Tag Archives: Sexual Wellness

The importance of human sexuality in counseling

By Juquatta D. Brewer and Janiah Tolbert October 20, 2023

A close up of two people holding hands with a sunset behind them. Their hands are interlocked.

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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.


Helpful Resources


headshot of Juquatta D. Brewer

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 jbrewer1@seattleu.edu.


headshot of Janiah Tolbert

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.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences. Learn more about our writing guidelines and submission process at ct.counseling.org/author-guidelines.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Why, when and how to talk with grieving clients about sex

By Kailey Bradley and Victoria Kress March 14, 2023

An older man sits on a couch with his hands on either side of his face and a woman with a pen and notepad sits across from him


Grief is an experience that everyone navigates at different points in their lives. For the past three years, the COVID-19 pandemic has impacted peoples’ lives in myriad ways and left many experiencing significant grief.

Loss can also deeply affect one’s sexuality, a concept referred to as sexual bereavement. Any form of loss, not just the loss of a sexual partner, can alter one’s sexual desire. As noted in Alice Radosh and Linda Simkin’s 2016 article published in Reproductive Health Matters, both sexuality and grief are stigmatized, which creates a double-barreled taboo. This double stigma can result in someone not feeling comfortable or confident addressing the topic.

When working with clients who have experienced loss, counselors must consider the interplay between grief and sexuality. There are few spaces where clients can address their grief and even fewer safe spaces where they can discuss their sexuality, so it is important that counselors consider how they can approach this subject with clients. This article discusses why this topic is important and when and how counselors can address the intersection of grief and sexuality with clients.

Why is this topic important?

Radosh and Simkin noted that some bereaved clients want to discuss how their sexuality has changed as a result of grief, yet they are often hesitant to do so. Clients may perceive that sexuality and grief cannot coexist. If this is the case, then they may feel shame if they have sexual feelings while grieving. Clients may also believe it is inappropriate to admit that they miss intimacy or that their sexual desire has changed. Other clients may perceive sexuality as distant and remote — something that may never again feel accessible.

The complexities of this topic, combined with counselors’ and clients’ personal discomfort, may cause counselors to avoid addressing it. This discomfort can arise because counselors are uncertain about how to broach the topic, counselors are uncomfortable with the topic of sexuality in general or the client is hesitant to bring the topic up. Although we do not know a lot about how various aspects of sexuality are affected after a loss, it is clear this is an issue that people experience as part of their normal development and growth, so counselors must be prepared to address this topic.

When to address this topic?

Although there is no right time to address this topic, counselors can introduce conversations related to the topic early in the counseling process. They could include questions about how grief has impacted the client’s sexuality on the intake form and then use the information the client provided to gently broach the topic during the first session. Counselors may also need to go slow and consider if it makes sense to bring up the topic during one of the initial sessions. For example, it may not be a good idea to discuss it in the first session if the client has a lot of shame around the topic of sexuality. In this situation, clinicians need to establish therapeutic trust and rapport before mentioning the topic. This approach will help clients feel safe enough to share their experiences.

Counselors can also ask clients to describe the various realms in their lives that have been affected by loss and grief, and they can mention sexuality as one possible area. And throughout the counseling process, clinicians can validate and normalize their clients’ experiences regarding grief and sexuality.

Because clients will move at their own pace and some may want to revisit the topic throughout counseling, regular check-ins with clients can be helpful. Counselors can encourage clients to engage in these difficult conversations by asking them to create “permission slips” to attend to forgotten or challenging dimensions of grief. Clinicians can give clients a scrap piece of paper and ask them to write out an area in their lives that is affected by grief that they find difficult to discuss. Another option is for counselors to write down overlooked topics related to grief and sexuality — such as dating, desire and arousal, physical changes, ways to talk about grief with a partner — on a sheet of paper and then ask clients to choose a topic from the list they want to discuss.

How can counselors help clients?

There is limited research on how to support clients’ sexuality in the context of grief. Formal interventions, however, may not be as important as the compassionate environment and empathic presence a counselor provides. Empathic presence can help clients introduce difficult conversations at their own pace and on their own terms.

Psychoeducation can also play an important role in counseling this population. For example, counselors can share that for some clients, sexual desire and arousal increase after a loss while others have the opposite experience. Providing education around the different reactions people have to grief can validate clients’ experiences and help them connect with the ways they may be experiencing grief. Counselors can also teach clients that grief is not just relegated to the cognitive or emotional domain; our bodies carry and process grief as well, and in this way, our bodies grieve. Providing this education to clients may allow them to feel relief that their somatic reactions surrounding sexuality after a loss are valid.

Another area of psychoeducation that could be valuable to clients is the identification of their grieving styles. The Grief Pattern Inventory is a tool that can help clients gain insight into how they are approaching the grief process. (For more, see Kenneth Doka and Terry Martin’s Men Don’t Cry, Women Do: Transcending Gender Stereotypes of Grief.) Understanding how a person is grieving can help the client and counselor gain valuable insight into the client’s grief process. Intuitive grief is an emotional style of grief in which emotional expression is valued, whereas instrumental grief is a cognitive style of grief in which problem-solving is valued. According to Doka and Martin, a client who identifies as having an intuitive style of grief will prefer a space to emotionally express the wide range of feelings that emerge when considering the intersection of sexuality and grief. In contrast, a client who identifies with an instrumental style of grief may prefer using specific techniques to reengage with their sexuality because they may view the changes in their sexuality after a loss as a problem to be solved. Counselors can introduce this concept to clients and invite them to consider how their grieving style may be affecting how they approach their sexuality after loss.

Finally, creative interventions can be a powerful way to help clients navigate these issues. Counselors can invite clients to write themselves a permission slip to engage with their sexuality in whatever way feels appropriate to them. For example, they might write, “I give myself permission to lean into the feelings that arise when I consider how my sexuality has changed in the following ways.” Clinicians can also encourage clients to create a grief playlist in which they share songs that help describe or capture the feelings surrounding the areas of their life that are affected by grief (including sexuality). Clients could share their grief playlists with their partners and identify how their grief experience is similar or different. Overall, outward expression of loss can help validate the complexity of feelings that arise when navigating this double-barreled taboo.

Addressing personal biases

When working with this population, it is important to be mindful of biases that both the client and counselor may have about grief and sexuality. Some common biases include the assumption that sexual desire disappears after a loss, sexuality is not appropriate to discuss after a loss or having sexual desire after a loss is wrong. To address these biases, counselors can use reflective questions and journaling prompts that ask individuals to reflect on what they have been taught culturally about grief etiquette, sexuality and scripts surrounding what is normal after grief. Again, some might feel judgmental of a griever whose sexual desire and/or arousal has increased after a death. However, addressing our own biases will help create a hospitable environment where a client is met with nonjudgment.


Counselors play an important role in empowering clients who are grieving. Even though we live in a grief-avoidant culture where we shy away from pain, counselors can create a refuge of hospitality where we can openly acknowledge what is uncomfortable. It is in our power and our scope of practice to gently remind clients that it is OK to talk about the intersection of grief and sexuality and to meet our clients with compassionate curiosity and encourage them to grant themselves permission and space to grieve and embrace their sexuality after loss in whatever way makes sense to them.


Kailey Bradley is a licensed professional counselor with supervision designation in Ohio, a national certified counselor and a certified thanatologist. She specializes in the intersections of grief and sexuality as well as issues surrounding chronic and terminal illness. She has a background in hospice work and feels that advocating for grievers is her life’s passion. Contact her at kailey@allrefuge.com.

Victoria Kress is a distinguished professor at Youngstown State University. She is a licensed professional clinical counselor and supervisor in Ohio, a national certified counselor and a certified clinical mental health counselor. She has published extensively on many topics related to counselor practice. Contact her at victoriaEkress@gmail.com.

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.

Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Behind the book: Handbook for Human Sexuality Counseling: A Sex Positive Approach

Compiled by Bethany Bray December 2, 2022

Sexuality is often a taboo topic in the United States, and that extends to the counseling profession. Only two states, Florida and California, require a human sexuality course for counselor licensure.

Not only are there few counselor-specific resources on human sexuality, but the majority of them “address the basic concepts of sexuality and gender … from a narrow cisgender, heteronormative, and pathological framework,” write Angela Schubert and Mark Pope, co-editors of the new American Counseling Association book Handbook for Human Sexuality Counseling: A Sex Positive Approach.

“Sexuality is part of the human experience,” they note. “However, it is often disregarded in both counselor training and the actual process of counseling.”

Pope, a past ACA president and professor emeritus at the University of Missouri–St. Louis, and Schubert, a former student of Pope’s and associate professor at Central Methodist University in Missouri and lead clinician at Brightside Counseling Services in Colorado, collaborated on the book to begin to address this knowledge gap. They are both also leaders in the Association of Counseling Sexology & Sexual Wellness (ACSSW), an organizational affiliate of ACA. (Schubert is past president and Pope is trustee.)

What does a sex positive approach look like in counseling? And what might counselors be missing if they fail to bring up sexuality in the counseling room? Counseling Today sent the co-editors some questions via email to learn more.


Q&A: Handbook for Human Sexuality Counseling: A Sex Positive Approach

Responses by co-editors Angela Schubert and Mark Pope


Sexuality is an uncomfortable topic for some people. Have you received any pushback from within the counseling profession as you’ve researched and published this book?

Angela Schubert: Not at all. In fact, quite the opposite response. People, and more specifically mental health professionals and students alike, are eager for this information. Yes, there are books out there that discuss the basics of sexuality, but none have taken on a candid and comprehensively sex positive viewpoint.

Mark Pope: What Angie said. And when we approached ACA to publish our book, they were so very supportive and eager to have such a book in their publications list. There is nothing like and as comprehensive as our book available to counseling professionals. It’s historic for ACA to publish this book and we are quite proud of it. We assembled an amazingly knowledgeable and talented group of authors from a variety of professions who deal with human sexuality, including professional counselors, school counselors, counseling psychologists, clinical social workers, urologists, neurologists and others. One of the urologists even did the drawings in the physiological chapter.


Sex education is lacking — or nonexistent — for many American students. From your perspective, what should professional counselors’ role be in filling that knowledge gap?

AS: This is a tough question because most professional counselors in the U.S. are in fact former American students. They too may have received minimal sexuality education. As a result, it is highly likely a counselor may first need to become educated themselves on the topic of human sexuality as it relates to counseling. This can be done via workshops, trainings, webinars or a class conducted by licensed mental health professionals and/or organizations that support comprehensive sexuality training. Joining associations like ACSSW would also greatly benefit counselors. ACSSW in particular provides free sexuality counseling webinars to their members. When a counselor has the proper knowledge, they are better equipped to fill the gap with their clients. Ultimately, we hope this book contributes to bridging that gap for counselors and counselor educators.

MP: We have chapters in our book that address this directly. One that focuses on sex education for students in elementary, middle and secondary schools and another for counselors-in-training. It is so important that counselors take the lead in their work settings to advocate for comprehensive sex education for the whole person. But first we must be educated ourselves about sex. This is where counselor education programs are failing their students and where the Council for Accreditation of Counseling and Related Educational Programs (CACREP) is as well.


What should those conversations look like with individual clients (or students)?

AS: Conversations with clients should be conducted from a sex positive framework. This type of approach asks counselors to engage in a dialog inclusive of intentional curiosity, radical respect and candid openness. What do each of those look like? Intentional curiosity sets the stage to speak freely and without judgment. Radical respect embraces the belief that every sexual story deserves to be heard. Lastly, it is imperative for counselors to approach sexual issues in the same way they approach suicide, depression, anxiety, etc. — with candid openness.

MP: Realistically, each client/student is different, but each requires the foundational unconditional positive regard that we all learn in our counseling techniques classes.


What would you want counselors to know about examining their own feelings and possible biases regarding sexuality in order to best help clients? What is the best way to do this?

AS: It is important to recognize that we are all full of biases when it comes to sexuality. There is nothing wrong with that. The key is to lean in to any discomfort and open yourself up to exploring your personal biases, baggage and damage that might influence your therapeutic filter with clients. This could be done by picking up this book, for example, and reflecting on how you feel and think about the material presented. You might also participate in individual counseling or engage in a formal experience such as a Sexual Attitudes Reassessment (SAR) seminar. A SAR is an intensive professional development program that aims to challenge participants to evaluate their own internal beliefs, values and attitudes toward sexuality topics.

MP: It’s not much different than dealing with any personal bias that you have — [it’s about] awareness, knowledge and skills. Be authentic and ask caring questions of your peers.


What advice would you give to a counselor who has a client who talks about a sexual topic that the counselor doesn’t understand, know about or feel comfortable addressing?

AS: I start off an initial session by stating to the client, “I know a lot about a lot of things, but I don’t know you. You are the expert of your story. There might be moments where I might need some more information to better understand how to support you.” Counselors not only set the stage to give permission to their clients to express themselves freely about sexuality, but they also need to give themselves permission to ask.

With that said, it is not on the client to do the work for the counselor. If you have a client who starts talking about sexual contracts and your only knowledge of that is what you saw in 50 Shades of Grey, you might want to clarify what the sexual contract means to the client. If emotions are coming up, it is important to bracket any feelings that arise and check back in with yourself to see where the discomfort came from and find ways to adequately educate yourself on the topic.

MP: Listen to your client/student and then consult with a specialist in this area. It’s basic ethics 101. And if you don’t already have such a specialist in your professional referral list, then do the research to find one now, before this happens, because it will happen. It happens to all of us.


What topics or discussions (with clients) regarding sexual issues might be beyond counselors’ scope of practice? Is there anything you’d want practitioners to know about this?

AS: In Chapter 3, Robert J. Zeglin and his co-authors did a phenomenal job addressing this very issue. They created a knowledge-based decision-making matrix that incorporated both the ethical decision-making model and Jack Annon’s PLISSIT (permission giving, limited information, specific suggestions and intensive therapy) model. The combination allows for counselors to ethically identify what topics fall within scope of practice, as well as those in need of referral. Ultimately, practitioners are in an optimal position and within their scope to give permission to clients to speak freely about sexual issues, as well as to provide limited information and specific suggestions (within the scope of competency, of course).

MP: As we work with clients/students, we always must be concerned first with ruling out physiological causes which would require an appropriate physician referral, but we must be sure to not send them off unprepared for such a meeting or to send them off too early without us having a full picture of the problem or problems.


Only two states, Florida and California, require a human sexuality course for counselor licensure. What would it take to change that? What would you want counselors who don’t live in those two states to know about educating themselves?

AS: The first question really is, why is this the case? It could be assumed that human sexuality is not considered a core aspect of human identity — not just by the mental health field but also by those in position to create and implement the educational and licensure requirements. And because most counseling programs abide by their respective state licensure requirements and CACREP standards, most do not require students to take a human sexuality course. This is where counseling programs can really make a difference. Regardless of what the state says, counseling programs can still require students to take a human sexuality counseling course. Counselors can also join efforts with their state counseling association to lobby for an inclusion of a sex education requirement for licensure.

MP: Counselors can also join groups such as ACSSW and attend their human sexuality and counseling webinars. They can subscribe to the Journal of Counseling Sexology & Sexual Wellness, the only journal dedicated to counseling and sexual wellness. Last, they could attend any sexual mental health conferences, such as [those of the] American Association of Sexuality Educators, Counselors and Therapists (AASECT), the Society for the Scientific Study of Sexuality (SSSS) and the Center for Sex Education.


What made you collaborate on this book — why do you feel it’s needed now?

AS: We met each other when I first entered the master’s program at the University of Missouri-Saint Louis (UMSL) in 2004. Dr. Pope and the rest of the UMSL faculty went as far as they could with elective courses on the topic of sexuality, yet more was needed. We made an agreement that once I graduated with my Ph.D. and settled into a professor position, we would create a book that addressed every topic I wished I had seen during my training. And here we are. Ultimately, the way I see it [is that] it is unethical as a mental health profession to not train practitioners on the topic of sexuality. Sexuality is, in fact, a key component of mental wellness. This book aims to support the ethical practices of the mental health field.

MP: It is clear to me that this topic and human sexuality as a whole need to be formally recognized as an integral part of human wellness and human development. Human sexuality is not an elective! And we need to advocate for this as a core component of our profession.



Handbook for Human Sexuality Counseling: A Sex Positive Approach was published by the American Counseling Association this year. It is available both in print and as an e-book at counseling.org/store or by calling 800-298-2276.



Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The shame of sexual addiction

By Scott Stolarick September 6, 2022

Editor’s Note: This article uses terminology commonly used in the addiction and criminology fields.

Josh is six months sober. He is finally feeling the confidence to branch out and insert himself in a social situation and test the waters. At dinner with some acquaintances, Josh orders a soda much to the surprise of the others. Without much hesitation, Josh discloses that he is an alcoholic and quit drinking. He shares a sobriety coin with the group and receives unbridled support and praise for his courageous journey.

Like Josh, Derek is also six months sober. He is at a social gathering and his friends decide to watch a rather risqué television show that everyone is talking about. Because he is among friends, Derek takes a risk and discloses that he is a sex addict and is not supposed to watch those types of shows because of potential triggers and the risk of relapse. You could hear a pin drop in the room. This reaction caused Derek to regret coming forward with this disclosure, and he awkwardly excuses himself. 

These two different reactions to addiction illustrate that not all recovery is created equal. Unfortunately, most laypeople do not know what sexual addiction is much less how to deal with it if it affects them or others they know. Although sexual addiction has received some high-profile exposure with movies such as Don Jon and celebrities Tiger Woods and David Duchovny revealing that they are addicted to sex, the issue still remains foreign to most. 

What is sexual addiction? 

In his book Out of the Shadows: Understanding Sexual Addiction, Patrick Carnes, an expert on sex addiction and treatment, defines sexual addiction as “any sexually related compulsive behavior which interferes with normal living and causes severe stress on family, friends, loved ones and one’s work environment.” This behavior can manifest in a variety of ways, including the overuse of pornography, promiscuity, infidelity, paid sexual encounters and a high frequency of sex (even within a committed relationship). 

There are several stereotypes that often come to mind when people hear the term “sex addict.” Sometimes the term is used synonymously with sex offender, and although the two terms can certainly coexist, they can also be mutually exclusive. Many people think a sex addict is that creepy-looking person they tend to avoid, the person who is unsuccessful in pursuit of relationships, the social outcast, the person without means and resources, or the person with the corny pickup lines in bars. And although all of these descriptions could be part of a sex addict’s profile, focusing on stereotypes is an antiquated and closed-minded way of thinking, especially when it comes to understanding sexual addiction. 

I treated sex offenders on an outpatient basis for 26 years. If I learned one thing, it was the fact that these individuals came in all shapes, sizes, colors, genders and socioeconomic backgrounds. Often, it was the unassuming person, ostensibly the harmless law-abiding type, who was committing the most heinous crimes. A sex addict can be your “happily married” neighbor, your pastor, a doctor, a lawyer, a man or a woman. Sexual and gender orientation are also not factors that determine sex addiction. In other words, this issue does not discriminate, and neither should we in our attempts to understand and/or treat it. 

Twelve-step programs emphasize the need to completely abstain from the identified problematic behaviors, but this philosophy is not as straightforward as it sounds when it comes to sexual behavior. Instead of educating people about healthier sexuality, some recovery movements emphasize complete abstinence of sexual behavior, outside of marriage and committed relationships, which results in extreme pressure and self-imposed guilt and shame. Carnes coined the term “sexual anorexia” to describe the shame-based and unhealthy avoidance of sexual behavior. People often avoid even discussing sex and sexual problems, but this same approach should not be used when clinically treating problems in sexual behavior.

I have mistakenly referred past sex addict clients to support groups in which they were shamed for having sexual thoughts and masturbating. This triggered relapse behavior and a general clinical regression. 

While sexual addiction does parallel other forms of addictive behavior, it is also quite different. All people have a libido. Granted this exists to varying degrees, but it is there, and as humans we possess it. Sexual behavior and reproduction rituals also exists in various levels of the animal kingdom. Creatures that can reproduce asexually such as worms also elect to mate with other worms as another reproductive option. Therefore, when approaching the problem of sexual addiction, I believe it is our duty to conceptualize it knowing that sexual desire is a common denominator (at various levels) among both humans and animals. The fact that sexuality is a core part of the human experience explains why categorically it is different from other types of addiction such as alcohol and substance use, gambling, and shopping. Sure, there is a strong argument for genetic predisposition, but not all people are genetically predisposed to addiction. Sexual addiction is not a cookie-cutter issue, so I feel it cannot be dealt with via thought extinction, complete behavioral abstinence and a pathologizing mindset. Later in this article, I discuss some treatment approaches that encompass both the similarities and differences of other addictions. 

The mental health profession still struggles with accepting and working to develop agreed-upon diagnostic criteria for sexual addiction. The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) does not acknowledge sexual addiction, but it is hoped that the next version of the DSM will acknowledge the congruence between behavioral and chemical addiction and include sexual addiction as a legitimate diagnosis. In 2014, the American Society of Addiction Medicine, however, recognized sexual addiction as a legitimate addictive disorder. This lack of congruency around sexual addiction demonstrates the barriers that counselors and the public often face when trying to conceptualize sexual addiction. 

What are the signs? 

Looking at the behavioral manifestation and realizing how the behavior shows up is one important aspect when determining if someone is struggling with a sexual addiction. Understanding what drives the behavior is also crucial. Having said that, I am not professing to have a recipe for recognizing someone with a sexual addiction, but there are telltale signs. Common personality traits seen in sex addicts are obsessive thoughts, impulsivity, shame, depression, maladaptive coping methods for perceived losses of control, poor communication skills, high risk tolerance for sexual behavior and a hyperactive focus on sex. Any one or combination of these traits is often seen in cases of active sexual addiction. 


Sexual addiction is considered a process or behavioral addiction. Process addictions, which also include excessive shopping and gambling, are marked by a strong desire to engage in behaviors despite the potentially negative consequences. Thus, the elevated mood associated with addictions, albeit temporary, is often viewed as the elixir for troubling life circumstances and unwelcomed thoughts. The addict is vigorously chasing this elevated mood, but the behavior of engaging in the addiction is often followed by intense feelings of guilt and shame. In my work with sex offenders, I often used the term “transitory guilt,” which is a short-lived guilt that is very intense in nature and not manageable to carry around in one’s mind, to describe the offensive cycle of behavior. A myriad of thinking errors or cognitive distortions are used to decrease and eventually eliminate the guilt, thus putting the offender in a position to reoffend. This process is similar to what sex addicts experience, but it is even more accelerated because the actual guilt and shame process decreases in duration throughout the life of the addictive behaviors. 

I’m sure many readers are already aware that sexual addiction has a serious impact. I can say without hesitation that it has the potential to be a relationship and life wrecker, and it often does just that. For the addict, sexual addiction can result in relational, legal and financial consequences. It can also cause someone to experience shame, low self-worth, depression and anxiety. 

Sexual satiation perpetuates the addictive process by propelling it into deeper and more deviant places. A pornography addict, for example, might “upgrade” to impersonal sexual encounters, and then impersonal sexual encounters may lead to illegal sexual acts, such as voyeurism and exhibitionism. The addict’s objective is to continually seek gratification when the usual sources have lost their luster, so to speak. And pornography use can also complicate one’s ability to become aroused. The degrading and other unrealistic themes depicted in pornography create highly distorted expectations of what should occur within the context of real-life sexual relationships, thus rendering the addict incapable of arousal in those situations. This can also lead to men experiencing pornography-induced erectile dysfunction because the sexual outlets that are supposed to be acceptable and appropriate no longer elicit arousal.

Someone’s sexual addiction can also affect their loved ones, friends and work. The partner of a sex addict, for example, may feel disregarded, betrayed, devalued, replaced, insufficient and so on. If the additive behavior manifests in the workplace, the employer may have to terminate the person because the addictive behavior is affecting their work productivity. 

The internet, dating apps and virtual reality have ushered in a new world of opportunities for the sex addict. The saying “a kid in a candy store” has never been more applicable as it pertains to the anonymity, accessibility, variety and cost-free options that technology provides. Not only does television media inundate viewers with a “sex sells” approach to advertising, but the internet provides a wide array of sexual options at one’s fingertips. These factors certainly present added layers in the creation of a solid and effective recovery/treatment plan. 

What does treatment look like?

I personally believe that a clinician treating someone with a sexual addiction should have some level of clinical experience in this area. Counselors should not venture into this arena because they think it is interesting or they want to learn along with the client. This could be significantly more harmful than helpful and could lead the client and all those associated with the client down the wrong path. At the very least, a background in addictions or forensic psychology should be a qualification. Counselors can also receive training and specialized certifications in sexual addictions, such as the certified sex addiction therapist program at the International Institute for Trauma and Addiction Professionals, which was founded by Carnes. The bottom line is that if you have zero experience working with this population, you should refer accordingly and seek training if you want to work in this area. 

Providing clinical treatment for sex addicts involves first conducting a thorough assessment of the identified circumstances. You must also gather an extensive social history with relevant collateral contacts. Remember, the addict’s point of view is not the only one; family members, friends and other treating professionals may have relevant data to offer. Examining the addict’s personal motivation for change, patterns of acting out, trauma history and other addictive manifestations are other crucial areas of exploration. And for those in relationships, it may be necessary to refer the significant other for services to address their trauma. 

Here are some other core clinical strategies counselors can use when working with sex addicts: 

  • Establish the artful balance between engagement and accountability. 
  • Set clear boundaries within the clinical arena. If an addict learns they can manipulate you, they will. 
  • Ask clients to use accountability software on their electronic devices. Obviously, this is not foolproof, but it offers some external control.
  • Develop allies within the addict’s life system to aid in supporting the treatment plan. 
  • Refer to a psychiatrist for a medication assessment to address anxiety and depression. Psychiatric medications can also act as a helpful libido suppressant while the client develops new skills. 
  • Work with clients to establish definitions of healthy sexual behavior and fantasy. 
  • Help clients develop adequate social skills training. 
  • Integrate bibliotherapy and appropriate support groups as needed.
  • Be empathetic. 

Collaboration within care is important with this population. Make no mistake about it: Treating a sex addict in a vacuum is not clinically recommended. As clinicians, we have to embrace our inner case manager to keep up with the demands of this work. 

And remember, we play an important role in helping clients who are struggling with sexual addiction. With counseling, they can learn that sex is not a bad thing and that they can experience it in a healthy way.



Scott Stolarick is a licensed clinical professional counselor who has been practicing in the state of Illinois for 30 years. He is an experienced administrator and clinical supervisor as well as a seasoned clinician. Scott has management and leadership certifications from the University of Notre Dame and Cornell University. Scott is currently a program director for Arbor Counseling Center in Gurnee, Illinois. 


Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, visit ct.counseling.org/feedback.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Sex-positive counseling

By Lindsey Phillips May 24, 2022

Sexuality is a core aspect of the human experience, yet it is often a topic clouded in shame and secrecy. Some people can’t even bring themselves to say the word “sex” out loud, resorting instead to euphemisms such as “the birds and the bees,” “the horizontal tango” or “getting to know someone in the biblical sense.” 

Mental health professionals who consider themselves sex-positive providers are hoping to change the way that people — including other helping professionals — think and talk about sex. In a recent Healthline article, sex educator Goody Howard defined sex positivity as “the idea that people should have space to embody, explore and learn about their sexuality and gender without judgment or shame.” 

Counseling already provides clients with that safe, nonjudgmental space. So, why aren’t more professional counselors talking about sex? 

Steve Ratcliff, a licensed professional clinical counselor in New Mexico and a licensed professional counselor (LPC) in Oregon, believes that too often clinicians avoid discussing sexuality and sexual wellness with clients out of their own fear or shame around the topic. Sometimes counselors incorrectly assume that sex is a topic reserved only for sex therapists, Ratcliff says. Although sex therapy does involve talking about sex, it’s much more than that. As he explains, sex therapists are trained to treat sexual disorders and concerns such as vaginismus (i.e., the involuntary tensing or contracting of the vaginal muscles out of fear of vaginal penetration) or erectile disappointment. 

“Some counselors consider talking about sex as tantamount to having sex with the client,” continues Ratcliff, a member of the American Counseling Association. “There’s this fear that if I talk about it, I’m running a risk ethically or in terms of liability. But if there is a significant clinical issue that we’re not addressing because of our own discomfort that might raise a larger liability and malpractice issue — are we not treating a client’s shame just because it’s sexual?”

Clinicians don’t have to specialize in sex therapy to broach the topic of sexual wellness with their clients. “Sexual issues and mental health go hand in hand, and they influence each other in very distinct ways,” says Angela Schubert, an LPC at Brightside Counseling Services in Greenwood Village, Colorado. For example, growing up in a household where homophobia is present could cause stress, especially if one of the family members is attracted to people of the same sex. And someone who lost their partner of 35 years may be depressed at the thought that they will no longer be able to have sex with this person. But as Schubert points out, clinicians don’t often ask or consider how sexuality may play a role in a person’s mental health. 

Clinical sex education (or a lack thereof) 

Ratcliff is a private practice therapist at Liberated Counseling and a sexual diversity researcher at The Alternative Sexualities Health Research Alliance (TASHRA). He says broaching sexuality is a skill that all counselors should have, yet most clinicians receive little to no training on the topic in graduate school.

“It is unethical how we approach sexuality in the field of counseling right now,” argues Schubert, an associate professor and director of online learning for the clinical counseling program at Central Methodist University in Fayette, Missouri. Only two states — Florida and California — require counselors to take a human sexuality course to be licensed. And human sexuality is mentioned in just two CACREP standards (rehabilitation counseling and marriage, couple and family counseling), she adds. 

On top of that, sex education varies widely in state public schools in the United States, with many providing inadequate information. As of April 2022, the Guttmacher Institute reported that 26 states and Washington, D.C., mandate both sex education and HIV education, and only 18 states require these education programs to be medically accurate. 

“You’re born and raised into an environment where there’s no formal sex education,” Schubert says. “So, you come into the counseling field as a master’s student already with your arm behind your back in terms of your knowledge and understanding of sexuality in a formal way. [However,] what you [do] have … are all these biases, values and assumptions related to sexuality. … And then you have a counseling program that does not require you to take a human sexuality course and may not even address human sexuality. How does this reality align with our ethical obligation to do no harm? We can do much better.”

Ratcliff would like to see CACREP add at least one required course on human sexuality to its standards. “One three-unit course in human sexuality in graduate school is not enough to become a sex therapist,” he says. “But it might be enough to provide a little bit of education, a little bit of exposure to different sexualities and a chance to work on our own stuff [biases] … and give us a chance to grow as well.”

Until that happens, the onus of finding training is placed on the counselor. Ratcliff and Lily Gonzalez, an LPC and sex therapist who is the co-founder of Moving Mosaic Therapy & Counseling in Chicago, suggest that counselors look for trainings through sex-positive associations such as the Association of Counseling Sexology & Sexual Wellness (ACSSW), which is an organizational affiliate of ACA, and the American Association of Sexuality Educators, Counselors and Therapists (AASECT). In particular, they both recommend attending a sexual attitude reassessment class, which involves process-oriented trainings that challenge attendees to evaluate their own beliefs and values toward sexuality and sex-related topics. These trainings provide clinicians with an opportunity to learn more about sexuality, explore any potential biases or conflicts, and practice their ability to self-regulate when exposed to things outside of their comfort level, Ratcliff explains. 

“You will be triggered” during these classes, Gonzalez says. “But you need to be because you need to know what’s going to trigger you [in session]. You need to understand what your limits and discomforts are and work through those. If we’re not comfortable with our own sexuality, we’re going to be really uncomfortable helping someone navigate theirs.”  

Giving and getting permission 

Consent is a crucial part of not only sex but also sex therapy. Clinicians can underscore the importance of consent by first asking and obtaining the client’s permission to discuss sexuality and sexual behavior, Gonzalez notes. She says that can be as simple as stating, “I’ve noticed you struggling with this problem related to sex. Can we go there?”

Counselors can also broach the topic of sexuality even before meeting clients, says Schubert, co-founder and president of ACSSW. This can be done in how they introduce themselves or through the language they include on their paperwork and intake forms, she explains. For instance, a clinician could note that they are a “sex-positive counselor” on their website. 

Cheryl Walker, an associate professional counselor and sex therapist at GlobeCoRe in Atlanta, creates a safe, welcoming environment in her clinical practice by forgoing binary systems of classification on her intake forms. “Folks who struggle with sexual wellness are [often] fighting these labels that are placed on them,” she observes. She includes blank spaces so clients can fill in how they want to be identified rather than forcing them to check a box, and she makes a point to ask about pronouns.

By engaging in binary thinking (“Are you this or that?”) or making assumptions, “counselors censor and close off conversations that the client either wants to have or needs to have,” says Walker, moderator of the ACA Sexual Wellness in Counseling interest network. “As clinicians, we can make sure we have this open space, this ambiguous space, so that the client can fill in the blanks.” 

Ratcliff, a member of AASECT, often works with sexually and racially diverse populations. He makes it known on his website and clinical paperwork that he is an LGBTQ+, kink-, polyamory- and consensual nonmonogamy-affirming provider and a sex-positive counselor. Using inclusive, affirming language and asking questions about sexuality on intake paperwork will cue clients that the counseling office is a safe place to discuss sex and sexuality, he says. 

Even if counselors are cautious in how they broach conversations around sex and sexuality, mistakes can happen. When they do, Ratcliff advises counselors to take ownership and apologize for their misstep. 

Barriers to sexual wellness

Sexuality is a significant part of who we are as human beings, but it is something that “we’ve been taught to hide, to be ashamed of and to not bring into the room,” Gonzalez notes. She says much of her clinical work involves providing psychoeducation related to the human body, culture and the origins of one’s sexual knowledge. Because counselors are often helping clients navigate something internal and hidden, it is helpful to have a trauma-informed background when doing sex therapy, she adds. 

Ratcliff notes that many people learn about sex from their peers or through the internet or television, and this inadequate education frequently leads to common misconceptions. People may incorrectly assume that older people or people with disabilities don’t enjoy or have sex, for example. 

Any sexual desire or preference that does not align with society’s accepted “norms” often results in feelings of shame, Ratcliff continues. Men may be embarrassed if they enjoy prostate massages because they have been conditioned to believe that the penis is the major sexual organ. And women might not feel the freedom to enjoy their sexuality because, as Ratcliff notes, female sexuality is highly pathologized in American culture. He says it is common for women to report not having an orgasm until much later in life when some of that shame has been dispelled. 

Religion often influences how people view sexuality. Gonzalez finds that it sometimes results in the overlap of sexual shame and self-shame. If someone is taught that being good involves being a “clean,” moral person, then that spills into their perception of their sexual self, she says. As a result, enjoying sex or being aroused by pornography may make them feel like a “bad” person. 

Walker, who is part of the University of Michigan’s sexual health certificate program 2022 cohort, also works with clients who are conflicted about sexuality because of their religious beliefs. Some are taught that touching themselves sexually makes them bad people, so they never learn what feels good to them physically, she says. 

One’s understanding of sexuality is also shaped by media — in this case, referring to all movies, TV shows and social media, not just pornography. Walker points out that television often perpetuates the fallacy that all people are equally desirable and that the path to love is simple — it just requires dinner and flowers, she jokes. So, when people experience in real life that love and sex aren’t simple and straightforward, they often wonder what is wrong with them. 

Counselors will often need to help clients realize how these external and internal factors affect their understanding of sexuality. “People do not often talk about sex,” Schubert observes, “yet it narrates a lot of our worldview, whether it’s something we are conscious of or not.” 

Schubert often has her counseling students and clients explore their sexual scripts — the narratives they have formed about sex based on embedded cultural beliefs, social messaging, biology, personal experiences, and formal or informal education about sexuality. She says counselors can begin to unpack these internalized messages by asking clients questions such as “What messages about sex did you receive as a child? Did anyone say, ‘I love you’? What did you learn about gender roles growing up?” 

Schubert often introduces the concept of a sexual script by having clients visualize it as an umbrella. Sexuality is the tip of the umbrella, and the parts of the umbrella connected to the tip all form one’s sexual script. The umbrella panels represent one’s identities and experiences; the ribs running along these panels are the beliefs, biases and assumptions; and the shorter ribs that hold the umbrella open are one’s values, she explains. 

Schubert, co-editor of the forthcoming Handbook for Human Sexuality Counseling: A Sex Positive Approach, published by ACA, provides a hypothetical example of working with a male client who struggles to say the word “masturbation.” Instead, he repeatedly says “that thing we do” rather than using the word in front of the clinician because he fears they would think less of him if he verbalized it. In this scenario, Schubert would prompt this client to explore the possible reasons behind his hesitation to say sexual words by using the sexual script exercise. She would ask him questions such as “Where did you first learn it wasn’t OK to say masturbation? Did your caregivers ever talk about sex with you? What did your religion or culture say about masturbation?” 

Gonzalez finds the bio-psycho-social model beneficial in helping clients understand the way that their life experiences affect sexual wellness. She explains that clinicians can explore any physical limitations or illness that might be hampering the client’s sexual wellness (biological), the client’s emotional reactions to sexuality such as past traumas or current stressors that affect it (psychological), and societal influences and expectations around sexuality such as the client’s religious views and the gendered roles they were taught as a child (social). 

For example, Gonzalez describes how a Latin American woman who is born into a religious and patriarchal environment may have certain expectations around sex. This woman may feel the need to be chaste in the way she presents herself to society yet also be sexually pleasing to her husband (what is referred to in psychoanalytic literature as “the Madonna-whore complex”). This woman wasn’t taught how to enjoy sex but instead views it as a service or act that she must perform, Gonzalez explains. Applying the bio-psycho-social model would help the client process this internalized messaging around sexuality and allow her to start working on her own sexual wellness, Gonzalez says. 

She finds this model particularly helpful when she’s working with partners who come from different cultures or religions. Counselors can use it to discuss each person’s cultural upbringing and models of love and how this affects what they expect and want sexually from each other, Gonzalez says. 

Reconnecting to our bodies 

One key aspect in helping clients achieve sexual satisfaction is broadening the definition of what sexual wellness means. “Our society has done a really good job of making us think outside our body instead of inside our body,” Gonzalez says. “And we’ve been taught to be performative. We’ve been taught to think, ‘Do I look cute in this [sexual] position? Do I look cute in this outfit?’ and not necessarily [think about] what feels good” and pleasurable. 

Body mapping is a technique Gonzalez uses to get clients out of their heads and back into their bodies. She may ask clients to explore their bodies without sexual intent to really learn themselves better. For example, the next time a client takes a shower, they could be mindful and notice how it feels when the water hits different parts of their body and where they enjoy the sensation more. This could progress to the counselor recommending that they masturbate at home with the same sense of exploration — and without the goal of having an orgasm. The touch doesn’t even have to involve a sexual organ; it could be the simple act of sensually touching their thigh, Gonzalez adds. 

Sometimes counselors must first help clients consider their own emotions, traumas and triggers around sexual pleasure. The body is capable of not only providing pleasure but also holding on to trauma, Gonzalez notes, which can cause certain parts of the body to trigger an emotional response. These bodily responses operate as the body’s “brakes and accelerators of sex,” a phrase Gonzalez credits to Emily Nagoski’s Come as You Are: The Surprising New Science That Will Transform Your Sex Life. Environmental factors such as location, music and aromas can also affect how someone responds to sex, she adds. 

“Body mapping can help the person understand where their bodily accelerators … and brakes are,” Gonzalez explains. “We want to avoid the brakes so that they don’t get in the way … and pay more attention to the accelerators, but you can’t do that without knowing your body.”  

Walker says mindfulness and meditation techniques are also great tools to help clients be fully engaged in the present moment rather than focused on life stressors or their own anxieties and insecurities around sexual performance. 

If a woman, for example, is anxious about sexual penetration because of a past sexual trauma or a religious belief that sex is “bad,” then her body may tighten and tense whenever she engages in sexual acts. This action restricts blood flow to the area, Walker says, which will cause further stress and displeasure. A counselor could use mindfulness techniques such as engaging the five senses (what she sees, hears, smells, etc.) to help the client learn to ground herself in the present moment and relax her pelvic area. 

Pathologizing sexuality

Many clients feel particularly vulnerable discussing sexuality, which means it can be easy to hurt or offend them if the counselor’s biases or opinions enter the session. Several clients have told Gonzalez about negative experiences they had when disclosing their sexual practices to other therapists, including one client who was devastated when a clinician stated “You must hate yourself” after learning they were into bondage, discipline, dominance and submission (BDSM). Gonzalez says part of her clinical work involves first healing the trauma caused by such negative or biased comments. 

If a client mentions a sexual practice such as BDSM, then Gonzalez may ask, “What does BDSM mean for you? How does that fit into your life? How do you receive pleasure from it? Is this experience consensual, and do you have a contract that defines the power exchange?” But she never assumes that this sexual experience has anything to do with the client’s reason for coming to counseling.

We have to differentiate between what the client sees as their problem and what we think the problem is,” Gonzalez stresses. 

Unfortunately, value impositions are common when discussing sexuality, Ratcliff says. After all, sex is a topic that often evokes strong reactions — positive or negative — from people. If someone enjoys something that makes the counselor uncomfortable or is outside of their accepted sexual norms, then it may become easier for the counselor to insert their own opinions and thoughts onto the situation, he notes. For example, Ratcliff says, if a clinician is bothered by the thought of a client who says they enjoy being tied up with rope, the clinician may be more likely to infer that the client’s preferred sexual activities underlie why they struggle with assertiveness or why they are depressed. 

Sex positivity requires clinicians to maintain an open mind and be inclusive of all types of sexual expression — even those that shock them. “It’s OK for counselors to have things that ‘ick’ us out,” Ratcliff says. “Our challenge as professionals is to be able to work with people who enjoy those things and regulate ourselves.”

Biases about sex are sometimes written into the theories, approaches and assessments that counselors use. Ratcliff finds that he often needs to tweak or translate his approaches and interventions to fit the needs of his clients. He sometimes uses online relationship psychological assessments such as the Gottman Relationship Checkup, but these are often based on cisgender, heterosexual couples, so they use terms such as “affair” — a word that doesn’t fit or work for clients in a consensual nonmonogamous relationship. In fact, putting forward the concept of having an affair or cheating runs the risk of pathologizing this type of relationship, he says, so he asks clients to replace the word “affair” with “relationship betrayal,” which is a more appropriate and inclusive description. 

Walker advises clinicians to look over their clinical forms, exercises and handouts with a discerning eye to ensure they contain gender-expansive and sex-positive language. This may involve making simple changes such as including examples with the pronoun “they” or using the word “partner(s)” instead of “couple,” she says. 

Readjusting one’s language can also help counselors and clients to shift their mindset and reconsider potential stigmas associated with certain terms. Schubert often chooses to say “sexually explicit material,” for instance, instead of “pornography” because she finds this phrasing helps to remove negative connotations around it and allows clients to discuss — without shame — what materials they are using and how that might be influencing their sexual wellness. 

Boundaries and transference

Establishing clear, healthy boundaries is important in any therapeutic relationship, but it becomes crucial when addressing a topic that many people consider sensitive or taboo. Gonzalez says that clients sometimes ask questions about her sexual life and preferences, such as if she’s queer or polyamorous. She turns this back to the client and asks, “What about that is interesting to you?” This question allows her to gauge if the client is asking out of curiosity, if there is any possible issue of transference at play or if they need to know that she understands them on a deeper level.

Counselors need to be careful in self-disclosing about their own sexuality in counseling, Ratcliff says. He suggests discussing sexuality in a broader, more general sense. For example, the clinician could tell the client, “Some people enjoy this sexual activity” rather than saying, “I enjoy this sexual activity.”   

Ratcliff cautions that counselors should also be mindful of potential power impositions and harm that self-disclosure can cause. For example, a therapist disclosing that they are interested in a particular type of kink to a client who is also into kink can create an implicit power dynamic, he notes. 

Walker acknowledges that it is relatively common for transference to occur when discussing intimate topics but not necessarily for the reason people might assume. It isn’t because sex therapy is filled with salacious talk, she says, but because the counselor is a nonjudgmental person who is affirming all of the client’s strengths and qualities, which may not be acknowledged by others in the client’s life. 

Schubert once had a client admit that they were struggling because they thought that they might be developing romantic feelings for her. Schubert didn’t shy away from the discussion; instead, she asked the client to explain what they were feeling. The client told her that she was the only woman they were able to talk with about such intimate things, and they weren’t sure why they couldn’t say the same things to their partner. Schubert said, “It seems to me that this is the first time — that you’re aware of — where you’ve been able to be fully yourself and be heard. That’s powerful because it shows how courageous you are in your ability to be vulnerable with another person, and specifically another woman.” 

This response helped shift the conversation away from any possible transference or attraction, Schubert says, and placed it back into the therapeutic realm. Then, together they explored what it was like for this client to be heard and whether it was time for him and his partner to go to couples counseling so they could figure out why he was having trouble discussing intimate topics.

By embracing a sex-positive attitude, counselors can help begin to break the silence, shame and stigma surrounding sexuality. Clinicians are “taught so well to meet people where they are in their journey,” Gonzalez says, and sexuality “is just another part of the client’s journey, another part of who they are.



Sex counseling versus sex therapy

Although the terms sex counseling and sex therapy are often used interchangeably, some mental health professionals note a distinction between the two. “A sex therapist can do more in-depth psychotherapeutic work with a client,” explains Lily Gonzalez, a licensed professional counselor and sex therapist in Chicago, “whereas a sex counselor is more high-level counseling and psychoeducation, but not the deeper psychotherapy, and their work is usually limited in time.”

The Association of Counseling Sexology & Sexual Wellness (ACSSW), an organizational affiliate of ACA that promotes sexuality as a central aspect of being human, defines sexuality counseling as a professional relationship that aims to do the following: 

  • Help people increase their comfort and awareness of sexuality and sexual experiences
  • Validate sexuality as a core aspect of the human experience
  • Provide evidence-based education regarding sexual health concerns 
  • Support clients as they navigate various influences on their sexuality 
  • Empower clients to express their sexuality while also respecting their own and other’s sexual rights 
  • Promote sexual wellness 

(See ACSSW’s website counselingsexology.com for more on sexuality counseling and sexual wellness.)

The American Association of Sexuality Educators, Counselors and Therapists (AASECT) distinguishes between AASECT-certified sexuality counselors and therapists. AASECT notes that sexuality counselors come from a variety of professions, including counselors, nurses and clergy, and they help clients resolve sexual-related concerns through problem-solving techniques and psychoeducation. Sexuality counseling is typically short-term care and focuses on the immediate concern or problem. 

AASECT-certified sexuality therapists, on the other hand, are licensed mental health professionals who provide in-depth psychotherapy and have specialized training in treating clients with sexual issues and concerns. They are capable of both treating simple sexual concerns and offering more comprehensive, intensive psychotherapy if needed. 

(For more on the differences between AASECT’s certifications, see aasect.org/certification-types-distinguishing-sexuality-educators-counselors-and-therapists.)



Resources on sexual health and wellness 



Lindsey Phillips is the senior editor for Counseling Today. Contact her at lphillips@counseling.org.


Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.