Therapists Attitudes Knowledge Comfort and Willingness to

Chapter 1: Introduction to the Study

Marriage and family therapists are uncomfortable discussing topics of a sexual

nature (Cupit, 2010; Harris & Hays, 2008). Researchers have found that this lack of

comfort has persisted (Dermer & Bachenberg, 2015). Beginning therapists are

particularly prone to avoid sexual topics with their clients (Timm, 2009). Comfort

impacts competency; knowledge alone is not sufficient (Dermer & Bachenberg, 2015). It

is important to be both comfortable and knowledgeable as a therapist (Voss, 2015). The

World Health Organization (2006) affirmed sexual health as a human right, and

according to Dermer and Bachenberg (2015), therapists should affirm sexual health to

their clients. However, adequate training to improve therapist comfort levels in sexual

topics has not increased during the past 40 years (Dermer & Bachenberg, 2015).

Attitudes and knowledge have an impact on how therapists practice therapy and how they

implement interventions (Dermer & Bachenberg, 2015). Understanding therapists’

attitudes toward sexuality will provide a better understanding of how attitudes impact the

comfort level of the therapist when engaging the client on sexual topics (Dermer &

Bachenberg, 2015; Russell, 2012).

In Chapter 1, I present an overview of this study, including a description of the

social problem, gaps in the literature, and hypotheses. I introduce Bowen’s (1976) theory,

which provided the framework for the study. Finally, I define the terms and variables,

present the research design, and discuss the limitations, delimitations, assumptions, and

significance of the study.

Background

Harris and Hays’s (2008) research on marriage and family therapists’ willingness

to engage in discussions of sexuality with their clients was the seminal work in this area

and the only peer-reviewed journal article that addressed this variable within the

Bowenian theoretical framework. Harris and Hays published their first study addressing

marriage and family therapists’ attitudes toward lesbian, gay, bisexual, and transgender

(LGBT) individuals in 2012. There has been some research into the link between licensed

clinical marriage and family therapists’ (LCMFT) attitudes and comfort, and between

LCMFTs’ attitudes and practice (Anderson, 2002; Giami & Pacey, 2006; Juergens, 2006;

Weerakoon & Stiernborg, 1996; Yelton & Delfin, 2015). There have been studies on the

link between LCMFT knowledge, comfort, and attitudes toward sexuality (West et al.,

2012). There have also been studies addressing how LCMFT comfort and knowledge

impact willingness to discuss sexuality (Hanzlik & Gaubatz, 2012; Harris & Hays, 2008).

Only two studies addressed all four variables concerning how knowledge and

attitudes about human sexuality impact comfort and willingness to engage with clients

about their sexuality, but neither included participants from the marriage and family

therapy community; instead, the authors surveyed counselors (Cupit, 2010; Juergens,

2006). Sexuality is important to the individual and is recognized not only for its

importance but as a human right by the World Health Organization (2006). Therapists

who do not address sexuality with their clients can cause harm both to themselves and the

client (Cupit, 2010; LoFrisco, 2013; Ridley, 2006). Therapists are still “not comfortable

discussing sexual issues with their clients” (Cupit, 2010, p. 9), and this is leading to harm

(Dermer & Bachenberg, 2015). There has not been a study addressing all of the variables

as applied to marriage and family therapists. I intended for this study to fill the gap in the

literature to increase the understanding of how personal attitudes about human sexuality

factor into marriage and family therapists’ willingness to discuss sexual topics with their

clients. Findings may improve therapists’ abilities to address this issue by reducing their

anxiety and reducing the chance of harm to clients.

Problem Statement

The research problem was that marriage and family therapists are not comfortable

discussing sexual issues with clients to the point of not being willing to broach the topic

(Cupit, 2010; Dermer & Bachenberg, 2015; Harris & Hays, 2008; LoFrisco, 2013; Timm,

2009). Therapists may cause significant damage by not proactively addressing the issue

of sexual health or by dismissing it when brought up by the client (Cupit, 2010; Harris &

Hays, 2008; Juergens, Smedema, & Berven, 2009; LoFrisco, 2013; Papaharitou et al.,

2008; Timm, 2009). Many therapists fail to assist their clients in dealing with these issues

(Harris & Hays, 2008; Juergens et al., 2009; Papaharitou et al., 2008). Based on a

literature search of many databases, I found only one peer-reviewed journal article that

addressed marriage and family therapists discussing sexual issues with clients in which

the researchers found a link between knowledge, comfort, and willingness to engage

(Harris & Hays, 2008). I found only two peer-reviewed journal articles addressing the

link between attitudes and comfort (Hanzlik & Gaubatz, 2012; Russell, 2012).

Furthermore, I found only one peer-reviewed journal article addressing the variable of

willingness to engage clients in sexual discussions with a marriage and family therapist

(Harris & Hays, 2008). If therapists do not help clients to feel comfortable talking about

their sex life because they will not broach the topic of sexuality, then they should address

this problem (Harris & Hays, 2008). Building upon the previous research by examining

the variable of therapists’ attitudes compared with the other three variables of knowledge,

comfort, and willingness was needed to increase the knowledge base in the field (Cupit,

2010; Dermer & Bachenberg, 2015; Harris & Hays, 2008; LoFrisco, 2013; Miller &

Byers, 2012; Russell, 2012).

Purpose

In this quantitative study, I used Bowenian theory to examine the relationship

between therapists’ attitudes, knowledge, comfort, and willingness to engage clients in a

discussion of their sexuality (see Harris & Hays, 2008; Kerr & Bowen, 1988; Schnarch,

1998). The independent variables were (a) attitudes, (b) knowledge, (c) training, (d)

supervision experience, (e) clinical experience, (f) sex, (g) age, (h) strength of religion, (i)

sexual orientation, (j) practice experience, (k) practice setting, (l) graduate specialization,

and (m) relationship status; the dependent variables were (a) comfort and (b) willingness

to engage.

Research Questions and Hypotheses

The following research questions (RQs) and hypotheses were used to guide the

study:

RQ1: What is the relationship between attitudes, knowledge, training, supervision

experience, and clinical experience and a therapist’s willingness to discuss sexual topics

with clients?

H01: There is no statistically significant relationship between attitudes,

knowledge, training, supervision experience, and clinical experience and a therapist’s

willingness to discuss sexual topics with clients.

Ha1: There is a statistically significant relationship between attitudes, knowledge,

training, supervision experience, and clinical experience and a therapist’s willingness to

discuss sexual topics with clients.

RQ2: What is the relationship between attitudes, knowledge, training, supervision

experience, and clinical experience and a therapist’s comfort discussing sexual topics

with clients?

H02: There is no statistically significant relationship between attitudes,

knowledge, training, supervision experience, and clinical experience and a therapist’s

comfort discussing sexual topics with clients.

Ha2: There is a statistically significant relationship between attitudes, knowledge,

training, supervision experience, and clinical experience and a therapist’s comfort

discussing sexual topics with clients.

RQ3: What independent variables (attitudes, knowledge, training, supervision

experience, and clinical experience) predict a therapist’s comfort level with sexuality?

H03: There is no statistically significant predictive relationship between the

independent variables (attitudes, knowledge, training, supervision experience, and

clinical experience) and a therapist’s comfort level with sexuality.

Ha3: There is a statistically significant predictive relationship between the

independent variables (attitudes, knowledge, training, supervision experience, and

clinical experience) and a therapist’s comfort level with sexuality.

RQ4: What independent variables (attitudes, knowledge, training, supervision

experience, and clinical experience) predict a therapist’s willingness to discuss sexual

topics with clients?

H04: There is no statistically significant predictive relationship between the

independent variables (attitudes, knowledge, training, supervision experience, and

clinical experience) and a therapist’s willingness to discuss sexual topics with clients.

Ha4: There is a statistically significant predictive relationship between the

independent variables (attitudes, knowledge, training, supervision experience, and

clinical experience) and a therapist’s willingness to discuss sexual topics with clients.

RQ5: What is the relationship between the independent variables of a therapist’s

age, sex, sexual orientation, number of years in practice, type of graduate program,

relationship status, practice setting, or strength of religion and the dependent variable of

the sexual comfort of a therapist?

H05: There is no statistically significant relationship between the independent

variables of a therapist’s age, sex, sexual orientation, number of years in practice, type of

graduate program, relationship status, practice setting, or strength of religion and the

dependent variable of the sexual comfort of a therapist.

Ha5: There is a statistically significant relationship between the independent

variables of a therapist’s age, sex, sexual orientation, number of years in practice, type of

graduate program, relationship status, practice setting, or strength of religion and the

dependent variable of the sexual comfort of a therapist.

RQ6: What is the relationship between the independent variables of a therapist’s

age, sex, sexual orientation, number of years in practice, type of graduate program,

relationship status, practice setting, or strength of religion and the dependent variable of a

therapist’s willingness to discuss sexual topics?

H06: There is no statistically significant relationship between the independent

variables of a therapist’s age, sex, sexual orientation, number of years in practice, type of

graduate program, relationship status, practice setting, or strength of religion and the

dependent variable of a therapist’s willingness to discuss sexual topics?

Ha6: There is a statistically significant relationship between the independent

variables of a therapist’s age, sex, sexual orientation, number of years in practice, type of

graduate program, relationship status, practice setting, or strength of religion and the

dependent variable of a therapist’s willingness to discuss sexual topics.

Theoretical Base

The theoretical framework for this study was Bowenian theory (see Baer &

Murdock, 1995; Bowen, 1976; Harris & Hays, 2008; Kerr & Bowen, 1988; Schnarch,

1998). Bowen (1976) developed this theory as a practicing therapist while observing

families in both structured and unstructured settings. Bowen examined the ability of

therapists to remain emotionally present and nonreactionary while being able to express

their values and dispense assessments (Baer & Murdock, 1995). The major theoretical

constructs of Bowenian theory appropriate for this study were therapists’ anxiety and

reactivity (see Cupit, 2010; Harris & Hays, 2008). According to Bowenian theory, it is

difficult for therapists to be helpful to clients in the therapeutic relationship when the

therapists’ emotional reactions interfere with their awareness (Kerr & Bowen, 1988;

Schnarch, 1991). According to Harris and Hays (2008), “Bowen’s concepts of anxiety

and reactivity are helpful in conceptualizing why a therapist might not engage his or her

clients in a discussion of sexuality” (p. 241). Basing this study on Bowenian theory may

add to the understanding of how these variables fit into a system and impact therapists

and how they may or may not relate to each other in decreasing anxiety (see Baer &

Murdock, 1995; Harris & Hays, 2008). The goal of this study was to increase the

understanding of how therapists may decrease their anxiety so they can positively engage

the client in discussions of sexuality (Harris & Hays, 2008).

Nature of the Study

The nature of this study was quantitative. Previous studies had used quantitative

methods based on Bowenian theory. I used a correlational study design to examine

relationships among the variables.

Definitions

Attitudes (toward discussing sexuality with the client): Therapists’ attitudes in this

study were defined as therapists being aware of their biases, beliefs, and judgments and

not allowing them to negatively influence their view of their clients as individuals or the

subject matter broached by the client in the therapeutic relationship. A negative attitude

toward a client’s sexual orientation would constitute a barrier to the therapist’s

effectiveness. Through self-understanding, negative attitudes can be avoided (Cort,

Attenborough, & Watson, 2001; Masters & Johnson, 1970).

Comfort with sexual discussions: The therapist’s ability to (a) accept and respect

clients’ sexual practices, (b) have open discussions about clients’ sexuality, and (c)

communicate effectively regarding sexuality (Graham & Smith, 1984). Comfort with

discussing sexual issues is a broad concept involving “cognitive, affective, and

behavioral responses to sexuality” (Graham & Smith, 1984, p. 439). The ability to be

comfortable with sexual issues is “a developmental task influenced by the physiological,

psychological, sociological, spiritual or religious, educational, and sexual aspects of one’s

being.” (Graham & Smith, 1984, p. 440).

Sexual issues: Sexual issues and dysfunctions “are broadly defined as any sexual

concern a client may have and the psychological issues that accompany it” (LoFrisco,

2013, p. 17). Examples of common sexual issues include “sexual performance, sexual

dysfunctions, gender issues, sexual abuse, sexual disorders, sexual addiction, sexual

trauma, sexual shame and sexual intimacy issues” (LoFrisco, 2013, p. 17).

Sexual knowledge: “Sexual knowledge is defined as possession of correct

information regarding human sexuality, including a good understanding of the dynamics

and psychological effects of sexual dysfunctions, information about the sexual response

phases, and an awareness of what is considered to be normal or average” (LoFrisco,

2013, p. 17).

Willingness (to engage a client in a discussion about sexuality): The likelihood

that the therapist will proactively broach or discuss sexual issues with the client (Harris &

Hays, 2008).

Assumptions

I made several assumptions in this quantitative correlational study. I assumed that

therapists want to help their clients. I also assumed that therapists who filled out their

surveys were honest and that the information provided by them was accurate. I assumed

that the therapists who filled out the survey were representative of the larger population. I

assumed, as did Cupit (2010), that “the instruments that were used in this study are

reliable and valid and accurately measure sexual comfort [and therapists’] sexual

attitudes, sexual knowledge, training experience with sexual issues, supervision

experience addressing sexuality, and clinical experience with sexual issues” (p. 14). I

assumed that the participants volunteered willingly and that their answers did not reflect

any impairment or agenda or were given while under duress. Because the participants

answered questions anonymously, I assumed that the participants were licensed marriage

and family therapists and that they fully understood the informed consent packet and how

anonymity and confidentiality worked as it pertained to the survey. These assumptions

were necessary to meet the demands of social science research standards as laid out by

Creswell (2013).

Scope and Delimitations

I limited the study to licensed marriage and family therapists practicing in the

United States. The study focused on the quantitative gaps in the research regarding how

therapists’ knowledge and attitudes impact comfort and willingness to engage clients.

The study included an online survey made up of seven scales to assess these variables

and their potential correlations. Therapists answered questions regarding their knowledge

of sexual issues/sexuality, attitudes toward sexual issues/sexuality, training, education,

clinical experience, and supervision experience. Additionally, therapists answered

questions regarding their comfort while discussing sexual issues with clients and their

willingness to initiate the discussion with a client regarding sexual issues. I tested the

hypotheses using a quantitative correlational research design (see Bramante, 2015), and

research questions to determine whether there were any relationships between the

independent variables and dependent variables. Generalizability of this study was limited

because I only drew participants from the United States; the theoretical perspective of

Bowen can also be viewed as a delimitation. Also, I did not include sexual

inappropriateness, sexual transference, and sexual counter-transference in this study, nor

did I include criteria regarding sexual orientation because they were beyond the scope of

this study.

Limitations

Pyrczak and Bruce (2000) defined a limitation as a “weakness or handicap that

potentially limits the validity of the results” (p. 57). In this study, there were limitations

related to internal validity, including methods of sampling, instrumentation, testing, and

administration. Even with a random sample, the level of control is reduced because of the

design being quasi-experimental and not purely experimental (see Campbell & Stanley,

1966). Regarding testing and survey administration, this study was not on par with any

study that included in-person methods to collect data, and because the study was web

based, nonresponses may have increased due to lack of access or inability to understand

how the survey link and Survey Monkey system works (see Millar & Dillman, 2011).

Internet surveys are affordable and efficient and allow a broad reach that might not

otherwise be possible, which made them a good fit for this study despite the limitations

(see Ward, Clark, Zabriskie, & Morris, 2012). Additional limitations of this study were

that therapists may have felt they must provide the politically correct or socially

enlightened answer that did not reflect their true perspective. Also, a more conservative

or traditional therapist may have avoided answering certain survey questions because of

their potential for being too personal in nature; this may have also led therapists to not

return the survey or to exit the survey early because they did not want the information to

be known even though I assured them anonymity.

Significance

Therapists need to be willing to initiate and discuss with clients, their sexual

health issues (LoFrisco, 2013). Because this is not occurring on a regular basis, I

conducted a study to address how the therapy community may increase the willingness of

therapists to discuss sexual issues with their clients. Anderson (2002) asked “what effect

does the combination of the variables of human sexuality knowledge, experience, and

attitudes have on the sexual comfort” (p. 8) and willingness to engage clients in

discussions of sexuality? I attempted to answer this question to further the understanding

in this area. Few researchers have delved into this area, and this gap in understanding

negatively impacts millions of Americans who rely on marriage and family therapists for

guidance when dealing with sexual health issues (Cupit, 2010; Dermer & Bachenberg,

2015; Harris & Hays, 2008; Juergens et al., 2009; LoFrisco, 2013; Papaharitou et al.,

2008; Timm, 2009). The results of this study may inform the marriage and family therapy

community education curriculum used to prepare therapists in school and postgraduate

studies, and the results of this study may inform the training methods used in workshops,

supervision, and clinical settings to prepare therapists through understanding of the

elements that impact their willingness to discuss sexual health issues with a client (see

Cupit, 2010). Therapists may use the results from this study as a basis for positive change

within the marriage and family therapy community by addressing a problem and

suggesting potential solutions so that the population that is suffering from sexual

dysfunction may be better served.

Summary

Chapter 1 provided an overview of the scope of this study concerning marriage

and family therapists and the pressing concern that therapists are not initiating and

engaging in discussions with their clients regarding sexual health issues. The potential for

harm to the client formed part of the basis for this study; the other was the dearth of

literature in this area. I reviewed the independent variables addressed in this study

(knowledge, with its subsets of training, supervision, clinical experience, and attitudes)

and the dependent variables of comfort and willingness to engage and discuss with a

client regarding a sexual issue. I described the quantitative correlational research design,

including the survey method. The survey comprised instruments that were reliable and

valid, and I analyzed data using multiple regression analysis. The results from this study

may be used to start a conversation within the marriage and family therapy community in

hopes that educational institutions will take note and better prepare marriage and family

therapists for practice. Findings may also be used to improve the care provided by those

in practice. In Chapter 2, I review the literature from other disciplines in addition to the

marriage and family therapy discipline to provide an in-depth perspective on the issues.

Chapter 2: Literature Review

A current problem within the community of marriage and family therapists is a

lack of knowledge, comfort, and willingness to engage clients about their sexuality

(Dermer & Bachenberg, 2015; Harris & Hays, 2008). Therapists are not engaging their

clients regarding sexual health issues because of lack of comfort; avoiding or dismissing

the issue can result in damage to the client (Cupit, 2010; Harris & Hays, 2008; Juergens

et al., 2009; LoFrisco, 2013; Papaharitou et al., 2008; Timm, 2009). The purpose of this

study was to examine the relationship between the independent variables of therapists’

attitudes and knowledge and the dependent variables of therapists’ comfort with sexual

topics and willingness to discuss sexual topics. A better understanding of how these

variables interact with each other during the process of therapeutic discussions of

sexuality from the therapists’ perspective may provide a significant addition to the body

of research in this area.

Synopsis of Current Literature

Haesler, Bauer, and Fetherstonhaugh (2016) studied health care professionals’

attitudes and knowledge regarding sexuality and found a lack of confidence and

knowledge in providing treatment to patients; many health care professionals in their

study considered sexuality to be outside the scope of their practice, while still indicating

“that a positive and respectful attitude toward sexuality is important” (as cited in

Saunamäki, Andersson, & Engström, 2010, p. 1308). Haesler et al. (2016) found that

therapists’ knowledge and attitudes were significant contributors to predicting how

therapists interacted with clients regarding sexuality. Although health care professionals

as a group considered sexuality to be an important part of the human experience, many

did not wish to provide treatment in that area for their clients (Verschuren, Enzlin,

Geertzen, Dijkstra, & Dekker, 2013). According to Cupit (2010), there has been a steady

decline in research in the area of sexuality since the 1970s. Dermer and Bachenberg

(2015) found that marriage and family therapists have not made any significant progress

in the past 40 years, and that their comfort has not improved regarding sexuality as a

topic. Russell (2012) examined counselors’ attitudes and knowledge about sexuality as a

topic and found that attitude was the primary predictor of whether counselors addressed

sexuality with clients. The first researchers to address therapists’ comfort and willingness

to engage in topics of sexuality were Harris and Hays (2008). Since then, several other

researchers have examined different groups—primarily counselors and psychologists—

about several relevant variables, but no study has addressed all four variables as applied

to the marriage and family therapist community. Given the importance of human

sexuality to the individual, the prevalence of sexual dysfunction presently occurring in

both men and women, and the therapeutic setting offering the only available resource for

individuals, broadening the understanding of this issue is important to encourage more

effective practice among marriage and family therapists (Bancroft, 2009a; Harris & Hays,

2008; Laumann et al., 2007; Lyons, Bieschke, Dendy, Worthington, & Georgemiller,

2010; Shifren, Brigitta, Russo, Segreti, & Johannes, 2008).

Chapter 2 starts with a discussion of the research strategy employed in compiling

this literature review, along with key terms used and databases accessed. I discuss the

theoretical foundation upon which I based this study—Bowen’s theory (see Kerr &

Bowen, 1988). Bowen posited that anxiety held therapists back from discussing sexual

topics with clients (Harris & Hays, 2008; Kerr & Bowen, 1988). Following the

presentation of the theoretical foundation, I discuss each variable (knowledge, attitude,

comfort, and willingness to engage) within several subsections of health care

professionals, including counselors, therapists, and psychologists. I explain the

importance of these variables to therapeutic practice, their relevance to this study, the gap

in the literature, and the need for further study. I conclude with a summary.

Literature Research Strategy

I conducted multiple searches using the following databases: Academic Search

Complete, Dissertations and Theses, Dissertations and Theses at Walden University,

ERIC, Expanded Academic ASAP, MEDLINE (with full text), ProQuest Central,

ProQuest Health & Medical Complete, ProQuest Nursing & Allied Health Source,

PsycARTICLES, PsycINFO, PubMed, SAGE Premier, SocINDEX (with full text),

Taylor and Francis Online, and Thoreau Multi-Database Search. I also used the Google

Scholar search engine. The key words used in the literature review included counselor,

therapist, psychology, psychologist, therapy, marriage and family therapy/therapist,

nurse, nursing, medical, health care, allied health, health care professional, and

physician. I combined these search terms with the words sex, sexuality, attitude, comfort,

knowledge, approach, willingness to engage, and discussion. For example, one search

included the words “therapist attitude sexuality.” Appendix A provides a detailed list of

search terms.

I used the same databases to search for Bowen’s theory related to sexuality in a

therapeutic context. Most authors published their materials within the last 5 years.

Although this filter was typically viable in the area of medicine and health care, other

areas lacked relevant literature within the 5-year parameter. Peer-reviewed journal

articles constitute most of the literature cited in this chapter. I also review doctoral

dissertations, textbooks, and handbooks.

Because the focus of this study was sexuality and how it is addressed in a

therapeutic setting, sex, sexuality, and sexual issues are thoroughly defined and reviewed.

I included all available research in the area of marriage and family therapists’ comfort,

knowledge, attitudes, and willingness to discuss sexual issues with clients. In the area of

marriage and family therapy, the seminal work was Harris and Hays’s (2008) study

regarding therapists’ comfort and willingness; this was the only peer-reviewed research

related to this area as applied specifically to marriage and family therapists. Miller and

Byers (2012) conducted important research regarding psychologists, a different type of

mental health professional. Similar to Cupit (2010), I found limited literature available on

these subjects, so I expanded my review beyond the marriage and family therapy area to

include other health care professionals such as counselors, psychologists, and

rehabilitation counselors, which proved helpful and illustrative of the issues facing the

marriage and family therapy community.

Theoretical Foundation

Bowen (1976) developed a family systems theory based on his work as a

practicing family therapist, observing clients in both structured and unstructured settings.

The major theoretical constructs of Bowenian theory appropriate for this study were

anxiety and reactivity (see Cupit, 2010; Harris & Hays, 2008, Schnarch, 1998). When

therapists’ emotional reactions interfere with their awareness, it is difficult to be helpful

in the therapeutic relationship (Kerr & Bowen, 1988; Schnarch, 1991). Schnarch (1991)

emphasized how important human sexuality was by stating that “the expression of

sexuality is a window into who each person is and how they relate to each other” (p. 20).

If therapists lose awareness of what is going on within the therapeutic relationship

because they have become anxious and allowed their emotions to stop or severely impede

the process, they not only impair the process with clients but “also could perpetuate the

symptoms of the problem within the system” (Harris & Hays, 2008, p. 241). This lack of

awareness causes the exact type of harm that Cupit (2010) and LoFrisco (2013) stated

should not occur in the therapeutic relationship. The way that therapists have dealt with

this anxiety is by not addressing the topic (Cupit, 2010; Harris & Hays, 2008; LoFrisco,

2013; Schnarch, 1991; Yelton & Delfin, 2015). It is imperative that the therapist is

relaxed when initiating the discussion about sexuality, and the therapist needs to be aware

that the client is often waiting for the therapist to initiate the discussion (Harris & Hays,

2008; Hays, 2002). For an individual to become a fully integrated sexual being, the

therapist must act as the model of how to move past the anxiety that is acting as a barrier

to progress (Harris & Hays, 2008; Schnarch, 1991, 1998). Harris and Hays (2008)

applied Bowen’s theory in their research, which addressed the relationships “between

therapists’ sexual knowledge and their comfort with sexual material and how these

factors influenced the likelihood that the therapists will engage in sexual discussions with

their clients” (p. 241).

Cupit (2010) chose Rogers’s (1951) person-centered theory of self-actualization

as the lens through which to analyze the subject of counselors’ comfort and willingness to

discuss sexual topics with clients. Cupit also used four of the instruments developed by

Harris and Hays (2008) in her study design. Cupit and LoFrisco (2013) both cited the

lack of research that continues to negatively impact this area, a circumstance that led

Cupit (2010) to use the Harris and Hays (2008) instruments.

I chose the Bowenian theory for the current study to further Harris and Hays’s

(2008) seminal research and to stay within the framework they established on this topic. I

also chose Bowenian theory to address the main issues reported by therapists in

discussing sexuality with clients: that they feel anxious, emotionally unready, and

reactive about starting a discussion about a client’s sexual health. Kelsey, Stiles, Spiller,

and Diekhoff (2013) found that 52% of therapists do not view themselves as competent to

discuss bondage, dominance, sadism, and masochism with clients and would refer a

client presenting with this issue to someone else.

The Bowenian theory was appropriate for the present study because it was the

only theory chosen by Harris and Hays (2008). Moreover, there had not been any

research done in this area since the Harris and Hays study. The Bowenian theory

provided the best lens to understand anxiety and emotional reactivity on the part of the

therapist when discussing sexual topics with clients. Also, Bowenian theory provided

continuity to the reader by building on the framework developed by Harris and Hays

(2008). The research questions related to Bowenian theory focused on the influence the

perceptions of sexual knowledge have on therapists and how to increase their feelings of

competency. I included attitude as the missing variable to provide a clearer picture of

what factors influence therapists in their willingness to engage clients in a discussion

about sexuality.

Sexuality

Sexuality is an important aspect of people’s lives and a major component of

mental health for the client (Bancroft, 2009a; Cupit, 2009; Lyons et al., 2010). Human

sexuality “encompasses gender identities and roles, sexual orientation, eroticism,

pleasure, intimacy, and reproduction” (WHO, 2006, p. 5). Diamond and Huebner (2012)

supported the links between well-being and sexuality and between the quality of life and

sex life of a couple. An individual’s sexuality is a human right that the therapist should

cherish and nurture. However, the ideological background of the therapist can inhibit

open discussion (M. S. Green, Murphy, & Blumer, 2010).

Shifren et al. (2008) found that 43% of adult women suffered from ongoing,

regularly recurring sexual dysfunction. This rate varied depending upon which

dysfunction was being measured (arousal, interest, lubrication, or failure to orgasm) ,but

the incidence at which these dysfunctions occurred appeared to support previous research

(McCabe et al., 2016). Because of the small amount of literature on this topic, however, it

was difficult to assess the scope of female sexual dysfunction in the United States

(McCabe et al., 2016).

Men were also likely to have sexual dysfunction issues, with 22% over age 40

suffering from erectile dysfunction (Laumann et al., 2007). If a sexual issue remained

unresolved, the potential consequences were less happiness for the individual, which then

impacted his or her well-being (Rosen & Bachmann, 2008). Despite the regularity with

which sexual issues occur and the negative consequences if sexual issues are not

addressed, there exists a systemic failure by the therapeutic community to address these

concerns (Harris & Hays, 2008; Juergens et al., 2009; Papaharitou et al., 2008;

Weerakoon, Sitharthan, & Skowronski, 2008). Cupit (2010) noted the steady decrease of

research on the topic of sexuality since the 1970s.

In the Diagnostic and Statistical Manual of Mental Disorders (DSM–5; American

Psychiatric Association, 2013), the authors have reorganized sexual disorders, and they

have merged or eliminated some categories entirely (Graham, 2016). For example, the

authors combined hypoactive sexual desire disorder and female sexual arousal disorder

into a single, broader definition: female sexual interest/arousal disorder (Graham, 2016).

In the same fashion, they merged dyspareunia and vaginismus into genito-pelvic

pain/penetration disorder (IsHak & Tobia, 2013).

Male hypoactive sexual desire disorder is now a category. The authors renamed

male orgasmic disorder as delayed ejaculation with broader definitions included and both

male dyspareunia and male sexual pain were removed (IsHak & Tobia, 2013). The

authors did not make these changes without controversy but reflected the most current

empirical research available (IsHak & Tobia, 2013). That the DSM-5 includes these

sexual disorders and syndromes and that the definition of specific disorders is still in flux

indicates the ongoing importance of human sexuality as related to psychotherapy.

Comfort

Health Care Professionals’ Comfort With Sexual Topics

Graham and Smith (1984) developed the following definition of sexual comfort

over 30 years ago: “Sexual comfort is a broad, complex construct involving cognitive,

affective, and behavioral responses to sexuality; as well as a developmental task

influenced by the physiological, psychological, sociological, spiritual or religious,

educational, and sexual aspects of one’s being” (p. 439). This definition continues to

provide a framework to determine the comfort level of therapists dealing with the topic of

sexuality with clients. Graham and Smith (1984) found that attitudes, feelings, and

communication skills had an impact on sexual comfort. Haboubi and Lincoln (2003), in

their survey of 100 doctors, nurses, occupational therapists, and physiotherapists found

that 90% of respondents agreed that sexual health was important and that they should

address it as part of the health care approach. Ninety-four percent of these health care

professionals would not initiate a discussion of sexuality with a patient due to lack of

comfort. Most felt poorly trained to handle a discussion regarding a patient’s sexuality

(Haboubi & Lincoln, 2003). These findings were similar to previous research, however,

about whether gender, attitude, or knowledge impacted this discomfort. Fifty percent of

the respondents cited embarrassment as a barrier to discussing sexual issues, even though

60% of respondents said that they would feel comfortable discussing sexual issues with

clients (Haboubi & Lincoln, 2003). In a more recent study of nurses, researchers found

that 66% felt comfortable discussing sexual issues with patients (Saunamäki et al., 2010).

Older nurses were more confident and comfortable discussing patients’ sexual issues and

concerns and also displayed a more positive attitude toward sexuality and dealing with

sexual health. In a similar study, 67% of nurses felt comfortable discussing sexual issues

with patients, but only 40% felt the need to do so; 33% did not feel comfortable initiating

the discussion or discussing sexual health issues with patients (Kotronoulas,

Papadopoulou, & Patiraki, 2009). In an earlier study, Magnan and Reynolds (2006) found

that OB/GYN and rehabilitation nurses were more comfortable than their other nursing

specialization peers and noted certain specializations as a barrier to discussing sexual

issues with patients.

Lack of comfort and failure to address sexual issues was also found in surveys

involving physicians, but was more pronounced in geriatric care, female-specific care,

and disabilities (Haboubi & Lincoln, 2003; Maciel & Laganà, 2014; Pauls et al., 2005;

Thomason, Capps, Lefler, & Richard-Davis, 2015). In a qualitative study of physicians

from the United Kingdom, Dyer and das Nair (2013) found that physicians were not

comfortable initiating conversation with patients regarding sexual issues due to personal

discomfort and a fear of “opening up a can of worms” (p. 2658). Physicians also noted a

greater challenge when addressing sexuality with minority groups, including Blacks,

nonheterosexuals, people with disabilities, and the aging (Dyer & das Nair, 2013).

Verschuren et al. (2013) found that 67% of the 177 health care professionals surveyed

had not addressed sexuality with patients. The authors discovered this particular group of

physicians and rehabilitation professionals ranked high on the comfort index; however,

the majority did not consider it their role to discuss sexual issues with patients being

fitted for prosthetics.

Kazukauskas and Lam (2010) found that comfort was at a medium level for

rehabilitation health care professionals. They also found a correlational link between

attitudes and knowledge impacting the comfort of the rehabilitation health care

professional when approaching and discussing sexual topics with patients.

Helland, Garratt, Kjeken, Kvien, and Dagfinrud (2013) found that Rheumatology

physicians who had sexuality-specific education were more comfortable discussing the

associated topics with patients. Higgins et al. (2012) found that when health care

professionals engaged in a one-day program geared toward an interdisciplinary approach

to sexuality, participant comfort levels regarding sexuality increased. In a longitudinal

mixed methods study of 37 rehabilitation practitioners that comprised of 23 nurses, ten

community staff, three allied health and one medical practitioner, researchers found that

comfort did not change significantly over time between the control and experimental

group. Nevertheless, comfort did increase over a 2-year period (although the authors did

not proffer an opinion about why) (Fronek, Kendall, Booth, Eugarde, & Geraghty, 2011).

Counselors’ and Therapists’ Comfort With Sexual Topics

Sexual comfort impacts every aspect of the client’s being and the comfort level of

counselors and therapists in discussing sexuality with their clients should be of prime

importance (Graham & Smith, 1984). As the counselors’ knowledge of sexuality

increase, their comfort levels increase as well (Graham & Smith, 1984). Haboubi and

Lincoln (2003) found that doctors and nurses were more comfortable discussing sexual

topics with patients than therapists were with their clients.

If clients felt that their therapists were not comfortable with the topic of sexuality,

that discomfort could damage the therapeutic relationship, make the topic taboo, or

alienate clients from the help they need (Cupit, 2010). In a study of counselors, Anderson

(2002) analyzed the variables that impact comfort and found a positive correlation

between experience and comfort: The more years in practice correlated with greater

comfort in discussing sexual topics. However, the largest predictor variable of comfort

was the counselor’s attitude toward sexuality; therapist instructors were encouraged to

promote more liberal sexual attitudes among their student therapists (Anderson, 2002).

In research involving mental health counselors, participants reported being

comfortable with sexual topics, but that did not correlate with how frequently they

initiated those topics with clients (LoFrisco, 2013). The research also reported that

counselors who often initiated sexual conversations with clients also had a higher level of

comfort with sexuality.

Sexuality is a sensitive topic and several researchers have determined that

therapists’ and counselors’ levels of comfort in discussing sexual topics with clients need

to increase so that they can address clients’ sexual concerns (Harris & Hays, 2008; Hartl

et al., 2007; Papaharitou et al., 2008; Weerakoon et al., 2008). Counselors prepare to

initiate sexual discussion and normalize it because they cannot assume that “…clients

will initiate a discussion about sexual health issues even when it is an area of concern for

them” (Hays, 2002, p. 4).

LoFrisco (2013) pointed out that there is little empirical research on how the

willingness component of the process can increase. Furthermore, the research done to

date to find a connection between knowledge and comfort has been conflicting. Harris

and Hays (2008) did not find a connection, nor did Decker (2010), which corroborates

previous findings by Ford and Hendrick (2003). However, Haag (2008) and Weerakoon

et al. (2008) did, in fact, find a positive correlation between knowledge and comfort in

direct contradiction to the other researchers.

Harris and Hays’s (2008) study was the only one exploring the relationship

between comfort and knowledge and how these impact therapists’ willingness. However,

they did not measure test–retest reliability or content validity and used low-reliability

portions of their instrument. Haag (2008) used no reliability or validity measures.

Comfort is not just an aspect of how the therapist and counselor view the topic of

sexuality, but also impacts how the counselor addresses an individual belonging to a

sexual minority (M. S. Green et al., 2010). Student counselors were uncomfortable when

addressing issues with lesbian and transgender couples (Rutter, Leech, Anderson, &

Saunders, 2010). Therapists who support civil unions and human rights are more

comfortable discussing sexual topics with gay, lesbian, bisexual, and transgender (LGBT)

individuals, but less comfortable when discussing sexual topics with couples (M. S.

Green et al., 2010). This result was supported by the research of Juergens et al. (2009)

and M. S. Green et al. (2010), who found that therapists’ attitudes impacted comfort.

Kazukauskas and Lam (2010) found that knowledge and attitude were significantly

correlated with comfort on the part of the counselor engaging the patient to discuss a

topic regarding sexuality. In a more recent study, Pebdani (2013) tried to determine what

correlations could be established regarding rehabilitation counselors and found that

knowledge had a negative correlation to discomfort. As sexual knowledge increased,

discomfort levels decreased.

Pukall (2009) argued that the therapist who was not comfortable discussing

sexual health issues could not provide effective therapy. Therapists’ or counselors’

discomfort in discussing sexual topics was a significant barrier in the ability of clients to

establish a therapeutic alliance with them and receive quality care (Bancroft, 2009b;

Kazukauskas & Lam, 2010; Moser, 2009; Nasserzadeh, 2009). Donovan (2011) and

Cupit (2010) both found that proper supervision and training helped to increase comfort

for the therapist or counselor, and thereby, diminished this barrier.

Voss (2015) found that comfort for therapists and counselors who dealt with

sexual topics impacted competencies. Therefore, comfort was an important facet of

therapists’ relationships with clients. Easton’s (2015) research involving rehabilitation

counselors working with patients with autism found they were more comfortable when

addressing general sexual issues than when addressing sexually-explicit topics (such as

masturbation). For the community of marriage and family therapists and counselors as a

whole, there has been little overall improvement in comfort regarding discussion of

sexuality over the past 30 years (Dermer & Bachenberg, 2015).

Psychologists’ Comfort With Sexual Topics

Clinical psychology students were the participants in three studies regarding

sexuality and comfort (Hanzlik & Gaubatz, 2012; Miller & Byers, 2012; Zimmerman,

2015). Hanzlik and Gaubatz (2012) did a cross-sectional study of 138 clinical PsyD

students to assess their comfort levels when dealing with clients’ sexual issues. Hanzlik

and Gaubatz found that trainees had lower levels of comfort when discussing specific

sexual concerns but had higher levels of comfort “when asked globally about discussing

sexual issues with clients” (p. 219). These researchers also found that trainees had similar

levels of comfort in discussions of sexuality with female clients, but female trainees had

lower levels of comfort compared to their male peers when discussing sexual issues with

male clients. Hanzlik and Gaubatz found a positive correlation between sexual attitudes

and comfort and between sexual training and comfort but did not find any correlations

between general education and comfort.

Zimmerman (2015) found that 85.1% of the clinical psychology student

participants in their study were comfortable with transgender clients but had insufficient

training to help implement action for these clients. Miller and Byers’s (2012) study

design included psychologists and their findings indicated that with sexuality-specific

education and supervision, participants’ confidence and self-efficacy—variables related

to comfort—increased.

Attitudes

Health Care Professionals’ Attitudes Toward Sexual Topics

Sexuality and sexual health are a priority in the treatment of patients (Cupit, 2010;

Helland et al., 2013; Verschuren et al., 2013). Verschuren et al. (2013) found that two-

thirds of physician participants in their research thought sexuality was important, but only

one-third considered it part of their duties to engage the patient in sexual topics. These

researchers coined the term conspiracy of silence to indicate a dynamic in which both the

physician and the patient avoid potentially awkward discussions about sexuality

(Verschuren et al., 2013). Similarly, Helland et al. (2013) found that 96% of health care

providers involved in rheumatological care considered sexuality to be a relevant topic,

but 71% of these participants rarely or never raised the issue while 88% thought the

patient should initiate this topic.

In the past decade, there has been a positive shift in the attitudes of health care

workers regarding sexuality and the treatment of individuals who are members of the

LGBT community (McCune, Imborek, Ho, Hardy-Fairbanks, & Stockdale, 2015). For

my purpose, “the definition of attitude involves an emotional expression of what we

value, believe in, and what we consider to be ‘right’” (see Stuart, 2014, p. 23).

Nicol, Chapman, Watkins, Young, and Shields (2013) had similar results.

Attitudes of health care professionals were significantly impacted by “…professional

group, gender, Caucasian race, political voting behavior, presence of religious beliefs, the

frequency of attendance at religious services, the frequency of praying, and having a

friend who was openly lesbian, gay, bisexual and transgender” (p. 3396). Wilson et al.

(2014) found that religiosity and familiarity with sexual issues and LGBT issues were

predictive of less positive attitudes toward sexuality, treatment of sexual health issues,

and dealing with LGBT patients with the 475 mental health students who participated in

their survey.

Universally positive and open-minded attitudes toward sexuality were not the

norm, however. For example, Malaysian medical student participants held conservative

beliefs and did not wish to engage with patients on various sexual health topics (Sidi et

al., 2013). A recent study of Brazilian OB/GYN medical students revealed conservative

attitudes as well (Vieira et al., 2015).

Turkish nurse participants held conservative, negative attitudes toward sexuality

and discussing sexual issues with patients (Arikan, Meydanlioglu, Ozcan, & Ozer, 2015).

However, Bal and Sahiner (2015), who conducted a similar study of 155 Turkish nurses

in the same year, found these negative and conservative attitudes could improve with

proper, sexuality-specific training. In contrast, male medical students in India held neutral

attitudes toward homosexual patients, homosexuality, and discussing sexual topics with

non-heterosexual patients while female medical students held positive attitudes (Banwari,

Mistry, Soni, Parikh, & Ghandi, 2015). These researchers noted a lack of sexual

knowledge among participants, which they attributed to underlying attitudes; other

research echoed this analysis (Banwari et al., 2015; Sidi et al., 2013).

Studies focused on nurses’ attitudes have been evenly split. For example, in their

research with nurses, Kotronoules et al. (2009) found that participants had positive

attitudes toward sexuality. In contrast, others found negative attitudes among their

nursing participants toward sexuality and dealing with sexual health issues (Chapman,

Watkins, Zappia, Nicol, & Shields, 2012; Eliason, DeJoseph, Dibble, Deevey, & Chinn,

2011). Based on the data collected from nursing students, Strong and Folse (2015) found

negative attitudes when participants discussed sexuality with patients in the LGBT

community. Attitudes improved significantly, however, after an intervention was

administered to these student nurses (Strong & Folse, 2015). Likewise, Tugut and

Golbasi’s (2015) research noted this effect in nurses when attitudes, knowledge, and

behaviors improved after receiving specific sexuality assessment skills training. Sung and

Lin (2013) found among their nurse participants in a quasi-experimental study with a

control group that sexuality-specific training positively affected attitudes, beliefs, and

behaviors. Sung, Huang, and Lin (2015) found a relationship between knowledge and

attitude and the importance of not only educating nurses with sexually specific training to

improve knowledge, but also to stress the importance of a positive attitude toward sexual

health issues when dealing with patients.

Lapinski, Sexton, and Baker (2014) found that osteopathic medical students had

positive attitudes toward sexual minority patients when discussing sexual issues and

treating them; participants who self-identified as LGBT had even higher positive scores

in the attitude category regarding discussion and treatment. However, these osteopathic

students were unequipped to treat the LGBT population; the researchers recommended

LGBT sexuality-focused education to remedy this deficit among this category of health

care practitioners (Lapinski et al., 2014).

The data from nonwestern, non-North American midwives showed participants to

have positive attitudes toward sexuality, discussing sexual topics with patients, and

providing counseling on sexual topics. However, this was a single study, and the data

may not be generalizable to the field of midwifery (Khadivzadeh, Ardaghi, Mazloum, &

Modaresi, 2016). These participant midwives were also inadequately trained and had a

significant lack of sexual knowledge (Khadivzadeh et al., 2016).

Valvano et al. (2014) found a general difference among 479 members of various

health care disciplines regarding educational quality and quantity. There was also a wide

variation of attitudes with dentists having the most negative. Based on their research,

34% of medical students and 98% of psychology students had no patient contact

regarding sexual health issues. Valvano et al. (2014) stressed that negative attitudes could

have an undesirable impact on patients, while attitudes toward sexual health issues

among health care professionals seemed to be positive; these attitudes linked to sexually-

specific health training. They argued that it was important to provide this type of training

(Valvano et al., 2014).

Physician’s assistants had liberal attitudes toward sexuality, with the majority

(64%) holding these liberal attitudes, 35.4% holding neutral attitudes, and 0.6% holding

conservative attitudes (Wolf, 2012). Two factors significantly impacted the physician’s

assistants’ attitudes: ethnicity and relationship with religion. Wolf (2012) urged students

to examine their sexual beliefs and attitudes due to the impact those beliefs and attitudes

would have on their ability to assist patients with their sexual health issues. Wolf’s

(2012) question on religion was a simple “yes” or “no” question as to whether the

participant considered themselves to be religious. In contrast to Wolf’s findings, Cupit

(2010), in her study of counselors, did not find any statistically significant relationships

between her independent variables and religion. I did not find any other studies in my

literature review that included the variable of religion. Harris and Hays (2008) suggested

that religion was a variable that should be included in future research, which is why Cupit

(2010) included it as a single item on a Likert-type scale of 1 to 5 in her research.

Health care professionals’ attitudes toward the sexuality of their older patients

were markedly different between people working in nursing home medical facilities and

those working in hospitals (Doll, 2013). Thirty-two percent of the nursing home

administrators and nurses reported that they would be disgusted to discuss sexuality with

a patient, while 20% stated that they would panic, and “20% would ignore the behavior”

(Doll, 2013, p. 59).

Haesler et al. (2016) conducted a systematic review of 23 studies concerning

health care professionals’ knowledge and “attitudes toward sexuality and sexual health of

older people” (p. 65) that they published during an 11-year period (2004 to 2015). The

authors concluded that practitioners were still reluctant to engage older patients on their

sexuality due to attitudes influenced by negative and less permissive societal attitudes and

lack of knowledge.

Moreno, Gan, Zasler, and McKerral (2015) found that physicians treating

traumatic brain injuries thought that sexuality was important and had positive attitudes

toward discussing it. However, they did not discuss sexuality with patients. The

physicians who treated traumatic brain injuries had more positive and permissive

attitudes than other participants who included family care physicians, psychologists,

general practitioners, and other highly educated health care professionals (Moreno et al.,

2015).

These various researchers who had focused on the attitudes of health care

professionals regarding sexuality and discussing sexual topics with their patients had

reached different conclusions. Results were influenced by the area, specialty or discipline

in question, geographic region, and cultural background of participants.

Counselors’ and Therapists’ Attitudes Concerning Sexual Topics

Attitudes are concepts that therapists apply to social objects that have a firm base.

Conversely, the values held by therapists tend to focus more on ideals (Hitlin & Piliavin,

2004). Several researchers have concluded that therapists avoid sexual discussions due to

lack of comfort (Harris & Hays, 2008; Shalev & Yerushalmi, 2009; Timm, 2009). It is

assumed that greater knowledge would equate to greater comfort. However, attitude is

another important component of the process that can lead to comfort and willingness to

discuss sexual health issues (Papaharitou et al., 2008). Personal values and experiences

influence attitudes toward sexual issues; through training and self-awareness, comfort can

increase, anxiety can decrease, and willingness to engage can begin (Hilton, 1997). While

authors conducted a number of studies in the late 1990s and early 2000s (as reviewed in

the following paragraphs), a lack of new literature exists on attitudes, knowledge,

practices, and behaviors concerning engaging clients in sexuality discussions among

marriage and family therapists and counselors (Dunk, 2007; Yelton & Delfin, 2015).

In her research of 310 licensed counselors in three different states, Anderson

concluded that a “combination of factors influenced counselors’ sexual comfort and

willingness to engage clients about sexual health issues ” (as cited in Cupit, 2010, p. 23).

Most impactful were sexual attitudes, training and experience, and personal experience.

Harris and Hays (2008) addressed several of these components and determined that

supervised experience and training, along with knowledge, improved sexual comfort.

Juergens (2006) found that sexuality education and knowledge impacted attitudes and

attitudes impacted comfort. Cort et al. (2001) identified negative attitudes as a major

barrier that prevented the discussion of sexuality with clients. Hilton (1997) found that

counselors’ comfort was linked to their attitudes about sexuality and their knowledge-

base about sexuality. Similarly, Weerakoon and Stiernborg (1996) found a positive

relationship between sexual attitudes and knowledge. This, in turn, influenced sexual

comfort.

If the therapist’s perception of the patient’s sexual attitudes and values appeared

to be of a nontraditional making, the therapists were less likely to engage the clients in

sexual discussions (Weerakoon & Stiernborg, 1996). Negative bias in this area was why

it was important for therapists to understand their attitudes regarding sex and sexuality

(Stayton, 1998). As therapists increased their awareness, it became more likely they

would also decrease the likelihood of negatively viewing patients and causing discomfort

or harm (Stayton, 1998; Ridley, 2006). Based on this exploration of attitudes, therapists

improved their interactions with patients and avoided imposing a negative belief system

regarding sexuality onto the patient (Weerakoon & Stiernborg, 1996).

Once therapists understood their sexual attitudes, they were able to create a safe,

non-judgmental environment for the client in which—due to the comfort—the client was

more open and engaged (Andrews, 2000). Anderson (2002) found that attitude impacts

personal bias and attitude, and values were only ascertained and adjusted by awareness.

Knowledge was a combination of training and education, and these two components

impacted sexual comfort and willingness to discuss sexual health issues. Even those who

did not believe that knowledge impacted comfort found that was one of the important

issues in understanding how to improve comfort and willingness to engage (Anderson,

2002). West et al. (2012) found a link between knowledge, comfort, and attitudes toward

sexuality as well as a correlation between religiosity and negative attitudes. West et al.

also found that social, economic, and gender factors impacted attitudes, further

underscoring how complex and complicated attitudes were in their nature. Similarly,

Procter (2013) found that religiosity and religious fundamentalism were predictive of

negative attitudes toward LGBT clients and damaged the therapeutic alliance. Negative

attitudes also impacted how likely the therapist was to refer a lesbian, gay, or bisexual

client for services, according to other research (McGeorge, Carlson, & Farrell, 2015).

In Goldstein’s (2014) study with 100 students in a Council for Accreditation of

Counseling and Related Educational Programs’ (CACREP) course, she found that the 60

master’s students had less positive attitudes toward transgender and LGB clients than did

the 40 doctoral students. The author did not discover a reason for that occurrence but

hypothesized that multicultural classes taken by only the doctoral students might have

impacted these results. Both masters and doctoral students in both psychology and

counseling exhibited positive attitudes toward counseling transgender clients (Goldstein,

2014).

In their study with marriage and family therapists, psychologists, and social

workers, Alessi, Dillon, and Kim (2015) found no differences in attitudes toward gay and

lesbian clients, “even after controlling for years of practice experience and age” (p. 455).

Rather, it was the level of training that was associated with and indicative of a more

positive attitude, self-efficacy, and positive beliefs. Kelsey et al. (2013) studied

therapists’ attitudes toward bondage, discipline, sadism, and masochism (BDSM) and

found that those with more training had more positive attitudes toward treatment and

discussion of BDSM with clients. Forty-eight percent of therapists viewed themselves as

competent, while 52% did not; therapists with more experience treating clients who

engaged in BDSM had more positive attitudes than those who did not have as much

experience (Kelsey et al., 2013).

Farmer, Welfare, and Burge (2013) found that counselors in a variety of settings

had positive attitudes toward the LGB community but lacked the knowledge and

competency to engage their LGB clients about their sexual issues. Parker (2012) found a

similar connection between attitudes and training in that the more sexuality-specific

training a high school counselor had received, the greater their positive attitudes toward

discussing sexual topics with students who also had intellectual disabilities. Furthermore,

the level of comfort a high school counselor had to discuss sexuality with students, the

more positive his or her attitude was toward discussing sexuality (Parker, 2012).

Psychologists’ Attitudes Concerning Sexual Topics

Psychologists’ attitudes toward discussing sexual topics correlate with comfort.

With permissive attitudes, their comfort levels increased (Hanzlik & Gaubatz, 2012).

Attitudes did not only impact comfort, but also their willingness to engage clients

regarding a sexual topic (Flaget-Greener, Gonzalez, & Sprankle, 2015). Flaget-Greener et

al. (2015) did not find any link between attitudes and sociodemographics (age,

sex/gender) clinical education, experience, and specialty in research involving 119

doctoral-level psychologists. Findings in other disciplines showed results in which those

variables were impactful. “This…may be explained by the [educational] homogeneity”

(p. 19) of the survey participants: Higher levels of education equate with higher levels of

permissiveness. These findings were in line with previous research done by Miller and

Byers who stated that “a key finding of this study is that attitudes toward sexuality

education and training are significant predictors of psychologists’ willingness to assess

sexual health” (as cited in Flaget-Greener et al., 2015, p. 20).

Johnson and Federman (2014) also found that attitudes impacted psychologists in

their approach to dealing with LGBT issues, including sexual issues, in their study of 384

Veterans Administration psychologists. They found that psychologists from more

broadminded regions in the US had more positive attitudes toward LGBT issues,

including sexual issues. Psychologists with more positive attitudes also had more training

and were open to pursuing more LGBT-specific training. Moreover, younger

psychologists who had received LGBT-specific training had more positive attitudes

(Johnson & Federman, 2014).

Moreno et al. (2015) found that psychologists had more negative attitudes toward

sexuality than did other health professionals. This is in slight contrast to what Alessi et al.

(2015) found: no difference in attitudes after controlling for age, practice years, and

sociodemographic information between family therapists, psychologists, and social

workers. However, given that Moreno et al. (2015) found that these negative attitude

levels were similar between the psychologists and social workers involved in their study,

this result did not contradict Alessi et al.’s findings. Also, Jabson et al. (2016) found that

psychologists and social workers as a whole had more negative attitudes when compared

to physicians.

Willingness to Engage

Health Care Professionals’ Willingness to Engage Patients

Physicians do not, as a whole, willingly initiate or engage in sexual topics with

their patients. Two studies found that most physicians did not ask sexual health questions

during intake visits, mostly due to a lack of training, which negatively impacted medical

students’ attitudes toward sexual health issues (Cushing, Evans, & Hall, 2005; St.

Lawrence et al., 2002). Rheumatology health care providers seldom or never raised

sexual topics 71% of the time. This result corresponded to other research in which 88%

of health care providers viewed it as the patient’s role to initiate discussions of sexuality

(Helland et al., 2013).

In another seminal study, Haboubi and Lincoln (2003) found that 94% of the

health care professionals surveyed would not initiate sexual discussions, even though the

overwhelming majority agreed that sexual health was important and should be addressed.

Furthermore, several researchers have found that general practitioners rarely ask about

sexual health issues, which correlated with a lack of sexuality training (Byrne, Doherty,

McGee, & Murphy, 2010; Laumann et al., 2009; Shepherd, Heke, & O’Donovan, 2009).

Stead, Br, Fallowfield, and Sealby (2003) came to a similar conclusion based on a “lack

of sexual knowledge and skills, as well as feelings of embarrassment, lack of time, lack

of privacy and lack of resources” (p. 670) as the prime reasons for doctors and nurses not

discussing sexual health with their patients. Patients perceived doctors as insensitive

when they avoided sexual health questions (Hinchliff, Gott, & Galena, 2005); this

perceived insensitivity made patients feel distressed (Dixon-Woods et al., 2002).

In Turkey, nurses were studied using a descriptive and comparative design;

researchers found that 68.9% of participants viewed the topic of sexuality as “too private

to discuss” with patients (Arikan et al., 2015, p. 327). The majority of these nurses

(72.2%) did not see the need to spend time discussing sexuality issues with patients.

These researchers used the Sexual Attitudes and Beliefs Scale (SABS) and found a

significant correlation between participant’s SABS scale score and willingness to discuss

sexual issues (the higher the score, the more likely the nurse was to discuss the issues).

Moreover, these authors recommended more education, which was a common theme

throughout most of the literature (Arikan et al., 2015).

Bal and Sahiner (2015) found similar results in their descriptive design studying

Turkish nursing students and determined that the barriers in discussing sexuality with

patients were insufficient time, training, or comfort. These researchers also used SABS

and found that 80% of nursing students were not willing to give advice even when the

patient started the discussion. They concluded that more education on sexuality was

necessary to develop this area of medicine (Bal & Sahiner, 2015). Dyer and das Nair’s

(2013) review of the literature about United Kingdom health care providers (doctors and

nurses) revealed an overall theme that health care providers were not interested in

bringing up topics of sexuality or engaging in discussion with patients about their sexual

health. In Sweden, a study using correlative and comparative design with the SABS

instrument using a convenience sample of Swedish nurses found 80% did not start

conversations with patients about sexual health issues and concerns. This number did not

correlate with the fact that 66% felt comfortable discussing the topic, according to the

survey results (Saunamäki et al., 2010). These researchers recommended more education

to improve the nurses’ abilities to engage in and provide holistic care to patients

regarding their sexual health issues.

The results of the Swedish study were not dissimilar from those found in a study

by Vieira et al. (2015) of Brazilian OB-GYNs in which 56% either never or rarely took a

sexual history, which would be a natural way to allow the possibility of a discussion

about sexuality with their patients. Fifty-one percent did not feel confident or competent

to take a sexual history or discuss the topic with a patient. Ninety-one percent of the

survey participants had graduated within the past five years and should have had the most

up-to-date training. However, 49% received no formal training, and 29% received 6

hours or less during residency. During their doctoral studies, 63.4% had received no

sexuality coursework, and 27.9% had 6 hours or less of sexuality coursework or

supervision. In other words, the inability for health care practitioners to discuss sex with

their patients is not only a Western or Eastern medicine issue but a global issue that needs

to be addressed (Vieira et al., 2015).

In a review of three decades of research with oncology nurses (18 articles) in a

meta-analysis, the authors found that oncology nurses rarely discussed sexual health

topics with patients for a variety of reasons: limited sexual knowledge, incorrect

assumptions, lack of comfort, and society-related factors (Kotronoulas et al., 2009).

Levesque (2013) used a descriptive design with convenience sampling to study nurse

practitioner students’ knowledge, attitudes, and self-efficacy. Levesque found that

students had positive attitudes, but little knowledge and low self-efficacy toward

transgender patients (i.e., they were unlikely to initiate the discussion with the patient).

Magnan and Reynolds (2006) studied barriers to discussing sexual health with nurses

across five nursing specializations (OB/GYN, oncology, medicine, surgery, and

rehabilitation) and found that nurses thought patients did not want them to discuss sexual

topics. This was the leading barrier across all nursing disciplines. The next major barrier

was lack of time.

Maciel and Laganà (2014) designed a study to examine a different aspect of the

sexual health discussion: How often did OB-GYNs discuss older women’s sexuality with

them? They found that two-thirds routinely asked patients about their sexual activity,

40% asked about sexual concerns or dysfunctions, and 29% asked about sexual

satisfaction. The authors noted that when clinicians did not raise sexual topics, the

patients determined that these topics were not appropriate and should not be discussed

causing further anxiety and unmet needs. Ninety-seven percent of the older female

participants wanted to discuss sexual issues with their treating OB-GYN (Maciel &

Laganà, 2014).

The Maciel and Laganà (2014) result was conflicting slightly with an earlier study

by Pauls et al. (2005) examining 471 member-physicians of the American

Urogynecologic Society. Sixty-eight percent were familiar with treating sexual

dysfunction in women, 47% thought sexual health screening for dysfunction was

somewhat important, and 42% believed it was important. However, 13% used

questionnaires for screening purposes, 22% always screened for dysfunction using

questionnaires or in-person discussion, 55% screened most of the time, and 23% never

screened or discussed sexual dysfunction with patients at all. The study authors stated

that sexual issues were reported at a higher percentage and were “more prevalent in

females (43%) than males (31%)” (p. 460).

Only 33% of physicians involved in the treatment of patients with amputations

addressed sexual health in any way (Verschuren et al., 2013). Verschuren et al. (2013)

used the Knowledge, Comfort, Approach, and Attitudes toward Sexuality Scale

(KCAASS) in a Dutch-adapted form to conduct their study. KCAASS was originally

developed for assessing physicians interacting with spinal cord injury patients.

Verschuren et al. (2013) analyzed the data by “using chi-squared-tests, independent

sample t-tests and one-way analysis of variance (ANOVA) with a least significant

difference (LSD) post hoc test.” Then, Verschuren et al. (2013) measured the effect size

using Cohen’s d and “Multivariate logistic regression analysis (stepwise backward) was

used to predict the odds of receiving a question about sexuality or address the issue of

sexuality” (p. 1699).

Moreno et al. (2015) examined how 16 men and 22 women who were, on

average, 2.6 years out from traumatic brain injuries, had experienced care regarding their

sexual health. The data revealed a low frequency of discussion about sexual health or

reproductive issues; their sexual needs went largely unaddressed and unmet. Participants

viewed the discussion of sexual topics as the treating physician’s role to raise with them

and not the role of a family physician, psychologist, general practitioner, or other health

care professionals (Moreno et al., 2015).

Counselors’ and Therapists’ Willingness to Engage Patients

There is a dearth of literature on the willingness of counselors and therapists to

engage clients in discussion of sexual topics (LoFrisco, 2013). Harris and Hays (2008)

did the original, seminal study prompting an ongoing conversation within the community

of therapists about how this variable impacted practice (Cupit, 2010; LoFrisco, 2013).

Harris and Hays (2008) did not make a distinction in their research, however, between

graduate-level supervision and postgraduate supervision of counselors. This distinction is

important due to the duration involved with each and is significantly different. Therefore,

level of education could impact the comfort and willingness to engage clients on sexual

issues.

Certified rehabilitation counselors who work with autism spectrum disorder

(ASD) patients were willing to discuss sexual topics with their patients and were

comfortable while discussing sexual topics with their patients (Easton, 2015). Gender

was not a factor in comfort or willingness; subjective normative beliefs, perceived

behavioral controls, and attitude were the variables that had strong correlations with a

willingness to engage as a whole. Attitudes toward sexuality and ASD did not have a

strong correlation. Easton (2015) reasoned that this outcome was influenced by the fact

that the framework used for the study had not been applied before and the sample was

small and homogenous. Easton encouraged further study using social cognitive theory as

the framework to examine counselors’ attitudes toward sexuality.

In their research with practicing certified rehabilitation counselors, Juergens et al.

(2009) found that “sexuality knowledge, sexuality education, attitudes toward the

sexuality of people with disabilities and comfort with sexuality affect the willingness of

rehabilitation counselors to discuss sexuality with clients with sexuality knowledge and

comfort with sexuality” had “direct effects on willingness among participants” (p. 113).

Cupit (2010) found that the more comfortable counselors were, the more likely

they were to engage the client. A significant correlation was found (r =.19, p<.01)

between sexual attitude (idealistic) and sexual comfort. Other sexual attitudes (i.e.,

attitudes toward birth control, sexual attitudes toward permissiveness and instrumentality,

strength of religion, and graduate specialization) did not result in a correlation.

Correlations were only found in the following variables with sexual comfort: sexual

attitudes regarding idealistic sexuality, human sexuality training, and supervision

experience in the area. While not all attitudes have a correlational relationship with

sexual comfort or with a willingness to engage, delineating which attitudes are associated

with a willingness to engage is important. Cupit found that the older counselors were, the

more willing they were to engage, while Harris and Hays (2008) found that age was not

impactful. This dichotomy of results is seen throughout the literature with some

researchers finding that gender or age was impactful, while others did not, suggesting the

need for further research. For example, Decker (2010) did not find a connection between

demographic variables, such as age, and willingness to engage, but did determine that

experience impacted and affected a therapist’s willingness to engage a client regarding a

sexual topic. Decker found that experience influenced comfort and that this had an impact

on willingness to engage; in contrast, age, experience, and training did not impact

comfort.

Yelton and Delfin (2015) found that 36% to 64% of mental health counselors

were willing to initiate a sexual topic discussion with a client. The percentages varied

based on the disciplinary background, with social workers having the lowest willingness

to initiate. With only 75 participants derived using convenience sampling, these results

may not be a true reflection of the overall area of practice (Yelton & Delfin, 2015).

Psychologists’ Willingness to Engage Patients

In their study of 110 practicing US and Canadian psychologists (83.6% of whom

were clinically-focused, and 16.4% of whom were counseling-focused), Miller and Byers

(2012) found that sexuality was not often brought up or addressed and older

psychologists were slightly more willing to engage clients about sexuality. Miller and

Byers used Bandura’s theoretical framework for understanding and interpreting the

results based on how self-efficacy impacted the process. They concluded that an increase

in knowledge germane to sexuality and postgraduate sexuality-focused workshops and

other educational opportunities were key to increasing self-efficacy and increasing

willingness to engage patients about sexual topics.

Træen and Schaller (2013) examined the predictive factors for willingness to

discuss sexual issues with their patients in a sample of Norwegian psychologists. Their

data revealed that attitudes and beliefs were the predictive factors after controlling for

age, gender, years of practice, and training in sexology. Older, more experienced

psychologists were more willing to discuss sexual issues. However, one in five reported

that they often or always engaged their clients about their sexuality. This result was

similar to Miller and Byers’s (2012) results.

Hanzlik and Gaubatz (2012) focused their study on the comfort of PsyD students

when discussing sexual issues with clients; these participants were not willing to engage

with clients on sexual topics. Furthermore, male clients who saw female therapists may

“…suffer from the tacit minimization or even outright avoidance of their sexual

concerns.” The authors found this concerning since an ever-increasing number of female

psychologists are entering the field (Hanzlik & Gaubatz, 2012, p. 229).

Knowledge

Health Care Professionals’ Knowledge Regarding Sexual Topics

Reflected in the literature was an overall lack of knowledge regarding sexuality

among all involved in health care, therapy and counseling, and psychology. This lack of

knowledge represents a barrier to communication with patients and clients (Bal &

Sahiner, 2015). The following literature is representative of this widespread phenomenon.

In a study of Turkish nurses, Bal and Sahiner (2015) found that lack of sexual

knowledge was a barrier to communication with patients about their sexual issues. Nurses

attitudes were positively impacted regarding communicating with patients about sexual

health concerns with training and knowledge. In Haboubi and Lincoln’s (2003) analysis

of 813 replies from nurses to their survey, they found that previous training in sexuality

was low at 14%, while 86% had no training or little training. Of the respondents who had

undergone training, 53% thought it had improved their knowledge and practice, 27%

thought it had just improved knowledge, and 20% thought it had been of no use, which

may be more reflective of the instructors than their opinions regarding training.

In their research, Banwari et al. (2015) used the Attitudes toward Homosexuals

Questionnaire (AHQ) and the Sex Education and Knowledge about Homosexuality

Questionnaire (SEKHQ) and analyzed the results using multiple linear regression. The

results were only applicable to the Indian physicians who participated in their survey, but

the authors noted that these results were in line with American and Canadian knowledge

bases, with a slightly more biased framework concerning homosexuality because of

cultural factors.

Saunamäki et al. (2010) surveyed Swedish registered nurses using the SABS;

90% of those surveyed understood the importance of sexual health and concerns of

patients. However, 60% did not feel confident discussing these topics due to a lack of

competency and knowledge. Saunamäki et al. argued for further education as a means to

increase knowledge for nurses dealing with patients regarding sexual concerns.

Vieira et al. (2015) studied Brazilian OB/GYN residents, 49% of whom had

received no training up to that point regarding sexuality, with 29% reporting having

received 6 hours of training or less. Fifty-six percent never or rarely took a sexual history,

and 51% did not feel competent to do so. The authors concluded that there was an

immediate need for sexually-specific training for medical students and residents.

In research conducted in the southeast US, 38% of medical students had received

no sexuality training (Valvano et al., 2014). Helland et al. (2013) surveyed individuals

working in a variety of disciplines—nurses, physicians, physiotherapists, occupational

therapists, social workers, and psychologists—and found that 53% of those surveyed

stated that lack of knowledge was a significant barrier. The professionals who had more

education in sexuality initiated the discussion with patients more often and were more

comfortable in the process. Haesler et al. (2016) studied health care professionals’

attitudes and knowledge toward older patients’ sexuality. These practitioners did not have

sufficient knowledge and considered older patients’ sexual health to be beyond their

scope of practice. In other words, lack of knowledge was a barrier.

Kotronoules et al. (2009) conducted a comprehensive meta-analysis of the

literature, examining 18 studies over three decades regarding oncology nurses and

sexuality. Oncology nurses had positive attitudes, but limited sexual knowledge; this was

a barrier to discussing sexual health issues with patients.

Lapinski et al. (2014) studied attitudes, knowledge, and acceptance of LGBT

patients by 1335 osteopathic medical students using the Klein Sexual Orientation Grid

and the Homosexuality Attitude Scale. The participants reported favorable attitudes and

acceptance levels; these were higher in those who self-identified as LGBT. “Only 125

respondents (12.9%) obtained a passing score” on the section testing medically relevant

knowledge of sexual issues (p. 792). While the LGBT self-identified students’ scores

were higher than their heterosexual peers, the study results suggested that students lacked

adequate knowledge for the competent treatment of sexual health issues for the LGBT

community.

Levesque (2013) conducted a similar study of 416 nurse practitioners with the

variables being self-efficacy, attitudes, and knowledge, but used the Attitudes Toward

Transgender Survey and Health Care Provider Survey by Burch (2005) to understand the

nurse practitioners’ perspective. Nurse practitioners lacked both knowledge and self-

efficacy; a result, the authors argued, that impacted their ability to interact with and

engage transgender patients on sexual health issues. Kline (2014) found a similar result

when he surveyed 80 nurse practitioners, 80% of whom agreed they needed more training

to serve the transgender community competently. Riggs and Bartholomaeus (2016)

surveyed Australian mental health nurses using the Attitudes Toward Transgender

Individuals Scale and Counselor Attitude Toward Transgender Scale and found that those

who had undertaken training on transgender health issues had a higher knowledge than

those who had not been trained. The survey results also indicated a correlation between

older age and higher knowledge, as well as between female nurses and higher knowledge.

Although limited by its small sample size (n=96), the study authors believed that it was

generalizable to the larger mental health nursing population, including in the United

States and Canada. In Sidi et al.’s (2013) research involving Malaysian medical students

regarding general sexual health knowledge and attitudes, 73.2% of those surveyed

reported that “they had not received adequate training,” (p. 107) education, and

knowledge regarding how to deal with sexual health issues in the measures used. Fifty-

five percent had adequate sexual health knowledge. Sidi et al. stressed the importance of

integrating sexual health training and education into the core of the medical school

curriculum and noted that integration could achieve more positive attitudes and higher

knowledge while reducing the likelihood that therapists would not overlook patient’

sexual health concerns or leave them unaddressed.

There are few studies designed to examine sexual training and its long-term

effects. One of the few was a longitudinal study designed by Fronek et al. (2011) as a

follow-up (2 years later) to a randomized controlled study regarding training for

rehabilitation practitioners working with people who had experienced spinal cord

injuries. The researcher found that training had a long-lasting impact on practitioners’

knowledge, attitudes, and comfort. Fronek et al. noted that the more focused the training

was to the discipline and the individual needs of the practitioners, the more likely the

positive effects would be impactful and lasting.

Using the KCAASS, Verschuren et al. (2013) studied physicians’ knowledge

regarding sexual health issues and how often these issues were addressed for patients

with lower limb amputation. The participants rated their knowledge as almost sufficient,

but the results from the instrument indicated that their knowledge was, in fact,

sufficiently competent. Despite having sufficient knowledge, Verschuren et al. (2013)

still recommended more training specific to sexual knowledge to increase overall sexual

knowledge and to improve the comfort, competency, and willingness of physicians to

engage with patients on sexual topics. West et al. (2012) also encouraged implementation

of curriculum focused on sexual health and related issues for medical students due to the

impact of knowledge on other important variables including attitude, skill, and comfort.

Higgins et al. (2012) conducted a mixed methods study with health care

providers, using a pre-test and post-test survey and interviews after a 1-day training

program had been presented to participants. Data were analyzed using

t-tests. The researchers found marked improvement for health care providers who

participated in the program concerning their knowledge, comfort, and skill when

discussing sexual topics with patients.

Strong and Folse (2015) did a similar training intervention designed to improve

undergraduate nursing students’ attitudes and knowledge regarding LGBT patients.

Strong and Folse’s intervention was not about sexual health issues in general, but rather

was focused on the medical needs of transgender patients, including their sexual health

concerns. The Attitudes Toward Lesbians and Gay Men Scale was used, which had high

internal consistency as determined by Cronbach’s alpha, and high reliability (α=.95). The

authors used two other instruments they had developed; the post-test results revealed a

statistically significant increase in knowledge on all 15 items and revealed positive

attitudes toward the LGBT patient community.

In Taiwan, Sung and Lin (2013) used a 12-week-long educational intervention for

a quasi-experimental study using both control and experimental group. Both groups were

comprised of 95 nursing students. The researchers analyzed the longitudinal results from

the pre-tests and post-tests, using the hierarchical linear model. The results of the

intervention were both positive and statistically significant. The results revealed that the

students in the experimental group showed significant improvements over those in the

control group on knowledge (β=−0.27, P<0.001), attitude (β=−0.38, P<0.001), and self-

efficacy (β=−0.90, P<0.001)” (p. 498).

Tugut and Golbasi (2015) designed an educational intervention—a total of 18

hours presented over 3 days—to the experimental group of Turkish nursing students.

Participant assignment to the experimental group or the control group was randomized.

The researchers assessed the students’ attitudes, knowledge, and skill by using the

“Sexuality Assessment Information Test, Sexual Attitude and Beliefs Scale, and

Sexuality Assessment Skills Check List” (p. 1). After the intervention, the scores of “the

experimental group [were] significantly higher than mean scores of students in the

control group (p < .05)” (p. 1). Tugut and Golbasi highlighted the importance sexual

health was to a complete understanding of how to interact with and assess patients’ needs

and to engage in a holistic practice of medicine. The educational component regarding

sexual health was found lacking. The nursing students did not have the necessary

informational base upon which to rely when engaging with patients. This, in turn, formed

a barrier, which with proper training, was overcome.

Simpson, Anwar, Wilson, and Bertapelle (2006) found marked improvement after

training staff members who worked with patients having neurological disabilities. In this

experimental study (with control and experimental groups), Simpson et al. used the

Sexual Attitude Scale, the Role Skills Intervention Survey, a single item for comfort, and

an author-designed knowledge assessment. The experimental group and control group

had similar pretest scores but significantly different posttest scores; the gains from the

experimental group were also found six months later. The staff who had been in the

experimental group were found to engage patients more often about sexual health issues

and were more knowledgeable.

Similar positive results were not observed among Tennessee physicians from two

hospitals in a study designed to determine the impact of training and mandatory protocols

regarding anti-discrimination for the sexual and gender minority community (SGM)

(Jabson et al., 2016). Although one hospital had implemented these protocols and

training, there was no significant difference in knowledge or treatment of SGM patients

found between the physicians who had taken the training and those who did not. The

authors recommended more research into affirmative practices that might help the SGM

community to discover a more effective way to minimize or eliminate discrimination

against SGM patients.

Counselors’ and Therapists’ Knowledge Regarding Sexual Topics

Harris and Hays’s (2008) research into the willingness of marriage and family

therapists to engage their clients as impacted by the variables of sexuality knowledge and

comfort was a seminal article on this topic and is the most often cited resource. The

authors found that sexuality knowledge and supervision, with training specific to

sexuality, influenced the willingness of therapists to engage their clients. While Harris

and Hays’s (2008) findings conflicted with Decker (2010) regarding how knowledge

impacted comfort, both Decker, Harris, and Hays agreed that supervision was a

cornerstone upon which the foundation of a great therapist, willing to engage and discuss

sexual health issues with patients, was laid. Harris and Hays highlighted the importance

of graduate-level sexuality education and training because it impacted the comfort and

willingness of therapists to interact with clients and decreased the anxiety inherent in

discussing this topic. Harris and Hays used the Bowenian theoretical framework for their

research on this topic; the only study to do so.

Decker (2010) focused her dissertation on supervisors and how they addressed the

needs of clients regarding sexuality; the supervisors had sufficient knowledge in nine of

15 areas regarding the sexual health needs of clients. Decker found that over 70% of

supervisors recommended trainees include sexuality as a consideration and 50%

recommended that trainees take a sexual history of their clients. The supervisors who had

sought out graduate courses or postgraduation training in sexuality areas reported having

more knowledge. However, a correlation between knowledge and comfort was not found,

conflicting with other studies, including Harris and Hays (2008), who did find a

correlation between knowledge and comfort. Decker noted the dearth of research in this

area, which prompted her to create the survey instrument she used in her research.

In contrast, Kazukauskas and Lam (2010) found a correlation between comfort

and knowledge among their certified rehabilitation counselor participants; as knowledge

increased, comfort increased as well. While participant data showed average knowledge,

there was also a need for further education to increase competency, decrease approach

anxiety, and improve the quality of care.

Pebdani (2013) conducted a similar study regarding rehabilitation master’s

program students using the same instruments as Kazukauskas and Lam (2010) and found

that training had a significant impact on knowledge regarding sexual needs of patients

who were going through rehabilitation. Pebdani noted that these findings were consistent

with the prior research and that training focused on sexuality improved sexual knowledge

of the counselors who then, as demonstrated by Juergens et al. (2009), were more willing

to engage patients and were more comfortable in the process.

Farmer et al. (2013) studied 468 school and community counselors’ competency

with LGB knowledge and attitudes. Participants’ requisite knowledge was lacking

regarding how to interact with and address the needs of this population. School

counselors were shown to have lower scores than their community colleagues in this area.

Farmer et al. noted that these findings were consistent with previous research where there

was a general lack of knowledge.

In a meta-analysis of marriage and family therapists, Dermer and Bachenberg

(2015) addressed the fact that no significant advancement by marriage and family

therapists has been made regarding treatment of clients’ sexual health needs and

concerns; neither has therapists’ comfort in discussing sexuality with clients.

Furthermore, there has not been a call to change the educational structure so these skills

and knowledge can be acquired.

Psychologists’ Knowledge Regarding Sexual Topics

There is also a lack of literature on the topic under discussion in the field of

psychology. Several of the following studies were conducted in other disciplines but

included psychologists as participants.

Flaget-Greener et al. (2015) conducted a survey of “119 doctoral-level

psychologists licensed in the US, who reported to be the members of the American

Psychological Association (APA)” (p. 13) to discover whether education, training,

sociodemographic characteristics, and attitudes had any impact on their willingness to

engage clients in sexual topics. Flaget-Greener et al. did not find a link or correlation

between education and attitude toward treating older individuals’ sexual health concerns.

The authors noted that this might have been due to the homogeneity of the participants:

Permissive attitudes tend to correlate with higher education. Flaget-Greener et al. found

“that attitudes toward older adults’ sexuality and sexual education and training were

predictive of psychologists’ willingness to assess older adults’ sexual health, despite

participants’ demographic characteristics” (p. 19). They concluded that a key component

in increasing psychologists’ willingness to engage is to increase training specific to

sexuality and sexuality education, along with changing attitudes.

In a study of 384 Veterans Administration psychologists, participants completed a

survey regarding their attitudes and knowledge, needs and interests in training, self-

reported competence, current practice, experience, and training regarding LGBT patients

(Johnson & Federman, 2014). Data indicated that 83.6% had attended one course or less

regarding transgender issues; 55.8% had one class period or less on sexual orientation

issues. Over 55% did not ask questions about sexual orientation to aid their treatment

options, 92% did not ask about gender identity. Johnson and Federman (2014) noted the

significant relationship between training specific to LGBT issues in graduate school and

the long-term positive effects this training had on attitudes and experience. These results

underscore the importance of knowledge acquisition.

Valvano et al. (2014) found that psychology students received the least amount of

classroom hours focused on sexuality when compared to the other allied health

disciplines: 69% received no sexuality education on how to interact with clients about

their sexuality. This was compared to 9% of nurses who had not received a similar

education. The authors also found that medical students had the highest number of direct

contact with patients (only 38% had no hours of direct contact) regarding sexual health

issues, while psychology students had the least (94% had no hours of direct contact).

Psychology students seemed to be aware of this by rating their quality of education

regarding sexuality significantly lower (M = 2.06, SD = 1.01) than their medical student

peers (p < 0.01 for all comparisons). Valvano et al. also noted that students not only

lacked sufficient quantity, but the quality of sexuality education was also lacking. The

authors argued that this lack resulted in psychologists who were ill-equipped to handle

such discussions and would not be confident in their ability to do so. Valvano et al. urged

that curriculum devoted to sexuality, sexual health, and direct contact with clients be

integrated into the educational paradigm. Their conclusion was consistent with Decker’s

(2010). Despite the fact that Decker was examining counselors in her study, it would

seem appropriate to consider her conclusions in light of Valvano et al.’s

recommendations.

Summary and Conclusions

In summary, the literature pointed out that marriage and family therapists are not

meeting the needs of their clients, that this need is pressing, and that failure to meet the

need could cause damage (Cupit, 2010; Harris & Hays, 2008; Juergens et al., 2009;

LoFrisco, 2013; Papaharitou et al., 2008; Timm, 2009). This is not a unique problem to

the marriage and family therapy profession because a wide variety of health care and

medical professions are currently dealing with similar problems of failing to engage and

address sexual health issues (Helland et al., 2013; Kotronoulas et al., 2009; Verschuren et

al., 2013; Vieira et al., 2015)

In conclusion, no studies were found that included the independent variables of

knowledge and attitude to determine the effect on the dependent variables of comfort and

willingness to engage clients in sexual discussions for marriage and family therapists.

Furthermore, no researchers used the instruments in the manner I proposed: to determine

what impact, if any, knowledge and attitude have on comfort and willingness to engage

clients about their sexual lives and experiences by the marriage and family therapists

surveyed. The need for this study is further strengthened by the lack of studies in this area

(Cupit, 2010; Decker, 2010; Harris & Hays, 2008; LoFrisco, 2013; Miller & Byers, 2012;

Yelton & Delfin, 2015). The methodology chosen for this study, which follows similar

design and method choices of Cupit (2010) and Harris and Hays (2008), is discussed in

Chapter 3.

Chapter 3: Methodology

The purpose of this study was to examine the variables that affect marriage and

family therapists’ willingness and comfort to engage in and discuss the topic of sexuality

with clients to whom they provide therapy. The overarching research question was the

following: How can therapists’ increase their levels of comfort and their willingness-to-

engage so clients’ care does not suffer and therapy is a positive experience conducted in a

protective environment? The two dependent variables investigated were (a) therapists’

comfort in discussing sexual topics, and (b) therapists’ willingness to engage and discuss

sexuality with clients. The independent variables that were measured were therapists’ (a)

attitudes, (b) knowledge, (c) training, (d) supervision experience, (e) clinical experience,

(f) sex, (g) age, (h) strength of religion, (i) sexual orientation, (j) practice experience, (k)

practice setting, (l) graduate specialization, and (m) relationship status.

This study was quantitative and correlational and was derived from the methods

from Cohen, Manion, and Morrison (2007). I consulted Bowen and Kerr (1988) for

guidance regarding the use of Bowenian theory, and Harris and Hays (2008) for how I

should treat the variables within a Bowenian framework.

In Chapter 3, I explain why the correlational design was appropriate and describe

the study instruments. I also provide the rationale, population, sample size, and sampling

procedures for the study. Next, I provide information on data collection, measurement

instruments, operationalization of variables, data analysis, and threats to validity. Finally,

I address ethical issues and procedures used to mitigate any concerns.

Research Design and Rationale

The purpose of this study was to examine how the independent variables of sexual

knowledge, training, supervision, clinical experience, and personal sexual attitudes of

therapists influence their comfort and willingness to engage in and discuss the topic of

sexuality with a client. The study purpose dictated the research methodology and the

associated design that I used (see Conrad & Serlin, 2005; Edmondson & McManus,

2007). Harris and Hays (2008) and Cupit (2010) used quantitative methodology for

similar research. I designed the current study to determine the specific factors that

influence a particular outcome and to identify the best predictors of therapists’

willingness to engage in topics of sexuality and therapists’ comfort discussing sexuality

with clients. I considered a quantitative approach as best suited for the study’s purpose

(see Creswell, 2009).

A qualitative approach was not suitable for this study because the issue of

therapists not being comfortable and not being willing to discuss sexual issues with

clients was not new (see Harris & Hays, 2008). The variables necessary to examine the

relationships between sexual knowledge, training, supervision, clinical experience, sexual

attitudes, sexual comfort, and willingness to engage and discuss sexual topics were well

known and did not require an exploratory approach (see Creswell, 2009). Because these

variables were known, I could measure the predictive relationships among them.

I used a cross-sectional correlational survey design because this design lends itself

to research and analyzing predictive relationships among variables (see Creswell, 2009).

This type of survey design was appropriate for identifying correlations (see Marczyk,

DeMatteo, & Festinger, 2005; Monette, Sullivan, & DeJong, 2007). The cross-sectional

survey design is the typical choice for this type of research, requiring less time to finish

and fewer resources (see Carlson & Morrison, 2009; Polit & Beck, 2006). The survey

design is also an appropriate choice when standardized instruments are used for data

collection from a large number of participants who live in different geographical areas

(see Creswell, 2009; Kothari, 2004). The cross-sectional design allows for the generation

of a hypothesis from the variables assessed, which allows for the addition of knowledge

to the topic area and for further research (see Carlson & Morrison, 2009).

I did not add a longitudinal dimension to this study because of the lengthy follow-

up process that would have been required, as well as the cost associated with such a study

(see Aschengrau & Seage, 2008). One of the benefits of the chosen design was there were

no issues from participants dropping out that could have skewed the results (see

Aschengrau & Seage, 2008). Although this design did not allow for causation to be

established among the variables and the survey approach may have resulted in low

internal validity, the design allowed for precise findings that yielded answers to the

research questions (see Creswell, 2009; Frankfort-Nachmias & Nachmias, 2008; Szklo &

Nieto, 2014).

Population

The population from which I drew the participants were state-licensed, active,

marriage and family therapists who provided therapy to clients. Participants were actively

engaged in therapy with clients and were not engaged in other types of employment, such

as teaching. This population was finite: There are 32,070 marriage and family therapists

practicing in the United States, according to the most recent Bureau of Labor Statistics

from May 2016 (U.S. Department of Labor, Bureau of Labor Statistics , 2017).

Sampling and Sampling Procedures

I used random sampling in this study (see Frankfort-Nachmias & Nachmias,

2008). Simple random sampling is a probability-based sample design that I used to ensure

every U.S. marriage and family therapist had “an equal and nonzero probability in being

selected” (see Frankfort-Nachmias & Nachmias, 2008, p. 169). I drew the sample from a

list of marriage and family therapists practicing in the United States, who were licensed

in their state, who possessed a master’s or doctoral degree, and who were active in their

profession. This list was available for purchase online.

Determining the sample size necessary to provide accurate results was based on

three factors. The first was the power of statistical analysis (see Kuehl, 2000). The second

was effect size, which measured the relationship between the independent and dependent

variables and the magnitude that resulted. Level of significance was the third factor that

impacted the sample size. I used G*Power to determine the necessary minimum sample

size based on a level of significance. I used a high power of 0.95, a medium effect size

equal to f2 = 0.15, and a significance level of 0.5. The total number of predictors was two,

and I used a 95% confidence level with a confidence interval of ±5%. Given these

parameters, the minimum sample size was 107 as computed with G*Power using the F

test for multiple linear regression with the fixed model and R2 deviation from zero.

A type II error (Merriam-Webster, n.d.) can occur when doing statistical analysis

(Frankfort-Nachmias & Nachmias, 2008). To guard against this failure to reject a false

null hypothesis, which can be attributed to inadequate sample size, I included at least 110

participants in the analysis (see Frankfort-Nachmias & Nachmias, 2008). Therefore, at

least 110 marriage and family therapists had to complete and return the surveys. I chose

the participants at random from the email lists, and I expected about 10-15% to be

returned based on previous literature. To achieve this goal of 110 surveys completed by

marriage and family therapists, I emailed the survey to 2,000 marriage and family

therapists to meet the minimum sample size, as computed by G*Power, necessary to

reduce the chances of a type II error occurring during the statistical analysis.

Procedures

Survey Monkey is an online service available free of charge that I used to design

and create the survey for this research. I composed an e-mail invitation to potential

participants, e-mailed the survey link to those who accepted the invitation, and collected

the responses. Step 1 in this process was to convert the existing instruments into the

Survey Monkey’s questionnaire format. Step 2 was to compose an e-mail explaining the

study and send the email to 2000 potential participants to solicit their participation. The

survey explanation included an outline detailing the purpose of the study and how I

would maintain anonymity. I required informed consent from each participant before

starting the survey; the participants affirmed their voluntary participation and

understanding that they were free to quit at any time if they felt uncomfortable or

otherwise compromised before gaining access to the survey. I did not use follow-up

procedures in this study. I tracked the results on Survey Monkey, verified the data to

ensure no corruption or errors occurred in its transmission (Step 3), and analyzed the data

using Statistical Package for the Social Sciences (SPSS) 24 (Step 4).

Instrumentation and Operationalization of Constructs

Demographic Data

Cupit (2010) developed the demographic data instruments that I used in this

study. The author used this instrument when studying “counselors who were members of

the American Counseling Association” (p. 13). The variables measured by this instrument

were sex, age, strength of religion, sexual orientation, practice experience, practice

setting, graduate specialization, and relationship status. Published reliability and validity

values were not relevant because I used this instrument to collect demographic

information about the participants.

24-Item Miller-Fisk Sexual Knowledge Questionnaire

Warren Miller and Norman Fisk developed the original 49-item Miller-Fisk

Sexual Knowledge Questionnaire in 1969, consisting of questions related to sex drive,

fertility, reproduction, contraception, and menstruation (Gough, 1974). I used a shortened

version of this instrument, the 24-Item Miller Fisk Sexual Knowledge Questionnaire, in

the current study. The questions on this instrument were either true/false or multiple

choice with four options. I based the total score on the correct number of answers, and a

high score indicated sexual knowledge. An example item was “Withdrawal is an effective

means of contraception (birth control)” with a true/false answer.

This shortened version was tested for validity in a study that involved 209 male

participants and 146 female participants in Sample 1, and 78 male participants and 100

female participants in Sample 2 (Gough, 1974). Statistical significance was found at

every point-biserial coefficient when measured in the .01 level; internal consistency was

found to be sufficient (Gough, 1974). In follow-up research, 355 students were tested for

odd-even reliability coefficients; the corrected coefficients were found to be .62 for

female participants, .70 for male participants, and .67 overall (Gough, 1974). The mean

for the male participants was 15.51, with an SD = 3.77; the mean for the female

participants was 16.55, with an SD = 3.47 (Gough, 1974). The overall mean was 15.94

with an SD = 3.69 (Gough, 1974). The 1.04 difference between the two sexes gave a t

ratio of 2.68, p ≤ .01 (Gough, 1974). Cupit (2010) subsequently used this instrument as

did Russell, Gates, and Viggiani (2016) in the most recent research on mental health

counselors’ attitudes and knowledge toward sexual health issues.

Sexual Comfort Scale

Harris and Hays (2008) developed the Sexual Comfort Scale and used it in their

initial study using a 7-point Likert-type scale (1 = uncomfortable; 7 = comfortable) to

measure how comfortable a therapist would be discussing sexual topics with clients. An

example item was “I respond openly and confidently when my sexual values are

challenged.” The Sexual Comfort Scale was appropriate for this study because I aimed to

survey marriage and family therapists using the same variables as those used by Harris

and Hayes (2008); my research was an extension of their work. Harris and Hays (2008)

found the Cronbach’s alpha at 0.86 but there was no validity or reliability data beyond

that for this instrument.

Brief Sexual Attitudes Scale

Hendrick, Hendrick, and Reich (2006) developed the Brief Sexual Attitudes Scale

(BSAS), which was an update to the authors’ previous scale, the Sexual Attitudes Scale

(SAS). The BSAS was appropriate for this study because several researchers had used it

to measure the sexual comfort of mental health professionals (see Cupit, 2012; Hanzlik &

Gaubatz, 2012). The subscales of the BSAS include birth control, permissiveness,

instrumentality, and communion.

Hendrick et al. (2006) designed the BSAS with a 5-point, Likert-type scale from 1

= strongly agree to 5 = strongly disagree. Low scores indicated permissive sexual

attitudes. Example items were “I would like to have sex with many partners” or “Casual

sex is permissible.” I used this scale to measure sexual attitudes of the marriage and

family therapists in the current study.

Hendrick et al. (2006) used three different samples to measure the reliability and

validity of the BSAS. The authors drew the first sample from 674 undergraduates from a

university in the southwestern portion of the United States, and the resulting four

subscales’ alphas were birth control = 0.84, permissiveness = 0.93, instrumentality =

0.77, and communion = 0.71. This was consistent with previous alphas from the original

SAS. The BSAS “performed similarly to the original scale (and consistently with

previous research) when correlated with the other scales” (Hendrick et al., 2006, p. 81).

Hendrick et al.’s (2006) second study included 528 participants enrolled at the

same university who were in a psychology course. Hendrick et al. compared the SAS

with the BSAS and found a 0.98 on a goodness of fit index. The chi-square test indicated

that the difference between the scales was highly significant (p < 0.001). The alphas for

the subscale were birth control = 0.87, permissiveness = 0.95, instrumentality = 0.80, and

communion = 0.79; the correlations drawn from the BSAS were comparable to the SAS.

Hendrick et al.’s (2006) third and final study also drew participants from the same

university and they also selected 518 participants from psychology students who were in

the introductory phase. The test–retest reliability was found 0.20 or lower when

measured. The alphas were birth control = 0.88, permissiveness = 0.95, instrumentality =

0.77, and communion = 0.73 with the retest as follows: birth control = 0.57,

permissiveness = 0.92, instrumentality = 0.75, and communion = 0.86. The subscales

included 10 items for permissiveness, three items for birth control, five items for

communion, and instrumentality with five items.

Sexuality Education Scale

Harris and Hays (2008) developed the Sexuality Education Scale, which consists

of seven items. For example, Harris and Hays and Cupit (2010) both used this scale in

their research with marriage and family therapists and counselors respectively regarding

the variables in this study. “There are no reliability or validity data on this scale” (Cupit,

2010, p. 72). However, Harris and Hays found it suitable (Cupit, 2010).

Experience in Supervision Scale

The Experience in Supervision Scale was developed to measure the number of

interactions therapists had while being supervised that involved discussions of sexuality

(Harris & Hays, 2008). Cupit (2010) and Harris and Hays (2008) also used this

instrument in their studies of marriage and family therapists and counselors respectively

regarding the variables in the current study. “There is no reliability or validity data for

this scale” (Cupit, p. 73).

Clinical Experience Scale

Harris and Hays (2008) created the Clinical Experience Scale to assess the

aggregate experience therapists had in clinical settings discussing sexual issues. Cupit

(2010) and Harris and Hays also used this instrument in their studies of marriage and

family therapists and counselors respectively regarding the variables in the current study.

“There is no reliability or validity data for this scale” (Cupit, p. 73).

Sexuality Discussion With Clients Scale

Harris and Hays (2008) developed the Sexuality Discussion with Clients Scale to

assess the willingness of therapists to engage in discussions with clients about sexual

topics. It was appropriate for this study because Harris and Hays and Cupit (2010) had

used it in their study of marriage and family therapists and counselors respectively

regarding the variables I am examining. Cronbach’s alpha was 0.90 in Harris and Hays’s

study; there was no other data regarding the validity or reliability of this instrument.

Operationalization

I measured sexual knowledge using the 24-item Miller-Fisk Sexual Knowledge

Questionnaire (see Gough, 1974). The participants answered the questions as true/false or

multiple-choice with four options. I based the total score on the correct number of

answers where a high score indicates sexual knowledge. An example item is “Withdrawal

is an effective means of contraception (birth control)” with a true/false answer.

I measured sexual attitudes using the BSAS, which is a Likert-type scale

consisting of a 5-point spectrum (see Hendrick et al., 2006). Participants indicated the

extent of their agreement or disagreement on this sliding scale. A lower score indicated a

permissive attitude toward sexuality from 1 = (strongly agree) to 5 = (strongly disagree).

An example item statement is “I would like to have sex with many partners” or “Casual

sex is permissible.” I used this scale to measure marriage and family therapists’ sexual

knowledge.

I measured sexual comfort using the Sexual Comfort Scale (SCS) (see Harris and

Hays, 2008). Hays (2002) developed it by using a 7-point Likert-type scale to measure

how comfortable a therapist would be discussing particular topics with clients. An

example item is “I respond openly and confidently when my sexual values are

challenged” with a scale of 1 = (uncomfortable) to 7 = (comfortable). The higher the

score, the more likely the therapist would be comfortable with discussing sexual issues

with clients. I used this scale to measure marriage and family therapists’ sexual comfort

as it related to the therapy setting.

The Sexuality Education and Supervision Scale is a mix of multiple choice, using

a 7-point Likert-type scale with single answer questions, i.e., what is your gender?

(Harris & Hays, 2008). The instrument assigns one point “for each indication of

participation in sexuality education venue” (Harris & Hays, p. 243). The instrument

consists of 12 items; seven focused on education and five focused on supervision. Higher

scores indicate significant experience levels in discussing sexual topics with clients. I

used this scale to measure the marriage and family therapists’ sexual educational

background and supervision experience.

The Clinical Experience Scale is an instrument comprised of five items with a

multiple-choice format, and “…higher scores indicate more clinical experience” (Harris

& Hays, 2008, p. 243). An example item is “Clinical experience with sexual issues” with

a multiple-choice answer portion with answer options such as “I have clinical experience

with only one or two cases involving sexuality issues.” I used this scale to measure

marriage and family therapists’ clinical experience. The last scale from Harris and Hays

(2008) is the Sexuality Discussion with Clients Scale. This scale is comprised of nine

items that measure on a 7-point Likert-type scale. A higher score indicates that a marriage

and family therapist has an increased willingness to initiate a sexual discussion with a

client. I used this scale to measure marriage and family therapists’ willingness to discuss

sexual issues with clients. I examined the independent variables of sex, age, strength of

religion, sexual orientation, practice experience, practice setting, graduate specialization,

and relationship status using the Demographic Data instrument (see Cupit, 2010).

Data Analysis Plan

The data analysis software I employed in this research was SPSS 24.0. I ran a

frequency analysis to ensure I had correctly entered the data and there were no missing

values due to answers omitted by participants. I also eliminated missing data as needed.

Thereafter, I analyzed the data using a similar approach to that of Harris and Hays (2008)

and Cupit (2010), which included using “descriptive statistics, correlation, comparative,

and multiple regression analysis using stepwise linear regression” (see Cupit, p. 76). I

used stepwise linear regression to determine which of the following independent

variables, attitudes, knowledge, training, supervision experience, and clinical experience,

or which combination of those independent variables, attitudes, knowledge, training,

supervision experience, and clinical experience, had the greatest statistical significance

when acting upon the dependent variable of a therapist’s comfort level with sexuality.

The BSAS measured the independent variables for attitudes, the Miller-Fisk Sexual

Knowledge Questionnaire for knowledge, sexuality education and Supervision Scale for

training and supervision, and the Clinical Experience Scale for clinical experience. The

variables of attitudes and knowledge were ordinal because I measured them on a 7-point

Likert-type scales. The variables of training, supervision experience, and clinical

experience were nominal because I measured them by items that if checked, increased the

score, i.e., the more items checked, the higher the score. I measured the dependent

variable of the therapist’s comfort level with sexuality by using the Sexual Comfort

Scale, which is also a 7-point Likert-type scale; the variable was ordinal.

I also used stepwise linear regression to determine which independent variables

(attitudes, knowledge, training, supervision experience, and clinical experience) or which

combination of independent variables (attitudes, knowledge, training, supervision

experience, and clinical experience) had the greatest statistical significance when acting

upon the dependent variable of a therapist’s willingness to discuss sexual topics with

clients. The BSAS measured the independent variables for attitudes, the Miller-Fisk

Sexual Knowledge Questionnaire for Knowledge, Sexuality Education and Supervision

Scale for training and supervision, and the Clinical Experience Scale for clinical

experience; the variables of attitudes and knowledge were ordinal because I measured

them on 7-point Likert-type scales. The variables of training, supervision experience, and

clinical experience were nominal since I measured them by items that, if checked,

increased the score, i.e., the more items checked, the higher the score. The Sexuality

Discussion measured the dependent variable of the therapist’s willingness to discuss

sexual topics with the Sexuality Discussion with Clients Scale; this scale is also a 7-point

Likert-type scale, and the variable was ordinal. Stepwise linear regression was an

appropriate statistical test and provided a statistical analysis method wherein I used both

nominal and ordinal variables in the same test to analyze their impact on the dependent

variable.

Research Questions and Hypotheses

I used the following research questions (RQs) and hypotheses to guide the study:

RQ1: What is the relationship between attitudes, knowledge, training, supervision

experience, and clinical experience and a therapist’s willingness to discuss sexual topics

with clients?

H01: There is no statistically significant relationship between attitudes,

knowledge, training, supervision experience, and clinical experience and a therapist’s

willingness to discuss sexual topics with clients.

Ha1: There is a statistically significant relationship between attitudes, knowledge,

training, supervision experience, and clinical experience and a therapist’s willingness to

discuss sexual topics with clients.