Although many have posited sexuality counseling as a specialty, the universal nature of sexual experience makes it reasonable to expect counselors to have a basic knowledge of sexuality and sexuality counseling interventions. Because sexuality is a developmental process, the likelihood that a counselor will work with clients struggling with some aspect of their sexuality is high, regardless of the counselor’s concentration or setting. Although sexuality counseling does require specialized interventions, counselors need to increase their competency in meeting the needs of their clients.

Currently, standards from the Council for Accreditation of Counseling and Related Educational Programs only require that a sexuality counseling course be included as part of the marriage, couples and family counseling concentration. Although some programs offer sexuality counseling as an elective course, many counselors graduate from their programs without this specific training. As a result, counselors need to be proactive in seeking professional development opportunities beyond their graduate-level training. Specific goals to increase sexuality counseling competency include:

• Exploring the various dimensions of sexuality
• Increasing self-awareness regarding sexual biases, values and beliefs
• Increasing comfort with addressing sexuality with clients 
• Becoming more proficient in the assessment and diagnosis of sexual problems
• Increasing knowledge of healthy sexual development

 Introduction to sexuality counseling

An introduction to sexuality counseling involves two components:

1) Becoming aware of sexuality-related constructs and myths to target the biases, values and beliefs of counselors and counselors-in-training

2) Defining sexuality counseling

Although sexuality counseling has often been viewed as a specialty within the counseling profession, there is increasing support to view it instead as an area in which all counselors need to demonstrate a basic degree of proficiency because it is relevant in all developmental stages across the life span. In their book Sexuality Counseling for Couples: An Integrative Approach (2006), Lynn L. Long, Judith A. Burnett and R. Valorie Thomas define sexuality counseling as “a process that addresses sex education, values clarification, exploration of sexual attitudes and beliefs, and exploration of self-image, sexual identity, gender role development and relationship issues.” Maintaining a broad definition of sexuality counseling expands the clientele with whom interventions may be implemented to assist in meeting their overall wellness goals. We also want to emphasize that the process of sexuality counseling often begins in individual counseling and expands to couples counseling.

As counselors enter the counseling relationship, they also bring their own subjective experiences of sexuality, much of which they may not be aware of until and unless sexuality becomes the focus of the counseling process. Lack of awareness can lead to counselors responding in a manner that is not therapeutic for clients, such as changing the subject, minimizing the client’s concern, or providing inaccurate or biased information. On the other hand, increased self-awareness regarding sexuality equips counselors to manage their own emotional responses and maintain objectivity. Counselors can increase their self-awareness and their comfort level addressing sexuality in various ways, including:

• Writing down personal definitions of terms related to sexuality (for example, sexuality, sexual orientation, gender, gender roles and gender identity), discussing those definitions with colleagues and/or supervisors, and researching definitions of these constructs through the American Association of Sexuality Educators, Counselors and Therapists (AASECT), the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC) and other organizations.
• Attending conference workshops focused on sexuality. Networking with other professionals can provide valuable opportunities to collaborate on cases, discuss personal reactions and increase knowledge and awareness of sexuality counseling.
• Seeking information on sexuality from reputable websites such as siecus.org (the Sexuality Information and Education Council of the United States), scarleteen.com (Sex Ed for the Real World) or iasscs.org/program/archive-sexology (Archive for Sexology).
• Exploring myths that self and/or others have expressed about sexuality. This includes considering stories, images and messages received from culture and family about gender, relationships and sexual behavior. Some examples may include:
• Gender: “Boys don’t cry.” “Girls are sugar and spice.”
• Relationships: Believing it is your partner’s job to make you happy. Believing that conflict in a relationship means the relationship is in trouble.
• Sexual behavior: “Men think about sex all of the time.” “Women are less sexual than men.”
• Joining professional organizations or networks that focus on sexuality. These include AASECT, ALGBTIC, the American Counseling Association’s Sexual Wellness in Counseling Interest Network and others.

Sexual dysfunction

Although counselors need to be aware of healthy aspects of the developmental experience of sexuality, they also need to be knowledgeable about sexual dysfunction. It is important to assess the limitations of one’s expertise and know when to refer a client to a certified sex therapist. Sex therapists specialize in the treatment of sexual dysfunctions. Prior to making a referral, it may be necessary to educate clients about the nature of sex therapy to dispel myths and increase their willingness to pursue more intensive interventions for sexual concerns because many clients worry about stigmatization.

Assessment is essential to determining if a referral is more appropriate than providing sexuality counseling interventions. The Diagnostic and Statistical Manual of Mental Disorders (DSM) outlines sexual dysfunctions recognized by the American Psychiatric Association. According to the DSM-5, sexual dysfunctions have been modified from previous editions to deviate from Kaplan’s sexual response cycle, noting that these phases may not be distinct. Sexual dysfunctions are gender specific, and there is a requirement that symptoms be present for at least six months and that the severity of the symptoms meet specific criteria.

Sexuality issues

Sexuality concerns go beyond dysfunction. Many clients experience distress over normal developmental sexual experiences, such as sexual orientation and gender identity, and over experiences that fall outside of normal sexual development, such as sexual trauma. For normal sexual development concerns, the counselor may implement interventions focused on assisting the client in resolving dilemmas between “self” and “other” concepts such as cultural and/or religious beliefs and sexual experiences, values and behaviors, or biological and psychological aspects. It is helpful for counselors to reach beyond the binary conceptualization of these social constructs (male/female, gay/straight, etc.). One model that may be beneficial in assisting counselors and clients to view sexuality as a fluid construct is Whalley’s Continua (2005), which asserts that sexuality has several components that may be viewed as continua, with clients falling somewhere between two extremes. This model identifies biological sex, sexual orientation, gender and gender expression as distinct aspects of sexuality that interact to create a total picture of a person’s sexual identity. The use of flexible models such as Whalley’s Continua allows counselors to have an open dialogue with clients during assessment and intervention stages about various aspects of their sexual experience and expression, rather than making assumptions.

For those experiences that fall outside of the norm, such as trauma, interventions would focus on minimizing the negative impact and symptoms associated with those experiences. Specific, evidence-based treatment approaches have been established to focus on traumatic responses. Numerous assessments are accessible to counselors to determine traumatic symptoms. In addition, trauma — particularly sexual trauma — has a significant impact on an individual’s sexual functioning.

Specific to childhood sexual trauma, a lack of knowledge might exist concerning what is a normal and not-so-normal sexual experience. One of the authors of this article had a former client who had experienced sexual abuse as a child and rape as an adult. It was difficult for this client to discern physical sensations that were healthy and pleasant. In her particular situation, the client first needed to become comfortable with her own body and learn about where specific genitalia were located. Once she became familiar with her body and the sensations created when her genitalia were touched, this demystified some of the previous trauma-related associations she had with sexual experiences.

Models of sexuality counseling

Several approaches have been established in sexuality counseling, each with distinct assumptions regarding sexuality that guide the techniques used to address the sexual concerns of clients.

Behavioral and cognitive-behavioral approaches assume that sexual behavior is learned and, therefore, can be unlearned. As such, a person’s sexual history is based on past behaviors and can be changed through behavioral rehearsal. From this perspective, interventions may include:

• Psychoeducation: Providing education regarding sexual experiences that are normal, developmental and abnormal. 
• Cognitive restructuring: Addressing thinking errors and myths regarding sexuality and sexual behavior.
• Caring days: Each partner creates a list of detailed behaviors he or she would like his or her mate to perform, and both partners are assigned to engage in these behaviors on a consistent basis.
• Behavioral techniques: Addressing specific sexual concerns through techniques such as systematic desensitization, assertion training and squeeze/start-stop techniques.

Murray Bowen’s intergenerational approach assumes that family patterns are repeated within a relationship, which can result in sexual problems. Specific emphasis is placed on the level of differentiation as essential in maintaining intimacy and sexual desire. Given this premise, interventions that counselors would use include:

• Genograms: A pictorial means of gaining information regarding family patterns. It typically includes a minimum of three generations.
• Detriangulation: Recognizing dysfunctional communication patterns and encouraging direct communication.

Problem-focused approaches assert that sexual problems exist to keep couples in balance and occur within a system, with changes to one part of the system affecting all other parts of the system. This mode of therapy is brief, usually taking place within 10 sessions. Interventions from this perspective include:

• Joining: The process of connecting with each member in the client system.
• Enactment: Developing enactments or scenes typical of the couple’s dynamics to diagnose the problem and create change.
• Reframing: Communicating a person’s experience in a way that shifts his or her perspective.
• Directives: Addressing client behaviors by giving specific instructions to illicit a new behavior.
• Rituals: Events that provide meaning for clients.

Solution-focused approaches assume that change is inevitable and emphasize identifying solutions to problems rather than focusing on how the problem developed. In addition, strengths are highlighted, and only small changes are necessary. Interventions include use of:

• The miracle question: “Suppose a miracle happens tonight and your sexual concern is gone. What would be different?”
• Scaling: Framing likelihood for change on a scale of 1 to 10. “What makes that the number you chose?”
• Highlighting previous successes: Looking for times when the client (or clients) solved the problem successfully in the past. 

Communication approaches assume that open communication fosters healthy sexual relationships. On the basis of this assumption, behavior serves to communicate in verbal and nonverbal ways, maintaining connection in a relationship. As such, techniques include:

• The use of “I” statements 
• Communication and problem-solving skills training 

The integrative model for sexuality counseling (emphasized by Lynne L. Long, Judith A. Burnett and R. Valorie Thomas) uses a systematic focus of understanding problems from both partners’ perspectives to reduce blame and increase collaboration. This model stresses cognitive, affective and behavioral changes in sexual patterns using resources and strengths. The model incorporates five stages: assessment, goals setting, interventions, maintenance and validation.

Assessment in sexuality counseling

Just as it is important to be aware of personal biases and to determine a model of sexuality counseling, assessment is essential to conceptualizing a client’s sexual concern. Prior to assessing, a counselor should contemplate several questions that will aid the process.

• Who is the conversation for?
• What is the purpose of gathering information? What will be done with it?
• What does the client need or want to tell? What will he or she find useful in this conversation?
• Is there anything I know thus far that would indicate sexual issues?
• Am I avoiding asking about sex, or is it really not relevant?
• Will my client feel comfortable talking to me about sex? How will I know?
• How will I know if I am being inappropriate or intrusive with my questions? 

After a counselor has pondered these questions, the next step is determining the most effective means of assessment. The counseling model may help in determining the specific assessment tool, but options should not be limited based solely on the model. It is also important to take into account a client’s needs, level of functioning and personality characteristics to determine the most effective means of assessment. Some examples of assessments of sexual concerns include:

• Sexual genogram: Using a genogram, explore messages, gender roles, behaviors, communication, secrets and history related to sexuality. 
• Sexual history: Usually used with preadolescents and older clients. Using a form, ask questions about details of the client’s sexual behavior. 
• Formal tests: Select formal assessment tools after looking at psychometric properties, the nature of the problem and ease of administration. These tools should be used early in the counseling process. Ideally, a combination of measures is more helpful.
• Observation: Includes what the counselor notices in session in the client’s verbal and nonverbal behaviors, the client’s self-observations and so on.

Treatment planning and maintenance

After assessment of sexuality and sexual behavior has been conducted, the next steps involve identifying goals, developing a treatment plan and implementing interventions. When setting goals with a client, it is important to first determine a common definition of the problem. Counselors should clarify terminology used by clients for sexual concepts to ensure that a mutual understanding is present. When a significant difference exists between the perspectives of the counselor and the client with regard to sexual language, an agreement should be reached concerning terminology to be used in the counseling process to minimize confusion.

Making goals realistic and behavioral in nature will increase the likelihood of success due to the ability to measure progress. It is also important to view sexual concerns as external to the client rather than being an aspect of the client’s personality to minimize blame and empower the client to make necessary changes. For example, a client who does not initiate sex with a partner may view the sexual concern as a “time problem” rather than an unwillingness to have sex or a lack of attraction to the partner. When working with a couple, it is important to assist the couple in developing a mutual definition of the problem and goals.

Once clear and measurable goals are established, the counselor is then able to determine the most appropriate intervention to address the sexual concern. Sexuality counseling interventions are viewed as active in nature, requiring the client to be the primary means of facilitating change and monitoring the effect of implemented changes. As the client moves forward in addressing sexual concerns, interventions move toward maintenance, which involves scaling back on sessions, educating the client about relapse and setbacks, and modifying the environment to support new behaviors. Preparing clients for setbacks includes discussing life events, stressors and resources.

Summary

The nature of sexuality counseling is being redefined as an essential skill for counselors, regardless of concentration. Although clients may enter into counseling with a specific sexuality concern, often they may feel uncomfortable discussing sexuality or may not be aware of the connection between sexual behavior and overall wellness. It may not be obvious that there is a sexual concern, making it essential to be direct when addressing sexuality with clients. There are numerous ways counselors can communicate an invitation for clients to discuss sexuality, including having books on the bookshelf that focus on sexuality and sexual behavior. Clients will notice this as they look around your office space, and that may offer reassurance that you are comfortable discussing sexuality concerns.

Another means of opening that door of discussion to clients is to include sexuality-specific questions in the assessment process, including specific questions on an intake form. For example, if a client presents with depression symptoms, you may ask, “How has your mood affected your sex life?” Or you may ask about the client’s sexual functioning regardless of whether symptoms are present (“How has your sex life been lately?”).

The case of a former client demonstrates the importance of the intake form in encouraging discussions around sexuality. In essence, the client knew he was being deployed in a few months and said he was concerned about the viability of his relationship with his girlfriend. This was discussed in the initial counseling session, but the presenting concern on the intake form mentioned he thought he could have a sexual addiction. In the next session, the intake form was used to introduce this. He revealed that he was masturbating extensively to online pornography but did not have a physical relationship with his girlfriend. Bringing the topic up through the intake form appeared to give the client permission to discuss his concerns openly.

Another way to introduce this topic in counseling is to highlight sexuality as part of overall wellness when discussing your philosophy of counseling.

Because counselors-in-training may not be required to take or even have access to a specific course in sexuality counseling, it is important that counselors seek opportunities to build their skills in addressing sexuality with all clients, regardless of age.

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Knowledge Share articles are adapted from sessions presented at American Counseling Association conferences.

 

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Wynn Dupkoski Mallicoat is a licensed professional counselor, licensed professional counselor supervisor, facilitator of ACA’s Sexual Wellness in Counseling Interest Network and contributing faculty member at Walden University. Her research emphasis has focused on enhancing sexuality counseling training through presentations, publications and leadership. Contact her at wenndy.mallicoat@waldenu.edu.

Donna M. Gibson is an associate professor of counselor education at Virginia Commonwealth University. She is a licensed professional counselor and a past president of the Association for Assessment and Research in Counseling, a division of ACA. Contact her at dgibson7@vcu.edu.