Sex-positive counseling

By Lindsey Phillips

May 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 

• American Association of Sexuality Educators, Counselors and Therapists (aasect.org)
• Association of Counseling Sexology & Sexual Wellness (counselingsexology.com)
• Journal of Counseling Sexology & Sexual Wellness (digitalcommons.unf.edu/jcssw/)
• National Coalition for Sexual Freedom (ncsfreedom.org)
• National Institute for Sexual Health and Wellness (nishw.org)
• The Alternative Sexualities Health Research Alliance (tashra.org)
• The Association of Black Sexologists and Clinicians (theabsc.com)