The Sexual and Parenting Rights of People with Physical and Psychical Disabilities: Attitudes of Italians and Socio-Demographic Factors Involved in Recognition and Denial

The sexual and parenting rights (SPRs) of people with disabilities (PwDs) are under-recognized. Sociodemographic factors may influence attitudes towards them. The aims of this study were: (1) to analyze the levels of agreement of a sample of Italian people with some SPRs of PwDs; (2) to inquire if the SPRs of people with psychical disabilities (PwPSYDs) were less recognized than those with physical disabilities (PwPHDs); (3) to verify if sociodemographic characteristics associated with under-recognition. An online anonymous survey was distributed using non-random sampling methods to conduct an inquiry into the level of agreement with statements regarding the SPRs of PwPHDs and PwPSYDs to have satisfying sexuality, to marry, and to adopt children. Answers from 973 Italian participants, aged 18–84 years (71.1% females) were analyzed. At least 70% of respondents declared in favor of the SPRs of PwPHDs. The SPRs of PwPSYDs were always subjected to higher under-recognition. Religiosity, male sex, higher age, and lower education were the factors most often associated with being against the SPRs of PwDs. Improved identification of the less tolerant respondents and the less recognized categories may allow for specific strategies for promoting the recognition of the SPRs for PwDs.


Introduction
More than 15% of the world's population lives with one or more disabilities, including physical and sensory impairments, developmental and intellectual disabilities, and psychosocial disabilities [1]. Disabilities are defined by the UN Convention on the Rights religious people tending to hold more conservative opinions [25]. However, most research on attitudes towards the SPRs of PwDs has engaged primarily their family members, supporting staff, or university students, while a few updated studies enrolled samples from the general population [3,27,29].
In Italy, serious issues of prejudice and discrimination against minorities exist, to the point that a bill was recently proposed in Parliament seeking to punish acts of discrimination and incitement to violence against gay, lesbian, transgender people, and PwDs [30]. The so-called "Zan Law", after being approved in the Chamber of Deputies, was recently rejected in the Senate [31]. This refusal immediately provoked several street demonstrations in the main Italian squares, in which thousands of people took part [32]. Indeed, even if, apparently, Italians would be mostly in favor of granting more rights to minorities, our previous study also indicated that SPRs are less recognized in minorities, such as LGB people [33]. As far as we know, no recent research in Italy inquired into the societal level of agreement with the SPRs of PwPHDs and PwPSYD, or the socio-demographic predictors of unfavorable attitudes towards reducing inequalities.
The aim of this study was therefore to analyze the level of agreement of the Italian general population with the right of PwPHDs and PwPSYDs to have satisfactory sexuality, to marry and to adopt a child, and to evaluate whether the SPRs of PwPSYDs were subject to less recognition, compared to PwPHDs. A further objective was to better understand which socio-demographic characteristics of Italian people were significantly associated with a lower agreement with the SPRs for PwPHDS and PwPSYDs.

Inclusion/Exclusion Criteria for Study Participants
The study was designed to be proposed to the entire Italian adult population. Therefore, criteria for participation were having reached the age of majority, under Italian laws, and being born and resident in Italy.

Study Design and General Description
The data reported in this paper is extracted from a larger, original study which, through an online questionnaire, cross-sectionally investigated the 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 satisfying sexuality, to marry, to adopt children, to be hired for any job, and to be free to choose how they lived with their sexuality [34].
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).

Specific Contents of the Questionnaire
The online questionnaire was developed with Google Forms (Google LLC, Mountain View, CA, USA) to collect information related to socio-demographic data of respondents and their level of agreement with statements related to the abovementioned SPRs.
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 (categorical question, which included all obtainable levels of Italian education and which was recoded into 'undergraduate', 'graduate', and 'post-graduate'); region of origin (open question, which was recoded in coming from 'North', 'Center' or 'South-Islands'); occupational status ('student', 'employed', or 'unemployed/retired'); occupation (open question, which was recoded in 'healthcare worker' including doctors, psychologists, nurses and other health professionals and 'other profession'), sexual orientation (completely heterosexual, mostly heterosexual, bisexual, mostly homosexual and completely homosexual, which was recoded in 'com-pletely heterosexual' or 'not-completely heterosexual'); relational status (open question, which was recoded in '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 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). 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.

Data Collection
The questionnaire was distributed via email and through the main social media by all the authors and by colleagues affiliated with their associations, through an exponential non-discriminative snowball sampling approach. A direct link to the questionnaire was also published on the website of the Italian Federation of Scientific Sexology (www.fissonline.it, accessed on 28 September 2021). 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 place 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. In this case, no data, except that a refusal had occurred, together with its date of occurrence, was recorded. People who accepted to participate accessed the survey. In the second case, all their answers were automatically collected by the software.

Statistical Analyses
All data transformations and 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 to evaluate the normality of distributions.
Since answers to most questions about SPRs 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 right.
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 SPRs were dichotomized (a score of 1, 2 or 3 was classified as "disagreement" and a score of 4, 5, 6 as "agreement"). Then, univariate and multiple binary logistic regression analyses were conducted to identify the socio-demographic variables associated with "agreement" with each SPRs for PwPHDs and PwPSYDs, taking "disagreement" as a reference. Values were expressed as odds ratio (OR) and 95% confidence intervals (95% CI). To exclude multicollinearity, the variance inflation factor (VIF) was calculated for each predictor. Dummy variables were obtained from non-dichotomous ones and calculated by selecting for reference the most prevalent category. A VIF greater than 2.5 (which corresponds to an R 2 of 0.60) was considered indicative of multicollinearity.
The level of significance was established at 95% (p < 0.05) for all statistical analyses.

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 were not born or did not live in 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). Demographics are shown in detail in Table 1. Most participants were female (71.1%) and people under 40 years of age (70.5%); middle-aged people and seniors (people over 50) represented 12.4% of the sample. Sixhundred and forty-one (65.9%) were graduates and post-graduates; 21.9% of the sample consisted of healthcare workers (34.3% of employed). Four-hundred and eighty-two out of 509 participants declared 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 right of PwDs to have satisfactory sexuality ( Figure 1). Only 1.1%, 1.4%, and 2.4% of participants answered being completely, moderately, or mildly against it, while 4.1%, 8.9%, and 82.0% declared mildly, moderately, or completely in favor of it. A slightly lower number of respondents expressed complete, moderate, or slight agreement with the right of PwPSYDs to have 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-Rank test indicated that the median ranks for PwPHDs were statistically significantly higher than the median ranks for PwPSYDs (Z = 13.04, p < 0.001). declared mildly, moderately, or completely in favor of it. A slightly lower number of respondents expressed complete, moderate, or slight agreement with the right of PwPSYDs to have satisfactory sexuality (63.4%, 11.4%, and 10.8%, respectively), while 7.9%, 2.8%, and 3.7% were mildly, moderately, or completely opposed. 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. The complete disagreement is represented in black. Labels are presented only for response options chosen by at least 2% of participants.
The Wilcoxon Signed-Rank test indicated that the median ranks for PwPHDs were statistically significantly higher than the median ranks for PwPSYDs (Z = 13.04 p < 0.001).

Socio-Demographic Variables Associated with Agreement with PwPHDs's Right to Have 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 satisfactory sexuality ( Table 2). None of the VIF exceeded 2.5. The multiple logistic regression analysis included all predictors and indicated that only positive associations between 'agreement' and sex 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. The complete disagreement is represented in black. Labels are presented only for response options chosen by at least 2% of participants.

Socio-Demographic Variables Associated with Agreement with PwPHDs's Right to Have 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 satisfactory sexuality ( Table 2). None of the VIF exceeded 2.5. The multiple logistic regression analysis included all predictors and 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 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 Satisfactory Sexuality
The results of the univariate logistic regression analyses suggested the existence of an association between agreement with the right of people with PSYDs to have satisfac-tory sexuality and sex, religion, regional origin, occupational status, relational condition, and level of education ( Table 2). None of the VIF exceeded 2.5. The multiple logistic regression analysis included all predictors and indicated that most of these associations maintained statistical significance. In particular, being female, atheist, a graduate, employed, or a student, and living with a partner were related to higher odds for agreement than being male (O.R. = 1.55; 95% C.I.  Overall, 98.3% of participants declared in agreement with the right of PwPHDs to marry, while 78.7% of them answered being favorable to marriage for PwPSYD ( Figure 1). In particular, 88.8% of participants expressed strong agreement with the possibility for PwHDs to get married, while 6.7% and 2.8% declared moderately and mildly in favor, 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 (Figure 1).
The Wilcoxon Signed-Rank test indicated that the median ranks for PwPHDs were statistically significantly higher than the median ranks for PwPSYDs (Z = 17.85, p < 0.001).

Socio-Demographic Variables Associated with Agreement with PwPHDs's Right to Get Married
The results of the logistic regression analyses are to be interpreted 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 right of people with PSYDs to marry and all considered predictors, with the exception of provenance ( Table 3). None of the VIF exceeded 2.5. The multiple logistic regression analysis included all predictors and indicated that most of these associations maintained statistical significance in the multivariate model. In particular, being female, atheist/agnostic, post-graduate, 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 right of PwDs to adopt a child encountered the agreement of 71.7% of the sample, while 21.8% of respondents declared themselves in favor of the adoption of a child by the PwPSYDs (Figure 1). A total of 5.1%, 3.1%, and 10.1% of participants answered being completely, moderately, or mildly opposed to this right 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 < 0.001).

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 right 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 right of people with PSYDs to adopt a child and age, sexual orientation religion, and level of education ( Table 4). None of the VIF exceeded 2.5. The multiple logistic regression analysis included all predictors and indicated that religion and education maintained statistical significance in the multivariate model. Indeed, being post-graduate and atheist/agnostic were related to higher odds for agreement than being under-graduate (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). Table 4. Socio-demographic features and percentages of agreement with the right of people with physical and psychical disabilities to adopt a child: frequencies (in percentages) and results of the univariate and multiple logistic regression analyses. Significant differences with respect to the reference are reported in bold.

Discussion
To our knowledge, this is the first published research to conduct an inquiry into the levels of agreement with the SPRs of PwDs in the Italian general population and the socio-demographic variables, which may associate with positive or negative attitudes.
The results of this study indicate that the very large majority of Italians declared in agreement with the right of PwPHDs to have satisfactory sexuality and to marry, and were most inclined to agree with their right to adopt a child, albeit to a lesser extent. Consistent with other research, the percentage of people who disagreed with these SPRs when related to PwPSYDs was significantly higher [11]. In particular, almost 80% of our sample declared against the right for adoption for PwPSYDs. Indeed, the sexuality of PwPSYDs was found to be judged as less appropriate than that of persons without any disability or with physical disabilities [11]. It was observed that stereotypes exist regarding PwPSYDs, who are deemed incapable of judgment and control, unpredictable, and possibly dangerous: these stereotypes may elicit false beliefs about unsafe sex, promiscuity, or abuse [11]. Even though we did not investigate beliefs or stereotypes associated with the recognition of the SPRs of PwDs, we can hypothesize that they may also explain our findings.
Consistent with other studies [18,19], opinions concerning the possibility for PwDs to adopt a child were more unfavorable than those related to sexuality and marriage, confirming that participants considered this aspect to be more complex and, perhaps, to have implications beyond the mere SPRs of the individuals, and to require abilities that many would judge to be too complex to be carried on by PwDs, and, in particular, by PwPSYDs. Different from another study by Cuskelly and Gilmore [18], who observed less favorable, yet still substantially positive, attitudes about parenting in PwPSYDs, Italian respondents declared for the most tendentially or completely against PwPSYDs being allowed to adopt a child. This difference could also be amplified by the fact that the present research requires a specific opinion related to adoption and not on the general possibility of being parents.
Consistent with other research, women appeared to be more supportive of PwDs' right to have satisfactory sexuality and of PwPSYDs' right to marry than men, while no differences between genders were observed about parenting [22,23].
Regarding socio-demographic variables, our data revealed that religion was a strong predictor of negative attitudes in most analyses, 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 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 also found a relationship between the level of education and the presence of agreement. In general, we observed that undergraduates tended to express more disagreement than graduates and post-graduates with SPRs of PwDs, and that post-graduates tended to agree in slightly higher percentages than graduates (with the exception of items relating to satisfactory sexuality). 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 [35]. Even if in our sample medical doctors and psychologists represented up to 44.4% of post-graduates, our data appear to be inconsistent with the results of this research. However, it should be noted that our survey did not require participants to specify whether their work involved contact with (or care of) PwDs. For this reason, it is possible that our sample included both people who had frequent contact with PwDs and people who had rare or absent relationships with them.
In some comparisons, we observed that the proportion of people in agreement with the SPRs 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 percentage than heterosexuals (88.5% vs. 75.5%) to these SPRs. To our knowledge, there are no other studies that have investigated sexual orientation as a predictor for agreement with the SPRs 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.
Our study presents some strengths and many limitations. As abovementioned, the main limitations concern the poor representativeness of the enrolled sample, being composed mainly of women, young people, and graduates, and in high percentages by healthcare workers, therefore limiting the validity of this research. In any case, most of the literature on this topic derives from studies enrolling limited convenience samples of a few tens or hundreds of participants, mostly recruited among relatives, students, or care providers of PwDs. For this reason, even if not perfectly representative of the Italian population, our data fit into a line of research whose results tend to be hampered by selection bias.
Other limitations concern having included a limited number of variables among predictors. It is possible to hypothesize that people's level of agreement may be associated with other factors, e.g., having a relative with physical/psychical disability, or pending an adoption. We can also hypothesize that people were more sensitized to these topics since they were often discussed in politics and media. However, it is not straightforward that greater exposure may have implied greater agreement.
A strength of our research is the fact that it is the first Italian study to have evaluated the opinions of people in the community regarding the civil and sexual rights of PwDs. Until now, to our knowledge, there were no Italian data relating to the topic.
Another strength is represented by the sample size. A sample of almost a thousand people is numerically very consistent and definitely higher than most of the works published so far on the topic. Although the results on the levels of agreement expressed by the entire sample must be interpreted with caution due to the aforementioned limitations, the sample size allowed to make predictions about the effect of different socio-demographic variables on the agreement with the SPRs of PwDs. Our data may therefore represent a useful background for more rigorous studies and interventions aimed at information and training campaigns on the issues of civil and sexual rights of minorities.

Conclusions
Despite its limitations, this study has important implications regarding the SPRs of PwDs 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 a child. Second, our data confirmed that PwPSYDs face more discrimination than PwPHIDs. Actions are needed to overcome the prejudice and stigma towards them. Lastly, evidence is shown that certain characteristics of the population affect the level of recognition of PwDs' rights, in particular having strong religious beliefs is related to lower recognition. Furthermore, male sex, higher age, and lower education contributed in some analyses to outline the more uncompromising profiles. Other research demonstrated that specific training on sex and disability can lead to more positive attitudes related to their SPRs [22]. 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.
People's psychological well-being is severely hampered by a discriminatory environment. In Italy, ignorance and discrimination are also sustained by the lack of national policies of sexual education, and by the intention of the political majority to discourage any action that could reduce inequalities in SPRs or promote structured interventions of sex education at a national level. This is due to both cultural and economic reasons. The recent rejection of the 'Zan Law' [31] confirms that it is no longer possible to wait for the ideal solution represented by national policies, and it is important to design targeted interventions to optimize resources. To do this, we believe that the results of this study are useful because they indicate which people discriminate the most and which rights are denied the most. This can direct educational interventions on specific issues and aimed at proper recipients and conducted in proper environments, i.e., where people are most discriminated against. Informed Consent Statement: An opt-in approach was used in this research. Informed consent was requested upon fulfillment of the online survey. The "I Agree" button allowed participants to click and begin answering the questionnaire, in order to collect their data online. If they did not agree to participate in the study, they had the option to click an "I Do Not Agree" button so that their data were not submitted and collected online.

Data Availability Statement:
The data presented in this study are available on request from the corresponding author. The Scientific Committee of the Italian Federation of Sexology reserves the right to verify Ethic approval and permissions for research submitted by the applicant, and to approve database sharing at their own discretion.

Conflicts of Interest:
The authors declare no conflict of interest.