Knowledge about sexual orientation among student counselors : A survey in Japan

Department of Psychology, Faculty of Human Science, Hiroshima Bunkyo Women’s University. 1-2-1 Kabe-higashi, Asakita-ku, Hiroshima-shi, Hiroshima 731-0295, Japan. Health Service Center, Hiroshima University. 1-7-1 Kagamiyama Higashi-hiroshima, Hiroshima 739-8514, Japan. Hiroshima University Hospital. 1-2-3, Kasumi, Minami-ku, Hiroshima-shi, Hiroshima 734-8551, Japan. School of Nursing, Takarazuka University. 1-13-16, Shibata, Kita-ku, Osaka-shi, Osaka 530-0012, Japan.


INTRODUCTION
A person's sexuality comprises the following three components: biological sex, gender identity and sexual orientation.Gender identity refers to the awareness of one's own gender, whether a person considers themselves male or female; sexual orientation indicates which gender is the object of a person's romantic feelings or sexual desires.Sexual minority is a generic term for people whose sexual orientation, identity or practices differ from that of the majority of the society.
For instance, the minorities in terms of gender identity are people whose gender identities are inconsistent with their biological sex are called transgender (including gender identity disorder), and the minorities in terms of sexual orientation are homosexuals and bisexuals.
Mental health problems have been reported among sexual minorities, such as depression, anxiety, drug and alcohol use, and high rates of suicide attempts (Cochran et al., 2003;Stall et al., 2003;Wichstrom andHegna, 2003, Hidaka et al., 2006).These problems have been linked to the psychological stress of social stigmatization (Meyer, 1995;Ghindia and Kola 1996;Mays and Cochran, 2001;King et al., 2008;Halkitis, 2012) in Japan and elsewhere.
Homosexuals in Japanese society, which generally assumes everyone to be heterosexual, experience conditions of chronic stress and often have conflicting feelings about their own sexual orientation as a consequence of discrimination and prejudice within society.In a study of more than 1,000 Japanese homosexual men, bisexual men, and men questioning their sexual orientation, 71% had a high level of anxiety, and 13% had a high level of depression.Moreover, 83% experienced bullying in school, and 15% had attempted suicide.Another study of a large sample of Japanese urban youth showed that non-heterosexual men were six times more likely to have attempted suicide than heterosexual men (Hidaka et al., 2008).These results indicate that one of the risk factors for suicide among young Japanese men is being homosexual or bisexual.A study on adolescent milestone events for Japanese gay men reported that the average age of first thoughts about suicide was 16.4 years, the average age of clearly identifying as gay was 17.0 years, and the average age of the first suicide attempt due to sexual orientation was 20.2 years.
In Japanese society, which is dominated by heterosexuality and negative attitudes toward homosexuality, the difficulties that homosexual and bisexual men experience in their early development can lead to a decline in self-esteem.Difficulties such as bullying by others and suicide attempts affect self-esteem and may contribute to increased risks for both suicide and human immunodeficiency virus (HIV) contraction (Hidaka and Operario, 2009).No similar study on lesbians in Japan has been conducted to date.Mental health conditions, suicide ideation, suicide attempts, and HIV infection among 10 to 20 year-old lesbian, gay, or bisexual (LGB) individuals are receiving much attention in other countries, as well as Japan (Russell and Joyner, 2001;Bontempo and D'Augelli, 2002;Berlan et al., 2010).Since sexuality is a major issue between puberty and adolescence, difficulties coping with stigmas against homosexuality might increase during this period (Rotheram-Borus and Fernandez, 1995).It is, therefore, important to enhance psychological support systems that address adolescent sexuality.However, only a few opportunities exist for discussing LGB clinical psychology in Japan.Although treatment guidelines for gender identity disorder were created by the Japanese society of psychiatry and neurology, only a few professional psychologists have initiated organized discussions on LGB psychology.Moreover, the understanding of sexual orientation may vary among specialists (Sasaki et al., 2012).
In a study that reported on Japanese counselors' clinical biases toward homosexual clients, it was found that counselors showed more negative reactions to homosexual clients than to heterosexual clients, due to factors related to homophobia (Shinagawa, 2006).Although counselors generally intend to treat homosexual clients without bias, they may have an underlying evasive attitude toward such clients (Shinagawa and Kodama, 2005).There is a distinct need for education and training of Japanese clinical psychologists to improve their ability to provide psychological support for LGB clients (Kasai and Okahashi, 2011).However, no study has been conducted to assess the extent to which Japanese clinical psychologists receive sexuality education during their professional training, and what specific knowledge they acquire.
One organization offering counseling to Japanese youth provides on-campus services for university students.According to the Japan student services organization (2011), 87.9% of Japanese universities, including national, prefectural, municipal and private universities, have more than one student counselor with professional c//redentials.Such professionals, trained as clinical psychologists or medical doctors, play a support role aimed at helping students with both school-related problems and various mental health and interpersonal relationship issues.
The present study targeted clinical psychologists engaged in student counseling in Japan and investigated their level of clinical knowledge about sexual orientation.We also assessed the relationship between sexuality education and self-learning experiences and knowledge.We hypothesized that counselors who received no/little education regarding homosexual topics would have limited knowledge.Basic data from this study may clarify issues pertaining to sexuality education and training of clinical psychologists.

Participants and procedures
This study conducted between October and November, 2012, as a part of the acquired immune deficiency syndrome (AIDS) research projects sponsored by the ministry of health, Labour and welfare in Japan.The study targeted certified clinical psychologists or "university counselors" who were certified by the Japanese association of student counseling, who were engaged in student counseling at four-year universities in the Chu-Shikoku and Kinki areas.Each campus within the target area on the university list available from the website of the ministry of education, culture, sports, science and Technology of Japan was either called or emailed.The presence and number of student counselors who would be eligible to participate was then assessed.Among the universities that confirmed the presence of counselors, questionnaires were sent to all student counseling institutions that agreed to receive them.Anonymously self-administered questionnaires in Japanese were sent to institutions and each study participant returned the questionnaire individually by mail.Participants received stationery as an incentive.Informed consent was requested from all participants on the first page of the questionnaire.The study protocol was approved by the ethics board of Hiroshima Bunkyo women's university.

Measures
Knowledge about sexuality: Thirteen items for the questionnaire were originally created, with response options including: "I think so," "I don't think so," or "I don't know."The questionnaire included the following four categories: 1) "Basic knowledge about homosexuality," which contained three items, such as "homosexuality is a mental illness," "Many homosexual (gay) men use feminine language and gestures," and "Many homosexual (lesbian) women use masculine language and gestures;" 2) "Knowledge about sexual orientation," which contained four items, such as "one can decide whether to be homosexual or heterosexual," "Homosexuality can be changed to heterosexuality by treatment and effort.,""I don't know the difference between gender identity disorder and homosexuality," and "Sexual orientation is a term used to describe homosexuality, heterosexuality, and bisexuality;" 3) "Clinical knowledge about homosexuality," which contained four items, such as "One of the main factors involved in becoming homosexual is confusion of gender identity (identifying oneself as a man or woman)," "One of the main factors behind homosexuality is parent-child relationships in childhood," "it is appropriate to psychologically intervene to change homosexuality to heterosexuality for a client wanting to treat homosexuality," and "Current society is likely to worsen the mental health of homosexuals;" and 4) "clinical knowledge about gender identity disorder," which contained two items, such as "One of the main factors behind gender identity disorder is parent-child relationships in childhood," "it is appropriate to support a client who is diagnosed with gender identity disorder to be able to live as the gender s/he wants."These categories and items were created based on the findings of a pilot study targeting Japanese counselors.Clinically appropriate answers (correct answers) for each item were decided according to the report of the American psychological association (APA, 2009) .

Education on homosexuality and self-learning experiences:
Participants were instructed to choose an answer from response alternatives (multiple answers possible) about whether they received education on homosexuality in undergraduate or graduate clinical psychologist training programs.They were also asked about self-learning experiences, outside of undergraduate and graduate education, regarding the clinical psychology of homosexuality.If they reported self-learning experiences, they were asked to select what self-learning source they used from a list of multiple alternatives.If they did not have such experiences, they were asked for explanations, which they could select from response alternatives.

Experiences of having sexual minority clients:
Participants were asked about the number of student clients they had counseled who were homosexual men, bisexual men, homosexual women, bisexual women, transgender people and others.Screening item: Participants were asked whether they were certified clinical psychologists or "university counselors" who were certified by the Japanese association of student counseling.If the res-pondents did not have either of certificates, they were excluded from participants.Demographics: Participants were asked about their gender, age, years of clinical experience and working conditions.In addition, they were asked whether they had received clinical psychology training overseas, and whether they had close homosexual, bisexual, or transgender friends.
Table 2 summarizes the results of the 13 questionnaire items regarding knowledge about sexuality.The percenttage of correct answers for the category "basic knowledge about homosexuality" (items 1-3) was about 80%.However, the percentage of correct answers for the category "knowledge about sexual orientation" was much lower.Among all study participants, 39.7% knew the meaning of the term "sexual orientation" (item 7), only about half correctly responded to the prompt "one can decide whether to be homosexual or heterosexual" (item 4), and 76.6% correctly responded to the prompt "it is appropriate to support a client who is diagnosed with gender identity disorder to be able to live as the gender s/he wants" (item 11), which was an item in the category "clinical knowledge about gender identity disorder." Conversely, only 22.3% correctly responded to the prompt "it is appropriate to psychologically intervene to change homosexuality to heterosexuality for a client wanting to treat homosexuality" (item 12), which was an item in the category "clinical knowledge about homosexuality."Moreover, there were a number of a In Japan, a Bachelor's degree is a prerequisite for becoming a certified clinical psychologist or "university counselor." participants who did not realize that they had confused issues of sexual orientation and gender identity.Of the participants, 78.8% responded "I don't think so" to the prompt "I don't know the difference between gender identity disorder and homosexuality" (item 6), and 37.8% correctly responded to the prompt "one of the factors involved in becoming homosexual is confusion about gender identity (identifying oneself as man or woman)" (item 9).A χ 2 test on each of the 13 items revealed differences in the response rate for all items except item 9 (Table 2).Forty-four (13.7%) participants reported having received education on homosexuality in undergraduate training.Of all participants, 277 had attended graduate school and 41 (14.8%) of those reported receiving education on homosexuality during their graduate clinical psychology training.The percentage of those who received education on homosexuality was low in both undergraduate and graduate schools.Table 3 shows the topics learned by participants who had received education on homosexuality.In both undergraduate and graduate schools, less than 30% of participants had received education on "counseling skills," and some responded that they "can't remember" what they learned (27.3% undergraduate and 17.1% graduate programs).
When asked about self-learning outside of undergraduate and graduate education (Table 4), 216 (67.3%) reported having learned on their own.The majority of participants (122; 56.5%) reported having "read books on homosexuality," while 101 (46.8%) reported having "browsed websites about homosexuality."Participants who did not have self-learning experiences about the clinical psychology of homosexuality were asked for an explanation.The majority (67.6%) answered that they had "never been aware of homosexuality." As professional training for counselors in Japan is usually covered in graduate schools, this study focused on homosexuality education received during graduate school and via self-learning and assessed their associations with knowledge on sexuality.Table 5 is a cross tabulation for the percentage of correct answers to questions on sexuality and homosexuality education received during graduate school and via self-learning.A two-way (graduate education × self-learning) analysis of variance using the arcsine transformation method was applied to correct the answer rate on each cell.The effect of homosexuality education during graduate school was significant for only one item ("8.One of the main factors behind gender identity disorder is parent-child relationships in childhood."),indicating that the percentage of correct answers was significantly higher among participants who received homosexuality education in graduate schools (p < .05).The effect of homosexuality education via self-learning was also significant for only one item ("7.Sexual orientation is a term used to describe homosexuality, heterosexuality, and bisexuality."),indicating that the percentage of correct answers was significantly higher among self-learning participants (p < .01).The interaction effect was not significant for all items.
Other factors may be associated with knowledge on sexuality such as having close friends or acquaintances belonging to a sexual minority, having clients belonging to a sexual minority, education received during undergraduate school, and years of clinical experience.Therefore, we assessed the associations of these factors with the participants' actual level of knowledge of sexuality.We first calculated a total score using 13 items, with correct answers receiving one point and incorrect answers receiving zero points (M=7.74,SD=2.54).With this score as the base variable, we conducted a multiple linear regression analysis (forced entry) with the following six factors as explanatory variables: undergraduate education on sexuality, graduate education on sexuality, self-learning on sexuality, experiences with homosexual/ bisexual clients, having homosexual/bisexual friends and acquaintances, and years of professional experience as a counselor.
Except years of professional experience, each explanatory variable was entered as a dummy variable with "yes" as one and "no" as zero.Years of professional experience was entered as a dummy variable with the group with low number of years of experience as zero and that with high number of years of experience as one.The low group consisted of participants with less than 14 years of professional experience and the high group consisted of participants with 14 or more years of professional experience, based on the average value of 13.8 years.Only experiences through self-learning had a significant positive standard partial regression coefficient with the knowledge score (Table 6).

DISCUSSION
In this study, associations were found between knowledge about sexuality among Japanese student counselors and past education received.Although about 80% of the participants answered correctly for the category "basic knowledge about homosexuality," their clinical knowledge and understanding of gender identity and differences in sexual orientation were limited.
We found that Japanese clinical psychologists rarely received formal education on homosexuality during the course of their professional training.It appeared instead that most clinical psychologists relied on self-learning.Prior studies in Western countries have indicated  inadequate levels of sexuality education (Eliason and Huges, 2004;Malley et al.2004;Javaherian et al., 2008), and the results in Japan were similar.This study demonstrated that neither graduate school learning experiences nor self-learning were helpful in improving the level of knowledge of sexuality.
Such experiences did not necessarily translate into appropriate clinical practice.For instance, if a counselor believes that "one of the main factors involved in becoming homosexual is confusion of gender identity," s/he might inappropriately bring up issues of gender identity or gender role when counseling a homosexual.Such actions may lead to a failure to develop rapport with the counselee, or hinder the counselee from understanding her/his sexual identity.It is imperative that a strategy be developed to include sexuality education in the training of Japanese clinical psychologists.Such a strategy must necessarily include opportunities for those already working as clinical psychologists to receive educational training, as well as the development of educational tools.Since the most common response for having never initiated self-learning was "I have never been aware of homosexuality," campaigns to increase the awareness of and efforts to highlight the challenges faced by homosexuals are also needed.
One strength of this study was its high response rate, with 66% of questionnaire recipients responding by mail.Had the collection rate been low, there would have been suspicion of result bias, as only counselors who were interested in this theme would have participated (Alderson et. al, 2009).Limitations of this study include the targeting of only two geographical areas and that only a limited number of student counselors were trained as clinical psychologists.In order to provide psychological support to homosexuals, a positive attitude toward diverse sexuality is important, along with training in actual skills for dealing with distress arising from sexuality issues.Further research on these themes is warranted.

CONCLUSION
Our findings clarified the level of Japanese student counselors' clinical knowledge and the issues pertaining to sexuality education and training of clinical psychologists.It is important to standardize counselor education regarding homosexuality and raise the awareness of counselors, in order to provide appropriate support to LGB students, and to thereby, help reduce the frequency of suicide attempts, depression, etc. in this population.

Table 1 .
Demographic characteristics of participants

Table 3 .
Education on homosexuality

Table 4 .
Self-learning experiences about homosexuality

Table 5 .
Associations between percentage of correct answers on sexuality knowledge questions and graduate education or self-learning about homosexuality a Using the arcsine transformation method, NS Not significant, ** p<.01, * p<.05.