Professional Psychology: Research and Practice 2003, Vol. 34, No.

1, 80 87

Copyright 2003 by the American Psychological Association, Inc. 0735-7028/03/$12.00 DOI: 10.1037/0735-7028.34.1.80

Therapists Sexual Values for Self and Clients: Implications for Practice and Training
Michele P. Ford
Vanderbilt University

Susan S. Hendrick
Texas Tech University

Therapists may be confronted with clients whose sexual values and behaviors are different from their own. To understand more about therapists sexual values and how these values may affect therapy, the current study assessed therapists sexual values for both themselves and their clients in the areas of premarital, casual, and extramarital sex, open marriages, sexual orientation, and sex in adolescence and late adulthood. Therapists differed selectively in their sexual values depending on their gender, religious involvement, and political affiliation. Therapists appeared comfortable working with a variety of sexual issues in therapy, and it appears that training in sexual issues is helpful in clinical work.

A female client comes for her first session with a therapist, and part way through the session she states that she believes she is lesbian but is not sure. Another client, who has been attending marital therapy, admits to the therapist in an individual session that he is having an extramarital affair. Another client, who is HIV positive, reveals that he is having unprotected sex. How does the therapist feel in these situations, and how does the therapist respond? For most of our clients, sexuality is an important aspect of their lives. Concerns such as infidelity and sexual practices are often brought into therapy either as the primary presenting problem or as a related issue. Therapists may have specific values regarding their personal sexual practices and those of their clients, yet this topic has been explored less than other value areas. The current project addressed therapists sexual values for themselves and their clients, how therapists handle value conflicts as they arise in therapy, and therapists assessment of their training in sexual issues. Bergin (1980) theorized that there is likely a significant discrepancy between the values of therapists and clients, and subsequent research has shown that therapists values not only influence the effectiveness of therapy but also influenceand often change clients personal values (e.g., Arizmendi, Beutler, Shanfield, Crago, & Hagaman, 1985; Beutler, 1979; E. W. Kelly, 1995; T. A. Kelly, 1990; T. Kelly & Strupp, 1992). Jensen and Bergin (1988) found that one of the themes of mental health values reflected in their study was related to sexuality, with therapists reportedly having specific values related to sexuality. Research has also indicated that sexuality is one of the main areas in which clients

and therapists disagree; therapists values are typically more liberal than those of their clients (e.g., Khan & Cross, 1983; Roman, Charles, & Karasu, 1978). Increasing attention has been given to sexual involvement between therapist and client, and resources have been developed to aid in training on the topic (e.g., Pope, Sonne, & Holroyd, 1993; Pope & Vasquez, 1998), but the issue of sexual values and therapy has been neglected. Although the difficulty of talking about sexual issues in therapy has been noted (Gilbert & Scher, 1998), Corey, Corey, and Callanan (1998) highlighted the need for more research to be conducted in the area of therapists personal values, attitudes, and biases regarding various sexual practices and lifestyles. Relevant sexual topics, drawn from the literature, are reviewed briefly in the following section, and the current project is then presented.

Areas of Sexuality
Premarital sex has increased dramatically in recent decades. Michael and colleagues (1998) found that in the United States, only 22% of men and 18% of women ages 18 24 had not engaged in sexual intercourse prior to marriage. Peoples attitudes toward premarital sex have become more permissive, though men report more permissive attitudes than women toward premarital sex (Michael et al., 1998). Premarital sex often occurs in direct opposition to religious values and traditional beliefs about sexual practices and may still be considered an unconventional, inappropriate practice by some people (Wilson, 1995). It is not clear how therapists and clients values on this issue might compare, and indeed, therapists may differ in their attitudes on the basis of background characteristics such as gender, religion, or politics. Casual or nonrelational sex has been defined as a sexual experience driven by lust that exists outside of an intimate relationship (Levant, 1997), and the occurrence of multiple sex partners has increased for both sexes (Michael et al., 1998). Therapists may differ in their evaluations of casual sex. For example, Hecker, Trepper, Wetchler, and Fontaine (1996) found that both gender and religiosity affected therapists interpretations of sexual relationships shown in vignettes. Therapists who were shown the vignettes viewed both the male and the female unmarried clients
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MICHELE PATTERSON FORD received her PhD in counseling psychology from Texas Tech University in 2000. She is a staff psychologist at the Vanderbilt University Psychological and Counseling Center. SUSAN S. HENDRICK received her PhD in counseling in 1978 from Kent State University. She is a professor of psychology at Texas Tech University. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Susan S. Hendrick, Department of Psychology, Box 42051, Texas Tech University, Lubbock, Texas 79409-2051. E-mail: susan.hendrick@ttu.edu

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who had varied sexual partners as being more pathological; male therapists tended to do more pathologizing than female therapists. Male therapists who identified themselves as being highly religious viewed clients as being more sexually addicted than did other raters. Therapists values and attitudes about casual sex are especially important in the age of AIDS, because sexual intimacy and safety issues must be taken very seriously. Extramarital sex was defined in the present study as sexual intercourse that occurs outside the context of a married or committed, cohabitating, partnered relationship, with a person of either the same or other sex, without the knowledge or consent of the relationship partner. Extramarital sexuality or infidelity is likely to have different meanings for mental health professionals and professionals who are not in the field of mental health (Pittman & Wagers, 1995). Some therapists may view infidelity as a problem in and of itself or as the symptom of a deeper relational problem. Yet referring to extramarital sex as adultery or infidelity implies religious and or moralistic values (Westfall, 1989) that may trouble some therapists. This poses an interesting paradox to the practicing professional and accentuates the importance of a therapists own personal values on this issue (Pittman & Wagers, 1995). In contrast, an open marriage can be defined as one in which outside sexual relationships occur with the knowledge of the spouse. Swinging involves both spouses in an exchange of partners (Knapp, 1974, 1975). Marriage counselors who were surveyed indicated that they held negative views toward swinging, extramarital sex, and open marriages, respectively (Knapp, 1974). Therapists reported being able to work supportively with clients engaging in these behaviors, yet a significant percentage indicated that they would attempt to influence their clients to abandon these practices. Statistics indicate that gay male and lesbian persons seek therapy at a significantly higher rate than the general population (Bradford & Ryan, 1987; Committee on Lesbian and Gay Concerns, 1991; Morgan, 1992). Despite the increased visibility of gays and lesbians in society and in therapeutic settings (Brown, 1995), public and professional attitudes often fall short of affirming gay men and lesbians (as well as bisexual and transgendered persons). Research is mixed concerning how positive therapists attitudes are toward gay male and lesbian clients (Friedman, 1996; Liddle, 1995), though therapists may espouse negative attitudes toward gay men or lesbians as a group and yet be able to work professionally with an individual who identifies as lesbian or gay. The number of adolescents engaging in sexual intercourse has increased significantly (Darling, Kallen, & VanDusen, 1984; Herold & Marshall, 1996). Issues are complex for all involved. Parents often find themselves torn between preaching abstinence and helping their children acquire birth control and protection from sexually transmitted diseases. Adolescents, too, may be torn between adhering to the moral codes of abstinence outlined by families and churches and the peer and media pressure to engage in sexual activity (Stodghill, 1998). Counselors of adolescents may provide sexual education and convey responsible sexual values while also offering a safe environment in which adolescents may explore these issues. Finally, although sexuality is often viewed as something for the youthful and not for the aged (Deacon, Minichiello, & Plummer, 1995; Levy, 1994), research has shown that some degree of sexual desire is felt across the life span, and people can remain sexually

active if they are in good health and have an appropriate partner (Levy, 1994). It appears that values permeate the therapeutic process, and sexual values are no exception. The current study was designed to increase our understanding of therapists personal sexual values, their values for clients, their ways of handling discrepancies between these sets of values, and the amount and perceived effectiveness of therapists training in handling sexual value dilemmas in therapy.

The Therapists Sexual Values Project Procedure

A questionnaire was developed (by Michele P. Ford) on the basis of existing literature, with the intent of contributing to that literature; the questionnaire was critiqued and revised before distribution. Definitions of all terms (e.g., premarital sex) were provided in the questionnaire. Questionnaires were sent to 1,000 practicing professional therapists who were members of either of two professional associations: the American Psychological Association (APA) or the American Association for Marriage and Family Therapy (AAMFT). These professions were chosen to increase the variety of practicing professionals who serve a diverse population of clients. From the APA, 500 members were selected from a provided list of 1,000 active practitioners (a randomized list of practicing professional APA members that was demographically representative); every other name was chosen. From the AAMFT, 500 members were selected from a provided list of approximately 12,600 persons meeting the requirements for clinical membership. Every 25th name was chosen. Participants were selected systematically, and no attempt was made to oversample for any demographic characteristics, including race or ethnicity. The lists were cross-referenced so that duplicate questionnaires were not sent. Participants were mailed the questionnaire, a cover letter (including informed-consent information), and a stamped envelope. Reminder letters were sent after 3 weeks. All information was kept anonymous and confidential. The questionnaire had three sections, all based on previous literature or designed to extend the literature. The demographics section included questions about personal characteristics (e.g., age, gender), professional characteristics (e.g. degree, years of practice), common issues dealt with in practice, and sexuality training. The values portion assessed participants values related to each of the sexuality areas reviewed in the literature and inquired about sexual practices that therapists would be uncomfortable working with in therapy (22 items). The difficult-situations section included two open-ended questions, the first asking how therapists handled situations in which they indicated being personally uncomfortable working with clients, and the second asking about the most difficult situation the therapist had encountered regarding sexual values and therapeutic practice.1

Therapist Sample
Of the 1,000 questionnaires mailed, 1 was returned as undeliverable, and a total of 318 (32%) questionnaires were returned, 314
1

The questionnaire is available from Michele P. Ford upon request.

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of which were usable. The final response rate of 32% was not ideal but is comparable to the rates for other studies of this type (e.g., Kruse & Canning, 2002). On the basis of age, gender, and race/ ethnicity, the sample was comparable to samples in other studies of therapists values (Jensen & Bergin, 1988). Nevertheless, future studies should sample a more demographically representative group to ensure greater generalizability. It is very likely that race, ethnicity, and other cultural factors would influence therapists values and practice. In order to retain all respondents data and have groups large enough for comparisons, we combined some groups. It is possible that these groups might differ from each other. In addition, there is a chance of sample bias in that persons who responded to the questionnaire may have been more comfortable with sexual issues than were persons who did not respond. The mean age of the sample was 50.95 years, and the average number of years in practice was 17.66 years. A fuller description of the sample is provided in Table 1. All participants did not fill out all items, and some items elicited more than one response. Thus percentages may total less or more than 100%.

Values Survey
The first 9 statements inquired about general sexual valuesfor example, the first item stated, Sex is an expression of love and commitment. The next 13 statements inquired about issues that would cause the respondent to be personally uncomfortable if working with a client. For example, the first item stated, I would be personally uncomfortable working with a client who engages in premarital sex. Items were rated on a 5-point Likert-type scale (A strongly agree; E strongly disagree). Sample sizes and degrees of freedom varied slightly across analyses because not every respondent answered every question. Respondents were grouped by gender, religious involvement, and political affiliation, which resulted in a number of significant differences. (All remaining comparison information is available from Michele P. Ford and includes comparisons on relationship status, parental status, religious attendance, type of graduate program, type of degree, theoretical orientation, whether APA or AAMFT member, and professional setting.) Because of the ex-

Table 1 Attributes of Therapist Sample

Attribute Gender Ethnicity Organizational membership Graduate degrees 54% female; 46% male 96% Caucasian; 1% Hispanic; 1% Asian; 2% African American or other 55% APA; 48% AAMFT; 7% both 40% clinical psychology; 22% counseling psychology; 13% MFT; 6% social work; 4% educational psychology; 1% HDFS; 13% degree in another field or more than one field 66% doctorates (51% PhD, 8% EdD, 7% PsyD); 20% MA/MS; 8% MSW, 6% more than one degree or other 91% heterosexual; 4% gay male or lesbian; 3% bisexual 81% married/partnered; 8% divorced; 5% single; 4% living together or widow/widower 81% yes; 19% no 12% strongly liberal; 45% liberal; 31% moderate; 11% conservative; 1% strongly conservative 41% Protestant; 16% Jewish; 14% Catholic; 17% nonreligious; 12% other 28% cognitivebehavioral; 23% family systems; 17% psychoanalytic/psychodynamic; 6% interpersonal; 3% humanistic; 2% behavioral; 2% client centered; 1% existential; 17% other or more than one 66% independent individual or group practice; 8% hospital or clinic; 8% CMHC; 4% university/college counseling center; 3% other university setting; 4% evenly distributed across school, business, and government; 7% other or more than one 73% individual adult; 42% couple/marital; 18% family; 11% individual adolescent; 8% individual child; 6% group; 1% sex therapy; 4% other % of total sample

Level of degree Sexual orientation Relationship status Children Political values Religious affiliation Theoretical orientation

Work setting

Therapy practice

Note. APA American Psychological Association; AAMFT American Association of Marriage and Family Therapy; MFT marriage and family therapy; HDFS human development and family studies; CMHC community mental health center.

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ploratory nature of this research and the number of repeated analyses conducted, the significance level was set at .005 for t tests and F ratios. Also note that higher numbers indicate greater levels of disagreement, and lower numbers indicate greater levels of agreement. Gender. An independent groups t test indicated significant gender differences on 6 of the 22 statements, as shown in Table 2. Women endorsed the statements Sex should be reserved for marriage only and I would be personally uncomfortable working with a client who engages in same-sex sexual practices significantly less than males. Men endorsed the statements Homosexuality is a natural expression of sexuality in humans, People are fundamentally bisexual, I would be personally uncomfortable working with a client who engages in group sex, and I would be personally uncomfortable working with a client who engages in sadomasochism significantly less than women. Overall, it appears that female respondents tended to be more comfortable with sexual orientation issues, and male respondents tended to be more comfortable with nonnormative sexual behaviors. Religious affiliation. One-way analyses of variance (ANOVAs) were used; results for six items are shown in the upper portion of Table 3. Significant F ratios were found for seven items, but there were no mean differences on one item. Overall, respondents identifying themselves as Catholic and Protestant were more endorsing of sexual relations as an expression of love and commitment (Item 24), reserving sex for marriage only (Item 25), and sexual exclusivity within committed relationships (Item 26). Nonreligious and (to some extent) Jewish respondents expressed greater comfort with homosexuality as natural (Item 31) and clients same-sex sexual practices (Item 40), although all groups relatively disagreed with the item indicating some level of discomfort with homosexual

clients. Catholics were less comfortable working with clients who were considering an abortion (Item 43). Political values. We used one-way ANOVAs to compare responses for participants with differing political values. Significant differences were found on nine items, shown in the lower portion of Table 3. Overall, politically conservative respondents were more endorsing of sex as an expression of love and commitment (Item 24), reserving sex for marriage only (Item 25), and sexual exclusivity within committed relationships (Item 26) than were politically liberal respondents. Politically liberal respondents were more endorsing of the following items: Marriage provides too many restrictions on sexual freedom (Item 28), homosexuality is natural (Item 31), and the idea that people are fundamentally bisexual (Item 32). Politically liberal respondents were somewhat more comfortable working with sexual orientation issues (i.e., with both homosexual [Item 40] and bisexual [Item 41] orientations) and with clients who were considering having an abortion (Item 43). Overall, considering gender, religion, and political values, the items showing the greatest number of group differences related to (a) sex involving marriage, commitment, and exclusivity; (b) same-sex and bisexual practices; and (c) abortion. It is important to remember, however, that therapists relatively disagreed with items describing difficulty in working with clients. These results suggest that although therapists have personal opinions about sexual practices, such opinions are inclusive of a broad range of beliefs and practices. When therapist beliefs conflict with those of clients, therapists appear to be able to set aside their personal values in order to assist clients in therapy.

Practice and Training Questions

Questions regarding specific practice and training issues were also presented to therapist respondents. Selected responses are shown in Table 4. More than 75% reported having received training in sexual issues, whereas 22% reported having received no training. Over 50% reported training in conducting a psychosexual history or assessment, though 41% reported no training. Many reported having received such training in graduate school. When asked if their training had adequately prepared them, however, the mean response was 3.0 on a 15 point scale (SD 0.96), indicating a neutral response. Eighty percent of respondents reported that 25% or less of their practice was devoted to sexual issues, with 16% reporting 26 50%, and the remaining 4% reporting 51100%. Although infidelity and incest/abuse were the issues most frequently worked on in therapy, other issues were common also. Therapists typically initiated discussion of sexual issues with clients at least some of the time, and although they mentioned a number of issues that were difficult to handle in therapy, they reported handling such issues in a variety of ways. (Note that percentages do not add up to 100% because respondents left particular questions blank.)

Table 2 T tests for Significant Value Differences Between Women and Men
Mean Item Sex should be reserved for marriage only. Homosexuality is a natural expression of sexuality in humans. People are fundamentally bisexual. I would be personally uncomfortable working with a client who engages in same-sex sexual practices. I would be personally uncomfortable working with a client who engages in group sex. I would be personally uncomfortable working with a client who engages in sadomasochism. Women 3.6 2.0 3.3 Men 3.2 2.6 3.7 t 2.96* 4.63* 4.06*

4.6

4.3

2.80*

3.4

3.9

4.14*

Implications
2.7 3.4 5.34*

Values
This research supports previous conclusions (Jensen & Bergin, 1988) that the practice of therapy is not value free, particularly

Note. Ns 169 women and 142144 men. Means could vary from 1.0 to 5.0. The lower the mean, the greater the agreement with the item. * p .005.

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Table 3 Means and F Ratios for Religious Affiliation and Political Values
Item Group Religious affiliation Protestant Sex is an expression of love and commitment. Sex should be reserved for marriage only. It is important that married couples/life partners have sexual relations exclusively within the marriage/committed partnership. Homosexuality is a natural expression of sexuality in humans. I would be personally uncomfortable working with a client who engages in same-sex sexual practices. I would be personally uncomfortable working with a client who is considering having an abortion. 1.8ab 2.9a Catholic 1.7a 3.3ab Jewish 2.1b 3.9c
a

Other 2.1b 3.5bc

Nonreligious 2.2b 4.0c 4.87* 13.63*

1.6a 2.6b

1.6a 2.3ab

2.0b 2.1ab

1.8a 2.1ab

2.0b 1.9a

6.28* 4.78*

4.3a

4.4abc

4.8c

4.4ab

4.7bc

6.13*

4.3ab

3.9a

4.7b Political valuesb

4.3ab

4.7b

7.40*

Scon/con Sex is an expression of love and commitment. Sex should be reserved for marriage only. It is important that married couples/life partners have sexual relations exclusively within the marriage/committed partnership. Marriage is an unhealthy, unnatural restriction on sexual freedom. Homosexuality is a natural expression of sexuality in humans. People are fundamentally bisexual. I would be personally uncomfortable working with a client who engages in same-sex sexual practices. I would be personally uncomfortable working with a client who engages in sexual practices with individuals of both sexes. I would be personally uncomfortable working with a client who is considering having an abortion. 1.5a 2.1a

Mod 1.9ab 3.1b

Liberal 2.0ab 3.8c

Sliberal 2.2b 4.2c 4.34* 36.93*

1.4a 4.8b 3.6d 4.2c

1.7ab 4.6ab 2.6c 3.6b

1.8b 4.5ab 1.9b 3.3b

2.5c 4.3a 1.4a 2.8a

13.70* 4.49* 45.86* 15.86*

3.9a

4.4b

4.6bc

4.9c

15.44*

3.9a

4.2ab

4.3b

4.7c

6.65*

4.1a

4.2ab

4.5ab

4.6b

4.45*

Note. Means could vary from 1.0 to 5.0. The lower the mean, the greater the agreement with the item. Row means with no subscripts in common differed at the .05 level by the multiple-range test. Scon/Con strongly conservative/conservative; Mod moderate, Sliberal strongly liberal. a Ns 127128 Protestant, 43 Catholic, 51 Jewish, 37 other, 52 nonreligious. b Ns 39 strongly conservative/conservative, 93 moderate, 132134 liberal, 35 strongly liberal. * p .005.

where sexual values are concerned. Respondents to this survey indicated that they valued, or had positive attitudes toward, such things as sex as an expression of love and commitment, and fidelity and monogamy in marital relationships and committed life partnerships. Sexuality was seen as a life span behavior, with sex in later adulthood valued more than sex during adolescence. Though there were a number of significant differences based on gender, religious preference, and political affiliation, therapists

expressed comfort working with a variety of issues. Group differences tended to be a matter of degree of comfort rather than of one group being able to work with an issue and one group being unable to work with the same issue. Therapists reported handling value conflicts by such strategies as referring clients or consulting with a colleague, supervisor, or peer. Indeed, these are cited as ethical ways to handle conflicts in therapy (e.g., Bersoff, 1995). It appears that therapists tend to be aware of their personal values

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Table 4 Practice and Training Issues

Issue Issues most commonly worked with in therapy Incest or sexual abuse (combined) Extramarital sex Premarital sex Gay/lesbian/bisexual issues Adolescent sexuality Sexual practices (e.g., oral sex, masturbation) Sexual dysfunction (e.g., premature ejaculation, vaginismus) Abortion Relational sexual violence Sexual assault/coercion Sexual harassment Paraphilias Open marriages/swinging Consensual sadomasochism Group sex Type and timing of training During graduate school Continuing education, workshops, seminars, etc. Supervision On internship or postdoctoral training Other (e.g., reading, tapes, conferences) How often initiated discussion of sexual issues with clients Routinely Often Sometimes, as relevant Rarely Never Most personally uncomfortable sexual value that client issue dealt with Incest; rape; sexual abuse; abuse perpetrators, pedophiles Safety issues/unsafe sex Infidelity/dishonesty; sadomasochism Issues similar to therapists own; adolescent sexuality Client attraction to therapist; group sex; sexual orientation/transsexual/transgender Therapist attraction to client; abortion; bestiality Nonconsensual sexual acts; casual sex; pornography; promiscuity, prostitution; swinging/open marriages Other or anecdotal Did not apply How they handled personally these personally uncomfortable clinical situations Refer client Discuss issue with client Consult with colleague/supervisor/peer Self-examination; seek additional knowledge; look at issue from clients viewpoint Seek personal therapy; discuss unsafe sex Help client explore issue Other or did not apply 40 25 18 4 each 2 each 1 21 15 each 10 6 each 4 each 3 each 2 each 1 each 18 12 27 19 47 5 2 45 29 6 5 12 67 61 42 42 41 28 27 24 21 20 18 6 3 3 1 % response

and make efforts to keep their values from having a negative impact on their clients.

Training Options
Overall, practicing therapists reported being able to work with a variety of issues in therapy. Given therapists tendencies to hold

somewhat liberal values, it is important that clients who hold very conservative sexual values and who enter therapy be free to retain those values, just as that freedom is important for clients whose values are more liberal than those of the therapist. It should be reiterated that although group differences were found across all demographic categories examined in this study, the sample was not

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diverse enough to allow analyses of racial, ethnic, and cultural differences. Research needs to be conducted that oversamples practitioners from specific racial and ethnic groups in order to explore both differences and similarities in sexual values. Two major implications arise from the current research. First is the issue of ethical behavior by practitioners (and by implication, ethics training), and second is the issue of specific training in sexual issues. This study provides reassurance that practitioners deal with difficult therapy situations, such as working with uncomfortable sexual issues, by employing ethical behaviors, such as referring the client, discussing the issue with the client, and/or consulting with colleagues, supervisors, or peers. This level of professional care speaks well of practitioners as well as of the current ethics training provided in professional training programs. Such findings suggest the need for continued and even expanded graduate training in ethics, however, because an appropriate standard of care could still be improved. The issue of training in sexual issues is highlighted by therapists reporting that although they received graduate or postgraduate training in such topics, they were only neutral about whether their training adequately prepared them to actually work with sexual issues in therapy. Although ethical dilemmas regarding sexual attraction in therapy are currently discussed in most ethics courses, such courses should perhaps not be the only forum for therapists-in-training to learn about sexual issues and sexual values. A specialized graduate seminar could be developed to explore such topics as sex therapy, sexuality across the life span (including sections on sex and illness, sex and disability), and sexual orientation and variation. Because course additions may not be practical, existing courses (e.g., marriage and family counseling, developmental psychology) could be augmented with sexual values components. Course material on sexuality in general and sexual values in particular is likely to facilitate the work of trainers who need to help trainees examine sexual values. General practicum training and internship training could also include sexuality as part of the curriculum. The Association of Psychology Postdoctoral and Internship Centers suggests that internship training be conducted in modules that allow trainees to learn about clinical issues that are similar and relevant to each other. The following suggested training topics, based on our experiences in teaching, training, and clinical practice, are examples of potential topics that could be addressed during practicum, internship, or postdoctoral training. Seminars could occur weekly, lasting approximately 12 hr, depending on time allotted for training.

5. Effective Use of Sexual Transference in Therapy: Addresses the identification of sexual transference in therapy and focuses on ways in which to make effective therapeutic use of such transference as part of the treatment process. 6. Sex Therapy Methods and Techniques: Discusses methods of sex therapy as well as specific treatment protocols for the most common presenting sexual problems. 7. Sexual Dysfunction: Continues the material of the previous session, addressing physical and psychological reasons for sexual problems as well as specific techniques matched to specific problems. 8. Nontraditional Sexual Practices: Discusses sexual practices that are less commonly addressed, such as sadomasochism, crossdressing, group sex, and open marriages. These suggestions are not meant to be definitive but rather are offered simply as examples of the types of topics that could be included in training modules. Overall, this study indicates that therapists do encounter sexual values dilemmas in their work with clients, but these dilemmas are recognized and handled ethically. Increased training of graduate students as well as practicing therapists in areas of sexuality in general, and therapist sexual values in particular, can only serve to strengthen the therapy professions.

References
Arizmendi, T. G., Beutler, L. E., Shanfield, S. B., Crago, M., & Hagaman, R. (1985). Clienttherapist value similarity and psychotherapy outcome: A microscopic analysis. Psychotherapy, 22, 16 21. Bergin, A. (1980). Psychotherapy and religious values. Journal of Consulting and Clinical Psychology, 48, 95105. Bersoff, D. N. (1995). Ethical conflicts in psychology. Washington, DC: American Psychological Association. Beutler, L. E. (1979). Values, beliefs, religion, and the persuasive influence of psychotherapy. Psychotherapy: Theory, Research, and Practice, 16, 432 440. Bradford, J., & Ryan, C. (1987). National Lesbian Health Care Survey: Mental health implications. Richmond: Virginia Commonwealth University Research Laboratory. Brown, L. S. (1995). Therapy with same-sex couples: An introduction. In N. S. Jacobson & A. S. Gurman (Eds.), Clinical handbook of couples therapy (pp. 274 291). New York: Guilford Press. Committee on Lesbian and Gay Concerns. (1991). Final report of the task force on bias in psychotherapy with lesbians and gay men. Washington, DC: American Psychological Association. Corey, G., Corey, M. S., & Callanan, P. (1998). Issues and ethics in the helping professions. Pacific Grove, CA: Brooks/Cole. Darling, C., Kallen, D. J., & VanDusen, J. E. (1984). Sex in transition, 1900 1980. Journal of Youth and Adolescence, 13, 385399. Deacon, S., Minichiello, V., & Plummer, D. (1995). Sexuality and older people: Revisiting the assumptions. Educational Gerontology, 21, 497 513. Friedman, L. J. (1996). An examination of attitudes toward gay men and lesbians among Louisiana licensed professional counselors. Dissertation Abstracts International, 56, 3837A. Gilbert, L. A., & Scher, M. (1998). Gender and sex in counseling and psychotherapy. Boston: Allyn & Bacon. Hecker, L. L., Trepper, T. S., Wetchler, J. L., & Fontaine, K. L. (1996). The influence of therapist values, religiosity and gender in the initial assessment of sexual addiction by family therapists. American Journal of Family Therapy, 23, 261272. Herold, E. S., & Marshall, S. K. (1996). Adolescent sexual development. In G. R. Adams, R. Montemayor, & T. P. Gullotta (Eds.), Advances in

Sample Training Modules

1. Introduction to Sexuality and Therapy: Introduces the importance of incorporating clients sexuality into therapy and discusses how to introduce this topic in clinical work. 2. Sexual Attraction in Therapy: Deals with recognizing and addressing clients sexual attraction to therapists and therapists sexual attraction to clients. 3. Discussing Sex With Clients: Helps students understand how to facilitate exploration of this issue as part of therapy. 4. Sexual Preferences and Practices: Introduces the topic of sexual orientation as well as common sexual practices and problems encountered in therapy.

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Received December 10, 2001 Revision received August 5, 2002 Accepted September 16, 2002