Current Sexual Health Reports (2020) 12:195–201

https://doi.org/10.1007/s11930-020-00270-8

SEXUAL ORIENTATION AND IDENTITY (E COLEMAN AND GN RIDER, SECTION EDITORS)

Intersectionality in Sex Therapy: Opportunities for Promoting Sexual

Wellness Among Queer People of Color
Dagoberto Heredia Jr 1 & G. Nic Rider 2

Published online: 20 July 2020

# Springer Science+Business Media, LLC, part of Springer Nature 2020

Abstract
Purpose of Review Intersectionality theory acknowledges that a significant part of the distress experienced by queer people of
color (QPOC) is caused by systems of oppression in society. Given the dearth of literature linking intersectionality to sex therapy,
combined with a lack of sex therapy research centering on the experiences of QPOC, sexual wellness advocates often utilize
unidimensional approaches that focus exclusively on either LGBTQ people or people of color. This review presents the follow-
ing: (1) an overview of the gaps eliciting unidimensional approaches to sex therapy practice and research, (2) an illustration of
intersectionality’s theoretical underpinnings as a queer and oppression-responsive approach, and (3) applications for sex therapy
practice with QPOC.
Recent Findings The intersectionality framework provides an opportunity to explore overlapping forms of oppression (e.g.,
racism, heterosexism, cisnormativity) and to make social justice and resilience/resistance central topics in the promotion of
sexual wellness. The framework can guide sexual wellness advocates in their mission to better understand the harm posed by
oppressive systems, how these systems impact sexual problems, and how they can intervene to reduce conditions that undermine
sexual wellness and freedom.
Summary It is in the sexual health field’s best interest to comprehensively adopt intersectionality to advance the field toward a
culture that critiques and dismantles social structures that limit the possibilities of pleasurable sex among oppressed communities.
Individual sex therapists can contribute to the inclusion of the intersectionality framework in therapy by critiquing harmful social
structures, attending to both sexual dysfunction and sexual pleasure, attending to both oppression and resilience/resistance, and
actively collaborating with the communities they serve.

Keywords Sex therapy . Intersectionality . Queer people of color

Sexual medicine has often described sexual dysfunction as a
primary physical concern and has focused on the physiologi-
cal bases of sexual problems [1]. Sexuality educators, re-
searchers, and therapists who work with marginalized groups,
however, understand that sexual problems manifest in the
This article is part of the Topical Collection on Sexual Orientation and
Identity
* Dagoberto Heredia, Jr
Heredia.Dagoberto@mayo.edu
1 dation, coercion, prejudice, and the infringement of any indi-
Department of Psychiatry and Psychology, Mayo Clinic, 200 First
Street SW, Rochester, MN 55905, USA
2 sex therapy to therapeutic practice that is responsive to the
Program in Human Sexuality, National Center for Gender Spectrum
Health, University of Minnesota Medical School, 1300 S. 2nd Street,
Ste 180, Minneapolis, MN 55454, USA
context of overlapping systems of oppression that maintain
and exacerbate biological, psychological, and social factors
of sexual wellness. Sexual wellness advocates have begun to
move away from perspectives that emphasize biological and
Western-defined conceptualizations of human sexuality in fa-
vor of frameworks that consider the impact of oppressive dy-
namics within and across cultural contexts [2–4]. Sexual well-
ness does not exist in a cultural vacuum and as such, how
individuals experience themselves and each other in relation
to social identities or positions (e.g., race, ethnicity, gender,
sexual orientation, ability) carries sexual implications. While
many sex therapists oppose “all forms of harassment, intimi-
vidual’s civil rights” [5], there is a dearth of literature linking
client’s oppressed experience and resilience factors. The
intersectionality framework offered in this article, discussed
196
as related to sexual and gender diverse people of color (i.e.,
queer people of color; QPOC), posits that oppression and
resilience/resistance are defining contributors to sexual
wellness.
Existing literature suggests that QPOC experience unique
stressors associated with their racial, ethnic, gender, and sex-
ual identities. QPOC have been shown to experience racism
and ethnocentrism in lesbian, gay, bisexual, transgender,
queer, and questioning (LGBTQ) spaces, events, and media.
For example, Black and African American QPOC have been
refused entry and have received poorer service in gay bars and
nightclubs [6]. Latinx QPOC have been encouraged to “check
[their] color at the door” at national LGBTQ gatherings
wherein immigration issues were deemed irrelevant to the
liberation movement [7]. LGBTQ magazines rarely feature
Asian American, Native Hawaiian, or Pacific Islander
QPOC in press work and instead position them to the outskirts
of the greater LGBTQ community by offering “how to gab in
Gaysian” guides to primarily White audiences [8].
Additionally, established LGBTQ community organizations
have gained negative reputations among QPOC for reinforc-
ing white normativity despite having inclusive mandates and
staff of color [9].
Research has also shown that QPOC face various forms of
oppression in romantic and sexual relationships; with regard
to racism and ethnocentrism, Callander et al. found that gay
white cisgender men were most likely to specifically exclude
non-white potential partners in their online dating profiles
[10]. When people of color are seen as acceptable sexual
and romantic partners, they are often objectified and reduced
to stereotypical traits associated with their race and/or ethnic-
ity [11]. With regard to transnegativity and masculine
privileging, Blair et al. found that heterosexual cisgender
men and women were most likely to exclude gender-diverse
persons from their potential dating pool [12]. Further, partic-
ipants who were willing to date gender-diverse persons dis-
proportionately reported openness to dating transgender men
but not transgender women. Researchers have begun to inves-
tigate the interactive effect of oppression on the sexual well-
ness of QPOC. Based on scholarship on internalized stigma, if
prevailing forms of enacted oppression are directed inward
and applied to the self, oppression can result in increased
anxious and depressive distress among LGBTQ people [13,
14]. These stressors may be directly related to poor sexual
health outcomes and can limit opportunities for experiencing
sexual pleasure. For example, emerging evidence suggests
that internalized stigma may play a role in connecting overt
experiences of oppression (e.g., victimization) to risky sexual
behavior [15, 16], lower-quality relationships [17], intimate
partner violence [18], and fear of accessing sexual health in-
formation [19].
This article will explore intersectionality theory as a frame-
work for promoting sexual wellness and the implications of
Curr Sex Health Rep (2020) 12:195–201
this oppression-responsive framework for strengthening sex
therapy practice with QPOC. It will provide a brief description
of intersectionality theory, a framework which has received
increasing attention in psychology and other fields [20•], in
addition to describing strategies for integrating comprehen-
sive intersectional perspectives in sex therapy with QPOC.
Intersectionality in Sex Therapy
Intersectionality theory was first developed by Black feminist
scholar-activists Kimberlé Crenshaw [21, 22] and Patricia Hill
Collins [23] as a framework for understanding the multiple
forms of oppression faced by women of color in the USA.
The framework centers on the importance of attending to mul-
tiple, intersecting identities and their ascribed social positions
(e.g., race, ethnicity, sexual orientation, gender identity) to-
gether with the unique privilege, power, and disadvantage
dynamics that characterize those intersections. For oppressed
groups, intersecting systems of oppression are experienced
and struggled against simultaneously and as such, equity ini-
tiatives must recognize and address multiple forms of oppres-
sion in tandem [20•]. For example, scholars critiqued both
antidiscrimination law and feminist theory for downplaying
the experiences of Black women by viewing racism as sepa-
rate from sexism rather than considering both as intersecting
forms of oppression. As another example, early LGBTQ
movements and queer theory were critiqued for centering
the experience of White, cisgender individuals and minimiz-
ing how queer identities and sexuality are shaped by colonial-
ism [7, 24, 25]. Further, a substantial proportion of literature
on sex therapy assumes a heterosexual and dyadic default [26]
that fails to capture or address the unique needs of sexual and
gender-diverse people.
A central tenet of intersectionality theory highlights the
need for structural-level changes that advance social justice
and uplift oppressed groups. Many sexuality researchers and
therapists drawing on intersectionality have lost sight of the
social justice core of the framework by focusing on identity
without describing the inequities ascribed to those identities
and opportunities for ameliorating them [27]. Given the field’s
increasing interest in diversity and inclusion, sexual wellness
advocates are uniquely suited to uphold the critical and social
justice cores of the intersectionality framework. Sex therapists
in particular can contribute to the comprehensive integration
of intersectionality perspectives in sex therapy research and
practice.
At first glance, a focus on oppression and social justice may
not appear relevant to sex therapy and sexuality research.
However, growing bodies of research highlight the impor-
tance of attending to sociocultural concomitants of sexual
problems [2, 3, 26, 28••]. These and numerous other articles
describe inequality within and across groups and how
Curr Sex Health Rep (2020) 12:195–201
oppression contributes to sexual concerns, suggesting that dis-
cussions on interlocking systems of oppression are well within
the realm of sex therapy and research. Gaining an in-depth
understanding of the oppression-sexual wellness relationship
is vital for advancing sexual equity in meaningful and cultur-
ally relevant ways. The intersectionality framework can guide
sexual wellness advocates in their mission to better understand
the harm posed by oppressive systems, how these systems
impact sexual problems, and how they can intervene to reduce
conditions that undermine sexual wellness and freedom.
Shifting from Dysfunction and Oppression
to Pleasure and Resilience
A review of the sexual health literature demonstrates that most
training programs and therapists discuss sex in the context of
minimizing sexual dysfunction or reducing risk of sexually
transmitted infections [29, 30]. Despite calls to advance more
pleasure-based and sex-positive approaches to sex therapy
[28••, 31•], there is a dearth of research describing strategies
for discussing sexual pleasure and healthy sexual functioning.
Sex positivity is characterized by a nonjudgmental and open
attitude toward sex wherein sexual activity is viewed as a
natural and normal facet of the human experience [32]. Sex-
positive societies embrace broader scopes of normal sexual
activity and validate pleasurable and non-procreative aspects
of sex [33] including diverse sexual expressions, practices,
and identities [34]. In contrast, sex-negative societies hold
views that describe sexual activity as harmful, dangerous, or
problematic [35]. In the USA, clinician avoidance of uncom-
fortable topics in therapy, in particular discussions on sex and
sexual functioning, can be attributed to the prevalence of neg-
ative values and attitudes about human sexuality [33]. Given
that clinician attitudes have been shown to impact psychother-
apy skills [36], challenging internalized sex-negative attitudes
in favor of positive and pleasure-based conceptualizations of
sexuality is important. Although generally positive ap-
proaches have been shown to be beneficial for working with
sexual and gender-diverse people [37], a pleasure-based and
sex-positive approach to the treatment of sexual concerns is of
supreme relevance, especially among QPOC who struggle to
identify the positive potential of their sex due to overt, subtle,
and internalized stigma. For example, sex therapists can safe-
guard the sexual resilience of QPOC by facilitating awareness
of and naming oppression across sexual/relational contexts
and identifying ways of resisting against oppressive dynamics
by role-playing assertive boundary setting and exploring plea-
surable, queer-affirmative sexual practices.
The minority stress model has also been helpful for under-
standing the way that oppression negatively impacts lesbian,
gay, and bisexual (LGB) people [38]. Although the model was
not originally designed for QPOC or gender-diverse people, it
197
describes multiple ways in which sexual and gender-diverse
people experience distress caused by oppression by way of
external stressors (e.g., discrimination, violence, rejection)
and internal stressors (e.g., fear of further victimization, mis-
trust, internalized stigma). A growing body of literature has
supported and expanded the minority stress model. Testa
et al. expanded the model to reflect gender minority stress
and resilience among transgender and non-binary populations
[39]. In particular, identity pride and community connected-
ness were negatively associated with depressive and social
anxiety symptoms. This finding falls in line with Meyer’s orig-
inal assertion suggesting that connection to other sexual and
gender-diverse people provides the opportunity to access a
sense of identity pride as well as emotional support from indi-
viduals with shared experience [38]. While these conclusions
add important information to the literature, they share certain
limitations. Specifically, studies examining the minority stress
model utilize samples wherein QPOC are underrepresented
[39, 40] and measures meant to assess minority stress and
resilience do not capture the distress associated with simulta-
neously experiencing other forms of oppression such as racism,
ethnocentrism, or nativism [41]. As such, it is hoped that future
studies will capture the unique stress and resilience factors that
may exist for QPOC navigating interlocking systems of op-
pression. Until then, we can surmise from the existing evidence
that QPOC also actively resist oppressive forces and use
empowering strategies via community connections and identity
pride, especially when exposed to social contexts that promote
the prideful integration of multiple identities (e.g., gay, Latinx,
polyamorous). Indeed, both community connections and iden-
tity pride are likely to carry positive implications for QPOC
navigating sexual concerns, especially when the positive po-
tential of their sex is limited by social isolation, internalized
stigma, situational avoidance, or experiential avoidance.
Incorporating Intersectionality in Sex Therapy
To engage oppression-responsive practice with QPOC, sex
therapists must familiarize themselves with the philosophy
and practices of the American Association of Sexuality
Educators, Counselors, and Therapists (AASECT). The core
values described in the organization’s Vision of Sexual Health
describes an unwavering opposition of “all abuses of sexuality
including, but not limited to, harassment, intimidation, coer-
cion, prejudice, and the infringement of any individual’s sex-
ual and civil rights” [42]. Although this proclamation focuses
on sexuality, a statement released in 2017 in response to vio-
lence in Charlottesville, VA, highlighted the organization’s
commitment to challenging multiple forms of oppression that
limit human and sexual rights for “people of all faiths, gen-
ders, races, ethnicities, nationalities, sexual orientations, and
abilities” [5]. Inherent in these assertions is a focus on
198
diversity, cultural context, and dynamics of power and privi-
lege. In sex therapy with QPOC, these factors are of extreme
importance given that the clinician’s knowledge of oppressive
structures and their ability to confidently assess the deleterious
impact of oppression play a major role in the conceptualiza-
tion, assessment, and course of the client’s treatment.
The intersectionality framework allows for a more nuanced
and holistic understanding of QPOC presenting to sex thera-
py. Several assessment and intervention approaches philo-
sophically align with the intersectionality framework such as
the use of the biopsychosocial model to assess for contributors
of sexual problems, gathering information about vulnerability
factors (e.g., individual factors, relationship factors, and med-
ical factors), and the administration of brief interventions such
as sexual psychoeducation, cognitive behavioral therapy,
mindfulness, sensate focus, and the collaborative sexual
menu. To extend the therapeutic benefits of these practices,
sex therapists are encouraged to consider how a client’s mul-
tifaceted experience of oppression serves as a barrier to or
otherwise affects enjoyment of sex. For example, clinicians
can employ an intersectional approach by resisting the urge to
focus solely on the client’s multiple identities (e.g., trans mas-
culine, gay, and AfroLatinx; genderqueer, queer, and Filipinx)
without also considering the interlocking systems of oppres-
sion associated with those identities (e.g., transnegativity,
homonegativity, ethnocentrism, and racism). To best achieve
this, clinicians should simultaneously (1) be aware of the cli-
ent’s multiple marginalized identities and messages clients
receive about their identities (e.g., objectification and
hypersexualization of trans women of color); (2) assess how
the client’s sexual problem is affected by interlocking systems
of oppression; (3) integrate the client’s personal narratives and
resilience factors in sex therapy; (4) work collaboratively with
the client identify strategies of resistance to oppression that are
healing, restorative, and that work to enhance a sense of agen-
cy and empowerment against the factors that limit the pleasure
potential of their sex; and (5) understand that Western notions
of agency and empowerment may endanger QPOC who nav-
igate hostile cultural or political climates.
The intersectionality framework also aligns with “third-
wave” cognitive and behavioral therapies that may be partic-
ularly applicable to sex therapy given their sensitivity to con-
structs of acceptance, awareness, and cognitive flexibility.
Central among third-wave approaches is Acceptance and
Commitment Therapy (ACT) which integrates the under-
standing, observation, and acceptance of thoughts and feelings
in response to a client’s pattern of experiential avoidance [43].
From the combined perspectives of the intersectionality
framework and ACT, sexual problems can manifest through
contact with hostile and invalidating external factors (e.g.,
victimization and objectification) as well as cognitive fusion
whereby thoughts (e.g., an expectation of oppression) become
functionally equivalent to experienced oppressive events [44].
Curr Sex Health Rep (2020) 12:195–201
For a QPOC who is chronically exposed to oppressive sys-
tems, the thought, “I will always be rejected by potential part-
ners either because of my Blackness, my sexuality, or my
gender expression” is evaluated not just as a thought but rather
as functionally equivalent to an actual oppressive event. The
deleterious impact of this process can be reinforced when
QPOC experience invalidation or minimization of their con-
cerns when seeking care at predominantly white-serving
LGBTQ community centers [9]. Systemic oppression and
cognitive fusion, as they relate to sexual problems, are harmful
because they foster the avoidance of distressing thoughts and
reinforce the avoidance of potentially restorative experiences
[45]. The intersectionality framework and ACT approach can
help address sexual concerns among QPOC by increasing
their awareness of patterns of cognitive fusion and facilitating
the development of flexible psychological and behavioral cop-
ing strategies [46] that reduce sexual problems and promote
sexual resilience in the face of subtle and overt oppression.
Further, sex therapists can promote the practice of committed
action (i.e., resistance) toward identified values (e.g., connec-
tion, sexual pleasure, and agency) or resilience factors (e.g.,
identity pride and community connection) to mitigate sexual
concerns that manifest as a result of experienced oppression,
cognitive fusion, or experiential avoidance.
Collaborating with Queer People of Color
In order to dismantle forces that undermine sexual health and
freedom, sexuality educators, researchers, and therapists must
communicate directly with communities that struggle against
oppression. The process of developing collaborative relation-
ships with oppressed communities falls in line with the foun-
dational tenets of the intersectionality framework and is dis-
tinct from the field’s traditional focus on research and clinical
practice. Patient and Family Advisory Councils (PFACs) pro-
vide a useful approach to collaboration as it involves equal
partnerships between clinicians and the people they serve
[47]. The purpose of PFAC meetings is to convene in the spirit
of building social and clinical practice change. Community
members serve as equal partners and contribute to the devel-
opment and implementation of quality improvement initia-
tives aimed at meaningfully improving the acceptability and
efficacy of their care. As one example, Mayo Clinic’s
Transgender and Intersex Specialty Care Clinic developed a
PFAC for the purpose of developing meaningful partnerships
with gender-diverse clients, their families, and chosen fami-
lies. Given that most gender clinics are founded and main-
tained by cisgender providers, the PFAC was vital for
restructuring and advancing the clinic in a manner that centers
intersectional perspectives. To that end, intra-group differ-
ences of race, ethnicity, sexual orientation, and dis/ability
were represented in group membership and celebrated as
Curr Sex Health Rep (2020) 12:195–201
imperative for change-making. Quality improvement themes
derived from the PFAC’s initial meetings include (1) deliver-
ing inclusivity trainings for providers throughout the medical
system and educators in the community, (2) revising clinic
materials to include a comprehensive list of available services
(e.g., gender affirmative sex therapy), (3) developing patient
education materials on sexual pleasure and wellness, and (4)
updating patient instructions for perioperative care. This en-
gagement approach may be of interest to clinical or research
groups who seek to improve their work in a manner that is
responsive to the multifaceted communities they serve.
Applied to the advancement of sex therapy for QPOC,
PFACs provide an opportunity for clinicians to learn directly
from community members who manage multiple forms of
oppression and their associated consequences.
We acknowledge that PFACs may not be the best or most
feasible approach to implement in all professional settings, but
the approach can serve as a model from which to collaborate
more frequently with QPOC. Many research and practice agen-
cies engage with community members in ways that depart from
the PFAC approach through focus groups, advisory boards, or
discussion forums [48]. Each of these processes has the poten-
tial to empower oppressed communities and bring to the fore-
front perspectives that advance scientific knowledge and im-
prove service delivery. Within the University of Minnesota’s
Program in Human Sexuality, Spencer et al. used community-
engaged methods to develop a pleasure-based and sex-positive
sex therapy group for transfeminine spectrum adults [28••]. The
curriculum for the therapy group was based on information
gathered from a series of community focus groups with
White, Latina, and African American transfeminine spectrum
clients who identified that health care providers are not typical-
ly educated or competent to address their sexual concerns.
Additional themes derived from the focus groups and incorpo-
rated into the curriculum for the therapy group include dating,
sexual exploration, transmisogyny, and the impact of medical
interventions. By collaborating directly with QPOC, sex thera-
pists begin the process of developing individual and group
treatments that minimize the impact of oppressive systems
and uplift resilience factors that protect QPOC from the nega-
tive effects of oppression.
These examples serve as start-points for the development of
collaborative relationships with QPOC. By collaborating direct-
ly with QPOC, we make their experiences and concerns more
prominent in sexuality education, research, and therapy. PFACs
and other community-engaged methods provide a platform for
sexual health advocates to learn about the specific risk and re-
silience factors that characterize QPOC and in turn are better
suited to tailor established sexual wellness interventions to their
needs. Further, to promote a long-term environment that priori-
tizes collaboration, community-engagement methods should be
highlighted and better represented by organizations committed
to the advancement of sexual and civil rights of all people.
199
Conclusion
Many fields have expressed interest in the intersectionality
framework given its focus on understanding interlocking sys-
tems of oppression and its commitment to advancing social
justice and equity [20•]. To date, the intersectionality frame-
work has yet to be incorporated into the field of sex therapy,
leaving clinicians with little information on the deleterious
impact of oppression on the sexual wellness of oppressed
communities. It is in the sexual health field’s best interest to
comprehensively adopt intersectionality to advance the field
toward a culture that critiques and dismantles social structures
that limit the possibility of pleasurable sex among oppressed
communities.
Individual sex therapists can contribute to the inclusion of
the intersectionality framework in therapy by critiquing harm-
ful social structures, attending to both sexual dysfunction and
sexual pleasure, attending to both oppression and resilience,
and actively collaborating with the communities they serve.
There are numerous examples of individual sex therapists,
sexual health researchers, organizations, and community ad-
vocates that can guide our efforts to meet the needs of QPOC
struggling with sexual concerns. Their insights, combined
with the foundational tenets of the intersectionality frame-
work, have much to contribute to existing initiatives that ad-
vance sexual wellness, justice, and equity. As the field of sex
therapy integrates the intersectionality framework, sexual
wellness advocates will be better equipped to minimize the
sexual problems that manifest from complex and cumulative
exposure to oppressive systems. Further, sex therapists will
gather the knowledge necessary to more confidently stimulate
structural-level changes that promote sexual wellness within
and across oppressed groups.
Compliance with Ethical Standards
Conflict of Interest The authors declare that they have no conflicts of
interest.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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