Aptitudes and Attitudes Among Licensed Professional Counselors Regarding

Aptitudes and Attitudes among Licensed Professional Counselors Regarding

Human Sexuality and Sexual Counseling in Puerto Rico: An Exploratory Study

A Dissertation

Submitted to the Faculty of

The American Academy of Clinical Sexologists

In Partial Fulfillment of the Requirements

For the Degree of Doctor of Philosophy

Clinical Sexology

Orlando García Colón, MPH, MFC, LPC

Orlando, Florida

May 2017

III

Abstract

The purpose of this study was to explore the aptitude and attitude exhibited by a group of

Licensed Professional Counselors in Puerto Rico regarding human sexuality and sex counseling.

Descriptive data was gathered by a self-administrated questionnaire. Out of the 100 counselors that were invited to participate, 64 accepted the invitation. The sample group (N=64) was recruited according to their availability. Due to the size of the sample the results do not reflect the reality of all professional counselors in Puerto Rico.

The participants were asked to answered basic socio-demographic questions. Almost half of the sample group was composed by Guidance Counselors. Majority of the participants were women with more than 15 years of experience in the field and who worked in the public education system. The level of knowledge was measured by two factors; previous education on sexuality and by the results obtained on a self-evaluation exercise using a Likert scale. The instrument included 22 basic concepts related to sexuality. More than half of the respondents

(56%) answered they had taken a course on human sexuality. The present results indicated that

49% of the sample considered that they had a high or very high level of knowledge concerning human sexuality.

In this study attitude was defined as a learned manner or disposition to approach and evaluate a situation or a subject. In this case, 83% of the sample was willing to improve their education on human sexuality and 56% was willing to intervene on cases involving sex counseling. Therefore, the investigator concluded that in general, professional counselors in

Puerto Rico exhibit a positive attitude toward human sexuality and sex counseling.

It was also found that the most common topics that counselors were willing to intervene included; contraceptive methods, female and male reproductive systems and sexually transmitted infections. All these subjects are commonly found in medical books rather than in counseling books. On the contrary, some of the topics they were most likely to refer were; psychogenic female and male sexual dysfunctions, fetishes and paraphilias. These subjects are usually found in counseling books. These results combined with the fact that almost one-half of the participants

(47%) studied human sexuality at bachelor’s degree level, suggests that the type of knowledge that they demonstrated was must likely learned in sex health classes rather than sexuality counseling courses. This finding suggests that the knowledge participants reported was learned from a biology point of view rather than from a counseling perpective. Further investigations are therefore recommended.

Vita

Orlando García, MPH, MFC, is a licensed professional marriage and family counselor, a certified sex educator and sex therapist in Puerto Rico. He completed his Master’s Degree in

Public Health at the Graduate School of Public Health, Medical Science Campus of the

University of Puerto Rico. He obtained his human sexuality education certification from the

Professional Studies Division of the University of Puerto Rico. He earned his second Master’s

Degree in Marriage and Family Counseling at the Central University of Bayamon, P.R. and later attained a sex therapist certification from the Carlos Albizu University, San Juan Campus.

Currently, he is a candidate for the degree of Doctor of Philosophy in Clinical Sexology from the

American Academy of Clinical Sexologists.

His professional history includes working for the Puerto Rico Health Department Ryan

White II Program, San Juan, P.R. as a program evaluator. He has also worked as a research interviewer on various investigations at the Behavioral Science Research Institute, Medical

Science Campus of the University of Puerto Rico. Currently, he is an adjunct professor of professional counseling and human sexuality at Central University of Bayamon, P.R. and active member of the Asociación Puertorriqueña de Educadores, Consejeros y Terapeutas Sexuales

(AsPECTS) (Puerto Rican Asociation of Sex Educators, Counselors, and Therapists).

Dedication

To all licensed professional counselors who dedicate their lives to promoting good mental health in Puerto Rico. But specially to those who always aspire more, those who seek growth as professionals and as individuals. But especially to those counselors who demonstrate interest in human sexuality and sex counseling.

VII

Acknowledgements

I would like to extend my deepest appreciation to all the people that in one way or another contributed to making this study possible. And I would like to give special thanks to my

Dissertation Committee; Dr. Carmen Várcarcel-Mercado, Dr. William Granzig and Dr. Karla

Narvaez, for their guidance, support and trust. I am especially grateful to Dr. Várcarcel-Mercado for accepting being chairperson of my committee, and for her time and encouragement.

I would also like to acknowledge and thank the people who helped me validate my research instrument. Dr. Waldo Sánchez, Dr. Myrian Guadalupe, Dr. Karla Narvaez, Dr. Agnes

Ferrer and Ms. Yamilet Arroyo and to Dr. Idania Rodríguez for her contribution to the SPSS data program and analysis. Also, I would like to thank Mr. Cutberto Camacho and Ms. Amnerys

Colón for their technical assistance and the five graduate counseling students who anonymously participated in the pilot test to validate the questionnaire.

I would also like to recognize and thank the participants. Without their willingness and thirst for knowledge this investigation would have never been possible. Thank you all.

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List of Tables

Table 1 – Socio-demographic Characteristics of Professional Counselors …………………….42

Table 2 – Knowledge and Willingness to Have Further Studies in Human Sexuality …………43

Table 3 – Level of Knowledge About Human Sexuality Concepts …………………………….44

Table 4 – Intention to Refer or Intervene on Cases Regarding Human Sexuality ……………...48

Table 5 – Intention to Receive Training Regarding Human Sexuality …………………………51

Table 6 – Chi Square Test of Level of Knowledge Among Counselors by Selected

Characteristics ……………………………………………………………………….56

Table 7 - Chi Square Test of Level of Knowledge Among Counselors by Years of

Experience ………………………………………………………………………...…57

Table 8 – Chi Square Test Willingness to Refer or Intervene in Cases Among

Counselors by Selected Characteristics ……………………………………………...58

Table 9 – Chi Square of Interest in Receiving Training About Human Sexuality

Concepts Among Counselors by Years of Experience ………………………………59

Table 10 – Chi Square Test of Interest of Counselors for Hours of Training by

Category of Interest to Take a Full Course in Counseling on Human

Sexuality ……………………………………………………………………………..60

Table 11 – Chi Square Test of Interest of Counselors for Hour of training by

Category of Interest to Take a Certificate on Human Sexuality …………………….61

Table 12 -Chi Square of Interest of Training by Category of Interest to Obtain an

Academic Degree on Human Sexuality ……………………………………………....61

Table 13 – T-test results of Selected Categories and Concepts ………………………………..62

Table of Content

Abstract …………………………………………………………………………………...IV

Vita ………………………………………………………………………………………..VI

Dedication ………………………………………………………………………………..VII

Acknowledgments ………………………………………………………………………VIII

List of Tables …………………………………………………………………………….IX

Chapter One: The Problem ………………………………………………………………..1

Introduction ……………………………………………………………………….1

Rationale and Purpose of the Study ………………………………………………3

Research Questions ……………………………………………………………….3

Limitations / Delimitations ……………………………………………………….4

Operational Definitions …………………………………………………………..5

Chapter Two: Literature Review …………………………………………………………6

Introduction ………………………………………………………………………6

Gender Identity ………………………………………………………………….13

Sexual Orientation ………………………………………………………………14

Classification of Sexual Orientation ……………………………………………14

Transgender ……………………………………………………………………15

Intersexuality …………………………………………………………………..16

Eroticism ………………………………………………………………………17

Sexual Dysfunction ……………………………………………………………18

Hypoactive Sexual Desire Disorder …………………………………………...18

Sexual Arousal Disorder ………………………………………………………18

Orgasmic Disorder …………………………………………………………….19

Sexual Pain Disorder…………………………………………………………...19

Erectile Dysfunction …………………………………………………………...20

Orgasm and Ejaculation Disorders in Men ……………………………………20

Delayed Ejaculation, Anejaculation and Male Anorgasmia …………………..20

Female Reproductive System ………………………………………………….21

Male Reproductive System ……………………………………………………21

Sexually Transmitted Infections ………………………………………………23

Sexuality in People with Disabilities …………………………………………24

Sexual Abuse ………………………………………………………………….25

Sexual Harassment ……………………………………………………………27

Sexual Taboos ………………………………………………………………...27

Sexual Myths ………………………………………………………………….28

Paraphilias …………………………………………………………………….28

Fetishism ……………………………………………………………………...30

LGTTBIQ Issues ……………………………………………………………...31

Sexual Response Cycle ……………………………………………………….32

Contraceptive Methods ……………………………………………………….33

Cybersex ………………………………………………………………………34

Chapter Three: Methodology …………………………………………………………36

Research Design ………………………………………………………………36

The Sample and Distribution ………………………………………………….36

The Instrument ………………………………………………………………...37

Validation of the Instrument …………………………………………………..39

Chapter Four: Findings………………………………………………………………...41

Figure 1: Concepts About Human Sexuality with Limited Knowledge ………45

Figure 2: Leading Concepts About Human Sexuality with High Knowledge ...46

Figure 3: Level of Knowledge Scale Among Counselors ……………………..46

Figure 4: Topics that Counselors are More Likely to Refer …………………..49

Figure 5: Topics that Counselors are More Likely to Intervene ……………....49

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Figure 6: Topics that Counselors are Less Likely to Receive Training ……..52

Figure 7: Topics that Counselors are More Likely to Receive Training …….52

Figure 8: Topics by Preferred Number of Training Hours …………………..53

Chapter Five: Conclusions and Recommendations ………………………………….63

Biography ……………………………………………………………………………67

Apendicces…………………………………………………………………………...74

Appendix A: Illustration Female Reproductive System …………………….74

Appendix B: Illustration Male Reproductive System ……………………….75

Appendix C: List of Paraphilias ……………………………………………..76

Appendix D: List of Contraceptives Methods ……………………………….78

Appendix E: Inventory of Aptitudes and Attitudes in Human Sexuality and

Sexual Counseling (Letter of Invitation Spanish Version) ………….84

Appendix F: Inventory of Aptitudes and Attitudes in Human Sexuality and

Sexual Counseling (Letter of Invitation English Version) ………….85

Appendix G: Questionnaire (Spanish Version) ……………………………..86

Appendix H: Questionnaire (English Version) ……………………………..89

Appendix I: Instrument for Validation of the Inventory of Aptitudes and Attitudes

in Human Sexuality and Sexual Counseling (Spanish Version) …...92

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Appendix J: Instrument for Validation of the Inventory of Aptitudes and Attitudes

in Human Sexuality and Sexual Counseling (English Version) ….121

XIV

Chapter 1: The Problem

Introduction

Professional counselors assist clients in determining the cause of their discomfort and in finding solutions to situations that are creating emotional stressors or psychogenic physical manifestations. During the process of counseling, clients learn to identify the cause of their symptoms and to improve their skills to cope with situations that are adversely affecting them.

They strengthen their self-esteem and change how they perceive themselves, others, and the world around them. The American Counseling Association (ACA) describes professional counseling as a professional relationship that empowers diverse individuals, families, and groups to accomplish mental health, wellness, education, and career goals. The National Board for

Certified Counselors (NBCC) defines professional counseling as the process whereby specially trained individuals work with others individually, in families, and/or in groups to address and strive to resolve personal and interpersonal issues through active listening, goal setting and behavior changes and by teaching problem-solving and other skills. Often, mental health and emotional wellness involve sexuality.

Sexuality is a central aspect of being human throughout life [that] encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and reproduction.

Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, legal, historical, religious and spiritual factors (WHO, 2006a).

Issues regarding sexuality should be addressed free of bias and with a proper and kowledgeable professional attitude, especially because counselors are ethically responsible for providing the best treatment possible while protecting their clients’ well-being (Corey, Corey, &

Callanan, 2003). This study is primarily focused on how counselors’ aptitudes impact their attitudes during the process of sexuality counseling. This process includes sex education; value clarification; exploration of sexual attitudes and beliefs; and exploration of self-image, sexual identity, gender role development, and relationship issues (Rosen & Weinstein, 1988a).

As human beings, our sexual attitudes and aptitudes are nurtured as we age through sexual experience, exposure, guidance, and counseling. As professional counselors, however, we must go further and include formal education. An effective sexuality counselor raises a client’s awareness of how to promote healthy sexual behaviors. Professional counselors need knowledge and skills to work with clients in their respective developmental stages and to provide strategies and approaches that will help prevent mental and emotional discomfort. A competent professional counselor must be qualified to work in all areas of human behavior, including human sexuality. It makes perfect sense for a skilled professional counselor to demonstrate proficiency in sexuality counseling when working with individuals who are having issues of a sexual nature or couples having problems in their marriage caused by sexual behaviors or dysfunctions.

The process of improving aptitudes and modifying attitudes concerning sexuality counseling should start with appropriate curriculum content. The development of courses and educational programs is imperative in achieving this goal. The field of professional counseling is constantly expanding its scope of expertise to meet a variety of situations that present on a daily basis as a result of an evolving society.

Rationale and Purpose of the Study

The complete lack of research focusing on how professional counselors relate to sexuality counseling in Puerto Rico justifies the objectives and rationale behind this investigation. The field of professional counseling was first regulated by the Department of Health under Law 147 in August 2002 and to date, this is the first study of its kind. Existing research views sexual counseling from a remediative or a forensic perspective. Typically, these studies research attitudes toward sex offenders or address some other forensic point of view. The purpose of this study is to explore the aptitudes and attitudes of Licensed Professional Counselors in Puerto Rico regarding sexuality as part of human nature be and sexual counseling as part of the counseling process. The information gathered through this investigation will help to identify areas for professional improvement and skill development regarding how to intervene with clients presenting with any type of symptomatology related to sexual behavior, sexual situations, sexual discomfort, or sexual trauma.

Research Questions

1. What level of aptitude is demonstrated by Licensed Professional Counselors in Puerto Rico regarding human sexuality?

2. Do Licensed Professional Counselors in Puerto Rico exhibit a positive or negative attitude toward sexuality counseling?

3. Are Licensed Professional Counselors in Puerto Rico interested in investing time in furthering their education on various subjects related to human sexuality and sexuality counseling?

4. Does previous education on human sexuality have an impact on the level of aptitude demonstrated by Licensed Professional Counselors in Puerto Rico regarding human sexuality?

5. Does previous education on human sexuality have an impact on the attitudes exhibited by

Licensed Professional Counselors in Puerto Rico regarding human sexuality?

Limitations

This investigation was an exploratory study of transversal design using a quantitative methodology. A self-administered questionnaire was used to collect the data. The study was limited to gathering basic socio-demographic information about the participants and their perception of human sexuality and sexuality counseling. The questionnaire was distributed among a sample group of Licensed Professional Counselors. Specific limitations and delimitations are as follow:

1. The sample group was selected based on convenience and availability.

2. The merit of the gathered data is based on the accuracy of the compiled answers.

3. The sample group was limited to professional counselors in Puerto Rico.

Delimitations

1. The dependency on the truthfulness of the participants when answering the self-administered questionnaire; and

2. The size of the sample group in comparison to the amount of Licensed Professional

Counselors in Puerto Rico.

Operational Definitions

1. Aptitude - The level of knowledge acquired through experience and formal training.

2. Attitude - A learned manner or disposition to approach and evaluate a situation or a subject.

3. Positive attitude – Willingness to approach a situation with the best disposition and academic preparation.

4. Negative attitude – Resistance to approach a situation with the best disposition and academic preparation.

5. Human sexuality – It involves sex, gender, sexual identity, sexual orientation, eroticism, sexual health, sex education, beliefs, values, fantasies, desires, responses, and behavior.

6. Sexuality counseling – The use of an interactive helping process focusing on the need to address sexual practices or beliefs or to help cope with a sexual event or disorder.

7. Licensed Professional Counselor – A professional counselor licensed in the Commonwealth of

Puerto Rico with a masters or doctoral degree in any of the following areas: school counseling, couples and family counseling, mental health counseling, addiction counseling, guidance counseling, or general counseling.

Chapter Two: Literature Review

Introduction

One of the most challenging areas of counseling is human sexuality. The aim of sexuality counseling is to equip individuals with the most appropriate perspective toward sex and sexuality because they are important to an individual’s life. Because it is quite important for clients to have a healthy view of their sexuality, professional counselors must be knowledgeable about sexuality in all its manifestations. For many years, counselors have recognized the diversity of styles and patterns of human sexual expression (L’Abate & Talmadge, 1987). Counseling as a profession has the ultimate goal of assisting human beings in the process of moving towards existential fullness.

This study explores aptitudes and attitudes on human sexuality and sexual counseling among professional counselors in Puerto Rico. It is hypothesized that their aptitude will define their attitudes towards sexuality. Despite the importance of understanding human sexuality in the counseling process, the Council for Accreditation of Counseling and Related Programs

(CACREP) has not established significant regulations to guide counselors in learning about human sexuality. Only marriage counselors and couples and family counselors are expected to possess the knowledge and skills necessary to address a wide variety of issues in the context of relationships and families (CACREP, 2016). All professional counselors should be required to study human sexuality. The following literature review presents reasons why professional counselors should explore sexuality education.

Attitudes are defined as learned tendencies to evaluate situations in a certain manner. It is also suggested that there are several components that make up attitudes known as the ABC’s of

6 attitudes. These components include three types: cognitive (thoughts and beliefs about a subject), affective (how the object, person, issue, or event makes you feel), and behavioral (how the attitude influences behavior). Attitudes can also be explicit or implicit. Explicit attitudes are those that are conscious and influence our behaviors and beliefs. Implicit attitudes are unconscious but still have an effect on our beliefs and behaviors (Cherry, 2017). Additionally, attitudes are usually projected as positive or negative. A positive attitude is perceived as a good disposition that is constructive, cooperative, or optimistic and a negative attitude is perceived as the opposite – a disposition that is not constructive, cooperative, or optimistic (“Attitudes,”

2017). Attitudes in sexuality counseling are usually studied from a reactive point of view toward a particular subject or situation.

For example, there have been many studies on sexual dysfunction and other specific sex- related issues but very few on how professional counselors tend to address them. For example, a study by Laumann (1999) investigated the prevalence and the risk of suffering from sexual dysfunction and their impacts on different social groups in the US. The study used the survey method to collect data from a sample of 3159 people. The participants included 1749 women and

1410 men aged 18 to 59 years. The results of the study showed that sexual dysfunction was present in 43% of women and 31% of males. Women had more sexual dysfunction issues than men because of differences in demographic features such as education level and age. The study concluded that sexual dysfunction was high among men and women with poor emotional and physical health due to unhealthy sexual relationships, establishing the need for sexuality counseling.

Many people do not address their sexual problems. A study by Harris (2008) surveyed

175 clinical counselors from the American Association for Marriage and Family Therapy to

7 examine how their clinical levels of education, their perspectives about sexual knowledge, and their feelings about sexual education material supported their ability to participate in sexuality discussions with their patients. The findings indicated that the lessons and experiences of sexuality education were the foundation for a therapist's level of comfort with clients. The study concluded that it was through sexuality education programs that knowledge about sex was obtained and passed down to patients, thus increasing their comfort level. High comfort levels are imperative for an effective sexual counseling process.

Patient expectations also influence sexual counseling. Reynolds and Magnan (2005) conducted a study to examine factors that hindered the use of sexuality counseling and assessment in the nursing profession. The study created a historical account of the collaborative group methods from an established Sexuality Attitudes and Beliefs Survey (SABS). The sample consisted of 35 nurses who worked in outpatient and inpatient areas in oncology and HIV/AIDS departments. The researchers used the survey as a data collection method. The results of the study indicated that the collaborative initiative created a piloted tool to measure nurses' attitudes and beliefs regarding human sexuality and counseling. The outcome suggested that participants had their patient's expectations in mind and were interested in spending sufficient time with them during counseling; they were also interested in establishing a sense of confidentiality. Also included was the desire to gain a higher level of trust and confidence to be able to explain emerging issues with the patient. This is very similar to what professional counselors experience on a daily basis.

Sexual awareness is significant in seeking healthy sexual behaviors. The topic of human sexuality and counseling is addressed based on our awareness and perceptions. There is rising interest in the misconceptions of human sexuality and its complexity. For example, many

8 teenagers have poor knowledge of their sexuality resulting in a high incidence of pregnancy.

Kunene (1995) conducted a descriptive study at a youth center to investigate how teens understand human sexuality and how they feel about the many cases of early teenage pregnancy.

The study also focused on understanding where teenagers obtained information about their sexuality. The sample included 210 teenagers of which 100 were boys and 110 were girls.

Seventy-eight percent of the teenagers were aged 16-19. Questionnaires were used to collect data from the subjects.

The results of the study showed that although the adolescents were more knowledgeable on the physiology and anatomy of their reproductive organs at their stated ages, they did not have the appropriate sexuality counseling information that was significant in helping them understand the consequences of engaging in what is considered high-risk sexual behavior. The study also indicated that parents and guardians were not actively involved in educating their children, even though the teenagers were willing to receive parental advice. The results also indicated that boys were the least counseled. The report showed that 76% of the male sample did not visit the youth health center to receive guidance. The study concluded that 26% of the girls were aware of the adverse effects of unwanted teenage pregnancy because they visited the youth health center, where services were provided. One limitation of this study was that the sample was focused on teenagers.

Education helps counselors better understand human sexuality. One of the most common related topics of human sexuality in the US is family size. A study was carried out by Mosher and Bachrach (1996) to understand changes in US fertility from 1988 to 1995. The research used surveys and telephone interviews as data collection methods. The study sample included women aged 30 to 34 years. The findings were based on variables such as intercourse with their partners,

9 the use of family planning drugs, diseases of the reproductive system, and fertility problems. The findings of the study indicated that there were higher premarital sex behaviors, which resulted in a large number of births among unmarried women. Educated and well-counseled women used contraceptives before having intercourse. The study also concluded that there was a high number of unwanted births between 1982 and 1988.

Sexual counseling is not a priority for many people. A research article by Summerville

(1998) examined women’s experiences and issues related to inpatient reproductive care. The sample included 24 participants aged 17 to 63 years. Structured interviews were used by the researchers to collect data on different variables that served as the basis for their sexual counseling experience, sexual issues, and recommendations about sexual rehabilitation practices.

The findings projected that two out of 24 women acknowledged receiving in-depth sexual counseling. The rest of the sample believed that sexual counseling was not a priority at that time.

The study concluded that the participants had strong views about their sexuality and were not interested in seeking help from health professionals when the subject of sexuality was raised.

A study by Steadman (2014) investigated the attitudes of parents regarding sexual counseling for their children in schools. A sample of 344 parents from Utah was selected randomly to participate in the investigation. The researchers used a short online survey to collect data from the 344 Utah parents. The survey addressed different topics associated with sexuality.

The areas of interest comprised school-based sexuality education and adolescent sexuality. The findings showed that attitudes about institution-based sexuality counseling were categorized to either avoid risks associated with irresponsible sexual behavior or to focus on managing and reducing the risks as a result of “immoral” sexual acts. Parents reported that health counselors in

Utah public schools were supposed to teach a state-authorized risk-avoidance program that

10 prohibited the advocacy of family planning contraceptives. The risk mitigation method supported the use of contraceptives such as condoms among the sexually active students to manage the risk of sexually transmitted diseases or unwanted teenage pregnancy. The findings of the study also supported that Utah laws and institutional regulations should be evaluated to provide sexuality guidance that correlates with the best practices of parenting and professional attitudes.

Certain barriers exist in personal sexual counseling. A study by Herson (199) looked at the primary factors that prevented people from seeking sex counseling. The study focused on the health professional–patient relationship in a clinical setting and the ease of sharing information about sexuality. The article also identified recommendations for overcoming such barriers. The researchers collected data from an annual nursing rehabilitation workshop about knowledge and attitudes in attending to patients. The participants discussed the obstacles they confronted when sharing information on sexuality with their patients and family members. The findings showed that participants presented four primary obstacles that prevented them from disseminating information on sexuality to patients. These factors were lack of time to discuss sexuality information with patients, lack of clear understanding on how to share the information, lack of patient readiness, and personal aptitudes and attitudes about sexuality. The participants came up with some recommendations on how to improve the sharing of sexual education information with their patients. They suggested the adoption of open sharing forums with the clients in clinical settings, identifying the emotional issues about sexuality and enhancing peer counseling among patients.

A counselor's attitude is a very influential factor in the process of sexual counseling. A study by Jones (2013) investigated professional counselors’ attitudes towards their patients. A sample of 133 professional counselors was selected randomly from a teen rehabilitation center in

Michigan. The pool of instructors consisted of 32.3% females and 67.7% males. The study used the survey method to collect data from the participants. The results of the study showed that counselors had worked with sex offenders for 0 to 18 years and that most offenders had received three full months of counseling. The article concluded that a healthy professional relationship was established between the youth sex offender and the counselor, consequently improving the attitudes of counselors towards offenders. Attitudes toward sex offenders is one of the most studied topics related to sexuality counseling.

Another study on counselors and sex offenders, by Nelson (2001), investigated the attitudes of professional counselors and the relationship between these attitudes and their experiences as counselors, their training, and their personal characteristics. The results of this exploratory study aimed to facilitate and increase the understanding of counselors' attitudes towards sex offenders. Participants in this study consisted of 437 counselors who were members of the Association of Mental Health Counselors (AMHCA) and the International Association of

Addicts and Counselors of Offenders (IAAOC). Each participant completed a survey packet containing the Attitudes toward Sex Offenders Scale (ATS) and personal background questions.

The results of this study indicated that counselors tended to have a slightly positive attitude towards sex offenders and that experience and training and the emotional status of victims was related to better attitudes towards the sex offenders. The purpose of the study was to collect information that could be used to improve the quality and effectiveness of services provided by counselors to sex offenders.

The following key concepts are introduced to assist with the understanding of the perceptions and the presumed association between the aptitudes and attitudes of participant counselors regarding their process of sexuality counseling:

Gender identity. Identity refers to those aspects or characteristics that make it possible to differentiate ourselves from other people. Identity constitutes a personal construction – the uniqueness and the exclusivity of an individual. There are many different ways of defining or understanding what a person's identity is. Within the field of psychology, Dr. Erik H. Erickson, was one of the pioneers in talking about identity, referring to it as an affirmation that manifests itself in the individual and cultural identity of a person. Throughout his work, Erickson (1968) proposed that identity was the result of three types of processes: biological, psychological, and social.

From a more sociological perspective, Parsons (1968) mentioned that identity is a central system of meanings for an individual personality that guides normatively and gives meaning to people's actions. These meanings are not merely arbitrary constructions defined by individuals but emerge in close relation with the internalization of values, norms, and cultural issues that are generalized and shared by a social system. Gender identity, like general identity, involves many variables and processes. According to Hawkesworth (1997), this term is sometimes used as an attribute or characteristic of an individual, and at other times, as a characteristic of interpersonal relationships or as a type of social organization. Therefore, when one speaks about gender identity, it is often viewed from a biological perspective and refers to the personal sense of being male or female.

Trew and Kremer (1998) suggested there are several approaches to the study of the gender and identity constructs. They considered that there is some confusion between the social aspects and the psychological aspects because for some theorists, identity is based on the meanings granted to men and women, while for others, identity is formed by the process with

13 which men and women define themselves. However, several other authors have made substantial contributions to the understanding of this construct, for example, Money and Ehrdardt (1972) indicate that gender identity is defined as "equality of self, unity, and persistence of one's own individuality as male, as female, or ambivalent." From this stance, identity refers to what one says and does to indicate to others or oneself that one is male or female. As Cook (1990) points out, gender roles are a way of organizing the universe.

Sexual orientation. The American Psychological Association (APA) refers to sexual orientation as "an enduring pattern of emotional, romantic or sexual attraction to men, women or both sexes." It is the term used to describe whether a person feels sexual desire for people of the opposite gender, the same gender, or both. Many people are curious about sexual orientation.

Often, they wonder about the factors that make someone bisexual, heterosexual, or homosexual and how they can determine the sexual orientation of a person. Sexual orientation is not a decision we make consciously; we do not prefer to be homosexual or heterosexual, we simply are. The APA also states that although much research has examined the possible genetic, hormonal, developmental, social, and cultural influences on sexual orientation, no findings have emerged that permit scientists to conclude that sexual orientation is determined by any particular factor or set of factors. Some say homosexuality is a result of the genetic code and others say that hormonal influences during the prenatal period are an important determinant.

Classification of sexual orientation. Heterosexuality is the social term applied to people of a particular sex who are attracted to people of the opposite sex. Homosexuality and lesbianism

14 are the social terms applied to those individuals who manifest sexual attraction towards individuals of the same gender. Bisexuality is an attraction towards people of both sexes, male and female. A fourth orientation has been recently introduced. Asexuality is a lack of sexual attraction and orientation. Although it has been recently introduced, Dr. Alfred Kinsey was aware of it since 1948, and in his Heterosexual-Homosexual Rating Scale, referred to these individuals as "X/No socio-sexual contacts or reactions." These individuals do not manifest physical or emotional sexual attraction towards any person of any gender. Because there is no specific, known factor determining sexual orientation, it can be concluded that sexual orientation cannot be selected or changed.

Several theories suggest that sexual orientation is defined by several biological components of an individual's body and its development. Some theories present various biological factors related to the determination of sexual orientation such as genes, prenatal hormones, and cerebral structure. Sexual orientation has been persistently studied by disciplines such as biology, sociology, psychology, and anthropology, with the aim of finding its causes.

Changes in the social and scientific conceptualization of homosexuality and its treatment reflect variations in the prevailing paradigms about the causes of human behavior (Muscarella, Fink,

Grammer, & Kirk-Smith, 2001). It is not surprising, then, that until the 1960s, it was commonly believed that homosexuality was the result of childhood internal pathogenic influences involving both parents and children whose treatment was unsuccessful (Bulloughn & Bullough, 1994).

Recent studies postulate that biological factors are the primary basis for sexual orientation, but thus far, there is no evidence to substantiate that theory (Byne & Parsons, 1993).

Transgender. Transgender is a term that is used to describe people who, in different ways, identify with the opposite gender. The following are several interpretations of the meaning of transgender individuals. They are usually individuals who feel they are outside of conventional gender norms. They are men and women who “describe themselves as being born in the wrong body; that is, they feel that emotionally they are one sex while their bodies are another. For the most part, they do not consider themselves homosexual" (Kaplan, 2012). Being transgender does not invoke any sexual orientation because transgender individuals can also be identified as gay, heterosexual, or bisexual. The definition of transgender is different from the definition of transsexuality. Unlike the term transgender, transsexuality is a form of gender identity that is only identified with a binary gender, although it is contrary to the one assigned by biological sex. The term transsexuality was cited by Harry Benjamin in 1967 and is used for those who decide to undergo sexual reassignment surgery (SRS) as well as for those who do not make such a decision.

Intersexuality. Intersex was originally a medical term that was later embraced by some intersex persons. Many experts and individuals with intersex conditions have recently recommended adopting the term disorders of sex development (DSD). They feel that this term is more accurate and less stigmatizing than the term intersex (APA, 2006).

Intersexuality is a term that is generally used for a variety of situations in which a person is born with reproductive or sexual anatomy that does not seem to fit into the conventional definitions of masculine or feminine. For example, a person may be born with external genitalia, typically that of a woman, but internally, may have testes. A person can also be born with genitals that appear to be somewhere between typical male and female genitalia. For example, a baby may be born

16 with a clitoris longer than average, may lack a vaginal opening, or may have a common duct for both the urethra and the vaginal opening. A baby could also be born with a phallus that is considered smaller than the average penis or with a scrotum that is divided in a way that resembles a vagina (Mazur, Colsman, & Sandberg, 2007).

Thus, there is no unique intersexual anatomy. This variability in body composition is something that is not always evident at birth. Sometimes a person does not discover that he or she has an intersexual anatomy until puberty when the expected body changes typical of a woman or man do not occur. Some people live and die with an intersexual anatomy without anyone, even them, knowing it. Intersexuality is basically a variation in form and body composition and is not a pathology. An intersex person can be born with ambiguous genitals and be totally healthy.

According to the Intersex Society of North America, “intersex is a general term used for a variety of conditions in which a person is born with reproductive or sexual anatomy that does not fit typical definitions of female or male." Intersexuality is a congenital difference in physical sexual characteristics and physical differences in chromosomes, genetic expression, and hormonal differences in reproductive parts such as the testicles, penis, vulva, clitoris, or ovaries.

Intersexuality is not about transitioning, identity, or a trans experience and it is not about same- sex attraction.

Eroticism. Eroticism, unlike basic sexual activity, is a psychological quest independent of the fundamental goal of reproduction and the desire for children (Bataille, 1987). Eroticism is learning to experiment and enjoy body sensations without guilt. It is an expression of sexuality

17 and sensuality; it is arousal and desire. The definitions of eroticism and erotology vary depending on the reference source (Vinson & McKeal, 2008).

Sexual Dysfunction. Sexual dysfunctions are defined by the Diagnostic and Statistical

Manual of Mental Disorders Fifth Edition (DSM-5) as follows:

Sexual dysfunctions include delayed ejaculation, erectile disorder, female orgasmic

disorder, female sexual interest/arousal disorder, genito-pelvic pain/penetration disorder,

male hypoactive sexual desire disorder, premature (early) ejaculation,

substance/medication-induced sexual dysfunction, other specified sexual dysfunction,

and unspecified sexual dysfunction. Sexual dysfunctions are a heterogeneous group of

disorders that are typically characterized by a clinically significant disturbance in a

person's ability to respond sexually or to experience sexual pleasure. An individual may

have several sexual dysfunctions at the same time.

The sub-sections below will present the sexual dysfunctions discussed in the article entitled “Physiology of Female Sexual Function and Dysfunction” (Berman, 2005).

Hypoactive sexual desire disorder. This refers to the persistent or recurring deficiency

(or absence) of sexual fantasies/thoughts or receptivity to sexual activity that causes personal distress. Hypoactive sexual desire disorder may result from psychological/emotional factors or be secondary to physiologic problems such as hormone deficiencies or medical or surgical interventions. Any disruption of the female hormonal milieu caused by natural menopause, surgically or medically induced menopause, or endocrine disorders can result in inhibited sexual desire.

Sexual arousal disorder. This refers to the persistent or recurring inability to attain or maintain adequate sexual excitement causing personal distress. It may be experienced as a lack of subjective excitement, lack of genital response (lubrication/swelling), or other somatic responses. Disorders of arousal include, but are not limited to, lack of or diminished vaginal lubrication, decreased clitoral and labial sensation, decreased clitoral and labial engorgement, or lack of vaginal smooth muscle relaxation. These conditions may occur secondary to psychological factors; however, often there is a medical/physiologic basis such as diminished vaginal/clitoral blood flow, prior pelvic trauma, pelvic surgery, or medications.

Orgasmic disorder. This refers to the persistent or recurrent difficulty, delay in, or absence of attaining orgasm following sufficient sexual stimulation and arousal that causes personal distress. This may be a primary condition (never achieving an orgasm) or a secondary condition as a result of surgery, trauma, or hormone deficiencies. Primary anorgasmia can be secondary to emotional trauma or sexual abuse; however, medical/physical factors, as well as medications (i.e., Serotonin re-uptake inhibitors) can contribute to or exacerbate the problem.

Sexual pain disorders. Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse. Dyspareunia can develop secondary to medical problems such as vestibulitis, vaginal atrophy, or vaginal infection. It can be either physiologically or psychologically based, or a combination of the two. Vaginismus is recurrent or persistent involuntary spasms of the musculature of the outer third of the vagina that interferes with vaginal penetration and causes personal distress. Vaginismus usually develops as a conditioned response to painful penetration or secondary to psychological/emotional factors.

The next set of sub-sections will present additional dysfunctions as discussed in the article entitled “Summary of the Recommendations on Sexual Dysfunctions in Men” (Montorsi,

Adaikan, Becher, Giuliano, Khoury, Lou, & Broderick, 2010).

Erectile dysfunction. Erectile dysfunction (ED) is defined as the consistent or recurrent inability of a man to attain and maintain a penile erection sufficient for sexual activity. A diagnosis of ED is primarily based on patient self-reports. Although the diagnosis may be supported by objective testing (or partner reports), these measures cannot substitute the patient's self-reports in classifying the disorder or establishing the diagnosis.

Orgasm and ejaculation disorders in men. Premature ejaculation (PE) can be referred to as rapid or early ejaculation and is defined according to three essential criteria: a) brief ejaculatory latency; b) loss of control; and c) psychological distress in the patient or partner. An ejaculatory latency of two minutes or less may qualify a man for the diagnosis, which should include consistent inability to delay or control ejaculation with marked distress about the condition. All three components should be present to qualify for the diagnosis. Subtypes of the disorder are symptom-based, including lifelong versus acquired PE, global versus situational PE, and the co-occurrence of other sexual problems, particularly ED. Approximately 30% of men with PE have co-occurring ED, which typically results in early ejaculation without a full erection. A wide degree of severity is seen with patients ejaculating upon or prior to penetration in the most severe cases.

Delayed ejaculation, anejaculation, and male anorgasmia. Male orgasmic dysfunction

(MOD) includes a spectrum of disorders in men ranging from delayed ejaculation to a complete inability to ejaculate, anejaculation, and retrograde ejaculation. Multiple etiological factors have been identified, including both organic and psychogenic factors. Any medical disease, drug, or

20 surgical procedure that interferes with either central control of ejaculation or the peripheral sympathetic nerve supply to the vas and bladder neck, the somatic efferent nerve supply to the pelvic floor, or the somatic afferent nerve supply to the penis can result in delayed ejaculation, anejaculation, and anorgasmia. Ejaculatory dysfunction and loss of orgasmic sensation commonly occur following prostate or bladder surgery and have been reported in association with lower urinary tract symptoms (LUTS) in aging men.

Female reproductive system. The primary function of the female reproductive system is the production of female sex cells. It also acts as an endocrine organ, producing estrogen and progesterone, as well as for the fertilization and development of the embryo into a fetus. The female reproductive system consists of the internal genitalia that includes the ovaries, fallopian tubes, uterus and vagina, and the external genitalia or vulva, labia majora, labia minora, and the clitoris (Le Vay, 2001). The ovaries are two sex glands that harbor the ovules and produce the female sex hormones estrogen and progesterone. They are located on each side of the uterus at the top of the pelvic cavity. They are attached by ligaments to the uterus and the pelvic wall, together with the fimbriae of the fallopian tubes. These are ducts about ten to fourteen centimeters in length that connect the ovaries to the uterus. They are responsible for collecting the eggs that come from the ovaries and bringing them to the womb. The uterus or womb is a cavity that houses the eggs and is where the baby develops during pregnancy. It measures seven to eight centimeters in length and three centimeters in width. It has three layers: the internal layer is the endometrium, the intermediate layer is formed by smooth muscle, and the extreme layer is formed by a more elastic tissue (my.clevelandclinic.org, 1995-2017) (Appendix A).

Male reproductive system. The male reproductive system is divided into the external and internal genital organs. The sex organs work to produce and release male sex cells. They also produce hormones that help develop the primary and secondary sexual characteristics in men, especially during puberty. The external genital organs of the male reproductive system include the penis and the testicular pouch or scrotum. This organ covers the testicles and is formed by skin. Its function is to contain and maintain the testicles at a suitable temperature so that they can produce spermatozoa. The penis is the sexual organ and is used for intercourse and to eliminate urine and semen. It has the property of filling with blood and hardening when stimulated. The penis leads the semen out of the body through the urethra, the same conduit that carries the urine from the bladder to the outside. Therefore, it has both reproductive/sexual functions and urinary system functions.

The internal genital organs of the male reproductive system are the testicles. The testicles are egg-shaped and are located in the scrotum. They produce testosterone and sperm. The vas deferens are two muscular tubes that connect the epididymis to the ejaculatory ducts. Their function is to transport the mature spermatozoa to the seminal vesicle. These are released with ejaculation. The prostate is the organ of the male reproductive tract and genito-urinary system that is located at the exit of the urinary bladder. It contains cells that produce part of the seminal fluid, the function of which is to nourish and protect the sperm in the semen. Sperm itself is continuously being formed (Le Vay, 2001).

The seminal vesicles are responsible for making seminal fluid so that the sperm can move easily and for nourishing and protecting sperm cells. The urethra is the duct for the expulsion of the urine that was previously stored in the bladder. It also allows the passage of semen from the seminal vesicle to the outside. The epididymis is a tight and heavily coiled tube connected to

22 each testicle. This is where the sperm is stored after it is produced. The ejaculatory duct is the conduit of the male reproductive tract that carries the semen from the seminal vesicle to the urethra. In ejaculation, the semen passes through the ducts and is then expelled by the penis. The

Cowper’s or Bulbourethral glands are two glands located inferior to the prostate, segregating a liquid that is part of the seminal fluid (my.clevelandclinic.org. 1995-2017) (Appendix B).

Sexually transmitted infections. According to the World Health Organization (WHO), sexually transmitted diseases are caused by infections that are transmitted from one person to another during sexual contact. Some of these infections do not present any symptoms. From a medical point of view, infections are called diseases when they have symptoms. That is why they are also known as "sexually transmitted infections." However, the term "sexually transmitted diseases" or "STDs" is often used, even if there are typically no symptoms of the disease.

Counseling interventions and behavioral approaches represent the primary prevention measures against STIs, including HIV. These interventions usually include the following: comprehensive sex education, counseling before and after STI and HIV testing, counseling on safer sexual practices and risk reduction, and the promotion of condom use and interventions targeting high-risk population groups.

Guidelines for counseling and testing for HIV antibody are based on public health

considerations for HIV testing. Including the principles of counseling before and after

testing, confidentiality of personal information, and the understanding that a person may

decline to be tested without being denied healthcare services, except where testing is

required by law (CDC, 1999).

Additionally, counseling can improve people's ability to recognize STI symptoms, increasing the likelihood that they will seek care or encourage their sexual partners to do so.

Unfortunately, the lack of public sensitivity, a lack of training for healthcare personnel, and the widespread stigma surrounding STIs continue to make it more difficult to use these interventions.

Planned Parenthood indicates that condoms, when used correctly, are one of the most effective methods of protection against STIs, including HIV, and are effective 98% of the time in preventing pregnancy. Female condoms are effective and safe but within the framework of national programs, they are not used as widely as male condoms. Efforts to identify interventions that can minimize high risk sexual behaviors and help change these behaviors continue to be challenging. Research has demonstrated that it is necessary to focus on carefully defined populations to incorporate them into design, implementation, and evaluation activities.

Sexuality in people with disabilities. Some say that sexuality among people with functional diversity is neither better nor worse than that of others but reality proves otherwise.

Occupational therapists, as well as other rehabilitation professionals, are aware that sexuality counseling is an important aspect of rehabilitation (Neistadt, 1986). One of the biggest problems originates in the resistance of parents to address their children's sexuality. Unfortunately, even today, myths surrounding the sexuality of people with disabilities still exist. Some are considered asexual and others are considered hypersexual. These myths have an adverse impact on their sexuality. They are silent and diverse and sex education is seen as dangerous and unnecessary; therefore, sexuality is avoided and repressed, limiting the full exercise of sexual and reproductive rights. When professional rehabilitation counselors neglect to acknowledge, or discuss sexuality

24 issues with their clients, they may be inadvertently sending the message that their counselors do not see them as sexual beings, thus continuing to perpetuate negative stereotypes (Pebdania,

2013).

Professionals should be mediators who do not let their personal beliefs guide or regulate the sexuality of persons with disabilities. On the contrary, they should put themselves at the service of their patients and their patients’ parents, acting as mediators who offer not opinions, but knowledge and professional help.

Sexual abuse. Sexual abuse involves attitudes and behaviors of one person over another, without the victim’s consent or knowledge and for the aggressor’s own sexual satisfaction. It ranges from a threat to deception, seduction, or confusion. It is considered abuse if the other person does not want it or is deceived, and it can occur within a couple. It is an act that seeks to dominate, possess, and repress the person through sexuality. Sometimes the aggressor acts violently towards the victim, who feels helpless, unprotected, and humiliated. At other times, the aggressor relies on the trust placed in him or her in the closeness of an affective relationship, then breaks the limits of intimacy by introducing erotic elements. When the aggressor establishes a confused relationship, the abuse is not only sexual but also an abuse of trust, especially when the victim is a child. For some time, most of the studies on sexual abuse came from North

America and some skeptics believed that it might be uniquely common to that area. However, there have been community epidemiological surveys in at least 20 different countries, finding child sexual abuse histories in a large fraction of the population (Finkelhor, 1997).

Working with families in which there have been incidents of child abuse is one of the most challenging assignments for a professional counselor (Hunter, 2006). There are many effects of aggression and they are expressed in the most important areas of a person. It is lived as a traumatic event, something that impresses on the victim so much that it cannot be expressed, and therefore, he or she tries to forget it. However, traumatic events tend to manifest themselves and come to light in the form of repetition, violence, behavioral problems, or sexual dysfunctions. Sexual abuse is not just penetration or physical aggression. It ranges from physical contact such as touching, masturbation, oral sex, to non physical contact sexually charged behaviors such as exhibitionism, eroticization with sexual stories, or pornography. It can be prolonged over time or be an isolated event. It can happen within the nucleus of a family, an institution or workplace, or with a neighbor, teacher or doctor. There is no specific scope.

The consequences of abuse will be more severe with greater affective involvement or with symbolic or moral authorities in relation to the temporal duration of such abuse. The signs may not be distinctive but there are indicators that something in general is wrong and more specifically, that something is wrong with one’s sexuality. Therefore, it is important to take such indicators into consideration because the sooner the underlying problem is detected, the sooner the victim can get help.

The WHO (2013) defines sexual violence as follows:

Any sexual act, the attempt to consummate a sexual act, the comments or unwanted

sexual advances, or actions to market or use in any other way the sexuality of a person

through coercion by other person, regardless of the relationship of the victim with the

victim, any area, including the home and the workplace.

Sexual violence encompasses sex under duress of any kind including the use of physical

force, attempts to obtain sex under duress, aggression with sexual organs, and sexual

harassment including sexual humiliation, marriage, or forced cohabitation such as child

marriage or prostitution. It also includes forced labor and marketing of women, forced

abortion, denial of the right to use contraception or to take protective measures against

diseases, and acts of violence that affect sexual integrity such as female genital mutilation

and virginity.

Sexual Harassment. Sexual harassment is behavior directed against a specific person and is characterized by repeated harassment and persecution with the goal getting the person to agree to do what is insistently demanded. Sexual harassment is a form of gender discrimination and although men may be subjected to sexual harassment, the reality is that the majority of victims are women.

Some of the serious effects suffered by victims of this type of harassment include emotional stress, humiliation, anxiety, depression, anger, and impotence. If the aggression is in the workplace, the victim may exhibit tension, low performance, and absenteeism. Mental and physical stress symptoms, as well as diminished productivity and self-confidence, are common reactions (Crull, 1982). Sexual harassment is a violation of the dignity, physical health, and psychology of the victim, who tends to feel guilty and despised. What differentiates sexual harassment from friendly behavior is that the former is unwanted and the latter is accepted and mutual. Sexual attention becomes harassment if it continues after a person has clearly said that that attention is considered offensive.

Sexual taboos. The term taboo is of Polynesian origin and it is applied to individuals or things with which any form of contact is prohibited because they are considered sacred or forbidden (Merrian-Webster, 2017). Taboos are, in most cases, related to sexuality and are commonly oriented towards deviations and sexual obsessions. Sexual taboos are transmitted from parents to children and are accentuated when young people search for information and experiences about sexuality, which they access through friends, magazines, movies, or pornographic websites, and other informal souces. When the adquired information is wrong the result is a distorted view of couple relationships and bodily sensations. Innumerable sexual myths, fantasies, and legends abound. The term taboo refers to an absolute prohibition based on religion, traditions, social mores, or superstition. These generalized prohibitions at the sexual level usually constitute sins. The disappearance of taboos and their consequent transformation are due to sexuality counseling and education.

Sexual myths. According to the dictionary of the Royal Spanish Academy, a myth is a

“wonderful narration located outside historical time and featuring characters from a divine or heroic character and frequently interprets the origin of the world or great events of humanity.”

The myth may be an idea without foundation, as in the case of fallacies, because these constructs are propagated and form a stable, socially accepted belief, often for no reason whatsoever.

Paraphilias. According to the Journal of the American Academy of Psychiatry and the

Law, the DSM-5 changed the name from paraphilia to paraphilic disorder and redefined the term paraphilia so that it now refers to a persistent, intense, atypical sexual arousal pattern,

28 independent of whether it causes any distress or impairment, which, by itself, would not be considered a disorder. These behavioral activities do not correspond to the sexual intimacy of most individuals and couples, as shown by the pioneering sexologist Alfred Kinsey in his survey of thousands of Americans as early as 1948, also known as the Kinsey Report. Some patterns involve distressing or disabling sexual drives or behaviors involving inanimate objects, children, or other adults, or the suffering or humiliation of oneself or the couple, and certain sexual preferences. Although they might seem unusual to other people or health care personnel they do not necessarily constitute a paraphilia. Excitation patterns are considered pathological only when they become mandatory for sexual functioning, when they involve inappropriate partners, or when they cause anguish or significant deterioration in the social, labor, or other critical areas of functionality.

People with paraphilias may have an alteration in the ability to feel affection and to maintain reciprocal emotional sexual intimacy with their partners. There may also be alterations to other aspects of personal and emotional adjustment. The pattern of erotic arousal is usually well developed before puberty. In a study done by Andrade, Vincent, and Saleh in 2006, 50% of the adult participants indicated that their paraphilias began when they were adolescents. There is not a defined cause for a paraphilia but there is a strong compulsive component to this behavior

(Buhrich & McConaghy, 2001). Researchers often hypothesize about possible reasons for the development of paraphilic behavior such as anxiety or early emotional trauma. Interfering with normal psychosexual development, the standard pattern of excitement is replaced by a different pattern, sometimes through early exposure to an experience with a clear sexual charge that reinforces the person's experience of sexual pleasure. The pattern of sexual arousal often acquires symbolic and conditioning elements such as a fetish that symbolizes the object of arousal but

29 may also have been chosen because it was accidentally associated with curiosity, desire, and excitement. Situations vary from case to case. In 1984, John Money (cited in Fankhanel, 2008), posited that paraphilias may be playful and harmless while others unwelcome or even dangerous to a consenting partner. Initially, in 1984, he identified 33 paraphilias, but in 1988, due to his continued studies in the field, he identified another 17 (Appendix C).

Currently, paraphilias are known as sexual, erotic behaviors that are not understood by most people. There are some paraphilic activities that can be found within normal sexuality if they are sporadically practiced or as part of foreplay. In the field of sexology, stigmatization by the imposition of discriminatory labels on controversial topics such as human sexuality is avoided.

Fetishism. The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition

(DSM-5) considers fetishism a paraphilia. Fetishism is the use of an inanimate object (the fetish) as the preferred method to produce sexual excitement. However, commonly, this word is used to describe particular sexual interests, such as sexual role play, preferences for physical characteristics, and preferred sexual activities. The fetish can replace the usual sexual activity with a partner or can be integrated into sexual activity with a consenting partner. Minor fetish behaviors as a compliment to consensual sexual behavior is not considered a disorder because there is no significant distress, disability, or dysfunction. The most intense compulsive fetishist arousal patterns can cause problems in one’s relationship or consume and destroy one’s life.

Sexual stimulation is usually motivated by turning the five senses towards the erogenous zones of the body, although sometimes these are replaced by garments or objects, becoming the

30 only way to obtain satisfaction. A person who lives with this sexuality is called a fetishist.

Today, it is difficult to know the different ways that human beings achieve their sexual satisfaction, beyond the traditional intimate relationship. DSM-5 considers fetishism a paraphilia, and defines the term as sexual fantasies, impulses, and behaviors linked to the use of non- animated objects, such as women's underwear. Such fantasies produce social deterioration and significant discomfort at the clinical level of the subject.

LGTTBIQ issues. We all have a sexual orientation and a gender identity, but regardless of how diverse these may be, this usually means discrimination against members of the Lesbian,

Gay, Bisexual and Transgender community. This is an issue that transcends community and affects us all. Sexual orientation covers sexual desires, feelings, practices, and identification. In

2001, Steve Rainey, from Kent State University, and Jerry Trusty, from Pennsylvania State

University, conducted a survey of 132 counseling students in a program accredited by the

Council for Accreditation of Counseling and Related Educational Programs (2001). Participants attended a medium-sized, regional university in the southwestern part of the US. According to them, religiosity, political views, and previous experience with lesbians were the strongest predictors of attitudes toward gay men and lesbians. It is important to point out that counselors should be aware of their own values when helping others (Corey, Corey, & Callanan, 1998).

Sexual orientation is an attraction to people of the same or different sex. Gender identity refers to the complex relationship between sex and gender, referring to a person's experience of self-expression in relation to social categories of masculinity or femininity. Amnesty

International believes that all individuals, regardless of their sexual orientation or gender identity, should be able to enjoy their human rights. Although the Universal Declaration of

Human Rights does not explicitly mention sexual orientation or gender identity, evolving conceptions of international human rights law form a broad interpretation to include the rights and the protection of LGBTTIQ people around the world (United Nations General Assembly,

1948).

Article 2 of the Universal Declaration of Human Rights specifies that "[e]veryone has all the rights and freedoms set forth in this Declaration, without distinction as to race, color, sex, language, religion, political or other opinion, national or social origin, economic status, birth or other status,” thereby emphasizing the absolute right of each human being not to be discriminated against because of his or her sexual orientation or gender identity (Assembly,

U.G., 1948).

Sexual response cycle. The cycle of sexual response refers to the sequence of physical and emotional changes that occurs when a person becomes sexually aroused and engages in sexually stimulating activities, including intercourse and masturbation. Masters and Johnson first characterized the female sexual response in 1966 as consisting of four successive phases: excitement, plateau, orgasmic, and resolution phases. During sexual arousal, both the clitoris and the labia minora become engorged with blood and vaginal and clitoral length and diameter both increase. Masters and Johnson also observed that the labia minora increase in diameter by two to three times during sexual excitement and consequently become everted, exposing their inner surface (Berman, 2005)

In 1979, Kaplan proposed the aspect of “desire,” and a three-phase model consisting of desire, arousal, and orgasm, with desire being the factor inciting the overall response cycle. This three-

32 phase model is the basis for the DSM-5 definitions of female sexual dysfunction, as well as the re-classification system made by the American Foundation for Urologic Disease (AFUD)

Consensus Panel in October of 1998 (Berman, 2005).

The sexual response cycle has five phases: desire, arousal, plateau, orgasm, and resolution. Both men and women experience these phases. However, the time it takes to move from one phase to another is different. For example, it is not very common for two people in a couple to reach orgasm at the same time. Additionally, the intensity of sexual response and time spent in each phase varies from person to person. Understanding these differences can help couples better understand each other's bodies and reactions to improve sexual experience.

Contraceptive methods. Each person should choose their contraceptive method according to his or her own life situation, lifestyle, sexual life, number of children desired, number of partners, values, socio-economic position, etc. The characteristics of the method should take into account the health conditions that may be affected by its use such as high blood pressure, smoking, cardiovascular diseases, reproductive tract infections, etc.

According to DrEd.com, an online medical site operated by Health Bridge Limited and regulated by the Care Quality Commission (CQC), in the last 50 years, the number of contraception methods has dramatically increased. You can differentiate between different types of contraception based on how they work. There are barrier methods (e.g. condoms or a cervical cap), hormonal methods (e.g., the pill), intrauterine devices (IUDs), and sterilization (Appendix

D). This website indicates that most contraceptives work as follows:

1. By preventing an egg from being released every month (hormones);

2. By preventing sperm from reaching the egg (barrier and some IUD methods);

3. By blocking the reproductive function in men or women (sterilization); or

4. By preventing a fertilized egg from implanting in the uterus (hormones).

The role of the health professional is to inform a patient of all the options and verify the eligibility criteria in such a way as to help the patient make a decision of his or her own free and informed will. The health professional should also inform of side effects, or possible problems that may arise. This information and guidance process should be continuous and includes follow- up. Contraceptive methods have different characteristics that should be considered when making a selection. This consideration is necessary in order for the method to achieve reproductive goals effectively and safely.

Cybersex. Cybersex is a form of virtual sex in which two or more people connected through a computer network send sexually explicit media that depicts a sexual experience. It is a type of role play in which participants pretend to be having sex, describe their actions, and respond to messages from other participants in order to stimulate their sexual desires and fantasies. The quality of a virtual sex encounter generally depends on the ability of participants to evoke or show a vivid picture in the minds of their partners. In many cases, the participants invent a personality, specific qualities, and an emotional connection. There is a distinction between people who use Internet sex to improve their offline sex life and those who use it as a substitution (Griffiths, 2017).

Undoubtedly, the internet has gained ground in all fields, including issues related to sexuality. This modality is safe from the point of initiating sexual exchanges and facilitates personal discovery but can become quite conflicting if the medium is abused.

Taken together, the results of the literature review conclude that our attitudes and aptitudes are significant in understanding our sexuality. It is evident that sexual expectations, awareness, education, and environment influence sexual counseling. Professional counselors play a significant role in managing barriers that affect the process of sexuality counseling. They need to educate themselves to be aware of the complexity of the human sexual behavior spectrum. We should always aspire to have an accurate knowledge of our sexuality.

Chapter Three: Methodology

The purpose of this study is to examine the perception, skills, and knowledge of a sample of professional counselors in Puerto Rico regarding human sexuality and sexual counseling. The analysis of the data presented a distribution of the sample based on socio-demographic characteristics, knowledge of the concepts, desirability to train, and willingness to intervene or refer.

Research Design

The study had an exploratory design with a quantitative methodology. This design was selected because no previous studies on this subject and on this population, could be identified.

Exploratory studies attempt to lay the groundwork that will lead to future studies. They usually determine trends, identify potential relationships between variables, and set the tone for more rigorous future investigations (Dankhe, 1986). A quantitative methodology explains phenomena by collecting numerical data that is analyzed using mathematics-based methods (Aliaga &

Gunderson, 2005). When quantitative methods are used, they usually involve surveys or questionnaires and statistical analyses. In this case, self-administered questionnaires are used and the collected data is analyzed using the Statistical Package for Social Sciences (SPSS).

The sample and distribution. A non-probability sample was selected because the participants were chosen through availability sampling ("Samples in Research," 2017). After inviting 100 subjects to participate, 64 decided to participate and submitted a complete self- administered questionnaire. The participants were approached personally by the researcher at

36 professional continuing education activities (CE courses), non-for-profit organizations, and postsecondary educational institutions. All the participants were given a letter of invitation that explained the purpose of the study as well as confidentiality and reliability issues (Appendix E:

Spanish Version; Appendix F: English Version); a pre-addressed, stamped envelope; and a copy of the questionnaire, which included specific instructions. The letter and the questionnaire were redacted and distributed in Spanish, the primary language of Puerto Rico. Participants who were willing to complete the self-administered questionnaire onsite were given an envelope so they could seal the instrument and submit it to the researcher.

The instrument. The questionnaire was called the Inventario de Aptitudes y Actitudes en

Sexualidad Humana y Consejería Sexual (Inventory of Aptitudes and Attitudes in Human

Sexuality and Sexual Counseling (Inventory)) (Appendix G: English Version; Appendix H:

Spanish Version). This instrument included six questions designed to gather socio-demographic, one question to gather information on the respondent’s previous education on sexuality, and three questions to gather academic interest information. These questions collected specific information about academic specialties within the counseling field, highest obtained academic degree, years of experience in the field, work scenario, age, and gender. Question number seven asked about previous education on sexuality and inquired whether the education was obtained as part of a bachelor’s, master’s or doctoral degree program. Questions 8-10 measured the level of interest in training in the field of sexuality and how extensive this training would be. The choices included a single course, an official certification, and a full academic degree. Additionally, utilizing a Likert Scale, respondents were to self-evaluate and choose a score based on their presumed level of knowledge on 22 topics related to sexuality. The Likert Scale was developed

37 by psychologist Rensis Likert in 1932 and is commonly used to rate the degree to which a respondent agrees or disagrees with a statement and to measure attitudes (Sullivan & Artino,

2013). The scores fluctuated between one, representing a very limited level of knowledge, and four, representing a very high level of knowledge.

The 22 (twenty-two) concepts included in the questionnaire were:

1. Gender Identity

2. Sexual Orientation

3. Transgender

4. Transsexuality

5. Intersexuality

6. Eroticism

7. Psychogenic female sexual dysfunctions

8. Psychogenic male sexual dysfunctions

9. Female reproductive system

10. Male reproductive system

11. Sexually Transmitted Infections

12. Sexuality in people with disabilities

13. Sexual abuse

14. Sexual harassment

15. Sexual taboos

16. Sexual Myths

17. Paraphilias

18. Fetishes

19. LGTTBIQ Issues

20. Sexual response cycle

21. Contraceptive methods

22. Cyber sex

The instrument also inquired about the respondent’s willingness to intervene or refer in cases regarding specific concepts and the intent to receive training on such concepts. The training sessions were divided into 4, 8, 12, and 16 hours.

Validation of the instrument. Before the questionnaire was distributed, it went through an exhaustive validation process. This process commenced after a validity and reliability test for the questionnaire was developed (Heale & Twycross, 2015) (Appendix G: Spanish Version;

Appendix H: English Version). To complete the first phase of validation, five experts were contacted: three PhDs in the areas of psychoeducational assessment, school psychology, educational leadership, and management; one EdD in professional counseling; and one MS in investigative evaluations. These experts were asked to analyze the clarity and effectiveness of each question. As the final step to complete validation, the instrument was administered to five professional counselors in training. These graduate students were asked to answer all the

39 questions and comment on the instrument. After they confirmed the questionnaire’s clarity and effectiveness, validation was completed and the instrument was qualified for administration. The process of distribution lasted five months, from September 2016 to February 2017.

Chapter Four: Findings

The Inventory was sent to 100 professional counselors on human sexuality and sexual counseling in Puerto Rico. From these, 64 (=N) professional counselors submitted a complete

Inventory. The Inventory compiled information on the aptitudes and attitudes of professional counselors on human sexuality and sexual counseling.

Table 1 shows the socio-demographic characteristics of the sample. Nearly 50% of the counselors had an academic specialty in school counseling while the other combined specialties of mental health, addictive disorders, couples and family counseling, and general counseling basically constituted the other 50%. A high majority of participants had master’s degrees, 15 years of experience or less, and most of them worked in the public education system or postsecondary public education system. Additionally, a high proportion of the respondents were older than 40 years of age and nearly 85% were females.

Among the participants, more than half had taken a university course in human sexuality and half of these took the course at the master’s level. When asked about their willingness to take a course, pursue certification, or obtain an academic degree in human sexuality, as the proposed level increased, their willingness decreased. For example, more than 90% of the participants were willing to take a full course in counseling on human sexuality (only five were not willing).

However, when the level changed to a certificate, only approximately 75% indicated that they would be willing to pursue the option. Willingness diminished to 48.4% when asked about obtaining an academic degree in human sexuality (see Table 2).

Table 1 Socio-demographic Characteristics of Professional Counselors

Variables N Percent Academic specialty Guidance Counseling 30 46.9 Other types of counseling 34 53.1

Highest academic degree Master's degree 56 87.5 Doctorate’s degree 8 12.5

Years of experience 15 years or less 36 56.3 16 years or more 28 43.8

Job scenarios Public education system 20 31.3 Postsecondary public education system 14 21.9 Non-profit 9 14.1 Private post-secondary 9 14.1 Private educational system 5 7.8 Private practice 4 6.3 Other 3 4.7

Age 40 years or younger 19 29.7 Older than 40 years 45 70.3

Sex Male 10 15.6 Female 54 84.4

Table 2 Knowledge and Willingness to Have Further Studies in Human Sexuality

Variables N Percent Took a university course in human sexuality No 28 43.8 Yes 36 56.3

Level when the university course in human sexuality was taken Bachelor’s degree level 16 44.4 Master’s degree level 18 50.0 Doctorate’s degree level 2 5.6

Willingness to take a full course in counseling on human sexuality No 5 7.8 Yes 59 92.2

Interested in completing a certification in human sexuality No 14 21.9 Yes 50 78.1

Interested in completing an academic degree in human sexuality No 33 51.6 Yes 31 48.4

There were 22 concepts related to human sexuality for which the professional counselors indicated their level of knowledge (Table 3). The categories of level of knowledge, for summary purposes, were condensed into two levels: limited and high. Limited includes responses of very limited and limited, while high contains responses of high and very high. More than 60% of respondents declared limited knowledge on the concepts of transsexuality, intersexuality, eroticism, psychogenic female sexual dysfunctions, psychogenic male sexual dysfunctions, sexuality in people with disabilities, paraphilias, fetishes, and sexual response cycle. On the other hand, more than 60% of respondents reported a high level of knowledge on sexual orientation,

43 the female reproductive system, the male reproductive system, sexually transmitted infections, sexual abuse, sexual harassment, and contraceptive methods,

Table 3 Level of Knowledge About Human Sexuality Concepts

Limited High Topic N % N % Gender Identity 27 42.2 37 57.8 Sexual Orientation 21 33.3 42 66.7 Transgender 37 57.8 27 42.2 Transsexuality 41 64.1 23 35.9 Intersexuality 47 73.4 17 26.6 Eroticism 32 75.6 32 24.4 Psychogenic female 48 75.0 16 25.0 sexual dysfunctions Psychogenic male 48 75.0 16 25.0 sexual dysfunctions Female reproductive 12 18.7 52 81.3 system Male reproductive 17 26.6 47 73.4 system Sexually Transmitted 13 20.3 51 79.7 Infections Sexuality in people with 45 70.3 19 29.7 disabilities Sexual abuse 25 39.1 39 60.9 Sexual harassment 20 31.2 44 68.8 Sexual taboos 29 45.3 35 54.7 Sexual Myths 33 51.6 31 48.4 Paraphilias 43 67.2 21 32.8 Fetishes 43 67.2 21 32.8 LGTTBQ Issues 31 48.4 33 51.6 Sexual response cycle 39 60.9 25 39.1 Contraceptive methods 14 21.9 50 78.1 Cybersex 36 56.2 28 43.8

Figure 1 presents the five concepts with the highest responses of limited level of knowledge. All these concepts were selected by at least 70% of the professional counselors who completed the Inventory. These topics were (in ascending order) sexuality in people with disabilities, intersexuality, psychogenic female sexual dysfunctions, psychogenic male sexual dysfunctions, and eroticism.

Eroticism 75.6

Psychogenic male sexual dysfunctions 75.0

Psychogenic female sexual 75.0 dysfunctions

Intersexuality 73.4

Sexuality in people with disabilities 70.3

66.0 68.0 70.0 72.0 74.0 76.0

Figure 1. Concepts About Human Sexuality with Limited Knowledge Among Counselors

Figure 2 shows the five concepts with the highest responses of high level of knowledge.

The selection ranged between 68% and 81% of the professional counselors. These topics were

(in ascending order) sexual harassment, male reproductive system, contraceptive methods, sexually transmitted infections, and female reproductive system.

Female reproductive system 81.3

Sexually Transmitted Infections 79.7

Contraceptive methods 78.1

Male reproductive system 73.4

Sexual harassment 68.8

60.0 65.0 70.0 75.0 80.0 85.0

Figure 2. Leading Concepts About Human Sexuality with High Knowledge Among Counselors

With the responses given to the concepts, I created a level of knowledge scale. Figure 3 shows that more than two thirds of the professionals had a high knowledge of these topics.

However, there was one case who had very limited knowledge regarding these topics.

Very limited Limited High

23%

75%

Figure 3. Level of Knowledge Scale Among Counselors About Human Sexuality Concepts

In the Inventory, the counselors answered if they would refer or intervene with cases related to the 22 concepts mentioned previously (Table 4). The concepts intersexuality, psychogenic female sexual dysfunctions, psychogenic male sexual dysfunctions, paraphilias, and fetishes had more than 60% of counselors referring a case. On the contrary, gender identity,

46 sexual orientation, female reproductive system, male reproductive system, sexually transmitted infections, sexual harassment, sexual taboos, sexual myths, LGTTBQ issues, and contraceptive methods had more than 60% where counselors indicated that they would intervene. Finally, the mean number of topics that counselors would refer was 9.6 ± 6.5 and the mean number of topics in which counselors would intervene is 12.4 ± 6.5.

Figure 4 presents the five topics that counselors are more likely to refer. All these concepts were selected by at least 60% of the professional counselors who completed the

Inventory. The topics were (in descending order) psychogenic male sexual dysfunctions, psychogenic female sexual dysfunctions, fetishes, intersexuality, and paraphilias.

Figure 5 shows the five topics that counselors are more likely to intervene with. These topics were selected by between 68% and 81% of the professional counselors. The topics were

(in descending order) contraceptive methods, sexual orientation, female reproductive system, gender identity, male reproductive system, sexually transmitted infections.

Table 4 Intention to Refer or Intervene on Cases Regarding Human Sexuality

Refer Intervene Topic N % N % Gender Identity 17 26.6 47 73.4 Sexual Orientation 13 20.3 51 79.7 Transgender 31 48.4 33 51.6 Transsexuality 32 50.0 32 50.0 Intersexuality 41 64.1 23 35.9 Eroticism 35 54.7 29 45.3 Psychogenic female 43 67.2 21 32.8 sexual dysfunctions Psychogenic male 45 70.3 19 29.7 sexual dysfunctions Female reproductive 13 20.3 51 79.7 system Male reproductive 18 28.1 46 71.9 system Sexually Transmitted 20 31.3 44 68.8 Infections Sexuality in people with 36 56.3 28 43.8 disabilities Sexual abuse 27 42.2 37 57.8 Sexual harassment 23 35.9 41 64.1 Sexual taboos 22 34.4 42 65.6 Sexual Myths 23 35.9 41 64.1 Paraphilias 41 64.1 23 35.9 Fetishes 41 64.1 23 35.9 LGTTBQ Issues 22 34.4 42 65.6 Sexual response cycle 33 51.6 31 48.4 Contraceptive methods 12 18.8 52 81.3 Cybersex 26 40.6 38 59.4

70.3 67.2 72.0 64.1 64.1 64.1 66.0 60.0 54.0 48.0 42.0 36.0 30.0 24.0 18.0 12.0 6.0 0.0 Psychogenic Psychogenic Fetishes Intersexuality Paraphilias male sexual female sexual dysfunctions dysfunctions

Figure 4. Human Sexuality Topics that Counselors are More Likely to Refer

84.0 81.3 79.7 79.7 73.4 71.9 68.8 70.0

56.0

42.0

28.0

14.0

0.0 Sexual Female Gender Male Sexually Contraceptive Orientation reproductive Identity reproductive Transmitted methods system system Infections

Figure 5. Human Sexuality Topics that Counselors are More Likely to Intervene

In the Inventory, the counselors answered if they would like to receive training related to

22 concepts related to human sexuality (Table 5). For the concepts, female reproductive system, male reproductive system, sexually transmitted infections, sexual abuse, sexual harassment, and contraceptive methods more than 20% of counselors indicated that they would not receive training on these topics. On the contrary, more than 90% counselors indicated that they would receive training about psychogenic female sexual dysfunctions, psychogenic male sexual

49 dysfunctions, and sexuality in people with disabilities. Between 80% and 89% of the counselors selected 13 concepts that they would also want to have training.

Figure 6 presents five topics that counselors indicated would not want to receive training.

All these concepts were selected by between 23% to 31% of the professional counselors who completed the Inventory. The topics were (in descending order) male reproductive system, female reproductive system, contraceptive methods, sexual abuse, and sexual harassment.

Figure 7 shows five topics that between 87% and 92% of counselors indicated they want to receive training. The topics were (in descending order) psychogenic female sexual dysfunctions, sexuality in people with disabilities, psychogenic male sexual dysfunctions, paraphilias, and

LGTTBQ issues.

Table 5 Intention to Receive Training Regarding Human Sexuality

No Yes Topic N % N % Gender Identity 9 14.1 55 85.9 Sexual Orientation 11 17.2 53 82.8 Transgender 8 12.7 55 87.3 Transsexuality 8 12.7 55 87.3 Intersexuality 8 12.7 55 87.3 Eroticism 8 12.7 55 87.3 Psychogenic female 5 7.8 59 92.2 sexual dysfunctions Psychogenic male 6 9.5 57 90.5 sexual dysfunctions Female reproductive 20 31.3 44 68.8 system Male reproductive 20 31.7 43 68.3 system Sexually Transmitted 14 21.9 50 78.1 Infections Sexuality in people with 5 7.8 59 92.2 disabilities Sexual abuse 15 23.4 48 75 Sexual harassment 15 23.4 49 76.6 Sexual taboos 11 17.2 53 82.8 Sexual Myths 12 18.8 52 81.3 Paraphilias 8 12.5 56 87.5 Fetishes 9 14.1 55 85.9 LGTTBQ Issues 8 12.5 56 87.5 Sexual response cycle 11 17.7 51 82.3 Contraceptive methods 18 28.6 45 71.4 Cybersex 9 14.3 54 85.7

35 31.7 31.3 30 28.6

25 23.4 23.4

0 Male Female Contraceptive Sexual abuse Sexual reproductive reproductive methods harassment system system

Figure 6. Human Sexuality Topics that Counselors are Less Likely to Receive Training

92.2 92.2 90.5 96 87.5 87.5

0 Psychogenic Sexuality in Psychogenic Paraphilias LGTTBQ Issues female sexual people with male sexual dysfunctions disabilities dysfunctions

Figure 7. Human Sexuality Topics that Counselors are More Likely to Receive Training

Figure 8 presents a heat map of human sexuality concepts and hours interested in training. The darkest blue colors represent a higher percentage in those categories. The category of four hours had the highest percentages among 16 of the concepts.

Hours Concepts 4 8 16 20 Gender Identity 29.8 31.6 7.0 26.3 Sexual Orientation 36.4 29.1 9.1 21.8 Transgender 29.6 29.6 13.0 24.1 Transsexuality 27.8 31.5 9.3 27.8 Intersexuality 29.6 27.8 11.1 27.8 Eroticism 27.3 38.2 5.5 27.3 Psychogenic female sexual 37.3 23.7 11.9 25.4 dysfunctions Psychogenic male sexual 42.1 19.3 10.5 26.3 dysfunctions Female reproductive system 50.0 17.4 6.5 23.9 Male reproductive system 54.5 13.6 6.8 22.7 Sexually Transmitted 51.0 21.6 7.8 17.6 Infections Sexuality in people with 32.8 27.6 10.3 27.6 disabilities Sexual abuse 29.4 21.6 11.8 35.3 Sexual harassment 33.3 33.3 7.8 23.5 Sexual taboos 37.0 29.6 7.4 24.1 Sexual Myths 41.5 26.4 7.5 22.6 Paraphilias 42.9 21.4 10.7 23.2 Fetishes 42.9 19.6 14.3 21.4 LGTTBQ Issues 29.8 28.1 14.0 26.3 Sexual response cycle 36.5 21.2 17.3 23.1 Contraceptive methods 50.0 19.6 6.5 21.7 Cybersex 40.0 27.3 7.3 23.6

Figure 8. Human Sexuality Topics by Preferred Number of Training Hours Heat Map

All the concepts in the Inventory were analyzed by means of a Chi-square test by academic specialty, age, taken academic course on human sexuality, would like to take a full course on human sexuality, would take a certificate on human sexuality, would obtain an academic degree in human sexuality, and years of experience. Data on only those who were statistically significant are shown in Tables 5 thru 12.

Table 6 shows the concepts within level of knowledge that were statistically significant by category. When compared by academic specialty, there was limited knowledge about psychogenic male sexual dysfunctions among people with other types of counseling (88.2%)

(other specialties except Guidance Counseling). Additionally, people with other type of counseling degree (other specialties except Guidance Counseling) had limited knowledge about sexual myths (64.7%). When compared by age, the highest knowledge about human sexuality was seen among people older than 40 years (97.8%). There was limited knowledge about transgender (84.2%), transsexuality among (89.5%), eroticism (84.2%), psychogenic female sexual dysfunctions (94.7%), sexuality in people with disabilities (89.5%), sexual taboos

(68.4%), sexual myths (73.7%), and sexual response cycle (73.7%) among younger people.

Additionally, a higher percentage of people 40 years or older reported having more knowledge regarding the female reproductive system (86.7%), and sexually transmitted infections (88.9%).

When comparing if the counselors have taken an university course in human sexuality, it was found that people who have not taken an university course of sexuality had limited knowledge about fetishes (75.0%). Additionally, people who have taken an university course of sexuality had a high knowledge about contraceptive methods (91.7%). Nevertheless, there was high knowledge about sexual orientation among those who are not interested in completing an academic degree in human sexuality (75.8%). When analyzing the interest to take a full course

54 on human sexuality, it was found that there were only five people who will not take a course in human sexuality. Nevertheless, a high percentage of these people (60%) have a high knowledge regarding gender identity. All five-people indicated that they have a high knowledge regarding eroticism. However, those who will like to take a full course in counseling on human sexuality have limited knowledge about sexuality in people with disabilities (74.6%) and fetishes (71.2%).

There were differences by years of experience in 17 human sexual concepts (Table 7).

Those with more years of work experience had high level of knowledge on human sexual topics

(92.9%). Similarly, they had high knowledge on gender identity (82.1%), sexual orientation

(85.2%), the female reproductive system (89.3%), and the male reproductive system (85.7).

Additionally, there was high knowledge among these group regarding sexually transmitted infections (92.9%), sexual abuse (85.7%), sexual taboos (82.1%), sexual myths (71.4%) and

LGTTBQ issues (71.4%). People with less work experience had limited knowledge about the concepts transgender (80.6), transsexuality (83.3%), intersexuality (83.3%), and eroticism (80%).

They also had limited knowledge about psychogenic female sexual dysfunctions (91.7%), psychogenic male sexual dysfunctions (91.7%), sexuality in people with disabilities (80.6%), and sexual response cycle (69.4%).

Table 6 Chi Square Test of Level of Knowledge Among Counselors by Selected Characteristics

Category Chi square p-value Academic specialty Psychogenic male sexual 8.3 0.040 dysfunctions Sexual myths 8.2 0.042 Age Level of knowledge scale 8.8 0.012 Transgender 12.7 0.005 Transsexuality 11.2 0.010 Eroticism 9.2 0.026 Psychogenic female sexual 10.8 0.013 dysfunctions Female reproductive system 11.6 0.009 Sexually transmitted 8.2 0.042 infections Sexuality in people with 24.7 0.000 disabilities Sexual taboos 8.4 0.038 Sexual myths 10.7 0.013 Sexual response cycle 9.8 0.020 Took a university course in human sexuality Fetishes 9.0 0.030 Contraceptive methods 9.8 0.020 Interested in completing an academic degree in human sexuality Sexual Orientation 8.5 0.037 Interested in a full course in counseling on human sexuality Gender Identity 12.4 0.006 Eroticism 10.4 0.016 Sexuality in people with 11.3 0.010 disabilities Fetishes 8.9 0.031

Table 7 Chi Square Test of Level of Knowledge Among Counselors by Years of Experience

Category Chi square p-value Years of experience Level of knowledge scale 8.5 0.014 Gender identity 15.0 0.002 Sexual orientation 10.4 0.015 Transgender 21.3 0.000 Transsexuality 16.1 0.001 Intersexuality 9.8 0.020 Eroticism 9.2 0.027 Psychogenic female sexual 15.9 0.001 dysfunctions Psychogenic male sexual 13.1 0.004 dysfunctions Female reproductive system 13.4 0.004 Male reproductive system 11.6 0.009 Sexually transmitted 9.1 0.028 infections Sexuality in people with 18.2 0.000 disabilities Sexual abuse 14.5 0.002 Sexual taboos 19.1 0.000 Sexual myths 13.5 0.004 LGTTBQ issues 11.1 0.011 Sexual response cycle 10.4 0.015

Table 8 shows the statistically significant concepts regarding the willingness to refer or intervene in cases by category. People with more years of experience indicated that they would intervene in a case related to transgender (67.9%). However, people willing to take a full course in counseling on human sexuality indicated more that they would refer a case related to paraphilia (69.5%).

Table 8 Chi Square Test Willingness to Refer or Intervene in Cases Among Counselors by Selected Characteristics

Category Chi square p-value Years of experience Transgender 4.2 0.041 Interested in a full course in counseling on human sexuality Paraphilias 6.9 0.009

Table 9 shows the concepts that were statistically significant between interest in receiving training about human sexuality and several categories. People with less years of experience indicated more willingness to receive training about sexual abuse (88.9%) and sexual response cycle (94.3%). People who would like to take a full in course in human sexuality were more willing to receive training about sexual orientation (86.4%), eroticism (91.4%), sexual paraphilias (91.5%), fetishes (89.8%), and cybersex (88.1%).

Table 9 Chi Square Test of Interest in Receiving Training About Human Sexuality Concepts Among Counselors by Years of Experience

Category Chi square p-value Years of experience Sexual abuse 9.2 0.01 Sexual response cycle 6.2 0.013 Interested in a full course in counseling on human sexuality Sexual orientation 4.1 0.043 Eroticism 6.8 0.009 Paraphilias 7.0 0.008 Fetishes 5.8 0.016 Cybersex 15.7 < 0.0001

Table 10 shows the interest of counselor for hour of training by category of interest to take a full course in counseling on human sexuality. People who would like to take a full course on human sexuality selected in a higher proportion having eight hours or more of training about eroticism (73.1%), LGTTBQ issues (71.7%), sexual abuse (70.8%), and transsexuality (70.6%).

Additionally, they selected having eight hours or more of training about human sexuality

(62.7%), transgender (68.6%), sexuality in people with disabilities (68.5%), sexual harassment

(68.1%), intersexuality (66.8%), sexual taboos (66.0%), sexual response cycle (63.3%), psychogenic female sexual dysfunctions (62.5%), and sexual myths (61.2%). Finally, the topics with fewer selections among those who would like to take a full course on human sexuality included cybersex (59.6%), paraphilias (58.5%), fetishes (58.5%), psychogenic male sexual dysfunctions (57.4%), female reproductive system (52.4%), contraceptive methods (51.2%), sexually transmitted infections (47.9%), and male reproductive system (46.3%).

Table 11 shows the interest of counselor for hour of training by category of interest to take a certification in human sexuality. People who would like to take a certification on human sexuality selected in a higher proportion having eight hours or more of training about sexual orientation (71.4%), transgender (76.7%), transsexuality (77.3%), eroticism (80.0%), sexual taboos (71.4%), and sexual myths (68.3%). Table 12 shows the interest of counselor for hour of training by category of interest to obtain an academic degree in human sexuality. People who would like to obtain an academic degree on human sexuality selected in a higher proportion having eight hours or more about transgender (88.5%), transsexuality (92.3%), intersexuality

(88.9%), and eroticism (84.6%). They also selected in a higher proportion having eight hours or more about the male reproductive system (62.5%), sexually transmitted infections (66.7%), sexual taboos (79.3%), paraphilias (75.9%), and fetishes (78.6%).

Table 10 Chi Square Test of Interest of Counselor for Hour of Training by Category of Interest to Take a Full Course in Counseling on Human Sexuality

Category Chi square p-value Interested in a full course in counseling on human sexuality Sexual orientation 14.4 0.013 Transgender 18.3 0.003 Transsexuality 18.3 0.003 Intersexuality 18.3 0.003 Eroticism 18.4 0.001 Psychogenic female sexual 19.9 0.001 dysfunctions Psychogenic male sexual 19.1 0.001 dysfunctions Female reproductive system 13.1 0.011 Male reproductive system 15.1 0.004 Sexually transmitted 17.2 0.002 infections Sexuality in people with 15.5 0.004 disabilities Sexual abuse 17.1 0.002 Sexual harassment 13.6 0.009 Sexual taboos 16.8 0.002 Sexual myths 15.9 0.003 Paraphilias 19.8 0.001 Fetishes 19.8 0.001 LGTTBQ issues 15.7 0.004 Sexual response cycle 18.2 0.001 Contraceptive methods 16.0 0.003 Cyber sex 18.392 0.001

Table 11 Chi Square Test of Interest of Counselor for Hour of Training by Category of Interest to Take a Certificate on Human Sexuality

Category Chi square p-value Interested in a certificate in counseling on human sexuality Sexual orientation 12.5 .028 Transgender 12.9 .025 Transsexuality 11.4 .044 Eroticism 11.5 .022 Sexual taboos 9.9 .042 Sexual myths 11.3 .023

Table 12 Chi Square Test of Interest of Counselor for Hour of Training by Category of Interest to Obtain an Academic Degree on Human Sexuality

Category Chi square p-value Interested to Obtain an Academic Degree on human sexuality Transgender 15.8 0.007 Transsexuality 17.3 0.004 Intersexuality 16.4 0.006 Eroticism 10.3 0.036 Male reproductive system 10.2 0.038 Sexually transmitted infections 15.5 0.004 Sexual taboos 9.7 0.045 Paraphilias 10.9 0.028 Fetishes 12.8 0.012

In addition to the chi-square, a student’s t-test was performed to determine if there were differences in the mean of several variables and categories of interest. There were statistically significant differences among the level of knowledge scale (Table 13) by years of experience, age, and willingness to take a full course on human sexuality. Table 13 also shows the difference among those who indicated that would refer cases and those who would intervene with cases by the willingness to take a full course on human sexuality. Those with more years of

61 experience, an older age, and those who would not take a full course on human sexuality had higher levels of knowledge on human sexuality. Those who indicated that would refer cases and indicated that were willing to take the course. Finally, those who indicated that would not intervene in a case were not interested in taking the course.

Table 13 T-test results of Selected Categories and Concepts Scale N Mean Std. t p-value Deviation Level of Knowledge Years of Less than 36 48.8 13.2 experience 15 years -4.5 < 0.0001 15 years or 28 63.5 12.6 more Age 40 years or 19 46.5 13.4 younger -3.3 0.002 Older than 45 58.9 13.9 40 years Would take a full courese No 5 70.2 9.3 2.5 0.017 on human sexuality Yes 59 53.9 14.5 Refer cases Would take a No 5 4.0 2.6 full course -2.0 0.045 on human Yes 59 10.1 6.5 sexuality Intervene with cases Would take a No 5 18.0 2.6 full course 2.0 0.045 on human sexuality Yes 59 11.9 6.5

Chapter Five: Conclusions and Recommendations

The descriptive data gathered for this study provided basic information about the ways that professional counselors viewed themselves regarding human sexuality and sex counseling.

Almost one-half of the participants in the sample majored in guidance counseling and were working in the Puerto Rican public educational system at the time of participation. The majority of the sample was female with a Master’s degree level of education and more than 15 years of work experience. The fact that almost one-half of the participants had majored in guidance counseling and was working in the public educational system relates to the evolution of professional counseling in Puerto Rico. It began in 1943 when a group of teachers was granted awards to study guidance counseling at Columbia University in New York and Michigan State

University (Arce, 2016). Since then, the Puerto Rico Department of Education has been the primary employer of licensed professional counselors.

The first research question posed for the study asks about the levels of aptitude demonstrated by professional counselors regarding human sexuality. In this investigation, the level of aptitude was measured by two variables. The first variable, indicates whether the participant had previous formal education in the field of human sexuality and the second is the participants’ self-assessed score on 22 basic topics of human sexuality. The data were derived from items in the questionnaire. The results found that more than one-half of the sample (56%) reported formal education on human sexuality. However, only an average of 49% reported a high or very high level of knowledge regarding human sexuality. According to these results, the investigator concluded that the participant counselors had moderate aptitude levels.

The second research question concerns the type of attitude that participants expressed toward human sexuality and sex counseling. A positive attitude reflects a willingness to improve one’s education on sexuality and an intention to intervene in cases related to the 22 topics examined in the study. A negative attitude demonstrates a lack of interest in improving one’s education on sexuality and a willingness to refer cases as opposed to intervention and provision of sex counseling. The analysis found that the majority of the participants, (an average of 83%) was willing to improve education, although the more time and complexity involved in the process the lower the percentage of willing participants. In addition, more than one-half of the sample, (an average of 56%) reported that they would intervene in cases related to sexuality rather than refer them. The investigator concluded that the participant counselors exhibited a positive attitude regarding human sexuality and sex counseling.

The third research question specifically addressed whether the participants were willing to invest time in additional education on topics of human sexuality. The results indicated that 59 of the 64 participants (92%) were willing to invest at least four hours of training in at least one- half of the 22 topics presented in the questionnaire. Considering these results, the investigator concluded that the participant counselors were willing to invest time in training in the field of sexuality.

The collected data also were analyzed to determine whether having taken a course in human sexuality influenced the level of aptitude (Research Question 4) and the willingness of the participants to intervene in cases requiring sex counseling (Research Question 5). This analysis was performed by using T-Test to assess whether the means of two groups were statistically different from each other (T-Test, 2017). The regarding level of aptitude found that the average

64 mean of those who had studied human sexuality was 58 versus those who had not studied which was a mean of 52.

The four highest scores on the level of knowledge were expressed about concepts mainly found in medical books (Figure 2) and the four concepts with the most limited levels of knowledge are mostly found in sex counseling books (Figure 1). These results combined with the fact that almost one-half of the participants (47%) studied human sexuality at bachelor’s degree level, suggests that the type of knowledge that they demonstrated was must likely learned in sex health classes rather than sexuality counseling courses. The results for the willingness to intervene showed that those who had studied sexuality resulted in a mean of 13 and those who had not studied resulted in a mean of 11. In both cases, sex education had a positive impact on the participant results. In Puerto Rico, as in most countries, sexology services are fragmented and given by a diverse group of people. Examples include teachers, physicians, psychologists, social workers, and professional counselors. These people are professionals that further specialize in the sexual aspects of their professions. Puerto Rico has laws that govern the practices of medicine, psychology, professional counseling, social work, and others. However, those laws do not address how those professionals can practice sex therapy, sex education, and sex counseling within their profession (Valcárcel-Mercado, 2012). Currently there are no specific laws to regulate sex counseling in Puerto Rico. However, professional counselors have a duty to provide the best possible services by following the five ethical principles of counseling: autonomy, non- maleficence, beneficence, justice, and fidelity (ACA 2005). Professional counseling provides an excellent basis for continuing specialized studies in sexuality and to establish compliance with the standards of regulatory agencies, such as the American Association of Sexuality Educators,

Counselors and Therapists (AASECT).

Recommendations

This study’s findings allow us to identify areas of opportunities for improvement in the practice of sex counseling by professional counselors in Puerto Rico, as follows.

1.The collected data could be used to guide development of specific training sessions on human sexuality.

2.The collected data provide topics according to the levels of interest expressed by the participants.

3-Customized training could be designed according to the participants preferred hours.

4-The inclusion of sex education in counseling programs’ curricula should be a priority for educational institutions in order to comply with the continuous development of this profession and not just with the accreditation requirements established by CACREP (2017).

Members of the professional counseling profession must continue to survey the expected future role of the counselor (Altekruse, Harris, & Brand, 2001). Regretfully, only a few counseling programs offered in Puerto Rico, include a course on sex counseling, although a few organizations offer certification in this field. Graduate students aspiring to become licensed professional counselors should carefully evaluate the standards of the programs they are considering. If we do not look ahead, we can lose control of own destiny or, in this case, that of the counseling profession (Yep, 2015).

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Appendix A

Female Reproductive System

Appendix B

Male Reproductive System

Appendix C

List of Paraphilias (as cited by Fankhanel, 2008)

Money (1984) posits that paraphilias may be playful and harmless while others unwelcome to a partner, or dangerous even to a consenting partner. Originally, he identifies 33 paraphilias:

Acrotomophilia (Amputee Partner) Ephebophilia (Youth)

Apotemnophilia (Self-Amputee) Erotophonophilia (Lust Murder)

Asphyxiophilia (Self-Strangulation) Fetishism

Autagonistophilia (on Stage) Gerontophilia (Elder)

Autassassinophilia (Own Murder Staged) Hyphephilia (Fabrics)

Autonepiophilia (Diaperism) Kleptophilia (Stealing)

Coprophilia (Feces) Klismaphilia (Enemas) Masochism Scoptophilia (Watching Coitus)

Mysophilia (Filth) Somnophilia (Sleeper)

Narratophilia (Erotic Talk) Stigmatophilia (Piercing; Tattoo)

Necrophilia (Corpse) Symphorophilia (Disaster) Telephone Scatophilia Pedophilia (Child) (Lewdness) Pictophilia (Pictures) Troilism (Couple + One)

Peiodeiktophilia (Penile Exhibitionism) Urophilia or Undinism

Rapism or Biastophilia (Violent Assault) Voyeurism or Peeping-Tomism

Sadism Zoophilia (Animal)

During Money’s (1988) continued studies on paraphilias, he identified other such as:

1. Adolescentilism (Impersonating an adolescent)

2. Andromimetophilia (Male impersonator’s partner)

3. Autagonistophilia (Live-show self-display)

4. Biastophilia (Raptophilia)

5. Catheterophilia (Catheter)

6. Chrematistophilia (Blackmail payment)

7. Chronophilia (Age discrepancy)

8. Exhibitionism (Indecent exposure)

9. Formicophilia (Crawling things)

10. Gynemimetophilia (Female-impersonator partner)

11. Hybristophilia (Criminal convict partner)

12. Infantilism (Impersonating a baby) 13. Mixophilia (Scoptophilia)

14. Morphophilia (Physique discrepancy)

15. Nepiophilia (Infant partner, diper-aged)

16. Olfacophilia (Smell fetish)

17. Toucherism (Touching a stranger)

Appendix D

The following list of contraceptives methods are described on DrEd.com:

1-The Pill: It was invented in 1960. Fifty years on, many new inventions have been added

to the list of available contraception methods, but the pill remains the most popular form

of female contraception. The contraceptive pill will prevent you from getting pregnant in

95% of cases and it comes close to providing 99% protection if you take one pill every

day as prescribed. The pill can come in two forms: the combined contraceptive pill

(containing the hormones estrogen and progestin) or the mini-pill (only progestin). The

Male Condom: Among the different types of contraceptives, the male condom is a strong

contender to the title of most common contraception method. It is easy to use, affordable

and offers the best protection against STIs (e.g. gonorrhea, chlamydia, HIV, etc.).

Condoms are usually made of latex, but if you are allergic to latex, some brands also

specialize in condoms made of polyurethane or lambskin. These two are also compatible

with lube (latex condoms are not, unless with water-based lubricant); however, lambskin

condoms do not provide protection against STIs.

2-The Female Condom: Just like the male condom, the female condom is one of the few

types of contraception that a woman can buy over-the-counter at pharmacies and grocery

stores without a prescription. It was first introduced twenty years ago and offers 95%

effective protection for pregnancy, as well as some protection against STIs. Female

condoms are generally more expensive than the male ones but they are less likely to

burst. They can be inserted up to eight hours before sex.

3-The Diaphragm: It is placed inside the vagina so that it prevents the sperm from getting into the uterus. Despite being a barrier method, it doesn't protect against STIs. The diaphragm must be coated with spermicide each time before sex and a doctor needs to show how it is used and a prescription is needed. It is inserted at least six hours before sex and it needs to be removed after 24 hours for cleaning. Depending on the material and type of the diaphragm, it can be reused many times.

4-The Cervical Cap – Femcap: It is a thimble-shaped latex cup, basically like a diaphragm but smaller. It also needs to be used with a spermicide. The cervical cap must remain in the vagina at least 6 hours after sex, but it also has to be taken out within 48 hours after sex. Because some women get cystitis (bladder infection) from using a diaphragm, the cervical cap is a useful replacement because it has less contact with the vagina (it only covers the cervix). The problem with contraceptives such as the Femcap or the diaphragm is that their effectiveness - 92 to 95% protection in ideal use - is lower than other types (98-99%) and that they offer only partial protection against STIs (e.g. no

HIV protection).

5-The Intrauterine Device (IUD): There are two types of IUDs: hormonal or copper- based devices. Hormonal and copper IUDs are part of the few long-term solutions, meaning that you can keep them inside the vagina for up to five or ten years respectively.

The effectiveness rate for IUDs is above 99%, however they provide no protection against STIs. Note that IUDs can be a form of emergency contraception if the device is inserted within 5 days after unprotected sex. A doctor has to properly inserted and follow up is required (e.g. a few follow-ups and check-ups for possible infection in the first weeks).

6-The Contraceptive Implant: It is another option among the types of contraceptives that offer long term protection. It lasts for about three years on average. Just like IUDs, the implant does not protect against STIs. The contraceptive implant contains progestin

(progesterone), the same hormone as the contraceptive pill. The hormone is released into your body at a steady, slow pace for three years, producing the same effects as the pill.

The implant is inserted in the arm by a healthcare specialist and must be removed after three years. Since the risk of human mistake is ruled out, the implant has a much higher effectiveness rate than the pill – around 99.99%.

7-The Contraceptive Sponge: It is a small, round-shaped foam (polyurethane) placed deep inside the vagina. It contains spermicide so that sperm does not get past the foam.

You should leave the sponge inside the vagina for at least six hours after sex, but remove it within 24 hours following sexual intercourse (to lessen the risk of toxic shock). The sponge does not protect past those 24 hours and does not provide any STI protection. It is sometimes used as a backup for other contraception methods. It can be bought without a prescription.

8-Spermicide: It is a recurrent "ingredient" in contraception because it proves very effective when used in combination with other methods (e.g. diaphragm, sponge). In itself spermicide doesn't always offer the best protection against pregnancy, although this is also due to inconsistent use of the product. A prescription is not needed to buy spermicide and it has very few associated side-effects and it does not protect against

STIs.

9-Contraceptive Injections: This method dates back to the 60s with the invention of artificial progesterone (progestin). One shot of hormones lasts in the body for 8 to 12

80 weeks (3 months) and has the same effect as the pill. Injections are about 99% effective, with pregnancy occurring mostly with women who forgot to renew their contraceptive shot in time (i.e. past weeks 11 to 12). Obviously, once the shot is given it cannot be reversed.

10-The Vaginal Ring: This contraceptive ring is a small, transparent plastic ring that is inserted in the vagina and kept for three weeks. It should be removed during menstruation and replaced with a new one after that. The ring contains the same hormones as the contraceptive pill (progesterone and estrogen), therefore providing the same kind of effective protection and side effects. A doctor's prescription is needed to buy the ring.

11-The Contraceptive Patch: It is exactly the same thing as the contraceptive pill but in the form of a patch. It provides the same effective protection against pregnancy and has the side effects (positive and negative). It does not protect from STIs. The patch is worn for three weeks and taken off for one week - allowing for menstrual cycle – then a new patch is needed. The patch is an interesting option eliminating the need to think about taking the pill every day. There is however a risk of skin irritation, and a (rare) chance that the patch accidentally comes off.

8-Emergency Contraception: This method exists to stop from getting pregnant if unprotected sex occurred. It is for one-off occasions and is not recommended for daily use. It is particularly useful if a condom broke or if contraceptive pills are forgotten. The most common brand of morning after pill is Levonelle®. It should be taken ideally within

24 hours after unprotected sex (this offers over 95% protection). The longer the wait, the less effective it will be. After 72 hours (3 days) the effectiveness drops to below 50%.

9-Sterilization: It is an option available to both men and women. As far as male contraception is concerned, the technique is called vasectomy and consists in tying off and cutting the tubes that carry sperm – without the need for a scalpel intervention or stitches. The man can then go home in the same day. This provides no protection against

STIs and the effects are for life. In very rare cases (less than 1%), the tubes can grow back, making pregnancy a risk. As for female sterilization, this is also a very simple operation after which the patient can go back home the very same day. There are choices between surgical and non-surgical types of sterilization. Surgical sterilization (known as tubal litigation) requires very small cuts in the belly to access the Fallopian tubes, cut them and tie them so that they cannot link the ovaries with the uterus any more. The effects are permanent. Non-surgical sterilization consists of placing a coil in each

Fallopian tube – through the vagina and uterus – so that scars appear and eventually block each tube completely. The scars may take up to 3 months to completely block the tubes and the patient needs to use another method of contraception in the meantime. Both options also offer more than 99% of protection against pregnancy (and none against

STIs) because of rare cases where blocked tubes happen to grow back and reconnect (1 in

200 women).

10-Natural Family Planning: Although not a device or a pill, this is still a method of contraception. Natural family planning relies on knowing the menstrual cycle (periods) so that couples avoid having sex when the woman is fertile. Three techniques (basal body temperature, cervical mucus and rhythm/calendar method) can be used for this, with higher protection rates when all three methods are used in combination. The effectiveness of this type of contraception varies between 75% to 99% (but 85% on average) with the

82 higher uncertainty due to the fact that most women do not have a perfectly regular menstrual cycle.

Appendix E

Inventario de Aptitudes y Actitudes en Sexualidad Humana y Consejería Sexual

Saludos. Mi nombre es Orlando García, soy Consejero Profesional Licenciado y estudiante del programa doctoral en sexología clínica de la American Academy of Clinical Sexologists en Orlando, Florida. Como requísito para mi disertación doctoral estoy realizando un estudio exploratorio entre Consejeros Profesionales en Puerto Rico. Por esta razón le estoy solicitando su cooperación y participación voluntaria.

Este estudio tiene como propósito recopilar información sobre las aptitudes y actitudes entre consejeros profesionales sobre la sexualidad humana y la consejería sexual en Puerto Rico. De usted consentir participar en el estudio se le entregará una copia de un cuestionario autoadmistrable el cual podrá llenar de inmediato y en estricta confidencialidad. Le tomará entre 10 a 12 minutos. Lo entregará en un sobre sellado. Si desea, también tiene puede llenarlo en su casa o trabajo. En ese caso se le proveerá un sobre con un sello postal para que lo envíe por correo sin ningún costo para usted. En ningún momento tendrá que escribir su nombre ni cualquier otra información que lo pueda identificar. El proceso es completamente anónimo y confidencial. Solo se le solicitará cierta información sociodemográfica básica.

El propósito de este estudio es estríctamente académico. La información recopilada no será utilizada para otros fines. No se presentarán datos especifícos de ningún cuestionario sino de manera global una vez concluída la investigación.

Su cooperación y participación en este estudio asistirá en la comprensión de la percepción existente sobre la sexualidad humana y la consejeria sexual. Esto ayudará a desarrollar herramientas educativas que complementen la prestación de nuestros servicios como Consejeros Profesionales en estas áreas cuando se nos presente la situación. Gracias adelantadas por su participación.

Appendix F Letter of Invitation

Inventory of Aptitudes and Attitudes in Human Sexuality and Sexual Counseling

Greetings. My name is Orlando Garcia, I am Licensed Professional Counselor and student of the doctoral program in clinical sexology at the American Academy of Clinical Sexologists in Orlando, Florida. As a requirement for my doctoral dissertation I am conducting an exploratory study among Professional Counselors in Puerto Rico. For this reason, I am requesting your cooperation and voluntary participation.

This study aims to compile information on the aptitudes and attitudes among professional counselors on human sexuality and sexual counseling in Puerto Rico. If you consent to participate in the study you will be given a copy of a self-administered questionnaire which you can fill immediately and in strict confidence. It will take you 10 to 12 minutes. And you will return it in a sealed envelope. If you wish, you can also fill it at home or work. In that case, you will be provided an envelope with a postage stamp to mail it at no cost to you. At no time will you have to write your name or any other information that can identify you. The process is completely anonymous and confidential. You will only be asked for certain basic sociodemographic information.

The purpose of this study is strictly academic. The information collected will not be used for other purposes. No specific data will be presented for any questionnaire but overall on completion of the investigation.

Your cooperation and participation in this study will assist in understanding the existing perception about human sexuality and sexual counseling. This will help develop educational tools that complement the provision of our services as Professional Counselors in these areas when the situation presents itself to us. Thank you in advance for your participation.

Appendix G Questionnaire Spanish Version

Inventario de Aptitudes y Actitudes en Sexualidad Humana y Consejería Sexual

1-Especialidad académica en Consejería

□ Escolar □ Salud Mental □ Desórdenes Adictivos

□ Pareja y Familia □ General □ Orientación y Consejeria

2- Grado Académico más alto obtenido

□ Maestría □ Doctorado

3-Años de experiencia laboral

□ Menos de 5 años □ Entre 6 y 10 años □ Entre 11 y 15 años

□ Entre 16 y 20 años □ Más de 20 años

4-Escenario laboral

□ Práctica privada □ Organización sin fines de lucro □ Sistema educativo público

□ Sistema educativo privado □ Sistema educativo público postsecundario

□ Sistema educativo privado postsecundario □ Otro (Especifíque) ______

5-Edad

□ Menor de 25 años □ Entre 26 y 30 años □ Entre 31 y 35 años

□ Entre 36 y 40 años □ Entre 41 y 45 años □ Más de 46 años

6-Sexo

□ Hombre □ Mujer □ Otro (Especifíque) ______

7-¿Alguna vez has tomado un curso de menos de 40 horas en sexualidad humana?

Si ___ No___

(Si respondió si, indique a que nivel. Si respondió no, continue a la pregunta 8)

□A nivel de bachillerato □A nivel de maestria □A nivel doctoral

8-¿Alguna vez has tomado un curso de más de 40 horas en sexualidad humana?

Si ___ No ___

9-¿Tomarías un curso completo (40 horas o más) en consejeria en sexualidad humana?

Si ___ No ___

10-¿Obtendrías una certificación en sexualidad humana?

Si ___ No ___

11-¿Obtendrías un grado académico en sexualidad humana?

Si ___ No ___

Inventario de Aptitudes y Actitudes en Sexualidad Humana y Consejería Sexual

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes ¿Si te llegara un caso ¿Te Aproximadamente conceptos? relacionado a este tema lo adiestrarías ¿Cuantas horas Escriba la puntuación en la columna refieres o intervienes? en éste tema? estarías interesado azul. Responda con una marca de Responda con en adiestrarte? cotejo ( √ ) una marca de Responda con una 1- Muy Limitado cotejo ( √ ) marca de cotejo ( √ ) 2- Limitado 3- Alto 4- Muy Alto → → → → Refiero Intervengo → Si No → 4 8 16 20 1.Identidad de género → → → 2.Orientación sexual → → → 3.Transgénero → → → 4.Transexualidad → → → 5.Intersexualidad → → → 6.Erotismo

7.Disfunciones sexuales → → → é femeninas psicog nicas * 8.Disfunciones sexuales → → → masculinas psicogénicas * 9.Sistema reproductor → → → femenino 10.Sistema reproductor → → → masculino 11.Infecciones de transmisión → → → sexual 12.Sexualidad en personas con → → → discapacidades → → → 13.Abuso sexual → → → 14.Acoso sexual → → → 15.Tabues sexuales → → → 16.Mitos sexuales → → → 17.Parafilias 18.Fetiches 19.Asuntos LGTTBIQ → → → 20.Ciclo de respuesta sexual → → → 21.Métodos anticonceptivos → → → → 22.Sexo cibernético → →

* Psicogénico- De origen psicológico o emocional Gracias por su participación

Appendix H

Questionnaire English Version

Inventory of Aptitudes and Attitudes in Human Sexuality and Sexual Counseling

Instructions: Answer the questions according to your reality. Use a check mark. Use a check mark (√)

1- Academic Specialty in Counseling (You can select more than one)

□ School Counseling □ Mental Health Counseling □ Addictive Disorders Counseling

□ Couple and Family Counseling □ General Counseling □ Guidance Counseling

2 - Highest Academic Degree obtained

□ Master's degree □ Doctorate degree

3- Years of work experience

□ 5 years or less □ Between 6 and 10 years □ Between 11 and 15 years

□ Between 16 and 20 □ 21 years or longer

4- Job scenario (You can select more than one)

□ Private practice □ Non-profit organization □ Public education system

□ Private educational system □ Postsecondary public education system

□ Private post-secondary education system □ Other (Specify) ______

5- Age

□ 25 years or younger □ Between 26 and 30 years □ Between 31 and 35 years

□ Between 36 and 40 years □ Between 41 and 45 years □ 46 years or older

6- Sex

□ Male □ Female □ Other (Specify) ______

7- Have you ever taken a university course in human sexuality?

Yes___ No___

(If you answered yes, state at what level. If you answered no, continue to question 8)

□ Bachelor’s degree level □ Master’s degree level □ Doctorate degree level

8- Would you take a full course in counseling on human sexuality? Yes___ No___

9 - Would you be interested in completing a certification in human sexuality?

Yes___ No___

10- Would you be interested in completing an academic degree in human sexuality?

Yes___ No___

Inventory of Aptitudes and Attitudes in Human Sexuality and Sexual Counseling

What score would you award Respond only if you Your level of knowledge about the answered yes to the following concepts? If you get a case related to Would you previous question. Write the score on the blue column. this topic do you refer or train Approximately intervene? on this How many hours 1- Very Limited Respond with a checkmark subject? would you be 2- Limited (√) Respond with interested in 3- High a checkmark training? Respond 4- Very High (√)) with a checkmark (√) Refer Intervene Yes No 4 8 16 20 1. Gender Identity → → → 2. Sexual Orientation → → → 3. Transgender → → → 4. Transsexuality → → → 5. Intersexuality → → → 6. Eroticism → → → 7. Psychogenic female sexual → → → dysfunctions *

8. Psychogenic male → → → sexual dysfunctions * 9. Female reproductive system → → → 10. Male reproductive system 11. Sexually Transmitted → → → Infections 12. Sexuality in people with → → → disabilities 13. Sexual abuse → → → 14. Sexual harassment 15. Sexual taboos → → → → → → 16. Sexual Myths → → → 17. Paraphilias → → → 18. Fetishes → → → → → → 19. LGTTBIQ Issues → → → 20. Sexual response cycle → → → 21. Contraceptive methods → → → → 22.Cyber sex → →

* Psychogenic - Of psychological or emotional origin Thank you for your participation

Appendix I

Instrumento de Validación del Inventario de Aptitudes y Actitudes en

Sexualidad Humana y Consejería Sexual

Instrumento de Validación del Inventario de Aptitudes y Actitudes en Sexualidad Humana y Consejería Sexual

1-Especialidad académica en Consejeria

□ Escolar □ Salud Mental □ Desórdenes Adictivos

□ Pareja y Familia □ General □ Orientación y Consejería

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

2- Grado Académico más alto obtenido

□ Maestría □ Doctorado

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

3- Años de experiencia laboral

□ 5 años o menos □ Entre 6 y 10 años □ Entre 11 y 15 años

□ Entre 16 y 20 años □ 21 años o más

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

4-Escenario laboral

□ Práctica privada □ Organización sin fines de lucro □ Sistema educativo público

□ Sistema educativo privado □ Sistema educativo público postsecundario

□ Sistema educativo privado postsecundario □ Otro (Especifíque) ______

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

5-Edad

□ 25 años o menor □ Entre 26 y 30 años □ Entre 31 y 35 años

□ Entre 36 y 40 años □ Entre 41 y 45 años □ 46 años o más

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

6-Sexo

□ Hombre □ Mujer □ Otro (Especifíque) ______

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

7-¿Alguna vez has tomado un curso universitario en sexualidad humana? Si ___ No___

□ A nivel de bachillerato □ A nivel de maestria □ A nivel doctoral

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

8-¿Tomarías un curso completo en consejería en sexualidad humana? Si ___ No ___

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

9-¿Estarías interesado(a) en completar una certificación en sexualidad humana? Si ___ No ___

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

10-¿Estarías interesado(a) en completar un grado académico en sexualidad humana? Si___ No ___

Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Sugerencias:

______

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

1.Identidad de género Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

2.Orientación sexual Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

3.Transgénero Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

4.Transexualidad Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

5.Intersexualidad Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

6.Erotismo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

7.Disfunciones sexuales femeninas psicogénicas Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

8.Disfunciones sexuales masculinas psicogénicas Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

9.Sistema reproductor femenino Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

10.Sistema reproductor masculino Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

11.Infecciones de transmisión sexual Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

12.Sexualidad en personas con discapacidades Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

13.Abuso sexual Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

14.Acoso sexual Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

15.Tabues sexuales Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

16.Mitos sexuales Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

17.Parafilias Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

18.Fetiches Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

100

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

19.Asuntos LGTTBIQ Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

20.Ciclo de respuesta sexual Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

21.Métodos anticonceptivos Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

101

¿Qué puntuación otorgarías a tu nivel de conocimiento sobre los siguientes conceptos? 1- Muy Limitado 2- Limitado 3- Alto 4- Muy Alto

22.Sexo cibernético Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Sugerencias:______

______

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

1.Identidad de género

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

2.Orientación sexual

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

102

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

3.Transgénero Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

4.Transexualidad

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

5.Intersexualidad

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

6.Erotismo

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

103

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

7.Disfunciones sexuales femeninas psicogénicas

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

8.Disfunciones sexuales masculinas psicogénicas

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

9.Sistema reproductor femenino

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

10.Sistema reproductor masculine

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

104

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

11.Infecciones de transmisión sexual

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

12.Sexualidad en personas con discapacidades

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

13.Abuso sexual

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

14.Acoso sexual

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

105

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

15.Tabues sexuales

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

16.Mitos sexuales

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

17.Parafilias

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

18.Fetiches

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

106

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

19.Asuntos LGTTBIQ

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

20.Ciclo de respuesta sexual

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

21.Métodos anticonceptivos

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Si te llegara un caso relacionado a este tema lo refieres o intervienes?

22.Sexo cibernético

Refiero Intervengo Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

107

Sugerencias:______

______

¿Te adiestrarías en este tema?

1.Identidad de género

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

2.Orientación sexual

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

3.Transgénero

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

108

¿Te adiestrarías en este tema?

4.Transexualidad

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

5.Intersexualidad

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

6.Erotismo

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

7.Disfunciones sexuales femeninas psicogénicas

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

109

¿Te adiestrarías en este tema?

8.Disfunciones sexuales masculinas psicogénicas

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

9.Sistema reproductor femenino

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

10.Sistema reproductor masculino

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

11.Infecciones de transmisión sexual

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

110

¿Te adiestrarías en este tema?

12.Sexualidad en personas con discapacidades

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

13.Abuso sexual

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

14.Acoso sexual

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

15.Tabues sexuales

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

111

¿Te adiestrarías en este tema?

16.Mitos sexuales

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

17.Parafilias

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

18.Fetiches

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

19.Asuntos LGTTBIQ

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

112

¿Te adiestrarías en este tema?

20.Ciclo de respuesta sexual

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

21.Métodos anticonceptivos

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

¿Te adiestrarías en este tema?

22.Sexo cibernético

Si No Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Sugerencias:______

______

113

La siguiente pregunta solo se contesta si el participante está interesado en recibir adiestramiento en alguno de los conceptos presentados.

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

1.Identidad de género

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

2.Orientación sexual

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

3.Transgénero

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

114

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

4.Transexualidad

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

5.Intersexualidad

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

6.Erotismo

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

7.Disfunciones sexuales femeninas psicogénicas

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

115

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

8.Disfunciones sexuales masculinas psicogénicas

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

9.Sistema reproductor femenino

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

10.Sistema reproductor masculino

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

11.Infecciones de transmisión sexual

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

116

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

12.Sexualidad en personas con discapacidades

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

13.Abuso sexual

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

14.Acoso sexual

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

15.Tabues sexuales

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

117

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

16.Mitos sexuales

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

17.Parafilias

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

18.Fetiches

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

19.Asuntos LGTTBIQ

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

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Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

20.Ciclo de respuesta sexual

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

21.Métodos anticonceptivos

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Aproximadamente, ¿Cuantas horas estarías interesado en adiestrarte?

22.Sexo cibernético

4 8 16 20 Pregunta Si No ¿Encuentra esta pregunta fácil de entender? ¿Encuentra esta pregunta relevante para la investigación? ¿La redactaría de otra manera?

Sugerencias:______

______

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Información Opcional

Esta información se utilizará para darle crédito por su cooperación tan valiosa.

Nombre y título académico: ______

120

Appendix J

Instrument for Validation of the Inventory of Aptitudes and Attitudes in Human

Sexuality and Sexual Counseling

121

Instrument for Validation of the Inventory of Aptitudes and Attitudes in Human Sexuality and

Sexual Counseling

1- Academic Specialty in Counseling

□ School Counseling □ Mental Health Counseling □ Addictive Disorders Counseling

□ Couple and Family Counseling □ General Counseling □ Guidance Counseling

Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

2- Highest Academic Degree obtained

□ Master's degree □ Doctorate degree

Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

3- Years of work experience

□ 5 years or less □ Between 6 and 10 years □ Between 11 and 15 years

□ Between 16 and 20 □ 21 years or longer

Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

4- Job scenario

□ Private practice □ Non-profit organization □ Public education system

□ Private educational system □ Postsecondary public education system

□ Private post-secondary education system □ Other (Specify) ______

Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

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5- Age

□ 25 years or younger □ Between 26 and 30 years □ Between 31 and 35 years

□ Between 36 and 40 years □ Between 41 and 45 years □ 46 years or older

Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

6- Sex

□ Male □ Female □ Other (Specify) ______

Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

7- - Have you ever taken a university course in human sexuality? Yes ___ No___

□ Bachelor’s degree level □ Master’s degree level □ Doctorate degree level

Question Si No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

8- Would you take a full course in counseling on human sexuality? Yes ___ No ___

Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

9- Would you be interested in completing a certification in human sexuality? Yes ___ No ___

Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

123

10- Would you be interested in completing an academic degree in human sexuality? Yes ___ No ___

Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

Suggestions:

______

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

1. Gender Identity Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

2. Sexual Orientation Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

124

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

3. Transgender Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently? What score would you award your level of knowledge about the following concepts? 1-Very Limited 2- Limited 3- High 4- Very High

4. Transsexuality Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

5. Intersexuality Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

125

6. Eroticism Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

7. Psychogenic female sexual dysfunctions Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

8. Psychogenic male sexual dysfunctions Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

9. Female reproductive system Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

126

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

10. Male reproductive system Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

11. Sexually Transmitted Infections Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

12. Sexuality in people with disabilities Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

127

What score would you award your level of knowledge about the following concepts?

1- Very Limited 2- Limited 3- High 4- Very High

13. Sexual abuse Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts?

1- Very Limited 2- Limited 3- High 4- Very High

14. Sexual harassment Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts?

1- Very Limited 2- Limited 3- High 4- Very High

15. Sexual taboos Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

128

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

16. Sexual Myths Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

17. Paraphilias Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

18. Fetishes Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

129

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

19. LGTTBIQ Issues Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

20. Sexual response cycle Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

21. Contraceptive methods Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

130

What score would you award your level of knowledge about the following concepts? 1- Very Limited 2- Limited 3- High 4- Very High

22.Cybersex Question Yes No Do you find this question easy to understand? Do you find this question relevant to the research? Would you write it differently?

Suggestions:

______

If you get a case related to this topic do you refer or intervene?

1. Gender Identity