Sexual and reproductive health is a fundamental human right and a core component of well-being, including for individuals with disabilities. Despite increasing attention, sexuality in disability remains under-addressed due to persistent structural, cultural, and educational barriers. Clinical approaches have historically relied on models such as PLISSIT and its evolutions (ex-PLISSIT), providing a foundation for addressing sexual health. However, with growing awareness of intersectionality, these models need to be expanded within more inclusive frameworks. Contemporary approaches should incorporate LGBTQI+ perspectives and recognize pelvic floor rehabilitation as integral to sexual well-being. Therefore, a comprehensive, multidisciplinary model is needed to address the diverse dimensions of sexuality in disability. This work aims to overview sexual function across different disabilities and propose an updated, inclusive clinical model.

A narrative literature review was conducted integrating epidemiological data, clinical evidence and sociocultural perspectives on sexuality and disability. The analysis addressed sexual dysfunctions, risk of abuse, LGBTQI+ identities and healthcare access across intellectual, motor, sensory, neurodivergent and psychiatric disabilities. Particular attention was given to perineal dysfunctions. The ALIVE+ model was developed through integration of literature findings with clinical experience in neurorehabilitation, pelvic floor rehabilitation and sexual medicine, and refined through multidisciplinary collaboration.

Individuals with disabilities report levels of sexual activity comparable to the general population but face significant barriers. Notably, children with disabilities have a threefold higher risk of sexual abuse, increasing to 2.5–10 times in intellectual disabilities, with prevalence in boys reaching 13.8% vs 3.7% in peers without disabilities .
Sexual dysfunctions vary by subtype (table 1):
-Intellectual disabilities: premature ejaculation, erectile dysfunction, hypoactive desire, anorgasmia, dyspareunia.
-Motor disabilities: erectile dysfunction, ejaculatory disorders, reduced libido, anorgasmia, vaginal dryness, dyspareunia.
-Sensory disabilities: preserved physiology but relational/communication barriers and higher abuse risk.
-Neurodivergence: anorgasmia, premature ejaculation, fluctuating libido, sensory-related difficulties.
-Psychiatric conditions: reduced libido, arousal disorders, anorgasmia, erectile dysfunction, or hypersexuality.
Evidence on the prevalence of sexual dysfunction is limited and inconsistent; it is likely underdiagnosed due to stigma and limited clinical attention.
Within this framework, the ALIVE+ model (fig.1) is proposed as a structured and inclusive approach: Ask & Affirm, Language & Listening, Information & Intervention, Visit & Validation, and Education & Empowerment, with “+” indicating multidisciplinary teamwork.
The ALIVE+ model provides a cultural and clinical framework to systematically include and address these elements, such as abuse risk and diverse sexual dysfunctions, within routine care. The model integrates communication, clinical evaluation (including pelvic health), and tailored interventions, positioning pelvic floor rehabilitation as a key tool to improve sexual function and quality of life, while promoting autonomy, dignity, and person-centered care.

These findings highlight that disability represents an umbrella term encompassing highly heterogeneous conditions; therefore, effective clinical management requires the ability to identify prevalent dysfunctions within each subgroup and to tailor (phenotype) interventions to the individual. A one-size-fits-all approach is inadequate, as sexual health needs vary according to neurological, cognitive, psychological, and social factors. In this context, the ALIVE+ model offers a simple yet comprehensive framework that supports a cultural shift in clinical practice. It provides healthcare professionals with a practical and accessible guide to address sexuality in an inclusive, respectful, and structured way, while also facilitating appropriate referral to specialized services when needed. By integrating intersectionality, LGBTQI+ inclusivity, and rehabilitation strategies, this model contributes to reducing stigma, improving access to care, and enhancing clinical and psychosocial outcomes.

Sexuality is an essential component of health and human dignity for people with disabilities. Integrating established models such as ex-PLISSIT with innovative frameworks like ALIVE+ is crucial to ensure inclusive, multidisciplinary, and effective sexual healthcare. This approach supports a modern vision of sexual well-being grounded in autonomy, inclusivity, and human rights.

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