Many sex educators have said that probably the most difficult aspect of their preparation in becoming sex educators was not a lack of accurate knowledge about sex and sexuality, but their own struggle in developing a healthy attitude toward themselves and their own sexuality. Most clinicians did not grow up in open environments that facilitated becoming comfortable with themselves in the area of sexuality.

Explorations about sexuality will necessarily involve explorations about values. For clinicians who wish to provide successful corrective experiences to their clients, it will be essential to be skilled in clarifying and maintaining awareness of values around sexuality – both the client's values and one's own values.

The following exercise will serve to help the clinician focus on some of the value complexities that can arise in the process of assessing sexual concerns with clients.

Before starting the didactic portion of this course:

Number a separate sheet of paper from 1-21 or print this list of value statements.

First, take some time to reflect briefly on each statement. Without analyzing and soul searching, write down A for Agree and D for Disagree for each statement.

Next, go back to each statement and reflect on what the statement means to you in terms of your life, the way you were raised, the messages you have held on to, and any other information that informs your values and beliefs.

1. I believe sex is for fun.
2. I have sexual fantasies at times.
3. I approve of masturbation for myself.
4. I believe that small children of any age should be allowed to masturbate.
5. I approve (or approved) of premarital intercourse for myself.
6. I would approve of premarital intercourse for my 16 year-old son.
7. I would approve of premarital intercourse for my 16 year-old daughter.
8. For me, oral-genital sex is an acceptable alternative to intercourse.
9. For me, mutual stimulation to orgasm is an acceptable alternative to intercourse.
10. I believe that a good sexual relationship is the most important factor in a marriage.
11. For me, love is necessary in order to have good sex.
12. While in a committed relationship, I have found myself sexually attracted to someone else.
13. I believe that by far the best kind of sex is spontaneous and unplanned.
14. I believe that homosexuals should not work with young children.
15. For me, casual sex (such as a one-night stand) can be exciting, fulfilling, and practiced with little guilt.
16. When it comes to sex, there is a great difference between what I do and what I would like to do.
17. Masturbation is an acceptable way of relieving sexual tensions, even if a person is in a committed relationship.
18. I believe AIDS is a punishment for immoral behavior.
19. I feel comfortable discussing sexual issues with my partner.
20. I have had difficulty reconciling my religious beliefs with my sexual behaviors.
21. At times in my life, I have had sexual concerns.
Now, go back through the list and reflect on your answers in a deeper, thoughtful way and see what reactions are evoked. Are there some that are easy to answer? Others that are more difficult? Some that evoke anger? Guilt? Shame? Excitement? Frustration? Anxiety? Sadness? Happiness? Other feelings?

Finally, respond to the following question and sentence completion statements.

1. To whom would YOU go with a sexual concern?
2. My greatest difficulty in dealing with sexual concerns of clients is_____________
3. My greatest asset in dealing with sexual concerns of clients is ____________.

One of the challenges of doing sexual counseling/therapy is to work within the patient’s system of values and beliefs. When the patient comes from a similar background to the clinician, this is frequently easier for the clinician. When the patient comes from a background that is radically different from that of the clinician, this can be a much greater challenge.

A prerequisite for being able to handle this challenge is to have the capacity to understand one's own values and control one's own emotional responses – so that the focus of attention can remain on the client's values and concerns, instead of what is difficult or confusing for the clinician.

This presentation of material will work at three levels that have been described in the literature. First, clinicians who work with clients from different cultural backgrounds are supposed to be culturally aware. (Sue and Sue, 1999) This is to say that – at the very least – clinicians should be aware of their own cultural background - and aware of how the socialization from that background has created certain assumptions and biases that shape how they see and interact with the world.

These assumptions and biases – left unattended – can create blinders on the eyes of the clinician when working with clients from different cultures. This is because these items are often embedded in value systems that are so familiar and comfortable for the clinician that they are almost invisible. These biases can cause the clinician to shape the therapeutic experience in ways that affirm and make comfortable the values of the clinician, while denying and discounting the experience and cultural material of the client.

Cultural awareness requires that the clinician remove his or her blinders and strive to become comfortable working with the cultural differences that exist between the client and clinician (Sue and Sue, 1999). The cognitive parts of this involve keeping one's thinking and perception flexible and remaining open to seeing and understanding different world views.

The emotional part of this may at times be even more difficult than the cognitive part. The emotional part requires the laying aside of any hidden or buried cultural biases and tolerating the discomfort of having one's own deeply held personal – and/or professional - values challenged by someone who may partially or wholly disagree with and reject those values.

The human and personal components of being a clinician can be sorely tested by this. The clinician's core defining values may be the central reason why he or she entered the mental health field in the first place. It may be for religious or spiritual reasons, or it may be for deeply held personal values and beliefs. However it is based, this set of core defining values often serves a very important centering function in the emotional life of the clinician, in addition to bringing comfort, certainty, and meaning to the work that he or she does.

For this reason, having one's most important values questioned or rejected can be a very disturbing or unsettling emotional experience. It can provoke powerful countertransference feelings and inclinations to translate those feelings into actions. This is a real risk or danger in cross-cultural work. With emotionally laden arenas such as sexuality, the ability to maintain a sufficient degree of cultural neutrality can be even more difficult.

However, one of the ethical sacrifices that is required of those who choose this profession is the willingness to engage in these difficult questions - without running away too easily and too quickly towards that which is more personally comfortable. One cannot practice ethically without being able and willing to tolerate a certain amount of the discomfort that comes with sitting with cultural differences.

The final piece of being culturally aware is to know one's limitations when working with clients from different backgrounds (Sue and Sue, 1999). This falls under the category of operating within one's area of competence. When clinicians are not able to remove their own blinders or handle the emotional challenges of working with clients with different world views, the culturally aware clinician is at least able to know this about himself or herself, and know when to refer the client to another clinician who may be better able to respond to the cultural needs of the client.

The second level of cultural competence involves being culturally knowledgeable (Sue and Sue, 1999). This requires that the clinician possess a significant degree of understanding concerning the cultural elements of the client that are relevant to the definition of problems and solutions. This includes knowing the role - in relation to the dominant culture - of the minority group of which the client is a member.

(Not to state the obvious, but this also requires that the clinician has a quite clear picture of the landscape of the dominant culture, what its biases are, what its assumptions are, what the weaknesses, flaws, and internal contradictions in its perceptions and values are, etc.)

The culturally knowledgeable clinician should also have a solid background in the relevant practice literature concerning practice with non-dominant cultural groups, and also understand the institutional and cultural barriers that impede minority groups from using mental health services (Sue and Sue, 1999).

Finally, the third and highest level of cultural competence is being culturally skilled (Sue and Sue, 1999). This requires that the clinician possess a wide range of skills to use in interventions with clients from different cultural backgrounds, including fluency with verbal and non-verbal modes of communication that are well-received and understood by the clients within their own cultural experience (Sue and Sue, 1999).

This level of cultural competence also requires that the clinician be able – and willing – to intercede on the behalf of the client when the client's cultural components are "right" and the dominant culture's cultural components are "wrong" (Sue and Sue, 1999). When the dominant culture's values are "dysfunctional" for the client from a different cultural background, the clinician must not be blinded by his or her own biases, and unwilling or unable to grasp this.

Let us take as examples the following situations. 1) A woman who has grown up with the belief that touching herself is bad might have difficulty with a program that encourages her to become orgasmic with self-stimulation before she incorporates a partner; 2) People who believe they must be highly skilled in certain behaviors and responses in order to be a “real” man or a “real” woman are programmed for performance anxiety.

Example: A couple in their 30s came to a therapist complaining of the woman’s difficulty experiencing orgasm. What surfaced were their beliefs that 1) a man should be able to give a woman an orgasm, 2) the orgasm should come only from intercourse and the husband’s thrusting, and 3) real women have orgasms with just intercourse, and no other forms of genital touching should be necessary. The woman was in fact able to have an orgasm with intercourse, but this was taking 45 minutes to one hour of thrusting. The husband’s comment was, “I’m tired.” As a result of the pressure to perform that he was feeling with each sexual encounter, he was actually beginning to lose his desire.

Negative sexual experiences repeated over time will eventually begin to impact desire. The man who has the belief that he has to “give” his partner an orgasm, the young mother who, despite her fatigue and frequent irritation with her spouse, continues to have obligatory sex, the man who frequently experiences erectile difficulty, and the woman who experiences pain with each act of intercourse may be headed down the road to low or no desire.