A Sexual Wellbeing Framework to Address Sexuality in Therapy with Transgender, Nonbinary, and Gender Expansive Clients

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Table 1. Principles of the applied sexual wellbeing approach.

Component of sexual wellbeing approach	Summary	Intervention strategies
Principle #1: Consider the cultural context and intersections of marginalized identities (race, gender, sexual orientation, ability, etc.)	Sexual wellbeing is situated in a cultural context and is influenced by one’s identities and social locations. Access to material resources shapes sexual autonomy and an individual’s options for safe and pleasurable sexual experiences.	Engage in reflexivity and critical self-evaluation; Educate self about unfamiliar cultural contexts; Initiate discussions about clinician/client identities in a way that is relevant and beneficial to the client; and Ask questions about positive and negative messages received about sexuality from culture, family, religion, education, friends, and community.
Principle #2: Appreciating individual variation in the factors that contribute to sexual wellbeing	Sexual wellbeing is dynamically shaped by multiple biological, psychological, social, and cultural factors and includes all aspects of sexuality. The specific contributions to sexual wellbeing vary across people (e.g., some value sexual pleasure, others do not).	1. Avoid generalizing own sexuality experience to client and/or client’s experience to those of all TNBGE clients; 2. Work together to help client understand what sexual wellbeing means to them; and 3. Identify factors contributing to client’s contentment with their sexual life.
Principle #3: Understanding sexual wellbeing as a fluctuating state, rather than a static endpoint	Sexual wellbeing is not static but is constantly shaped by individuals’ sexual and daily experiences over time.	1. Help client identify how their sexual wellbeing has changed over time; and 2. Discuss with clients how they feel about their sexuality across different situations, sexual experiences, and with different partners.
Principle #4: Nonjudgmental discussion and assessment of sexual experiences and behaviors	No consensual sexual behavior or experience is considered healthy or unhealthy in and of itself. The behavioral and emotional consequences determine whether a sexual behavior or experience is adaptive for that specific individual, at that specific moment in time.	1. Replace euphemisms with specific and gender affirming language; 2. Avoid judgmental language and evaluations about whether a sexual behavior or experience is "good" or "bad;” 3. Differentiate and distance the work in therapy from clinician’s sexual values; and 4. When concerned about a specific sexual behavior or experience, evaluate what the client gains from that behavior, assess client’s subjective evaluations of the behavior or experience, and assess client’s sexual values.
Principle #5: Countering sexual and gender-based stigma and recognizing sexual resilience	Binary gender bias shapes how we view sexuality, act during a sexual experience, and interact with others. TNBGE individuals face stigma and gender binary bias in their daily and sexual lives, as well as in therapy.	Engage in reflexivity around gender bias; Repair when microaggressions or other ruptures occur; and Assess client strengths and protective factors including community connectedness, pride in racial, gender, and sexual orientation identities, support systems, meaningful prior or current relationships (romantic, sexual, and non-sexual), and what client currently values in their sexual life
Principle #6: Expanding understanding of sexual orientation identity	Sexual orientation labels are often used as proxies to convey information about sexual experiences. Traditional sexual orientation labels are also limiting for many TNBGE clients.	Ask clients about their experience of their sexual orientation identity, considering whether "confusion" is simply a product of the limitations of traditional sexual orientation labels and language; abd If important to client, assist with exploring and expanding client’s understanding of sexual orientation identity.
Principle #7: Recognizing sexual fluidity	Sexual orientation, sexual desires, sexual attractions, and relationships can shift over time and across situations for some individuals. This type of change is normative and does not represent that the client is "confused." The cause of fluidity is unknown and likely to be multiply determined.	Assess changes in attractions, desires, behaviors, and relationships over time and across situations; and Provide psychoeducation about sexual fluidity, recognizing that change does not occur from a single factor, particularly for clients distressed about experienced changes.
Principle #8: Identifying that genitals and hormones are just one of many inputs involved in sexual responses and pleasure	Hormones are often assumed to determine sexual functioning and genitals are often perceived as the primary organ associated with the sexual response. This overemphasis on hormones and genitals has not been supported by research. From a sexual wellbeing framework, both genitals and hormones are important but only two myriad factors that contribute to sexual pleasure, sexual functioning, and the sexual response.	Critically challenge beliefs that genitals are the only organ involved in sexual experiences; Avoid asking about genitals and functioning based on clinicians’ curiosity that lack relevance for understanding of TNBGE sexuality (“how exactly do you use your genitals during sex?”); and Use horizontaling interventions to enhance pleasure and comfort: expanding the field of awareness to the body as a whole (rather than on genitals alone).
Principle #9: Decentering orgasm as the predominant means of sexual pleasure	When orgasm is viewed as the means of sexual pleasure, sexual activity becomes goal-centered. Decentering the focus from orgasm enables individuals to feel increased pleasure and comfort.	Use horizontaling interventions: attending to the moment-by-moment experiences of sexual pleasure, expanding the field of awareness to the body as a whole, mindfulness interventions (focusing on immersive, rather than observatory attention); and Engage in sexual exploration, focusing on promoting pleasure and comfort rather than obtaining an orgasm.
Principle #10: Assessing sexual comfort and sexual pleasure	Sexual pleasure and comfort are often overlooked in favor of focusing conversations on sexual safety, though discussions about sexual pleasure can help to enhance sexual wellbeing. Many TNBGE folks do not experience dysphoria during sexual experiences, but some do.	Assess, but avoid assuming, presence of body or genital dysphoria during sexual activity; Assess differences between partnered and solitary sexual experiences; and Encourage masturbation as a safe way to explore ways to be sexual that feel affirming and increase comfort with sexuality, provided that masturbation is pleasurable for the client.
Principle #11: Promoting immersive, participatory attention in sexual experiences	Plethora of research suggests that sexual pleasure and sexual responses depend on a specific form of attention: to become fully immersed in the experience.	When exploring a new sexual strategy, ensure client first experiments in a safe context in which gender affirmation is more likely (e.g., masturbatory contexts if anxiety with partners is probable); Teach mindfulness of sexual sensations in a safe environment; cultivate immersive, participatory attention (rather than observatory attention); Consider use of fantasy to promote engagement with sensations and psychological experiences of pleasure; and Explore other sexual experiences that can heighten flow during sexual activity (examples familiar to clients include tantric sex, BDSM, viewing gender affirming sexual imagery, etc.).
Principle #12: Facilitating sexual experiences that are gender affirming	Gender affirmation is critical for sexual wellbeing. Among TNBGE folks who experience dysphoria during sexual experiences, alleviating dysphoria by facilitating gender affirming sexual experiences may enhance clients’ overall wellbeing.	Refer clients to resources related to sexual material that is not pathologizing or fetishizing of TNBGE people; Use of gender affirming fantasies; Renaming genitals and/or cultivating gender affirming language during "sex talk" to promote gender affirmation; and Explore different contexts, behaviors, and forms of touch that promote gender affirmation, and support sexual exploration in safe and affirming contexts.
Principle #13: Cultivating freedom for sexual exploration	Sexual exploration has been shown to improve sexual satisfaction and sexual wellbeing. Leverage solitary experiences to promote gender affirming sexual experiences.	Assess what clients want in their sexual lives, allow client to explore sexuality and novel sexual experiences without judgment; and Leverage safe and affirming partnerships or comfort with masturbation to explore sexual desires, fantasies, needs, wants, and affirming ways of touching and sensing.
Principle #14: Consent as a means to balance sexual safety and sexual pleasure	Models of consent have shifted according to policy and based on research. Consent should be conceptualized as a process embedded within a social and gendered context and consent processes differ across relationships, people, and situations. From our sexual wellbeing framework, consent should be viewed as a means to ensure the balance between sexual safety and pleasure.	Enhance partner communication, and practice asking for needs; Help client distinguish willingness from desire and wanting sexual activity; Help client recognize anti-trans stigma in dating contexts, discuss gender socialization and impact on consent and sexual safety, and cultivate ways to enhance sexual safety; and If relevant, provide psychoeducation on consent as a process that should be negotiated, rather than something that is implicit and assumed.