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

Although most clinicians believe that discussing sexuality is important clinically, most clinicians do not initiate these discussions. Further, for therapists working with transgender, nonbinary, and gender expansive (TNBGE) clients, discussing sexuality may feel challenging when therapists fear inadvertently stigmatizing or mischaracterizing their clients and their concerns. We propose a sexual wellbeing framework as an adjunctive to traditional feminist therapy, in which discussions about sexuality is comfortable and appropriate to the goals of therapy. We review existing evidence that suggests sexual wellbeing of TNBGE clients may be enhanced by (a) attending to the client's larger sociocultural context in which sexual wellbeing emerges, (b) understanding that sexual wellbeing is multiply determined, the contributing factors to sexual wellbeing are unique for each person, and sexual wellbeing changes over time and across situations, (c) challenging assumptions that genitals, hormones, and sexual functioning are the most important aspects of sexual wellbeing, (d) emphasizing sexual comfort and pleasure by enhancing immersive attention and facilitating gender affirming sexual experiences, and (e) conceptualizing consent as a means to ensure safe and pleasurable experiences. We conclude by offering clinical scenarios that present practical considerations when applying the sexual wellbeing framework to illustrate the ways in which conversations with TNBGE clients about sexuality can enhance sexual wellbeing.