Editorial introduction

We are fortunate to continue to have thoughtful guidance from the last Editor-in-Chief (EIC), Dr. Alex Iantaffi, here at Sexual and Relationship Therapy (SRT). Indeed, it was Alex’s last suggestion for Volume 33(4) that there may be enough articles focused on bondage/discipline-dominance/submission-sadomasochism (BDSM)/kink for this issue to be a special issue. This valuable suggestion prompted me to look at the availability of articles focused on BDSM/kink and discover that there were quite a few, but, alas not quite enough for a whole special issue. There were, however, enough articles to broaden the focus to be inclusive of not only erotic diversity (BDSM/kink), but also gender, sexual, and relational diversity. Thus, this became a Special Issue on Gender, Sexual, Erotic, and Relational Diversity (GSERD).

Gender, sexual, erotic, and relational diversity (GSERD) is an emerging umbrella term and related conceptualization aimed at more comprehensively recognizing the diversity within people than the more historical and popularized conceptualizations of most Westernized societies that exists in terms of sexuality and gender (like lesbian, gay, bisexual, and transgender+; LGBT+) (Davies & Barker, 2015; Twist, 2016). This theoretical conceptualization includes the diversity within and between humans around gender (e.g. cisgender, transgender, agender, etc.), sexuality (e.g. heterosexual, gay, lesbian, asexual, bisexual, pansexual, etc.), eroticism (e.g. kinky, fetishists, non-kinky, etc.), and relationality (e.g. monogamous, monogamish, polyamorous, etc.). In this issue we are thankful to have articles that represent a good mix in each of these areas of diversity.

As some of these areas of diversity have historically received more attention than others in the literature and by sex and relational therapists, I thought it helpful to include a few measures that therapists can make use of to self-assess (or use to assess trainees, students, and supervisees) in terms of where they may be on their awareness, knowledge, and skills (Kim, Cartwright, Asay, & D’Andrea, 2003) in relation to some of these areas that have received less attention. Thus, in relation to gender diversity, included is an co-editorial piece and related measure on cisgenderism, which is the ideology delegitimizes people’s own understanding of their gender and bodies (Ansara & Hegarty, 2012). And in relation to relational diversity, a co-editorial piece and measure regarding monogamism or the dominant belief that monogamy is the only legitimate relational orientation, which results in discrimination stemming from mononormativity (Blumer, Haym, Zimmerman, & Prouty, 2014), is included. With the inclusion of these measures a helpful suggestion for readers of this Special Issue on GSERD may be to first complete the measures before reading the articles and record one’s scores. And then to complete the measures again upon completion of the articles and see how one’s scores may have changed. In this way, readers have an opportunity to measure in real time their growth in relation to GSERD.

To close, I hope you find this Special Issue on GSERD both interesting and informative for yourself, your clinical and supervisory participants, and the everyday people in your life.

Special issue co-editorialCONTACT Y. Gavriel Ansara [email protected] Ansara Psychotherapy & Imanadari Counselling, Sydney, Australia

Cisgenderism measure¹

Purpose

Researchers are aware of the need to evaluate professional practice regarding minoritised populations, and that these evaluations can be part of effective interventions to address what some call “cultural malpractice” (Hall, 1997) and others consider a lack of cultural humility in one’s mental health practices (Tervalon & Murray-Garcia, 1998). Such cultural malpractice occurs when providers operate via a dominant colonial perspective, without regard for people’s myriad diverse cultural viewpoints.

One area where clinicians operate without cultural humility for diversity is with regard to gender. Indeed, colonially-based societies (e.g. United States (US), United Kingdom (UK), Canada), typically define gender based on particular “biological sex” characteristics and treat externally imposed gender/sex classifications (Carrera, DePalma, & Lameiras, 2012) as more authoritative than people’s own understanding. Within these societies, the presumed and dominant norm for gender is the “cisgender” norm of one’s gender being determined by one’s assigned at birth by external authorities. This view of gender perpetuates cisgenderism in clinical practice.

Cisgenderism is the ideology that invalidates or pathologizes people’s own understanding of their gender and bodies, where their gender identities and expressions are not typically associated with their assigned sex/gender category at birth (Ansara & Hegarty, 2012). Cisgenderism critiques both the ethnocentric functions of the cisgender gender binary and the “transgender/cisgender” gender binary (e.g. Ansara & Hegarty, 2014). In terms of ethnocentricity, in many societies, gender is not automatically presumed to correspond with particular anatomical attributes. Additionally, cisgenderism is not experienced solely by people who are labeled as “trans” by others, and thus can affect people with intersex characteristics, women with polycystic ovary syndrome, people dis-abled by society, and people who identify with non-binary gender identities.

Mental health providers are often the first port of call for people of trans and/or non-binary experience or identity. For instance, such providers often work with people of trans experience or identity—who constitute roughly 9.4% of the adult population of the US—and who are victims of hate crimes at disproportionate levels when compared to people of cisgender experience, and who experience higher than average rates of depression, anxiety, substance use, bullying, victimization, homelessness and suicidality largely due to stigma and discrimination (Grossman & D'Augelli, 2007). Despite these needs, helping professionals are not immune from the impact of cisgenderism (Blumer, Ansara, & Watson, 2013) and are often unprepared to affirmatively work with people of gender diverse experience (Goldberg, 2009).

We, Ansara, Twist, Miller, and VandenBosch (2014), developed the first psychometric tool to measure and evaluate cultural humility regarding gender diversity using a similar format to that of the measure of cultural competency by Kim, Cartwright, Asay, and D’Andrea (2003). Our measure consisted of 59 questions, 9 of which focused on demographics, and the remaining 49 questions were divided into three subscales—awareness, knowledge, and skills.

The Awareness Subscale of the cisgenderism measure (20 items) is aimed at measuring the level of awareness of cisgenderism of clinicians. Participants respond to a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree). Statements focus on legal, social, and cultural components of gender, as well as commonly held beliefs about gender, particularly in colonially based Western societies.

The Knowledge Subscale of the cisgenderism measure (14 items) is aimed at measuring the level of knowledge of cisgenderism of clinicians. Participants rank their knowledge of 14 items on a 4-point Likert scale (1 = very limited, 4 = very good). Various terms about types of genders such as gender binary, non-binary gender, transgender, agender, androgynous, polygender, genderqueer, and two-spirit, comprise the knowledge section. Cisgenderism, misgendering, and binarizing are also included, as well as terms like preferred gender pronoun.

The Skills Subscale of the cisgenderism measure (15 items) focuses on measuring the level of skills of clinicians to combat cisgenderism in practice. Participants rate their ability to perform a number of skills based on a 4-point Likert-type scale (1 = very limited, 4 = very good). Skills covered include: comfort level; appropriate use of gender pronouns; awareness of cisgender privilege and various assumptions; ability to use appropriate forms, assessments, and practices; advocate; and secure appropriate resources.

Development

We pilot tested the measure through pre-post testing. The first and second authors held a training aimed at reducing cisgenderism in practice (Ansara & Blumer, 2014). This training included 41 mental health counseling/family therapy students, faculty, staff, alumni, and community practitioners at a medium-sized Midwestern university in the spring of 2014.

Upon Institutional Review Board approval, participants completed a pre-post training measure that included demographics and focused on cultural humility related to measuring levels of cisgenderism, administered by the third author. The measure was completed in paper-pencil format at the beginning and end of the training. A factor analysis of the items of the measure as a whole (minus the demographics) from the training was conducted to see how well each item fit the subscale to which it was assigned. All of the items fit their respective subscale and were retained.

Response mode and timing

The instructions of the cisgenderism measure are as follows: “This measure is designed to obtain information on the participant’s awareness, knowledge and skills regarding cisgenderism in practice. The measure includes a list of statements and/or questions related to a variety of areas regarding cisgenderism. Please, read each statement/question carefully. From the available choices, select the one that best fits your reaction to each statement/question. Thank you in advance for your participation.” The cisgenderism measure typically takes between 13 and 18 min to complete.

Scoring

The Awareness Subscale contains 20 items, with all items reverse coded except items 5, 7, 9, 13, and 17. The highest possible score on the Awareness Subscale is 80, which indicates a high self-rated awareness of cisgenderism. The Knowledge Subscale contains 14 items, with all items coded as is. The highest possible score on the Knowledge Subscale, which indicates a high self-rated knowledge of cisgenderism, is 56. The Skills Subscale has 15 items, and all items are coded as is. The highest possible score on the Skills Subscale, which indicates high self-rated skills in managing cisgenderism, is 60. The three subscales can be used alone or summed for an overall score—with the highest possible summed score equaling 196.

Reliability

All three subscales have demonstrated high internal reliabilities. The Awareness Subscale demonstrated a Cronbach's alpha of α = .85. The Knowledge Subscale demonstrated a Cronbach's alpha of α = .96. The Skills Subscale demonstrated a Cronbach's alpha of α = .92.

Validity

The cisgenderism measure has demonstrated high face validity by report of the people who vetted the measure (which included the authors and graduate school level family and sex therapy trainees of the second author), as well as the pilot testing participants before and after attending the training. Paired t-tests compared the 41 pilot participants’ pre-post test means on each of the three subscales. There was a statistically significant moderate increase in Awareness, t(48) = −5.72, p < .001 (d = .40); a large increase in Knowledge, t(63) = 9.20, p < .001 (d = .91); and a medium increase in Skills, t(58) = −4.816, p < .001 (d = .54). There was a moderate effect on Awareness d = .40, a large effect on Knowledge d = .91, and a medium effect on Skills d = .54.

Cisgenderism measure

Instructions: This measure is designed to obtain information on the participant’s awareness, knowledge and skills regarding cisgenderism in practice. The measure includes a list of statements and/or questions related to a variety of areas regarding cisgenderism. Please, read each statement/question carefully. From the available choices, select the one that best fits your reaction to each statement/question. Thank you in advance for your participation.

Awareness

Table

At the present time, how would you rate your degree of agreement or disagreement with the following statements…	Strongly disagree	Disagree	Agree	Strongly agree
1. There are only two valid genders, woman and man.	1	2	3	4
2. A person with a uterus cannot be a man.	1	2	3	4
3. The best solution, when unsure of someone’s gender, is to avoid gender pronouns.	1	2	3	4
4. People of trans experience need psychotherapy to deal with their gender issues.	1	2	3	4
5. I am comfortable with a policy that allows a woman who was assigned as male at birth to use a woman’s bathroom in workplace, treatment, or school settings.	1	2	3	4
6. Intersex people need medical intervention to make their bodies appear normal.	1	2	3	4
7. People need access to medical services (e.g. hormones, surgical procedures, etc.) for gender affirmation.	1	2	3	4
8. I have the right to know whether one of my colleagues or peers has previously lived in a different gender.	1	2	3	4
9. My prospective romantic and/or sexual partners should not have to disclose to me that they have previously lived in a different gender.	1	2	3	4
10. Gender is conceptualized in similar ways across cultures.	1	2	3	4
11. When meeting new people, I can determine their preferred gender pronouns (he, she, etc.) by their voice and physical characteristics.	1	2	3	4
12. People who do not identify as women or men would be happier if they would pick one or the other.	1	2	3	4
13. I am comfortable with a man whose identity documents say female having access to all-male housing.	1	2	3	4
14. Being called “tranny,” on the street is not emotionally or psychologically harmful.	1	2	3	4
15. LGBTI people are not heterosexual.	1	2	3	4
16. Rix is a person whose physical characteristics are noted as intersex, and Mischel is a person of trans experience. Rix and Mischel’s medical, academic, and/or mental health needs are the same.	1	2	3	4
17. A student whose documents say Christina and female prefers to be called Jason and treated as a man. This student should be listed as Jason and described as he/him in school or treatment records.	1	2	3	4
18. People who undergo medical intervention to change their bodies go through a sex change.	1	2	3	4
19. Cisgenderism is an -ism that only trans people experience.	1	2	3	4
20. A woman who was assigned as male is “outside the gender binary.”	1	2	3	4

Knowledge

Table

At the present time, how would you rate your understanding of the following terms…	Very limited	Limited	Good	Very good
21. Gender binary	1	2	3	4
22. Assigned/administrative sex	1	2	3	4
23. Non-binary gender	1	2	3	4
24. Transgender/transexperience	1	2	3	4
25. Androgynous	1	2	3	4
26. Agender	1	2	3	4
27. Intersex	1	2	3	4
28. Polygender	1	2	3	4
29. Cisgenderism	1	2	3	4
30. Misgendering	1	2	3	4
31. Two-spirit	1	2	3	4
32. Genderqueer	1	2	3	4
33. Binarizing	1	2	3	4
34. Preferred gender pronoun (PGP)	1	2	3	4

Skills

Table

At the present time, how would you rate your ability to…	Very limited	Limited	Good	Very good
35. State your preferred gender pronouns when meeting new people.	1	2	3	4
36. Treat someone who appears visually female to you as a man.	1	2	3	4
37. Refrain from making the assumption that someone who presents as a particular gender was raised as that gender from birth.	1	2	3	4
38. Be supportive of the mental health needs of an individual whose gender is not typically associated with their assigned sex category, such as a woman who was assigned as male.	1	2	3	4
39. Effectively secure information and resources to better serve binary-identified women and men of trans experience.	1	2	3	4
40. Effectively secure information and resources to better serve people with non-binary genders, such as someone who identifies as genderqueer.	1	2	3	4
41. Effectively secure information and resources to better serve intersex people.	1	2	3	4
42. Provide culturally appropriate and informed support to someone with a culturally specific, non-binary gender, such as someone who identifies as kathoey, Bissu, calabai, calalai, Fa’affafine or Two-Spirit.	1	2	3	4
43. Be an advocate for those experiencing cisgenderism in their workplaces, schools, and/or families.	1	2	3	4
44. Be comfortable interacting with people who identify as a gender that is not typically associated with their physical characteristics.	1	2	3	4
45. Refrain from making assumptions about the nature of the relationship between people based on your perceptions of their genders.	1	2	3	4
46. Treat people in ways that are consistent with their own understanding of their gender and bodies.	1	2	3	4
47. Effectively and respectfully take responsibility for misgendering people.	1	2	3	4
48. Identify your own cisgenderist practices.	1	2	3	4
49. Design or adapt your forms and other paperwork to include and respect people of all genders (e.g. allow people to select their own gender(s) rather than assigning gender categories or options).	1	2	3	4

Special issue co-editorialCONTACT Markie L. C. Twist [email protected] Human Development and Family Studies Department, University of Wisconsin-Stout, Menomonie, WI, USA

Monogamism measure¹

Purpose

Relational orientation refers to an enduring pattern of romantic and/or sexual attraction in the form of monogamy, non-monogamy (consensual or non-consensual), or both monogamy and non-monogamy (e.g. monogamish, open relationship) (Blumer, Haym, Zimmerman, & Prouty, 2014; Davis, 2011). As with many orientations, people identify on a continuum.

In Western cultures monogamy is the presumed norm and thereby, the dominant relational orientation. People identifying outside of a monogamous can be considered a relational orientation minority (Blumer et al., 2014). Rates of people in the United States engaging in consensual non-monogamy (CNM) at some point in their life range from 5.3% to 20% (Rubin, Moors, Matsick, Ziegler, & Conley, 2014). Multi-partnered individuals and relational systems often experience monogamism,

the dominant belief that monogamy is the only legitimate relational orientation, which results in discrimination stemming from mononormativity (Blumer et al., 2014).

Discrimination may lead CNM individuals and systems to seek services from mental health providers. It is important for providers to recognize the role of monogamous privilege (Davis, 2011) and the negative effects of mononormative assumptions within society, as well as in their own clinical practices (Blumer, 2014). Schechinger (2016) reported that 73% of relational orientation minority clientele specified the most unhelpful clinical practice experienced from providers was judgment or pathologizing of CNM.

We, Twist, Prouty, Haym, and VandenBosch (2014), developed a measure of cultural sensitivity towards relational orientation minorities modeled after the measure of cultural competency by Kim, Cartwright, Asay, and D’Andrea (2003). Kim et al.’s (2003) measure is used to measure a provider’s level of racism on subscales of awareness, knowledge and skills. Our instrument measures a provider's level of monogamism on subscales of awareness, knowledge, and skills. Our original survey consisted of 47 items, reduced to 40 items by factor analysis for the final scale, and is divided into three subscales—awareness, knowledge, and skills.

The Awareness Subscale of the monogamism measure (14 items) is aimed at measuring the level of awareness of monogamism of clinicians. Participants respond to a 4-point Likert scale (1 = strongly disagree, 4 = strongly agree). Statements focus on legal, social, and cultural components of relational orientation and common beliefs about the benefits and downfalls of CNM.

The Knowledge Subscale of the monogamism measure (12 items) is aimed at measuring the level of knowledge of monogamism of clinicians. Participants rank items on a 4-point Likert scale (1 = very limited, 4 = very good). Various terms connected to relational orientation, such as CNM, open relationship, plural marriage, multi-partnered relationships, relational orientation, polyamory, polygyny, and swinging, comprise the knowledge section.

The Skills Subscale of the monogamism measure (17 items) focuses on measuring the level of skills of clinicians to combat monogamism in practice. Participants rank their ability to perform skills on a 4-point Likert-type scale (1 = very limited, 4 = very good). Skills covered within this section include: level of comfort; awareness of monogamous privilege and related assumptions; appropriate use of forms, assessments, and practices; advocacy; and securing effective resources.

Development

We pilot tested the measure through pre-post testing. The first author held a training aimed at increasing cultural sensitivity and reducing monogamism in practice (Blumer, 2014). This training included 30 mental health counseling/family therapy students, faculty, staff, alumni, and community practitioners at a medium-sized Midwestern university in the fall of 2014.

Institutional Review Board approval was obtained. Participants completed a pre-post training measure that included demographics and focused on cultural sensitivity related to measuring levels of monogamism, administered by the fourth author. The measure was taken in paper-pencil format at the beginning of the training and again upon completion of the training.

Following initial pilot testing, the measure was administered pre-post at a national training aimed at reducing monogamism in practice (Twist, Haym, Iantaffi, & Prouty, 2015). A factor analysis of the items of the measure as a whole (minus the demographics) from the trainings combined (n = 42) was conducted. Thus, the final monogamism measure contains a total of 40 questions—13 items on the Awareness Subscale, 13 items on the Knowledge Subscale, and 14 items on the Skills Subscale.

Response mode and timing

The instructions of the monogamism measure are as follows: “This measure is designed to obtain information on the participant’s awareness, knowledge and skills regarding monogamism in practice. The measure includes a list of statements and/or questions related to a variety of areas regarding monogamism. Please, read each statement/question carefully. From the available choices, select the one that best fits your reaction to each statement/question. Thank you in advance for your participation.” The monogamism measure typically takes between 10 and 15 min to complete.

Scoring

Using the Likert-type scale responses, two of the subscales—Knowledge and Skills—are additive with no need for reverse-scoring of any item. The highest possible score on the Knowledge subscale, which indicates a high level of knowledge of monogamism, is 52. The highest possible score on the Skills subscale, which indicates a high level of skills in managing monogamism, is 56. The Awareness subscale consists of 13 items. Items 1, 4, 8, 9, 11, and 12 must have their scores reversed prior to adding the 13 items. The highest possible score on the Awareness subscale is 52, indicating a high level of awareness of monogamism. The three subscales can be used alone or summed for an overall score–with the highest possible summed score equaling 160. Overall, high scores reflect low monogamism and high cultural sensitivity.

Reliability

The internal reliabilities of each of the final subscales were high. The Awareness subscale demonstrated a Cronbach’s alpha of α = .89. The Knowledge subscale demonstrated a Cronbach’s alpha of α = .96. The Skills subscale demonstrated a Cronbach’s alpha of α = .96.

Validity

The monogamism measure has demonstrated high face validity by report of the people who vetted the measure (including the authors and doctoral level family therapy trainees of the second author), as well as the pilot testing participants before and after attending workshops. Paired t-tests compared the 30 original pilot participants’ pre-posttest means on each of the three subscales. Participants’ post-test scores did not improve significantly from their pre-test scores on the Monogamism Awareness Subscale (pretest M = 50.46, posttest M = 51.97; t(28) = −1.75, p =.09); but their scores did significantly improve on both the Monogamism Knowledge Subscale (pretest M = 36.28, posttest M = 46.21; t(28) = −7.26, p < .0001), and Monogamism Skills Subscale (pretest M = 30.92, posttest M = 35.33; t(27) = −5.95, p < .0001).

Monogamism measure

Instructions: This measure is designed to obtain information on the participant’s awareness, knowledge and skills regarding monogamism in practice. All responses are confidential. The measure includes a list of statements and/or questions related to a variety of areas regarding monogamism. Please, read each statement/question carefully. From the available choices, select the one that best fits your reaction to each statement/question. Thank you in advance for your participation.

Awareness

Table

At the present time, please rate your degree of agreement or disagreement with the following statements…	Strongly disagree	Disagree	Agree	Strongly agree
1. Marriage is conceptualized in virtually the same way across cultures.	1	2	3	4
2. I am comfortable with a law that enables more than two consenting adults to marry each other.	1	2	3	4
3. Aaliyah moved from Kenya with her two husbands, and her marriage to both men should be legally recognized in the U.S. or Canada.	1	2	3	4
4. Romantic relationships involving more than two people are inherently harmful to all of the individuals involved.	1	2	3	4
5. Multi-partner-headed families are more similar to than different from two-person-headed families.	1	2	3	4
6. I am comfortable with multi-parents having the same parenting rights as two parents.	1	2	3	4
7. Legal benefits accorded dyadic relationships should also apply to multi-partnered relationships.	1	2	3	4
8. Calling someone a “polyg” is not emotionally or psychologically harmful.	1	2	3	4
9. Polyamorous relationships are unstable and work better in theory than in practice.	1	2	3	4
10. I am comfortable with a policy that allows Sarah and Mary, who are both spiritual wives of Zachary, to be able to visit him during his hospital stay.	1	2	3	4
11. People who are in polygamous relationships would be happier if they were in monogamous relationships.	1	2	3	4
12. Having a sexual relationship with more than one consenting adult at the same time is considering infidelity or cheating.	1	2	3	4
13. Having more than one legal adult spouse or partner for religious or spiritual reasons should be a right in the U.S. and Canada.	1	2	3	4

Knowledge

Table

At the present time, please rate your understanding of the following terms…	Very limited	Limited	Good	Very good
14. Consensual non-monogamy	1	2	3	4
15. Mononormativity	1	2	3	4
16. Open relationship	1	2	3	4
17. Plural marriage	1	2	3	4
18. Multi-partnered relationships	1	2	3	4
19. Polyamory	1	2	3	4
20. Polyandry	1	2	3	4
21. Polygamy	1	2	3	4
22. Polygyny	1	2	3	4
23. Relational orientation	1	2	3	4
24. Swinging	1	2	3	4
25. Monogamism	1	2	3	4
26. Monogamous privilege	1	2	3	4

Skills

Table

At the present time, please rate your ability to…	Very limited	Limited	Good	Very good
27. Not assume that someone who presents for couples therapy has only one partner.	1	2	3	4
28. Assess the mental health needs of an individual who identifies with a non-monogamous relational orientation.	1	2	3	4
29. Be comfortable interacting with a multi-partnered family.	1	2	3	4
30. Identify the strengths and weaknesses of psychological tests in terms of their use with clients identifying with a minority relational orientation.	1	2	3	4
31. Effectively secure information and resources to better serve people who have a non-monogamous relational orientation.	1	2	3	4
32. Identify instances of monogamism in your clinical practice.	1	2	3	4
33. Design or adapt your forms and other paperwork to include and respect people of all relational orientations.	1	2	3	4
34. Not assume that a person I am working with has either a single parent or two parent/s.	1	2	3	4
35. Effectively secure information and resources to better serve people in multi-partnered families.	1	2	3	4
36. Effectively and respectfully take responsibility for engaging in mononormative practices.	1	2	3	4
37. Treat people in ways that are consistent with their own understanding of romantic and/or sexual relationships.	1	2	3	4
38. Inquire about a person’s relational orientation in a manner that is effective and respectful.	1	2	3	4
39. Refrain from making assumptions about the nature of the relationship between people based upon your own perceptions of relationships and families.	1	2	3	4
40. Be comfortable interacting with people who identify as polyamorous.	1	2	3	4

Note

Notes

1 The development of this measure was in part made possible through the following grant funding source of the second author—(1) 2014–2015 Student Research Support Initiative, University of Wisconsin-Stout, College of Education, Health, and Human Sciences, and the second and fourth author—(2) 2013 Professional Development Grant, University of Wisconsin-Stout.

1 The development of this measure was in part made possible through the following grant funding sources of the first author—(1) 2013–2014 Research Support Grant from University of Wisconsin-Stout, College of Education, Health, and Human Sciences, and (2) 2014–2015 Student Research Support Initiative, University of Wisconsin-Stout, College of Education, Health, and Human Sciences.