Positive sexuality, sexual wellbeing, rights, socially constructed, barriers, practice approach, PLISSIT model
Three sections follow:
Background Material that provides the context for the topic
A suggested Practice Approach
A list of Supporting Material / References
Feedback welcome!
Background Material
Sexuality is a central aspect of being human and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles, and relationships. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious, and spiritual factors (Dunk, 2007).
Positive Sexuality / Sexual Wellbeing
Social workers have tended to compartmentalise sexuality into specific contexts. LGBTIQA+, sexual assault, unwanted pregnancies, and sexually transmitted diseases are just a few of the areas social workers find themselves supporting clients. However, as the definition above indicates, sexuality is a core human attribute that is intertwined with all areas of people’s lives (Dodd & Tolman, 2017; Dunk, 2007; Kassel, 2020.) Because sex and sexuality are such vast concepts that intertwine with all areas of our lives, there is an emerging theme in social work practice around the need to formally recognise sexuality as an important dimension of self. This is sometimes referred to as ‘sex positivity’ or a ‘sex-positive approach’ where people are allowed space to embody, explore, and learn about their sexuality and gender without judgment or shame. Sex positivity values consent, communication, and education that allows people to make informed choices about their bodies. It involves being non-judgmental and respectful regarding the diversity of sexuality and gender expressions, as long as there is consent. Becoming sex-positive can be a tremendous source of health, celebration, nurturance, healing, and well-being. In essence sexual concerns are seen as a relevant part of everyday life to be discussed openly (Dunk, 2007; Kassel, 2020).
However, conversations about healthy sexuality, positive sexuality, and sexual well-being that are well ensconced in many disciplines are all but absent from current social work literature, education, and practice. Social work literature on sexuality expounds a deficit model of sexuality that runs counter to social work’s holistic, person-in-environment, life span and strengths-based perspective, as well as its commitment to social justice. Social work should shift away from a pervasive focus on sexuality as solely risk based to one of balance, incorporating the normative nature and importance of sexuality, intimacy, pleasure, and desire within social work curricula, practice, and dialogue in general (Dodd & Tolman, 2017).
Over the course of the adolescent years, emerging adulthood, middle adulthood, and the later years, the development of healthy sexuality in our society includes becoming knowledgeable and comfortable with one’s (changing) sexuality over time; learning to appreciate and respect one’s own feelings (emotional, sexual) and those of others; gaining viable sexual knowledge and learning to communicate with partners; gaining access to resources for sexual safety and health; developing a sense of empowerment to make active choices in and about sexual situations; establishing a sense of entitlement to physical and emotional dimensions of connection, desire, and pleasure; and acquiring experience, insight, and information about romantic and sexual relationships. Social workers have a responsibility to engage with these aspects of our clients’ sexuality, to illuminate a vital dimension of their identities and attend to their overall sense of selfhood and well- being (Dodd & Tolman, 2017).
Sexuality is an important aspect of one’s identity
Positive sexuality can be considered as part of a rights-based framework—sexual rights. This brings everyday sexuality to be more in line with another identity marker, that of culture, which is seen as a key concern of social work. Culture is positioned as an aspect of identity, rather than linked to particular areas of practice. Compartmentalising sexuality into specialised areas of practice has acted to eclipse the need for sexuality to be approached as an everyday characteristic of the self. Were sexuality to be seen as a human right, it would be of central concern to a profession whose work centres around the rights of people (Dodd & Tolman, 2017; Dunk, 2007).
Sexuality is socially constructed
Sexuality connects body, identity, and social norms—it is socially constructed. Social workers should adopt a constructionist and a critical perspective on sexuality. Social workers should expand their existing focus on risk and illness to include discussions of sexuality in relation to diversity, power, social identity, pleasure, intimacy and relationship. 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 (Brewer & Tolbert, 2023; Giertsen et al., 2023).
Acknowledging sexuality as socially constructed rejects any universal blueprint for a ‘normal’ sexual experience. It changes the focus from trying to change or ‘fix’ people to fit social norms to critiquing the social and cultural conditions that shape their subjective sexual experiences. It challenges heteronormativity and the medicalisation of human sexuality (Giertsen et al., 2023).
Barriers to discussing sexuality with clients
Discomfort with the topic of sex and sexuality serves as one barrier that often prevents social workers and other health professionals from broaching the topic with clients. However, even if discussing sex makes a social worker uncomfortable, she or he still needs 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. Ethically and culturally competent social workers must ensure that their own “stuff” does not affect the assessment and interventions used with clients (Brewer & Tolbert, 2023).
Lack of knowledge of everyday sexuality and/or feeling a lack of competence are other reasons why social workers may not discuss sexuality or sexual wellness with clients (Brewer & Tolbert, 2023; Dunk, 2007). A knowledge of everyday sexuality is vital to the practice and education of social workers who work with a variety of clients faced with increasing complexities brought about by late-modernity (Dunk, 20027).
The first step is to develop the language needed to talk about sex. Social workers who do not know or are unfamiliar with sexual terminology may feel less inclined to broach the subject of sex with clients. Although it is impossible to know every relevant term, social workers need to be willing and open to become familiar with the potential language clients may use in sessions by staying current with sexuality-related research, attending trainings and workshops or joining professional organizations (Brewer & Tolbert, 2023). Two references are included in the Supplementary Material section that follows that may assist in familiarising social workers with common terms and language around sexuality (Abrams, 2022a & 2022b). Also, 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 (Brewer & Tolbert, 2023).
Learning more about human sexuality will allow social workers to continue to grow professionally and improve their knowledge of various aspects of the human experience, including sexuality. Helpful resources include the following (from Brewer & Tolbert, 2023):
Association of Counseling Sexology & Sexual Wellness https://www.counselingsexology.com/
Handbook for Human Sexuality Counseling: A Sex Positive Approach by Angela M. Schubert and Mark Pope, 2023
Handbook of Sexuality-Related Measures (fourth edition) edited by Robin Milhausen, John Sakaluk, Terri Fisher, Clive Davis and William Yarber, 2020
Journal of Counseling Sexology & Sexual Wellness
“Sex-positive counseling” by Lindsey Phillips, Counseling Today, June 2022
Sex Therapy With Erotically Marginalized Clients: Nine Principles of Clinical Support by Damon Constantinides, Shannon Sennott and Davis Chandler, 2019
Society for Sexual, Affectional, Intersex, and Gender Expansive Identities https://saigecounseling.org/
Practice Approach
Sexuality counselling is 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 (Phillips, 2022).
The PLISSIT model
Brewer and Tolbert (2023) suggest the PLISSIT model, developed by ANNON in 1976, as a way of social workers integrating sex therapy into their work. The acronym PLISSIT stands for permission, limited information, specific suggestions and intensive therapy. All social workers can operate within the first three interventions of the PLISSIT model — permission, limited information and specific suggestions. Many of these interventions are ones that counsellors 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, counsellors 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 counselling beyond what the social worker can provide. At this point, it would be appropriate to refer out to a sex therapist.
Other aspects relevant to practice
The following, drawn from a number of authors, could be introduced at different stages of the PLISSIT model.
Prior to engaging in sexuality counselling, social workers should engage in education about sexuality so they can provide limited information and specific suggestions about client needs (Dunk, 2007).
A way of obtaining permission is to incorporate sexuality into assessment procedures, e.g. the bio-psychosocial-spiritual assessment tool. 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) (Dunk, 2007).
Include positive (not just risk-based) questions about sexuality without making assumptions about the number of or gender of partners:
Are you in any sexual relationships?
How do you feel about the sexual relationships you are in? (Brewer & Tolbert, 2023).
Ask clients a range of questions about their sexual relationships, such as:
What kind of sex do you enjoy?
Are you able to tell your partner(s)what you like sexually?
Are there any sexual experiences that you’d like to explore with your partner(s) but haven’t yet? (Dodd & Tolman, 2017).
When engaging with a client about partner’s recent diagnosis of a chronic illness, add questions related to sexuality, for example:
Has the illness affected your sexual relationship?
Has there been an impact on sex drive or desire for either of you? (Dodd & Tolman, 2017).
Social workers need to respond in a client-centered, professional, and knowledgeable manner when clients present sexuality-related issues. The social worker does not need to be an expert in sexuality issues. However, the social worker can build trust with the client through demonstrating a comfort level and willingness to research and discuss the sexuality information the client needs. This includes recognising and challenging personal bias (Giertsen et al., 2023).
Adopt a constructionist and critical perspective when exploring sexuality. Our experience and knowledge of sexuality is socially, linguistically, discursively, politically, culturally, and historically constructed. Society, through the media, education system, religion, legal, medical, and mental health systems, not only limits and restricts our sexual expressions, feelings, and actions, but also encourages and moulds them (Brewer & Tolbert, 2023; Giertsen et al., 2023).
If not an expert in sexuality, be prepared to refer a client to a specialist in sexual problems for intensive therapy (Dunk, 2007).
Supplementary Material / References
(available on request)
Abrams, M. (2022a). 47 Terms That Describe Sexual Attraction, Behavior, and Orientation. Healthline. https://www.healthline.com/health/different-types-of-sexuality
Abrams, M. (2022b). 68 Terms That Describe Gender Identity and Expression. Healthline. https://www.healthline.com/health/different-genders
Brewer, J. D., & Tolbert, J. (2023, October 20). The importance of human sexuality in counseling. Counseling Today. https://ct.counseling.org/2023/10/the-importance-of-human-sexuality-in-counseling/
Dodd, S. J., & Tolman, D. (2017). Reviving a positive discourse on sexuality within social work. Social Work, 62(3), 227-234. doi: 10.1093/sw/swx016
Dunk, P. (2007). Everyday sexuality and social work: Locating sexuality in professional practice and education. Social Work and Society, 5(2), 135-142.
Giertsen, M., Lavie-Aayi, M., & McKay, K. (2023). Teaching about sex and sexuality in social work: An international critical perspective. Social Work Education, 42(6), 867-884. https://doi.org/10.1080/02615479.2021.1990252
Kassel, G. (2020 September 3) What Does It Actually Mean to Be ‘Sex Positive’? Healthline. https://www.healthline.com/health/healthy-sex/sex-positive-meaning
Phillips, L. (2022, May 24). Sex-positive counselling. Counseling Today. https://ct.counseling.org/2022/05/sex-positive-counseling/