The sexual rights of people with physical and psychical disabilities: attitudes of Italians and socio-demographic factors involved in recognition and denial

: The aims of this study were to analyze the level of agreement of a sample of Italian people with some of the sexual rights (SRs) of people with physical and psychical disabilities (PwPHDs and PwPSYDs), to inquire if PwPSYDs were subject to less recognition than PwPHDs, and if so-cio-demographic characteristics, such as age, sex, education, occupation, geographical origin, relational status, sexual orientation, and religiosity, associated with being against these SRs. The level of agreement or disagreement (on a 6-point Likert scale) with statements regarding the right of PwPHDs and PwPSYDs to have a satisfying sexuality, to marry, to adopt a child, was inquired with an online anonymous questionnaire. 973 participants, aged 18 – 84 years (71.1% females) were considered for analyses; At least 7 out of 10 participants declared in favor of the SRs of PwPHDs, while the SRs of PwPSYDs were always subjected to higher underrecognition. Religiosity almost invariably associated to being against the SRs of PwDs. Being male, of higher age and lower education also associated with lower recognition. A better identification of the less tolerant respondents and of the less recognized categories may allow for specific strategies for promoting the recognition of the SRs for PwDs.

and incitement to violence against gay, lesbian, transgender and PwDs [28]. Our previous study indicated that SRs are less recognized in minorities such as LGB people [29]. As far as we know, no recent studies in Italy inquired the societal level of agreement with the SRs of PwPHDs and PwPSYD, or the socio-demographic predictors of a more unfavourable attitude.
The aim of this study was therefore to analyze the level of agreement of the Italian general population with the SR of PwPHDs and PwPSYDs to have a satisfactory sexuality, to marry and to adopt a child, and to evaluate whether the SR of PwPSYDs were subject to less recognition, compared to PwPHDs. Further objective was to better understand which socio-demographic characteristics of Italian people significantly associated with lower agreement with the SR for PwPHDS and PwPSYDs.

Study design and description
The data reported in this paper is extracted from a larger, original study which cross-sectionally investigated attitudes of Italian people regarding the right of particular minorities or demographic categories (i.e. heterosexual, homosexual, bisexual and transsexual men, women or couples; PwPHDs; PwPSYDs, minors; seniors; sex-workers) to have a satisfying sexuality, to marry, to adopt children, to be hired for any job and to be free to live their sexuality [30].
The study was approved by the Scientific Committee of the Italian Federation of Scientific Sexology (FISS) and carried out in cooperation between the Youth Section of FISS (FISS Youth) and the Youth Initiative Committee of the World Association of Sexual Health (WAS YIC). An internet-based anonymous questionnaire was developed with Google Forms (Google LLC, Mountain View, CA, USA) to collect information related to socio-demographic data of respondents and level of agreement with statements related to the abovementioned SRs.
The questionnaire was distributed through the main social media by all the authors and by colleagues affiliated with their associations, through a snowball sampling approach, and published on the website of the Italian Federation of Scientific Sexology (www.fissonline.it). The first page of the form presented the proponent Institutions, explained the rationale, objectives and contents of the survey, and advised that the survey was reserved exclusively for people aged 18 or over. 'I agree' or 'I do not agree' options on the first page of the questionnaire were used in lieu of a signature, to provide informed consent. People who did not accept to participate were redirected to the last page of the form and thanked for their potential interest, while those who accepted accessed the survey.

Inclusion/exclusion criteria
The questionnaire was designed to be proposed to the entire Italian adult population. Therefore, the only criterion for inclusion/exclusion was having reached the age of majority, in accordance with Italian laws.

Specific contents of the questionnaire
Two main kinds of information were considered: (a) socio-demographic information: age in years (categorized in three groups of comparable size) ; biological sex (female, male); education (undergraduated, graduated, post-graduated); region of origin (open question, which was recoded in coming from North, Center or South-Islands); occupational status (student, employed or unemployed/retired); sexual orientation (completely heterosexual, mostly heterosexual, bisexual, mostly homosexual and completely homosexual, which was recoded in 'completely or not-completely heterosexual'); relational status (single, in a committed relationship, cohabiting with a partner, married); religiosity (non-believer, believer, practicing); kind of religion (multiple choice with free field to enter non-prefilled data).
(b) the level of agreement with the right for PwPHDs, and PwPSYDs to have a satisfying sexuality, to marry and to adopt children, coded on a 6-point likert-type scale, (1 = complete disagreement; 2 = moderate disagreement; 3 = mild disagreement; 4 = mild agreement; 5 = moderate agreement; 6 = complete agreement). In order to prompt to a stance, it was not possible to express intermediate opinions between agreement and disagreement or to avoid answering one or more questions.

Statistical analyses
All analyses were performed with IBM SPSS version 20 (SPSS Inc. Chicago, IL, USA). Descriptive analyses included calculation of the mean ± standard deviations for continuous variables, and absolute frequencies and percentages for categorical ones. The Shapiro-Wilk test was performed in order to evaluate the normality of distributions.
Since answers to most questions about SRs were highly skewed towards higher scores, the Wilcoxon matched pairs test was used to compare, the levels of agreement with the right of PwPHDs and PwPSYDs to each SR.
Multiple ordinal regression models failed to respect the assumption of proportional odds, due to a large number of empty cells. Therefore, answers to questions related to the SRs were dichotomized (a score of 1, 2 or 3 was classified as "disagreement" and a score of 4, 5, 6 as "agreement") and multiple binary logistic regression analyses were conducted to identify those socio-demographic variables which associated with "agreement" with each SR for PwPHDs and PwPSYDs, taking "disagreement" as a reference. Values were expressed as odds ratio (OR) and 95% confidence intervals (95% CI).
The level of significance was established at 95% (p < 0.05) for all statistical analyses.
In order to exclude multicollinearity, the Variance Inflation Factor (VIF) was calculated for each predictor. Dummy variables were obtained from non dicothomous ones and calculated by selecting for reference the most prevalent category. A VIF greater than 2.5 (which corresponds to an R² of .60) was considered indicative of multicollinearity.

Descriptives
One thousand and seven out of 1015 people who had accessed the questionnaire provided informed consent to the research. Of these, 34 (3.4%) were excluded from further analyses because they belonged, were born, or resided in countries other than Italy.
The analyzed sample was therefore composed of 973 participants, aged between 18 and 84 years (mean age: 35.5 ±11.7; median age: 33.0). More than two thirds of them were female (71.1%) and people under 40 (70.5%). Middle-aged and seniors (people over 50) represented 12.4% of the sample. Graduates and post-graduates constituted 65.9% of the sample, which was made for 29.3% by Medical Doctors or Psychologists. Demographics are shown in detail in table 1. Four-hundred and eighty-two out of 509 participants declaring themselves non-atheists were catholics (94.6%), therefore, due to the low presence of non-catholic responders, 'kind of religion' was excluded from potential predictors of 'agreement'.

Percentages of agreement and comparison between PwPHDs and PwPSYDs
Overall, more than 85% of the sample declared in agreement with the SR of PwDs to have a satisfactory sexuality (Graph 1). Only 1.1%, 1.4%, and 2.4% of participants answered being completely, moderately or mildly opposed to this SR for PwPHDs, while 4.1%, 8.9% and 82.0% declared mildly, moderately or completely in favor. A slightly lower number of respondents expressed complete, moderate or slight agreement with the right of PwPSYDs to have a satisfactory sexuality (63.4%, 11.4%, and 10.8%, respectively), while 7.9%, 2.8% and 3.7% were mildly, moderately or completely opposed.
The Wilcoxon Signed-Ranks Test indicated that the median ranks for PwPHDs were statistically significantly higher than the median ranks for PwPSYDs (Z = 13.04 p < .001).

Socio-demographic variables associated with agreement with PwPHDs's right to have a satisfactory sexuality
The results of the univariate logistic regression analyses suggested the existence of an association between demographics, such as sex, education, occupation and relational status, and agreement with the SR of people with PhD to have a satisfactory sexuality (table 2), while the multiple logistic regression analysis, indicated that only positive associations between 'agreement' and sex were maintained, when taking into account other potential predictors. Women agreed in significantly higher percentages than men (96.1% vs 92.5%) with the right of PwPHDs to have a satisfying sexuality (O.R. = 2.11; 95% C.I.: 1.11 -4.01; p = 0.022).

Socio-demographic variables associated with agreement with PwPSYDs's right to have a satisfactory sexuality
The results of the univariate logistic regression analyses suggested the existence of an association between agreement with the SR of people with PSYDs to have a satisfactory sexuality and sex, religion, regional origin, occupational status, relational condition and level of education (table 2). Most of these associations maintained statistical significance in the multivariate model. In particular, being female, atheist, graduated, employed or student and living with a partner were related to higher odds for agreement than being male (O.R. = 1.55; 95% C.I.

Percentages of agreement and comparison between PwPHDs and PwPSYDs
Overall, 98.3% participants declared in agreement with the right of PwPHDs to marry, while 78.7% of them answered being favourable to marriage for PwPSYD (Graph 1). In particular, 88.8% participants expressed strong agreement with the possibility fot PwHDs to get married, while 6.7% and 2.8% declared moderately and mildly in favour, and only 1.7% expressed disagreement. A noticeable lower number of respondents expressed complete, moderate or slight agreement with the right of PwPSYDs to marry (51.1%, 11.9%, and 15.7%, respectively), while 11.3%, 4.7% and 5.2% were mildly, moderately or completely opposed (Graph 1).
The Wilcoxon Signed-Ranks Test indicated that the median ranks for PwPHDs were statistically significantly higher than the median ranks for PwPSYDs (Z = 17.85 p < .001). 3.3.2. Socio-demographic variables associated with agreement with PwPHDs's right to get married

Socio-demographic variables associated with agreement with PwPHDs's right to get married
The results of the logistic regression analyses are to interpret with caution, due to the extremely low number of people against marriage for PwPHDs in our sample (Table 3). Atheists/agnostics agreed in significantly higher percentages than churchgoers (99.6% vs 95.9%) with the right of PwPHDs to marry, and a positive significant association seemed to exist between 'agreement' and religiosity in multiple regression analysis (O.R. = 7.22; 95% C.I.: 1.32 -39.62; p = 0.023).

Socio-demographic variables associated with agreement with PwPSYDs's right to get married
The results of the univariate logistic regression analyses suggested the existence of an association between agreement with the SR of people with PSYDs to marry and all considered predictors, with the exception of provenance (table 3). Most of these associations maintained statistical significance in the multivariate model. In particular, being female, atheist/agnostic, post-graduated, student and non (completely) heterosexual were related to higher odds for agreement than being male

Percentages of agreement and comparison between PwPHDs and PwPSYDs
The SR of PwDs to adopt a child encountered the agreement of 71.7% of the sample, while 21.8% of respondents declared being favourable all'adozione di un bambino da parte delle PwPSYDs (Graph 1). 5.1%, 3.1%, and 10.1% of participants answered being completely, moderately or mildly opposed to this SR for PwPHDs, while 14.7%, 17.9% and 49.1% declared mildly, moderately or completely in favor. A noticeable lower number of respondents expressed complete, moderate or slight agreement with the right of PwPSYDs adopt (6.0%, 3.5%, and 12.3%, respectively), while 21.1%, 19.7% and 37.4% were mildly, moderately or completely opposed.
The Wilcoxon Signed-Ranks Test indicated that the median ranks for PwPHDs were statistically significantly higher than the median ranks for PwPSYDs (Z = 24.57 p < .001).

Socio-demographic variables associated with agreement with PwPHDs's right to adopt a child
The results of the univariate logistic regression analyses suggested the existence of an association between education, religiosity, sexual orientation and relational status, and agreement with the SR of people with PhD to adopt a child (table 4). In the multiple logistic regression analysis, indicated that positive associations were maintained between 'agreement' and education and sexual orientation, when taking into account other potential predictors. Post-graduates and non (completely) heterosexuals agreed in significantly higher percentages than undergraduates (O.R. = 1.84; 95% C.I.: 1.14 -2.98; p = 0.013) and heterosexual people (O.R. = 2.03; 95% C.I.: 1.26 -3.27; p = 0.004) with the right of PwPHDs to adopt a child.

Socio-demographic variables associated with agreement with PwPSYDs's right to adopt a child
The results of the univariate logistic regression analyses suggested the existence of an association between agreement with the SR of people with PSYDs to adopt a child and age, sexual orientation religion, and level of education (table 4). These two latter maintained statistical significance in the multivariate model. Indeed, being post-graduated and atheist/agnostic were related to higher odds for agreement than being undergraduated (O.R. = 1.97; 95% C.I.: 1.26 -3.08; p = 0.003), or churchgoer (O.R. = 2.28; 95% C.I.: 1.3 -3.99; p = 0.004).  Figure 1. Distribution of responses inquiring agreement with the sexual rights of people with physical disabilities (PHDs) and Psychical disabilities (PSYDs) to have satisfactory sexuality, to get married, and to adopt a child. The light gray columns with black labels represent the agreement responses. The dark gray columns with white labels represent the disagreement responses. Labels are presented only for response options chosen by at least 2% of participants.

Discussion
To our knowledge, this is the first published research to inquire the levels of agreement with the SRs of PwDs in the Italian general population and the socio-demographic variables which may associate to positive or negative attitudes. The results of this study indicate that in very large majority Italians declared themselves in agreement with the right of PwPHDs to have a satisfactory sexuality and to marry, and mostly inclined to express agreement with their right to adopt a child, albeit to a lesser extent. Consistent to other research, the percentage of people who disagreed with these SRs when related to PwPSYDs was significantly higher [9], reaching almost 80% for adoption. Indeed, sexuality of PwPSYDs was foud to be judged as less appropriate than that of persons without any disability or with physical disabilities, since PwPSYDs elicit stereotypes of inability of judgment and control, impredictability and danger, resulting in false beliefs about unsafe sex, promiscuity or abuse [9].
Coherently with other studies [16,17], Italians' views about adoption in both categories of PwDs were more unfavourable than for sexuality and marriage, confirming that participants considered this aspect to be more complex and to perhaps have implications beyond the mere SRs of the individuals and requires abilities that many would judge to be beyond those of PwDs, and, in particular, of PwPSYDs. Differently to another study by Cuskelly and Gilmore [16], who had observed less favorable, yet still substantially positive, attitudes about parenting in PwPSYDs, Italian respondents declared themselves for the most tendentially or completely opposite to adoption by PwPSYDs. This difference could also be amplified by the fact that the present research requires a specific opinion on adoption and not on the general possibility of being parents.
Consistent with other research, women appeared to be more supportive of PwDs' SR to have a satisfactory sexuality and of PwPSYDs' SR to marry than men, while no differences between genders were observed in relation to parenting [20,21].
Regarding socio-demographic variables, our data revealed that religion was a strong predictor of negative attitudes in relation to the SRs of PwDs, with churchgoers as the most uncompromising category. Indeed,religious culture, with a "religious ethical model" has contributed in the past to the structuring of "false myths" about disability, supporting the opinion that a disabled body or mind is an indication of an inner (moral) ugliness (sin); therefore, the myth of a physical perfection that recalls purity and divine goodness, of very ancient memory, is very often found at the basis of prejudices on the causes of the impairment [6].
We found also a relationship between the level of education and the presence of agreement in relation to the SRs of the PwDs. In general, we observed that undergraduates tended to express more disagreement than graduates and post-graduates with SRs of PwDs. However, post-graduate people also tended to agree to a greater extent than undergraduates, albeit to a lesser extent than graduates. This trend can be explained by considering that, in our sample, medical doctors and psychologists represented up to 44.4% of post-graduates. Other research revealed that students and professionals who had frequent contact with PwPSYDs generally had more negative attitudes compared to those who had less experience with them [31].
In most comparisons we observed that the proportion of people in agreement with the SRs of the PwDs decreased with increasing age. However, in most univariate and multivariate analyses age did not appear to be a significant predictor of agreement, contrary to what has been reported in some literature which indicated age as an important predictor of negative attitudes towards the sexuality of PwD and in particular of those with intellectual disabilities. In any case, it is necessary to consider that our sample was mainly constituted by young people. Therefore, middle-aged and elderly people could be under-represented.
Sexual orientation was significant in predicting attitudes towards marriage and adoption, with not completely heterosexuals agreeing in a significantly higher percent-age than heterosexuals (88.5% vs 75.5%) to these SRs. To our knowledge, there are no other studies that have investigated sexual orientation as a predictor for the SRs of PwDs. We can hypothesize that, given that in the period in which the survey was administered the question of the "Zan" law was much debated, non-heterosexual people were also much more sensitive to the issues of legitimizing unconventional couples or parenting for minorities.

Conclusions
Although its limitations, this study has important implications regarding PWDs' SRs in Italy. Firstly, even if quite positive opinions were expressed in most answers, important work is needed to overcome the cultural barriers that prevent PwDs from fully exercising their rights, in particular the right to adopt. Second, it was confirmed that PwPSYDs are the most discriminated. Actions are needed to overcome the prejudice and stigma towards them. Lastly, evidence is shown that certain characteristics of the population strongly affect the level of recognition of PwDs' SRs, in particular having strong religious beliefs is related to lower recognition. Other research demonstrated that specific training on sex and disability can lead to more positive attitudes related to their SRs [20]. For this reason, it is necessary to work specifically on populations with the highest risk factors for uncompromising attitudes, focusing efforts where possible on improving knowledge and overcoming stereotypes based on fears and ignorance. The normalization sexuality in disability should also be pursued through policies to disseminate correct and realistic knowledge.