A Dissertation Entitled Exploring the Relationship Between

A Dissertation

entitled

Exploring the Relationship Between Independently Licensed Counselor Identity Factors and

Human Sexuality Competencies

Meagan McBride

Submitted to the Graduate Faculty as partial fulfillment of the requirements for the

Doctor of Philosophy Degree in

Counselor Education

______Christopher P. Roseman, Ph.D., Committee Chair

______Madeline E. Clark, Ph.D., Committee Member

______John M. Laux, Ph.D., Committee Member

______Jennifer L. Reynolds, Ph.D., Committee Member

______Amanda Bryant-Friedrich, PhD, Dean College of Graduate Studies

The University of Toledo

July, 2018

This document is copyrighted material. Under copyright law, no parts of this document may be reproduced without the expressed permission of the author. An Abstract of

Exploring the Relationship Between Independently Licensed Counselor Identity Factors and

Human Sexuality Competencies

Meagan McBride

Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Doctor of Philosophy Degree in Counselor Education

The University of Toledo

July, 2018

Human sexuality is a profound and multifaceted psychosocial component of the human condition that is universally experience. As such, it is an inevitability that issues related to sexuality will come up in counseling; however, there is a lack of scientific-based sex education in K-12 schools. Additionally, there is no requirement, except for in two states, for students in mental health counseling programs to complete a course on human sexuality. This quantitative study aimed to explore current practicing counselors’ knowledge, skills, attitudes, and comfort in addressing sexuality concerns with clients. Participants were gathered from current list serves serving counselors nationwide via online survey requests. Using a demographic sheet and the

Knowledge, Comfort, Approach, and Attitude towards Sexuality Scale (KCAASS), a hierarchical multiple regression was run to identify whether counselor demographic area of practice is a significant predictor of KCASS score. Clinical and educational implications as well as future research were discussed. The results of this study provided implications for counseling practice, counselor education, and supervision.

Keywords: human sexuality, counseling, sex education

iii For my dad, my sister, my kids, and my lobster. Riley, thank you for being my foundation and always taking care of your girls, I will continue to work to be half the parent you are. Hillary, there is nothing better than being your little sister, and no greater sister than you. Love you hunyeah! Madison and Marshall, you have made me stronger, more adventurous, and braver than ever. I love you both to the moon and back, thank you for all the times you encouraged me to keep going. Dan, your support and sacrifice are how we survived (not just because you fed us!), thank you. 30+.

iiii Acknowledgments

This dissertation is a culmination of not only this research, but an entire program, and the development of a counselor educator. None of this would be possible without the guidance, mentoring, and support of Dr. Christopher Roseman. Thank you for recruiting me, mentoring me, and pushing me. Through your example, the challenges you presented me with, and your high expectations you have led me to new heights. To Dr. Clark, who both insisted on research rigor and gave me the tools and guidance to deliver, thank you for expecting greatness. To Dr.

Laux, who pushed me to ask questions from a different angle and allowed me space to explore.

And Dr. Reynolds, who has provided continued support, guidance, and patience. I am humbled to have had you all as my dissertation committee and as mentors, advisors, and leaders.

Enormous and unending thanks to Ms. Sue Martin, who made even the hardest of days brighter. The members of my cohort, for the laughs, the lunches, and the shared space of the GA office. To the (soon-to-be-Dr.) Kaitlyn Forristal for being “my person” for the last three years, feeding me when I forgot to eat, and countless late-night conversations. To Dr. Katie Gamby for keeping me grounded and for the most amazing hugs. Also to all of those who walked this journey before me and with me. And finally, to Dr. Jared Rose, who inspired me long before I began this journey and has been a constant support and role model. I am forever changed through all of you.

Table of Contents

Abstract ...... iii

Table of Contents ...... v

Chapter 1 ………...... 1

1.1 Introduction ...... 1

1.2 Background of the Problem ...... 2

1.3 Purpose of the Study ...... 5

1.4 Significance of the Study ...... 6

1.5 Research Questions & Hypotheses ...... 7

1.5.1 Research Question One ...... 7

1.5.1.1 Null Hypothesis One ...... 7

1.5.1.2 Research Hypothesis ...... 7

1.5.2 Research Question Two ...... 8

1.5.2.1 Null Hypothesis Two ...... 8

1.5.2.2 Research Hypothesis ...... 8

1.5.3 Research Question Three ...... 8

1.5.3.1 Null Hypothesis Three ...... 8

1.5.3.2 Research Hypothesis ...... 9

1.5.4 Research Question Four ...... 9

1.5.4.1 Null Hypothesis Four ...... 9

1.5.4.2 Research Hypothesis ...... 9

1.5.5 Research Question Five ...... 10

1.5.5.1 Null Hypothesis Five ...... 10

1.5.5.2 Research Hypothesis ...... 10

1.5.6 Research Question Six ...... 10

1.5.6.1 Null Hypothesis Six ...... 10

1.5.6.2 Research Hypothesis ...... 10

1.6 Study Definition of Terms ...... 11

1.6.1 Human Sexuality ...... 11

1.6.2 Sex Education ...... 11

1.6.3 Urban ...... 11

1.6.4 Suburban ...... 11

1.6.5 Rural ...... 12

Chapter 2 …………...... 13

2.1 Literature Review ...... 13

2.2 Essential facets of Human Sexuality ...... 13

2.3 History of Human Sexuality Education in America ...... 15

2.3.1 Professional Ethics and Standards ...... 14

2.3.2 History……...... 16

2.3.3 (1800s) ...... 16

2.3.4 (1900s) ...... 16

2.3.5 Progressive Era ...... 17

2.3.6 Modern Day ...... 18

vii

2.4 National Demographics on Sex Education in Schools ...... 19

2.4.1 Parents as Educators ...... 21

2.4.2 Health Care Providers ...... 22

2.4.3 Digital Media ...... 23

2.5 Human Sexuality Outcomes ...... 24

2.5.1 Physical Health ...... 24

2.5.2 Mental Health ...... 26

2.6 Counselor Education Programs Human Sexuality Requirement ...... 27

2.6.1 How counselor education programs prepare students to address ......

issues related to human sexuality...... 29

2.7 Impact of Counselor Geographic Location ...... 31

2.8 Defining Urban, Suburban, and Rural Geographic Locations ……………...33

2.8.1 Impact of rural geographic location ...... 34

2.8.2 Ethical Issues in rural Counseling ...... 36

2.8.3 Barriers to Mental Health Treatment ...... 37

2.9 Knowledge, Skills, Attitudes, and Comfort with Human Sexuality Scale .....38

Chapter 3 ...... 40

3.1.1 Research Design ...... 40

3.1.2 Participants ...... 42

3.1.3 Sampling Procedure ...... 43

3.2 Instrumentation ...... 43

3.2.1 KCASS ...... 44

viii

3.2.2 Demographic Questionnaire ...... 47

3.2.2.1 Age ...... 47

3.2.2.2 Gender ...... 49

3.2.2.3 Sexual identity ...... 49

3.2.2.4 Geographic location of origin ...... 49

3.2.2.5 Geographic location of practice ...... 49

3.2.2.5 Geographic location of residence ...... 49

3.2.2.6 Spiritual Identity ...... 49

3.2.2.7 Number of human sexuality courses taken ...... 50

3.3 Data Cleaning ...... 50

3.3.1 Assumption Testing ...... 53

3.3.1.1 Hierarchical Linear Regression (HLR) ...... 53

3.3.1.2 Factorial Analysis of Variance (ANOVA) ...... 54

3.4 Data Analysis ...... 54

Chapter 4 ...... 57

4.1 Results ...... 57

4.1.1 Research Question and Hypotheses ...... 57

4.1.2 Research Question One ...... 57

4.1.2.1 Null Hypothesis One ...... 57

4.1.2.2 Research Hypothesis ...... 57

4.1.3 Research Question Two ...... 58

4.1.3.1 Null Hypothesis Two ...... 58

4.3.3.2 Research Hypothesis ...... 58

4.1.4 Research Question Three ...... 58

4.1.4.1 Null Hypothesis Three ...... 59

4.1.4.2 Research Hypothesis ...... 59

4.1.5 Research Question Four ...... 59

4.1.5.1 Null Hypothesis Four ...... 60

4.1.5.2 Research Hypothesis ...... 60

4.1.6 Research Question Five ...... 60

4.1.6.1 Null Hypothesis Five ...... 60

4.1.6.2 Research Hypothesis ...... 61

4.1.7 Research Question Six ...... 61

4.1.7.1 Null Hypothesis Six ...... 61

4.1.7.2 Research Hypothesis ...... 61

4.2 Variables of Interest ...... 62

4.2.1 KCASS ...... 62

4.2.2 Demographic Variables ...... 63

4.2.3 Correlations Between Variables of Interest ...... 63

4.3 Research Question One ...... 64

4.3.1 Regression One ...... 65

4.4 Research Question Two ...... 68

4.4.1 Regression Two ...... 69

4.5 Research Question Three ...... 73

4.5.1 Regression Three ...... 74

4.6 Research Question Four ...... 77

4.6.1 Regression Four ...... 78

4.7 Research Question Five ...... 81

4.7.1 Regression Five ...... 82

4.7 Research Question Six ...... 85

4.8 Summary ...... 85

Chapter 5 ………...... 86

5.1 Discussion ...... 86

5.2 Review of Study ...... 86

5.3 Major Findings ...... 87

5.4 Implications for the Counseling Practice ...... 90

5.5 Implications for Counselor Education and Supervision ...... 91

5.6 Study Limitations ...... 92

5.7 Recommendations for Future Research ...... 93

5.8 Conclusion ...... 94

References ...... 96

A Knowledge, Comfort, Approach, and Attitudes Towards Sexuality Scale (KCAASS)

...... 113

B KCAASS (Modified) ...... 117

C Demographic Questionnaire ...... 120

D Informed Consent ...... 121

E Call for Participants ...... 122

Chapter 1

Introduction

Human sexuality, the compilation of characteristics that identify and convey the sexual nature of an individual, is one of the most profound psychosocial factors in an individual’s life

(Kazukauskas & Lam, 2010). Human sexuality is an important area of concern, and counseling competency and comfort in relation to this must be more readily understood. The purpose of this research, therefore, was to investigate counselors’ knowledge, comfort, approach and attitude in addressing sexuality concerns with their clients. This study intended to examine the effect of demographic information on composite Knowledge, Comfort, Approach, and Attitude towards

Sexuality Scale scores. Despite its significance, counselors often approach this topic with caution or avoid it altogether during the counseling process (Parritt & O’Callaghan, 2000; Southern &

Cade, 2011). In spite of this degree of discomfort with the topic, counselors need to work through their individual and cultural discomfort about sexual topics in order to best serve their clients.

A quantitative survey design is the best choice for this study because a qualitative design would not have allowed for the inclusion of as many participants across a large geographic span, increasing generalizability. The researcher used a cross-sectional survey design (Creswell, 2012) and analyzed the data through a hierarchical multiple linear regression in order to determine how much of the variance in counselors’ composite scores on their KCAASS was accounted for by their geographic locations after controlling for age, gender, spiritual identity, sexual identity, and number of human sexuality courses completed. The composite score on the KCAASS scale was the dependent variable.

Background of the Problem

Searches within academic research have not yielded many results regarding sex education prior to 1900, as little was written about sex education before this time (Pearsall, 2001). Sex education in public schools prior to 1900 was not a consideration because sex and the various components therein were not considered appropriate topics for the school environment (Kaslow,

2006). As culture and society progressed, schools moved towards a “family life education” paradigm in the 1960s, just before the “free love” era of the 1970s (Huber & Firmin, 2014). After the introduction of the birth control pill, abortion education, and government funding for sexual education, there has been a large push from the 1980s until now to return to abstinence-only sex education (Kaslow, 2006). This remains a controversial topic across the country, which impacts thousands of students and future counselors.

The American Public Health Association (APHA, 2014) asserted that all young people require certain knowledge, attitudes, and skills in order to avoid unintended pregnancy, sexually transmitted infections, and HIV, as well as to develop as sexually healthy adults. As of April

2017, according to the Guttmacher Institute, 24 states mandate sex education; of those, 22 require sex education and HIV education, and two mandate only sex education. Thirteen states require that this instruction be medically accurate. Eight states require that the program must give instruction that is “appropriate for the student’s cultural background and not be biased against any race, sex, or ethnicity” (Sexuality Information and Education Council of the United

States [SIECUS], 2015) When sex education is taught, 26 states require the classes to stress abstinence, 13 states require discussion of sexual orientation, nine of those states require that this discussion be inclusive, and four states require only negative information be disseminated about sexual orientation when sex education is taught. The absence of sexual education in the K-12 setting not only creates potential for harm and risk factors for youth and adolescents, it means

that future clinicians could be entering their counseling program without ever having received scientifically based sex education.

Courses such as Life Span Development and Multicultural Issues in Counseling integrate some issues of human sexuality in their curriculum; however, unless a student takes human sexuality or similar courses in their undergraduate degree, it is entirely possible that upon completion of their degree and licensure, a student could have never received accurate, comprehensive, or science-based human sexuality education prior to seeing clients.

Crockett, Shanahan, and Jackson-Newsom (2000) stated that the rural-urban distinction is an important social category. This distinction acts as the basis for self-definition and community identity, with important implications for the socialization of urban versus rural youth. Some researchers have posited that community identity and attitudes regarding sexuality hinders counselors’ ability to work with clients with issues related to sexuality (Bloom, Gutierrez, &

Lambie, 2015); however, how this demographic impacts counselor’s knowledge, attitudes, and comfort with sexuality has not previously been explored. There is a disparity between sex education in rural and urban settings, schools, and communities. Each of these factors have previously been connected to impacting attitudes, beliefs, behaviors, and pregnancy rates in these settings (Carter & Spear, 2002).

There is a lack of research on the high-risk sexual behaviors of rural adolescents in comparison to those of urban adolescents (Blinn-Pike, 2008). It is often difficult to conduct research and explore pregnancy-prevention and disease-prevention programs in rural schools due to limited access, protected subjects (pregnant women, youth), and lack of participation

(Crockett et al., 2000). The dearth of literature around these issues accentuates the need to conduct more research in rural areas. Researchers have noted the following areas for future

studies: the lack of information on the sexual attitudes and behaviors of rural adolescents; the difficulty rural professionals face when attempting to use school-based prevention curricula; and the lack of available adolescent sex education that have been shown to be effective, valid, and reliable with rural adolescents (Crockett et al., 2000). It is, therefore, imperative that professional counselors understand the impact of rural area of practice on counselors’ paradigms around human sexuality.

Distinct from sex as an act, sexuality is a multidimensional topic encompassing the biological, psychological, and sociocultural dimensions that influence one’s experiences, expressions, and perceptions (Molina, 1999). SIECUS (2015) has defined human sexuality as encompassing individuals’ sexual knowledge, beliefs, attitudes, values, and behaviors. The various dimensions of sexuality include the anatomy, physiology, and biochemistry of the sexual response system; identity, orientation, roles, and personality; and thoughts, feelings, and relationships. The expression of one’s sexuality is influenced by ethical, spiritual, cultural, and moral concerns (SIECUS, 2015).

Several researchers have posited that a professional’s community identity and attitudes regarding sexuality hinders his or her ability to work with clients with issues related to sexuality

(Bloom et al., 2015). The ways in which geographic, or community, demographics impact counselor’s knowledge, attitudes, and comfort with sexuality have not previously been explored.

It is important to study rural educators’ community identities as part of a larger effort to understand the attitudes and behaviors of rural youth (Gibbs, 1995). Researchers have largely ignored the health behaviors of rural adolescents. The factors that influence sexual behaviors among rural adolescents are not well understood, and the knowledge of how adults feel about

school-based sex education has been obtained nearly exclusively from urban samples (Blinn-

Pike, 2008).

While some scholars have explored the difficult ethics surrounding counseling in rural areas, there has been limited research on rural counselors. Rural professionals who work with adolescents’ decisions about sex education in their schools may be driven—at least in part—by social and cultural myths that life in rural areas is better than in urban areas (Bell, 1992). Blinn-

Pike (2008) stated that rural professionals may believe that rural youth are less at risk for pregnancy and disease because of the positive characteristics often attributed to rural families and communities, such as greater religiosity, reduced exposure to violence and illegal substances, and closer family ties. In this study, the researcher explored whether counselors’ geographic locations are a significant predictor of their KCAASS score.

Purpose of the Study

The purpose of this quantitative study was to explore if there is a relationship between practicing counselors’ knowledge, comfort, approach and attitudes in addressing sexuality concerns with clients and their geographic location. Components of human sexuality are universal to the human condition and are thus an inevitability in the counseling setting

(Kazukauskas & Lam, 2010; Parritt & O’Callaghan, 2000; Southern & Cade, 2011). The ACA

Code of Ethics preamble includes the following statement as it relates to multicultural practices in counseling: “honoring diversity and embracing a multicultural approach in support of worth, dignity, potential, and honoring uniqueness of people within their social and cultural contexts”

(ACA, 2014, p. 3). This statement reflects that counselors are ethically mandated to be accepting of all persons from diverse background and must be prepared to work with persons with varying concerns related to the human condition.

In addition to the ACA Code of Ethics (ACA, 2014), The Multicultural and Social Justice

Competencies (MSJCCs; Ratts, Singh, Nassar-McMillan, Butler, & McCullough, 2016) provided a guiding framework for counselors to help clients identify and eliminate barriers that oppress their lives. The MSJCCs are grounded in the following four domains: counselor self-awareness, client worldview, counseling relationship, and counseling and advocacy interventions (Ratts et al., 2016). The ACA Code of Ethics and the MSJCCs require counselors’ commitment to equal access and treatment of all persons; therefore, counselors need to work through their individual and cultural discomfort about sexual topics in order to understand how the various domains of human sexuality impacts the lives of marginalized persons and to best serve their clients (ACA,

2014; Ratts et al., 2016).

Human sexuality, sex education, and the impact of rural demographics on counselors’ knowledge and beliefs are all underrepresented topics in counseling literature and counselor education, limiting the effectiveness of education, conceptualization, and interventions. The aim of this study was to explore the relationship between counselors’ geographic location and their knowledge, comfort, approach, and attitudes around issues of human sexuality. Additionally, the results of this study may assist professional counselors and counselor educators through increased awareness of needed content in counselor education programs.

Significance of the Study

There is limited research, either quantitative or qualitative, regarding human sexuality in counseling. This study was unique because there is no research to date exploring the relationship between counselor geographic area and knowledge, comfort, approach, and attitudes towards sexuality. Through the results of this study counselors and counselor educators can gain a greater understanding of areas for increased education. The findings of this study could broaden the

knowledge presented in current wellness models in counseling and provide implications for serving marginalized populations in mental health settings.

Research Questions and Hypotheses

Research Question One

Is there a significant relationship between counselors’ geographic locations and their knowledge, comfort, approach, and attitudes about sexuality as measured by the composite score on the Knowledge, Comfort, Approach, and Attitude towards Sexuality Scale (KCAASS) when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken)?

Null Hypotheses One

There is not a significant relationship (p > .05) between counselors’ geographic locations and their knowledge, comfort, approach, and attitudes about sexuality as measured by the composite score on the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Research Hypothesis One

There is a significant relationship (p ≤ .05) between counselors’ geographic locations and their knowledge, comfort, approach, and attitudes about sexuality as measured by the composite score on Knowledge, Comfort, Approach, and Attitude towards Sexuality Scale (KCAASS) when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Research Question Two

Is there a significant relationship between counselors’ geographic locations and their knowledge of sexuality as measured by the KCAASS when controlling for participant

demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Null Hypotheses Two

There is not a significant relationship (p>.05) between counselors’ geographic locations and their knowledge of sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Research Hypothesis Two

There is a significant relationship (p ≤ .05) between counselors’ geographic locations of practice and their knowledge of sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Research Question Three

Is there a significant relationship between counselors’ geographic locations and their comfort with sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Null Hypotheses Three

There is not a significant relationship (p>.05) between counselors’ geographic locations of practice and their comfort with sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Research Hypothesis Three

There is a significant relationship (p ≤ .05) between counselors’ geographic locations and their comfort with sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Research Question Four

Is there a significant relationship between counselors’ geographic locations and their approach to sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Null Hypotheses Four

There is not a significant relationship (p>.05) between counselors’ geographic locations and their approach to sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Research Hypothesis Four

There is a significant relationship (p ≤ .05) between counselors’ geographic locations and their approach to sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken.

Research Question Five

Is there a significant relationship between counselors’ geographic locations and their attitudes about sexuality as measured by the KCAASS when controlling for participant

demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Null Hypotheses Five

There is not a significant relationship (p>.05) between counselors’ geographic locations and their attitudes about sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Research Hypothesis Five

There is a significant relationship (p ≤ .05) between counselors’ geographic locations and their attitudes about sexuality as measured by the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Research Question Six

Are there significant differences between counselors’ geographic and their attitudes about sexuality as measured by the composite KCAASS score and their demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken)?

H06: There are no significant differences (p>.05) between counselors’ geographic locations and their attitudes about sexuality as measured by the composite KCAASS score and their demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Null Hypotheses Six

There are significant differences (p ≤ .05) between counselors’ geographic locations and their attitudes about sexuality as measured by the composite KCAASS score and their

demographic factors (age, gender, sexual identity, religious identity, and number of human sexuality courses taken).

Study Definition of Terms

Human Sexuality

For the purposes of this study, human sexuality was defined as a multidimensional subject comprised of the biological, psychological, and sociocultural dimensions that influence one’s experiences, expressions, and perceptions (Molina, 1999).

Sex Education

While sex education is common in U.S. schools, its content varies considerably based on location. Topics such as abstinence and basic information on HIV and other sexually transmitted diseases (STDs) are commonly taught (Landry, Darroch, Singh, & Higgins, 2003). For the purposes of this study, sex education was defined as education encompassing components of human sexuality taught at any grade level (kindergarten through graduate studies).

Urban

Urban areas are defined by the Census Bureau as areas that represent densely developed territories, encompass residential, commercial, and other non-residential urban land uses with populations of 50,000 or more people (United States Census Bureau, n.d.).

Suburban

The Census Bureau identifies two types of urban areas: Urbanized Areas (UAs), which consist of 50,000 or more people, and Urban Clusters (UCs), which consist of more than 2,500 and less than 50,000 people. Urban Clusters are regularly referred to as suburban areas (United

States Census Bureau, n.d.).

Rural

The Census Bureau does not define rural areas. The Census Bureau designates rural areas by the lack of the area being Urban. Rural areas encompass all populations, housing, and territories not included in Urbanized Areas or Urbanized Clusters (United States Census Bureau, n.d.).

Chapter 2

Literature Review

This chapter will provide the reader with definitions and etiology of the dimensions of human sexuality. Historical trends and current national demographics on sex education along with the vast impacts of human sexuality. The literature review will review the body of literature on human sexuality education, specifically regarding counselors’ education on human sexuality.

The chapter will introduce the evidence of variances in rural and urban settings and discuss how these geographic demographics impact service delivery to clients. Through this review, the researcher aims to demonstrate the importance of sex education for all counselors, especially those coming from or headed to rural areas.

Essential Facets of Human Sexuality

Human sexuality is a multidimensional topic encompassing numerous dimensions that influence one’s life (Molina, 1999). The Sexuality Information and Education Council of the

United States (SIECUS) defines human sexuality as encompassing the sexual knowledge, beliefs, attitudes, values, and behaviors of individuals. Some of the dimensions of human sexuality include anatomy, physiology, identity, roles, thoughts, and relationships (Greenberg et al., 2007) and are influenced by ethical, spiritual, cultural, and moral concerns (SIECUS, 2005).

Under the multiple dimensions of human sexuality there are numerous components that are pivotal to one’s existence (Greenberg et al., 2007). For example, under the biological dimension, factors such as sex, genetics, reproduction, fertility, sexual arousal, and response are encompassed. Within the psychological dimension, factors such as body image, experiences, self-concept, expressiveness, and motivation are present. Within the sociocultural dimension, religious influences, multicultural influences, income and education, media influences, and others are factors (Greenberg et al., 2007). The comprehensive dimensions of the human experience that are impacted by human sexuality illustrate the numerous ways in which mental health stands to be impacted (Golanty & Edlin, 2011). Despite the comprehensive components of human sexuality there is a disparity in the sex education offered in community, school, and collegiate settings (Hall, Sales, Komro, & Santelli, 2016). This impacts attitudes, beliefs, and behaviors around human sexuality (Carter & Spear, 2002).

Human sexuality is a profound and multifaceted psychosocial component of the human condition that is universally experienced (Esho, 2012). These topics will be defined and explored as they intersect with formative education, counselor preparation, and client mental health. It is of note that the knowledge gap in human sexuality does not begin at the collegiate level; rather, there is a dearth of scientifically-based sex education in schools (K-12). In 2009 the American

Counseling Association completed an assessment of each state’s requirements for mental health counselor licensure. Through this survey, it is evident that two states require students complete a human sexuality course for counseling licensure (ACA, 2009). The implications of the lack of education from primary education through post-secondary education will be explored, and the impacts deficits in sex education can have on physical and mental health.

Professional Ethics and Standards

The American Counseling Association Code of Ethics (2014) Standard A.1.a. states that

“the primary responsibility of counselors is to respect the dignity and to promote the welfare of clients” (p. 4). In order to limit negative outcomes such as depression, anxiety, unplanned pregnancy, potential abuse/trauma, poor hygiene, and others associated with human sexuality

(Alexander et al., 2014; Domar, Broome, Zuttermeister, Seibel, & Friedman, 1992; Kirby, 2008;

Mueller, Gavin, & Kulkarni, 2008; Yu, 2010), counselors must be prepared and competent to address issues of human sexuality.

The concepts of understanding clients’ needs, concerns, and cultural impacts are reinforced through the ACA Code of Ethics in Standard E.5.c. (Historical and Social Prejudices in the Diagnosis of Pathology) which requires that "counselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and the role of mental health professionals in perpetuating these prejudices through diagnosis and treatment”

(ACA, 2014, p. 11). The social prejudice and stigma around human sexuality requires counselors be cognizant of and competent to address issues of human sexuality with their clients. The need for cultural competence and understanding of client stigmatization is addressed in the

Association of Multicultural Counseling and Development’s (AMCD) Multicultural Counseling and Social Justice Counseling Competencies (MSJCC; Ratts et al., 2016). While the

understanding of clients; needs and duty to do no harm are explicit in the code of ethics and

MSJCC, human sexuality is not explicitly addressed. Dupkoski (2011) stated that human sexuality “crosses culture, gender, age, and even species” (p. 1). Despite the universality of human sexuality experiences amidst all people (Southern & Cade, 2011), human sexuality issues are minimally addressed in counselor preparation programs, and counseling ethical standards do not specifically address human sexuality (ACA, 2014; Bloom et al., 2015; Southern & Cade,

2011).

The lack of scientific based sex education in schools (K-12), coupled with the minimal states requiring students in counseling programs to have dedicated curriculum in human sexuality, can lead to underprepared counselors, which Lambert, Bergin, and Collins (2000) stated can have “potential harm to their clients” (p. 27). Further, literature exploring human sexuality and counseling competencies, counseling literature exploring human sexuality outside of sexual identify work is limited (Bloom et al., 2015). The scarcity of literature around human sexuality in the counseling field indicates a significant omission in counselor preparation and professional counselors’ ability to safely treat and address the more vulnerable client issues.

History of Human Sexuality Education in America

Searches within academic research do not yield much in regard to sex education prior to

1900, as little was written about sex education before this time (Pearsall, 2001). Sex education in public schools prior to 1900 was not a consideration because sex and the various components therein were not appropriate topics for the school (Kaslow, 2006). During that time, health reformers in America associated bodily discipline with “ideal manhood,” and used sex education manuals to propagate that message (Irvine, 2004). Reverend John Todd's 1835 Student's Manual encouraged young men to overcome the "secret vice" of masturbation and stated that ejaculation

decreased energy and productivity (Barker-Benfield, 1972). During the same year, an article in the Boston Medical and Surgical Journal warned that ejaculation “should be made but sparingly,” stating that “sturdy manhood ... loses its energy and bends under too frequent expenditure of this important secretion” (Degler, 1974, p. 117). The 19th century was the beginning of the common school, when education became more accessible to a greater portion of society (Chang, 1985). At this time, however, schools varied widely with no set curriculum, and the distribution of the population in an area would predict the quality of the education in that area

(Cremin, 1980). As America moved into the Progressive Era (1890-1920), the era of the

Comstock laws outlawing distribution of birth control information or devices came to an end.

There was increased advocacy for social reform and sex education for youth came about (Huber

& Firmin, 2014). The progressives of the time comprised largely of academics and those in the medical field came together in an agreement that “experts” and the government should address social issues, and that schools could provide this aid in efforts to move away from the religious hold on sex education (Blount, 2003). During this time, sex education was more holistic, more comprehensive (Moran, 1996).

The National Education Association first discussed the subject in 1892, passing a resolution that called for "moral education in the schools" (McClellan, 1999, p. 36). In 1913,

Chicago became the first major city to implement sex education for high schools; however, the

Catholic Church launched a campaign against the initiative (Lindberg, Santelli, & Singh, 2006).

In 1918, in response to wide spread sexually transmitted diseases during World War I, Congress passed The Chamberlain-Kahn Act, which dedicated money to educate soldiers about syphilis and gonorrhea (Gonsalves & Staley, 2014). During this time, Americans began to view sex education as a public-health issue. The American Hygiene Association was founded 1914 as part

of the Progressive-era social purity movement, and taught soldiers about sexual hygiene throughout the war. Instructors used a machine called the stereomotorgraph to show soldiers microscopic slides of syphilis and gonorrhea organisms, as well as symptoms of the diseases on the body of an actual soldier (Imber, 1984). A 1919 report from the U.S. Department of Labor's

Children's Bureau likewise suggested that soldiers would have been better off if they had received sex instruction in school. "The worries and doubts and brooding imposed on boys and girls of the adolescent period as a result of lack of simple knowledge is a cruelty on the part of any society that is able to furnish that instruction," wrote the author of the report (Campos, 2002, p. 264).

The military's sex education programs led to similar instruction in secondary schools.

During the 1920s, schools began to integrate sex education into their curriculums. The American

Social Hygiene Association produced The Gift of Life, which explicitly warned students about the so-called “solitary vice:” “Masturbation may seriously hinder a boy's progress towards vigorous manhood. It is a selfish, childish, stupid habit” (Pinney, 1936, p. 39).

During the 1920s, between 20 and 40 percent of U.S. school systems had programs in social hygiene and sexuality (Lindberg et al., 2006). Sex education expanded over the next three decades. In the 1930s, the U.S. Office of Education began to publish materials and train teachers

(Carter, 2001). In the 1940s and '50s, courses in human sexuality began to appear on college campuses. In 1964, Mary Calderone, a physician who had been the medical director at Planned

Parenthood, founded the Sexuality Information and Education Council of the United States

(SIECUS). SIECUS was created in part to challenge the American Social Hygiene Association, which then dominated sex-education curriculum development. In 1968, The U.S. Office of

Education gave New York University a grant to develop graduate programs for training sex- education teachers (Fine & McClelland, 2006).

During the 1960s and 1970s, sex education became a political issue as religious conservatives created a movement challenging sex education in public schools. Groups like the

Christian Crusade and the John Birch Society challenged SIECUS and sex education overall for promoting promiscuity and moral depravity. In 1968, Gordon Drake and James Hargis distributed a pamphlet entitled “Is the School House the Proper Place to Teach Raw Sex?” and described sex education as communist indoctrination. These allegations led to beliefs and rumors that sex instructors were encouraging students to be homosexuals or even stripping and having sex in front of their classes. In her book Talk About Sex: The Battles Over Sex Education in the

United States, Janice M. Irvine (2004) stated that “Religious conservatives began using sex ed to their political advantage…They had this really scary rhetoric” (p. 4). Following this politicization and subsequent fears, groups of parents within school districts throughout the country started protesting sex-education programs.

During the 1980s amidst the AIDS and HIV pandemic, supporters of sex education began to rally again. By the mid-1990s, every state had passed mandates for AIDS education. As some form of sex education or AIDS/HIV education became mandated in schools, opposition to these mandates called for sex education to be “abstinence education” (Fine & McClelland, 2006).

Many of the groups in opposition to sex education rallied to add provisions for abstinence education to the 1996 Welfare Reform Act, and the Federal government directed tens of millions of dollars to abstinence-education programs for the first time (SIECUS). From the introduction of the pill, abortion education, and government funding becoming factors, there has been a large push from the 1980s until now to return to abstinence-only sex education, and this remains a

controversial topic across the country which impacts thousands of students and, subsequently, future counselors. One of the supporters of the sex education movement is the American Public

Health Association, founded in 1872 when scientific advances were helping to reveal causes of communicable diseases. The APHA began tracking data on sexually transmitted diseases at this at this time.

National Demographics on Sex Education in Schools

The American Public Health Association has been influential in impacting sex education guidelines based on collection of demographics from its founding in 1872 to current time. It has asserted that all young people need the knowledge, attitudes, and skills to avoid unintended pregnancy, sexually transmitted infections, and HIV so that they can develop as sexually healthy adults (APHA, 2014). As of April 2017, according to the Guttmacher Institute, 24 states mandate sex education; of those 24, 22 require sex education and HIV education, and two mandate only sex education. Thirteen states require that the instruction be medically accurate. Eight states require that the program must give instruction that is “appropriate for the student’s cultural background and not be biased against any race, sex, or ethnicity” (SIECUS, 2015) When sex education is taught, 26 states require abstinence be stressed, 13 states require discussion of sexual orientation, nine of those states require that discussion be inclusive, and four states require only negative information be disseminated about sexual orientation when sex education is taught.

Twenty-two states require that sex education include information on making healthy decisions around sexuality.

Using nationally representative data from the 2006-2010 and 2011-2013 National Survey of Family Growth, Lindberg, Maddow-Zimet, and Boonstra (2016) estimated changes over time in adolescents’ receipt of sex education. The survey examined ways that information was

disseminated including formal sources such as schools as well as informal dissemination such as from parents. The information gathered was assessed for differences in these trends by adolescents’ gender, race/ethnicity, age, and place of residence. The studies illustrated declines in receipt of formal sex education and low rates of parental communication may leave adolescents without instruction, particularly in nonmetropolitan areas. Lindberg et al. also found that between 2006-2010 and 2011-2013, there were significant declines in adolescent females’ receipt of formal instruction about birth control (70% to 60%), saying no to sex (89% to 82%), sexually transmitted disease (94% to 90%), and HIV/AIDS (89% to 86%). They also report a significant decline in males’ receipt of instruction about birth control (61% to 55%). Declines were concentrated among adolescents living in rural areas. The proportion of adolescents talking with their parents about sex education topics did not change significantly. Twenty-one percent of females and 35% of males did not receive instruction about methods of birth control from either formal sources or a caregiver (Lindberg et al., 2016).

Over the last 2 decades, there has been a significant decrease of sex education in the K-12 setting since the advent of the abstinence-only programming movement (Duposki, 2012).

Additionally, rural school districts are more widely impacted by the decrease of sex education, frequently presenting as an absence of any sex education being offered in rural areas (Bloom,

Gutierrez, Lambie, & Ali, 2016). This decrease of sexual education in the K-12 settings, as well as the absence of sex education in rural areas not only creates a potential for harm but also increases risk factors for youth and adolescents (Alexander et al., 2014). Adolescents may receive information about sexual health topics from a range of sources beyond formal instruction. Some identified sources of sexual health information and education include parents, health care providers, and digital media.

Parents as Educators

In 2011–2013, 70% of males and 78% of females aged 15–19 years reported having talked with a parent about at least one of six sex education topics: how to say no to sex, methods of birth control, STDs, where to get birth control, how to prevent HIV infection and how to use a condom (Guttmacher Institute, 2017). Young women were more likely than young men to talk with their parents about each of these sexual health topics except how to use a condom, which was more commonly discussed among males (45%) than among females (36%) (Guttmacher

Institute, 2017). Although most parents provide information about contraception or other sexual health topics, their knowledge of these topics may be inaccurate or incomplete.

While parents are encouraged to be the primary sex educators for their children, little is known about the accuracy of parents' views about condoms and oral contraceptives (Lindberg &

Maddow-Zimet, 2012). Substantial proportions of parents underestimated the effectiveness of condoms for preventing pregnancy and sexually transmitted diseases (STDs). Only 47% believed that condoms are very effective for STD prevention, and 40% for pregnancy prevention. Fifty- two percent thought that pill use prevents pregnancy almost all the time; 39% thought that the pill is very safe. Approximately one quarter of parents thought that most teenagers are capable of using condoms correctly; almost four in 10 thought that most teenagers can use the pill correctly.

All of these beliefs held by parents surveyed are factually flawed.

In 2004 Eisenberg ME et al. surveyed parents in an all-White, socially, politically, and religiously conservative, rural area in southern Illinois. Sexuality education was limited to the ninth grade, where it comprised 15% of a required "Healthy Lifestyles" course. Only 52% of parents responding agreed that "Personally, I provide adequate sexuality education for my children," while another 30% were unsure. Even more striking, only 15% felt that "Most parents

know how to give their children the sexuality education they need." This finding is consistent with other experts' observations that while parents prefer to be their children's primary sexuality educators, they are insecure about their ability to do so, and their knowledge base is, in fact, often inadequate (Leight, 1994; Reis & Seidl, 1989).

Health Care Providers

Both the American Medical Association and the American Academy of Pediatrics have recommended that adolescents’ primary care visits include time alone with health care providers to discuss sexuality and receive counseling about sexual concerns (Hagan, Shaw, & Duncan,

2008; Retford, Mullen, & Winkler, 1994). The American College of Obstetricians and

Gynecologists (ACOG) advised that contraceptive counseling be included in every visit with adolescents, including those who are not yet sexually active (ACOG, 2017). Despite these recommendations, only 45% of young people aged 15–17 reported in 2013–2015 that they spent time alone with a doctor or other health care provider during their most recent visit in the previous year (Fuentes, Ingerick, Jones, & Lindberg, 2017). Many adolescents feel uncomfortable talking with their health care provider about sexual health issues, and many providers also have concerns about discussing these issues (Boekeloo, 2014).

Digital Media

Access to the Internet is nearly universal among adolescents in the United States (Simon and Daneback, 2013). Digital media offers opportunities for youth to confidentially search for information on sensitive topics, and thus are a likely source of sexual health information for young people (Lenhart, 2015). Online sources may be particularly important for LGBTQ adolescents, whose needs may be left out of traditional sex education (Friedman & Morgan,

2009). The confidentiality of the Internet may also be source of comfort for adolescents, who

may not be comfortable discussing sexual health topics with parents or friends. In 2010, 19% of heterosexual youth, 40% of questioning youth, 65% of bisexual youth, and 78% of lesbian/gay/queer youth aged 13–18 surveyed reported that they had used the Internet to look up sexual health information in the past year (Mitchell, Ybarra, Korchmaros, & Kosciw, 2014).

The websites adolescents may turn to for sexual health information often have inaccurate information. For example, of 177 sexual health websites examined in a recent study, 46% of those addressing contraception and 35% of those addressing abortion contained inaccurate information (Buhi et al., 2010). The lack of consistency in sex education across the United States also means that if counseling students do not take a course on human sexuality in their undergraduate career, future clinicians could be entering their counseling program with no scientifically based sex education. There are well-documented impacts of human sexuality on physical and mental health well-being (Alexander et al., 2014; Kirby, 2008; Mueller et al., 2008;

Yu, 2010).

Human Sexuality Outcomes

Physical health. Since the 1970s, numerous scholars have examined the link between receiving sex education and subsequent sexual health outcomes in adolescence and adulthood

(Alexander et al., 2014; Yu, 2010). Research on formal sex education suggests it may have a protective influence on early sexual health behaviors. For example, several researchers have demonstrated that receiving formal sex education can delay first sexual activity experiences

(Alexander et al., 2014; Lindberg & Maddow-Zimet, 2012; Mueller et al., 2008). Formal sex education is reported to have a positive influence on young people’s decisions around contraceptives, including higher levels of contraception use at first sexual experience (Kirby,

Laris, & Rolleri, 2007; Lindberg & Maddow-Zimet, 2012; Mueller et al., 2008). Receipt of

formal sex education is also associated with proactive health behaviors such as screening/testing for sexually transmitted infections (STIs; Kirby, 2008). These findings have led to the proposal that the importance of sex education may be particularly salient for certain subgroups that are traditionally at risk for early first sex and for contracting STIs (Mueller et al., 2008).

Dodge, Reece, and Herbenick (2009) found that that receiving sex education in school may act as a protective factor against some negative sexual health practices, both on the occasion of first sex and later in life. Receiving sex education significantly increased the likelihood of using contraception at first sex, when first sex occurred before the age of 17 years. This supports the notion that sex education may be of particular importance for vulnerable subgroups that are at risk for early first sex (Mueller et al., 2008).

Human sexuality is commonly considered through the biological, psychological, and socio-cultural dimensions that affect expression and experience. If this multi-dimensional definition is accepted, then it becomes clear that the topic of human sexuality is relevant at all stages of life span, mental health, and development education and training (Molina, 1999). As stated previously, sexuality is a set of behaviors that encompass social, emotional, and physical interactions, including but not limited to sexual intercourse (Bruess & Greenberg, 1994). As such, sexuality education programs should focus on the broad spectrum of issues related to sexuality (Travers & Tincani, 2010). Inadequate hygiene and reproductive health skills may result in increased levels of chronic pain, illness, and potentially death (Fegan, Rauch, &

McCarthy, 1993). In addition to teaching adolescents and adults to report specific internal needs

(e.g., pain), skills related to reproductive health education and contraception in sexuality programming should be included as a preventative measure (Koller, 2000; Sullivan & Caterino,

2008; Travers & Tincani, 2010). Previous scholars have demonstrated effective programming for

teaching skills related to personal healthcare, which can be conceptualized as an aspect of sexuality (e.g., performing self-examinations, reporting genital discomfort) reducing risk factors for later physical health concerns.

There are marginalized populations greatly impacted by issues related to physical health in regard to human sexuality. Children and adolescents who have experienced sexual trauma at a young age, those lacking an understanding of social cues or norms, and those on the autism spectrum have potential for increased risk factors and increased opportunities for harm in regard to rules about privacy as it relates to sexuality (Hellemans, Colson, Verbracken, Vermeiren, &

Deboutte, 2007). Specifically, these individuals may be unclear regarding when and where sexual behavior is socially appropriate (e.g., at home in one’s bedroom) and where it is inappropriate (e.g., public spaces).

Another component of physical health under the human sexuality umbrella is that of infertility. Infertility, defined as the inability to achieve pregnancy after 1 year of unprotected intercourse, impacts 6.7 million women in the United States (Chandra, Copen, & Stephan, 2013).

Further, crossing the realm from physical outcomes to mental health outcomes, women with infertility have been found to have significantly higher depression scores and twice the prevalence of depression that fertile controls (Domar et al., 1992). Women facing infertility report doubting their femininity and sexual attractiveness, due to the linkage in our society of childbearing and femaleness (Syme, 1997). While infertility is a largely impactful outcome, it is not the only outcome that transverses the mental health realm. The link between sex education and physical outcomes is well documented. With mental health outcomes, the occurrences of one or more dimensions of human sexuality impacting individual’s mental health are also documented.

Mental health. Stress levels of individuals experiencing infertility or sexual dysfunction are equivalent to those with cancer or heart disease (Domar et al., 1992). Bauer, Knapp, and

Parsonage (2015) found that mothers’ prenatal and postnatal depression levels have a longitudinal impact on themselves as well as their children. In a recent study, Truijens, Spek,

Son, Guid, and Pop (2017) found that persistently high depressive symptoms were related to unplanned pregnancies. The association between unplanned pregnancy and perinatal depression was recently outlined in a systematic review of Abajobir, Maravilla, Alati, and Najman (2016).

These researchers concluded that the prevalence of depression during pregnancy is twofold in women with unintended pregnancy (Abajobir et al., 2016).

While mental health concerns can arise from issues within the realm of human sexuality, mental health concerns can also impact facets of human sexuality. Sexual dysfunction is a common symptom of depression. Although decreased libido is most often reported, difficulties with arousal, resulting in vaginal dryness in women and erectile dysfunction in men, and absent or delayed orgasm are also prevalent. Sexual dysfunction is also a frequent adverse effect of treatment with many antidepressants and is one of the leading reasons for clients report noncompliant medication use or ending medication regiments early (Kennedy & Rizvi, 2009).

There multiple ways that dimensions of human sexuality intersect with mental health.

Another well-researched and documented connection is the impact of sexual trauma on mental health, both in adolescents and adults. Banyard, Williams, and Siegel (2001) found that child sexual abuse victims reported a lifetime history of more exposure to various traumas and higher levels of mental health symptoms. Through their study they reported a strong positive correlation between child sexual abuse and psychological distress in adulthood. Sexual trauma, sexual assault, working with survivors, and crisis counseling are some of the well documented

intersections of mental health and human sexuality (Maguen et al., 2012; Mulder, Beautrais,

Joyce, & Fergusson, 1998; Read, Agar, Argyle, & Aderhold, 2003; Spataro et al., 2004). Even with the physical and mental health intersections with human sexuality, disparities in education persist. The comprehensive dimensions of the human experience that are impacted by human sexuality illustrate the numerous ways in which mental and physical health outcomes are impacted by human sexuality and the need for counselors’ competency in these areas.

Counselor Education Programs Human Sexuality Requirements

The American Counseling Association’s (ACA, 2014) Code of Ethics requires that ethical counselors fulfill their counseling roles within the bounds of their own skill and training

(Standard C.2.a.) and demonstrate competence within the realm of diverse client populations

(Standard C.2.a.). Therefore, ethical counselors must be (a) aware of their personal prejudice towards or against working with clients with issues related to sexuality, and (b) knowledgeable of research regarding human sexuality. Nevertheless, research regarding counselors’ comfort and attitudes towards sexuality are limited. Counseling professionals are called on to discuss their clients’ intimate, vulnerable, and difficult life experiences. Thus, counselors regularly encounter the profusion of themes and subjects that occur in relation to human sexuality (Hinman, 2013).

Human sexuality is not mandated for specific course work by the Council for

Accreditation of Counseling and Related Educational Programs (CACREP), which provides accreditation for multiple counseling subdisciplines (e.g., clinical mental health, school, rehabilitation, career, etc.), does require counseling students to know “etiology, nomenclature, treatment, referral, and prevention of mental and emotional disorders” (CACREP, 2016, p. 24).

According to the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V), disorders pertaining to human sexuality include sexual and gender identity disorders, paraphilias, and

sexual dysfunction (American Psychiatric Association, 2013). Therefore, CACREP (2016) requires counseling students to gain knowledge of these disorders. However, Dupkoski’s (2012) analysis of the American Counseling Association (ACA) and Association for Counselor

Education and Supervision (ACES) Syllabus Clearinghouse revealed that only “57 out of 395 syllabi, or 9.4%, included the word ‘sex’ in their content, but only four courses—about 1%— focused specifically on sexuality” (p. 5). However, counselors and counseling students may experience discomfort in talking about sensitive issues involved in human sexuality such as body fluids, nudity, fertility, porn use, and sexual pleasure (Hinman, 2013).

Counselors serve individuals, couples, and families working to improve the human condition (Harris & Haye, 2008), and with human sexuality being a profound and multifaceted psychosocial component of the human condition, it is an inevitability that issues related to sexuality will come up in counseling. Clinicians may be underserving clients, however, by not having adequate training, comfort, or exposure to issues of sexuality (Bloom et al., 2015).

Competence necessitates that, beyond skills and knowledge, counselors experience comfort with addressing sexual issues with clients (Kazukauskas & Lam, 2010; Miller & Byers, 2012). For example, Harris and Hays (2008) explored marriage and family therapists’ comfort with sexuality and willingness to discuss sexual issues with clients and identified that those with certified sex therapist status were most likely to discuss sexual issues with clients. Their results revealed that comfort with sexuality was a mitigating factor in therapists’ discussion of sexuality with clients.

How counselor education programs prepare students to address issues related to human sexuality. Addressing sexuality concerns with clients at some point is inevitable for all counselors, regardless of concentration (Fyfe, 1980). Searches within academic research do not

yield much in regard to sex education prior to 1900 as little was written about sex education before this time (Pearsall, 2001). Sex education in public schools prior to 1900 was not a consideration because sex and the various components therein was not considered an appropriate topic for the school (Kaslow, 2006). Prior to the 19th century, Christian theology was frequently integrated into subjects in schools, and textbooks integrated morality and the development of character from a Christian lens into the curriculum (Brown, 2002). The American Public Health

Association has asserted that all young people need the knowledge, attitudes, and skills to avoid unintended pregnancy, sexually transmitted infections, and HIV so that they can develop as sexually healthy adults (APHA, 2014).

As of April 2017, according to the Guttmacher Institute, 24 states mandate sex education; of those 24, 22 require sex education and HIV education, and two mandate only sex education. Thirteen states require that the instruction be medically accurate. Eight states require that the program must give instruction that is “appropriate for the student’s cultural background and not be biased against any race, sex, or ethnicity” (SIECUS, 2015). When sex education is taught, 26 states require abstinence be stressed, 13 states require discussion of sexual orientation, nine of those states require that discussion be inclusive, and four states require only negative information be disseminated about sexual orientation when sex education is taught. Twenty-two states require that sex education include information on making healthy decisions around sexuality. Eleven states require that sex education include instruction on how to talk to family members about sex. The absence of sexual education in the K-12 setting not only creates potential for harm and risk factors for youth and adolescents, it also means that if counseling students do not take a course on human sexuality in their undergraduate career, future clinicians could be entering their counseling program with no scientifically based sex education to date.

The perverseness of sexual issues within the counseling setting suggests the need for educating counseling students about human sexuality. In general, counseling students already possess high levels of stress, worry, and self-doubt during their preparation programs (Abel,

Abel, & Smith, 2012). At the same time, experiences of embarrassment and shame are common aspects of sexuality (Stein, 2005), and the vulnerability that accompanies sexual communication may heighten anxiety (Brown, Sorenson, & Hildebrand, 2012). Consequently, despite their own degree of discomfort with the topic of sexuality and aside from any other stresses that may be present, counselors need to work through their individual and cultural discomfort about sexual topics in order to best serve their clients (Hinman, 2013).

Even so, according the American Counseling Association survey of state counselor licensure boards conducted in 2009, only Florida and California require counseling students to take a course in human sexuality for licensure (ACA, 2009). Courses such as Life Span

Development and Multicultural Issues in Counseling integrate some issues of human sexuality in their curricula; however, unless a student takes human sexuality or a similar course in their undergraduate degree, it is entirely possible that upon completion of their degree and licensure, a student could have never received accurate, comprehensive, and/or scientifically based human sexuality education prior to seeing clients.

Impact of Counselor Geographic Location

Counselors’ identity, multicultural competencies, and diversity training are consistent components across counselor education programs (ACA, 2009). Jameson and Blank (2007) found that counselor education programs do not adequately explore the roles of rural counselors.

This finding is similar to those of Lawson and Venart (2005), who highlighted the need for a greater understanding of and training in rural counseling competencies. As 37.8% of the total

number of schools in America are in rural areas and 19.3% of the entire population (roughly 60 million Americans) live in rural areas, counselor education programs need to address the knowledge gap and lack of preparation through the infusion of rural counseling competencies into their curricula.

Crockett et al. (2000) stated that the rural–urban distinction is an important social category and is the basis for self-definition and community identity, with important implications for the socialization of urban versus rural youth. Some researchers have posited that a professional’s community identity and attitudes regarding sexuality hinder their ability to work with clients with issues related to sexuality (Bloom et al., 2016). However, how this demographic impacts counselors’ knowledge, attitudes, and comfort with sexuality has not previously been explored. There is a disparity between sex education in rural and urban settings, schools, and communities, which impacts attitudes, beliefs, behaviors, and pregnancy rates

(Carter & Spear, 2002).

The lack of research on the high-risk sexual behaviors of rural adolescents is often attributed to the difficulty of gaining access to conduct research and explore pregnancy- prevention and sex education in rural schools (Crockett et al., 2000; Blinn-Pike, 2009). More research needs to take place in rural areas because of the lack of information on the sexual attitudes and behaviors of rural adolescents, the difficulty rural professional face when attempting to use school-based prevention curricula, and the lack of available adolescent sex education that have been shown to be effective, valid, and reliable with rural adolescents

(Crockett et al., 2000).

Among the sociodemographic differences that Lindberg and Maddow-Zimet (2012) found in their analysis of the 2006-2010 and 2011-2013 National Survey of Family Growth are

the declines in formal sex education among teens residing in nonmetropolitan areas, encompassing both genders and many topics of instruction. This finding occurred without other reported declines in parental communication among rural teens. These patterns are concerning because rural adolescents are a particularly vulnerable group, with higher rates of teen pregnancy, lower rates of contraceptive use, and less access to sexual and reproductive health care services than their non-rural peers (Ng & Kaye, 2015).

With fewer resources, rural school districts may be particularly vulnerable to the influence of national and state educational policies emphasizing high-stakes testing in some subjects which may leave reduced time and resources for other subjects such as health education

(Dulude, Spillane, & Dumay, 2017). Similarly, within overall health education, sexual health topics may be of reduced priority compared to other topics. For example, SHPPS data indicated that from 2000 to 2012, declines in the share of school districts with policies about teaching HIV or other STD prevention were paralleled. Further research is needed to understand how different subjects may compete for inclusion in the curriculum or class- room, given limited time and other resources (Lindberg & Maddow-Zimet, 2012).

Defining Urban, Suburban, and Rural Geographic Locations

One of the difficulties in exploring the counseling needs of those in rural areas is the lack of a consistent definition of the word rural (United States Census Bureau, n.d.). One of the most commonly used definitions comes from the U.S. Census Bureau, which definition depends on population as a mitigating factor (Jameson & Blank, 2007). Urban areas, described by the

Census Bureau as areas that represent densely developed territories, encompass residential, commercial, and other non-residential urban land uses (United States Census Bureau, n.d.). The

Census Bureau further identifies two types of urban areas: Urbanized Areas (UAs), consisting of

50,000 or more people, and Urban Clusters (UCs), consisting of at least 2,500 and less than

50,000 people, which are regularly referred to as suburban areas. While only 3.5% of the U.S. land population is classified as urban, this is 62.7% of the U.S. population, and urban areas and the barriers and benefits to the populations therein, as well as the impacts of the urban demographic on the professional counselor role, are well explored (Sawyer, Gale, & Lambert,

2006). Urban settings, including community mental health facilities, are common experiences for counseling students.

The Census Bureau does not define rural areas; rather, rural areas are defined by the lack of being urban. Rural areas encompass all populations, housing, and territories not included in urbanized areas or urbanized clusters. Rural areas consist of more than 95% of the land in

America, representing 19.3% of the population. The National Board for Certified Counselors uses the definitions for Rural and Urban that are provided by the U.S. Department of Health and

Human Services, Health Resources and Services Administration (HRSA); the HRSA uses the

U.S. Census Bureau data.

Impact of rural geographic location. Rural areas often have the identity that they lack the social problems facing urban areas, such as gang violence, drive-by shootings, hard drugs, and crime, because of the influence of religion in the rural community and the apparent lack of access to illegal substances (Mulder et al., 1998). There is a common belief that rural youth are somehow insulated from the problems experienced by urban youth by virtue of their geographic isolation, closer family and community ties, and religiosity (Blinn-Pike, 2008). Educators understandably feel reluctant to base local decisions about sexuality education on national polls, which may not reflect opinions in their own locales. Parents in small towns and rural America might be less supportive of sexuality education, feeling that their children are less vulnerable to

the threats of AIDS, STDs, and teen pregnancy found in urban areas. Culture, beliefs sets, family of origin, spirituality, and socioeconomic status are factors that counselor educators explore and teach to counseling students. Multicultural competencies are pedagogical standards in counselor education programs yet rural issues are minimally addressed. While rural areas may vary from one another by way geography, cultural practice, ethnic makeup, and history, key factors shape the lives of all who live in rural areas in impactful ways. Cohn and Hastings (2013) asserted that these factors speak to a breadth of diversity often overlooked in the mental health literature, yet it is essential that counselors working in rural settings understand them.

Crockett et al. (2000) stated that the rural–urban distinction is an important social category and is the basis for self-definition and community identity, with important implications for the socialization of urban versus rural populations. Community identity can be defined as a sense of living in, belonging to, and having some commitment to a particular community. It concerns the perceptions of ideas about a particular community by its residents at a particular time. The urban-rural typology is based on the assumption that communities possess particular characteristics. Researchers have shown that a pattern exists related to the size of community and higher identification, with residents of smaller communities expressing a greater sense of community identification (Bloom et al., 2016).

Some researchers have posited that a professional’s community identity and attitudes regarding various topics such as sexuality hinder their ability to work with clients with issues related to the same (Bloom et al., 2016); however, how the rural verses urban demographic impacts counselor’s professional identity has been minimally addressed in the literature. The counselors’ community identity, the numerous possible ethical issues, and the barriers surrounding access to care are not the only factors to be considered when working in rural areas.

Persons living in rural areas are not homogeneous in terms of where they live, their socioeconomic status, or their cultural group; however, there are stressors that are prevalent within rural communities as a whole. In a report on the mental health needs of rural women from the American Psychological Association, (Mulder et al., 1998) indicated that in 1996, rural poverty was 15.9% compared to 13.2% in urban areas, and this gap is widening; 60% of rural areas are experiencing a shortage on mental health professionals; 56.9% of families with children are living below the poverty line; suicide rates, particularly in the rural west, are as much as three times as high as urban rates; teens in rural areas have a 30–40% higher pregnancy rate than their urban counterparts; 41% of women in rural areas are depressed or anxious compared to urban rates of 13–20%; and rural adolescents report higher rates of drug and alcohol abuse.

Identification with a small town may conjure up self descriptors such as friendly, neighborly, people-oriented, family-centered, and traditional. Identification with an urban area may result in one describing himself or herself as worldly, educated, cosmopolitan, and so on. The many social, political, and economic changes that have taken place in the history of a country may result in multiple types of identification based on the type of connectedness felt by its citizens.

No research has attempted to examine how community identity is related to particular decisions concerning school-based sex education. There are large differences between rural and urban areas, and the disparity of knowledge on these topics needs to be addressed not only in literature but in the counselor education curriculum as well.

Ethical issues in rural counseling. The difficulties that clinicians face in rural areas are well documented and tend to be themed around ethical issues (Jameson & Blank, 2007). Many of these findings point to such issues and in their discussions denote that specific training needs to be done around rural counseling. Little is known or published about how clinicians address these

ethical grey areas, some of which appear suddenly and require an immediate response (Nelson,

Barnard, & Cain, 2006).

Smaller populations in rural communities mean that counselors and those seeking counseling are more likely to interact in social settings or work together through participation in sporting activities or community services. These dual relationships are often unavoidable if a client happens to be, for example, the local dentist, mechanic or educator. The likelihood of interacting increases based on how isolated the community is, reducing the flexibility clinicians have for social or commercial interactions outside their community (Scopelliti, Judd, Grigg, Hodgins, &

Wood, 2004). Of particular note, especially for new professionals, is the issue of confidentiality.

In rural settings, confidentiality may be more difficult to ensure in practice, thus increasing the potential for a range of problems (Scopelliti et al., 2004). Strict adherence to confidentiality, on the other hand, has the potential of impacting adversely on important collaborative relationships in smaller communities. While some of the codes of ethics from the mental health professional regulatory bodies acknowledge the inevitability of establishing dual relationships with patients in small communities and the need to exercise caution in those cases, very little is offered in terms of guidance on how to manage these situations.

Barriers to mental health treatment. Bischoff, Reisbig, Springer, Schultz, Robinson, and Olson (2014) stated that “mental health disparities are prevalent in rural communities throughout North America” (p. 2). Those living in rural areas have higher rates of substance abuse, child abuse, domestic violence, depression, and suicide in comparison to their urban population counterparts, and rural residents are more likely to die from suicide than those in urban or suburban areas (Bischoff et al., 2014). Those in rural areas also have fewer mental health care resources to serve their predominant mental health needs as evidenced by the fact that

nearly two thirds (60%) of the designated mental healthcare professional shortage areas are located in non-metropolitan rural regions (United States Department of Health and Human

Services, 2011).

Another barrier that Bischoff et al. (2014) denoted is the stigma and culture of mental health in rural areas. Bischoff et al. found that rural communities are different than urban areas and that these differences impact and influence how mental health issues and treatment are perceived. Through their research, the authors found that the stigma of mental health problems and treatment is greater than what one might experience in urban areas (Bischoff et al., 2014).

With the majority of studies, research, and literature being based in urban populations, settings or demographics it is understandable why much of our knowledge and data being urban centric (Bloom et al., 2016; Cohn & Hastings, 2013). The drastic disparity between research done in rural and urban areas combined with the disparities in education and cultural identities between rural and urban settings, there is a need to understand if there is a difference between counselors knowledge, comfort, approach, and attitudes of human sexuality in rural and urban settings.

Chapter 3

Methodolgy

This chapter describes the methods used to explore the relationship between counselors’ geographic location and their knowledge, comfort, attitudes, and approach in addressing human sexuality with clients and counselors’ demographic factors (age, gender, sexual identity, spiritual identity, geographic location of origin, geographic location of residence, geographic location of practice, and number of post-secondary human sexuality courses taken). This chapter includes an overview of research design, participants, participant selection criteria, instrumentation, data collection procedures, power analysis, and data analysis.

Research Design

This study explored the relationship between counselors’ geographic area (i.e., rural, urban, or suburban) and their knowledge, comfort, approach, and attitudes towards sexuality as measured by The KCAASS (Kendall et al., 2003). This study was unique because there were no previous studies exploring the relationship between counselor geographic area and knowledge, comfort, approach, and attitudes towards sexuality.

Electronic surveys were used to collect data in this study. Electronic questionnaires are frequently used in correlational studies because the variables measured in the current study were all pre-existing (Granello & Wheaton, 2011). Counselors’ demographic area of practice and identity were pre-existing factors in this study. Counselors’ knowledge, attitudes, approach, and comfort evolve over time, thus allowing a survey method to be appropriate for this study

(Granello & Wheaton, 2011). Survey methods are cost-effective and allow for access to a diverse population in multiple geographic locations, which aided in the generalizability of this study

(Granello & Wheaton, 2011). A qualitative design would not allow the inclusion of as many varied participants, limiting generalizability.

Approval from the Institutional Review Board (IRB) was required for this study, and the research was subject to Human Subjects Review at the University of Toledo before initiating data collection. The sample (N= 186) identified as independently licensed mental health counselors with a master’s degree in mental health counseling located in all geographic areas within the United States. This included counselors from across the United States having met the requirements of their individual states’ education requirements for indepedent licensure.

Participants completed a consent form, a short demographic questionnaire, and the Knowledge,

Comfort, Approach, and Attitude of Sexuality Scale assessment (KCAASS) (Kendall et al.,

2003). The electronic surveys were distributed via various listservs related to counseling practice and education including CESNET, ACA Connect, and The Ohio Counseling Association (OCA) listserv.

Participant scores on the KCAASS (Kendall et al., 2003) and demographic data represent the main variables of interest (knowledge, comfort, approach, and attitude of sexuality and participant geographic location of origin, residence, and practice). Additional demographic data are used to explore the relationship between counselor demographic factors and to control for possible confounding variables (e.g., age, gender, sexual identity) as identified in previous studies (Bray & Schommer-Aikins, 2015; Grollman, 2017; Hendrick, Hendrick, Slapion-Foote,

& Foote, 1985); these were controlled by including these variables in the regression model according to their causal priority (Petrocelli, 2003). Correlating participant scores on the

KCAASS along with the constructs of age, gender, sexual identity, spiritual identity, and number

of human sexuality courses taken, utilizing multivariate statistics allowed for a deeper exploration of relationships among these constructs within the sample.

Participants

Participants in the study (N=186) identified as any independently licensed counselor with a master’s degree in mental health counseling located in all geographic areas within the United

States. This included counselors from across the United States having met the requirements of their individual states’ education requirements for independent licensure. Participants identifying as licensed counselors prior to completing the study met the requirements for assumptions for ex post facto design. Participants identified as being from, residing in, and practicing in rural, urban, or suburban locations. Regarding geographic location of origin, 70 (37.6 %) participants reported being from rural areas 57 (30.6%) reported from being from suburban areas, and 59 (31.7%) reported being from urban locations. For geographic location of residence, 48 (25.8%) reported living in rural areas, 78 (41.9%) reported living in suburban areas, and 60 (32.2%) reported living in urban areas. Finally, for geographic location of practice 34 (18.3%) participants reported practicing counseling in a rural area, 63 (33.8%) reported practicing in suburban areas, and 89 (47.8%) reported practicing in urban locations.

Participants’ age ranged from 23 years to 85 years (M= 40.14 years, SD= 12.84 years).

Regarding gender, 135 participants identified as women (72.5%), 5 identified as gender queer

(2.6%), 2 identified as gender non-binary (2.6%), 2 identified as gender fluid (2.6%), 1 identified as transgender (.05%), and 41 participants identified as male (22.0%). Spiritually, 95 participants identified as non-Christian (51.0%); six identified as Pagan/Wiccan (3.2%), 37 identified as

Atheist/None (19.8%), 12 identfied as Spiritual (6.4%), 2 identified as Buddhist (1%), 1 identified as “Possiblist” (.05%), 26 as Agnostic (12.9%), 9 as Jewish (4.8%), 1 as Secular

Humanist (.05%), and 1 participant identified as non-theistic (.05%). 91 participants identified as members of Christian denominations (48.92%); 59 participants reported their spiritual identity as “Christian” (31.7%), 2 as Greek Orthodox (1%), 3 as Lutheran (1.6%), 15 identified as

Catholic (8%), 3 as Presbyterian (1.6%), 2 as Protestant (1%), 2 as Roman Catholic (1%), 1 identified as Episcopal (.05%), 2 as Unitarian Universalist (1%), 1 as Latter Day Saint (.05%), as

1 identified as United Church of Christ (.05%). For sexual identity, 143 participants identified as heterosexual (76.8%). 43 participants identified as non-heterosexual (48.92%); 21 participants identified as gay (11.2%), 8 identified as bisexual (4.3%), 8 identified as lesbian (4.3%), 2 identified as queer (1.0%), 2 identified as pansexual (1.0%), one identified at fluid (.05%), and one identified as a sexual (.05%). In terms of number of post-secondary human sexuality courses taken, the number of classes taken ranged from zero to seven courses taken (M= 1.34 courses,

SD= 1.36 courses). 57 (30.6%) participants reported never completing a course on human sexuality, 55 (29.5%) participants reported completing 1 human sexuality course, 49 (26.3%) participants reported completing 2 human sexuality courses. 8 (.4%) participants reported completing 3 human sexuality courses, and 13 (6.98%) reported taking 4 or more human sexuality courses.

Sampling Procedures

Purposive, convenience, and snowball sampling were used to achieve desired sample size

(Creswell, 2012). Participants were recruited from listserv email groups for professional counselors and counseling educators: CESNET (counselor educators and counselor education students with approximately 3600 members) and OCA (counselors in Ohio with approximately

1254 members). Participants were asked complete an electronic survey; this survey included an informed consent component, demographic questionnaire, and the KCAASS.

The first call for participants was sent in April 2018, after proposal defense and IRB approval (see Appendix D for the full call for participants), and the survey closed in early June

2018 after adequate sample size was met. Data were collected over six weeks. Each listserv was solicited two times. The second call for participants occurred two weeks after the initial call.

Following the first call, 108 participants completed the survey. Following the second call and through June 2018, an additional 118 surveys were completed, for a total of 226 participants.

Instrumentation

Participants were emailed a link to the survey to the participants, which included three components: an informed consent document (Appendix D), the KCAASS (Appendix A), and a demographic questionnaire (Appendix C). The informed consent document was the first page of the survey, followed by the KCAASS, and concluding with the demographic questionnaire. The order of instrumentation was the same for all participants.

Knowledge, Comfort, Approach and Attitudes of Sexuality Scale

The KCAASS (Kendall et al., 2003) is a 45-item survey tool assessing professionals’ knowledge, approach, attitudes, and comfort in addressing sexuality specifically with persons with spinal cord injuries (SCI). The KCAASS was originally created as a spinal cord injury instrument and has been slightly modified four times (Kazukauskas & Lam, 2010; Post,

Gianotten, Heijnen, Lambers, & Willems, 2008; Verschuren et al., 2013). Validity for the original KCAASS was established using a multidisciplinary panel of experts in SCI rehabilitation to refine and revise the original draft of the questionnaire, followed by a pilot study

(Kendall et al., 2003). Cronbach’s alpha values for the original KCAASS indicate internal consistency reliability for the factors knowledge (.93), comfort (.98), approach (.80), and attitudes (.84), with a composite score of .96 (Kendall et al., 2003). The original KCAASS was

further validated with SCI populations by Fronek et al. (2005), who found Cronbach’s alpha values of .93, .97, .87, and .64 for the factors of knowledge, comfort, approach, and attitude, respectively.

Kazukauskas and Lam (2010) modified the KCAASS by adjusting the language from

“spinal cord” injury specific to “general disability.” Kazukauskas and Lam obtained Cronbach’s alpahs on the four factors of the KCAASS as follows: comfort (.97), knowledge (.93), approach

(.80), and attitude (.73). These results are comparable with both Kendall et al. (2003) and Fronek et al. (2005).

The KCAASS was modified by Post, Gianotten, Heijnen, Lambers, & Willems (2008) to be a more “generic” assessment used for multiple disciplines. This modification was done in two ways. The first was by replacing most references to “spinal cord injury” in the questions with the generic term “disability.” The second way it was modified was by deleting the last Attitude item:

“People with a spinal cord injury shouldn’t expect to have children.” The authors stated that “this item is not appropriate for most other diagnostic groups and an appropriate answer requires knowledge about the consequences of spinal cord injury that not every rehabilitation professional will have.”

This modified KCAASS, therefore, consisted of 44 items with summary scores for Knowledge

(range 14–56), Comfort (range 21–84), Approach (range 5–20), and Attitude (range 4–16).

Cronbach’s alpha are adequate (Santos, 1999); Knowledge [.85], Comfort [.95], and Approach

[.82]) The Attitude scale was insufficient (cronbach’s alpha = .57). Except for the KCAASS

Attitude subscale, all outcome variables had a sufficiently normal score distribution (skewness between -1 and 1; (Tabachnick & Fidell, 2013).

Verschuren et al. (2013) modified the KCAASS by translating it to Dutch and with modifications to the language from “spinal cord injuries” to make the questions more suitable for professionals working with people with an upper limb deficiency. Cronbach’s alpha in this adaptation of the Knowledge and Comfort scale was .95, for Approach .88 and for the Attitudes scale .76. The mean scores of all professionals for the Knowledge scale and Approach scale were

M=31.4, SD =8.5) and M = 9.6, SD = 3.7 respectively. The mean scores on the Comfort and

Attitudes scale were M= 63.0, SD =9.9 and M =15.2, SD = 1.5 respectively (Veruschuren et al.,

2013).

For this present study, with permission from the author, questions were adapted to make the language intentional for counselors, replacing words specific to rehabilitation therapists to words specific to mental health counselors. For example, the statement, “Patient says, ‘I want to have sex but my partner has lost interest—what should I do?’” was modified to state, “Client says ‘I want to have sex but my partner has lost interest—what should I do?’” the statement

“People with a spinal cord injury would find it hard to get a partner” was modified to state,

“People with a mental health diagnosis would find it hard to get a partner.” This allowed for the assessment of participants’ knowledge, attitudes, and comfort levels in a more general manner.

The KCAASS has been modified numerous times, with only one modification reducing one of the subscale’s validity scores. The effect of this modification on validity was accounted for as a limitation, which is discussed in more detail in the Discussion section. The full original assessment can be found in Appendix A, and the modified assessment can be found in Appendix

The KCAASS measures four components of counselor’s views of human sexuality. The

Knowledge subscale consists of fourteen questions. In the present sample the mean for

Knowledge subscale scores was 41.71, with a 6.63 standard deviation, and a range of 26. The scale had a high level of internal consistency in the present study, as determined by a Cronbach’s alpha of .92. The Comfort subscale consists of twenty questions. The mean for the Comfort subscale scores was 73.21, with a standard deviation of 10.73, and a range of 47. The scale had a high level of internal consistency determined by a Cronbach’s alpha of .96. The Approach subscale consisted of five questions. The mean for the approach subscale scores was 12.18, with a standard deviation of 3.77, and a range of 15. The scale had high internal consistency, as determined by a Cronbach’s alpha of .88. The Attitudes subscale consisted of five questions. The mean for the attitude subscale scores was 17.9, with a standard deviation of 2.16, and a range of

11. The scale had a usable internal consistency, as determined by a Cronbach’s alpha of .79, which is higher than the minimal acceptable value of .70 (Santos, 1999).

Demographic Information

Participant demographic data were gathered using a demographic questionnaire.

Demographic data were gathered to explore the relationship between counselor geographic area of practice and to control for possible confounding variables in the regression model according to their causal priority (Petrocelli, 2003). The following demographics were included in the analysis: age, gender, geographic area of origin (i.e., urban, rural, or suburban area), geographic area of residence (i.e., urban, rural, or suburban area) religious identification (participant write- in), geographic area of practice (i.e., urban, rural, or suburban area), number of human sexuality courses taken (participant write-in), and sexual identity (participant write-in). Correlating participant scores on the KCAASS, along with the constructs of the collected counselor demographics using multivariate statistics, allowed for an exploration of the relationships among these constructs within the sample.

Age. Previous research on age and attitudes of sexuality has predominantly included college-age students (Wilson, 1975), examined age and spirituality (Le Gall, Mullet, & Shafighi,

2002), and older adults and sexuality (Kang & Park, 2003) and has proved to be an impactful demographic in each of the mentioned studies. This demographic variable was included because it could have a relationship with KCAASS score and should be further explored in the current study. Participants provided their age on the demographic questionnaire.

Gender. Gender differences in attitudes towards sexual attitudes have been explored

(Hendrick, Hendrick, Slapion-Foote, & Foote, 1985) and significant differences were found in men and women’s attitudes of sexuality, with men reporting lower rates of open and affirming attitudes towards homosexuality and less openness to discussing sexual issues. The authors found empirical evidence for continuing the study of gender differences in sexual attitudes.

Participants indicated their gender identity through an open-response item on the demographic questionnaire.

Sexual identity. When exploring attitudes around gender, significant differences between those who identify as a sexual minority and those who identity as heterosexual and their attitudes around sexuality exist (Grollman, 2017). In this study, participants indicated their sexual identity through an open-response item on the demographic questionnaire. This allowed for a more diverse sample of counselors and a more inclusive way for participants to identify their sexual identity.

Geographic location of origin. Cultural identity, family culture, and demographic area during adolescence have proven predictors of attitudes around sexual behavior, sexual knowledge, and sexual beliefs (Bloom et al., 2015). Urban areas, described by the Census

Bureau as areas that represent densely developed territories, encompass residential, commercial,

and other non-residential urban land uses with populations of 50,000 or more people (United

States Census Bureau, n.d.). The Census Bureau does not define rural areas; rather, rural areas are defined by the lack of being urban. The Census Bureau also does not define suburban areas, suburban areas are defined as non-metropolitan, non-rural areas. The demographic form for participants defined “urban” as a metropolitan areas, “suburban” as including micropolitan or medium population clusters outside of metropolitan areas, and “rural” as neither suburban or urban areas with populations under 50,000 (United States Census Bureau, n.d.). Participants selected from these three choices on the demographic form.

Geographic location of practice. Crockett et al. (2000) stated that the rural-urban distinction is a poignant social category and is the foundation for self-definition and community identity, with important implications for the socialization of urban versus rural populations.

Some researchers have posited that a professional’s community identity and attitudes regarding sexuality hinder their ability to work with clients with issues related to sexuality (Bloom et al.,

2016). The demographic form for participants defined “urban” as a metropolitan areas,

“suburban” as including micropolitan or medium population clusters outside of metropolitan areas, and “rural” as neither suburban or urban areas with populations under 50,000. Participants selected from these options on the demographic form.

Geographic location of residence. The demographic form for participants defined

“urban” as a metropolitan areas, “suburban” as including micropolitan or medium population clusters outside of metropolitan areas, and “rural” as neither suburban or urban areas with populations under 50,000. Participants selected from these options on the demographic form.

Spiritual identity. The foundation of sexual health is regularly impacted by the attitudes of traditional religious understanding and teachings around sexuality (Slowinski, 2001).

Religious beliefs can contribute to the formation of sexual difficulties, and can also interfere with the progress of mental health therapy (Slowinski, 2001). In this study, participants indicated their spiritual identity through an open-response item on the demographic questionnaire. This allowed for a more diverse sample of counselors and a more inclusive way for participants to identify their spiritual identity.

Number of post-secondary human sexuality courses taken. Counselors are not required to take post-secondary human sexuality courses for licensure in most states; only

Florida and California require a human sexuality course for independent licensure (ACA, 2009).

Scholars have indicated that courses on human sexuality have significant impacts on knowledge, attitudes, and longitudinal views of human sexuality (Zuckerman, Tushup, & Finner, 1976).

Participants indicated the number of human sexuality courses they completed as a write-in number on the demographic form.

Data Cleaning

Data were screened to ensure they were usable to continue with statistical analyses. Two hundred twenty six surveys were submitted by participants. Surveys with incomplete information were screened from analysis, leaving 186 completed surveys (40 surveys were removed). A sample size of approximately 178 was determined acceptable for the purposes of the present study and to achieve Power of at least .80 at a significance level of p ≤ .05 (Cohen, 1988); the present sample exceeds this number (N = 186). Tabachnick and Fidell (2013) suggest that 104 + k (number of variables in the regression equation) as minimum sample size yielding adequate power; for the present study that would be 112. Power of .80 is appropriate for correlational research, and p ≤ .05 is an adequate significance level in counseling research (Balkin & Sheperis,

2009; Cohen, 1988).

Following this, appropriate KCAAS items were reversed scored, and raw totals for the knowledge, comfort, approach, and attitude subscales, and the KCAASS overall were computed.

Summary scores for each of the fours subscales were calculated, with higher scores representing greater knowledge and skills. The subscales of comfort, approach, and attitudes were reverse scored.

After cleaning the KCAASS data, demographic variables were cleaned and coded. All of the demographic variables gathered are categorical (i.e., gender, sexuality, spiritual identity, geographic area of origin, geographic area of practice), except for age and the number of human sexuality courses taken. Categorical variables were dummy coded for the purposes of regression analyses in this study. Dummy coding is required in multiple regression analysis because it allows for coding differing levels of measurement of certain variables into dichotomous variables

(Cohen, 1988). The demographic variables gender, spiritual identity, geographic location variables, and sexual identity were dummy coded and used as dichotomous variables for use in the regression. Gender was coded as “non-cismale” (0) and “cismale” (1). Spiritual identity was coded as “Christian” (1) and “non-Christian” (0). Geographic location of origin, residence, and practice were coded as “suburban and urban” (1) or “rural” (0). Age and number of courses were entered into the models as continuous variables.

Gender was coded based on the write-in responses from participants. Significant differences have been found in men and women’s attitudes of sexuality, with women being more accepting of homosexuality and comfortable discussing sexuality (Hendrick et al., 1985).

Women, transgender, and other genders were coded as 0, and cismen were coded as 1.

Sexual identity was coded based on the write-in responses from participants. With significant differences between those who identify as a sexual minority and those who identity as

heterosexual and their attitudes around sexuality (Grollman, 2017), those who identify as non- heterosexual were coded as 1, and 0 was attributed to heterosexual participants. Sexual identity was coded in this way due to non-heterosexual individuals having significantly more positive attitudes around sexuality (Grollman, 2017).

Geographic location of origin was coded based on the write-in responses from participants. A new variable was created and dummy coded for use in this regression model. A value of 0 was attributed to rural participants and a value of 1 was attributed to urban and suburban participants. Geographic location of origin was coded in this way due to the fact that the majority of the population of the country is from urban or suburban areas (United States

Census Bureau, n.d.).

Geographic location of residence was coded based on the write-in responses from participants. A new variable was created and dummy coded for use in this regression model. A value of 0 was attributed to rural participants and a value of 1 was attributed to urban and suburban participants. Geographic location of residence was coded like this due to the fact that the majority of the population of the country is from urban or suburban areas (United States

Census Bureau, n.d.).

Geographic location of practice was coded based on the write-in responses from participants. A new variable was created and dummy coded for use in this regression model. A value of 0 was attributed to rural participants and a value of 1 was attributed to urban and suburban participants. Geographic location of practice was coded like this due to the fact that the majority of the population of the country resides in urban or suburban areas (United States

Census Bureau, n.d.).

Spiritual identity was coded based on the write-in responses from participants. A new spiritual identity variable was created and dummy coded for use in the regression model. In this new variable, a value of 0 was attributed to non-Christian participants and a value of 1 was attributed to Christian participants. Spiritual identity was coded like this due to the fact that

Christianity was the majority in the sample.

The variable of number of human sexuality courses was identified by the participants.

The numerical value of how many courses that the participants identify taking with was used within the regression model as a numerical variable and it was not dummy coded.

Assumption Testing

Hierarchical Linear Regression (HLR). Assumption testing was completed prior to moving forward with data analysis. The KCAASS composite and subscale scores are normally distributed (skewness and kurtosis less than ±2), (Tabachnick & Fidell, 2013). KCAASS composite score has a skewness of -.533 and kurtosis of .017. The knowledge subscale has a skewness of -.155 and kurtosis of -.244. The comfort subscale has a skewness of -.928 and kurtosis of -.162. The approach subscale has a skewness of .286 and kurtosis of -.791. The attitude subscale has a skewness of -1.124 and kurtosis of 1.919. All are within acceptable ranges of normality (Tabachnick & Fidell, 2013). There was independence of residuals as assessed by a

Durbin Watson statistic of 1.926. All participants (N=186) indicated their age, gender, spiritual identity, sexual identity, number of courses taken, geographic location of origin, geographic location of residence, and geographic location of practice; after data cleaning there were no missing variables. The categorical variables (age, gender, spiritual identity, sexual identity, geographic location of origin, geographic location of residence, and geographic location of practice) were dummy coded for the regression model. These variables are categorical and were

not screened for normality. The continuous variables, age, met standards for normality

(skewness=.895, kurtosis= .211), and number of courses taken (skewness=1.53, kurtosis= 1.309), as both skewness and kurtosis were less than ±2 (Tabachnick & Fidell, 2013. There was homosedacity, as assessed by visual inspection of a plot of studentized residuals versus unstandardized predicted values. Multicollinearity was assessed through inspection of correlation coefficients and Tolerance/VIF values. No independent variables had correlations higher than .70 and no tolerance values were lower than .1. Unusual points were assessed through outliers, leverage points. and highly influential points. No items fell outside of 3 standard deviations, no leverage points were above .20, no Cook’s values were above 1, and no caseweight diagnostic table was produced. Residuals were normally distributed as assessed by visual interpretation of histogram.

Factorial Analysis of Variance (ANOVA). A factorial ANOVA was conducted to determine the effects of gender, spiritual identity, and sexual identity on composite KCASS scores. There was homogeneity of variances, as assessed by a Levene's test for equality of variances, p = .147. There was one outlier assessed as a value greater than 3 box-lengths from the edge of the box. Participant 109 was removed to explore if the outlier had an appreciable affect on the analysis, it did not significantly impact the results and the outlier was not removed.

KCAASS composite scores were normally distributed as assessed by a Shapiro-Wilk's test of normality, the results were .211 meeting the requirements for normality.

Data Analysis

Following data cleaning procedures, data were entered into SPSS 23 for analysis. The first hierarchical multiple regression was conducted using age, gender, spiritual identity, sexual identity, number of courses taken, geographic location of origin, residence, and practice and

KCASS composite scores. Variables were entered in three steps, in alignment with the model and the causal priority of the variables (Petrocelli, 2003). This allowed for the identification of the effect that independent variables (age, gender, spiritual identity, sexual identity, number of courses taken, geographic location of origin, residence) had on the dependent variable (KCASS composite scores). Step one included participant gender (Hendrick, Hendrick, Slapion-Foote, &

Foote, 1985), participant age (Le Gall, Mullet, & Shafighi, 2002), participant spiritual identity

(Slowinski, 2001), and participant sexual identity (Grollman, 2017) that have been shown to be related to sexuality stances. The second step included number of human sexuality courses taken

(Zuckerman, Tushup, & Finner, 1976). The final step included participants’ geographic location of origin, residence, and practice (Bloom et al., 2016; Bloom et al., 2015; Crockett et al. 2000).

The second regression was done in a similar manner, but in the second regression the

Knowledge subscale score was used as the dependent variable. Variables were entered in step- wise congruent with their causal priority. The first step included the demographic predictor variables of age, gender, spiritual identity, sexual identity. The second step included number of human sexuality courses taken. The final step included the entry included participants’ geographic location of origin, residence, and practice.

The third regression was done similar to the first and second, but in the third regression the Comfort subscale score was used as the dependent variable. Variables were entered in step- wise congruent with their causal priority. The first step included the demographic predictor variables of age, gender, spiritual identity, sexual identity. The second step included number of human sexuality courses taken. The final step included the entry included participants’ geographic location of origin, residence, and practice.

The fourth regression was completed similar to the first three, but in the fourth regression the Approach subscale scores was used as the dependent variable. Variables were entered in step-wise congruent with their causal priority. The first step included the demographic predictor variables of age, gender, spiritual identity, sexual identity. The second step included number of human sexuality courses taken. The final step included the entry included participants’ geographic location of origin, residence, and practice.

The final regression was done in the same manner, but in the fifth regression the

Attitudes subscale scores was used as the dependent variable. Variables were entered in step- wise congruent with their causal priority. The first step included the demographic predictor variables of age, gender, spiritual identity, sexual identity. The second step included number of human sexuality courses taken. The final step included the entry included participants’ geographic location of origin, residence, and practice.

To answer the sixth research question a factorial analysis of variance (ANOVA) was conducted.

The selected demographic factors of gender, spiritual identity, and sexual identity were entered into the model as the independent variables as they are categorical variables. The KCAASS composite score was entered as the dependent variable (continuous). Results of these analyses are discussed in Chapter 4.

Chapter 4

Results

Chapter four describes the results of data analyzed from participants that completed the

KCAASS and demographic questionnaire. The research questions and hypotheses, data cleaning, description of participant demographics, correlations between variables of interest, and descriptions of the results of main statistical analyses are included in this chapter.

Research Question and Hypotheses

Research Question One

Is there a significant relationship between counselors’ geographic locations and their knowledge, comfort, approach, and attitudes about sexuality as measured by the composite score on the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken)?

Null Hypothesis One

There is not a significant relationship (p > .05) between counselors’ geographic locations and their knowledge, comfort, approach, and attitudes about sexuality as measured by the composite score on the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Hypothesis One

There is a significant relationship (p ≤ .05) between counselors’ geographic locations and their knowledge, comfort, approach, and attitudes about sexuality as measured by the composite score on KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Question Two

Is there a significant relationship between counselors’ geographic locations and their knowledge of sexuality as measured by the knowledge subscale score on the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken)?

Null Hypothesis Two

There is not a significant relationship (p > .05) between counselors’ geographic locations and their knowledge of sexuality as measured by the knowledge subscale score on the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Hypothesis Two

There is a significant relationship (p ≤ .05) between counselors’ geographic locations and their knowledge of sexuality as measured by the knowledge subscale score on KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Question Three

Is there a significant relationship between counselors’ geographic locations and their comfort with sexuality as measured by the comfort subscale score on the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken)?

Null Hypothesis Three

There is not a significant relationship (p > .05) between counselors’ geographic locations and their comfort with sexuality as measured by the comfort subscale score on the KCAASS

when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Hypothesis Three

There is a significant relationship (p ≤ .05) between counselors’ geographic locations and their comfort with sexuality as measured by the comfort subscale score on KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Question Four

Is there a significant relationship between counselors’ geographic locations and their approach to sexuality as measured by the approach subscale score on the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken)?

Null Hypothesis Four

There is not a significant relationship (p > .05) between counselors’ geographic locations and their approach to sexuality as measured by the approach subscale score on the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Hypothesis Four

There is a significant relationship (p ≤ .05) between counselors’ geographic locations and their approach to sexuality as measured by the approach subscale score on Knowledge, Comfort,

Approach, and Attitude towards Sexuality Scale (KCAASS) when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Question Five

Is there a significant relationship between counselors’ geographic locations and their attitudes about sexuality as measured by the attitude subscale score on the Knowledge, Comfort,

Null Hypothesis Five

There is not a significant relationship (p > .05) between counselors’ geographic locations and their attitudes about sexuality as measured by the attitude subscale score on the KCAASS when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Hypothesis Five

There is a significant relationship (p ≤ .05) between counselors’ geographic locations and their attitudes about sexuality as measured by the attitude subscale score on Knowledge,

Comfort, Approach, and Attitude towards Sexuality Scale (KCAASS) when controlling for participant demographic factors (age, gender, sexual identity, spiritual identity, and number of human sexuality courses taken).

Research Question Six

Are there significant differences between counselors’ geographic locations and their attitudes about sexuality as measured by the composite KCAASS score and their demographic factors (age, gender, sexual identity, spirituality identity, geographic locations, and number of human sexuality courses taken)?

Null Hypothesis Six

There are no significant differences (p>.05) between counselors’ geographic locations and their attitudes about sexuality as measured by the composite KCAASS score and their demographic factors (age, gender, sexual identity, spiritual identity, geographic locations, and number of human sexuality courses taken).

Research Hypothesis Six

There are significant differences (p ≤ .05) between counselors’ geographic location of practice and their attitudes about sexuality as measured by the composite KCAASS score and their demographic factors (age, gender, sexual identity, spirituality identity, geographic locations, and number of human sexuality courses taken).

Variables of Interest

KCAASS

KCAASS composite total was computed along with subscale scores.

Table 1

KCAASS Descriptives

M SD Minimum Maximum

Composite Scores 163 23.37 86 180

Knowledge Subscale 41.17 6.63 26 56

Comfort Subscale 73.21 10.73 37 84

Approach Subscale 12.18 3.7 5 20

Attitude Subscale 17.9 2.16 9 20

Note: KCAASS = The Knowledge, Comfort, Approach and Attitudes toward Sexuality Scale

(Kendall et al., 2003)

The KCAASS composite and subscale scores were used for the hierarchical linear regression and factorial ANOVA analyses as continuous variables.

Correlations Between Research Variables of Interest

Pearson product correlations were calculated using SPSS 23 to explore the relationships between each variable of interest. The KCAASS composite score was negatively correlated with participant age (r= -.173, p= .001) and participant spiritual identity (r= -.204, p= .003). The

KCAASS composite score was correlated with participant number of courses taken (r=.198, p=.003), location of origin (r=.124, p=.030) and location of practice (r=.217, p=.030). These correlations indicate that younger participants scored lower, and the more courses a participant had taken the higher the participants score. Additionally, participants from or practicing in rural areas scored lower than those in suburban/rural areas.

The KCAASS knowledge subscale is positively correlated with participant age (r= .121, p= .050), gender (r= .156, p= .017), sexual identity (r= .282, p< .001), and with the number of courses taken (r= .308, p< .001). The knowledge subscale score was negatively correlated with spiritual identity (r= -.226, p= .001). The KCAASS comfort subscale was negatively correlated with spiritual identity (r=-.212, p= .002). The comfort subscale was also positively correlated with participant number of courses taken (r= .198, p= .004), location of origin (r= .148, p=.022), location of residence (r=.147, p=.022), and location of practice (r=.147, p=.002). The KCAASS approach subscale was positively correlated with participant age (r= .301, p< .001), gender (r=

.194, p= .004). The KCAASS attitude subscale was negatively correlated with participant gender

(r=-.164, p=.013) and spiritual identity (r=-.252, p< .001). The attitude subscale was significantly correlated with participant number of courses taken (r= .208, p=.002) and location of origin (r=.142, p=.027).

In regard to demographic variables, age was significantly correlated with gender (r=.214,

p=.002) and sexual identity (r= -.191, p=.004). Sexual identity was significantly correlated the

number of courses taken (r=.159, p=.015), location of residence (r=.236, p=.001), and location of

practice (r=.226, p=.001). Number of courses taken was significantly correlated with location of

origin (r= .150, p=.020 ). Participant location of origin was significantly correlated with location

of residence (r=.353, p< .001) and location of practice (r=.379, p< .001). The final significant

correlation was location of residence and location of practice (r= .579, p< .001).

Table 2

Correlations: Variables of Interest

Variable M SD 1 2 3 4 5 6 7 8 9 *- --- *.173 0.026 0.087 .*198 *.138 0.083 *.157 Composite Score 163 23.37 .204 Predictor Variables 2. Participant Age 40.14 12.84 ------*.214 *.191 *.123 0.055 0.056 -0.06 0.034 3 Participant ------0.108 0.05 0.038 Gender 0.022 0.072 0.051 4. Sexual Identity ------0.33 *.159 0.005 *.236 *.226 5. Spiritual ------0.16 Identity 0.038 0.083 0.177 6. Number of ------*.150 0.061 0.07 Courses Taken 1.34 1.36 7. Location of ------*.353 *.379 Origin 8. Location of ------*.579 Residence 9. Location of ------Practice

Notes. KCAASS Scores = Knowledge, Comfort, Approach, Attitudes Sexuality Scale scores;

Participant Factors = Participant Age, gender, sexual identity, spiritual identity, number of

courses taken, location of origin, location of residence, and location of practice.

*= p<.05

Table 3

Correlations: Variables of Interest & Subscales Number Location Location Location Sexual Spiritual of Age Gender of of of Identity Identity courses Origin residence Practice taken Knowledge -- *.121 *.156 *.282 *-.226 *.308 0.075 0.064 0.082 Subscale Comfort -- 0.077 -0.048 0.118 *-.212 *.192 *.148 *.147 *.208 Subscale Approach -- *.301 *.194 0.01 -0.075 0.109 0.062 0.003 0.097 Subscale Attitude -- -0.03 *-.164 0.1 *-.252 *.208 *.142 0.049 0.051 Subscale

Notes. KCAASS Scores = Knowledge, Comfort, Approach, Attitudes Sexuality Scale scores;

Participant Factors = Participant Age, gender, sexual identity, spiritual identity, number of

courses taken, location of origin, location of residence, and location of practice.

*= p<.05

Research Question One: Counselor Demographics and KCAASS Composite Score

Results of the first regression analysis are presented in Tables 4 and 5. The first two steps

in the regression are statistically significant (demographic variables of age, gender, spiritual

identity, sexual identity and number of courses taken). However, the third and final step, where

the geographic locations were added to the model did not significantly influence the

predictability of KCAASS composite scores. The full model of age, gender, spiritual identity,

sexual identity, number of courses taken geographic area of origin, residence, and practice to

predict KCAASS score (Model 3) was not statistically significant, R2 = .127, F (8, 177) = 3.209,

p = .002, adjusted R2 = .087. The addition of number of courses taken to the prediction of

KCAASS score (Model 2) led to a statistically significant increase in R2 of .114, F (5, 180) =

4.632, p < .000.

Table 4

Hierarchical Linear Regression Predicting Composite Score on Knowledge, Comfort, Attitudes,

Approach to sexuality Scale with age, gender, spiritual identity, sexual identity, number of college level human sexuality courses, geographic location of origin, geographic location of residence, and geographic location of practice. (N = 186)

Model 1 Model 2 Model 3 B ß B ß B ß

Constant 152.14 149.76 145.32 Age 0.088 *.213 0.355 *.195 0.333 *.183 Gender -0.85 -0.015 -2.1 -0.004 -0.014 *.183 Spiritual -9.78 *-.210 -9.913 *-.213 -9.23 *-.198 Sexual 3.27 0.059 1.42 0.026 0.8 0.014 Courses - - 3 *.176 2.81 *.195 Origin - - - - 2.9 0.06 Residence - - - - -1.44 -0.027 Practice - - - - 5.65 0.094

R2 0.084 0.114 0.127 F *4.166 *4.632 *3.209 ∆R2 0.084 *0.03 *0.013 ∆F *4.166 *6.033 0.857

Note. N=186, *p<.05

Table 5 Hierarchical Regression Analysis Predicting Counselor Composite Score with Demographic Factors

Step and predictor variables R2 ∆R2 ß Step 1: 0.084 0.084 Age *.213

Gender -0.015 Spiritual Identity *-.210 Sexual Identity 0.059 Step 2: 0.114 *0.03 Number of courses taken *.176 Step 3: 0.127 *0.013 Location of Origin 0.06 Location of Residence -0.027 Location of Practice 0.094 Note. N=186, *p<.05 Regression analyses indicate that the significant changes in this model are explained in the first and second step when age, gender, spiritual identity, sexual identity, and number of courses taken are entered into the model and no significant change with the addition of counselor location variables. The impact of counselor demographic variables contributed to the prediction of participants’ KCAASS composite score in the regression model. Age, spiritual identity, and number of courses taken appear to be stronger predictors based on the examination of the standardized beta weights.

Research Question Two: Counselor Demographics and KCAASS Knowledge Subscale

Score

Results of the regression analysis are presented in Table 6 and 7. Age was significantly correlated with knowledge subscal (r= .12, p= .05). Gender was significantly correlated with knowledge subscale (r= .156, p= .017). Sexual identity was significantly correlated with knowledge subscale (r= .28, p= .000). Spiritual identity was significantly correlated with knowledge subscale (r= -.226, p= .001). And number of post-secondary courses taken was significantly correlated with knowledge subscale (r= .308, p= .000). No significant correlations found between knowledge subscale score and participants’ location variables.

Table 6

Hierarchical Linear Regression Predicting Knowledge Subscale Score on Knowledge, Comfort,

Attitudes, Approach to sexuality Scale with age, gender, spiritual identity, sexual identity, number of college level human sexuality courses, geographic location of origin, geographic location of residence, and geographic location of practice. (N = 186)

Model 1 Model 2 Model 3 Variable B ß B ß B ß Constant 37.56 36.54 36.67 Age .086 *.167 .072 *.140 .073 *.141 Gender 1.635 * -.167 1.913 .120 1.87 .117 Spiritual -2.25 *-.170 -2.306 * -.174 -2.315 *-.175 Sexual 3.868 *.247 3.074 *.196 3.15 * 1.20 Courses -- -- 1.285 *.265 1.276 * .263 Origin ------.204 .015 Residence ------.134 -.009 Practice ------.209 -.012

R2 .144 .212 .212 . F *7.631 *9.685 *5.963 ∆R2 .144 .068 .000 ∆F *7.631 *15.631 .023 Note. N=186, *p<.05

Table 7

Hierarchical Regression Analysis Predicting Counselor Knowledge Subscale Score with

Demographic Factors

Step and predictor variables R2 ∆R2 ß Step 1: 0.144 0.144 Age *0.167 Gender *0.167 Spiritual Identity *-0.17 Sexual Identity *0.247

Step 2: 0.212 0.068 Number of courses taken *0.265 Step 3: 0.212 0.00 Location of Origin 0.015 Location of Residence -0.009 Location of Practice 0.012 Note. N=186, *p<.05

Regression analyses indicate that the significant changes in this model are explained in the first and second step when age, gender, spiritual identity, sexual identity, and number of courses taken are entered into the model and no significant change with the addition of counselor location variables. The impact of counselor demographic variables contributed to the prediction of participants’ KCAASS knowledge subscale score in the regression model. Age, spiritual identity, sexual identity and number of courses taken appear to be stronger predictors based on the examination of the standardized beta weights.

Research Question Three: Counselor Demographics and KCAASS Comfort Subscale Score

` Results of the regression analysis are presented in Table 8 and 9. Spiritual identity was significantly negatively correlated with comfort subscale score (r= -.212, p= .00). Number of post-secondary courses taken was significantly correlated with comfort subscale score (r= .192, p= .004). Participant location of origin was significantly correlated with comfort subscale score

(r= .148, p= .004). Participant location of residence was significantly correlated with comfort subscale score (r= .147, p= .022). Participant location of practice was significantly correlated with comfort subscale score (r= .208, p= .022).

Table 8

Hierarchical Linear Regression Predicting Comfort Subscale Score on Knowledge, Comfort,

Model 1 Model 2 Model 3 Variable B ß B ß B ß Constant 70.70 69.65 66.37 Age .112 .134 .098 .117 .085 .101 Gender -1.97 -.076 -1.68 -.065 -1.424 -.055 Spiritual -4.21 -.197 -4.268 * -.199 -3.823 *-.175 Sexual 2.189 * .086 1.317 *.168 .688 .027 Courses -- -- 1.317 *.168 1.226 *.156 Origin ------1.198 .054 Residence ------.320 .013 Practice ------3.470 .125

R2 .066 .093 .118 . F *3.193 *3.692 *2.947 ∆R2 .066 *.027 *.025 ∆F *3.193 *5.379 1.639 Note. N=186, *p<.05

Table 9

Hierarchical Regression Analysis Predicting Counselor Comfort Subscale Score with

Demographic Factors

Step and predictor variables R2 ∆R2 ß Step 1: 0.066 0.066 Age 0.134 Gender -0.076 Spiritual Identity -0.197 Sexual Identity *.086

Step 2: 0.093 *0.027 Number of courses taken *.168 Step 3: 0.118 *0.025 Location of Origin 0.054 Location of Residence 0.013 Location of Practice 0.125 Note. N=186, *p<.05

Regression analyses indicate that the significant changes in this model are explained in the first and second step when age, gender, spiritual identity, sexual identity, and number of courses taken are entered into the model and no significant change with the addition of counselor location variables. The impact of counselor demographic variables contributed to the prediction of participants’ KCAASS comfort subscale score in the regression model. Sexual identity and number of courses taken appear to be stronger predictors based on the examination of the standardized beta weights.

Research Question Four: Counselor Demographics and KCAASS Approach

Subscale Score

` Results of the regression analysis are presented in Table 10 and 11. Age was significantly negatively correlated with approach subscale score (r= -.301, p= .000). Gender was also significantly correlated with approach subscale score (r= -.194, p= .004). No other factors had significant correlations with the approach subscale scores.

Table 10

Hierarchical Linear Regression Predicting Approach Subscale Score on Knowledge, Comfort,

Model 1 Model 2 Model 3 Variable B ß B ß B ß Constant 8.907 8.703 8.314 Age .085 *.288 .082 * .278 .079 * .268 Gender 1.241 .137 1.297 * .143 1.343 *.148 Spiritual -.850 -.113 -.861 -.114 -.805 -.107 Sexual .113 .013 -.046 -.005 -.153 -.017 Courses -- -- .257 .093 .254 .092 Origin ------.024 -.003 Residence ------.408 -.047 Practice ------1.00 .103

R2 .121 .130 .137 . F *6.256 *5.369 *3.500 ∆R2 .121 *.008 *.007 ∆F *6.256 1.722 .463 Note. N=186, *p<.05

Table 11

Hierarchical Regression Analysis Predicting Counselor Approach Subscale Score with

Demographic Factors

Step and predictor variables R2 ∆R2 ß Step 1: 0.121 0.121 Age *.288 Gender 0.137 Spiritual Identity -0.113 Sexual Identity 0.013

Step 2: 0.13 0.008 Number of courses taken 0.093

Step 3: 0.137 0.007 Location of Origin -0.003 Location of Residence -0.047 Location of Practice 0.103

Note. N=186, *p<.05

Regression analyses indicate that the significant changes in this model are explained in the first step, where age, gender, spiritual identity, and sexual identity are entered into the model.

Table 7 presents the changes in the predictive relationship in all three steps of the regression. In step one, there are significant (p<.001) changes when age, gender, spiritual identity, and sexual identity is added to the model. The impact of counselor demographic variables contributed to the prediction of participants’ KCAASS approach subscale score in the regression model. Age appears to be the stronger predictor based on the examination of the standardized beta weights.

Research Question Five: Counselor Demographics and KCAASS Attitudes Subscale Score

Results of the regression analysis are presented in Table 12 and 13. Gender was significantly negatively correlated with attitudes subscale score (r= -.164, p= .013). Spiritual identity was significantly negatively correlated with attitudes subscale score (r= -.252, p< .000).

Number of post-secondary courses taken was significantly correlated with attitudes subscale score (r= .208, p= .002). Participant location of origin was significantly correlated with attitude subscale score (r= .142, p= .027).

Table 12

Hierarchical Linear Regression Predicting Attitude Subscale Score on Knowledge, Comfort,

Attitude Subscale Score KCAASS

Model 1 Model 2 Model 3 Variable B ß B ß B ß Constant 18.241 18.000 18.003

Age .007 .043 .004 .024 .004 .024 Gender -.867 *-.166 -.802 * -.154 -.873 * -.167 Spiritual -1.007 *-.233 --1.021 *-.236 -1.000 *-.231 Sexual .250 .049 .062 .012 .191 *.037 Courses -- -- .304 *.192 .275 .174 Origin ------.593 .133 Residence ------.180 -.036 Practice ------.276 -.049

R2 .090 .125 .140 . F *4.457 *5.157 *3.589 ∆R2 .090 *.036 *.014 ∆F *4.457 *7.334 .978 Note. N=186, *p<.05,

Table 13

Hierarchical Regression Analysis Predicting Counselor Attitude Subscale Score with

Demographic Factors

Attitude score Step and predictor variables R2 ∆R2 ß Step 1: 0.09 0.09 Age 0.043 Gender *-.166 Spiritual Identity *-.233 Sexual Identity 0.049 Step 2: 0.125 *0.036 Number of courses taken *.192 Step 3: 0.14 *0.014 Location of Origin 0.133 Location of Residence -0.036 Location of Practice -0.049 Note. N=186, *p<.05

Regression analyses indicate that the significant changes in this model are explained in the first and second steps, where age, gender, spiritual identity, sexual identity, and number of courses taken are entered into the model. Table 12 presents the changes in the predictive

relationship in all three steps of the regression. In step one, there are significant (p=.002) changes when age, gender, spiritual identity, and sexual identity is added to the model. Also in step two, there are significant (p=.007) changes when number of courses taken are added to the model.

The impact of counselor demographic variables contributed to the prediction of participants’

KCAASS attitude subscale score in the regression model. Gender, spiritual identity, and number of courses taken appear to be the stronger predictors based on the examination of the standardized beta weights.

Research Question Six: Counselor Demographics and KCAASS Composite Score

A factorial ANOVA was conducted to determine the effects of gender, spiritual identity, and sexual identity on composite KCASS scores. There was homogeneity of variances, as assessed by a Levene's test for equality of variances, p = .147. There was one outlier assessed as a value greater than 3 box-lengths from the edge of the box. KCAASS composite scores were normally distributed as assessed by Shapiro-Wilk's test of normality. The ANOVA failed to produce a statistically significant three-way interaction between gender, spiritual identity, and sexual identity, F(1, 178) = .25, p = .875. Therefore, based on the use of Factorial ANOVA for research question six, there were no significant differences found.

Summary

The results of the research questions provide no support for each research question hypothesis. Each regression analyses supported step one (age, gender, sexual identity, and sexual identity), step two (number of courses taken, or steps one and two. None of the regressions conducted supported step three (location variables) as significant. Each regression indicates that number of courses is minimally predictive of KCAASS scores. The sixth research hypothesis, which assumed significant differences between KCAASS scores and select participant

demographics of gender, sexual identity, and spiritual identity was not supported. In Chapter 5 the researcher will discuss these findings. This will include presenting the implications of these findings, identifying the limitations of this study, and providing the reader with suggestions for future research.

Chapter Five

This chapter discusses the results of the study presented in the previous chapter. In addition, implications of these findings, identifying the limitations of this study, and providing the reader with suggestions for future research will be discussed in this chapter.

Review of Study

Research shows that concerns around human sexuality are common, estimates range from

40% (Laumann, Paik, & Rosen, 1999) to 98.8% of women (Nusbaum, Gamble, Skinner, &

Heiman, 2000); and 30% (Laumann, Paik, & Rosen, 1999) to 50% of men (Levy, 1994).

Research also suggests that people are regularly not getting their sexual issues addressed (Harris

& Hays, 2008; Juergens, Smedema, & Berven, 2009; Papaharitou et al., 2008). And, it may be because many counselors aren’t equipped to deal with sexual issues (Harris & Hays, 2008;

Weerakoon, Jones, Pynor, & Kilburn-Watt, 2004).

Additionally, Jameson and Blank (2007) found that counselor education programs may not adequately explore the roles of rural counselors. Crockett et al. (2000) stated that the rural– urban distinction is an important social category and is the basis for self-definition and community identity, with important implications for the socialization of urban versus rural youth.

Some researchers have posited that a professional’s community identity and attitudes regarding sexuality hinder their ability to work with clients with issues related to sexuality (Bloom et al.,

2016). However, how this demographic may impact counselors’ knowledge, attitudes, and comfort with sexuality has not previously been explored.

The purpose of this study was to explore the relationships between counselor location, counselor demographic factors, and counselors KCAASS scores and add to the literature related to human sexuality, rural locations, and sex education in counseling. This study was conducted using electronic survey methods participants that were recruited from professional counseling listservs including CESNET and the OCA listserv. Participants were recruited over a five-week period in Spring 2018.

The sample in the present study included 186 professional counselors from rural, suburban, and urban geographic locations, genders, ages, spiritual identities, and sexual identities. Participants also reported the number of post-secondary human sexuality courses they had taken. The research questions outlined below were explored using five hierarchical linear regressions and a factorial ANOVA in SPSS 23.

Major Findings

Research Question One

The first research question used a hierarchical linear regression to explore the relationship between counselors’ location of origin, residence, and practice while adjusting for age, gender,

spiritual identity, sexual identity, and number or post-secondary courses taken and the composite

KCAASS score. The most essential finding in the present study indicates that counselor location or origin, residence, and practice are not significantly related to counselor KCAASS composite score.

The regression explored the relationship between participants’ location of origin, residence, and practice and counselors composite KCAASS score while adjusting for age, gender, spiritual identity, sexual identity, and number or post-secondary courses taken. The results of this regression were significant at the first and second step, indicating that age, gender, spiritual identity, sexual identity, and number of courses taken does slightly significantly predict

KCAASS scores and that location of origin, residence, and practice do not. In the present study it was found that older age was significantly correlated with human sexuality competencies (r= -

.173, β = .213, p=.001), as did participant spiritual identity (r=-.204, β = -.210, p=.003). Older counselors and those that did not identify as Christian had higher human sexuality competencies.

The number of human sexuality courses taken also significantly predicted human sexuality competencies (r=.124, β = -.176, p=.003). Counselor location of origin and practice were each weakly correlated of human sexuality competencies (r=.124, p=.030) and (r=.217, p=.030), indicating that participants in rural areas had lower human sexuality competencies.

Research Question Two

The second research question used a hierarchical linear regression to explore the relationship between counselors’ location of origin, residence, and practice while adjusting for age, gender, spiritual identity, sexual identity, and number or post-secondary courses taken and the KCAASS knowledge subscale score. The most essential finding in the present study indicates that counselor location or origin, residence, and practice are not significantly related to counselor

KCAASS knowledge subscale score. Increased age correlated to higher knowledge subscale scores. Higher age correlated to higher knowledge subscale scores. Non-heterosexual participants were correlated with higher knowledge subscale scores. And those not identifying as

Christian were correlated with higher knowledge subscale scores.

The regression explored the relationship between participants’ location of origin, residence, and practice and counselors KCAASS knowledge subscale score while adjusting for age, gender, spiritual identity, sexual identity, and number or post-secondary courses taken. Participants age was significantly correlated with human sexuality knowledge scores (r= .121, β = .167, p=.050), indicating that older participants scored higher on the knowledge subscale. Participant gender scores (r= .156, β = -.167, p=.017), sexual identity scores (r= .282, β = .247, p<.000), and spiritual identity scores (r= -.226, β = -.170, p=.001) were all significant predictors of knowledge subscale scores. Participants who identified as male, non-heterosexual, and/or not of a Christian faith had higher knowledge subscale scores. The number of human sexuality courses taken also significantly predicted knowledge subscale scores (r=.308, β = .265, p<.001).

Research Question Three

The third research question used a hierarchical linear regression to explore the relationship between counselors’ location of origin, residence, and practice while adjusting for age, gender, spiritual identity, sexual identity, and number or post-secondary courses taken and the KCAASS comfort subscale score. The most essential finding in the present study indicates that counselor location or origin, residence, and practice are slightly correlated to counselor

KCAASS comfort subscale score, however there was no significant F change in the third step.

The regression explored the relationship between participants’ location of origin, residence, and practice and counselors KCAASS comfort subscale score while adjusting for age,

gender, spiritual identity, sexual identity, and number or post-secondary courses taken. The results of this regression were significant at the first and second step, indicating that age, gender, spiritual identity, sexual identity, and number of courses taken does slightly significantly predict

KCAASS comfort subscale scores. The number of human sexuality courses taken also significantly predicted comfort subscale scores (r=.198, β = .168, p=.004). Counselor location of origin, residence, and practice were each weakly correlated with comfort subscale scores

(r=.148, p=.022), (r=.147, p=.022), and (r=.147, p=.002) respectively, indicating that participants in rural areas had lower comfort levels with human sexuality.

Research Question Four

The fourth research question used a hierarchical linear regression to explore the relationship between counselors’ location of origin, residence, and practice while adjusting for age, gender, spiritual identity, sexual identity, and number or post-secondary courses taken and the KCAASS approach subscale score. In the present study it was found that older age was significantly correlated with approach subscale score (r= .301, β = .288, p<.001), as did participant gender (r=

.194, β = .143, p=.00). Participants who identified and cis men and were older were correlated to higher approach subscale scores.

The regression explored the relationship between participants’ location of origin, residence, and practice and counselors KCAASS approach subscale score while adjusting for age, gender, spiritual identity, sexual identity, and number or post-secondary courses taken. The results of this regression were significant at the first step, indicating that age, gender, spiritual identity, and sexual identity are significantly predictive of KCAASS approach subscale scores and that location of origin, residence, and practice do not.

Research Question Five

The fifth research question used a hierarchical linear regression to explore the relationship between counselors’ location of origin, residence, and practice while adjusting for age, gender, spiritual identity, sexual identity, and number or post-secondary courses taken and the KCAASS attitude subscale score. In the present study it was found that gender was significantly correlated with positive attitudes towards human sexuality (r= -.164, β = -.166, p=.013), as did participant spiritual identity (r=-.252, β = -.236, p<.001). Women and those that did not identify as Christian had higher, more accepting attitudes of human sexuality. The number of human sexuality courses taken also significantly predicted attitudes of human sexuality (r=.208, β = .192, p=.002). Counselor location of origin was weakly correlated with attitudes of human sexuality (r=.142, p=.027) indicating that participants in rural areas had lower, less accepting attitudes of human sexuality. The results of this regression were significant at the first and second step, indicating that age, gender, spiritual identity, sexual identity, and number of courses taken are significantly predictive of KCAASS attitude subscale scores and that location of origin, residence, and practice do not.

Research Question Six

A factorial ANOVA was conducted to answer the sixth research question, which explored the relationship between select counselor demographics and composite KCAASS scores. The factorial ANOVA was not significant and indicates there are no significant differences in composite KCASS score based on a counselor’s gender, spiritual identity, and sexual identity.

Implications for Counseling Practice

Understanding human sexuality and the concerns clients have allows counselors to address concerns and reduce anxieties around concerns related to sexuality (Pereira et al., 2013).

In examining the prevalence of issues related to sexuality in the mental health field and understanding how various cultures and demographics impact counselor preparedness for working with clients, three key points are beneficial for counselors to explore: the prevalence of sexual issues in mental health; assessment and treatment for sexual concerns; and the universality of sexuality (Zeglin, Van Dam, Hergenrather, 2018). The relevance of sexual behaviors and functioning cannot be overlooked as an indicator of overall health and well-being

(Pereira et al., 2013). It is important for all counselors to be knowledgeable about the social constructs regarding healthy and dysfunctional sexual behaviors to assess the comprehensive impact of each client’s presenting issues.

Some interventions for working with clients with sexual concerns may include muscle relaxation techniques, emotional expression and reflection, and communication skills (Buchler,

2013). Giami suggests that communication skills include active and passive listening, verbalization and reflection of feelings, conflict management, and training in assertive behavior

(2002). Mindfulness training also assists with this goal, helping clients become aware of the moment, of what their bodies enjoy, and of what to encourage or discourage (Mize & Iantaffi,

2013). Cognitive behavioral therapy (CBT) is also used in conjunction with addressing maladaptive emotions around issues of human sexuality (Corey, 2005). These exercises allow clients to become comfortable with their bodies and/or partners, leading to higher sexual, physical or emotional intimacy. Additionally, existential therapy has been implemented when working with men and LGBT couples. Existential therapy helps clients understand their larger place in the world and the importance of connecting during sexual interaction. Both groups said their sexual dysfunction improved (Rutter, 2012; Milton, 2014).

Implications for Counselor Education and Supervision

The results from this study have implications for counselor education and supervision training programs. Data from the present study indicates that counselors who have taken courses in human sexuality have higher knowledge, more comfort, more positive and accepting attitudes, and higher overall competencies with human sexuality. While human sexuality is not a specific competency outlined by CACREP or ACA, it is universally experienced by all clients and counselors. The onus is on counselor educators to prepare future counselors to best serve their clients, and most importantly do no harm.

To prepare counselors for how to respond to issues involving human sexuality topics, videos and role play scenarios can be used (Heiden, 1993). Counselors-in-training need to be afforded an opportunity in their programs to explore their own personal assumptions, biases, and values regarding sexuality and to examine the perspectives of others in a safe environment while in training. Equipping counselors-in-training to address sexual issues will normalize the role of sexuality in overall mental health and set a precedent to address sexual difficulties within the context of presenting issues, therefore increasing the possibility that clients will address these issues. It is important to understand how to assess sexual functioning in a manner that does not imply sexual dysfunction in clients, impose the counselor’s values upon the client, or disrespect professional boundaries.

Additionally, the DSM varies in regard to its view of disordered sexuality. Working with future counselors to embrace sexuality as a universal human experience provides a foundation for broaching discussions about sexuality from a wellness perspective rather than focusing on sexual dysfunction and disorder. Counselor educators and supervisors need to move to presenting sexuality as the common experience among all persons with variation in sexual

expression that ranges from healthy to unhealthy and not a “special topic” (Zeglin, Van Dam,

Hergenrather, 2018).

Counselor educators need to focus more attention to sexuality given the prevalence of sexual issues among clients. Given the relationship between sexuality and mental health, sexuality should become a core issue for counselors to study throughout client life span development. Counselor educators need to create more opportunities for counselors-in training to gain more experience and knowledge in this core area. Counselor educators can work to teach counselors-in-training not to focus on sexual dysfunction and work to train counselors to broach conversations with their clients about their sexual experiences in safe and affirming ways.

Neglecting sexuality training in counselor education programs leaves counselors incompetent to address sexual issues in their clients.

Study Limitations

This study has limitations which should be addressed. Internal validity is the ability for a study to make strong justifications of the causal inferences about the relationships (Tabachnick

& Fiddell, 2013). Potential threats to internal validity in this study include selection bias, self- report bias, extreme response bias, ordering bias, and measurement bias. Participants who volunteered for this study may pose a threat to internal validity due to selection biases as this is a non-experimental design. It is possible that those who chose to participate in the survey were more interested in human sexuality to begin with. As with any survey of this type it is important to consider that there may be some bias in how or why people decided to participate. It is also important to note that there are limitations to what we can definitively know with self-report data. This survey simply asked what the person believed their level of knowledge was and belief

about knowledge and actual knowledge are not the same thing. Self-report responses also represent a threat to internal validity.

There were limitations of the variables measured in this study. Variables could have been measured differently or may be defined differently. Although the present study defines rural, urban, and suburban, each participant's understanding of these definitions could vary; therefore, the operationalization of location may have varied across participants. The approach subscale had consistently lower Cronbach’s alpha, it also has few questions than the other subscale and could contribute to the lower alpha. While the KCAASS has been normed and validated, it has not been used in the counseling profession before.

A participant could indicate if they had taken courses in human sexuality, and their age.

However, there was no way for participants to indicate years of experience in the counseling or other related fields. The present study is unable to explore counselors’ level of experience within the current sample.

External validity is the extent to which the results of a study can be generalized to the larger population. The present study is limited in terms of generalizability. While this sample size was adequate for statistical analyses (N= 186), the sample represents a fixed-point response measuring the participants’ attitudes and knowledge and a fixed time. The response rate could be a limitation. The sample was adequate for statistical analyses (N= 186), the response rate was relatively low. Thus, caution should be exercised in generalizing these results to all counselors.

Although it is important to note that according to ACA there are approximately 120,000 counselors nationwide (2011). The number of participants in this study was 186, which is a small percentage of the national population.

Recommendations for Future Research

As an exploratory study, this study aimed to explore the relationship between select counselor demographics and counselor KCAASS score. This research should be continued exploring what is yet unknown. Further explorations through qualitative methods to gain a deeper understanding of the largely unaccounted for variance beyond innate traits and knowledge gained on counselors’ human sexuality views. A more robust understanding of counselors’ competencies with human sexuality topics is needed. Future research should consider whether or not experience and education to human sexuality information has the ability to changes attitudes of counseling students. It might be also be important to explore how much exposure or experience is necessary to have a positive impact on attitudes and comfortability. Similarly, research should focus on whether or not human sexuality education in counselor training impacts how counselors work with clients who concerns within the dimensions of human sexuality.

Additionally, future research should explore client outcomes. No research exploring client experiences with human sexuality issues in counseling has been completed and could help to guide counselors practice and counselor educators understanding and conceptualization of the needs of the clients in regard to human sexuality.

Future research could be conducted to explore the effects of human sexuality courses in counseling programs. This research has been done in medical and education fields, and with undergraduates and all have reported positive findings from incorporating human sexuality course work into the foundational framework of those professions. However, no such study has been done in counseling and no such recommendations have been put forth.

While the current study did not support the hypothesis of the impact of location on human sexuality beliefs, rural demographics in counseling is a gap in the current body of literature. Further studies exploring the impact of rural communities on the counselor, the client,

and the system with enhanced operalization of the variables need to be explored. Finally, with much of the research supporting the need for sex education a final research direction should encompass exploring methods and techniques used to teach counselor trainees skills and build knowledge around human sexuality in preparation for serving clients.

Conclusion

While the findings of this present study did not support the research hypothesis with significant findings, the results support further research to more fully explore counselor human sexuality competencies. Beyond inherent traits, beyond foundational education, and regardless of location there are still a significant number of unknown of variables impacting counselors’ perceptions and understanding of human sexuality. With an understanding of the potential lack of education and the numerous dimensions and impacts of human sexuality on individual lives, this topic has room to be explored for deeper understanding in efforts to better serve future counselors and future clients.

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Appendix A

Knowledge, Comfort, Approach, and Attitudes Toward Sexuality Scale

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Appendix B

KCAASS Modified

On a scale of 1-4, please indicate your current level of knowledge in dealing with the following topics as they relate to people with mental health concerns.

No Limited Sound Excellent Knowledge Knowledge Knowledge Knowledge Sexual anatomy and physiology 1 2 3 4 Sexual positioning 1 2 3 4 Care of hygiene after sexual activity 1 2 3 4 Assistive devices and medications for achieving erections 1 2 3 4 Fertility procedures 1 2 3 4 Male and female contraception 1 2 3 4 Teenage sexuality issues 1 2 3 4 Working with people with a sexual identity different from your own 1 2 3 4

Changes in people's perception of their sexual identity (self-esteem, body image, sexuality) 1 2 3 4 Courtship and dating practices 1 2 3 4 Communication in relationships 1 2 3 4 Managing inappropriate behaviors 1 2 3 4 Methods of sexuality counseling 1 2 3 4 Professional issues in working with sexuality Sound Excellent concerns 1 2 3 4 ge Knowledge Knowledge

Please rate the following items on a scale from 1 (nil discomfort), to 4 (high discomfort) on the amount of discomfort you would feel in these situations.

Nil Low Medium High Discomfort Discomfort Discomfort Discomfort

When you are working with a client and they state they are sexually aroused 1 2 3 4

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A client bursts into tears in session and says "I am not a man anymore" 1 2 3 4 Male client asks "Will I ever be able to have an erection?" 1 2 3 4 Male client with erectile dysfunction asks "Can I still have sex?" 1 2 3 4 Female clients asks "Will I ever be able to have an orgasm again?" 1 2 3 4 Client with infertility concerns asks "Will I be able to have children?" 1 2 3 4 A client asks “Is it okay to have sex while I am on my period?” 1 2 3 4 Client asks "What if I am uncomfortable during sex?" 1 2 3 4

Partner asks "Will I hurt him/her during sex?" 1 2 3 4 Female client asks "Why am I so dry during sex?" 1 2 3 4 Female clients says "I like to be on top but I feel uncomfortable" 1 2 3 4 Client asks "Do you think anyone will ever go out with me?" 1 2 3 4 Client asks "I've never had sex before- what will it be like?" 1 2 3 4

Client says "None of my friends would ever go out with someone with my diagnosis" 1 2 3 4 Client asks for information about homosexuality 1 2 3 4 Teenage client asks "When do I get to watch porn?" 1 2 3 4

Client asks "How do I please my partner?" 1 2 3 4 Male client with erectile dysfunction says "I tried sex but I feel useless" 1 2 3 4 Client says "I feel numb so what is the point of sex?" 1 2 3 4

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Client says "I want to have sex but my partner has lost interest-what should I do?" 1 2 3 4 Client asks "How do I know if my partner is turned on?" 1 2 3 4

Please rate the following items on the scale from 1 (nil discomfort), to 4 (high discomfort) on the amount of discomfort you would feel in these situations.

Nil Low Medium High Discomfort Discomfort Discomfort Discomfort Your client discusses masturbation at inappropriate times 1 2 3 4 Your client and their partner make sexual comments towards each other in session 1 2 3 4 Client asks you for a date 1 2 3 4 Client makes a sexual advance towards you 1 2 3 4 Client says "Let's do it, we have this whole couch" 1 2 3 4

Read the following statements and indicate by circling the appropriate number whether you disagree or agree from 1 (disagree strongly) to 4 (agree strongly).

Disagree Agree Strongly Disagree Agree Strongly People shouldn't discuss sexual issues in counseling sessions 1 2 3 4 People with severe mental health concerns will find it hard to get a partner 1 2 3 4 People with mental health concerns are not sexually attractive to others 1 2 3 4 People with erectile dysfunction cannot be sexually aroused 1 2 3 4 People with fertility concerns shouldn't expect to have children 1 2 3 4

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Appendix C

Demographic Questionnaire

Age:______

Gender:______

Geographic location of origin: Rural ______Urban______Suburban_____

Geographic location of residence: Rural ______Urban______Suburban____

Geographic location of practice: Rural ______Urban______Suburban____

Religious/Spiritual Identification:______

Indicate the number of post-secondary human sexuality courses you have completed:______

What is your sexual identity:______

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Appendix D

Informed Consent

Meagan McBride Klein College of Health and Human Services, School of Intervention and Wellness Counselor Education Department, Rm 3100 The University of Toledo, Mail Stop 119 2801 W. Bancroft St., Toledo, Ohio 43606 Phone 419-530-2717 Fax 419-530-7879

ADULT RESEARCH SUBJECT - INFORMED CONSENT FORM

Exploring the Relationship Between Counselor Geographical Area of Practice and Composite Score on Knowledge, Skills, Attitudes, and Comfort with Human Sexuality Scale Score

Principal Investigator: Christopher Roseman, PhD

Primary Researcher: Meagan McBride Klein, M.A.

Purpose: You are invited to participate in the research project entitled, Exploring the Relationship Between Counselor Geographical Area of Practice and Composite Score on Knowledge, Skills, Attitudes, and Comfort with Human Sexuality Scale Score, which is being conducted at the University of Toledo under the direction of Dr. Christopher Roseman. The purpose of this study is to better understand the relationship between counselor demographics and their knowledge, skills, attitudes, and comfort with human sexuality.

Description of Procedures: This research study will take place via electronic survey with the researcher based in Toledo, Ohio and will consist of one demographic questionnaire and a 45 question survey. All identifying information will be removed from the data to ensure participant confidentiality.

Potential Risks: There are minimal risks to participation in this study, including loss of confidentiality.

Potential Benefits:. Others may benefit by learning about the results of this research.

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Confidentiality: The researchers will make every effort to prevent anyone who is not on the research team from knowing that you provided this information, or what that information is. The consent forms with signatures will be kept separate from responses, which will not include names and which will be presented to others only when combined with other responses. Although we will make every effort to protect your confidentiality, there is a low risk that this might be breached.

Voluntary Participation: Your refusal to participate in this study will involve no penalty or loss of benefits to which you are otherwise entitled and will not affect your relationship with The University of Toledo or any of your classes. In addition, you may discontinue participation at any time without any penalty or loss of benefits.

Contact Information: Before you decide to accept this invitation to take part in this study, you may ask any questions that you might have. If you have any questions at any time before, during or after your participation or experience any physical or psychological distress as a result of this research you should contact a member of the research team Dr. Christopher Roseman and/or Meagan McBride Klein. If you have questions beyond those answered by the research team or your rights as a research subject or research-related injuries, the Chairperson of the SBE Institutional Review Board may be contacted through the Office of Research on the main campus at (419) 530-2844. Before you sign this form, please ask any questions on any aspect of this study that is unclear to you. You may take as much time as necessary to think it over.

SIGNATURE SECTION – Please read carefully You are making a decision whether or not to participate in this research study. Your signature indicates that you have read the information provided above, you have had all your questions answered, and you have decided to take part in this research. The date you sign this document to enroll in this study, that is, today's date must fall between the dates indicated at the bottom of the page.

Name of Subject (please print) Signature Date

Name of Person Obtaining Signature Date Consent

This Adult Research Informed Consent document has been reviewed and approved by the University of Toledo Social, Behavioral and Educational IRB for the period of time specified in the box below.

Approved Number of Subjects:

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Appendix E

Call for Participants

Dear participant:

You are invited to participant in a research study entitled, Exploring the Relationship Between Counselor Geographic Area of Practice and Knowledge, Skills, Attitudes, and Comfort with Human Sexuality which is being conducted at the University of Toledo under the direction of Dr. Christopher Roseman. The purpose of this study is to better understand the relationship between counselor demographics and their knowledge, skills, attitudes, and comfort with human sexuality. The study will consist of 11 demographic questions and 45 survey questions.

Participant Criteria: Licensed Mental Health Counselor

Incentive Information:

Researcher Information: Meagan McBride [email protected]

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