Human sexuality is a topic that concerns every person, and sex-related issues are likely to appear in the counseling room. While some counselors will be prepared for these moments, others may not be. They may not know what to say or do if clients present sex-related concerns, or they may feel nervous, resistant or uneasy with the conversation. To overcome this, it’s important that we examine why sex is difficult to talk about with clients and better prepare and train counselors on sexuality to minimize discomfort and increase competence.
Finding adequate sex education training can be challenging. Human sexuality courses are often not required in programs accredited by the Council for Accreditation of Counseling and Related Educational Programs (CACREP). In the CACREP standards, sex and human sexuality are only cited under marriage and family therapy, clinical rehabilitation counseling, and rehabilitation counseling entry-level specialty areas. The clinical mental health counseling specialty area, which is the largest accredited area according to CACREP’s most recent annual report, does not mention sexuality at all. It’s not surprising then that many counselors who are knowledgeable about this topic are self-taught through personal research or by actively seeking training opportunities and resources.
However, there appears to be a shift in perspective regarding sexual wellness in the counseling profession. In the forthcoming 2024 CACREP standards, the lifespan development core standard does include sexual development and sexuality concerning overall wellness, demonstrating progress in advocacy efforts by many in the field for future counselors-in-training.
Learning more about human sexuality will allow us to continue to grow professionally and improve our knowledge of various aspects of the human experience, including sexuality, and ethically address those aspects of our clients’ lives.
The relevance of sexuality for clients
Counselors can benefit from and enrich their clients’ lives by understanding that sexual wellness is wellness and that pleasure is an act of self-care. Because much of the human experience involves participating in relationships — whether platonic, work/business-related, familial or intimate — counselors need to be prepared to talk about all aspects of those relationships. Creating space for discussing sex and sexuality in counseling helps foster an environment where the client is seen as a whole person. In turn, this allows the counselor to better understand the client. Clients’ views on their sexual self and sexuality can also provide insight into their self-image, confidence within their bodies and even their relationships with others.
Incorporating sexual wellness into sessions can help clients discover paths of sexual exploration and pleasure in all parts of their life. Counselors can use conversations on sex-related topics as an opportunity to educate clients on sexual anatomy, health and functioning to help them better understand their bodies and sexual experiences, which can increase overall pleasure. Counselors are also uniquely positioned to dispel taboos of sex and sexuality.
Hearing about clients’ sexual histories, concerns and barriers in engaging with their sexual selves exposes counselors to potential areas for advocacy in their communities. For example, if a counselor is working with a client with a disability who expresses difficulty accessing their local bondage, discipline, dominance and submission dungeon because it lacks ramp access or they struggle to navigate inside the club, then they could advocate for ramp access to the facility using the Americans with Disabilities Act as a reference or talk to the owners about hosting an “accessibility night” where individuals with all types of disabilities can participate. Providing a space where clients can holistically narrate their life’s wholeness without shame or persecution creates opportunities for growth and promotes overall wellness.
Let’s consider a few ways sexual wellness can impact our clients’ lives. Sexuality is a significant aspect of our clients’ lives, and sometimes sexual concerns can be a symptom of an underlying cause such as depression and anxiety. It is common for someone dealing with depressive symptoms to experience a decrease in their sexual desire and activity or for someone dealing with anxiety to have difficulty with orgasm, erection or ejaculation. Sexual trauma(s) can also affect a person’s sexual self or their concept of pleasure, and couples experiencing disharmony in their relationship are likely to encounter a lack of intimacy, which can negatively affect their sex life.
Addressing these concerns or just simply paying attention to sexual wellness can improve the client’s sexual satisfaction and mental health. Additionally, we need to consider the intersectionality of our client’s sexuality with other areas of their identities. Unpacking how factors such as race, gender and class affect sexuality can lead to some powerful insights and growth for a client when developing their sexual self. Exploring the intersectionality between sexuality and other areas of health, such as mental, physical and emotional, can also help clients to liberate themselves so that they may embrace their sexuality in all areas of their life.
If any counselor operates from a mindset of “That is not my place, and sex stuff should be addressed with a sex therapist,” then a major injustice is being done to clients, and they will miss a critical part of the puzzle. However, if counselors incorporate sex and sexuality into the counseling process, then they can provide support in educating, liberating, healing and advocating for their clients (sexual) wellness.
Using the PLISSIT model to address sexual health
The PLISSIT model, which was developed by Jack Annon in 1976, is one prevalent sex therapy model that counselors can integrate into their work with clients. The acronym PLISSIT stands for permission, limited information, specific suggestions and intensive therapy. This model provides a guide to assist counselors in facilitating appropriate interventions and conversations to work with clients around any sex-related concern. For example, if a clinician has a client who reports they are struggling with initiating and engaging in sexual activities with partners, the counselor can use the PLISSIT model to help the client minimize those difficulties.
Counselors do not have to be trained in treating depression or anxiety to allow clients space to speak openly about their experiences or provide psychoeducation about the physiological effects they are experiencing and ways anxiety or depression can manifest. The same is true for sexual health. In fact, all counselors can operate within the first three interventions of the PLISSIT model — permission, limited information and specific suggestions. Many of these interventions are ones that counselors already use with clients. The permission intervention involves creating a safe and open environment by showing unconditional positive regard during conversations about sex and sexuality, supporting clients in their struggles and desires, and giving clients permission to explore their attitudes, beliefs and history with their sexuality as they desire. The limited information intervention includes helping clients develop language to communicate their sexual needs, providing sex education or engaging in conversations about how their culture or peer influences may affect their views around sex. With the specific suggestion intervention, clinicians develop specific strategies to tackle clients’ concerns, such as educating them on sexual practices, developing a sexual script or exploring the root of their sexual fears and anxieties.
Because the interventions of the PLISSIT model build on one another, counselors should move through the first three interventions in a sequential order, but after working through each of the first three intervention levels, clinicians can cycle back to the previous interventions as needed. The length of time that practitioners use the “PLISS” portion of the model depends on the client’s ongoing progress with their concern.
If a client’s sexual concern progresses past a point where the first three interventions are not enough to address the problem, then the individual may benefit from more sex-focused counseling beyond what the counselor can provide with their current treatment plan and counseling goals. At this point, it would be appropriate to engage in the intensive therapy intervention and either refer out to a sex therapist or work with the client specifically on this concern if the clinician is trained in sex therapy.
Barriers to discussing sex with clients
Comfort with the topic of sex and sexuality serves as one barrier that often prevents counselors from broaching the topic with clients. Individuals may not feel comfortable talking about sex in their personal lives, let alone their professional ones. Initiating a conversation about sex can increase the clients’ comfort in discussing topics around sexual wellness and concerns that may be pertinent in their lives and within their presenting issues.
One could argue that letting a counselor’s own discomfort with the topic stop them from assessing, exploring and providing clients with opportunities to discuss sexuality and sexual wellness violates our ethical code because it allows the counselor’s personal values, beliefs and attitudes to influence a client’s treatment. Standard A.4.b. in the 2014 ACA Code of Ethics states that we have to be aware of and avoid imposing our values, attitudes, beliefs and behaviors on our clients. Even if discussing sex makes the counselor uncomfortable, they still need to assess the client’s interest in engaging in conversations around their sexual wellness and foster an environment that lets the client know that it is safe and appropriate to talk about this topic as it comes up. To be ethically and culturally competent counselors, we must ensure that our own “stuff” does not affect the assessment and interventions we use with clients.
Competency and lack of knowledge are two other reasons why counselors may not discuss sexuality or sexual wellness with clients. Often, competence increases comfort. Consider a topic that you feel that you know a lot about. Would you feel comfortable talking about it or bringing it up with clients as appropriate? The answer would probably be yes because when counselors feel knowledgeable about a subject, they are more comfortable talking about it. The first step in gaining competency is to develop the language needed to talk about sex. Counselors who do not know or are unfamiliar with sexual terminology may feel less inclined to broach the subject of sex with clients. It’s essential to use the correct body anatomy and reproductive system terminology. Learn common terms for various sexual and gender orientations and identities. It would also be helpful to educate yourself on what kink and other related sexual practices are. Although it is impossible to know every relevant term, counselors need to be willing and open to become familiar with the potential language clients may use in session by staying current in sexuality-related research, attending trainings and workshops or joining professional organizations. Increasing sexual knowledge and competency through language could help counselors feel more comfortable discussing sex-related topics and concerns with clients.
Increasing counselor competence
There are several ways the counseling profession can help clinicians increase their sexuality competence. The most crucial step is to increase training opportunities for counselors-in-training and practicing counselors. In counseling training programs, counselor educators could intentionally include topics about sex and sexuality from a sex-positive lens within various course curricula. Sex positivity encourages people to embrace, explore and learn about their sexuality without judgment or shame. Teaching counselors to approach sex from this lens could have powerful implications for clients. For example, a multicultural counseling course can include conversations about how different cultures and religions view and address sex and sexuality. An ethics course can include discussions on how to discuss sex with clients in an ethical way and how to maintain healthy boundaries while adhering to the ACA Code of Ethics. A human development through the lifespan course can include information on sexual development and expression in each life stage. In an assessment course, students can practice asking questions about sex during the initial interview, and a skills course can allow students to practice incorporating the PLISSIT model in session. All of these suggestions can be used in addition to having a human sexuality course in the curriculum.
Counselor practitioners can also increase their sexuality competency through continuing education training opportunities that focus on the importance of addressing sexual wellness and practical tips and interventions they can use in their practice. We have noticed an increase in workshops at counseling conferences and webinars that address sex issues in counseling, so there may be more opportunities for clinicians to register for these events. These trainings are invaluable opportunities that can help counselors increase their knowledge and comfort around sex-related topics.
Counselors must also stay current on human sexuality research within the field. But there is one caveat: Our profession needs more accessible research on sexuality and counseling. The Journal of Counseling Sexology & Sexual Wellness: Research, Practice, and Education is a free resource for culturally relevant sex research provided through the Association of Counseling Sexology & Sexual Wellness, an organizational affiliate of ACA. Regarding relevant research, any counselor in counseling Listservs may see requests for participants in sex-related research. Counselors and counselors-in-training should participate in sex-related research if they meet the inclusion criteria as this will help increase the available research on human sexuality.
In addition to educating themselves, counselors can also advocate for sexual wellness among their colleagues. During clinical consultations with colleagues, counselors can have frank conversations about the need to provide space for sexual wellness in their practice and ask relevant sex-related questions to encourage colleagues to consider the client’s whole person. Counselor supervisors can advocate for counselors-in-training to adopt a sex-positive approach in their work with clients. Supervisors can encourage supervisees to explore and assess sex and sexuality with clients. Counseling practitioners can also update paperwork and assessments to include information about sexual wellness.
Sex is a vital part of clients’ lives, so counselors must prepare to help them navigate the various areas and complexities of the experience.
- Association of Counseling Sexology & Sexual Wellness
- Handbook for Human Sexuality Counseling: A Sex Positive Approach by Angela M. Schubert and Mark Pope, 2023
- Handbook of Sexuality-Related Measures (fourth edition) edited by Robin Milhausen, John Sakaluk, Terri Fisher, Clive Davis and William Yarber, 2020
- Journal of Counseling Sexology & Sexual Wellness
- “Sex-positive counseling” by Lindsey Phillips, Counseling Today, June 2022
- Sex Therapy With Erotically Marginalized Clients: Nine Principles of Clinical Support by Damon Constantinides, Shannon Sennott and Davis Chandler, 2019
- Society for Sexual, Affectional, Intersex, and Gender Expansive Identities
Juquatta D. Brewer is a licensed professional counselor in Georgia and a counselor educator in the online clinical mental health counseling program at Seattle University. She enjoys engaging in research and training around sexual wellness, sexuality, and diagnostic and assessment skills. Contact her at firstname.lastname@example.org.
Janiah Tolbert is a master’s student in the online clinical mental health counseling program at Seattle University. She is passionate about creating safe spaces for individuals and couples to achieve greater levels of sexual health and wellness through the use of counseling and other integrative approaches. She hopes to specialize in working with Black women around sexuality and help them pursue a happy and healthy sexual lifestyle of their choosing.
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