Abstract

Individuals with disabilities, regardless of the type or nature of their condition, are likely to face certain challenges as they seek a high quality of life. Participation in healthy and constructive leisure should be an important and meaningful part of every person's life. Whether considered as free time away from work, a set of activities chosen for relaxation, recreation or enjoyment, or simply a 'state of mind' to which one escapes for peace or reflection, leisure is valued by people as an important feature of life. Leisure and recreation activities also serve as the primary means by which people come into contact with one another and form relationships and eventually opportunities for sexual expression. This article discusses important issues related to people with disabilities and quality of life as it relates to the role of leisure in sexuality. Specifically, definitions and historical perspectives of leisure are shared, components of leisure and barriers to leisure are addressed, information about the discipline of recreation therapy is presented, and the impact of leisure on disability and sexuality is explored.

Introduction

Throughout history human beings have sought for the best of what life has to offer, yet they often ponder the question, "What is necessary to live life to its fullest?" Within this Disability Studies Quarterly symposium experts have been asked to reflect on the role of sexuality in the lives of men and women with disabilities. Although the type and frequency of participation in sexual activity varies from person to person, differs within cultures, and potentially changes as one ages, physical intimacy is a primary aspect of being human and plays a key role in quality of life.

What is quality of life? Quality of life is a concept that exists without a concrete, consensus definition. Is it contingent upon some level of economic status, education, a level of physical health and functional ability, or mental and emotional well-being? Is it having a loving family, friends, freedom and self-determination? Might quality of life be seen as what people do with their free time, where and how they participate in recreation and leisure? Or is quality of life some combination of these factors, a subjective appraisal made by each individual about whether he or she is truly happy and satisfied with life and its opportunities? Does having a disability make achieving a high quality of life more or less difficult? Scholars and practitioners are challenged by the task of studying these questions (Hunt, 1997).

Similar to quality of life, leisure is a term that for most people is ambiguous and difficult to define. The concept of leisure is complex and more challenging to comprehend than one might first believe. What is leisure? Is it merely one's free time, the time or space outside of work? Does leisure refer to participation in certain activities that are diversional and bring happiness or relaxation either on a personal or interpersonal level? Or, is leisure a state of mind, a mental or possibly even spiritual place where one escapes from the stresses of life? A thorough examination of leisure involves understanding how it interplays with factors such as gender, race, aging and disability. In fact, close examination of leisure reveals that it shares many characteristics of sex itself. Sex, like leisure, comprises activity that typically occurs during people's free time, is enjoyable and serves to enhance feelings of attachment and closeness between people. Researchers and practitioners need to appreciate the dynamics and role of leisure in order to fully understand quality of life as it applies to people with disabilities and their access to sexual relationships (Roehrer Institute, 1989).

Understanding the nature and role of leisure is important when considering people with disabilities and their desire to have relationships and be sexually active. Most meaningful relationships result from spending significant time with others in settings of leisure or free time activity (Godbey, 1999). If a person is unable to participate satisfactorily in leisure, especially with others or in the presence of others, he or she is probably not going to develop the skills, confidence or opportunities needed to form interpersonal relationships that may lead to a mutual desire for intimacy and/or sexual activity.

Professionals within the field of recreation and leisure studies have amassed a substantial body of knowledge about leisure. This includes historical perspectives on leisure as well as analysis of its role in contemporary society (Kelly & Freysinger, 2000). Scholars have dedicated themselves to examining the role of leisure within developing societies and cultures throughout time (Huizinga, 1950; Pieper, 1963). Although a full summary of the literature about leisure is beyond the scope of this article, key elements will be highlighted.

The purpose of this article is to explore the role of sexuality within the lives of people with disabilities based upon the premise that leisure is a primary vehicle through which people come in contact with one another, relationships are formed and eventually, sexual activity may take place.

Conceptual Framework and Historical Perspectives of Leisure

Leisure is conceptually different from "recreation" or "play" though the terms are often used interchangeably. Recreation is thought of as activity that is structured, typically done with others and physical in nature such as organized sports. Playing or being playful, on the other hand, is used to describe activities or an attitude which is usually more carefree, spontaneous or childlike. It is important to note that the same activity experienced by different people can be recreation for some, leisure for others, and play for yet others. Also, an activity for one individual, on different occasions or within different settings, can be viewed as leisure at one point in time and recreation at another (Godbey, 1999).

Take basketball for example. If a teenager chooses to spend part of a lazy afternoon shooting baskets by herself at home without any real purpose in mind, she might consider that leisure. Later in the day she may invite friends over to play basketball and enjoy an hour of exercise, laughter and spontaneous fun while kidding around about boys at school or an upcoming math test. That weekend she goes to the community center that is hosting a recreational league where her basketball team is in the championship game. In this setting, competition is keen, teamwork is stressed, and winners and losers emerge. A similar analysis can be made of most, if not all, leisure activities in determining the times and places where characteristics of recreation, leisure and play emerge or shift as the nature of the activity changes.

Leisure and recreation have a place in the history of civilizations. Changes in social institutions, as well as technological advancements, have impacted the way leisure has been perceived and experienced. Leisure has, however, always existed though its form, nature and purpose have been fluid (Goodale & Godbey, 1988). Notably, ancient Romans were famous for their pools and public baths, as were the Greeks, who also instituted the Olympic Games. Secular and religious advancement in the Middle Ages defined the parameters of leisure within the lifestyles of that era. Martin Luther led the Protestant reformation that saw idleness as a sin (Linder, 1970) thereby impacting what people did in their free time. In later years as European civilization spread to the Americas, the Puritan influence placed utmost importance on work and productivity and taught that leisure existed primarily for religious contemplation (Goodale & Godbey, 1988).

The Industrial Revolution, along with the Great Depression, created significant societal changes and perspectives about leisure and recreation changed along with them (Rybczynski, 1991; de Grazia, 1962; Veblen, 1899). The Young Men's Christian Association (YMCA), which originated in Great Britain, grew in response to changing social needs throughout the early part of the 1900s and is credited for having invented or influenced sports such as basketball, volleyball, softball and racquetball, as well as swimming and camping programs.

The 1960s and 1970s are known most poignantly as an era of social revolutions. Sexual liberation and significant leisure-based events (e.g. Woodstock) did much to transform American society, free time use and notions of masculinity and femininity. Certainly one of the key scientific developments of this period was the invention of birth control. This greatly alleviated the fear of unwanted pregnancies and, for women especially, allowed sex to become something that could be more recreational (Allyn, 2000).

Reflecting on more recent decades, some scholars have examined the demands placed upon the American worker within a transforming global economy. Today one wonders if time for leisure, or interest in high quality leisure experiences, is increasing or decreasing. Technology reduces the amount of time needed to complete tasks and jobs are less physically demanding, yet leisure for most is actually decreasing as a result of pressures of productivity, materialism and the complexities of society (Schor, 1992; Rifkin, 1995). The economic and technological structure of society certainly impacts how leisure is viewed and determines the quantity and quality of leisure within our lives as individuals, families, communities and nations.

Leisure's Role in the Lives of Individuals

What role do leisure, recreation and play have for human beings as individuals? For all children, leisure exists as play, and play constitutes a large part of child development (Seefeldt, 2001). Human beings at a young age learn to walk, talk, move about, relate to people, and express individuality mostly through the context of play (Ellis, 1973; Jenkinson, 2001). Eisert and Lamorey (1996) studied children and reported that assessment of children's play is an effective method to ascertain the strengths and weaknesses of important developmental domains.

As children become teenagers and then young adults, with or without disability, experiences in recreation and leisure impact self-identity and esteem (Shaw, Kleiber & Caldwell 1995). Of course, depending on the person and what he or she is experiencing, the impact can be either positive or negative (Dugan, 2001). Widmer, Ellis & Trunnell (1996) state that particular leisure choices may place adolescents at increased risk to engage in delinquent behaviors. Wisely chosen recreation, however, is more likely to result in positive outcomes.

Groff & Kleiber (2001) completed a qualitative study regarding identity formation in an adapted sports program. Youths reported that involvement in the sports program: (a) provided an overall sense of competence in skills (transferable to other settings), (b) served as an outlet for the expression of emotion, (c) allowed for interaction with others in a social context not readily available in schools or other environments, and (d) provided a sense of independence and decreased awareness of disability. McKenney & Dattilo (2001) demonstrated that interventions associated with sports had some effect on the pro-social behavior of adolescents with disruptive behavior disorder although already existing antisocial behaviors did not appear to be diminished. These authors earlier studied leisure's role in the development of values, and stress the importance of choices made and behaviors formed during and within the context of leisure (Dattilo & McKenney, 2000). Similarly, a person who lacks self-esteem or identity, or seems to avoid relationships, may possibly be one for whom healthy recreation and leisure in social settings has been noticeably absent or problematic.

Dating, a significant activity adolescents and young adults, is a behavior where people participate in leisure or recreation activities together. Issues exist that may limit the dating opportunities of people with disabilities. Physical attractiveness is a common desirable quality of potential dates. If a person with a disability is perceived, or perceives himself or herself, as less physically attractive, the probability of dating is reduced. One's family may be overly protective or disapprove of dating. Another barrier to people with disabilities may be their own prejudices against dating other people with disabilities, but the idea that dating or marrying a person without a disability makes one feel normal or compensates for one's limitations. Another prevalent issue is that people with disabilities are perceived as being asexual, a belief that may prevent some from forming serious relationships (Rintala, et al., 1997; Gill, 1996; DeLoach, 1994).

Maturing young men and women at some point come to realize their bodies are capable of reproduction, that they have a procreative identity (Marsiglio, 1998). This is of considerable importance to overall identity formation and the vibrance of one's self-concept. Sex within a marriage or cohabitation relationship often changes as most partners commit to a monogamous relationship and sex falls within the day-to-day routine of two people's lives. Sex certainly is recognized as the mechanism through which children are conceived, but sex for the sake of physical and emotional bonding and sex for fun and pleasure is still the primary reason many people have sex. However, single adults who are sexually active, compared to married men and women, are more likely to view sex as recreational (Michael, Gagnon, Laumann and Kolata, 1994).

As people grow older, it is also likely they will have more and more discretionary time and more opportunities to participate in leisure. Through adulthood and into retirement years, although the type of activities may change, the importance of healthy leisure does not diminish. While the likelihood of obtaining a disability increases with age (Soldo & Freedman, 1994), interest in leisure activities remains strong. In fact, a recent survey commissioned by the American Association of Retired People reported that older Americans (aged 50+) place a high priority on activities such as spending time with family, socializing with friends, reading and spending time on hobbies and exercise.

Interestingly, "making love" was ranked first among men and third among women (after "spend time with family" and "spend a romantic evening with my spouse, partner or date") in activities respondents said they "really love" to do (AARP, 2002). AARP (1999) released data that indicated 67% of older men and 57% of older women stated that having "a satisfying sexual relationship" was an important attribute to quality of life. As expected, due to a variety of factors, the apparent need for a satisfying sexual relationship did decrease with age. Nearly 50% of men and women over the age of 75 reported that while sex was not a necessary attribute of quality of life, it was still important AARP/Modern Maturity (1999).

The Leisure Experience: Barriers to Participation & Critical Issues

Barriers, often called "constraints" in the leisure literature, are important to this discussion of leisure and people with disabilities. Constraints are things that interfere with the person's ability to learn about, access or fully participate in leisure. Jackson & Scott (1999) described there are three categories of constraints: intrapersonal, interpersonal, and structural. Intrapersonal constraints are defined as individual psychological attributes, such as poor self-confidence or recollection of past negative socialization, which interfere with the development of leisure preferences or the type of activities one finds enjoyable. Interpersonal constraints are barriers that emerge as social interaction takes place between family, friends or others. Barriers of this nature can include negative interactions with same age peers, communication difficulties or patterns of social isolation. Structural constraints refer to things such as lack of transportation, limited financial resources, stigmas against people with disabilities or inaccessibility of community programs that diminish the level of participation in leisure desired by the individual.

While every person occasionally has a problem or situation that limits or prevents what he or she does during free time, frequent constraints to leisure ultimately lead to a diminished quality of life. Another example of a structural constraint may be the detrimental effect of medications that can act to inhibit normal physical, psychological or emotional function in leisure and sexual activity. On the other hand, properly prescribed and administered medications can improve function and reduce symptoms of illness and may promote positive leisure and healthy sexual experiences. This view of constraints to leisure participation can help in understanding and alleviating barriers that people with disabilities may face (Jackson & Scott, 1999).

As an area of scholarly exploration leisure has been dissected and studied from many angles. Numerous issues have been identified and examined for their potential constraints on healthy leisure. Some of these include alcohol and drug use, personality and attitude, social class and race, sexual orientation, religion, gender-based roles and dynamics involved with masculinity and femininity.
Understanding the phenomenon of alcohol and drug use as it relates to leisure and sex is important. While alcohol and drugs are a potential problem for people of all ages, they are commonly found in the leisure environments of young people (Duffy, 2001). If abused, alcohol or drugs can pose serious physical, emotional, social and legal problems (Parker, 1998). Carruthers (1993) explored the ways in which individuals expect that alcohol consumption will affect their leisure experiences as being dependent on the leisure context. Alcohol and sexual activity is a dangerous combination. On college campuses in particular, despite warnings and information provided to students (e.g. Graddy, 2000), undesirable consequences often result (Cooper, 2002; van den Akker & Lees, 2001). Some of these include sexually-transmitted diseases and HIV/AIDS, unwanted pregnancy, emotional distress and physical harm. Unfortunately, people with disabilities are as much at risk to consume or rely upon drugs or alcohol during leisure and recreation as those without disabilities. In fact, some studies report the risk of alcohol/drug use is higher for people with disabilities than those who do not have disabilities (Snow, Wallace & Munro, 2001; Young, Rintala, Rossi, Hart & Fuhrer, 1995). These studies conclude that people with disabilities may be challenged by additional stress, poor self-esteem and social isolation, which are believed to be risk factors for drug and alcohol consumption (Radnitz, Tirch, Vincinguerra and Moran, 1999).

Similarly, an individual's personality often determines his or her attitudes toward leisure. One's attitude may be a carry-over from the environment in which one was raised or is influenced by identity formed due to work (Mannell & Reid, 1999). One's attitude, desire or need to participate in leisure translates into identifying what type of leisure experiences are best and what outcomes are realized (Driver & Bruns 1999). Personality traits (e.g. the love for adrenalin found in high-risk sports such as white-river rafting) and attitudes (e.g. being intrinsically passive or shy) affect choice and participation in leisure. The work of Floyd, McGuire, Shinew & Noe (1994) demonstrates how social class and race effect leisure activity.

Sexual orientation also impacts leisure. Individuals who are gay or lesbian may express differences in their preference for, and satisfaction with, certain leisure experiences (Pritchard, Morgan, Sedgley, Khan & Jenkins, 2000). Thus the context within which they experience leisure, meet new people and experience their sexuality is likely to be different than people with a heterosexual orientation. Viewing oneself as bi-sexual or transgendered will also impact where and how a person spends his or her leisure time and with whom he or she associates.

Religious activity impacts beliefs that dramatically influence leisure time choices and behavior during recreation. Religious values, or a sense of morality derived from other sources, are known to make many people desire an emotional loving relationship and, for some, for a legal marriage to be performed prior to engaging in sexual activity. Just as religion may influence leisure choices, most Americans report that religious beliefs guide their sexual behavior (Michael et al., 1994).

Gender roles and masculine/feminine traits also heavily impact the opportunities offered in leisure activities and in recreational settings (Aitchison, 1999). Many believe there are actual physiological differences between the brain and its chemistry for men and women (Blum, 1997; Moir & Jessel, 1991). Regardless of whether such structural differences in the brain exist, males and females, conditioned by cultural mores and societal values affecting thought and behavior, often choose to participate in different activities. If participating in the same activities, males and females often seek and experience different outcomes. Tepper (1999) wrote poignantly about the notion of manhood and its impact on disability and male sexuality. When listing treatment suggestions for men's sexual heath, he recommended that health practitioners be mindful of the need for "competitive recreational activities" (p.49).

People should determine whether leisure interests define their possible relationships with others and the extent to which their relationships with others define their leisure pursuits. Most people would agree that they are more likely to enter a long-term relationship or marry someone who shares similar attitudes and interests in leisure. All of these issues are important when attempting to understand the complexities associated with leisure. Removing obvious barriers to leisure is a good first step in allowing people with disabilities to participate fully.

Leisure's Influence on Disability and Sexuality

Sexuality, like leisure, should be viewed as inherently positive, something that adds to ones' happiness and satisfaction with life. When a person with a disability is unable to participate in a particular leisure or sexual activity or is dissatisfied with a leisure or sexual experience itself, only then does he or she realizes something is awry. Throughout all of history human beings have experienced and been impacted by disability. How disability has been construed and how people with disabilities were treated differed from century to century and place to place. Undoubtably, the leisure and recreation involvement of people with disabilities was consequently affected. Their acceptance as people with the right and access to the opportunities and resources necessary for quality of life has varied as eras have come and gone and cultures have waned or thrived. Treatment of people with disabilities often has depended upon the moral perspectives of the society toward the nature of disability. Bedini (1991) wrote a compelling article chronicling how people with disabilities not only have been historically denied opportunities for recreation, but have often been the subjects of amusement and exploitation within the context of leisure (i.e. carnival sideshows).

Consequently, how people with disabilities have been perceived has certainly impacted their opportunities for leisure. Reinforced by cultural and religious views society set parameters of what was acceptable activity, sexual or otherwise, for people with disabilities. Historically, people believed that disability reflected a sinful nature and was associated with shame and segregation resulted (Braddock, 1998). Medical models originally labeled disability as a defect or sickness to be cured through medical intervention and problems resulting from being disabled were deemed to reside within the individual. Early models of health regarded disability as a deficiency needing to be fixed by a rehabilitation professional or well-intentioned policy decision (Hayden, 2000).

More recent models reject the notion that persons with disabilities are in some way "defective." These models are based upon compensation for functional deficits by focusing on a person's strengths and abilities. Authors of these models have tried to consider the impact of the environmental context on individuals and most now realize health is more than the absence of illness or the presence of disability (Hochstenbach, 2002; Druss, Marcus, Rosenheck, Olfson, Tanieliean & Pincus, 2000). These advancements resulted in people with disabilities being more readily accepted into normal social situations and encouraged to participate in recreation and leisure activities. Many social and recreational programs in communities now seek to be inclusive allowing and encouraging people with disabilities to participate alongside those without disability (Dattilo & Williams, 1999). Numerous adaptive devices and modified equipment now allow people with disabilities to participate in most sports and leisure activities, separately or together with people who do not have disabilities.

Furthermore, through the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990, issues of social discrimination, including many which affect leisure participation, are being addressed (Kaplan, 2000). A new model representing the International Classification of Functioning, Disability and Health (ICF), endorsed by the World Health Organization, places primary emphasis on "activities and participation" for people with disabilities. Health conditions, body structures and personal and environmental factors are components that influence the individual's ability to engage in activities which are meaningful and instill quality of life (World Health Organization, 2001). For people with disabilities, like those without disabilities, activities which epitomize quality of life include those which are constructive leisure and recreational pursuits.

Having a disability, whether congenital or acquired, does not automatically eliminate a person's desire to experience enjoyment and be involved in creative and nurturing leisure activity. Simply having the chance to do things that are fun or relaxing brings meaning to life (Kelly & Freysinger, 2000). Williams and Dattilo (1997) studied youth with mental retardation and the effect of classroom leisure education. While some positive results were found relative to improved self-determination, social interaction and positive affect, their findings suggest the mere content of leisure education itself is not enough. They recommend varied ways of instructing youth with disabilities, including education of friends and family, to help reinforce what is being taught to the person with the disability. A disability may change what a person can participate in or may require modifications in equipment or game rules, but disability should not be allowed to be a barrier to positive recreation or leisure involvement.

Since leisure is known to be a means by which people come into contact with others, people with congenital or early onset disabilities may have severely restricted access to social opportunities. This is because they may have been excluded from these situations or never gained a level of comfort or confidence needed for positive interpersonal interaction. Limited knowledge of or chances to meet and get to know others further restricts dating prospects (Rintala et al., 1997), diminishing opportunities to have meaningful sexual relationships. Individuals who have (or are perceived to have) disabilities may intentionally be excluded, inadvertently left out, or somehow restrained from participation in leisure activities (Bedini, 2000). Rintala et al. (1997) reporting on dating issues for women with physical disabilities, stated that "persons with disabilities may have more difficulty in finding partners and forming personal relationships leading to intimacy than do people without disabilities" (p.219). They conclude, "Compared with women without disabilities, women with disabilities were less satisfied with their dating frequency, perceived more constraints on attracting dating partners, and perceived more societal and personal barriers to dating" (p.239).

Rintala et al. (1997) also addressed several ways that barriers related to disability directly affect leisure and interpersonal relations. If self-esteem is low it may interfere with the ability to share communicate effectively about one's interest in doing activities that would allow him or her to get to know a potential dating partner (Raymore, Godbey and Crawford (1994). If communication is poor, perhaps impacted by a cognitive or physical impairment, people will find it harder to establish a relationship. If perceived barriers in society support stigmas and genuine physical barriers exist in the public environment, these are likely to be the result of prejudice and ignorance as well as disregard for public policies such as the Americans with Disabilities Act (Rintala et al., 1997). Shaw (1999) has also written about the role of gender as a constraint to leisure participation, particularly for women. For example, women who are employed lack leisure time if they return home only to face the bulk of household tasks. Problems within the leisure domain are likely to significantly reduce the chances for people with disabilities to develop self-confidence, meet other people, form relationships and explore their sexuality.

It is important to note that within Western society, people today often live in media-driven cultures that promote sex and sexuality from almost every direction (Brown, Steele & Walsh-Childers, 2002). People with disabilities, however, are noticeably absent when sexuality is being used by advertisers to sell products. Many of these items are designed specifically for use in leisure activities aiming to allow people to have more leisure time (i.e. technology which helps people organize their schedule) or to create a better "leisure lifestyle." Interestingly, people with disabilities as a consumer group are not the target of sexually-oriented marketing. Media and advertisers promote an image of health and beauty to influence consumers. Thus, the physical and emotional benefits of leisure activity sometimes is forced to take a backseat to fashion, accessories or high-priced equipment which is more about promoting social status than recreation participation (Wynne, 1990).

As more people with disabilities become involved in mainstream society, a social benefit of public leisure involvement by people with disabilities is the reduction of the stigma that often is associated with people with disabilities. Sable (1995) showed that participation of youth with disabilities in regular recreation activity can positively impact non-disabled adolescents' acceptance of people with disabilities. The Americans with Disabilities Act of 1990 has been hailed as the most far-reaching piece of legislation affecting persons with disabilities (Stein, 1993). Leisure and recreation sites mandated to be accessible to people with disabilities include theaters, restaurants/bars and stadiums for sporting events. Access and participation in leisure for people with disabilities, individually and collectively, may be one of the best measures of acceptance and inclusion within society (Devine & Lashua, 2002).

Recreation's Therapeutic Nature: A Discipline's Focus

How have recreation professionals sought to identify and meet the needs of people with disabilities? The National Recreation and Park Association (NRPA) sponsors a yearly National Institute on Recreation Inclusion aimed to provide a forum where issues related to disability and leisure are discussed. Dattilo (2002) wrote a textbook dedicated to the rights of people with disabilities and their inclusion in recreation and leisure services. Full inclusion does not necessarily mean equal participation in all situations, but involves understanding personal and societal attitudes and using appropriate and respectful terminology regarding disability. Overcoming barriers to participation and facilitating self-determination of those with disabilities is important. Whenever possible they should own the experience of seeking and obtaining satisfying leisure and participate alongside people without disabilities (Dattilo, 2002).

The discipline of recreation therapy (also commonly referred to as therapeutic recreation) provides services to people with disabilities related to their need to access and participate in a meaningful leisure lifestyle. With some 40,000 practitioners within the United States, the profession of recreation therapy promotes the right to leisure for people with disabilities (Sylvester, 1992) and has served as the principal nexus between the recreation and leisure sciences and disability studies.

Recreation therapy is defined as using "treatment, education and recreation services to help people with illnesses, disabilities and other conditions to develop and use their leisure in ways that enhance their health, functional abilities, independence and quality of life" (National Therapeutic Recreation Society, 2000). Recreation therapy has roots in the clinical and medical arenas (Haun, 1966; Davis, 1952), but today practitioners also work in community settings with health protection and health promotion as a popular practice model (Austin, 1998). Recreation therapists work with people with disabilities to assess their needs related to leisure, help strengthen positive attitudes toward constructive leisure time use and increase skills, knowledge and use of resources. This education and training is done to empower the individual to participate independently in recreation and leisure activities of his or her choosing.
Typically recreation therapists, some 17,000 of whom are credentialed by the National Council of Therapeutic Recreation Certification (NCTRC, 2002), are employed in settings where people with disabilities or illness live, work or receive medical services. Some of these settings include nursing homes, mental health facilities, community recreation centers, hospitals and rehabilitation units, correctional settings, schools and non-profit community agencies.

The following serve as examples of how recreation therapists aim to use leisure or recreation interventions to enhance people's quality of life.

In nursing homes serving the elderly or younger persons who are ill or injured, a recreation therapist seeks to use purposeful, structured interventions such as reminiscence groups, reality orientation, sensory stimulation, animal assisted therapy, exercise, therapeutic humor, arts, crafts or horticulture to improve psychosocial well-being, physical and cognitive functioning and quality of life (Farias Tomaszewski, Jenkins & Keller, 2001; Mobily, Mobily, Lane & Semerjian, 1998).

In rehabilitation units and hospitals, recreation therapists work with people who are challenged by spinal cord or traumatic brain injuries, strokes, cancer, amputations and organ transplants where issues of self-confidence, pain management, boredom, community reintegration and changes to one's leisure lifestyle are addressed through individual counseling or group intervention (Holt & Ashton Shaeffer, 2001; Mobily & Verburg, 2001; Dattilo, Caldwell, Lee & Kleiber, 1998).

In community centers or schools, recreation therapists may work with youth with behavioral disorders, learning disabilities or mental retardation to learn how to identify and access leisure and recreation activities in the community, and to practice socially acceptable behavior while gaining skills in communication, trust and teamwork that will transfer over into other settings like the home or school (Howard, 2002; Howard & Peniston, 2002; Autry, 2001).

Assisting people with disabilities to access satisfying leisure lifestyles is paramount to assisting them in enjoying opportunities for sexual expression. Several examples from the clinical background of the authors will illustrate this point.

Children, ages 7 to 12, who were institutionalized in a residential program treating the effects of sexual and physical abuse and/or neglect, were enrolled in a county parks and recreation department's summer track program. Throughout this intervention, youth participated with other children from the community and were given instruction and opportunities to understand appropriate, non-sexualized behavior, the difference between good touches and bad touches, and how physical exercise can help in development of self-esteem and self-control and be an acceptable outlet for feelings that might lead to sexually-acting-out behaviors.

Patients from a spinal cord rehabilitation unit voiced their desire to attend a strip club as a leisure activity and the recreation therapist supported their plan out of respect for their autonomous choice.
A woman in a mental health facility confided to a recreation therapist that part of her depression was due to problems in her sex life where, according to her report, she resorted to self-stimulation because of apparent lack of interest on the part of her husband. She stated the lack of intimacy between the two of them exacerbated a diminished level of involvement in leisure pursuits they previously had found mutually satisfying.

By being aware of these types of situations and learning the best ways to promote independence while teaching needed skills and facilitating opportunities, health care practitioners can successfully incorporate important aspects of life relative to leisure, disability and sexuality.

Summary and Recommendations

This article has explored the role of leisure and recreation in people's lives. Specifically, for people with disabilities, issues related to leisure have been described based on their impact on disability and sexuality. Diminished participation in leisure and recreation severely hampers a person's opportunity to acquire a positive selfconcept and important social and interpersonal skills. Further, limited or negative leisure experiences decrease chances for the formation of meaningful relationships and participation in healthy sexual activity.

Every person in our society benefits from the full participation of all its members in enjoyable and satisfying lives. Awareness and acceptance of oneself as a sexual being is critical to quality of life and this is no less so for a person challenged by disability. Every aspect related to people who have disabilities and their access to sexual relationships and sexual exploration should be identified and understood. A fuller understanding of the nature and structure of leisure, recreation and play for people with disabilities will assist practitioners and researchers, and most importantly those individuals with disabilities, to act in ways which will allow individual growth and happiness. Ideally, sexuality will be experienced by individuals in situations that are self-determined and personally fulfilling, thus leading to growth and enjoyment.

The authors recommend that scholars, practitioners, educators, people who are advocates for people with disabilities and most importantly, people with disabilities themselves continue to study and consider the role of leisure in people's lives. Understanding likely barriers to leisure, dynamics associated with gender, race and culture, the potential effect of drug or alcohol use and the powerful effect of stigma on leisure for people with disabilities are crucial.

Leisure and how it interfaces with sexuality is a very important part of quality of life. Recreation adds variety, enjoyment and ample opportunity to make and keep friends. The role of leisure and recreational experience within the lives of people with disabilities is an essential part of a satisfying life and a primary pathway to love and intimacy in the most meaningful way.

References

AARP (2002). 2002 update: A survey of adult funstyles. American Association of Retired People. Retrieved June 18, 2002 from <www.aarp.org>.

AARP/Modern Maturity. (1999). AARP/Modern Maturity sexuality study. Retrieved June 18, 2002 from <www.modernmaturity.org>.

Aitchison, C. (1999). New cultural geographies: The spatiality of leisure, gender, and sexuality. Leisure Studies, 18, 19-39.

Allyn, D. (2000). Make love, not war: The sexual revolution, an unfettered history. Boston, MA: Little, Brown.

Austin, D. (1998). The health protection/health promotion model. Therapeutic Recreation Journal, 32(3), 109-123.

Autry, C. (2001). Adventure therapy with girls at risk: Responses to outdoor experiential activities. Therapeutic Recreation Journal, 35(4), 289-306.

Bedini, L. (2000). "Just sit down so we can talk:" Perceived stigma and community recreation pursuits of people with disabilities. Therapeutic Recreation Journal, 34(3), 55-68.

Bedini, L. (1991). Modern day "freaks"?: The exploitation of people with disabilities. Therapeutic Recreation Journal, 25(4), 61-70.

Blum, D. (1997). Sex on the brain: The biological differences between men and women. New York, NY: Viking.

Braddock, D. (1998). Mental retardation and developmental disabilities: Historical and contemporary perspectives. In D. Braddock, R. Hemp, S. Parish, & J. Westrich (Eds.) The state of the states in developmental disabilities (5th ed., pp. 3 21). Washington, DC: American Association on Mental Retardation.

Brown, J., Steele, J. & Walsh Childers, K. (2002). Sexual teens, sexual media: Investigating Media's Influence on Adolescent Sexuality. Mahwah, NJ: Erlbaum.

Carruthers, C. (1993). Leisure and alcohol expectancies. Journal of Leisure Research, 25(3), 229-244.

Cooper, M. (2002). Alcohol use and risky sexual behavior among college students and youth: Evaluating the evidence. Journal of Studies on Alcohol, 14, 101 117.

Dattilo, J.(2002). Inclusive leisure services: Responding to the rights of people with disabilities. State College, PA: Venture.

Dattilo, J. & McKenney, A. (2000) Values clarification. In J. Dattilo (Ed.) Facilitation techniques in therapeutic recreation. State College, PA: Venture.

Dattilo, J. & Williams, R. (1999). Inclusion and leisure service delivery. In E. Jackson & T. Burton (Eds.) Leisure Studies: Prospects for the Twenty First Century. State College, PA: Venture.

Dattilo, J., Caldwell, L., Lee, Y. & Kleiber, D. (1998). Returning to the community with a spinal cord injury: Implications for therapeutic recreation specialists. Therapeutic Recreation Journal, 32(1), 13 27.

Davis, J. (1952). Clinical applications of recreational therapy. Springfield, IL: Charles Thomas.

de Grazia, S. (1962). Of time, work, and leisure. Garden City, NY: Anchor.

DeLoach, C. (1994). Attitudes toward disability: Impact on sexual development and forging of intimate relationships. Journal of Applied Rehabilitation Counseling, 25(1), 18 25.

Devine, MA. & Lashua, B. (2002). Constructing social acceptance in inclusive leisure contexts: The role of individuals with disabilities. Therapeutic Recreation Journal, 36(1), 65 83.

Driver, B. & Bruns, D. (1999). Concepts and uses of the benefits approach to leisure. In E. Jackson & T. Burton (Eds.) Leisure Studies: Prospects for the Twenty First Century. State College, PA: Venture.

Druss, B., Marcus, S., Rosenheck, R., Olfson, M., Tanielian, T., & Pincus., H. (2000). Understanding disability in mental and general medical conditions. American Journal of Psychiatry, 157(9), 1485 1491.

Dugan, J. (2001). Positive and negative leisure in adolescence. Retrieved July 8, 2002 from <www.personal.psu.edu /faculty/n/x/nxd10/adleis2.htm>.

Duffy, E. (2001). Is alcohol frequently used by adolescents as a leisure activity? Retrieved July 8, 2002 from <www.personal.psu.edu/faculty/n/x/nxd10/adleis2.htm>.

Ellis, M. (1973). Why People Play. Englewood Cliffs, NJ: Prentice-Hall.

Eisert, D. & Lamorey, S. (1996). Play as a window on child development: The relationship between play and other developmental domains. Early Education and Development, 7(3), 221-235.

Farias Tomaszewski, S., Jenkins, S. & Keller, J. (2001). An evaluation of therapeutic horseback riding programs for adults with physical impairments. Therapeutic Recreation Journal, 35(3), 250-257.

Floyd, M., McGuire, F., Shinew, K. & Noe, F. (1994). Race, class, and leisure activity: Marginality and ethnicity revisited. Journal of Leisure Research, 26(2), 158 173.

Gill, C. (1996). Dating and relationship issues. Sexuality and Disability, 14(3), 183 190.

Godbey, G. (1999). Leisure and sexuality. In Leisure in your life: An exploration. State College, PA: Venture.

Goodale, T. & Godbey, G. (1988). The evolution of leisure. State College, PA: Venture.

Graddy, J. (2000). Dangerous bedfellows: Alcohol and sex. Retrieved July 8, 2002 from <www.health.ufl.edu/shcc/alc02.pdf>.

Groff, D. & Kleiber, D. (2001). Exploring the identity formation of youth involved in an adapted sports program. Therapeutic Recreation Journal, 35(4), 318 332.

Haun, P. (1966). Recreation: A medical viewpoint. New York, NY: Teachers College Press.

Hayden, M. (2000). Social policies for people with disabilities. In J. Midgley, M. Tracy, & M. Livermore (Eds.) The Handbook of Social Policy. Thousand Oaks, CA: Sage Publishing, Inc.

Hochstenbach, J. (2000). Rehabilitation is more than functional recovery. Disability and Rehabilitation, 22(4), 201-204.

Holt, M. & Ashton Schaeffer, C. (2001). TR's role in meeting the needs of heart transplant patients. Parks and Recreation, 36(5), 58 65.

Howard, D. (2002). Recreation's therapeutic nature: Professionals positioned to help children and youth at risk. In A. McKenney & D. Hibbler (Eds.), Serving Youth At Risk: Parks, Recreation and the Public Schools. Proceedings from Florida International University's Center for Urban Education & Innovation Youth At Risk Symposium, April 7, 2001.

Howard, D. & Peniston, L. (2002). The role of recreation in preventing youth with disabilities from coming into contact with the juvenile justice system and preventing recidivism. Washington, DC: Center for Effective Collaboration and Practice. Available from <www. cecp.air.org>.

Huizinga, J. (1950). Homo ludens. Boston, MA: Beacon.

Hunt, S. (1997). The problem of quality of life. Quality of Life Research, 6, 205 212.

Jackson, E. & Scott, D. (1999). Constraints to leisure. In E. Jackson & T. Burton (Eds.) Leisure Studies: Prospects for the Twenty-First Century. State College, PA: Venture.

Jenkinson, S. (2001). The genius of play: celebrating the spirit of childhood. Stroud, England: Hawthorn.

Kaplan, D. (2000). The definition of disability: Perspective of the disability community. Journal of Health Care Law and Policy, 3(2), 352 364.

Kelly, J. & Freysinger, V. (2000). 21st century leisure: current issues. Needham Heights, MA: Allyn & Bacon.

Linder, S. (1970). The harried leisure class. New York, NY: Columbia University.

Mannell, R. & Reid, D. (1999). Work and leisure. In E. Jackson & T. Burton (Eds.) Leisure Studies: Prospects for the Twenty-First Century. State College, PA: Venture.

Marsiglio, W. (1998). Procreative man. New York, NY: New York University Press.

McKenney, A. & Datillo, J. (2001). Effects of an intervention within a sport context on the prosocial behavior and antisocial behavior of adolescents with disruptive behavior disorders. Therapeutic Recreation Journal, 35, 123 140.

Michael, R. Gagnon, J., Laumann, E. & Kolata, G. (1994). Sex in America: A definitive survey. Boston, MA: Little, Brown.

Mobily, K. & Verburg, M. (2001). Aquatic therapy in community-based therapeutic recreation: pain management in a case of fibromyalgia. Therapeutic Recreation Journal, 35(1), 57 69.

Mobily, K., Mobily, P., Lane, B. & Semerjian, T. (1998). Using progressive resistance training as an intervention with older adults. Therapeutic Recreation Journal, 32(1), 42 53.

Moir, A. & Jessel, D. (1991). Brain sex: The real difference between men and women. New York, NY: Carol.

National Therapeutic Recreation Society (2000). Definition of therapeutic recreation practice. Retrieved July 1, 2002 from <www.nrpa.org>.

Parker, H. (1998). Illegal leisure: The normalization of adolescent recreational drug use. New York, NY: Routledge.

Pieper, J. (1963). Leisure: The basis of culture. Winnipeg, Canada: Mentor.

Pritchard, A., Morgan, N., Sedgley, D., Khan, E. & Jenkins, A. (2000). Sexuality and holiday choices: Conversations with gay and lesbian tourists. Leisure Studies, 19, 267 282.

Radnitz, C., Tirch,D., Vincinguerra, V. & Moran, A. (1999). Substance abuse and disability. In R. Ammerman, P. Ott., & R. Tarter (Eds.) Prevention and Societal Impact of Drug and Alcohol Abuse. Philadelphia, PA: Hahnemann.

Raymore, L., Godbey, G. & Crawford, D. (1994). Self esteem, gender, and socioeconomic status: Their relation to perceptions of constraint on leisure among adolescents. Journal of Leisure Research, 26(2), 99 118.

Rifkin, J. (1995). The end of work: The decline of the global labor force and the dawn of the post market era. New York, NY: G.P. Putman's Sons.

Rintala, D., Howland, C., Nosek, M., Bennett, J., Young, ME., Foley, C., Rossi, D. & Chanpong, G. (1997). Dating issues for women with physical disabilities. Sexuality and Disability, 15(4), 219 242.

Roeher Institute (1989). The pursuit of leisure: Enriching the lives of people who have a disability. Downsview, Ontario, Canada.

Rybczynski, W. (1991). Waiting for the weekend. New York, NY: Viking.

Sable, J. (1995). Efficacy of physical integration, disability awareness, and adventure programming on adolescents' acceptance of individuals with disabilities. Therapeutic Recreation Journal, 29(3), 206 217.

Schor, J. (1992). The overworked American. New York, NY: Basic.

Seefeldt, C. (2001). Playing to learn. Beltsville, MD: Gryphon House.

Shaw, S. (1999). Gender and leisure. In E. Jackson & T. Burton (Eds.) Leisure Studies: Prospects for the Twenty-First Century. State College, PA: Venture.

Shaw, S., Kleiber, D. & Caldwell, L. (1995). Leisure and identity formation in male and female adolescents: A preliminary examination. Therapeutic Recreation Journal, 27(3), 245 263.

Snow, P., Wallace, S. & Munro, G., (2001). Drug education with special needs populations: identifying and understanding the challenges. Drugs: Education, Prevention & Policy, 8(3), 261 273.

Soldo, B. & Freedman, V. (1994). Medical demography: interaction of disability dynamics and mortality. In L. Martin & S. Preston (Eds.) Demography of Aging. Washington, DC: National Academy Press, 1994.

Stein, J. (1993). The Americans with Disabilities Act: Implications for recreation and leisure. In Leisure Opportunities for Individuals with Disabilities: Legal Issues, Grosse, S. & Thompson, D. (Eds). American Alliance for Health, Physical Education, Recreation, and Dance.

Sylvester, C. (1992). Therapeutic recreation and the right to leisure. Therapeutic Recreation Journal, 26(2), 9 20.

Tepper, M. (1999). Letting go of restrictive notions of manhood: Male sexuality, disability and chronic illness. Sexuality and Disability, 17(1), 37 52.

van den Akker, O. & Lees, S. Leisure activities and adolescent sexual behavior. Sex Education, 1(2), 137 147.

Veblen, T. (1899). The theory of the leisure class. Mineola, NY: Dover. Reprinted 1994.

Widmer, M., Ellis, G. & Trunnell, E. (1996). Measurement of ethical behavior in leisure among high and low risk adolescents. Adolescence, 31(122), 397 408.

Williams, R. & Dattilo, J. (1997). Effects of leisure education on self determination, social interaction, and positive affect of young adults with mental retardation. Therapeutic Recreation Journal, 31, 244 258.

World Health Organization (2001). International Classification of Functioning, Disability and Health. Endorsed by the 54th World Health Assembly on May 22, 2001. Retrieved June 19th from <www3.who.int/icf/icftemplate.cfm>.

Wynne, D. (1990). Leisure, lifestyle, and the construction of social position. Leisure Studies, 9, 21 34.

Young, M., Rintala, D., Rossi, C., Hart, K. & Fuhrer, M. (1995). Alcohol and marijuana use in a community based sample of persons with spinal cord injury. Archives of Physical Medicine and Rehabilitation, 76, 525 532.