Week 1 Assignment

Inclusive sex therapy practices: a qualitative study of the techniques sex therapists use when working with diverse sexual populations

Michael D. Berrya,b and Anastasia Natasha Lezosc

aSex and Couple Therapy Service, McGill University Health Centre, Montreal, Canada; bLaboratory for the Biopsychosocial Study of Human Sexuality, Department of Psychology, McGill University, Montreal, Canada; cDepartment of Counselling Psychology, McGill University, Montreal, Canada

ARTICLE HISTORY Received 18 August 2015 Accepted 22 April 2016

ABSTRACT Attention to the clinical needs of diverse client populations, including lesbian, gay, bisexual, trans* and queer (LGBTQ) clients, openly non- monogamous clients, and bondage and discipline, sadism and masochism (BDSM) lifestyle clients, has grown in recent years. This study reports interview-based qualitative research findings, from a sample of sex therapy specialists and subject-matter experts (n D 34), on key clinical principles and practices used in the treatment of such diverse client groups. Three clinical principles are identified: therapist self-reflection, client-affirmation, and normalizing. Core clinical techniques to support these overarching principles are then described and discussed. The utility of such techniques, and relevant treatment considerations in inclusive sex therapy practice with diverse clients, are evaluated in relation to interview data.

KEYWORDS Sex therapy; LGBTQ; inclusive psychotherapy; diversity; minority clients

Introduction

It has been argued that a substantial proportion of research and clinical literature on sex and marital therapy assumes a heterosexual and dyadic default position. While much clin- ical literature proposes that techniques effective in heterosexual relationships may be applied to lesbian, gay, bisexual, trans* and queer (LGBTQ) populations, an overview of relevant literature suggests that critical attention should be given to the generalizability of heterosexual healthcare models, and the unique needs of diverse populations (Macdonald, 1998; Mayer et al., 2012; Spitalnick & McNair, 2005). As Barker and Langdridge argue, research on sex therapy with sexually diverse and non-normative populations � including LGBTQ and openly non-monogamous clients � is at a nascent stage in its development (Barker, 2011; Barker & Langdridge, 2010a). Additionally, published research suggests that psychotherapy generalists may often be undertrained in sexual psychotherapy and uncomfortable addressing sexual issues with their clients (Haboubi & Lincoln, 2003). With respect to LGB populations specifically, Evans and Barker hold,

CONTACT Michael D. Berry michael.berry2@mcgill.ca

© 2016 College of Sexual and Relationship Therapists

SEXUAL AND RELATIONSHIP THERAPY, 2017 VOL. 32, NO. 1, 2�21 http://dx.doi.org/10.1080/14681994.2016.1193133

research over the past decade has consistently confirmed that the majority of therapists are ill- equipped to work with lesbian, gay and bisexual (LGB) clients, having had little training on the topic of sexuality, and often expressing a lack of knowledge about such clients (2010, p. 375).

Consequently, attention to the points of convergence and divergence between hetero- sexual and non-heterosexual client groups are an important area for continued research. In this area, clinicians and researchers alike have begun to evaluate the degree to which best practices in sex therapy with normative (i.e. heterosexual, dyadically-partnered) client groups can be generalized to more diverse client groups.

The unique needs of diverse and non-normative client groups, and the distinctive skills and competencies psychosexual therapists require in their work with such populations, are an important area for current and future study. As a means of researching such diverse populations, it is held that semi-structured-interviews can be used to positive effect, and can be useful in accounting for the facts that: “[1] people construct their reality and [2] there are multiple, equally valid, socially constructed versions of ‘the truth’” (Hill et al., 2005, p. 199). As Smith and Osborn write, in a semi-structured interview, “the respondent shares more closely in the direction an interview takes, and the respondent can introduce an issue the investigator had not thought of. In this relationship, the respondents can be perceived as the experiential expert [sic.] on the subject and should therefore be allowed maximum opportunity to tell their own story” (2003, p. 57). Within this research project, we have used a semi-structured interview methodology, in order to identify the common- alities of experience (Hill, 2012) amongst clinical practitioners working with diverse sex- ual populations, and to explore the implications that these commonalities have for clinical best-practices.

This qualitative research project evaluates the special competencies, and clinical practi- ces sex therapists use in their work with non-normative client groups. The influence of broad social norms of sex and gender, as applicable to the client and therapist alike, is dis- cussed. The predominance of heterosexually oriented research and clinical literature, and the impact of this model, as identified by research participants, is then addressed. Finally, we describe a set of key clinical principles, which we have designated as the foundations of an “inclusive sex therapy” model that attempts to acknowledge sexual and gender diversity in client populations. The foundations of this inclusive model include values commonly observed in the contemporary psychotherapy field, such as nonjudgmentality and self-reflective practice. Consequently, data from this study are described, which indi- cate the prospective usefulness of specific counseling practices � including normalizing, horizontalizing, and client-affirmation (Langdridge, 2007) � in work with diverse client groups. The data gathered in this study suggest that widely-accepted, “common-sense” strategies, if employed in an intentionally reflective and self-conscious manner, may sup- port the implementation of inclusive practices in sex therapy.

Methodology

A series of open-ended verbal research interviews was conducted with sex therapy special- ists, and subject matter experts, from March 2012 to October 2013.

Participants (n D 34) were recruited using a snowball-sampling method, and were recruited based on their specialized clinical expertise (either research- or clinically-based)

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in sex and couple therapy. While the designations, professional licensure, and � in some instances � the primary treatment orientation/model differs between participants, the majority of interviewees are licensed practitioners in the sex and couple therapy speciali- zation. Table 1 provides an overview of the clinical licensure, degree level, and declared theoretical/clinical orientation of the interviewees who participated in this research. The majority of respondents are educated to the PhD level, and were licensed as psychothera- pists, or psychologists, at the time of interview.

The majority of interviews (n D 22) were conducted in an audio-only format (telephone, or Skype-audio-only), while the rest were conducted in person (n D 10) or by Skype-with- video (n D 2). 10 general questions were included, encompassing the domains of:

� the interviewee’s theoretical orientation, � background and licensure, as well as prior clinical training and experience, � client populations worked with, � clinical techniques used when covering sexual material/content from a psychother- apy vantage point,

Table 1. Interview participants’ licensure, degree level and theoretical orientation. Interviewee Professional licensure Degree level Theoretical orientation

1 Licensed psychologist PhD Existential/humanistic; sex therapy 2 Licensed psychologist PhD Cognitive behavioral; integrative;

sex therapy 3 Sex coach PhD Sex coaching 4 Licensed psychologist PhD Cognitive behavioral; mindfulness;

sex therapy 5 Licensed psychologist PhD N/R 6 Registered psychotherapist PhD N/R 7 Registered psychotherapist N/R Integrative 8 Registered psychotherapist Masters Sex therapy; family therapy 9 Licensed marriage and family therapist Masters Sexual health model 10 Licensed psychologist PhD Psychodynamic 11 Licensed marriage and family therapist PhD Sex therapy 12 Licensed marriage and family therapist Masters Cognitive therapy 13 Registered psychotherapist Postgrad. diploma Psychosexual therapy 14 Licensed clinical social worker Masters Integrative and LGBTQQIAA-affirming 15 Registered psychotherapist Masters Psychodynamic psychotherapy 16 Psychiatrist Medical doctor Psychiatric 17 Licensed psychologist PhD Sex therapy 18 Licensed clinical social worker PhD Cognitive behavioural; eclectic; relational 19 Registered psychotherapist Masters Integrative; sex therapy 20 Registered psychotherapist Masters N/R 21 Registered psychotherapist Bachelor of nursing Cognitive behavioral; sex therapy 22 Psychiatrist Medical doctor Humanistic; medical; sex therapy 23 Licensed psychologist PhD Integrative; sex therapy 24 Registered psychotherapist Masters Psychosexual therapy 25 Registered psychotherapist N/R Sex therapy 26 Registered psychotherapist Bachelor of nursing Sex therapy 27 Licensed psychologist PhD Psychosexual therapy 28 Registered psychotherapist N/R Integrative; psychosexual therapy 29 Registered psychotherapist PhD Sex therapy; sexual health model; family

systems 30 Licensed psychologist PhD Gestalt; sex therapy 31 Licensed psychologist PhD Sex therapy; sexology 32 N/A (researcher only) PhD Human sexuality research 33 Registered psychotherapist Masters Analytical psychology; sex therapy 34 Licensed psychologist PhD Psychodynamic psychotherapy

Note: N/R D not reported, N/A D not applicable.

4 M. D. BERRY AND A. N. LEZOS

� alliances and integrative treatments (especially referral practices), � experiences working with diverse and non-normative client groups, and � core values and clinical methodologies recommended in working with non-norma- tive client groups.

Interviews ranged in duration from 30 minutes to 90 minutes.

Researchers’ backgrounds and demographic details

Three researchers and one research supervisor participated in this research project. The primary researcher developed the interview procedure, in consultation with the research supervisor and with colleagues in a research seminar (see “Interview Methodology” section, below, for more information).

The primary researcher is a white, cisgendered male in his early 30s, who identifies as “hetero-flexible.” At the time of data collection, he was a PhD candidate in research psy- chology at University College London. His research specialization is in sex and relation- ship therapies, and treatment of sex- and gender-related issues; he identifies his primary theoretical orientation as psychodynamic and existential. His core beliefs on the psycho- therapeutic treatment of diverse client populations center on inclusivity, and diversity- affirming practice.

Research Associate 1 is a Chinese, cisgendered female in her late 20s, who identifies as heterosexual. At the time of data collection/analysis, she was a PhD candidate in experi- mental psychology, specializing in mentalization- and attachment-theory. She was recruited to assist with coding, and identified no prior expertise or preconceptions on the specific topics evaluated in this research.

Research Associate 2 is a bi-racial, cisgendered male in his mid-20s, who identifies as queer. At the time of data collection/analysis, he was a Masters student in counseling psy- chology, specializing in clinical psychotherapy with HIV-positive men. He was recruited to provide oversight for the coding procedure, and to act as an external auditor. He identi- fies his main beliefs on the topic as centering on LGBTQ-affirmative practice.

The Research Supervisor for this project is a white, male, cisgendered professor in psy- chology. He is in his 60s, and did not declare his sexual orientation. His primary theoreti- cal background is in psychodynamic and attachment research. He identified no major preconceptions on the specific topics evaluated in this research.

Interview methodology

A semi-structured verbal interview guide was used. This guide was developed by the first author of this paper, and subject to a three-phase review process, involving: (1) peer review, (2) supervisory review, and (3) subject expert review. The peer review process involved the presentation of the research model, and the proposed interview guide to two separate graduate student seminars in research psychology. Feedback was solicited from seminar participants, and the interview guide was revised accordingly. The interview guide was then subject to supervisory review by the research supervisor, and further amended in accordance with his feedback � at this stage, the interview guide was short- ened into a limited number of questions, and a more “open-ended” format was adopted.

SEXUAL AND RELATIONSHIP THERAPY 5

Finally, the review was subject to subject expert review. In this phase, three senior (i.e. more than 10 years of licensed clinical practice) psychotherapists reviewed the interview template, providing feedback for further revisions (these clinicians were not asked to describe their sex/gender orientation, or their primary theoretical model).

The final interview guide served as a general template for each interview, after being modified slightly on a case-by-case basis, based on the specific expertise of each inter- viewee. Consequently, a semi-structured interview technique was used in which themes of interest that arose in the dynamic interaction of the interview were explored. After each interview, a supervisory meeting was held with the research supervisor, who verified that the interview was topical and focused.

Data analysis method

Two data analysis methods were used conjunctively in analyzing the qualitative interview data: grounded theory and thematic analysis. In analyzing the interview data, we adhered to the grounded theory model developed by Glaser and Strauss (1967), and further elabo- rated by Charmaz (2003, 2006). This method entails working “back and forth” between: (1) the data obtained through interviews and (2) the underlying research theories and interview praxis. This grounded-theory-based analysis entailed an ongoing process of crit- ical and analytic reflection carried out throughout the course of the research project. This grounded theory methodology, can be “described more appropriately…as ‘retroduction’ than as induction: a ‘double fitting’ or alternating shaping of both observation and expla- nation, rather than an ex post facto discovery of explanatory ideas” (Katz, 2001, pp. 333�334). This form of grounded theorizing allows for a dynamic relationship between the collection and analysis of data (Bryant & Charmaz, 2007).

Thematic analysis was used to analyze the interview data, and identify themes/patterns expressed by interviewees. As Boyatzis writes, “a theme is a pattern found in the informa- tion that at minimum describes and organizes the possible observations and at maximum interprets aspects of the phenomenon” (Boyatzis, 1998, p. 4). It is also asserted that the themes produced through thematic analysis can be either inductive (deriving directly from analysis of the data), or deductive (deriving from a prior theory or research)(Braun & Clarke, 2006). Rather than an either-or methodology, however, Boyatzis has asserted that this model can be considered on a continuum between theory-driven and data-driven approaches. An inductive, data-driven coding model was used in this research project, with the primary coder deriving the themes and codes from a close reading of the data, and through inter-rater consultation.

Quality and trustworthiness in qualitative research: steps taken to ensure reliability and validity of the data

A number of steps were taken to ensure the reliability and validity of the data. As Morrow writes, the trustworthiness of qualitative data has several, trans-paradigmatic operational criteria (2005). These criteria include:

� social validity, � grounding in reflexive practice and measures to control for bias (including bracketing),

6 M. D. BERRY AND A. N. LEZOS

� adequacy of data, and � adequacy of interpretation.

First, in order to ensure reflexive practice, and control against bias, the lead researcher is engaged in a series of critical, phenomenologically based bracketing exercises, following the bracketing model developed by Fischer (2009). These exercises were designed to help him: (1) identify his biases and preconceptions and (2) “shelve” these biases through criti- cal self-reflection � especially critical journal-writing, and regular consultation with the research supervisor for this project.

To ensure reliability, after initial themes and codes were developed, the coding system was revised, and reliability was confirmed through an assessment of inter-rater reliability. In thematic analysis, inter-rater reliability is considered to be: the consistency of judgment between multiple different raters. Research Associate 1 was recruited to assess inter-rater reliability through double coding; both reviewers analyzed the same 20-page section of interview transcripts, to identify possible codes. In this method,

each person makes judgments without interacting or seeing the judgments of the other observer. Following the observation period or completion of the judgments, the two observ- ers compare their results…the two observers [then] discuss each observation until agreement is reached (Boyatzis, 1998, p. 151).

Through this method, a set of thematic codes was agreed between reviewers. A second, 20-page section of text was then assigned to each reviewer to code, using the pre-agreed set of codes. Inter-rater reliability was calculated for agreement on the presence of each code, between each reviewer. Cohen’s Kappa for inter-rater reliability was .72, which is regarded as good (Ballinger, Yardley, & Payne, 2004). Finally, the primary researcher developed a complete list of codes/themes, based on the content of all interviews.

Research Associate 2 was recruited to serve as an external auditor. He was recruited to review the interview coding scheme/chart, and provided with summary/example state- ments of the themes outlined in the coding scheme. This auditor provided qualitative feedback on the accuracy and completeness of the complete coding chart. The auditor’s feedback was provided both in-person, in a meeting with the primary researcher, and Research Associate 1, and in writing. Overall, the auditor deemed the complete chart to be consistent with the previously developed inter-rater chart, and accurate in reflecting the themes/sub-themes in the interviews.

The explanatory notes written for each interview were used as a reflective practice tech- nique to assess: the efficacy of the research method, the implications of interview content, and in particular, the contributions made by both the interviewee and the interviewer. The- matic analysis was used to analyze the interview data, and identify themes/patterns, related to clinical practice with LGBTQ and other “diverse population” clients, as expressed by interviewees. An inductive, data-driven coding model has been used in this research, with the primary coder deriving the themes and codes from a close reading of the data.

Steps taken to ensure client confidentiality

Interviews were not administered � and are not reported � anonymously. Informed con- sent for interviews specified that the interview participant would be cited, by name, as an

SEXUAL AND RELATIONSHIP THERAPY 7

academic source in any published findings. As this research project examined the practi- ces of mental health professionals, case studies and clinical examples were common in the interviews. A number of steps were taken to safeguard the anonymity and confidentiality of interviewees’ patients/clients. Interview participants were asked to report on case mate- rial anonymously, within the bounds of confidentiality. No content that could serve to identity-specific clients was requested, and any such content was carefully screened and removed from interview transcriptions.

Results: sexuality and normativity

Clients’ expectations about sex are identified as a crucial, defining element of the thera- peutic process. Data from this study suggest clients’ expectations are shaped by sociocul- tural influences. A number of interviewees suggest that such expectations may often take the form of particular (especially, performance-based) expectations about sexual behavior, which rely on a taken-for-granted view of the sexual response cycle. Additionally, the data suggest that clients may often hold a narrowly delimited view of healthy sexuality and appropriate sexual behavior. This “narrow view of what sex should involve” Barker stresses,

leads to them trying to only do a certain kind of narrow range of things. And of course, if those things don’t really do it for them, or if they become so tuned into the other person that they can’t really tune into themselves at all—or what they might desire—because they have to keep it in such a narrow range (research interview, March 30, 2012).

Furthermore, according to the data suggest that this narrow view of sexuality is largely defined by the culturally pervasive assumption that healthy individuals tend to: (A) desire to be sexually active (sub-theme 4-D) and (B) conform to a particular, well-defined set of sexual behaviors (sub-theme 4-B). A number of interviewees appear to agree with a wider body of published research, which holds that this circumscribed, culturally specific per- spective tends to restrict normative standards of sexuality to a particular set of behaviors, and a largely predetermined set of personal meanings, marked by:

� Heteronormativity � which privileges heterosexual relationships, implicitly or explic- itly devaluing non-heterosexuality, (sub-theme 1-B; sub-theme 4-C).

� Mononormativity � which sets monogamous unions as the de facto standard for sexual relationships,

� Presumption of male-active/female-passive sexuality. � Presumption that the desire/drive to have sex is a necessary criterion of normal/ healthy (sub-theme 4-D) sexuality (which opposes asexuality, and pathologizes/stig- matizes low levels of desire or sexual initiative)(Barker, research interview, March 30, 2012; Barker, 2005; Barker & Langdridge, 2010a, 2010b; Berry & Barker, 2014; Braun-Harvey, research interview, November 15, 2012; Winn, research interview, January 16, 2013).

This finding is linked to the thematic area of affirming client identities outside the nor- mative range. The data from this study suggest that the pressure to conform to these cul- turally sanctioned standards of sexual behavior is often an influential factor in the sex

8 M. D. BERRY AND A. N. LEZOS

therapy process, and that these normative pressures may influence both clients and thera- pists (including sex therapy specialists) (theme 3). To combat these normative pressures, intentional affirmation of diverse client identities may be used, with a view to counter-act- ing internalized prejudices/homophobia (theme 2).

In the clinical arena, a goal that many interviewees view as foundational is: fostering a critical and reflective examination of what the client really wants to attain through sex therapy. In many instances, this task involves a close evaluation, or re-evaluation, of the client’s initial goals, to determine how they fit with the client’s personal, and relational pri- orities. A relevant associated theme in the data is: emphasis on the possible need to affirm non-normative identities. Interviewees stress that internalized homophobia and other forms of internalized prejudice may influence clients’ initial goals, and are an important consideration in the therapy process (sub-theme 2-A). Consequently, a number of inter- viewees recommend the use of permission-giving as a client-affirmative clinical technique (theme 2, especially sub-theme 2-C). Additionally, the therapist’s use of a critical and self- reflective stance was identified as a sub-theme within the practice of affirmative sex ther- apy with diverse clients (theme 3). In order to meaningfully affirm diverse clients, the data support outside findings that it is necessary for the therapist to identify (to the great- est degree possible) their own biases/prejudices, which may often extend to the “minority” clients with whom they work.

The data suggest that a sense of internal conflict in relation to one’s own sexuality, or one’s deeper sexual desires/preferences, may not be uncommon for sexual “minority” cli- ents, and may be the consequence of socially conditioned messages about normal sexual behavior. This experience of sexual prohibitions may often contribute to the comorbid/ contributing experience of depression and anxiety that many clients face. Another rele- vant sub-theme is apparent in some interviewees’ emphasis on the importance of personal authenticity (sub-theme 2-F). The data appear to reflect an implicit assumption that valid/ viable clinical goals � often linked to the values of self-actualization, and personal fulfill- ment � depend on helping the client identify and negotiate core identity aspects (theme 2 and theme 3).

Results: sex therapy and non-normative clients

A number of interviewees make reference to the degree to which the clinical principles they use with heterosexual, dyadic clients can be generalized to diverse and “minority” clients. A number also share their thoughts on the possible limitations of such (i.e. het- erosexually-oriented) approaches in non-normative client groups, highlighting the differ- ences that may obtain when working with such clients.

A point of concern for many interviewees is the ostensively widespread limitation on sexual material/topics in general healthcare and psychotherapy training, identified by a number of specialist interviewees and in the wider literature (Athanadiasis et al., 2006; Barker, research interview, March 30, 2012; Braun-Harvey, research interview, November 15, 2012; Britton, research interview, March 7, 2012; Tsimitsiou et al., 2006) (sub-theme 1-C). The data collected in this study suggest that such training limitations and personal discomfort may also extend to specialist groups � such as couple and relationship thera- pists � for whom client sexuality may be a more immediate clinical issue. Ravella suggests that it may be relatively common for a couple or relationship counselor to avoid a focused

SEXUAL AND RELATIONSHIP THERAPY 9

discussion of sexual issues in general (research interview, January 11, 2013). Even for sex therapists working with LGBTQ clients, Britton suggests, it may be the case that “few have the background, the training, the sensitization, the language, the understanding, and the ok-ness with being able to ask the right questions” (Britton, research interview, March 7, 2012) (sub-theme 1-A). This factor is a main impetus for the high emphasis on advanced specialization training and professional development, evident in the research findings from this study. Data suggests that part of the diagnostic challenge when working with LGBTQ clients may also be systemic: it is held that the DSM diagnostic categories are, in and of themselves, heterosexually biased, being based on a heterosexual response- cycle model of penetrative sexuality (Tiefer, 1991).

Results: key principles in inclusive sex therapy

An emergent challenge in this study was: to determine how sex therapists can work effec- tively with a diverse range of clients, and to identify the clinical practices sex therapists use in dealing with non-normative clients. Analysis of survey data illustrates a number of key principles and practices that may facilitate critical and reflective diagnosis and treat- ment in the psychosexual therapy context. As stated above, the core inclusive principles identified in this research are consistent with widely-held humanistic values in the con- temporary psychotherapy field. Thus, in working with diverse clients, four main clinician principles are highly emphasized by interviewees:

(1) a nonjudgmental stance towards diverse clients, (2) an understanding of diversity � in particular, understanding the wide variety of

possible identities that a client may have, and the specific challenges that are likely to be associated with these identities, (sub-theme 4-A)

(3) an appreciation of fluidity � recognition that the client’s identity, behaviors and therapy goals are apt to change over time, and

(4) a reflective, self-critical approach to practice � a commitment to reflective practice, self-monitoring/introspection, and recognition of broad values and possible preju- dices, as well as situation-specific responses to particular clients (sub-theme 2-B).

The data suggest that the clinician’s conceptualization of diversity is rooted in an indi- vidually specific understanding of the identity categories that a client may occupy within the parameters of social discourse. It is emphasized that the clinician’s perspective (like the client’s) is influenced by the clinician’s subjective social and cultural background, which may contribute to the development of personal prejudices.

Table 2 presents an overview of the themes and sub-themes identified in the data from this study. In the following section, we will describe in greater detail the key principles identified in the data.

Results: key practices in inclusive sex therapy

In the data presented above, high level of importance is placed on therapists developing and maintaining a clear understanding of their own views of, and position on, non-nor- mative sexualities. While there is a widespread language of “openness,” and agreement on

10 M. D. BERRY AND A. N. LEZOS

Table 2. Inclusive sex therapy practices: themes and sub-themes identified in research interviews (n D 34), including representative statements. Themes/sub-themes Representative statements

(1) Interviewee identifies knowledge/ understanding of diversity as an important skill

there’s one sort of line whereby we regard LGBT, asexual, bondage and discipline, sadism and masochism (BDSM), non-monogamous, all of sort of what is seen as minority sexuality or gender. But it’s not actually minority in all cases, some of it’s majority. But, anyway, the marginalized ones, we can train people specifically in each of those things…So people have an awareness—they can get a lot more knowledge of specific identities and specific practices.

(1-A) Therapy field seen as ill-equipped to deal with diverse (i.e. LGBT) clients

[A lot of psychologists are] going to take their heteronormative bias, and they’re going to say: “oh, ok, all gay men just want to stick it in the anus, because there’s no vagina”.

I’ll bet you there are a lot of psychologists who don’t even know that there’s such a thing as anal-receptive and anal-active. “What would THAT mean?” they’d say.

(1-B) Interviewee emphasizes that a heteronormative model of sexual behavior may be common in mainstream sex therapy and/or sexual medicine

a lot of what is pathologized by the mental health community, specifically in the DSM and its diagnostic categories, and in the languaging and the posturing and the judging of many mental health practitioners, who actually work with some of the same people I work with, fail them in their lack of sensitivity, and even training, around sexuality.

[Clinician recommends] systemic approaches, and some of the systemic ways of questioning—Socratic questioning and circular and interventive interviewing techniques—they’re fabulously non-directive, but also very probing in a very respectful way. And I think the systemic notions of neutrality and curiosity, those key principles, are really good principles for looking at the sort of diversity of human sexual behavior.

one book I read … was like: “all of the examples in the book are going to be heterosexual people, because that’s statistically the norm, so, people in same-sex relationships will have to think about how it applies to them”. I was just like ahhhhhh?

(1-C) Need for more/better training (for sex therapists) in sexual diversity

I also think if you were to poll…certified sex therapists… what you’d find is that very, very, very few of them are gay-identified, and…few as well, have the background, the training, the sensitization, the language, the understanding, and the ok-ness with being able to ask the right questions.

(2) Interviewee emphasizes possible need to affirm identities outside the norm

we have to be aware of the world we live in, so that’s where something like Darren Langdridge’s gay-affirmative therapy is [useful]. You might have to work a bit at affirming, say, identities that are outside the norm, the normative, because the person has so much experience of having those disaffirmed, that you know, maybe you put your therapeutic weight around saying: “actually yes, kink is ok, non- monogamy is ok. Yes it’s alright to be gay.”

(2-A) Influence of internalized homophobia on client emphasized as important to treatment

a lot of…the work that I’m seeing and doing has been related to trauma histories, and internalized homophobia.

We spent quite a lot of time talking about [this client’s] sense of, really, disapproval, and his own very deep prejudice about homosexuals. So he was one of these gay people that—[while] he was quite keen on gay rights, and ostensibly was very active in protesting equality of sexual orientation…—actually he had terrible prejudices about it, and felt that gays were lesser.

(2-B) Interviewee emphasizes reflective stance (therapist’s use of)

when people say ‘open and supportive’ I often say to myself: ‘what the fuck does that mean? What are you talking about? So, when I supervise folks and they say “I want to be open and supportive” one of the things that comes up for me is you know, that position of being open and supportive is a potential iatrogenic injury to your client,

if they don’t understand what you mean, or you can’t define what that means.

(2-C) Permission-giving as a clinical technique

a lot of what we all do is permission-giving and normalizing. every session, re-permission them, we begin with permission. And there’s an implicit permission given just in having them being ok about asking for help around sex.

the fact that I’m going to demonstrate the language is itself permissive because it allows them to respond in a like manner. Sometimes I will frame a question which, as it were, subsumes another question along the way. Like I might say about masturbation: I don’t say ‘do you masturbate,’ I say ‘when you masturbate, do you find that…’

(continued)

SEXUAL AND RELATIONSHIP THERAPY 11

Table 2. (Continued )

Themes/sub-themes Representative statements

(2-D) Use of a non- pathologizing or sexual health model

I try not to pathologize any more than I have to. You know, sometimes a person will call me up and say: "my wife is experiencing sexual aversion," and I try to discourage them from labeling it.

I don’t like the word ‘dysfunction,’ you know? It’s all part of the DSM. I usually talk about sexual ‘problems’, or sexual ‘difficulties’, or sexual ‘issues’.

(2-E) Use of a dimensional (rather than categorical) model of sexual health/ problems

I see it as on the continuum of worry-problem-and-disorder, as see it as, on the continuum, a sexual problem, not a sexual disorder or dysfunction, or a psychiatric diagnosis.

(2-F) Emphasis on personal authenticity [My work focuses on] helping people become who they truly are. In other words, claiming the authenticity of their sexual being.

(2-G) Clinician lets the client lead the therapy process

I’m often quite led by the client…there’s quite a trust the client has a pretty good idea what the important things to bring are.

I would offer the opportunity to see whether they wanted [to discuss the therapy relationship] or not. I think it’s really important to give control, if you like, of the direction, to the client at all times.

(3) Use of normalizing the client’s concern or identity (as a clinical technique)

Whatever they’re dealing with, basically what you say is: “you know what? What you’re feeling right now is perfectly normal.

Across orientations, across modalities, normalizing is a terrifically important part of what a psychotherapist does. So, measuring outcomes, and measuring progress powerfully interfaces with normalization—that the expectations the people have about their lives change—and something that initially would have seemed to them utterly unsatisfactory as an outcome becomes, actually, a very good outcome.

He’s telling me “I’m a monster, I shouldn’t have been born”. And I’m telling him: “actually, that’s not [true].

Well, I don’t see transgender in that way, I don’t think there’s anything wrong with being transgender, and transgender people exist in all times and all cultures, and they’re perfectly ok people”.

(4) Interviewee uses social constructionism to conceptualize client cases

increasing the possibilities for somebody is really part of therapy. And loosening what is sedimented. And enabling them to see things a bit differently…In a way, therapy has a lot in common with, say, queer theory, or sort of certain branches of social constructionism, which are about kind of loosening up and trying to see multiple alternatives rather than just one fixed route.

(4-A) Interviewee emphasizes fluidity/ variability (and attention to fluidity) of client’s identity and sexuality

The reality is that sex by its nature tends to be variable, flexible, and have different roles and different meanings for people.

[One] way to go is the more queer kind of approach…not necessarily expecting them to be the same from session to session, and seeing sexuality as something much more fluid and changing and much more integrated with the rest of their life. And not really thinking: how do I work with a lesbian client? How do I work with a transgender client?

(4-B) Narrow definition of “sex” seen as prevalent in society (and as internalized by client)

To me, the problem with the word ‘sex’…is that it’s been so limited in its definition that I don’t even LIKE the word anymore. But when you talk about somebody seeking something, what the pleasure model, what I would like to see happen is that they actually seek connection. And that’s a whole different ball game. That’s not sticking-it-in and getting off, you know.

(4-C) Heteronormative model of sex seen as prevalent in society (affecting clients)

the entire world is still heterosexist and heteronormative, including [psychology] professionals.

(4-D) “Sexual imperative” (assumption that everyone wants sex) seen as prevalent in society

a lot of the information out there makes people feel abnormal if they don’t want to have sex, you know, five times a week.

12 M. D. BERRY AND A. N. LEZOS

the importance of psychotherapist “nonjudgmentality” within the data, Winn emphasizes that such terms are not self-evidently meaningful. Specifically when working with sexual “minority” clients, a critically self-aware understanding of � and ability to articulate � what is intended by “open and supportive” counseling is identified as an essential attri- bute. The “position of being open and supportive,” Winn emphasizes “is a potentially iat- rogenic injury to your client, if they don’t understand what you mean, or you can’t define what that means” (research interview, January 16, 2013) (theme 1).

Hence, while nonjudgmentality is largely viewed as a core principle and value of psy- chotherapeutic work (Rogers, 1957), the data gathered in this study indicate that nonjudg- mentality must be functionally linked to the other principles described, and supported by a range of clinical practices and techniques, which will be elaborated in the following sections.

In conjunction with a nonjudgmental orientation, the data suggest that a high level of lit- eracy and knowledge about sexual diversity is a key therapist attribute when dealing with clients in general, and non-normative clients in particular. We may identify the need for familiarity with: diversity, the core issues that specific client groups commonly face, and the specific language clients may use (Sub-theme 1-C). The importance of familiar understand- ing is illustrated by the fact that sexual “minority” is a problematic term, since, as stated above, it presupposes that LGBTQ individuals, and other sexualities outside the hegemonic norm, are statistically uncommon, obscuring the reality of sexual variance. As Barker emphasizes, while there is a culturally situated, widespread perception of LGBT, asexual, bondage and discipline, sadism and masochism (BDSM), non-monogamous, and queer individuals as being “minority” sexuality, they are “not actually minority in all cases”; con- sequently, rather than comprising an actual or statistical minority, these groups constitute a distinct conceptual category � constituting “what is seen as minority sexuality or gender” (Barker, research interview, March 30, 2012).

In addition to understanding such internal biases in the discourses about sexuality, it is important for the therapist to have a strong understanding of the subjective experiences clients may likely face. In working with gay male clients, for instance, Britton illustrates the importance of specialized knowledge, stating,

if I don’t even know the words, how can a guy who’s gay feel comfortable asking me “am I ok? Am I normal? How do I get past this? This is something I’m longing for.”? I have to have that nuanced background myself (Britton, research interview, March 7, 2012).

Specialist familiarity pertains to the intersections of a number of social factors, includ- ing: sexuality, race, class, gender and other variables. In this respect, attentiveness to the unique challenges particular clients may face, based on early life experiences is of eminent importance. As a number of interviewees point out, different social milieus, including sub-cultural groups and social classes, may respond very differently to sexual factors and diverse sexual identities, with clients facing varying levels of stigma and shaming, based on their social background. Appreciation of fluidity involves breaking down and challeng- ing dominant identity categories, addressing the client in a highly individuated way in order to understand them on their own terms, and potentially working to overcome or counteract some of the restraints of dominant discourse.

The data from this study provide evidence that social constructionist theory can be an invaluable diagnostic and psychotherapeutic framework, which may help the therapist to

SEXUAL AND RELATIONSHIP THERAPY 13

understand the client’s unique background and personal experiences (Theme 4). By focus- ing on the significant social and cultural variables that impact on a client’s sexuality and relationship, it may be possible to identify elements that inhibit or strengthen the client’s sexuality, and contextualize the role that sociocultural factors play both in the patient’s life and in the therapy process. Interviewees suggest that it is vital that the therapist works to maintain a sense of the dominant discourses that affect their clients, “knowing the sort of world that [their] clients are likely operating within” (Barker, research interview, March 30, 2012). This technique requires acknowledgement that sexual difficulties often occur within interpersonal social relationships, and are situated within a sociocultural context. A crucial factor when evaluating the sexual concerns of a non-normative client, therefore, may be in interpreting the client’s sociocultural milieu, evaluating how the client’s sexual difficulties may be rooted in their social setting, and how this may affect them � with or without their awareness.

Interview data indicate that the application of social constructionist theory (theme 4), and the therapist’s attempts to interpret and normalize the client’s sexuality and sexual problems (sub-theme 2-C), may generally involve a detailed sexual history taking. This often includes examination of the client’s family of origin, community experience, and early and ongoing messages surrounding sexuality. For LGBTQ clients, for example, it may be especially important to evaluate the early messages the client encountered in their family of origin, regarding sexual orientation, including the possible influence of hetero- normative models of sexuality. A vital benefit of using social constructionist theory is to help the client situate their sexual difficulties within the context of their own life. In this regard, working with social constructionist theory may compel the therapist to begin with the sexual problem presented by the client, and expand outwards, reflecting wider rela- tionship issues, or a more expansive range of psychosocial concerns.

More broadly, evaluating the social and relational context of sexuality and sexual diffi- culties vis-�a-vis social constructionism entails rendering explicit that which is implicit in a person’s life, by exploring the way that social messages and values may have been internal- ized by the client, both with and without the client’s awareness.

Discussion: practices in inclusive sex therapy � normalizing, horizontalizing, and affirming

At the level of clinical practice, a number of techniques, grounded in the principles identi- fied in the data, are relevant. First, thematic analysis of interview data revealed normalizing as another key practice, both in diagnosing/assessing clients, and throughout the treatment process (sub-theme 2-D). The technique of normalizing involves several dimensions. The therapist aims to help the client to conceive of sexual problems as understandable and nat- ural responses to psychological and relational factors. Further, the therapists seek to help the client develop a flexible perspective on sexual behavior, which reduces the level of stigma that may be associated with social standards of sexual behavior and normality. Therefore, as a clinical intervention, normalizing entails a number of facets, including:

� explicitly questioning normative standards of sexual behavior, under the assumption that imposing normative frameworks on client’s sexual behavior may produce iatro- genic injury (Winn, research interview, January 16, 2013),

14 M. D. BERRY AND A. N. LEZOS

� normalizing the client’s sexual identity, and possible fluidity of this identity (Barker, research interview, March 30, 2012),

� emphasizing that the client’s sexual difficulties and problems are normal responses to their current life circumstances, when compared to what others would likely experi- ence in such circumstances (sub-theme 2-C; Dunn, research interview, January 29, 2013; Fonagy, research interview, April 4, 2012),

� fostering a clinical environment in which the discussion of sexual issues and sexual problems is experienced as natural/appropriate (Hertlein, Weeks & Sendak, 2009; Milrod, research interview, October 11, 2012; Savage, research interview, November 4, 2012) ,

� situating clinical work within a context of critical research that self-consciously aims to challenge dominant standards of sexual normality, which are often seen as restric- tive and damaging to the client’s clinical aims (Barker, research interview, March 30, 2012; Kleinplatz, 1996; Mahrer, 2012; Ravella, research interview, January 11, 2013; Tiefer, 1996). Please consult Table 3 for an overview of the key principles and techni- ques of critical sex therapy.

Levine’s “first principle of clinical sexuality” clearly indicates the importance of social and cultural discourses, which define categories of normality and abnormality that strongly influence the client’s sexuality, and impact powerfully on sexual functioning (Levine, 2007). Consequently, as Fonagy emphasizes, “across orientations, across modali- ties, normalizing is a terrifically important part of what a psychotherapist does” (research interview, April 4, 2012). Normalization, for many interviewees, appears to serve a de- stigmatizing function, helping to problematize the expectations surrounding sexual behavior that contribute to the client’s sexual problem, or their subjective cognitive and affective experience of a perceived sexual dysfunction (sub-theme 2-E).

It is possible to identify two sexually specific aspects of normalization as a diagnostic and therapeutic technique: normalization of the client’s sexual identity and behaviors and normalization of the client’s sexual difficulties. Normalizing the client’s identity and desires/behaviors, serves an important “permission-giving” function, intended to help reduce the guilt or shame that may be implicated in the client’s sexuality. Normalizing the difficulties that have brought the client to therapy, Barker points out, is largely a matter “of saying: look, everyone who comes here struggles with this kind of stuff. It’s not, really, it’s not just you. It’s kind of everybody” (Barker, research interview, March 30, 2012). The data suggest that normalization is frequently supported by the use of psychoeducational

Table 3. Summary of inclusive sex therapy principles and techniques identified in survey of sex therapy specialists/experts. Principles � Maintaining a stance of nonjudgmental acceptance � Ensuring familiarity with sexual diversity � Use of social constructionist analysis Techniques � Normalizing (i.e. the client’s sexuality and/or sexual problem) � Horizontalizing (conceptualizing the client’s sexuality within the wider horizon of their identity) � Affirming-as-necessary (especially, affirming the client’s identity and subjective experiences) � Emphasis on reflective practice � Maintaining a non-pathologizing stance � Refuse to take on a client (in cases of obstructive, self-identified clinician bias/prejudice)

SEXUAL AND RELATIONSHIP THERAPY 15

techniques. Of particular importance is the critical stance towards categories of normality that the clinician models in the therapeutic encounter. As a number of interviewees indi- cate, normalizing should not result in the reification of categories of normality (i.e. by sit- uating the client within the norm and by implication positioning other behaviors as abnormal). Rather, normalization entails critically examining, or deconstructing, the cli- ent’s sense of abnormality, and problematizing/challenging the taken-for-granted notions of normality that affect the client’s sexual problems.

Another technique that may be useful for therapists working within an inclusive sex therapy orientation is: horizontalizing (Berry & Barker, 2014). Horizontalizing entails situating the client’s specific concern (i.e. a sexual problem/dysfunction) within the wider “horizon” of their lived experience, rather than focusing strictly on the clinical issue. Additionally, the clinician seeks to understand and work with specific salient aspects of the client identity (for instance, sexual “minority” status, or a non-normative sexual identity) within the wider psychosocial horizon. Thus, in horizontalizing the therapist refrains from treating the client’s sexual problems or sexual identity as the sole issue of importance in the therapy. Rather, a horizontalizing approach to the therapeutic encounter involves interpreting the client, and their clinical concerns, as complex, multidimensional and non-static. As Barker suggests, within this model, “you’re not seeing a person in front of you and thinking ‘they’re a lesbian’, ‘they’re a heterosexual’, ‘they’re asexual’, ‘they’re kinky’. It’s much more like…seeing that person as diverse, as ever-changing, as plural” (research interview, 2012, March 30, 2012). Sex, sexuality, and sexual problems, though very important, are considered to be only parts of the clinical picture. Horizontalizing may be of particular value for clients who them- selves have come to see a single � and often stigmatized � aspect of their sexuality as being singularly important or focal.

The data from this study suggest that this type of singular fixation may in fact serve to impede clinical work, particularly where clients experience shame or internalized preju- dice associated with some aspect of their sexuality. As such, the clinical technique of affirming-as-necessary is recommended as an inclusive sex therapy practice. In this respect, the “gay affirmative therapy” model � which aims to provide a “positive frame- work” for clinical practice that serves to affirm LGBTQ identities � offers a framework for working with non-normative clients, and diverse sexualities (Davies, 1996). Published research has shown that affirmative therapy can help counteract experiences of stigmati- zation or disaffirmation that the client has experienced, and potentially counteract dam- age to the client’s self-esteem, which the data from this study indicate may be a concern for some non-normative clients (Bigner & Wetchler, 2012; de Vries, de Vries, research interview, February 5, 2013; Rutter, 2012). Consequently, affirmative therapy may serve an immediately therapeutic effect, in addition to fostering the conditions for more effec- tive psychotherapy, by enabling the client to engage directly with issues that may have otherwise been (consciously or unconsciously) avoided.

As Langdridge states, the affirmative model requires the therapist to acknowledge and work with the dual impact that the psychotherapist and the wider sociocultural world have on the client’s sexual identity (Langdridge, 2007). Consequently, this therapeutic technique requires a high level of self-reflective awareness and critical engagement with the socially constructed aspects of the client’s identity, the clinician’s identity, and the context of the clinical encounter.

16 M. D. BERRY AND A. N. LEZOS

Discussion: use of reflective practice, maintaining a non-pathologizing stance, refusing to take on clients when obstructive therapist bias is present

The therapist’s ongoing reflective practice and critical self-evaluation are identified both in the data from this study and the wider published research as foundations for a well-articu- lated, open, nonjudgmental, and supportive stance (Mann, Gordon, & MacLeod, 2009; Stedmon & Dallos, 2009). While the therapist’s reflective practice may be a particularly important practical issue in working with diverse and non-normative clients, the core principles and techniques of self-reflection are of high importance with all clients and clinical issues. A number of tools may be usefully implemented in the therapist’s own practice, to foster critical self-reflection. Such tools may include journaling, mindfulness practice, or the therapist’s own psychotherapy/counseling (Berry & Barker, 2014). In addi- tion, interview data suggest that many therapists view clinical supervision and profes- sional dialogue with colleagues as very important reflective tools, which are often used to gain perspective on clinical practice, to gain insight into their own cognitive and affective responses to the therapy encounter, and to analyze transference and counter-transference processes.

A diagnostic and treatment framework that appears to be especially common amongst research participants is emphasis on a non-pathologizing model, or use of a sexual health model. Often used conjunctively, alongside normalizing, and within a stance of nonjudgmental acceptance, the sexual health (non-pathologizing) model emphasizes that many sexual concerns fall within the range of normal/healthy sexual functioning, and informs the critical orientation to standard diagnostic systems. Within this framework, there is a self-conscious attempt to avoid the language of pathology, and “the defining baseline [for a clinically treatable sexual issue] is whether it’s a prob- lem for them or not” (de Vries, research interview, February 5, 2013). Braun-Harvey, who works exclusively with men, and specializes in the outpatient treatment of men with concerns of out-of-control sexual behavior, describes his use of the sexual health model, stating:

I work from a sexual health perspective…I don’t do out-of-control sexual behaviour as a sex- ual disease, or disorder. I don’t use the terminology of addiction or, you know, another kind of disorder or disease perspective. I see it as on the continuum of worry-problem-and-disor- der, as…a sexual problem, not a sexual disorder or dysfunction, or a psychiatric diagnosis. (research interview, November 15, 2012)

For many psychosexual therapists working within an anti-pathologizing, or sexual- health, framework, the diagnostic language used in conventional psychodiagnostics is inherently problematic. Many interviewees who use this model emphasize the distinction between “problem” and “dysfunction,” stressing that the language employed in DSM is intrinsically pathologizing, as it casts variant sexuality and sexual behavior as dysfunc- tional/pathological. Table 2 provides a summary of critical sex therapy techniques drawn from the interview data, and relevant outside research, which are seen to be of particular utility in working with sexually diverse clients and client populations.

Finally, where nonjudgmentality and reflective practice continue to be obstructed by a therapist’s biases, a final avenue is suggested. Alman, a psychosexual therapist working within a principally cognitive behavioral framework, a technique that underlines the importance of self-reflective practice, and illustrates the pragmatic

SEXUAL AND RELATIONSHIP THERAPY 17

challenges of nonjudgmentality that the clinician may encounter. Genuine acceptance, she states, is

a necessity if you’re a sex therapist. You can’t even have that: you’d want to do what?—kind of response inside, let alone express it…So I feel if a [therapist] knows that they can’t deal with certain issues, then they shouldn’t. It’s a moral responsibility not to take clients who play in BDSM, for instance, if [the therapist] find[s] that personally repugnant. (Alman, research interview, January 9, 2013)

Thus, the conceptualization of moral/ethical responsibility she describes implies the following technique: refusing to accept a client, or terminating the therapy process in instances where a self-perceived bias/prejudice threatens to compromise the treatment. This technique appears to be strongly linked with self-reflective practice, as it presupposes recognition of one’s own biases and clinical limitations. There is a clear ethical mandate that psychotherapists refrain from administering psychotherapy services that are apt to be ineffectual, or damaging to the client, entrenched in the ethical protocols of the psycho- therapy profession (Leach & Harbin, 1997; Welfel, 2012). However, further research in this area is needed, in order to assess the overall use and efficacy of self-reflective practice amongst clinicians, and specifically to determine psychotherapists’ competencies in iden- tifying their own subjective biases, especially in working with sexual problems.

Limitations and future directions

Client diversity, and the strategies involved in working with varied client groups, is an impor- tant area for current research and clinical literature. The data gathered in this study, and described above, suggest the value of a number of core principles and key techniques that may be used critically in working with diverse client populations in sex therapy practice. While this data provide the foundation for a clinically applicable set of principles and guide- lines for working with diverse populations, which we have described in this paper, there are a number of limitations to this study that may be addressed through further research.

In terms of the research methodology, while the semi-structured interview format allowed for a more detailed and comprehensive examination of each participant’s areas of interest and expertise, this format limits the replicability of a qualitative study of this nature. Again, it is important to note that, measures (aforementioned) were taken to ensure trustworthy and credible data; however, in a qualitative study of this kind, these criteria for trustworthiness cannot be equated with exact replicability (Morrow, 2005). Additionally, with respect to the interview methodology differences in the format of inter- views (i.e. in-person versus Skype-with-video versus audio-only) create a difference in the qualitative experience of the interview, and appeared to correlate with a difference in length, with in-person interviews being longer, and more detailed. For future research, in- person interviews may be favorable.

Based on this research project, a number of areas for future research can be identi- fied. First, psychotherapy process and outcome research� both qualitative and quanti- tative � would be useful to assess the clinical advantages of these techniques in terms of therapy efficacy. In this respect, the further development of an inclusive sex therapy model, as an evidence-based therapy, is a productive objective for future research, in our assessment.

18 M. D. BERRY AND A. N. LEZOS

Conclusion

Based on the findings represented in this study, we have recommended prospective value of core principles including: maintenance of a nonjudgmental stance, developing and maintaining familiarity with sexual diversity, and the use of a social constructionist frame- work in conceptualizing work with diverse clients. Relatedly, we have described six clinical techniques, which are grounded in these principles. These include:

(1) normalizing, (2) horizontalizing, (3) affirming-as-necessary, (4) reflective practice, and (5) maintenance of a non-pathologizing stance.

Data from this study have also suggested that in instances where the therapist holds an obstructive bias towards a client, the onus falls on the therapist to (6) refuse to take on, or continue therapy with, this client.

The data and clinical recommendations presented here, in our assessment, are a needed addition to the field in light of the limited research on therapists’ work with diverse client populations. Clinical principle and practice literature, as presented here, is intended to help improve the confidence, knowledge, and insight of practitioners who work with increasingly diverse client populations.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Michael D. Berry, PhD, is a research associate in the laboratory for the Biopsychosocial Study of Sexuality at McGill University. He also serves as the manager of clinic operations for the Sex and Couple Therapy Service at the McGill University Health Centre. His primary interests include: the application of empirical research to advance clinical practice, and the use of fair and empowering clinical practices with diverse communities.

Anastasia Natasha Lezos, MA, is a graduate of the counselling psychology postgraduate program at McGill University in Montreal, Canada. She has a strong research interest in human sexuality, and a clinical interest in counselling and psychotherapy within a social justice framework.

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