Archives of Sexual Behavior, Vol. 4, No. 6, 1975
Rehabilitation Professionals and Sexual Counseling for Sphlal Cord Injured Adults Theodore M. Cole, M.D., 1 and Maureen R. Stevens, B.S. 1
The Michigan Rehabilitation Association (M.R.A.) and the Program in Human Sexuality o f the University o f Minnesota collaborated to produce a 1-day seminar on sexual function in spinal cord injury. Evaluation o f the participants and the seminar showed that the program was beneficial for most and harmful for few. Questionnaire responses indicated that f e w M.R.A. members are currently doing sexual counseling but many see an opportunity to do so. A relationship appeared between those who have received some form o f training in sexual counseling and those who are doing counseling with clients. It is postulated that frank and sincere discussion o f sexuality may improve rapport between client and counselor. However, before such an interaction can comfortably take place, the counselor may gain from an opportunity to examine his or her own attitudes toward human sexuality and gather more information about the sexuality o f physically disabled adults. KEY WORDS: rehabilitation; spinal cord; sexual counseling; pornography.
INTRODUCTION Although proponents of rehabilitation assert that they are interested in the total person, sexuality is one area where needs are largely unmet. Very little has been written in the rehabilitation literature about the sexuality of the physically disabled. Yet sexuality is a vital aspect o f living, whether in the nuclear family or in society at large.
This study was supported in part by Rehabilitation Research and Training Center Grant No. RT-2, Social and Rehabilitation Services, Department of Health, Education, and Welfare, Washington, D.C., the Bush Foundation, The Commonwealth Fund, and the University of Minnesota Medical School. 1Department of Medicine, University of Minnesota, Minneapolis, Minnesota. 631 © 1 9 7 5 P l e n u m Publishing C o r p o r a t i o n , 2 2 7 West 1 7 t h Street, New Y o r k , N . Y . 1 0 0 1 1 . NO part o f t h i s p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a retrieval s y s t e m , or t r a n s m i t t e d , in a n y f o r m or by a n y means, e l e c t r o n i c , m e c h a n i c a l , p h o t o c o p y i n g , m i c r o f i l m i n g , recording, o r o t h e r w i s e , w i t h o u t w r i t t e n permission o f the p u b l i s h e r .
632
Cole and Stevens
Psychosexual needs and family relationships are among the constellation of clients' needs and problems with which the counselor must deal. Other psychosocial aspects of the life sphere that the National Rehabilitation Counseling Association (1971) lists as being of concern to the counselor are the clients' desires, attitudes, ego strength, motivation, and social skills. It seems self-evident that these characteristics both help define sexuality and are in turn defined by sexuality. Erosion of the psychological concept of manhood, which is common among spinal cord injured and other physically handicapped males, frequently leads to depression, lowered self-esteem, and other destructive reactions that hinder rehabilitation efforts (Siller, 1969). Concepts of womanhood are equally important for the female client. Recognizing this need, the Michigan Rehabilitation Association (M.R.A.), in a 1-day experiment, pioneered a method of sex education for its membership. Faculty of the Program in Human Sexuality of the University of Minnesota Medical School were invited to present a 7-hr program on "Sexuality and Spinal Cord Injury" to the annual conference of the M.R.A. This article summarizes the data collected from that program and discusses some implications for clients and rehabilitation personnel.
METHOD The sexuality seminar was attended by 275 conference participants, about 39% of the total M.R.A. membership. These included personnel from the state rehabilitation agencies, regional offices, and private agencies, as well as people who use these services. Within each regional office, the opportunity to attend the M.R.A. annual convention, and thus the sexuality seminar, was extended to approximately 50% of the personnel. Using a format of talks, discussions, and movies, the M.R.A. seminar dealt with sexual material that became more explicit as the day progressed. Content began with simple nudity and went through fantasy, masturbation, and the physiology of sexual function in spinal cord injured adults. During the afternoon, a panel of three paraplegic or quadriplegic men and their able-bodied partners discussed with the audience their own sexual adjustments. This was followed by more movies dealing with explicit heterosexual activity and a lecture and movie on some of the behavioral aspects of sexual function in the spinal cord injured. Small groups were then formed to evaluate individual reactions to the program and its applicability to rehabilitation counseling. Summaries from the small groups were shared with all participants by utilizing small group leaders as a reactor panel. Evaluation was done by a questionnaire completed prior to the seminar and another filled out immediately after its conclusion.
Sexual Counseling for Spinal Cord Injured Adults
633
RESULTS
Seventy-seven percent of those attending the seminar, or 213 participants, completed preseminar questionnaires: 126 men and 87 women. Twenty-five participants were disabled by paraplegia, quadriplegia, polio, or multiple sclerosis or had visual or hearing losses. Fourteen persons classified themselves as administrators, secretaries, or others with no client counseling contact. Since we were interested only in those who have contact with a client which might include counseling, these 14 questionnaires were not tabulated further. The job titles of the remaining 199 respondents who did correctly complete the questionnaires suggested that they could potentially do sexual counseling in their professional roles. These respondents classified themselves in the following helping professions: 142 counselors, nine social workers, eight nurses, seven psychologists, six occupational therapists, two physicians, one speech therapist, one clergy, and 23 others. When participants were asked if sex counseling was expected of them in their work, 146 said no, 50 said yes, and 14 said it was inappropriate to their work. But when asked if they saw opportunities for sex counseling with their clients, 140 said yes and 73 said no. When asked if they actually did sexual counseling with their clients, 138 said no, 61 said yes, and 14 said it was inappropriate to their work. Figure 1 shows that of the 50 respondents who stated that they are expected to do sexual counseling in their work, 13 nonetheless said they are not doing it. Of the 146 who are not expected to do sexual counseling, 63 see the opportunity to do so but do not. Another 59 neither see the opportunity nor do any sexual counseling. Twenty-four respondents said that not only do they see the opportunity to counsel clients in the sexual area but also they do it even though it is not expected of them. When asked the reasons for not doing sexual counseling, 53 answered that it was not their agency's policy to do so. Forty-nine said that they had insufficient knowledge, and 23 said that time did not permit such counseling. Eight said they were personally uncomfortable with the subject, and five felt that sexual counseling was not that important. Since sex, age, and prior training of the counselor might be postulated as determinants of whether or not he perceived a need for or engaged in sexual counseling, these aspects were examined. When males were compared to females, no differences were found. Twenty-nine percent of both males and females were doing sexual counseling. Age did not make a significant difference. Of those under 36 years of age, 30% were doing sexual counseling, while of those 36 years or older, 28% were doing such counseling. The participants were asked to categorize their training for initiating counseling in sexual matters with clients. Ninety-five respondents said they had no
Cole and Stevens
634
training. The remainder said they had received training in one or more ways. Forty-two said they had done special reading, and 41 described themselves as self-taught. Twenty-seven reported that they had been professionally trained and 17 had attended specific training courses. A relationship was found when comparisons were made between those who consider themselves trained in some fashion and those who are counseling clients about their sexuality (see Table I). Fifty-one people who considered themselves as having had some training were doing some counseling with clients in the area of sexuality. But of the t99 respondents, only ten who consider themselves essentially untrained were doing any counsefing. The seminar ended late in the afternoon after the small discussion groups, and many people left immediately. A second evaluation was completed by those who remained. Only 132 people, or 49% of those completing the preseminar questionnaire, completed the 2-page postseminar evaluation. One hundred twenty-six, or 95%, reported that the seminar was beneficial or somewhat beneficial to them personally; seven people, or 5%, reported that it was not beneficial; 128 people, or 97%, reported that the 1-day experience was not harmful to them; while four people, or 3%, reported that they believed it was harmful or somewhat so. Although only 3% felt that the experience was harmful to them220-
-220
Inappropriate 2 0 0 - - Not--Answered - -
-200
180-
-180
160 -
Not E x p e c t e d
160
140-
to Counsel
140 120
12010080-
////
/'
....
.' ' '
~ //
20-
80
,I
-60
6040-
q00
Do See
Expected to Counsel
0
Expectation
I
~, . . . . . .
/
//z'/',J
,. /
/'/
i¢
Do C o ~ n ~ , / ,
L/r
~, ? ' / / / ' l / / / / / /
~/
]
'1
/ / / , 'j
Performance
-40
,I
Do
See
See
-20 ,0
Opportunity ?
Fig. 1. Number of those expected to counsel clients in sexuality compared to the number who do counseling and the number who see opportunity to counsel. See text for explanation.
Sexual Counseling for Spinal Cord Injured Adults
635
Table I. Number of Those Trained in Sexual Counseling Compared to the Number Who Do Counseling Do you do sexual counseling with clients?
Have you been trained in any way to do sexual counseling?
Yes No Not answered
Yes
No
51 10 --
41 85 7
Not answered 1 1 3
Selves, 28 of the 122 who answered the question, or 23%, said they felt it may have been harmful to others at the seminar. The participants were also asked to report what they would do differently if they were to implement some of the ideas gained from the seminar. Responses were placed into like categories, and the preponderant opinions fell into one of two categories. Most respondents would either initiate discussions of sexuality with their clients or be more aware and open to sex-related aspects of the clients' rehabilitation problems or program. Of those responding, 111 of 128 people, or 87%, stated that they felt a program like the 1-day seminar presented to the M.R.A. should be part of the professional training of a rehabilitation professional, while 17, or 13%, had reservations or were opposed to this idea. Since all of the information on which this report is based was gathered on the day of the seminar, there can be no assurance that the participants are now doing counseling that they were not doing previously. However, attitude change often precedes behavioral change. Since a majority were not counseling, and the majority reported that they would initiate discussion and be more aware in order to implement ideas gained, with 87% stating that they believed such a program should be part of the training of a rehabilitation professional, it seems reasonable to assume that some attendees are now asking new questions and exploring new avenues.
DISCUSSION The necessity for research into unmet but relevant needs of clients and the application in practice of appropriate research findings were underscored by the National Rehabilitation Association (1971). Data such as those reported here have relevance for rehabilitation workers and agencies. The information gathered does not support the hypothesis that one sex more than the other is inclined to engage in sexual counseling. Nor does it confirm the notion that sexual counseling is more likely to be undertaken by younger people than by older.
636
Cole and Stevens
Our tabulations suggest that counseling is much more likely to be undertaken by a rehabilitation professional who feels he or she has had some training in sexual counseling. Of those who are doing some counseling, five times as many consider themselves as having had some training as consider themselves without training. A natural selection process may be operating here. Those who are inclined to do counseling by nature of their personalities and interests may be the same people who seek out training. On the other hand, of those responding to our questionnaire, 10% who consider themselves untrained currently are engaging in some form of sexual counseling with clients. Therefore, the absence of training in sexual counseling does not totally inhibit rehabilitation personnel from attempting to do sexual counseling. Siller (1969) believes that the anxieties evoked by the concepts of sexuality are tremendously important to rehabilitation. The disturbing question that the client may continue to ask himself or herself is "Can I perform sexually?" This question may then be transformed by many into the basic psychological problems of "Am I a man?" and "Am I a woman?" Should the client feel that he or she is not sufficiently manly or womanly, and thus lower his or her self-esteem, other destructive actions resulting from such doubts may retard or abort otherwise appropriate and hopeful vocational rehabilitation efforts. Skipper et al. (1968) emphasize the similarities between men and women. Just as disabled men have important family ties which greatly affect their rehabilitation, so do women, married or unmarried. McPhee et al. (1963) and Litman (1964) have stressed the importance and relationship of family solidarity to the motivation of the disabled to pursue rehabilitation goals. Indeed, in order to maximize the rehabilitation outcome, the entire pattern of life style and preference must be dealt with. Guidance in this effort should be augmented by applied research into the sexuality of the physically disabled. Some in the field of rehabilitation, recognizing the need to consider clients' sexuality, have indicated some ofthe problems involved. Anxieties created within the rehabilitation personnel may compound the clients' problems of altered attitudes and abilities of sexual expression. According to Frankel (1967) rehabilitation personnel not infrequently feel concern, anxiety, fear, and a vague distress when patients talk about sex. The personal discomfort of the worker, inadequate academic preparation, agency restrictions, and the simple fact that human sexuality is an emotionally loaded topic all contribute to uneasiness on the part of rehabilitation personnel as well as others. The counselor's attitudes of comfort or discomfort, approval or disapproval, may be apparent and perceived by the client. The counselor may find himself or herself in a sensitive position. A judgmental posture or overreaction to the client's attempt to gain sexually related information may seal off that topic to any further discussion. The client may pick up the unspoken message that he or she is to go home and return only when there is an acceptable complaint. If
Sexual Counseling for Spinal Cord Injured Adults
637
the counselor is aware of this potential occurrence, he or she should ask if personal attitudes are enabling or prohibitive to the client. By unwillingness or inability to deal with the client's sexuality, is the counselor in effect adding a new disability to those the client already has? An interdisciplinary method of dealing with sexuality and physical disability has been described by Romano and Lassiter (1972). They employed a physician specializing in physical medicine to "review" anatomy and physiology with groups of disabled men and women. Such "review" actually served to cover existing gaps in knowledge in a noncondescending manner for people who might otherwise have been reluctant to admit to their lack of information. Common vernacular as well as technical language was used to help open doors to effective communication. After the physician had covered the basic physiological questions, social workers in the program continued working with groups to help people deal effectively with their own altered and/or developing sexuality. This interdisciplinary approach exemplifies one method that some rehabilitation counselors might wish to use when they have recognized the need for counseling in sexuality. Others might prefer to augment, if necessary, their own medicalphysical knowledge and work with the client by themselves. Rehabilitation workers who have had little experience in dealing with sexually related materials in their training probably do not generally expect their clients to express sexual problems. According to Frankel (1967), didactic course work or even field work seldom provides rehabilitation personnel with adequate guidelines for action. In addition, the policy of the agency may limit the scope of the worker's participation. This view was reported by many of the respondents answering questionnaires at the Michigan Rehabilitation Association's 1972 annual convention. Only a small percentage of the M.R.A. personnel are involved in sexual counseling, and a large percentage feel that counseling in human sexuality is not an expected part of their work. Since many rehabilitation personnel see opportunities for sexual counseling, yet are not expected to do such counseling, there may be a large area of need recognized but not treated.
REFERENCES
Frankel, A. (1967). Sexual problems in rehabilitation. J. Rehab. 32-33: 19-20. Hohmann, G. W. (1972). Considerations in management of psychosexual readjustment in the cord injured male. Rehab. Psychol. 19: 50-58. Litman, J. (1964). An analysis of the sociological factors affecting the rehabilitation of physically handicapped patients. Arch. Phys. Med. 45: 9-16. McPhee, W. M., Griffiths, K. A., and Mayleby, F. L. (1963). Adjustment of Vocational Rehabilitation Clients, Final Report, ~rRA Grants No. 178 and No. 757, University of Utah. National Rehabilitation Counseling Association (1971). Definition of role and functions of the rehabilitation counselor. Conference Proceedings, December 1-3, Washington, D.C.
638
Cole and Stevens
Romano, M. D., and Lassiter, R. E. (1972). Sexual counseling with the spinal cord injured. Arch. Phys. Med. 53: 568-575. Siller, J. (1969). Psychological situation of the disabled with spinal cord injuries. Rehab. Lit. 30: 290-296. Skipper, J. K., Jr., Fink, L , and Hallenbeck, P. N. (1968). Physical disability among married women: Problems in the husband-wife relationship. J. Rehab. 34: 16-19.
Rehabilitation Professionals and Sexual Counseling for Sphlal Cord Injured Adults Theodore M. Cole, M.D., 1 and Maureen R. Stevens, B.S. 1
The Michigan Rehabilitation Association (M.R.A.) and the Program in Human Sexuality o f the University o f Minnesota collaborated to produce a 1-day seminar on sexual function in spinal cord injury. Evaluation o f the participants and the seminar showed that the program was beneficial for most and harmful for few. Questionnaire responses indicated that f e w M.R.A. members are currently doing sexual counseling but many see an opportunity to do so. A relationship appeared between those who have received some form o f training in sexual counseling and those who are doing counseling with clients. It is postulated that frank and sincere discussion o f sexuality may improve rapport between client and counselor. However, before such an interaction can comfortably take place, the counselor may gain from an opportunity to examine his or her own attitudes toward human sexuality and gather more information about the sexuality o f physically disabled adults. KEY WORDS: rehabilitation; spinal cord; sexual counseling; pornography.
INTRODUCTION Although proponents of rehabilitation assert that they are interested in the total person, sexuality is one area where needs are largely unmet. Very little has been written in the rehabilitation literature about the sexuality of the physically disabled. Yet sexuality is a vital aspect o f living, whether in the nuclear family or in society at large.
This study was supported in part by Rehabilitation Research and Training Center Grant No. RT-2, Social and Rehabilitation Services, Department of Health, Education, and Welfare, Washington, D.C., the Bush Foundation, The Commonwealth Fund, and the University of Minnesota Medical School. 1Department of Medicine, University of Minnesota, Minneapolis, Minnesota. 631 © 1 9 7 5 P l e n u m Publishing C o r p o r a t i o n , 2 2 7 West 1 7 t h Street, New Y o r k , N . Y . 1 0 0 1 1 . NO part o f t h i s p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a retrieval s y s t e m , or t r a n s m i t t e d , in a n y f o r m or by a n y means, e l e c t r o n i c , m e c h a n i c a l , p h o t o c o p y i n g , m i c r o f i l m i n g , recording, o r o t h e r w i s e , w i t h o u t w r i t t e n permission o f the p u b l i s h e r .
632
Cole and Stevens
Psychosexual needs and family relationships are among the constellation of clients' needs and problems with which the counselor must deal. Other psychosocial aspects of the life sphere that the National Rehabilitation Counseling Association (1971) lists as being of concern to the counselor are the clients' desires, attitudes, ego strength, motivation, and social skills. It seems self-evident that these characteristics both help define sexuality and are in turn defined by sexuality. Erosion of the psychological concept of manhood, which is common among spinal cord injured and other physically handicapped males, frequently leads to depression, lowered self-esteem, and other destructive reactions that hinder rehabilitation efforts (Siller, 1969). Concepts of womanhood are equally important for the female client. Recognizing this need, the Michigan Rehabilitation Association (M.R.A.), in a 1-day experiment, pioneered a method of sex education for its membership. Faculty of the Program in Human Sexuality of the University of Minnesota Medical School were invited to present a 7-hr program on "Sexuality and Spinal Cord Injury" to the annual conference of the M.R.A. This article summarizes the data collected from that program and discusses some implications for clients and rehabilitation personnel.
METHOD The sexuality seminar was attended by 275 conference participants, about 39% of the total M.R.A. membership. These included personnel from the state rehabilitation agencies, regional offices, and private agencies, as well as people who use these services. Within each regional office, the opportunity to attend the M.R.A. annual convention, and thus the sexuality seminar, was extended to approximately 50% of the personnel. Using a format of talks, discussions, and movies, the M.R.A. seminar dealt with sexual material that became more explicit as the day progressed. Content began with simple nudity and went through fantasy, masturbation, and the physiology of sexual function in spinal cord injured adults. During the afternoon, a panel of three paraplegic or quadriplegic men and their able-bodied partners discussed with the audience their own sexual adjustments. This was followed by more movies dealing with explicit heterosexual activity and a lecture and movie on some of the behavioral aspects of sexual function in the spinal cord injured. Small groups were then formed to evaluate individual reactions to the program and its applicability to rehabilitation counseling. Summaries from the small groups were shared with all participants by utilizing small group leaders as a reactor panel. Evaluation was done by a questionnaire completed prior to the seminar and another filled out immediately after its conclusion.
Sexual Counseling for Spinal Cord Injured Adults
633
RESULTS
Seventy-seven percent of those attending the seminar, or 213 participants, completed preseminar questionnaires: 126 men and 87 women. Twenty-five participants were disabled by paraplegia, quadriplegia, polio, or multiple sclerosis or had visual or hearing losses. Fourteen persons classified themselves as administrators, secretaries, or others with no client counseling contact. Since we were interested only in those who have contact with a client which might include counseling, these 14 questionnaires were not tabulated further. The job titles of the remaining 199 respondents who did correctly complete the questionnaires suggested that they could potentially do sexual counseling in their professional roles. These respondents classified themselves in the following helping professions: 142 counselors, nine social workers, eight nurses, seven psychologists, six occupational therapists, two physicians, one speech therapist, one clergy, and 23 others. When participants were asked if sex counseling was expected of them in their work, 146 said no, 50 said yes, and 14 said it was inappropriate to their work. But when asked if they saw opportunities for sex counseling with their clients, 140 said yes and 73 said no. When asked if they actually did sexual counseling with their clients, 138 said no, 61 said yes, and 14 said it was inappropriate to their work. Figure 1 shows that of the 50 respondents who stated that they are expected to do sexual counseling in their work, 13 nonetheless said they are not doing it. Of the 146 who are not expected to do sexual counseling, 63 see the opportunity to do so but do not. Another 59 neither see the opportunity nor do any sexual counseling. Twenty-four respondents said that not only do they see the opportunity to counsel clients in the sexual area but also they do it even though it is not expected of them. When asked the reasons for not doing sexual counseling, 53 answered that it was not their agency's policy to do so. Forty-nine said that they had insufficient knowledge, and 23 said that time did not permit such counseling. Eight said they were personally uncomfortable with the subject, and five felt that sexual counseling was not that important. Since sex, age, and prior training of the counselor might be postulated as determinants of whether or not he perceived a need for or engaged in sexual counseling, these aspects were examined. When males were compared to females, no differences were found. Twenty-nine percent of both males and females were doing sexual counseling. Age did not make a significant difference. Of those under 36 years of age, 30% were doing sexual counseling, while of those 36 years or older, 28% were doing such counseling. The participants were asked to categorize their training for initiating counseling in sexual matters with clients. Ninety-five respondents said they had no
Cole and Stevens
634
training. The remainder said they had received training in one or more ways. Forty-two said they had done special reading, and 41 described themselves as self-taught. Twenty-seven reported that they had been professionally trained and 17 had attended specific training courses. A relationship was found when comparisons were made between those who consider themselves trained in some fashion and those who are counseling clients about their sexuality (see Table I). Fifty-one people who considered themselves as having had some training were doing some counseling with clients in the area of sexuality. But of the t99 respondents, only ten who consider themselves essentially untrained were doing any counsefing. The seminar ended late in the afternoon after the small discussion groups, and many people left immediately. A second evaluation was completed by those who remained. Only 132 people, or 49% of those completing the preseminar questionnaire, completed the 2-page postseminar evaluation. One hundred twenty-six, or 95%, reported that the seminar was beneficial or somewhat beneficial to them personally; seven people, or 5%, reported that it was not beneficial; 128 people, or 97%, reported that the 1-day experience was not harmful to them; while four people, or 3%, reported that they believed it was harmful or somewhat so. Although only 3% felt that the experience was harmful to them220-
-220
Inappropriate 2 0 0 - - Not--Answered - -
-200
180-
-180
160 -
Not E x p e c t e d
160
140-
to Counsel
140 120
12010080-
////
/'
....
.' ' '
~ //
20-
80
,I
-60
6040-
q00
Do See
Expected to Counsel
0
Expectation
I
~, . . . . . .
/
//z'/',J
,. /
/'/
i¢
Do C o ~ n ~ , / ,
L/r
~, ? ' / / / ' l / / / / / /
~/
]
'1
/ / / , 'j
Performance
-40
,I
Do
See
See
-20 ,0
Opportunity ?
Fig. 1. Number of those expected to counsel clients in sexuality compared to the number who do counseling and the number who see opportunity to counsel. See text for explanation.
Sexual Counseling for Spinal Cord Injured Adults
635
Table I. Number of Those Trained in Sexual Counseling Compared to the Number Who Do Counseling Do you do sexual counseling with clients?
Have you been trained in any way to do sexual counseling?
Yes No Not answered
Yes
No
51 10 --
41 85 7
Not answered 1 1 3
Selves, 28 of the 122 who answered the question, or 23%, said they felt it may have been harmful to others at the seminar. The participants were also asked to report what they would do differently if they were to implement some of the ideas gained from the seminar. Responses were placed into like categories, and the preponderant opinions fell into one of two categories. Most respondents would either initiate discussions of sexuality with their clients or be more aware and open to sex-related aspects of the clients' rehabilitation problems or program. Of those responding, 111 of 128 people, or 87%, stated that they felt a program like the 1-day seminar presented to the M.R.A. should be part of the professional training of a rehabilitation professional, while 17, or 13%, had reservations or were opposed to this idea. Since all of the information on which this report is based was gathered on the day of the seminar, there can be no assurance that the participants are now doing counseling that they were not doing previously. However, attitude change often precedes behavioral change. Since a majority were not counseling, and the majority reported that they would initiate discussion and be more aware in order to implement ideas gained, with 87% stating that they believed such a program should be part of the training of a rehabilitation professional, it seems reasonable to assume that some attendees are now asking new questions and exploring new avenues.
DISCUSSION The necessity for research into unmet but relevant needs of clients and the application in practice of appropriate research findings were underscored by the National Rehabilitation Association (1971). Data such as those reported here have relevance for rehabilitation workers and agencies. The information gathered does not support the hypothesis that one sex more than the other is inclined to engage in sexual counseling. Nor does it confirm the notion that sexual counseling is more likely to be undertaken by younger people than by older.
636
Cole and Stevens
Our tabulations suggest that counseling is much more likely to be undertaken by a rehabilitation professional who feels he or she has had some training in sexual counseling. Of those who are doing some counseling, five times as many consider themselves as having had some training as consider themselves without training. A natural selection process may be operating here. Those who are inclined to do counseling by nature of their personalities and interests may be the same people who seek out training. On the other hand, of those responding to our questionnaire, 10% who consider themselves untrained currently are engaging in some form of sexual counseling with clients. Therefore, the absence of training in sexual counseling does not totally inhibit rehabilitation personnel from attempting to do sexual counseling. Siller (1969) believes that the anxieties evoked by the concepts of sexuality are tremendously important to rehabilitation. The disturbing question that the client may continue to ask himself or herself is "Can I perform sexually?" This question may then be transformed by many into the basic psychological problems of "Am I a man?" and "Am I a woman?" Should the client feel that he or she is not sufficiently manly or womanly, and thus lower his or her self-esteem, other destructive actions resulting from such doubts may retard or abort otherwise appropriate and hopeful vocational rehabilitation efforts. Skipper et al. (1968) emphasize the similarities between men and women. Just as disabled men have important family ties which greatly affect their rehabilitation, so do women, married or unmarried. McPhee et al. (1963) and Litman (1964) have stressed the importance and relationship of family solidarity to the motivation of the disabled to pursue rehabilitation goals. Indeed, in order to maximize the rehabilitation outcome, the entire pattern of life style and preference must be dealt with. Guidance in this effort should be augmented by applied research into the sexuality of the physically disabled. Some in the field of rehabilitation, recognizing the need to consider clients' sexuality, have indicated some ofthe problems involved. Anxieties created within the rehabilitation personnel may compound the clients' problems of altered attitudes and abilities of sexual expression. According to Frankel (1967) rehabilitation personnel not infrequently feel concern, anxiety, fear, and a vague distress when patients talk about sex. The personal discomfort of the worker, inadequate academic preparation, agency restrictions, and the simple fact that human sexuality is an emotionally loaded topic all contribute to uneasiness on the part of rehabilitation personnel as well as others. The counselor's attitudes of comfort or discomfort, approval or disapproval, may be apparent and perceived by the client. The counselor may find himself or herself in a sensitive position. A judgmental posture or overreaction to the client's attempt to gain sexually related information may seal off that topic to any further discussion. The client may pick up the unspoken message that he or she is to go home and return only when there is an acceptable complaint. If
Sexual Counseling for Spinal Cord Injured Adults
637
the counselor is aware of this potential occurrence, he or she should ask if personal attitudes are enabling or prohibitive to the client. By unwillingness or inability to deal with the client's sexuality, is the counselor in effect adding a new disability to those the client already has? An interdisciplinary method of dealing with sexuality and physical disability has been described by Romano and Lassiter (1972). They employed a physician specializing in physical medicine to "review" anatomy and physiology with groups of disabled men and women. Such "review" actually served to cover existing gaps in knowledge in a noncondescending manner for people who might otherwise have been reluctant to admit to their lack of information. Common vernacular as well as technical language was used to help open doors to effective communication. After the physician had covered the basic physiological questions, social workers in the program continued working with groups to help people deal effectively with their own altered and/or developing sexuality. This interdisciplinary approach exemplifies one method that some rehabilitation counselors might wish to use when they have recognized the need for counseling in sexuality. Others might prefer to augment, if necessary, their own medicalphysical knowledge and work with the client by themselves. Rehabilitation workers who have had little experience in dealing with sexually related materials in their training probably do not generally expect their clients to express sexual problems. According to Frankel (1967), didactic course work or even field work seldom provides rehabilitation personnel with adequate guidelines for action. In addition, the policy of the agency may limit the scope of the worker's participation. This view was reported by many of the respondents answering questionnaires at the Michigan Rehabilitation Association's 1972 annual convention. Only a small percentage of the M.R.A. personnel are involved in sexual counseling, and a large percentage feel that counseling in human sexuality is not an expected part of their work. Since many rehabilitation personnel see opportunities for sexual counseling, yet are not expected to do such counseling, there may be a large area of need recognized but not treated.
REFERENCES
Frankel, A. (1967). Sexual problems in rehabilitation. J. Rehab. 32-33: 19-20. Hohmann, G. W. (1972). Considerations in management of psychosexual readjustment in the cord injured male. Rehab. Psychol. 19: 50-58. Litman, J. (1964). An analysis of the sociological factors affecting the rehabilitation of physically handicapped patients. Arch. Phys. Med. 45: 9-16. McPhee, W. M., Griffiths, K. A., and Mayleby, F. L. (1963). Adjustment of Vocational Rehabilitation Clients, Final Report, ~rRA Grants No. 178 and No. 757, University of Utah. National Rehabilitation Counseling Association (1971). Definition of role and functions of the rehabilitation counselor. Conference Proceedings, December 1-3, Washington, D.C.
638
Cole and Stevens
Romano, M. D., and Lassiter, R. E. (1972). Sexual counseling with the spinal cord injured. Arch. Phys. Med. 53: 568-575. Siller, J. (1969). Psychological situation of the disabled with spinal cord injuries. Rehab. Lit. 30: 290-296. Skipper, J. K., Jr., Fink, L , and Hallenbeck, P. N. (1968). Physical disability among married women: Problems in the husband-wife relationship. J. Rehab. 34: 16-19.
