cognitions, and behaviors (Findler, Vilchinsky, & Werner, 2007). Fourth, only two types of disability, schizophrenia and paraplegia, were examined in the current study. Schizophrenia can be viewed as one of the more stigmatized psychiatric disabilities, while paraplegia may be one of the least stigma tized physical disabilities. Fifth, participants’ knowledge of the heritability of both physical and psychiatric disabilities was not assessed. Therefore, the impact of this knowledge on attitudes could not be controlled for. Finally, the role of the visibility of the disabilities was also not addressed in this study. Future studies should include both genders and additional types of disabilities in the vignettes, use more heterogeneous samples and apply a more multidimensional perspective. Despite these limitations, the current findings should consti tute a contribution to any effort aimed at changing attitudes toward people with disabilities. Educating people with regard to the legitimacy of sexual activity for persons with a psychiatric disability should contribute to reducing misconceptions about mental illness. Presenting persons with a physical disability in the media in the context of dating, initiating, and maintaining friendship and intimate relationships may enhance their public acceptance.
References Antonak, R. F., & Livneh, H. (2000). Measurement of attitudes towards persons with disabilities. Disability and Rehabilitation: An Interna tional M ultidisciplinary Journal, 22, 2 1 1 -2 2 4 . doi:10.1080/ 096382800296782 Brodwin, M. G., & Orange, L. M. (2002). Attitudes toward disability. In J. D. Andrew & C. W. Faubion (Eds.), Rehabilitation services: An introduction fo r the human services professional (pp. 174-197). Osage Beach, MO: Aspen Professional Services. Chan, F., Tarvydas, V., Blalock, K., Strauser, D., & Atkins, B. (2009). Unifying and elevating rehabilitation counseling through model-driven, diversity-sensitive evidence-based practice. Rehabilitation Counseling Bulletin, 52, 114-119. doi:10.1177/0034355208323947 Cook, D. (1998). Psychosocial impact of disability. In R. M. Parker & E. M. Szymanski (Eds.), Rehabilitation counselling: Basics and beyond (3rd ed., pp. 303-326). Austin, TX: Pro-Ed. Corrigan, P. W., River, L. P., Lundin, R. K., Uphoff Wasowski, K. U., Campion, J., Mathisen, J., . . . & Kubiak, M. A. (2000). Stigmatizing attributions about mental illness. Journal o f Community Psychology, 28,
91-102. doi: 10.1002/(SICI) 1520-6629(200001)28:13 .O.CO;2-M Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry, 1, 16-20. Findler, L., Vilchinsky, N., & Werner, S. (2007). The Multidimensional Attitudes Scale toward persons with disabilities (MAS): Construction and validation. Rehabilitation Counseling Bulletin, 50, 166-176. doi: 10.1177/00343552070500030401 Juergens, M. H., & Miller-Smedema, S. (2009a). Sexuality and disability. In F. Chan, E. da Silva Cardoso, & J. A. Chronister (Eds.), Understand ing psychosocial adjustment to chronic illness and disability (pp. 443470). New York, NY: Springer. Juergens, M. H., Miller-Smedema, S., & Berven, N. L. (2009b). Willing ness of graduate students in rehabilitation counseling to discuss sexuality with clients. Rehabilitation Counseling Bulletin, 53, 3 4 -4 3 . doi: 10.1177/0034355209340587 Katz, S., & Shurka, E. (1977). The influence of contextual variables on evaluation of the physically disabled by the nondisabled. Rehabilitation Literature, 38, 369-373. Kaufman, M., Silverberg, C., & Odette, F. (2007). The ultimate guide to sex and disability: For all o f us who live with disabilities, chronic pain, and illness. San Francisco, CA: Cleis. Kravetz, S., Katz, S., & Albez, D. (1994). Attitudes toward Israeli war veterans with disabilities: Combat vs. noncombat military service and responsibility for the disability. Rehabilitation Counseling Bulletin, 37, 371-379. Livneh, H. (1982). On the origins of negative attitudes towards people with disabilities. Rehabilitation Literature, 43, 338-347. Livneh, H. (1988). A dimensional perspective on the origin of negative attitudes toward persons with disabilities. In H. E. Yuker (Ed.), Attitudes toward persons with disabilities (pp. 35-46). New York, NY: Springer. Milligan, M. S., & Neufeldt, A. H. (2001). The myth of asexuality: A Survey of social and empirical evidence. Sexuality and Disability, 19, 91-109. doi: 10.1023/A: 1010621705591 Olkin, R., & Howson, L. (1994). Attitudes toward and images of physical disability. Journal o f Social Behavior and Personality, 9, 81-96. Sakellariou, D. (2006). If not the disability, then what? Barriers to reclaim ing sexuality following spinal cord injury. Sexuality and Disability, 24, 101-111. doi: 10.1007/s 11195-006-9008-6 Scotti, J. R., Slack, B. S., Bowman, R. A., & Morris, T. L. (1996). College student attitudes concerning the sexuality of persons with mental retar dation: Development of the perceptions of sexuality scale. Sexuality and Disability, 14, 249-264. doi:10.1007/BF02590098 Shakespeare, T. (1999). The sexual politics of disabled masculinity. Sex uality and Disability, 17, 53-64. doi: 10.1023/A: 1021403829826 Tsang, H., Chan, F., & Chan, C. C. H. (2004). Attitudes of occupational therapy students toward placement of treatment facilities in the commu nity: A conjoint analysis. American Journal o f Occupational Therapy, 58, 426-434. doi:10.5014/ajot.58.4.426 Vilchinsky, N., Findler, L., & Werner, S. (2010). Attitudes toward people with disabilities: The perspective of attachment theory. Rehabilitation Psychology, 55, 298-306. doi:10.1037/a0020491 Wang, M. H., Thomas, K„ Chan, F., & Cheing, G. (2003). A conjoint analysis of factors influencing American and Taiwanese college stu dents’ preferences for people with disabilities. Rehabilitation Psychol ogy, 48, 195-201. doi: 10.1037/0090-5550.48.3.195 Weiner. B. (1995). Judgments o f responsibility: A foundation fo r a theory o f social contact. New Y ork, NY : Guilford Press. Weisel, A., Kravetz, S., Florian, V., & Shurka-Zemitsky, E. (1988). The structure of attitudes toward persons with disabilities: An Israeli valida tion of Siller’s Disability Factor Scales—General (DFS—G). Rehabili tation Psychology, 33, 227-238.
ATTITUDES TOWARD SEXUALITY AND DISABILITY Wolfe, P. S. (1997), The influence of personal values on issues of sexuality and disability. Sexuality and Disability, 15, 69-90. doi:10.1023/A: 1024731917753 Wong, D. W., Chan, F., Cardoso, E., Lam, C. S., & Miller, S. M. (2004). Rehabilitation counseling students’ attitudes toward people with disabil ities in three social contexts: A conjoint analysis. Rehabilitation Coun seling Bulletin, 47, 194-204. doi:10.1177/00343552040470040101 Wright, B. A. (1983). Physical Disability- A Psychosocial Approach. New York, NY: Harper Row. doi: 10.1037/10589-000
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Yoshida, K. K. (1994). Intimate and marital relationships. Sexuality and Disability, 12, 179-189. doi:10.1007/BF02547904
R eceived A pril 8, 2013 R evision received January 6, 2014 A ccepted January 8, 2014 ■
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© 2014 American Psychological Association 0090-5550/14/$ 12.00 DOI: 10.1037/a0035916
BRIEF REPORT
Attitudes Toward the Sexuality of Persons With Physical Versus Psychiatric Disabilities Ilanit Hasson-Ohayon, Ifat Hertz, Noa Vilchinsky, and Shlomo Kravetz Bar-Ilan University
Objective: Research has shown that attitudes toward different disabilities form a hierarchy, with observers exhibiting more positive attitudes toward persons with physical disabilities than toward persons with psychiatric disabilities. In addition, investigations of attitudes toward persons with a disability indicate that they are often perceived as asexual. The current study examined whether involvement of persons with either a physical or psychiatric disability in a sexual relationship moderates the relation between their type of disability and attitudes toward them. Method: After reading one of six randomly assigned vignettes, university students (IV = 195) filled out a semantic differential-based attitude scale (Katz & Shurka, 1977; Kravetz, Katz, & Albez, 1994). The six vignettes consisted of a male with a physical disability/with a psychiatric disability/without a disability, who was either involved/not involved in a sexual relationship. Results: An interaction between type of disability and involvement in a sexual relationship was found for two subscales of the attitudes scale, occupation and intelligence. Involvement in a sexual relationship was found to generate more positive attitudes when the target person had a physical disability but more negative attitudes when he had a psychiatric disability. Conclusions: Involvement in a sexual relationship seems to work in favor of persons with a physical disability because of the association of such a relationship with normality and adaptation. However, attributing such a relationship to persons with a psychiatric disability seems to be stigmatic. Keywords: attitudes, disability, sexuality
bilitation and social integration (Chan, Tarvydas, Blalock, Strauser, & Atkins, 2009), the investigation of putative factors that may en hance or moderate these attitudes is important.
Impact and Implications • The current study adds to the rehabilitation psychology liter ature by uncovering the moderating role of sexuality. Involvement in a sexual relationship generates more positive attitudes when the target person has a physical disability but more negative attitudes when he has a psychiatric disability. • Educational efforts aimed at reducing the social stigma of various disabilities should take into account the role that attitudes toward involvement in an intimate relationship play.
• Based on the findings that persons with disabilities are con sidered a priori asexual (Shakespeare, 1999), in the current study, we explored the impact of knowledge regarding the sexual activity of persons with either a physical or a psychiatric disability on attitudes toward these persons.
Attitudes Toward Persons With Disabilities and Toward These Persons’ Sexuality
Introduction Studies in the area of rehabilitation psychology have consis tently produced evidence of negative attitudes toward persons with both physical and psychiatric disabilities (e.g., Antonak & Livneh, 2000; Brodwin & Orange, 2002; Vilchinsky et ah, 2010; Wang, Thomas, Chan, & Cheing, 2003). Because attitudes toward persons with disabilities have a substantial negative impact on their reha-
Studies have identified a number of variables associated with negative attitudes toward persons with disabilities. In their thor ough reviews, Livneh (1988), and more recently Chan et al. (2009), provided social and psychological explanations of the negative attitudes toward persons with disabilities. Among these explanations are the fear of death, which is evoked when meeting a person with a disability, and the sociocultural conditioning that culminates in the stigmatization of persons who deviate from the cultural norm of “wholeness.” In addition, the authors differenti ated between variables that are observer related (e.g., age, gender, childhood influences) and variables that are related to the person with the disability— the target (e.g., type of disability) (Chan et ah, 2009; Livneh, 1988). Of note, an exaggerated “prodisabled” ori entation has also been found to be related to negative attitudes
This article was published Online First April 7, 2014. Ilanit Hasson-Ohayon, Ifat Hertz, Noa Vilchinsky, and Shlomo Kravetz, Department of Psychology, Bar-Ilan University. Correspondence concerning this article should be addressed to Ilanit Hasson-Ohayon, PhD, Department of Psychology, Bar-Ilan University, Ramat-Gan 5290002, Israel. E-mail: [email protected]
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toward persons with a disability (Weisel, Kravetz, Florian, & Shurka-Zernitsky, 1988). Type of disability appears to be the most substantial targetrelated variable that influences attitudes toward persons with a disability. Attitudes toward persons with physical disabilities are more positive than attitudes toward persons with psychiatric dis abilities (Chan et a l, 2009; Cook, 1998; Livneh, 1982; Tsang, Chan, & Chan, 2004; Wong, Chan, Cardoso, Lam, & Miller, 2004). Chan et al. (2009) provide a sociocognitive explanation of this hierarchy of preference. This explanation is based on Weiner’s social-cognitive attribution theory (Weiner, 1995). Accordingly, two dimensions of perceived causality account for the preference of types of disability. These dimensions are onset controllability (the disability resulted from own fault or by accident) and stability (the level of stability and improvability of the disability’s causes). Corrigan et al. (2000) showed that persons with psychiatric dis abilities are perceived as having more control over their disability than are persons with physical disabilities. Furthermore, persons with psychiatric disabilities are often perceived as dangerous and unpredictable and, in terms of disorder changeability, their disabil ity is considered to be more stable than is a physical one (Corrigan et al., 2000; Corrigan & Watson, 2002). This more intense stig matization of persons with psychiatric disabilities might color the way in which persons without disabilities perceive their sexuality. Persons with different kinds of disabilities overall have been considered asexual even to the extent of being conceived as a “third gender” (Juergens & Miller-Smedema, 2009a; Juergens, Miller-Smedema, & Berven, 2009b; Sakellariou, 2006; Shake speare, 1999). According to Juergens et al. (2009b), this miscon ception is the product of the three following beliefs: (1) that sex cannot be a high priority in the lives of persons with disabilities (Kaufman, Silverberg, & Odette, 2007); (2) that due to limited opportunities for sexual gratification, persons with disability do not develop a need for sex (Milligan & Neufeldt, 2001); and (3) that persons without disabilities perceive people with disabilities as helpless and childlike and therefore as asexual (Kaufman et al., 2007). Indeed, in their comprehensive review on attitudes toward disability and sexuality, Juergens et al. (2009b) reported that persons with disabilities were more accepted as coworkers and casual friends than as marital or dating partners (e.g., Olkin & Howson, 1994; Yoshida, 1994). Vilchinsky, Werner, and Findler (2010) also showed that interpersonal shyness and embarrassment that typically arises between people of the opposite sex on a first casual meeting, disappears when one of them is presented as having a disability.
The Current Study Based on the above-mentioned negative conceptions of the sexuality of persons with disabilities, and the established knowl edge regarding the hierarchy of preference of disabilities, the current study examined the attitudes of persons without disabilities toward persons with physical and psychiatric disabilities. In addi tion, it explored whether the involvement of the person with the disability in a sexual relationship would result in a more negative attitude, especially if that person had a psychiatric disability. Accordingly, this study’s hypotheses were as follows: (a) attitudes toward a person with a psychiatric disability will be more negative than attitudes toward a person with a physical disability, while
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attitudes toward the latter will be more negative than attitudes toward a person without any disability; and (b) type of disability will interact with involvement in a sexual relationship. Conse quently, attitudes toward persons without disability will not be moderated by sexual involvement, whereas attitudes toward per sons with either a psychiatric or a physical disability will be moderated by their sexual involvement. The attitudes toward per sons with a disability who are sexually active will be more nega tive than the attitudes toward those who are not sexually active. Furthermore, the expected negative impact of sexual involvement on attitudes toward persons with a disability will be greater for persons with a psychiatric disability than for persons with a phys ical disability.
Method Participants The study population was defined as university students; 209 potential participants were invited to take part in the study. Refusal and drop-out rates were low with only 10 students declining to participate in the study and an additional six who did not complete the questionnaires. Data analyses were carried-out on a sample of 195 participants. All participants provided informed consent. Ap proximately half of the sample was women (56.4%). The mean age for the total sample was 32.64 {SD = 9.53); 13.8% of the sample reported being acquainted with a person with a psychiatric disabil ity, and 16.9% reported being acquainted with a person with a physical disability.
Measures Sociodemographic questionnaire. This questionnaire con sisted of questions regarding the participants’ age, gender, educa tion, religiousness and acquaintance with persons with a disability. Vignettes. Six vignettes were specifically designed for the current study. In all six, a young man was presented as having a relationship with a young woman. Information regarding his age, education, and past events was provided. Alternating the catego ries of the independent variables (type of disability, involvement in a sexual relationship) resulted in the following six conditions: (a) a description of the couple having a platonic relationship where neither the man nor the woman had a disability; (b) a description of the couple having an intimate sexual relationship where neither the man nor the woman had a disability; (c) a description of the couple having a platonic relationship where the man was described as using a wheelchair due to paraplegia; (d) a description of the couple having a platonic relationship where the man was described as having schizophrenia and living in the community; (e) a de scription of the couple having an intimate sexual relationship where the man was described as using a wheelchair due to para plegia; and (f) a description of the couple having an intimate sexual relationship where the man was described as having schizo phrenia and living in the community. A semantic differential-based attitudes scale (Katz & Shurka, 1977; Kravetz et al., 1994). This scale was used to evaluate the attitude toward the person in each vignette. It consisted of 31 items that referred to five characteristics of the young men portrayed in the vignettes: personality (six items;
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e.g., self-confidence), sociality (seven items; e.g., friendly), occupation (six items; e.g., productivity at work), intelligence (six items; e.g., talented), and ethics (six items; e.g., decency). Each item consisted of a pair of adjectives that referred to the aforementioned personal characteristics. In keeping with the semantic differential technique, each one of the pair of adjec tives was placed at one end of a bipolar graphic scale with the positive adjective (e.g., careful at work) at one end and the negative adjective at the other end (i.e., careless at work). Lower scores on this scale represented more negative attitudes. Previous studies (Katz & Shurka, 1977; Kravetz et al., 1994) have uncovered high internal consistency for this scale. Cronbach’s alpha for the overall scale in the current study was .90. Cronbach’s alpha for the subscales ranged from .55 to .82.
Procedure After the Bar-Ilan University Review Board approved the re search protocol, the research questionnaires were administered to the research participants either in groups during classes or indi vidually. The participants were randomly assigned to one of the six conditions of the study, and participants were informed that they were taking part in an assessment of the validity of a new measure that was being developed by the department of psychology.
Results Correlations Among Attitudes Toward Persons With Disabilities and Sociodemographic Variables Correlations were calculated between participants’ background characteristics (sociodemographics and acquaintance) and the at titudes scale scores. The only background variable that was sig nificantly related to the total attitude scale and subscales scores was acquaintance with a person with a physical disability (r ranging from —.16 to —.17). Therefore, this variable was treated as covariate in subsequent analyses. In addition, no significant difference in the frequency of any of the background variables was detected for the two conditions of involvement in sexual relations (yes/no) or between the three conditions of disability (no disability/psychiatric disability/physical disability).
Type of Disability, Involvement in a Sexual Relationship, and Attitudes Toward People With Disabilities In order to assess the contribution of type of disability (no disability/psychiatric disability/physical disability) and sexual in volvement (yes/no) to the attitudes scale total score, a two-way (3 X 2) Analysis of Variance (ANOVA) was carried out. A twoway (3 X 2) Multivariate Analysis of Variance (MANOVA) was also conducted in order to assess the contribution of the same independent variables to the attitude scale’s different subscales scores. When the dependent variable was defined as the total score, no significant main or interactions effects were found. Also, when the five attitude subscales scores were analyzed, significant overall effects were not found for disability, sexuality, or their interaction. However, the following separate ANOVAs for each subscale re
vealed a significant main effect for type of disability for subscales of attitudes regarding personality and attitudes regarding sociality (F = 3.87, d f = 2,188, p < .05, partial p.2 = 0.04; F = 3.41, d f = 2.188, p < .05, partial p.2 = 0.04; respectively). According to post hoc analyses (Scheffé), participants expressed more positive atti tudes in these two domains toward a person with a physical disability (M = 3.62, SD = .53; M = 3.40, SD = .60, for personality and sociality respectively) or without any disability (M = 3.53, SD = .53; M = 3.37, SD = .55, for personality and sociality respectively) compared to a person with a psychiatric disability (M = 3.36, SD = .56; M = 3.16, SD = .55, for personality and sociality respectively). In addition, significant interaction effects between type of dis ability and involvement in sexual relationship were found for the occupation and intelligence attitudes subscales (F = 3.85, d f = 2.188, p < .05, partial fx2 = 0.04; F = 3.08, d f = 2,188, p < .05, partial p,2 = .03; respectively). As can be seen in Table 1, when the person in the vignette was described as having a psychiatric disability, participants expressed more negative attitudes regarding both his occupation and intelligence when he was involved in a sexual relationship than in the condition where he was not. An opposite picture emerged when the fictitious person was described as having a physical disability. This time participants expressed more positive attitudes toward this person’s occupation and intel ligence when he was allegedly involved in a sexual relationship than in the condition where he was not. No differences were found between the two levels of the sexual relationship domain among persons without a disability. Figure 1 and Figure 2 portray these results. The same trend was detected with regard to the other attitude subscales although the differences on these subscales were not statistically significant.
Discussion The main goal of the current study was to assess the putative moderating effect of being involved in a sexual relationship on the association between type of disability and attitudes toward persons with a disability. Based on the existing data in the field, our a priori assumptions were that sexual relationship involve ment would generate more negative attitudes toward people with both psychiatric and physical disabilities with a greater effect for psychiatric disabilities. Results, however, revealed that the difference between psychiatric disabilities and physical disabilities was more complex. It was found that involvement in a sexual relationship generated more positive attitudes when the target person had a physical disability but more negative attitudes when he had a psychiatric disability. Though limited empirical studies have been carried out on attitudes toward the sexual behavior of persons with a psychi atric disability, the assumption that the sexual behavior of such person is considered less legitimate is consistent with studies on attitudes toward the sexual behavior of persons with such other chronic neurological conditions as mental retardation. These stud ies show that the sexual activity of persons with mental retardation was judged as less appropriate than the sexual activity of persons without any disability (Scotti, Slack, Bowman, & Morris, 1996; Wolfe, 1997). Similarly, the present study shows that associating sexual activity with a psychiatric disability strengthens the stigma elicited by the latter disability. Since one source of psychiatric
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Table 1 Means and Standard Deviations of the Attitudes Scores by Disability Type and Sexual Relationship
Attitude No sexual relationship Sexual relationship Total Personality3* No sexual relationship Sexual relationship Total Sociality3* No sexual relationship Sexual relationship Total Occupation0* No sexual relationship Sexual relationship Total Morals No sexual relationship Sexual relationship Total Intelligence“* No sexual relationship Sexual relationship Total 3 Main effect of disability. *p < .05.
Persons without a disability M (SD)
Persons with a physical disability M (SD)
Persons with a psychiatric disability M (SD)
3.46 (.47) 3.40 (.39) 3.42 (.42)
3.41 (.45) 3.55 (.49) 3.47 (.47)
3.36 (.47) 3.24 (.48) 3.29 (.48)
3.56 (.60) 3.51 (.50) 3.53 (.53)
3.53 (.53) 3.73 (.53) 3.62 (.53)
3.40 (.64) 3.34 (.48) 3.37 (.57)
3.46 (.59) 3.31 (.51) 3.37 (.55)
3.39 (.56) 3.40 (.65) 3.40 (.60)
3.26 (.59) 3.10 (.50) 3.16 (.55)
3.34 (.51) 3.36 (.45) 3.35 (.47)
3.28 (.51) 3.52 (.54) 3.39 (.53)
3.35 (.59) 3.10 (.54) 3.21 (.57)
3.57 (.79) 3.49 (.53) 3.49 (.64)
3.50 (.62) 3.64 (.69) 3.56 (.64)
3.52 (.67) 3.45 (.61) 3.48 (.64)
3.40 (.48) 3.43 (.41) 3.42 (.44)
3.50 (.54) 3.64 (.62) 3.56 (.57)
3.53 (.52) 3.24 (.57) 3.38 (.60)
b Interaction effect between sexuality and disability.
related stigma consists of viewing persons with a psychiatric disability as dangerous and unpredictable (Corrigan et al., 2000), narratives that depict such persons as being sexually active may automatically elicit stereotypical attributions of poor judgment, unsafe sex, promiscuity or abuse. The findings of the present study suggest that the spread effect (Wright, 1983) of the sexuality of
persons with a psychiatric disability may be so strong that it affects attitudes toward such different personal characteristics as intelli gence and occupation— characteristics not necessarily related to sex. Sexuality in the context of physical disability, on the other hand, apparently gave rise to the opposite effect. Following the
■ Sexual involvement
■ Sexual involvement
■ No sexual involvement
■No sexual involvement
3 .6 -----------------------------------------------------------------------------
3.7 — ----------------------------------------------------------------------
Without disability
Physical disability Psychiatric disability
Figure 1. The results of the interaction between type of disability and involvement in a sexual relationship in the occupation domain of attitude.
Without disability
Physical disability Psychiatric disabflity
Figure 2. The results of the interaction between type of disability and involvement in sexual relationships in the intelligence domain of attitude.
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HASSON-OHAYON, HERTZ, VILCHINSKY, AND KRAVETZ
model of Juergens et al. (2009b), the current findings suggest that persons with a physical disability who are presented as sexually active convey a message that, (a) they are not that absorbed by their impairments to the degree that sex becomes irrelevant to them; (b) they have opportunities for sexual rela tions; and (c) they are not helpless, childlike, or asexual. Thus, the existence of sexual activity seems to work in favor of people with a physical disability by strengthening their appearance of normality and adaptation, whereas it marginalized persons with a psychiatric disability. Several limitations of the current study should be taken into consideration. First and foremost, the vignettes used only con sisted of a fictitious male. Therefore, no conclusions can be derived from the current finding regarding gender differences. Second, the study sample consisted of only students, further limiting generalizability. Third, the attitudes scale used as sessed attitudes toward functioning in different life domains, but it did not capture such attitudinal dimensions as affect, cognitions, and behaviors (Findler, Vilchinsky, & Werner, 2007). Fourth, only two types of disability, schizophrenia and paraplegia, were examined in the current study. Schizophrenia can be viewed as one of the more stigmatized psychiatric disabilities, while paraplegia may be one of the least stigma tized physical disabilities. Fifth, participants’ knowledge of the heritability of both physical and psychiatric disabilities was not assessed. Therefore, the impact of this knowledge on attitudes could not be controlled for. Finally, the role of the visibility of the disabilities was also not addressed in this study. Future studies should include both genders and additional types of disabilities in the vignettes, use more heterogeneous samples and apply a more multidimensional perspective. Despite these limitations, the current findings should consti tute a contribution to any effort aimed at changing attitudes toward people with disabilities. Educating people with regard to the legitimacy of sexual activity for persons with a psychiatric disability should contribute to reducing misconceptions about mental illness. Presenting persons with a physical disability in the media in the context of dating, initiating, and maintaining friendship and intimate relationships may enhance their public acceptance.
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R eceived A pril 8, 2013 R evision received January 6, 2014 A ccepted January 8, 2014 ■
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