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

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

Intersectional feminist scholars have argued that TNBGE identities push the boundaries of White, cisgender, heterosexual traditional perspectives on gender.Yet, there is a dearth of literature focused on TNBGE sexuality, prompting calls to attend to sexual pleasure in TNBGE populations (Berry & Lezos, 2017;Rider et al., 2019).This article describes a framework that can be used by clinicians to facilitate TNBGE clients to sexual wellbeing, which refers to an individual's global assessment of their sexual life (Lorimer et al., 2019) involving sexual safety and security, being respected as a sexual person (e.g., feeling others' positive regard for one's sexual, gender, and racial identities), sexual autonomy (i.e., the freedom to choose or reject sexual partners, behaviors, context, and timing, without pressure, force, or obligation), comfort with sexual experiences (solitary, partnered, or lack of either) and communication (e.g., with partners, healthcare providers, friends), and resilience to sexual stressors (recovery from adversity and dysfunctions, forgiving oneself and others for sexual mistakes, etc.) (Mitchell et al., 2021).

Is a Framework Necessary to Discuss Sexuality in Therapy?
Over 90% of healthcare professionals believe that addressing sexuality is a critical component to clients' mental and physical health (Haboubi & Lincoln, 2003), though few initiate discussions of sexuality, limit discussions of sexuality to sexual orientation identity, and often wait for their clients to raise sexual concerns (Crowell et al., 2017).However, clients also avoid discussions related to sexuality with providers (Miller & Byers, 2008), leaving sexual wellbeing often unaddressed in clinical contexts.
Clinicians are uncomfortable discussing sexuality with clients, in part, because they lack scientific knowledge about sexuality and receive minimal to no graduate training in sexuality (Harris & Hays, 2008;Miller & Byers, 2010) and lack training opportunities in continuing education (Miller & Byers, 2009).The dearth of adequate knowledge about sexuality is not unique to clinicians; most Americans receive limited information about sexuality (Lindberg et al., 2016).This lack of sexual knowledge means clinical discussions of sexuality rely heavily on clinicians' and clients' implicit knowledge.Relying on implicit knowledge can lead to clinical errors in diagnostic assessment and treatment planning based on perceptions of race, gender, sexual orientation identity, and relationship status and structures (e.g., Goldberg et al., 2008;Mizock & Lundquist, 2016;Tao et al., 2015).
Conversations about sexuality in therapy with TNBGE clients are particularly fraught.Since the adoption of the earliest guidelines for transgender care, clients have needed to "prove" their gender to access gender affirming care (Dean et al., 2016;Prunas, 2019).Historically, health professionals have barred TNBGE individuals from treatment-a practice referred to as gatekeeping-if clients professed non-heterosexual attraction, changes in sexual orientation, diverse sexual activities, or genders that did not fit within the binary conceptualization of gender (Budge, 2015).Clinicians need to be aware of past and present gatekeeping practices to effectively begin discussions about sexuality and address unspoken concerns about therapy that TNBGE clients may hold (Mizock & Lundquist, 2016).
Clinicians also need to be aware of the wide diversity that exists within and across TNBGE populations.Every TNBGE client is embedded within their own unique context and has a unique set of experiences, needs, and desires.Clinicians will benefit from adopting a principle-based framework to discuss sexuality with TNBGE clients.A sexual wellbeing framework composed of 14 principles is summarized in Table 1.The first four principles describe how to approach sexuality and provide the foundation for the remaining principles, which describe salient aspects of sexuality relevant to TNBGE clients' sexual wellbeing.

A Sexual Wellbeing Framework for Addressing Sexuality with TNBGE Clients
A sexual wellbeing approach to addressing sexuality with TNBGE clients focuses on situating sexual wellbeing in clients' wider sociocultural contexts, ameliorating clients' internalized transphobia known to impede sexual wellbeing (Kennis et al., 2022), and helping clients identify and challenge culturally-defined standards of sexuality, race, and gender that restrict their sexual wellbeing (Bradford et al., 2019;Tiefer, 1996).Examination of the sociocultural context (see Principle #1, Table 1) entails assessing all the dynamic and overlapping domains that influence how clients interact with the world around them.TNBGE clients' experiences should be conceptualized with intersectionality theory, which is rooted in Black feminism and describes how social identities (race, class, gender, sexual orientation, religion, ability, etc.) intersect to shape experience of privilege and marginalization across personal and social domains, including sexuality (e.g., Crenshaw, 2018;hooks, 2000).As such, sexual pleasure, autonomy, and sexual rights are culturally restricted by stigma, discrimination, and access to material resources.The specific ways in which these restrictions manifest vary across specific intersections of marginalized races, genders, sexual orientations, and class (Bay-Cheng, 2017; Gruskin et al., 2019).
Assumptions about gender, sexual orientation, race, and class can prevent clinicians from holding a non-judgmental and supportive stance toward multiply marginalized clients when discussing sexuality (e.g., see Hall & Graham, 2014).Therefore, a sexual wellbeing framework recommends clinicians engage in an ongoing reflexive practice that explores the sociocultural contexts that influence how clinicians appraise, value, and approach sexuality.A sexual wellbeing approach with TNBGE clients also (a) holds that sexuality is multifaceted and dynamic, (b) focuses on sexual pleasure, sexual comfort, and gender affirming experiences and, (c) centers consent as essential for balancing sexual safety and pleasure.Conceptualizing Sexual Wellbeing as Multifaceted and Dynamic Facilitates Non-Judgmental Discussions of Sexuality (Principles #2-4) Sexual wellbeing is shaped by myriad psychological (e.g., cognitions, emotions, attitudes), social (e.g., relationships), biological (e.g., hormones, sexual functioning, physical health), cultural (identity, stigma), and event-level (e.g., sexual behaviors, sexual experiences, sexual response, sexual pleasure, sexual scripts) factors across the lifespan.For example, the ways individuals experience their sexual wellbeing vary over time, across identity domains, and in response to relationships, activities, and desires, though important to note that individuals' sexual wellbeing may not be dependent on sexual relationships with others (Mitchell et al., 2021).By understanding that sexual wellbeing is shaped by individuals' sexual and daily experiences over time and can vary accordingly, clinicians can appreciate individual variation in sexual wellbeing (Principle #2) and conceptualize sexual wellbeing as an evolving state, rather than a static endpoint (Principle #3; see Table 1).
Although clinicians discern certain expressions of sexuality as being "normal" vs. "unusual," or "harmless" vs. "dangerous," a sexual wellbeing approach avoids these decontextualized judgments (Principle #4).Rather, clinicians can examine how specific sexual experiences, behaviors, or characteristics enhance or impede sexual wellbeing, recognizing that which behaviors impede (or enhance) sexual wellbeing will vary from person to person, from experience to experience, and over time (Fortenberry, 2014).Hence, the adaptiveness of any aspect of sexuality depends on its context, such that the specific emotional and behavioral consequences of sexual experiences, not therapist or client judgment, determine the contribution to sexual wellbeing.By considering the cultural context, appreciating individual variation, conceptualizing sexual wellbeing as an evolving state, and maintaining a nonjudgmental stance, clinicians can effectively address sexuality with TNBGE clients.
Countering Stigma and Recognizing Sexual Resilience (Principle #5; See Table 1) Therapists' abilities to approach sexual wellbeing from a multifaceted and dynamic perspective contextualizes TNBGE clients' concerns that arise from sexual and gender-based oppression (e.g., discrimination that plays out at individual, interpersonal, and systemic levels).For example, experiences of body-related gender dysphoria (Galupo & Pulice-Farrow, 2020) and unwanted fetishization (Flores et al., 2018) undermine security and safety and inhibit pathways to sexual wellbeing (see Bradford & Spencer, 2020).Yet, in a society that pathologizes TNBGE experience, subjects TNBGE individuals to violence and discrimination, and reduces TNBGE sexual experiences to that of genital functioning (Grabham, 2007), TNBGE clients also show remarkable resilience.TNBGE individuals have found ways to resist transphobia, affirm their gender, feel sexually desirable, avoid experiences that induce dysphoria, and tap into universal sources of sexual wellbeing available to all individuals across the gender spectrum, such as connection and intimacy, sexual pleasure, and comfort to explore diverse expressions of sexuality (Sevelius, 2013;Thurston & Allan, 2018).Therapists can work with clients to identify strategies for resisting stigma and oppression and build resilience.
Beyond Cisgender Conceptualizations of Sexual Orientations and Understanding Sexual Fluidity (Principles #6 and #7; See Table 1) Identity plays a central role in countering stigma.APA's guidelines call for clinicians to respect TNBGE clients as they work to authentically articulate gender identity and expression (APA, 2015).For many TNBGE clients, identifying the identity term that resonates with their felt experience provides a sense of belonging to a larger community who share that same experience and understanding (Brown, 2015).When TNBGE individuals develop pride in their identities as a TNBGE person and a person of color, they cultivate resilience in navigating anti-trans bias and buffering the negative impact of minority stress on health (Singh, 2013).A sexual wellbeing approach views the articulation of identity as an opportunity to deeply explore and deconstruct constraining narratives about gender, sexual orientation, and sexuality to deepen one's understanding of self.
As TNBGE individuals become more affirming of their own gender, they may begin to deconstruct their sexual orientation identity (prompting questions such as "What do I call myself?").Gender identities that counter the gender binary directly call into question traditional labels of sexual orientation, which often include the direction of attractions, desires, relationships, and behaviors, but also notions of one's own gender (attractions to genders that are the same vs.different).Hence, traditional sexual orientation labels may become more elusive and less meaningful as clients engage in gender exploration and challenge the gender binary.Indeed, TNBGE individuals often find traditional sexual orientation labels limiting and ultimately adopt a more expansive view on their sexual identity (Galupo et al., 2016;Kuper et al., 2012).In this way, discussions of identity present an opportunity to deconstruct the complexity of gender and sexuality.Gender and sexual orientation labels are proxies, imperfect and incomplete, for a host of complexly interconnected expressions and experiences of gender, sexual orientation, and sexuality.
The context of gender exploration often involves a number of social, biological, and psychological changes, which allows individuals to reconceptualize, reimagine, and reorganize various aspects of their sexuality that make them feel safe, comfortable, secure, autonomous, and respected and affirmed in their gender (Thurston & Allan, 2018).This offers a rich developmental context in which change in sexual desires, attractions, behaviors, relationships, and desires is possible (Hereth et al., 2020).The potential for sexual fluidity-a context-dependent change in one's previously established pattern of attractions, desires, behaviors, and relationships (Diamond, 2008)-contrasts essentialist perspectives on sexual orientation that describe sexual orientation as an enduring, stable trait that remains static over time.Many TNBGE individuals experience new attractions to genders that they did not experience previously (Katz-Wise et al., 2017).However, erotic flexibility in one's pattern of sexual response is unlikely to be elicited volitionally (Dickenson et al., 2020), and change in sexual orientation identity cannot serve as a foundation for sexual citizenship or rights (for a useful review, see Diamond & Rosky, 2016).On the contrary, therapeutic attempts to change sexual attractions cause substantial psychological harm, are ineffective, and are unethical (APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation, 2009).See Table 1 and the case scenarios for recommendations to address sexual fluidity.

Centering Sexual Comfort and Pleasure in TNBGE Clients
Sexual pleasure and comfort are often overlooked in favor of focusing conversations on sexual safety, though discussions about sexual pleasure and comfort directly enhance sexual wellbeing.Centering sexual comfort and pleasure first requires challenging misconceptions about the role of genitals, hormones, and sexual functioning in sexual pleasure and comfort.
Pleasure Is More than Genitals and Hormones (Principle #8) A common misconception is that the genitals determine who we are as sexual beings, how we act in sexual experiences, and how, where in our body, and from whom we derive pleasure (Grabham, 2007).From this lens, research has examined changes in sexuality in response to genital surgery and has found that TNBGE individuals who undergo genital surgery report increased frequency of sexual activity, greater sexual satisfaction, and less sexual dysfunction (LeBreton et al., 2017;van de Grift et al., 2019).
Research has also investigated changes to sexual functioning in response to hormone therapy.Transmasculine individuals taking androgens report an increase in sexual desire, greater motivation to pursue sexual activity, and a shift in the experience of orgasm, as more powerful, shorter, and with higher intensity (see Stephenson et al., 2017).Although gonadal hormones (e.g., estrogens, progestins, androgens) can organize behavior (e.g., a certain threshold of testosterone is necessary to experience desire), hormones are part of a responsive system; they change the probability that a sexual behavior occurs in response to a relevant stimulus or context.For example, androgens incentivize motivation for sexual activity and facilitate genital changes in response to sexual stimuli.Yet, androgens are merely one input in sexual functioning.In fact, some TNBGE individuals experience no change in sexual functioning as a result of redistribution of circulating gonadal hormones (Elaut et al., 2017).
The assumption that genitals and hormones are the primary determinant of sexual functioning fails to account for the multifaceted factors associated with sexual wellbeing.From a sexual wellbeing approach, when one input to sexuality changes (e.g., hormones), the relative balance of other incentives contributing to sexual wellbeing may also change (Pfaus et al., 2012).In response, some sensory experiences may become more or less salient to one's cumulative experience (Thurston & Allan, 2018).For example, transgender women who take androgen blockers and estrogens and/or progestins report difficulties with blood flow to the genitals, decreased sexual desire, and orgasms that require more effort.However, these changes are not always distressing because such changes are perceived as typical of their gender (Doorduin & Van Berlo, 2014).As well, transfeminine individuals report greater pleasure during certain sexual activities, orgasms that are more prolonged and involve full body sensations (for a review, see Holmberg et al., 2019), increased openness to their affective responses, and development of new erogenous zones, including greater erotic sensitivity in the nipples, thighs, back, neck, and other body parts (Rosenberg et al., 2019).The shift in erogenous zones demonstrates the integration of multiple factors in shaping erotic sensations, in which genital functioning is one of many inputs to sexual functioning.Thus, changes in one's sensory experience presents a clinical opportunity to explore the dynamic interactions between bodily sensation, gender, and sexuality.
Decentralize Orgasm to Augment Pleasure (Principle #9) Another common misperception is that pleasure relies exclusively on genital functioning and orgasm.Although many individuals describe orgasm as the zenith of sexual pleasure that arises from the genitals and consider orgasm to be the goal of sexual experiences, orgasm is not synonymous with sexual pleasure (Opperman et al., 2014).In fact, individuals often enjoy positive, rewarding sexual experiences without orgasming, and some people can orgasm in absence of genital or sexual stimulation (e.g., Herbenick & Fortenberry, 2011).Paradoxically, decentering orgasm as a goal in sexual activity and increasing non-genital sexual behaviors has been shown to improve sexual functioning and pleasure among individuals with sexual concerns (e.g., Brotto & Smith, 2014).Adopting a view of sexual pleasure that expands beyond genital sensation and orgasm can help clinicians appreciate the numerous, multifaceted ways that TNBGE clients experience sexual pleasure and comfort.
Among individuals who value sexual pleasure, sexual pleasure is a critical component of sexual wellbeing.Lindley et al. (2021) asked 358 transmasculine, nonbinary, and agender individuals to reflect on their experience of sexual satisfaction (an approximation of sexual wellbeing), and the most common theme was sexual pleasure, such that 50% described sexual pleasure as central to their sexual satisfaction.Participants reported that pleasure was derived directly from sexual experiences, including having an orgasm, being touched, learning what they enjoy sexually, exploring new and diverse sexual experiences, and intimacy and joy resulting from sexually satisfying a partner.The fact that sexual satisfaction is derived from pleasure, comfort, diverse experiences, and being seen and affirmed by one's partner or oneself conveys that sexual pleasure extends beyond genitals and exists in the dynamic interactions of sensations, emotions, cognitions, and relationships (with self or others).
Assessing Sexual Comfort and Pleasure (Principle #10) Sexual comfort and pleasure depend on the capacity to attend to the sexual context and to the moment-by-moment physiological sensations during sexual experiences.Attention influences the extent to which individuals interpret situations as sexual, the body responds with physiological sensations, and the psychophysiological experience of desire, arousal, and pleasure (Dickenson et al., 2020;Korff & Geer, 1983).Moreover, inhibitory emotional responses (e.g., negative affect, anxiety, concern about contracting STIs, bodily shame) impair sexual responses by detracting attention away from the elements of the sexual context that elicit sexual feelings (Anderson & Hamilton, 2015).
Although many TNBGE individuals do not experience dysphoria in ways that detract from sexuality (Lindley et al., 2021), centering present-moment attention has powerful implications for individuals who do experience body dysphoria during sexual experiences.Transgender individuals who reported experiencing "bad" orgasms describe instances where orgasm was treated as a gendered phenomenon, or that genital-related dysphoria resulted in distancing from physical pleasure, which was subsequently accompanied by feelings of disconnection or disgust (Chadwick et al., 2019).Hence, body dysphoria, when it occurs for some TNBGE clients, can be viewed as an extremely negative hedonic experience that detracts attention away from the embodied experience of sexual pleasure, preventing individuals from being fully immersed in their sexual experiences.
Assessing the presence of dysphoria during and sexual comfort with sexual experiences necessitates understanding solitary sexual experiences.Sex therapists frequently inquire about masturbation practices when taking a client's sexual history (Coleman, 2003) because understanding masturbation provides insight into the sexual problems.Concerns that present in partnered sexual experiences but are absent or reduced during masturbation can identify the specific factors that deter or enhance sexual wellbeing.When factors that impair sexual wellbeing (e.g., sexual dysfunction, feelings of guilt, shame, or maladaptive beliefs) occur across partnered and solitary contexts, sex therapists address concerns first in the context of masturbation when those experiences are less anxiety provoking than partnered activity.For TNBGE clients who struggle with body dysphoria, masturbation may offer a safe space for clients to explore new and diverse sexual activities, forms of touch, and techniques that are gender-affirming.Often, TNBGE clients report no difficulties with masturbation and enjoy solitary sexual activity as a safe and comfortable means to explore one's sexual fantasies, likes, and dislikes (Ellawala, 2018;Nikkelen & Kreukels, 2018).
Promoting Immersive, Participatory Attention in Sexual Experiences (Principle #11) Most sex therapy approaches leverage present-moment attention as a tool to enhance sexual pleasure and intimacy and reduce sexual concerns.That is, non-judgmental attention to the moment-by-moment erotic sensations is an effective antidote to sexual problems (Brotto & Heiman, 2007;Kaplan, 1980).However, for TNBGE clients, the specific type of presentmoment attention matters.Present-moment attention allocated in a participatory manner (i.e., becoming fully immersed in the experience) reliably enhances sexual responses, but present moment attention that involves a more detached, observational manner (e.g., spectatoring) can impede certain sexual responses (Both et al., 2011;Dickenson et al., 2020).For TNBGE clients who experience body dysphoria, mindfulness may increase pleasure during sexual experiences for some clients but may be iatrogenic for others.That is, non-judgmentally attending to body sensations with detached observation may dampen sexual response and lead to a hyper focus on genitals.In these cases, such techniques may be ineffective at decreasing dysphoria or, at worst, strongly exacerbate distress.
Thus, therapeutic techniques should aim to focus on creating the conditions that allow immersive, participatory attention to emerge.This is not a matter of attempting to change or ignore dysphoria or change one's feelings about sexuality, but an invitation to expand the field of awareness beyond the genitals to the hedonic aspects of the sexual response and sensations of the body as a whole.Interventions that aim to expand the field of sexual awareness are known as horizontaling interventions (Berry & Lezos, 2017).Some clients may be able to achieve this more expansive view of their sexual response by volitionally allocating one's non-judgmental, present-moment, participatory attention to the body as a whole.Mindfulness is only one route to becoming immersed in one's sexual experiences.
Facilitating Sexual Experiences That Are Gender Affirming (Principle #12) Subtle changes to thoughts, behaviors, or situations can also cultivate the contexts that allow immersion in sexual pleasure to emerge.Such strategies include letting thoughts come and go, turning attention to one's partner's body and sexual experiences, engaging in sexual behaviors that are consistent with one's gender role, and reinterpreting the gendered meaning of bodies and sexual behaviors (Doorduin & Van Berlo, 2014).Additional strategies involve finding ways to affirm gender when genitals become the focus of attention, accessing sexual resources that depict sexual empowerment, and sexual exploration.Renaming and reimagining genitals can be crucial to alleviate distress related to hyper-focus on genitals as indicative of identity (Edelman & Zimman, 2014).Creating gender affirming language for genitals and other erogenous parts of the body can promote gender affirmation during sexual experiences (see Bouman et al., 2017).Therapists can help clients self-assess and communicate with partners what language to use and how they would like to be touched during sexual activity (for a useful clinical resource, see Erickson-Schroth, 2014).
Other pathways to expand the field of awareness include use of fantasy and sexual exploration.Fantasy is a powerful lever to enhance sexual response (Lehmiller, 2018); fantasy creates compelling sexual images that become the center of attention.As such, fantasies direct attention to the sexual elements of the sexual experience, rather than attending to nonsexual thoughts (mental chatter, gender performance, concerns about partner perceptions of one's body).Fantasy may also help clients more easily connect to the moment-by-moment experiences of pleasure in the whole body by adopting a more expansive vision of their sexuality and gender.Indeed, research has shown that non-binary people have fantasies that allow for creative gender affirmation (Lindley et al., 2022).
Cultivating Freedom for Sexual Exploration (Principle #13) TNBGE individuals report that the ability to explore new sexual experiences is central to satisfying sexual experiences (Lindley et al., 2021;Thurston & Allan, 2018).Because sexual exploration is a personal adventure, clinicians should withhold all judgment, keeping in mind that the diversity of sexual expression is a key pathway toward sexual wellbeing.Rather than evaluate what stimuli or behaviors are "appropriate," a sexual wellbeing approach helps clients identify which behaviors facilitate safe, pleasurable, satisfying sexual experiences based on the consequences of those behaviors.Clinicians may find BDSM, sexual fetishes, or other sexual practices unusual, but for some clients, these sexual expressions may facilitate sexual wellbeing.For example, BDSM practitioners report adopting a more expansive and more mindful perspective during BDSM sexual experiences, which results in greater sexual pleasure and more transformative experiences (Labrecque et al., 2021).BDSM in queer communities also offers opportunities to disrupt culturally-defined sexual norms and move beyond heteronormative understandings of consent (Bauer, 2021).Of course, BDSM is not for everyone (for some, BDSM will impede sexual wellbeing) but individuals who wish to explore these possibilities should be able to do so without judgment.Sexual exploration is not limited to partnered sex.Solo or solitary sexual experiences are also a rich source of learning and contributor to sexual wellbeing.
Beyond attention and sexual pleasure, partners are a powerful input to sexual wellbeing and directly facilitate sexual comfort.Transmasculine and nonbinary participants reported that partners were instrumental in their sexual wellbeing, feeling connected and intimate with their partner increased their sexual satisfaction, and having partners that are open to new sexual experiences allowed for more comfortable exploration of sexuality (Lindley, 2021).In the context of widespread discrimination, fetishization, objectification, and even violence in sexual relationships (Lindley et al., 2022), having safe and affirming partners can buffer minority stress and help TNBGE individuals feel worthy of love and overcome internalized transphobia (Galupo et al., 2019(Galupo et al., , 2020)).
Consent is a Process That Optimizes the Balance Safety and Pleasure (Principle #14) The final principle of the sexual wellbeing approach concerns consent.As TNBGE individuals navigate new and varied sexual contexts from a different positionality in their gender, consent-the process by which individuals express their willingness to engage in various sexual activities-becomes an important tool to ensure access to safe and pleasurable sexual experiences.However, internalization of sexual scripts and transnegativity can limit TNBGE clients' sexual autonomy and lead to feeling disempowered to communicate with partners about sexual desires, needs, and willingness (Sevelius, 2009).For example, transgender men who have sex with men report having to contend with concerns about stigma and fear of rejection from cisgender men, which can compromise their ability to negotiate and communicate sexual activity (Rowniak et al., 2011).To help clients negotiate consent requires an understanding of the recent paradigm shifts of consent.
In brief, the model of consent has shifted away from non-consent, in which the impetus for consent is placed on an individual to say "no" to sexual activity toward affirmative consent, which involves a clear, unambiguous "yes" from all parties involved in sexual activities.Though not without controversy, this model shifts the relational and sexual dynamic from prevention of non-consent (e.g., avoidance of traumatic sexual experiences) to promoting consent as a process that promotes safe and pleasurable experiences.From this lens, sexual pleasure is optimized when sexual partners are willing (indicative of consent) and want (not indicative of consent) to engage in the activity.Helping clients distinguish consent as willingness from desire, arousal, and pleasure, which are not indicative of consent, can help clients become aware of what they (a) want and (b) are willing to do.
Importantly, sexual autonomy and empowerment are contextually and socially situated.For many TNBGE individuals, prevention of violence is a chief concern.TNBGE people of color, especially those with limited access to material resources, do not always share the same autonomy, agency, and empowerment as white TNBGE individuals.For example, TNBGE individuals are at heightened risk for non-consensual sexual interactions (Dank et al., 2014), with TNBGE people of color, especially Black transgender women, experiencing the highest rates of sexual and non-sexual violence (Dinno, 2017).Discussions of autonomy and consent must address the interlocking systems of oppression bound by gender and racial discrimination and systemic barriers to accessing material resources (food shortage, housing insecurity, limited access to private spaces to engage in sexual behavior, protection from violence from law enforcement, etc.).Therapists should work collaboratively with TNBGE clients of color to understand their community contexts, in terms of limitations and resilience.Connectedness to community support, social resources, and material resources buffer the negative impact of stigma, discrimination, and violence in LGBTQ communities and communities of color (Meyer, 2015;Bay-Cheng, 2011).Similarly, discussions of sexuality should avoid an overemphasis on sexual safety.Conversations about consent that center sexual comfort provide an important avenue to ensure adequate attention to both safety and pleasure.

Clinical Scenarios
To illustrate the sexual wellbeing approach, two clinical scenarios are presented followed by reflections for future sessions.The cases represent amalgamations of the types of people, concerns, and dynamics the authors have experienced working with TNBGE clients.
Client 1: Sexual Pleasure and Health with Body Dysphoria Case Scenario: Dr. Mills (she/her), a white heterosexual cisgender woman with a feminist therapy orientation, has been working with Ethan (he/him), a white, transmasculine young adult client for eight months.Ethan initially sought out therapy to address distress arising from gender dysphoria and to gain extra support while beginning hormone replacement therapy (HRT).During the past several months, Ethan reports feeling more confident in his gender and has successfully navigated challenging situations at work and school, resulting from anti-transgender stigma.
However, Ethan continues to experience significant interpersonal anxiety and body-related gender dysphoria, which he describes in nonspecific ways that Dr. Mills labels as vague.This has left Dr. Mills with the impression that Ethan experiences dysphoria more generally, rather than in response to discrete events.Ethan notes that dysphoria impacts him significantly, believing that he is not able to live up to his expectations for himself regarding gender roles and dynamics within relationships, feeling he is not productive as other men at work, and struggles feeling "masculine-enough" around cisgender men.For the last several sessions, Dr. Mills and Ethan have focused on these negative experiences, though Dr. Mills notices that they appear to be circling the same conversation each session, a sentiment the client also expressed.With both feeling stuck, Dr. Mills consults a colleague who suggests reflexivity and revisiting Dr. Mill's assumption about Ethan's dysphoria as more generalized, and to explore the specific circumstances in which his dysphoria may peak, including interpersonal interactions, romantic or sexual situations, activities of daily living, etc.
In their next session, Dr. Mills asks Ethan about the contextual factors in which Ethan's dysphoria peaks, providing examples as prompts, one of which includes "sexual experiences."Ethan immediately responds to the word "sexual" and describes for the first time how his dysphoria is worst during sexual activity with partners.He describes this as very distressing because it impacts his ability to be sexual with partners and sexuality is "extremely important" to his mental health.He shares with Dr. Mills that he is struggling to have sex with other people in ways that feel gender affirming.Specifically, he describes having chest and bottom dysphoria that make it difficult for him to feel aroused due to feeling distressed by and judgmental of his body.
Dr. Mills inquires about Ethan's desire for further medical interventions as a potential means to alleviate some of his dysphoria during sexual experiences.Ethan expresses that he is not interested in pursuing bottom surgery, and he might consider chest surgery in the future, but it is not a priority for him at this time.Dr. Mills asks whether Ethan has spoken to any of his sexual partners about his dysphoria and learns that Ethan is uncomfortable expressing his needs to his partners and feels that he must "go with the flow."Dr. Mills validates his concern and nonjudgmentally clarifies what Ethan means by "going with the flow."Ethan states that he wishes his partners would avoid certain areas of his body, but he worries that they will not want to engage with him if he asserts this need.He states that some of his partners ask for consent when it comes to interacting with his body during certain sex acts, but most of the time his partners only ask about consent at the start of sexual activity.Dr. Mills notices Ethan's rising discomfort as he discusses his sexuality, and when Dr. Mills asks about this discomfort, Ethan notes that he is afraid of being judged for having multiple sexual partners or saying something that could jeopardize his ability to continue HRT.

Reflections on the Sexual Wellbeing Framework as an Adjunctive to Therapy
This case presents opportunities to act in ways that are affirming to Ethan and create an egalitarian therapeutic space, consistent with feminist therapy.First, Dr. Mills engaged in a self-reflective process about his assumption that Ethan's dysphoria was generalized and consulted with another professional (engaging in reflexivity), resulting in a clinical conversation about sexuality.By explicitly naming sexual experiences as one of several contextual factors that might trigger dysphoria, Dr. Mills normalized sexuality as equally important and relevant as other life events and ultimately discovered that Ethan's dysphoria is most strongly triggered during sexual experiences with partners.Second, Dr. Mills continues to invite conversation about sexuality through maintaining a nonjudgmental disposition, seeking clarification when language was used as a proxy ("going with the flow") and asking only follow-up questions that were directly relevant to the subject matter.
Third, Dr. Mills naming of Ethan's discomfort presents an opportunity for a sexual wellbeing intervention, as it was situated within a conversation about consent.At this juncture, Dr. Mills should pause with Ethan to reflect on his discomfort and decide, together, whether Ethan feels safe and ready to discuss sexuality and his accompanying dysphoria.This interpersonal process can provide Ethan with the time and space to reflect on his sense of safety and whether he feels ready to talk about sexuality with Dr. Mills.In parallel to the dynamics playing out with his sexual partners, if Ethan were not yet ready, not discussing sexuality can send a powerful message that Ethan can be supported, affirmed, and respected in communicating his boundaries.If Ethan consents to a conversation about sexuality, Dr. Mills can facilitate Ethan's comfort in talking about the specifics of his dysphoria during sexual experiences by inquiring how Ethan likes to refer to his sexual anatomy (including primary and secondary sex characteristics), particularly within the context of a clinical conversation.This places the power of language in Ethan's hands, giving him agency to name or label his own body in a manner that is comfortable, congruent, and affirming to him.Moreover, this conversation sets a nonjudgmental foundation for future discussions about finding gender affirming language during sexual experiences.
Dr. Mills can also use the moment of naming distress as an opportunity to clarify the precise ways in which the therapeutic space is nonjudgmental and affirm that her role is not to gatekeep the client's access to medically affirming treatment, thereby addressing power dynamics.Providing informed consent throughout therapy, rather than only at the initiation of therapy, models consent as a process.Finally, the sexual wellbeing approach would also discourage Dr. Mills from dismissing Ethan's concern about being judged for having multiple partners.Rather, following the session, Dr. Mills might examine whether she holds a belief, judgment, or implicit bias that monogamous romantic relationships are healthier than multiple sexual partners and assess whether her own beliefs about sexuality and monogamy and her identity as heterosexual shape her interpretation of Ethan's behavior.Dr. Mills can ameliorate the impact of her own beliefs about sexuality through maintaining psychological distance from her own sexual values by placing higher priority on Ethan's sexual values, personal experiences, and the positive consequences of his sexual experiences.A constant line of silent mental inquiry that emphasizes the celebration of individual variation in sexual wellbeing (e.g., thinking "What does sexual wellbeing mean for Ethan, in particular?") may prove fruitful.

Further Directions for Intervention Based on a Sexual Wellbeing Approach
After establishing an environment in which sexuality is comfortable to discuss, Dr. Mills could assess dysphoria during sexual experiences and consider sexual comfort and pleasure.Assessing Ethan's comfort with and dysphoria during masturbation could lead to more information about the factors that prompt dysphoria: is discomfort that arises indicative of dysphoria or related to anxiety that might occur in the context of being seen and touched by others, for example.This assessment can provide helpful insights to inform interventions to enhance sexual comfort.For example, if Ethan experiences mild dysphoria during masturbation but generally feels satisfied, he might use solo sexual experiences to experiment with ways to optimize sexual pleasure and simultaneously lessen dysphoria.Dr. Mills could help Ethan brainstorm ideas he could employ, for example trying different sexual techniques, using particular gender affirming language, choosing to cover particular parts of his body during partnered sexual activity, using fantasy to alleviate thinking about his genitals, or attempting to shift his focus.At this point, horizontaling interventions may be used to center immersive, participatory attention to pleasurable sensations and help the client to avoid using observatory forms of attention that could heighten dysphoria.Among clients who have difficulty generating ideas, sexual resources that are gender affirming (rather than fetishizing) can aid in sexual exploration.After Ethan learns what factors help him to feel embodied in his sexual experiences and reduce dysphoria, Dr. Mills and Ethan could practice effectively communicating with his partners about his sexual desires, wants, and needs.
Another direction that Dr. Mills could pursue involves discussing the ways in which Ethan's dysphoria intersects with his expectations for his roles and relationships, given disruptions in his sense of productivity at work and his concern about whether he is "masculine enough" when spending time with cisgender men.Dr. Mills could inquire about Ethan's understanding of masculinity, conceptualized at the intersections of race, class, and gender.This cultural context indicates that Ethan is interacting with and navigating white hegemonic conceptualizations of masculinity from a new and different positionality (i.e., a white man).Dr. Mills may help Ethan understand which aspects of masculinity align with his values and sense of self and which do not, as well as understand the ways in which the pressure to embody masculinity is made manifest across both sexual and non-sexual experiences and how he feels during specific experiences.In the context of sexuality, Dr. Mills might inquire whether different ways of enacting masculinity during sexual acts facilitates or deters sexual comfort and pleasure.These discussions can allow Ethan to understand himself better and, when appropriate, how to resist the ubiquitous pressures of gender socialization in ways that align with his values and enhance his sexual wellbeing.
Client 2: Shifting Sexual Attractions Case Scenario: For the past 11 months, Dr. Drake (she/her), a queer Latina feminist therapist, has been working with Farah (she/her), a 50-year-old trans woman who had immigrated from Yemen with her wife when she was 30 years old.Farah described that she and her wife had been married for 25 years before they divorced due to her wife's intolerance of Farah's social and medical transition.Farah described that although her wife was initially reticent, she provided tacit support.Yet, once Farah began living as a woman across her life contexts and started to pursue gender affirming medical interventions (e.g., HRT, top surgery), her wife's reticence progressed to direct opposition and frequent arguments, resulting in a joint decision to divorce.Although Farah had seen a therapist to obtain letters of support for surgery, she had not yet worked with a therapist to address other concerns.Farah's grief about the divorce and challenges navigating other relationships were causing so much distress that Farah decided to contact Dr. Drake.Throughout feminist therapy, Dr. Drake engaged in reflexivity and addressed power dynamics to provide a validating space for Farah to process her grief about her divorce, prompting inquiry into contextual factors.Dr. Drake worked with Farah to help her identify the impact of the painful conversations she and her ex-wife had about Farah's gender and to begin to mitigate the power those conversations had over her other relationships.Over time, Farah reported feeling more comfortable in her gender as she processed her divorce and began to successfully navigate challenges in other relationships.
One session, Farah raises the topic of dating and expresses that she feels excited to be at a place where she is ready to start dating again.However, she has also been anxious to introduce this topic in therapy, because she has been noticing that although she felt attracted to women most of her life, she has recently begun to experience attraction to men.Farah describes this as confusing and stressful.She notes that she was already experiencing anxiety about coming out to the important people in her life as trans.She describes to Dr. Drake that growing up in a Muslim family made it challenging for her family to accept her as trans, so she feels very anxious about their reaction to this potential new disclosure.She discussed how her trans friends in the U.S. have told her she should "cut off" her family if they are not reacting with acceptance, but she cannot fathom doing so.Farah also describes how her own internalized cis heteronormativity continues to manifest in navigating her disclosure to others, and stem from her Muslim culture and reinforced in Western society.Additionally, Farah discusses experiencing significant shame in response to "not [being] able to make up my mind" regarding her attractions and believes that her sexual attractions should be static.She asks Dr. Drake, "Can my sexual orientation change?"Given the palpable discomfort with which Farah raised this topic, Dr. Drake pauses to engage in reflexivity, address power dynamics, and establish an egalitarian relationship.She checks in with Farah about how it felt to raise this topic with her, a queer, cisgender, woman of color.She tells Dr. Drake that while she felt anxious, she tried to assure herself that Dr. Drake would be more understanding than most, given that Dr. Drake is a queer woman of color.Dr. Drake then validates Farah's concerns, normalizes her anxiety about raising this topic with her family, and expresses a personal understanding of collectivist cultures, noting that severing communication with her family is not straightforward, nor always the best decision, given that Farah highly values her relationship with her family members.She assures Farah that while sexual fluidity can be anxietyprovoking, it is not uncommon.She also provides psychoeducation on sexual fluidity, specifying that sexual fluidity is a context-dependent change in one's established pattern of sexual attractions, desires, behaviors, and relationships.Farah asks whether she "chose to be this way" or whether HRT caused the changes in her attractions.Rather than simply answering these questions, Dr. Drake first examines with Farah the reasons and motivations behind these questions in order to empower the client both inside and outside of therapy.Farah reports she is worried that her distress about her sexual orientation would be her "fault" if she chose her sexual orientation or chose to take HRT and transition.Together, Dr. Drake and Farah examine the gendered and sexual messages that privilege certain sexual orientations over others (e.g., the cultural message that if a person can choose heterosexuality, then they should), and Farah starts to challenge her own internalized homonegativity.Farah begins to understand that sexual orientation is not always static or stable, feels hope that she might experience attractions toward men without fear or self-blame, and states that she will sign up for a dating app this week to "see who is out there."In the next session, she excitedly informs Dr. Drake she has a potential date.

Reflections on the Sexual Wellbeing Framework
In applying a sexual wellbeing approach, Dr. Drake attended to the cultural context of Farah's concerns, expanded Farah's perspective on sexual orientation, validated and normalized the potential for fluidity, and provided Farah with more information about shifts in sexual orientation and desires among TNBGE individuals.This approach creates space for Farah to discuss the complexities of her experience of sexual attraction, thoughts, and emotions.When Farah inquired about the causes of sexual fluidity, Dr. Drake could have simply noted the lack of evidence that fluidity results from any one specific factor (HRT, choice, trauma, confusion, etc.).Instead, she used this moment to further explore Farah's distress and uncovered internalized cultural messages that impedes Farah sexual wellbeing.
Further Directions for Intervention Based on a Sexual Wellbeing Approach Important to consider are the client's relative positionalities over time and how these have informed her prior experiences of interpersonal dynamics in romantic and/or sexual domains.Given that the client is reporting a shift in attraction toward men and has not yet experienced any sexual interactions with men, Dr. Drake might discuss the complexities of navigating sexual and romantic relationships in the next session.First, Dr. Drake might examine the type of relationship Farah envisions as she begins dating (sexual, romantic, or both sexual and romantic).If Farah wants to engage in sexual experiences, Dr. Drake could assess how Farah imagines negotiating sexual activity, discuss the role of consent (as a process involving the clear communication of willingness) as a means to ensure sexual safety and pleasure, and identify strategies that help Farah feel secure as she explores a new dating context, such as meeting dates in public to establish interest and practicing assertive communication to feel better prepared if and when issues around consent arise.
As a trans woman of color-a population that experiences disturbingly high rates of violence-safety concerns related to racism and its intersections with sexuality should be discussed in a broader conversation about the client's strengths and community-level resilience.For example, to optimize safety during dating situations, Dr. Drake and Farah together can assess Farah's connectedness to her ethnic and religious communities, connections to the LGBTQ community (particularly LGBTQ communities of color), availability of social resources (social support, support groups), and her access to material resources.These conversations may include considerations on when the client wants to disclose to partners that she is trans and what feels best to her from a lens of both safety and pleasure.This opens opportunities to explore with Farah how sexuality is considered, discussed, and conceptualized at the intersections of religion and culture in her family.
In future conversations about consent, Farah may find it helpful to distinguish willingness and wanting to engage in sexual activity by visualizing two separate, hypothetical scales.A client's ability to communicate an "enthusiastic yes" is simple when she is willing and wants to engage in sexual activity (e.g., an 8 out of 10 on a hypothetical willingness scale and an 8 on a hypothetical sexual desire scale), and "no" is communicated fairly unequivocally when both willingness and desire are low (a 1 of 10 on both scales).Less intuitive is how to navigate situations in which willingness and desire are not aligned.Dr. Drake might explore how Farah imagines negotiating sexual situations in which she feels a strong desire to engage in sexual activity (e.g., an 8 out of 10 on a hypothetical sexual desire scale) but is not willing (e.g., a 2 out of 10 on a hypothetical willingness scale) or when she experiences a high degree of willingness to engage in sexual activities (e.g., an 8 out of 10 on a hypothetical willingness scale), even though her desire for sexual activity is relatively low (e.g., a 3 out of 10 on a hypothetical sexual desire scale).Processing the details of such experiences provides insight into the clients' strengths, sexual resilience, and sexual values that buttress wellbeing and ways to help the client challenge messages about sexuality and race that impede sexual wellbeing.A sexual wellbeing approach would also open space for conversations between the therapist and client regarding sexual pleasure and exploration.Beginning questions might include "What does sexual wellbeing mean to you?" "What makes you feel good about your sexuality?"and "How do you want your sex life to look?"

Conclusion
The sexual wellbeing framework proposed and applied in the present article directly addresses the APA (2015) guidelines for clinical practice with transgender clients, as it relates to the domains of stigma, discrimination, and barriers to care; life span development; and research, education, and teaching.For example, although the sexual wellbeing framework centers the need to understand each individual's cultural context, more research is needed to expound the ways in which stigma and discrimination creates additional barriers to individuals' sexual wellbeing.Future research could also directly address sexual wellbeing concerns across the lifespan.Indeed, the needs and developmental processes of children and adolescents (e.g., the need for trans inclusive and gender affirming sex education) will be different from those of aging adults (e.g., navigating changes in sexual functioning and desire).Thus, having a framework to address sexual wellbeing across all stages of life is crucial to avoid applying interventions that are not age appropriate (Spencer et al., 2021).Finally, paramount in efforts to promote sexual wellbeing is provider education and training.We urge graduate training programs to incorporate curricula that ensures that mental health providers receive formal education in helping TNBGE clients address sexual wellbeing.
Therapists trained in and aligned with feminist values are well suited to this work.With a critical lens for understanding the ways in which experience occurs in context at the intersections of gender, sexuality, race, class, ability, and other dimensions of culture and identity, therapists are positioned to assist TNBGE clients in addressing sexuality and sexual wellbeing in a manner that is sexually and gender expansive.

Table 1 .
Principles of the applied sexual wellbeing approach.