Running head: MUSIC THERAPISTS ATTITUDES TOWARDS DISABILITY AND
Exploring music therapists’ attitudes towards disability and sexuality

Francesca Miller

A Thesis Submitted to
Slippery Rock University, Pennsylvania
in Partial Fulfillment of the Requirements for
the Degree of Master of Music Therapy

September 2024

Thesis Committee:
Dr. Susan Hadley, Ph.D., MT-BC (Advisor)
Cindy Lacom, Ph.D., Director of Gender and Diversity Studies
Vern Miller, Ph.D.(c), MT-BC

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MUSIC THERAPISTS’ ATTITUDES TOWARDS DISABILITY AND SEXUALITY

Exploring music therapists’ attitudes towards disability and sexuality

Presented to the
Slippery Rock University
Music Therapy Program

_________________________________________________________________
Susan Hadley, Ph.D., MT-BC, Thesis Advisor

_________________________________________________________________
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_________________________________________________________________
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Abstract
Music therapy has historically not addressed sex as a topic within clinical practice despite
its clinical relevance to the human experience. As a field that works with an abundance of
disabled clients who are often harmed by social and systemic infantilization which prevents them
from access to sexual knowledge, it could be argued that music therapists should be trained to
provide basic levels of support to this community in particular given the high level of need.
Nevertheless, there are many questions and conflicting ideas around music therapy scope of
practice as it pertains to these topics, barriers to education and clinical implementation and viable
solutions to this gap in knowledge as a profession. While the music therapy literature has seen an
increase in disability justice research in recent years, it offers little to nothing on the topic of
engaging in clinically relevant discussion of sex, and most certainly not within the context of
disability. This study aimed to examine music therapists’ educational and clinical experiences on
engaging in sexual topics with disabled clients, as well as measuring personal feelings of comfort
in engaging in these conversations. It was conducted via an anonymous survey intended to
collect quantitative and qualitative data from a wide array of music therapists. Data was collected
and analyzed according to an objectivist framework and qualitative data in particular was
analyzed for common themes. Results indicate a lack of training and education in the facilitation
of such topics, and the majority of participants reported complex feelings on the various
intersecting layers of these conversations. While many reported feeling discomfort in relation to
this topic, so too did many indicate a desire to reflect more critically and intentionally on the
subject. It is hoped that this study’s data will serve as an impetus for our field to shift cultural and
education practices to better prepare therapists for these conversations on these topics.

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Acknowledgements
Thank you to my professor Susan Hadley for changing my life. It’s hard to list all the
lessons I’ve learned from you, but one of the most important is the ability to see myself in the
larger context of the world. You’ve taught me that I can be compassionate with myself and still
hold myself accountable for my own baggage and its impact. You taught me the importance of
community and how to be responsible within them. You modeled for me how to fight for justice
in professional settings, which is something I aspire to do every day. I hope to show my
appreciation to you by helping pass along these lessons to as many people as I can. Thank you
for your patience, grace, and accountability.
Thank you to my SRU cohort. I’ve gained so many siblings in community from this
program and will be forever grateful for the intimacy and connection I’ve been able to forge with
you all. Grant, Celeste and Erin - thank you for always having my back.
Thank you to all clients I have worked with who have disabilities of all kinds. Thank you
for the privilege of allowing me to know you and for changing my life in so many beautiful
ways. I will continue to fight alongside you in challenging disabling systemic and social barriers,
and commit to keeping myself in check along the way.
Thank you to my DCC co-workers who loved and fought fiercely for our beloved patients
and helped me learn the value of working together against ableism and dehumanization. Thank
you to my current co-workers for fighting that fight alongside me now.
Thank you to all the people in my life who have loved, supported and held me down
these past few years. I love and appreciate you.

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TABLE OF CONTENTS
Abstract……………………………………………………………………………………………3
Acknowledgements………………………………………………………………………………..4
Table of Contents………………………………………………………………………………….5
List of Figures & Charts…………………………………………………………………………..7
Motivation for Research…………………………………………………………………………..8
Operational Definitions.…………………………………………………………………………...9
Literature Review………………………………………………………………………………...10
Impact of capitalism on disability……………………………………………………….10
Impact of the medical model on disability……………………………………………….11
Music therapists: Us and them………………………………………………..………….12
Therapist bias ……………………………………………………………………………13
Sexual topics and music therapy……………………………………………………...….14
Gaps in music therapy education and literature………………………………………….14
How related fields address sexual topics with disabled people………………………….15
Solutions-based thinking…………………………………………………………………16
Scope of practice…………………………………………………………………………17
Impact on disabled people……………………………………………………………….17
A lacking sexual education……………………………………………………....17
Quality of life: sociosexual skills and knowledge………………………………..19
Increased risk for sexual exploitation and violence…………..…………………20
Infantilization as a barrier……………………………………………………….21
Purpose Statement………………………………………………………………………………..22

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Methods…………………………………………………………………………………………..23
Research Design………………………………………………………………………….23
Recruitment………………………………………………………………………………24
Data Collection Instrument & Procedures……………………………………………….24
Data Analysis Procedures………………………………………………………………..24
Results……………………………………………………………………………………………25
Patient Demographics……………………………………………………………………25
Quantitative Results……………………………………………………………………...27
Qualitative Results, Themes & Subthemes………………………………………………33
Theme I: Training………………………………………………………………..34
Theme II: Clinical praxis of sexual topics with disabled & nondisabled clients...34
Theme III: Scope of practice……………………………………………………..36
Theme IV: Impact on disabled people .…………………………………………37
Theme V: Desire for further reflection .………………………………………...37
Theme VI: Need for more concise definitions………………………….………...39
Discussion………………………………………………………………………………………..40
Limitations & Design Considerations……………………………………………………43
Future Research………………………………………………………………………….45
Conclusion……………………………………………………………………………….46
References………………………………………………………………………………..………47

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LIST OF FIGURES, TABLES AND APPENDICES
Figure 1: Attitudes On Sexual Rights For Disabled People……………………………………..29
Table 1: Themes and Subthemes……………………………………………………..…………..34
Figure 2: Attitudes On The Therapist’ Responsibility To Initiate Sociocultural Conversations...29
Figure 3: Attitudes On Waiting For Clients To Initiate Sexual Topics…………………………..30
Figure 4: Attitudes On Discussing Sexual Topics In Non-Clinician Scenarios………………….31
Figure 5: Attitudes On Discussing Romantic Vs. Sexual Themes…………………..……………31
Figure 6: Attitudes On The Therapeutic Value Of Using Music With Sexual Themes ..…………32
Figure 7: Attitudes On The Therapeutic Value Of Using Music With Sexual Themes…..………33
Figure 8: Attitudes On Advocating For Clients Whose Caregivers Find Sexual Topics
Inappropriate……………..……………………..……………………..…………………...……33
Appendix A: Recruitment emails……………..……………………..……………………….…..53
Appendix B: Invitations to Participate……………..…………………..………………...………57
Appendix C Research Participant Informational Letter……………..…………………………...60

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Motivation for Research
In my earlier years as a music therapist, I began learning from Black, queer and disabled
advocates on social media which changed my perception of the world in many ways. Some of
these realizations were validating for me while others illuminated aspects of my own privilege I
had never before considered. This led me to join the Slippery Rock University Master of Music
Therapy program, a program which focuses on social justice, critical thinking about systems, and
the importance of community building. This, in tandem with my work with disabled adults in
particular, encouraged me to start reflecting on the deep-rootedness of ableism and the concept of
disability as a cultural taboo. It also encouraged me to reflect on where it was coming up in the
places I worked, as well as in my own views and biases.
This opening of my worldview allowed me to further reflect on my perception of sex as a
taboo subject in my experience as both a therapist and a patient in therapy. This is particularly so
with relationships which are queer in some way. In defining queer not solely as a sexual
orientation but as a way of being in the world that exists outside cultural definitions of
acceptability, one could argue that disabled sexuality is inherently queer. As a queer and disabled
woman experiencing her own journey toward sexual liberation, seeing my adult-aged, disabled
clients act out in “sexually inappropriate” ways made me reflect on the incredibly limited access
disabled adults have to sexual knowledge, particularly those who are institutionalized and/or
under guardianship. I noticed that this lack of appropriate sociosexual education geared toward
disabled people often leads to disabled adults not understanding sociosexual boundaries or
practices, which usually leads to them being referred to as “creepy” or “weird.” While people are
entitled to express their authentic response to being interacted with in a way which makes them
sexually uncomfortable, it seems misguided to blame people who are not given access to
sociosexual education for not understanding sociosexual conventions.

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Toward the end of my time in the MMT program, we were shown a documentary film
called “Crip Camp: A Disability Revolution” which I found to be life changing. This film
documented a group of campers at Camp Jened, a sleepaway camp for disabled teens in the early
1970s. Many of these campers ended up becoming historic figures in the Disability Civil Rights
Movement. This documentary not only showed me the power of advocacy and organized
movements, but also the power of growing roots in communities which fight to support each
other in a world that seeks to disable them. It made me reflect on the ridiculousness of seeing
disabled people openly and freely discussing their sexuality as groundbreaking, the same way
any friends at summer camp would. And yet it was, because that’s how little I’d ever heard it
discussed clinically, socially, in pretty much any context. It made me reflect on the
dehumanization disabled people experience in terms of sex but also in so many other aspects of
our lives. It made me want to work to help change that.
Operational Definitions.
For the purpose of this study, I will provide several operational definitions to help the
reader better understand my intentions for this research. Though disability is an expansive and
widely encompassing term which applies to many different communities, I will use the term
disability here to describe those specifically with intellectual, developmental and/or neurological
disorders. For this research, my operational definition of sexual topics—which can include a
wide variety of topics—includes discussion of sexual health, logistical and sociosexual
education, sexual or romantic attraction, sexual or romantic experience, masturbation, sexual
safety and consent.
To operationally define ableism, I draw on the work of Rauscher and McClintock (1997),
who describe ableism as “a pervasive system of discrimination and exclusion that oppresses
people who have mental, emotional, and physical disabilities…Deeply rooted beliefs about

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health, productivity, beauty and the value of human life, perpetuated by the public and private
media, combine to create an environment that that is often hostile” (p. 198).
Literature Review
Impact of Capitalism on disability
Though ableism has existed in many forms throughout human history, disability was not
defined as a social category in the U.S. until the late 19th century. This is likely due to the timing
of the Industrial Revolution and the subsequent push towards a more modern capitalist social
framework, one which we still live under today. The impact of capitalism on ableism and the
ways in which the medical model of disability reinforces capitalist values continue to harm
disabled people to this day (Jenkins, 2021). In the U.S., Jenkins argues that the dominance of
white, colonial values play a considerable role in the dehumanizing aspects of capitalism on
disabled people.
Capitalist ideals which value members of society based on their ability to work and
contribute to the workforce breed hierarchical systems of thinking to those existing within them.
Turner and Blackie (2018) posit that the emergence of capitalism in18th and 19th century
England led to the systematic marginalization of disabled people in the region. As a result,
disabled people were viewed as “economically unproductive ‘burdens’, whose inability to
conform to more stringent productivity demands, work or time discipline meant that they could
no longer compete in the workplace” (p. 200). This system, in conjunction with other systems
that further promote these ways of thinking, led to the creation of cultural hegemonies that work
to harm different groups of people, particularly those who have multiple marginalized identities.
To this point, Pimentel and Monteleone (2018) emphasize the importance of considering

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intersectional theory, which examines the ways these hegemonies operate and impact people who
have intersecting identity marginalizations such as race, disability, gender, etc.
Changulani (2023) speaks of the influence of hyper-individualism, a guiding principle of
capitalism. Hyper-individualism, structurally, emphasizes maximizing profit and gain as a means
to attain value and contentedness. As Finlay (2000) noted about those who work with disabled
people, “professionals are seen to act on behalf of the capitalist state by individualising social
problems, and suggesting that individuals are essentially responsible for the plight in which they
find themselves (which) shifts attention away from the structural inequalities” (p.83, as cited in
Baines et al., 2019).
Within this hyper-individualistic culture, independence and self-preservation are often
viewed as the only acceptable goals. In refusing to change the cultural script on living in ways
that promote healthy interdependence, community support, and networks of care, we perpetuate
the juggernaut of ableism in ways that will ultimately both impact disabled and nondisabled
people alike (Changulani, 2023).
Impact of the medical model on disability
While capitalism may be one of the systems that contributed to widespread ableism as a
cultural concept, the model under which healthcare professionals and the institutions that
commonly train them function to reinforce these harmful concepts (Lundberg & Chen, 2024;
Zaks, 2023). The U.S. healthcare system, though it has made strides over the years, still operates
largely under the medical model, particularly as it pertains to disability. According to the Office
of Developmental Primary Care at University of California San Francisco, “the Medical Model
views disability as a defect within the individual. Disability is an aberration compared to normal
traits and characteristics. In order to have a high quality of life, these defects must be cured,

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fixed, or completely eliminated. Health care and social service professionals have the sole power
to correct or modify these conditions” (“Medical and Social Models of Disability”, n.d., para. 2).
Disability is still widely seen by those working in healthcare as a personal problem to be
fixed rather than the result of a society which disables people who have impairments. Placing
sole responsibility on the impairment itself allows the systems doing the impairing to keep
functioning without accountability. While impairments of any kind certainly add to the
experience of disability, it is unproductive to look solely at this dimension of the disabled
experience. Eisenberg et al. (2015) suggested that instead of viewing impairment as a sole cause,
it should be examined for the ways it interacts with the limitations of social and physical
environments.
Music therapists: Us and them
The impact that these systemic influences have on the praxis of music therapy clinicians
working with disabled people is vast. As suggested by Fansler et al. (2019), the perpetuation of
certain hegemonic ideals reinforce the concept of borders between ourselves as practitioners and
our clients. In the case of disability, ableism and infantilization, assuming incompetence and
social emphasis on individualism and ability to contribute to the workforce could all be
considered such ideals (Campbell, 2014; Turner & Blackie, 2018). The American Music Therapy
Association Workforce Analysis data (2021) indicates a significant overrepresentation of music
therapists with dominant identities (88.3% white) and gender (96.6% cisgender, 86.4% women).
The lack of data cited in the study regarding disability among other salient identity markers of
clinicians such as sexuality and class indicate that disability is an identity associated with only
the client and not with the clinician, reinforcing an “us” vs. “them” mentality. Furthermore,
identity markers such as class and sexuality not being included in the data for clients nor

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clinicians suggests an assumption that these identity markers are not relevant in therapy and do
not impact the therapeutic process.
Therapist bias
Fansler et al. (2019) also reflected on the impact that the perpetuation of binary thinking
has on our perception of what is considered “normal” and “acceptable,” and how that ultimately
impacts marginalized communities. They referenced Britzman (1995) in their description of this
dichotomized way of understanding the world: “Britzman (1995) noted that the production of
binaries and our orientation to normalcy establishes the limits of what we can bear to know,
without which our certainty is uprooted.” In applying this thinking to music therapists’ bias
toward disabled people, even the best-intentioned therapists can and often do perpetuate harmful
practices towards disabled people, sometimes due to bias and sometimes as a function of their
job. Considering the influence of societal ableism in combination with the prevalence of the
deficit-based medical model, therapists are likely to perpetuate these ideals without actively
deconstructing such views (Eisenberg et al., 2019).
When considering therapist bias, it is also important to consider practitioner’s own
sociocultural relationship to disability (Hadley, 2013). Though the U.S. certainly perpetuates its
own set of cultural values, the vast array of cultural diversity that exists in this country also
contributes significantly to different people’s perceptions of these topics. Much like sex as a
topic, disability is often considered its own kind of taboo across many cultures (Cousins, 2009).
In considering these sociocultural factors in tandem with systemic attitudes and barriers between
disabled and nondisabled people, the potential for harm to disabled clients is self-evident.
Sexual topics and music therapy

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Within the music therapy literature, the practice of working with sexual topics comes up
in several contexts. The most commonly studied area seems to be utilizing music therapy in
working with sexual abuse survivors. Several studies have been conducted highlighting the
benefits of music therapy in working with this community, ranging from the power of
improvisation through processes such as Analytic Music Therapy (Strehlow, 2009) to supporting
clients in finding their voice again (Amir, 2004).
Furthermore, there has been recent work implementing Crip and Queer theories together
in the music therapy literature. Crip theory is an academic field named after the reclamation by
disabled people of the word “cripple” (McCruer, 2006). Kalenderidis’ (2020) discussion of Crip
theory was the one of the only sources found in the literature that spoke about disabled people
and sexual desirability:
Crip theory represents all disabled people, eliminating disability hierarchies…To identify
as “Crip” is to celebrate disability pride, which disrupts internalised ableism and societal
narratives that our lives are unlivable, and our bodies/minds are undesirable. It celebrates
difference and positions disability as part of the human condition (Clare, 2017).
(Kalenderidis, 2020)
Gaps in music therapy education and literature
While there has been an increased push for expansive, non-hierarchical ways of thinking
in music therapy (Bain et al., 2016; Baines, 2013; Baines et al., 2019; Boggan et al., 2017;
Fansler et al., 2019; Hadley, 2013), there is currently nothing within the music therapy literature
that specifically examines music therapists’ role in supporting disabled sexuality. One can only
hope that our role in supporting disabled sexual experiences is an area that will be examined
more often in the future. Similarly, my search of the literature found nothing in regard to

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education and training for music therapists’ around exploring sexual topics with their clients.
Though some research indicates an extremely limited number of academic music therapy
programs or trainings which cover the topic of sexuality, there is currently no professional
standard or competency for this to be included in the music therapy curriculum. Fansler et al.
(2019) note the role that curriculum has on a clinician’s knowledge-base and thus the clients they
work with. They stated, “Curriculum takes on a function of gatekeeping when we allow for only
one way of thinking to be acceptable and recognized. It is the soil into which we place our roots.
If our ways of researching, educating, and interacting are rooted in dominant and oppressive
ways of being, our profession limits itself in its ways of engaging with other ‘worlds’” (Fansler
et al., 2019).
How related fields address sexual topics with disabled people
In reviewing the literature of other related fields of professionals who work with disabled
people, studies from family therapy, counseling, education and hospital-based healthcare
providers show that there is more research that has been conducted in these fields than in music
therapy.
From my evaluation of the literature, I would argue that most healthcare fields
under-address the clinical discussion of sexual topics with disabled people. In the healthcare field
in general, Eisenberg et al. (2015) noted that personal discomfort around discussing sexual topics
often dooms budding professionals to a lack of competence in clinically addressing these topics.
In contextualizing this alongside the tendency of most healthcare professionals to work under the
medical model which encourages a deficit-based approach to disability, it is no wonder that
professionals in healthcare are struggling to address sexual topics with disabled clients.

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Even within the field of education, it has been noted that professionals experience
difficulties in delivering contextually-appropriate sex education to disabled individuals. Hall et
al. (2016) noted that the U.S. has a “highly diverse patchwork of sex education laws and
practices” (p. 29, as cited in McDaniels & Fleming, 2018) which often results in school districts
and educators creating sex education curricula based on personal worldviews and beliefs
regarding things like the morality of sex, beliefs on gender, orientation and disability. McDaniels
and Fleming (2018) noted that a consequence of this is that access to appropriate sex education
for disabled people (in the case of the study: intellectually disabled people) is consistently
lacking.
Solutions-based thinking
Despite the challenges faced by related healthcare fields, researchers in these fields are
innovatively brainstorming ways to combat these challenges. Harris and Hays (2008) conducted
a study measuring family therapist’s comfort and willingness to discuss sexual topics with
clients. Results indicated that most therapists’ will only engage in these discussions if their
comfort level in doing so is high and therefore must be given ample supervision and
education-based opportunities to increase knowledge and comfort in this area (Harris & Hays,
2008). Studies such as these indicate a desire within the field to examine discrepancies in care
and find effective solutions to combat them. Similarly, Burnes et al. (2017) noted the importance
for counseling psychologists to consider the intersection of disability and sexuality in their
clinical work. They stated, “addressing clients’ diverse desires and expressions is of paramount
importance when clients identify as having a disability, and psychologists should understand the
various ways that these identities should be brought into a sex-positive conceptualization of the
client” (p. 480). Likewise, Eisenberg et al. (2015) emphasized the need for all professionals

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working with disabled people to be educated on a) the social model of disability and b) the
biopsychosocial factors affecting sexual health both in general and in the context of disability.
Scope of practice
While addressing sexual topics may be within the scope of practice of other healthcare
professionals, music therapy is not a field that specializes in addressing sexual topics. However,
it is my assertion that given that sexuality is a major part of the human experience, music
therapists should at the very least be knowledgeable about how to support this aspect of our
clients’ humanity at a fundamental level. The Certification Board for Music Therapists (CBMT)
defines music therapy’s seven domains of practice as a) cognitive b) communicative c) emotional
d) musical e) physiological f) psychosocial g) sensorimotor h) spiritual (“Board Certification
Domains”, 2014). In examining these domains, it could be argued that outside of the musical
domain, no area mentioned is one that music therapists could consider themselves expert in
without additional training from a source outside the field. And yet, we educate music therapists
to have a baseline understanding of addressing needs in each of these areas, knowing that these
are needs that will likely emerge in therapy. It begs the question: why, then, are sexual topics
largely ignored in music therapy?
Impact on disabled people
A lacking sexual education
Sexuality is often conceptualized by people in isolated segments rather than a multitude
of aspects of the self, woven together into a rich, complex tapestry of being. While sexuality may
encompass things such as sexual knowledge, attitudes, and behaviors, its definition spans far
beyond these aspects alone. McDaniels and Fleming (2019) expand on the need for a more
holistic view of sexuality as a whole:

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Sexuality is greater than just participation in sexual relationships; it encompasses sexual
knowledge, beliefs, attitudes, and behaviors (Murphy & Young, 2005). It also includes
gender expression, how we feel about our bodies, how we feel about our relationships
with others, our physical and emotional growth, and how we reproduce (Alberta Health
Services, 2009). Sexual development is intertwined with fulfilling basic social needs such
as being liked and accepted, giving and receiving affection, maintaining privacy and
control over our own bodies, and feeling attractive (Murphy & Young). (McDaniels &
Fleming, 2018)
In view of this expansive definition, the need for contextually appropriate sexual education is
crucial for disabled and nondisabled people alike. For years in the U.S., sexual education has
been predominantly based on promoting abstinence and reduction of pregnancy and STDs
amongst primarily young, unmarried heterosexual couples. Though times have changed the
practices of many educators, the lack of federal standards in regards to sexual education allows
for an exorbitant amount of freedom for educators to mold the curriculum around their personal
views and beliefs (McDaniels & Fleming, 2018). With popular social norms and federal policies
still in place that echo eugenicist sentiments, the risk of exclusion for disabled people in this
regard is high (Turner & Crane, 2016). Guttmacher Institute (2016) reported that:
24 states and the District of Columbia (DC) mandate sexual health education, and
27 require that when it is provided, it meet specific requirements: 13 require
medical accuracy of information; 26 require that the information be age
appropriate; 8 require that instruction be culturally appropriate and free of racial,
ethnic, or sex bias; and two prohibit programs from. (Sex and HIV Education,
2023).

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Turner and Crane posit that to restrict disabled people’s access to their sexual identity is
to impact their well-being as a whole:
The erotic potential of a (disabled person) is often overlooked, but according to
Moin, Duvdevany and Mazor, sexual identity is very important to the ‘overall
psychological well-being and life satisfaction of all human beings’ (2009: 84).
One should keep in mind that a person’s sexuality does not develop in isolation
from other aspects of identity (Edwards and Elkins, 1988), (Turner & Crane,
2016).
Quality of life: Sociosexual skills and knowledge
Quality of life encompasses a wide variety of areas. Access to sexual knowledge is a
significant area of quality of life in that it allows for both a more intimate understanding of self
and potentially richer socialization experiences. If this knowledge is not contextually appropriate
in relation to disability, disabled people are at a major disadvantage in terms of developing
relevant sociosexual skills (Murray & Minnes, 1994). Halpern (1994) argued that the
development of sexual knowledge and sociosexual skills is crucial to one’s ability to experience
intimate relationships and make a healthy transition into the adult world (as cited in McDaniels
& Fleming, 2018). Accordingly, Betz, Hunsberger & Wright (1994) contend that learning
responsible adult sexual behaviors is a vital part of the developmental transition between
adolescence and adulthood. This ultimately frames the apparent lack of appropriate sociosexual
education for disabled people as a factor that is additionally disabling.
Similarly, Harader, Fullwood, and Hawthorne (2009) spoke about how educator’s
disability-negative assumptions and biases encroached upon disabled people’s access to equal
opportunities for appropriate sexual education. Studies have shown that intellectually disabled

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adolescents consistently have reduced sexual knowledge and reduced sexual education
opportunities as compared to their nondisabled counterparts (Cheng & Udry, 2002; Dukes &
McGuire, 2009; Konstantareas & Lunsky, 1997; McCabe, 1999; Murphy & O’Callaghan, 2004).
The result of this reduced access to knowledge and education often results in disabled people
experiencing little awareness of social taboos, misinterpretation of boundaries, or behaving in
ways that make people sociosexually uncomfortable in bids for connection (Timms & Goreczny,
2002; McDaniels & Fleming, 2018). This often leads to less success at connecting socially on an
intimate level, which further isolates disabled people who are already navigating systemic and
social ableism. In their comprehensive review of the literature, Turner and Crane (2016) cite
various studies which reference a theme of deep loneliness felt by disabled people in terms of
intimate and sensual relationships.
Increased risk for sexual exploitation and violence
According to the Disabilityjustice.org, disabled people are sexually assaulted at nearly
three times the rate of nondisabled people. In a 2005 study of disabled people, nearly 60% of
participants indicated they had experienced non-consensual sexual experiences. It is predicted
that 83% of women and 30% of men with developmental disabilities in particular will experience
sexual assault at some point in their lives (DisabilityJustice, 2023). Notably, of those who have
reported sexual assault, half of these women have reported being assaulted more than 10 times
(Disabled World News, 2012). These alarming statistics can be attributed to a variety of systemic
and interpersonal factors highlighted by Curtiss and Kammes’ (2020) examination of the risk of
sexual abuse of disabled adults via an ecological framework. Ecological Systems Theory seeks to
understand the individual within the context of the various systems that make up their
environment (Bronfenbrenner, 1979, 2005). The ways in which the exosystem, or the social

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structure within which the individual lives, impacts disabled people can be seen in examples
such as their lack of access to appropriate legal statutes regarding sexual assault which serve to
disenfranchise them, etc. The microsystem refers to the individual’s immediate settings such as
home, school and work, while the mesosystem refers to ways in which these systems interact.
Disabled people can be impacted at these levels by experiencing sexual violence from someone
within these immediate settings, and the risk for this is great considering that disabled people are
more likely to be sexually abused by those people within their microsystems (Curtiss &
Kammes, 2020). Curtiss and Kammes (2020) refer to the literature in determining a variety of
risk factors for sexual assault at the individual level, such as: “childhood victimization, drug and
alcohol use, parent’s marital abuse, depression, young age at first sexual experience, and being a
person of color (Brooks-Russell, Foshee, & Ennett, 2013; Cloutier, Martin, & Poole, 2002; East
& Hokoda, 2015; Makin-Byrd et al., 2013; Ullman & Vasquez, 2015).” As research shows,
disabled people experience risk of sexual violence at each level within this framework. This
illustrates a clear need for changing the ways we increase safety for disabled people in this
context in ways which favor education and empowerment over paternalism.
Infantilization as a barrier
A major factor that impedes disabled people’s access to sexual knowledge and education
is infantilization of disabled bodies and minds. Disabled people are often viewed socially as
inherently child-like and innocent or are, conversely, demonized. While infantilization harms
disabled people in a multitude of ways including assumptions around competence which lead to
social and vocational isolation, its impact is particularly evident in regards to their ability to
access sexual knowledge and education.

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People with intellectual disabilities are commonly targeted by desexualizing and
infantilizing stereotypes. They face what Collins (1990) calls controlling images—social
constructions aimed at normalizing and justifying forms of inequality—that, in this case,
desexualize and construct disabled people as “eternal children” and, on the other hand,
portray especially men with intellectual disabilities as potentially “dangerous.” (Santinele
Martino, 2020)
When disabled sexuality is not being discussed and disseminated through a paternalistic lens, it
often is not being discussed at all—least of all as a goal area or inherent human right. As inferred
by Turner and Crane (2016), “perhaps this is because adults with intellectual disabilities seem to
be sexual outsiders living on the fringe of normative sexual experiences” (p. 678). They also
noted the potential sabotage these infantilizing stereotypes have on access to realistic
representation of sexuality for disabled adults. Covarrubius and Fryberg (2015) expand upon the
concept of positive and realistic representation through the concept of “self-relevant role
models,” which is defined as people who share marginalized identities with the people they
clinically or professionally serve. In their work with Native American teachers working with
Native American middle school students, self-relevant role models proved to have a notable
effect on students’ positive feelings of belonging as well as their academic performance. This
supports claims in the literature that people belonging to marginalized communities benefit
considerably from positive and accurate representation in terms of both their confidence and
understanding of complex topics.
Purpose Statement
Given the gap in the music therapy literature and my assertion that sexuality is a major
part of the human experience and therefore must be a topic that we can address in music therapy,

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the purpose of this research was to explore the attitudes of music therapists as they pertain to the
domain of sexuality, and how these attitudes translate into their work with disabled adult clients.
This study aimed to examine the impact that cultural beliefs, personal feelings, education level,
and systemic ableism has on music therapy clinicians' inclination to addressing sexual topics in
therapy with disabled clients.

Methods
Research Design
This research was an anonymous survey which intended to collect data from a diversity
of music therapists. Both quantitative and qualitative data were collected and analyzed according
to an objectivist framework. Quantitative data was collected through multiple choice and Likert
scale questions, while qualitative data was collected through short written responses. All
questions (Appendix B & C) were developed under the supervision of my thesis advisor.
The survey contained a total of 25 questions, beginning with two pre-survey questions to
ensure those interested met the necessary criteria. The next five questions were multiple choice
questions and asked participants for demographic information in terms of race, age, disability,
gender and sexuality for the purpose of studying possible relationships or patterns amongst these
groups. Of the remaining questions, 20 were Likert-scale-style, ranging from “strongly disagree”
to “strongly agree” and another three were short answer. Questions 6 through 23 were written
based on six subcategories: 1) background attitudes and training 2) personal comfort level and
view of appropriateness discussing sex in general, in clinical scenarios, and specifically with
disabled clients 3) the tendency to wait or initiate these topics 4) approach in these discussions
with disabled vs. nondisabled clients 5) views on advocacy and 6) personal reflection. The
purpose of these questions was to get an overarching view of participants' attitudes, feelings,

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24

experiences and training in the context of discussing elements of culturally taboo aspects of
human experience such as sex and disability. Moreover, questions were designed to examine
participants’ views on the intersection of both these topics. The content of the written responses
was analyzed in terms of frequency of response rather than an interpretation of underlying
themes.
Recruitment
To recruit participants, I acquired access to the Certification Board for Music Therapists
(CBMT)’s official email list. The list contained the email addresses of 9,975 certified, US-based
music therapists. A recruitment email was sent out upon the opening of the survey, and two
follow-up emails were sent out on the seventh and fourteenth day respectively.
To qualify to participate in the study, respondents had to:
1. Be a US-based, board-certified music therapist
2. Have worked with disabled clients ages 18 and up
All participants had to consent to take part in the survey after reading the informational letter,
and were made aware that they could withdraw participation at any time.
Data Collection Instrument and Procedures
Data was collected through an online survey platform, Qualtrics XM, which I was
provided access to via Slippery Rock University. All data was stored securely within this
platform. The survey was made to be anonymous in that it did not require any identifying
information from participants and was open to anyone with access to the link who fit the study
criteria.
Data Analysis Procedures

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Quantitative data was analyzed via the descriptive statistics feature of Qualtrics XM.
Qualitative data was analyzed for common themes within participants’ responses.
Results
Participants were asked to fill out a 23-question anonymous online survey that was
designed to examine music therapists' personal beliefs and biases around addressing sexual
topics in music therapy with disabled clients. This included investigating participants'
educational experiences on the topics of sexuality and ableism, both concurrently and
independently of one another, examining their contextual and/or personal feelings about
elements of sexuality and their ability to address these within therapy, and studying their general
responses to the ways these themes emerge in the context of working with disabled clients in
music therapy. A total of 526 people consented to participate, though most questions received an
average response rate of 307 after the survey weeded out those who do not work with disabled
adults.
Participant Demographics
Participants were additionally asked to complete two pre-survey questions, which
included 1) whether they worked with disabled clients and 2) whether they worked with disabled
clients over the age of 18. While 91%, or 451 of the 497 respondents indicated that they do work
with disabled clients, only 82% or 410 indicated they work with disabled clients over the age of
18.
Participants were instructed to respond to a series of demographic-based questions,
including racial identity, age range, sexual orientation, gender expression and disability status.
When asked about their racial identity, 286 out of 307 respondents (93%) indicated that they
identify as white or Caucasian. Further, 21 respondents (7%) identified as Hispanic or Latino, 14
respondents (5%) identified as Asian, and 10 respondents (3%) identified as Black. Additionally,

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26

1 respondent identified as American Indian or Native Alaskan and another as Native Hawaiian or
Other Pacific Island, with both together ultimately equating to less than 1%. This aligned with
the racial demographics of AMTA, which are as follows: 88.3% white or Caucasian, 3.6%
Hispanic or Latino, 2.5% Asian, 2% as Black, 1.4% Native Hawaiian or Other Pacific Islander
and .29% American Indian or Native Alaskan (AMTA Workforce Analysis, 2021).
In reference to their age range, 182 out of 308 respondents (59%), indicated that they are
between the ages of 20-35. Of those 308 respondents, 63 (20%) indicated being between the ages
of 36-45, 47 (15%) indicated being between the ages of 46-59 and 29 (9%) indicated being age
60 or above. This somewhat aligned with the age demographics of AMTA, which are as follows:
22.8% are between 20-29, 29.1% are between 30-39, 18.5% are between 40-49, 14.2% are
between 50-59, 11.6% are between 60-69 and 3.9% are 70 and over (AMTA Workforce
Analysis, 2021).
When asked about their disability, only 21% of 307 respondents, or 64, identified as
disabled. When asked about their sexual orientation, 55% of 308 respondents, or 180, identified
as heterosexual. AMTA does not gather information about disability or sexuality so we cannot
compare these demographics. When asked about their gender identity, 78% of 306 respondents,
or 239, identified as cisgender women, 12% or 36 identified as non-binary or third gender, 8% or
24 identified as cisgender men and 2% or 7 indicated that they preferred not to say. This was
somewhat aligned with the gender demographics of AMTA’s gender statistics with a slightly
higher average of non-binary therapists: 88.4 identify as female/woman, 10.2% identify as
male/man, 1.4 % identify as gender queer/non-conforming, .2% identify as nonbinary, .2%
identify as trans male/man, 0.0% identify as trans female/woman, .7% indicated they go by a
different identifier and .9% indicated they preferred not to say (AMTA Workforce Analysis,

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27

2021).
Quantitative results
The survey was designed to start by examining participants' attitudes towards topics such
as sexuality being a human right and their sense of responsibility as it pertains to initiating topics
such as sexuality and/or other elements of sociocultural identity with their clients. The majority
of participants (71%) strongly agreed with the statement that sexuality is a human right for all
people regardless of disability status. Interestingly, strongly disagree is the second highest-rated
response (12%) to this statement (see Figure 1). When asked about whether or not it is the
responsibility of the therapist to initiate sociocultural conversations, including those around sex
and sexuality, 30% indicated that they neither agree nor disagree, with those who somewhat
agree not far behind at 28% (see Figure 2).
Figure 1
Attitudes on Sexual Rights For Disabled People

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28

Figure 2
Attitudes on The Therapist’ Responsibility To Initiate Sociocultural Conversations

The next set of questions aimed to examine participants' opinions about who should
initiate sexual topics, as well as their comfort level in addressing sex as a topic both personally
and clinically. The overwhelming majority of participants (49%) indicated that they strongly
agree with the statement that they wait for clients to bring up sexual topics before initiating them
themselves (See Figure 3). A large number of participants (41%) indicated that they somewhat
agree with the concept of being comfortable discussing sex in social, non-clinical situations, and
a further 39% indicated they are somewhat comfortable engaging with music that contains sexual
themes in clinical contexts with clients (See Figure 4). When asked if they feel comfortable
addressing romantic themes within music but not explicitly sexual themes, most participants
indicated that they either somewhat agree (35%) or strongly agree (30%). Similarly, the majority
of participants indicated they either strongly disagree (35%) or somewhat disagree (32%) with

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29

the idea of being more comfortable addressing sexually explicit themes in music versus romantic
themes (See Figure 5).
Figure 3
Attitudes On Waiting For Clients To Initiate Sexual Topics

The next section of questions focused on participants’ attitudes specifically as they
pertained to the role or appropriateness of sex as a topic in the clinical space. Most participants
(43%) strongly disagreed with the idea that sexual themes within music are generally
inappropriate and seldom clinically useful, with more than half (58%) indicating agreement with
the sentiment that examining these themes in sessions can be both clinically relevant and
therapeutically valuable (See Figure 6).
Figure 4
Attitudes On Discussing Sexual Topics In Non-Clinician Scenarios

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Figure 5
Attitudes On Discussing Romantic Vs. Sexual Themes

The next question aimed to assess whether or not the attitudes and comfort level of
participants change when discussing or initiating these topics specifically with disabled clients.
“Neither agree nor disagree” was the most commonly indicated response at 32% followed by
“strongly disagree” at 24% (See Figure 7).

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31

Figure 6
Attitudes On The Therapeutic Value Of Using Music With Sexual Themes

The final few questions sought participants’ feelings on the responsibility of the clinician
in the realm of advocating for the disabled clients’ right to openly discuss sexual topics in
therapy, particularly when this was at odds with the opinions or requests of caregivers and/or
legal guardians. When asked whether they would stop engaging in clinically relevant sexual
topics in therapy if a caregiver or guardian found this inappropriate, 58% of participants stated
that they would not. The majority of participants suggested that they would advocate for their
client in this scenario, with 52% indicating they strongly agree with this statement followed by
34% indicating that they somewhat agree (See Figure 8).

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Figure 7
Attitudes On The Therapeutic Value Of Using Music With Sexual Themes

Figure 8
Attitudes On Advocating For Clients Whose Caregivers Find Sexual Topics Inappropriate

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33

Qualitative results
In order to analyze the written responses, the researcher coded responses according to
frequency and forcefulness of response. These codes were then categorized into themes and
subthemes (see Table 1). Six main themes emerged: 1) Training, 2) Clinical praxis regarding
discussion of sexual topics, 3) Scope of practice, 4) Impact on disabled people, 5) Desire for
further reflection, and 6) Need for more concise definitions.
Table 1
Themes and Subthemes
Themes

Subthemes

Training

1. No formal training
2. In counseling classes
3. Additional training in and outside of
the field
4. Self-taught

Clinical praxis regarding discussion of sexual
topics

1. Lack of experience engaging in these
topics
2. Ableism’s impact on addressing the
topic
3. Expanding beyond disability alone

Scope of practice

1. Appropriateness of initiating topics
2. Ethical considerations for client safety
3. Risk of retraumatization

Impact on disabled people

1. Lack of access to sociosexual
education
2. Decreased access to healthy sexual
scenarios
3. Increased risk for sexual abuse

Desire for further reflection

1. The intersection of disability and sex
2. The impact of taboo topics and
ableism on clinical practice
3. Respect for the client’s sociocultural
background

MUSIC THERAPISTS’ ATTITUDES TOWARDS DISABILITY AND SEXUALITY
Need for more concise definitions

34

1. Definition differences of caregivers
and legal guardians
2. Legal and ethical implications of
disobeying a legal guardian
3. Participant desire for increased written
reflection space

Theme I: Training
Within the theme of training there were four subthemes: 1) No formal training, 2) In
counseling classes, 3) Additional training in and outside of the field, and 4) Self-taught. Over
half of participants indicated that they did not receive training or education in or outside the field
on addressing sexual identity and other sexual topics with disabled clients. At least 11
participants indicated being “somewhat” educated on these topics, though many stated it was not
in-depth. Participants who affirmed being educated to address sexual topics in therapy often
referenced individual professors, supervisors, or facilities who felt it was important to integrate
these topics into their education. Another common theme amongst those who indicated being
educated on these topics was access to counseling classes. 10 participants who were not formally
educated on these topics in the field became more educated through direct work experience,
gaining the knowledge and understanding on this subject which came from that experience. 9
participants indicated that they sought training both in and outside of the field, such as
Continuing Music Therapy Education workshops and seminars to other kinds of workshops,
courses and conferences. 5 participants named self-study as their main source of knowledge on
this topic.
Theme II: Clinical praxis regarding discussion of sexual topics
Within the theme of clinical praxis regarding discussion of sexual topics there were three
subthemes: 1) Lack of experience engaging in these topics and 2) Ableism’s impact on

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35

addressing the topic. When asked about their level of experience addressing sexual topics with
disabled clients, over 50 participants indicated that they generally do not, and in some cases have
never approached this topic with clients regardless of disability status. The most common
reasons cited for this were fear of being misconstrued and that these topics have not come up in
sessions. Still, around 40 participants indicated an understanding of the importance of making
space for these topics in therapy and voiced a willingness to do so in clinically relevant
scenarios. According to one participant:
“I have never had the opportunity to study this topic officially outside of my own
personal investigations and attempts to listen to disabled voices at large on the topic. This
leaves me feeling under qualified to engage in sexual topics with any client at all,
knowing 'good intentions' aren't enough to avoid possible harm. If presented the topic or
a situation related, I think I would seek supervision or getting the client in touch with a
more qualified professional (which at that point could I guess lead to the topic being
addressed in MT with enough coordination!)”
Roughly 45 participants also indicated feeling more comfortable discussing these topics when
clients initiate them first, while others stated that sexual topics should only be client-initiated
regardless of disability status. Some spoke to feeling comfortable specifically discussing consent
education and processing negative sexual experiences with disabled clients given their increased
risk to sexual abuse and violence. When asked whether ableism impacts their approach to
addressing sexual topics with disabled vs. nondisabled clients, just under 100 indicated that they
would address sexual topics as a whole differently with disabled and non-disabled clients due to
the impact ableism and infantilization have on these conversations for disabled people. One
participant wrote:

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36

“In theory I agree, but I don’t work directly with disabled clients on a frequent-enough
basis to address sexuality related issues. If I (worked with disabled clients frequently), I
believe that (they) would require different kinds of support than non-disabled clients
primarily due to the stigma of infantilization/being viewed as non sexual that disabled
people have to deal with. Then there are the additional physical, emotional, medical
and/or cognitive barriers that may be involved.”
Others stated that they would address these topics the same way regardless of the client’s
disability status. Some cited sexuality being a human right as to their reason for this, while others
felt conversations on sexual topics need to be highly individualized and based on a broader
sociocultural than disability alone. As one participant put it, “Cultural attitudes and availability
of knowledge on disabled sexuality is so taboo in our society, unfortunately, and it does not serve
a client to pretend like that doesn't exist”.
Theme III: Scope of practice
Within the theme of scope of practice, three subthemes emerged: 1) Appropriateness of
initiating topics, 2) Risk of retraumatization and 3) Ethical considerations for client safety. A few
participants stated believing that these topics are outside the scope of practice of music
therapists. Some felt these topics were not necessarily appropriate in music therapist settings
while others reported being actively discouraged from engaging in this topic in certain settings,
particularly mental health programs. Risk of retraumatization of and increased harm to disabled
clients by well-intentioned professionals who are untrained in facilitating these discussions was
also referenced almost 30 times. This coincides with another widely-reported view on the
consequences of academic and clinical lack of training in these areas and the need for
trauma-informed education. As stated by one participant,

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37

“If a therapist were to initiate the conversation, the therapist would need to be trauma
informed, and have a strong rapport with the person. Initiating the conversation in the
wrong way could be exploitive in its own right, and would trigger traumatic symptoms in
the wrong way. Specific and detailed training and protocols would be needed.”
According to participants, ethical considerations must be made in terms of one’s clinical ability
to safely facilitate sexual discussions. As another participant stated, “Ethics also needs to be
considered in terms of training of the music therapist and what is within scope of practice when
determining facilitation of discussions surrounding these issues as not to cause potential harm to
the client due to a well-meaning yet unprepared clinician.”
Theme IV: Impact on disabled people
The subthemes found in the theme of impact on disabled people were: 1) Lack of access
to sociosexual education, 2) Increased risk for sexual abuse, 3) Decreased access to healthy
sexual scenarios. Commonly referenced amongst participants was the impact that lack of access
to relevant sexual education has on disabled people. As one participated noted,
“Sex and sexuality is as important in the lives of adults with disabilities as it is for
neurotypical people has been my experience. However, since many assume adults with
disabilities don’t have sexual desires or shouldn’t, access to sex Ed is even more limited
than the neurotypical population. This creates many issues for folks trying to navigate
romantic and sexual relationships in a healthy way.”
Some consequences mentioned by participants include a higher risk of sexual violence or
coercion and increased likelihood of engaging in unsafe or unfulfilling sex practices. Further,
lack of access to developmentally appropriate sociosexual education often leads to a lack of
social skills to be able to engage in this aspect of life which can result in lower happiness overall.
Theme V: Desire for further reflection

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38

The subthemes contained in the theme of desire for further reflection were: 1) The
intersection of disability and sex, 2) The impact of taboo topics and ableism on clinical practice,
3) Respect for the client’s sociocultural background. Participants gave wide-ranging commentary
when asked to consider the thoughts and reflections that emerged for them while taking the
survey. Widely commented-upon was a noted desire to reflect further on the intersection of sex
and disability, as well as appreciation that these topics are being examined. Noted by one
participant:
“Disability is such a wide term, and sexuality in and of itself is such a varied experience
that it’s going to be different for each individual. I also recognize that disability is an
intersection that has to be approached in an informed manner and you must actively listen
to the client to understand what they need and the difficulty posed by ableism in having
the conversation in the first place.”
Similarly, close to 75 participants noted the impact that both systemic ableism and sex as an
often-taboo and deeply culturally-specific subject have on their own views and clinical practices.
At least 15 participants also referenced the idea that discussions around these topics must work
within the framework of the client’s sociocultural values and belief systems, ranging from wider,
culturally-specific beliefs to access needs such as communication methods for non-speaking
clients. One participant made a poignant point regarding the reality of these different factors
intersecting:
“Initiating conversations with clients about sexuality in a clinical setting - especially with
clients who do not communicate verbally - is tricky because those sessions are seldom
private (in home setting or group settings) and navigating other caregiver biases and
perceptions is very challenging. That deeply impacts my ability to support clients in

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39

processing topics related to their sexuality. Many folks desexualize disabled people and,
as a result, seem to think that any discussion around sexuality must be exploitative or
abusive by nature.”
Theme VI: Need for more concise definitions
The final theme, which focuses on the need for more concise definitions within the study,
contains three subthemes: 1) Definition differences of caregivers and legal guardians, 2) Legal
and ethical implications of disobeying a legal guardian and 3) Participant desire for increased
written reflection space. Close to 25 participants indicated that they would advocate for disabled
clients whose caregivers or legal guardians did not feel sexual topics were appropriate in a
clinical setting. Around 40 participants spoke to the importance of differentiating between a
caregiver and legal guardian, as well as the legal implications of disobeying a legal guardian’s
wishes. The potential consequences of this could include discontinuing therapy, which could
ultimately cause more harm than good. According to one participant, “I think it’s complicated,
because the client has the right to ask questions, learn about and explore their sexual identity, and
be interested in sexual topics. But addressing those when the legal guardian has said not to I
think runs the risk of them discontinuing therapy, which could be more harmful.” The general
sentiment of participants (just under half) who discussed this question expressed a desire and
willingness to advocate in this scenario, while acknowledging the multilayered complexity
involved in doing so. One participant surmised:
“I have found that I have to remind those around my clients that they are adults with
healthy and normal feelings. Many caregivers of clients with development disabilities
believe that because they enjoy children’s toys and TV shows that sexual topics of
exploration are unnecessary and inappropriate. It takes a lot of advocacy. I have also

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40

found that many of my clients with disabilities develop romantic or sexual feelings
towards me, their therapist. This can be a great opportunity to model healthy boundaries
and to discuss these topics further, if appropriate.”
Several participants also spoke to the limitations of having most of the questions in Likert-scale
style given the nuance and complexity of the discussion. More than 10 participants referenced a
desire to have more space within the survey to speak more in-depth about these complexities. A
participant who summarized this notion, wrote:
“This is an immensely complex issue concerning intersectionality that cannot be
answered in a Likert fashion. The lived experience of every individual is unique within
the context of their community and as they interact within and across other systems
throughout their lifetime. Then to consider one’s sexuality as an additional
variable—which may include different aspects of trauma and multiple layers that impact
mental health.”
Discussion
Due to the extremely limited data on this topic in the music therapy literature, I will
discuss the results of this study in relationship to the few music therapy studies I found, as well
as in relationship to the literature from related fields.
The first major point of comparison can be seen in the context of barriers to
conversations on sexual topics with disabled clients. More than half of participants cited lack of
training in these areas, which leads to feelings of inadequacy and under-qualification in terms of
knowing how to address them. This referenced lack of training is supported by the absence of
nearly any music therapy-specific literature on this topic. One participant stated:

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41

“I am now working more with school aged individuals and I really wish there was more
sexual education for students who are in special day classes. They do not receive the
same quality of education in this area as their general education peers and I believe it sets
them up for greater challenges as they transition into adulthood. Parents of teenagers in
my experience are very uncomfortable with this topic.”
In addition, literature in related fields also speaks to lack of uniform training opportunities and
noted high levels of discomfort noted in fields such as counseling and psychology (Burnes et al.,
2017; Hanzlik & Gaubatz, 2012). This literature indicates that the personal and professional
discomfort clinicians state experiencing in addressing sexual topics with disabled people are due
in large part to the uniform under-addressing of such topics with disabled people specifically.
This is significant despite the literature also consistently suggesting that they are interested in
engaging in these conversations (Eisenberg et al., 2015).
Several participants also referenced lack of appropriate sexual education (or in some
cases any sex education) available to disabled people as an injustice which also impacts their
feelings of comfort and confidence in their ability to address sexual topics in this context. This is
supported throughout the literature of related fields (Burnes et al., 2017; Eisenberg et al., 2015;
Gill & Hough, 2007; Hall et al., 2016; Hanzlik & Gaubatz, 2012; McDaniels & Fleming, 2018).
In addition to traditional means of sexual education, McDaniels and Fleming (2018)
noted the importance of providing opportunities for sociosexual skill development in areas of
emotional intimacy ranging from platonic friendship to romantic love. They emphasized the need
for clinicians to assume competence and see disabled people as both capable and worthy of
experiencing platonic and intimate forms of love. This sentiment is expressed by the following
participant:

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42

“It is, in my opinion, an enforcement of a dehumanizing dominant narrative about
disabled people that they are not qualified, mature, intelligent, or independent enough to
love, feel arousal and/or attraction, or have meaningful sexual or romantic partnerships to
avoid conversations about disability and sexuality in any therapeutic encounter.
Presenting an openness and willingness to hold space in therapy for clients' experiences
of sexuality and disability, in their own sociocultural context, is a meaningful act towards
deconstructing the narratives around sexuality and disability.”
Harris and Hays (2008) spoke about the role of the clinician in initiating conversations on sexual
topics with families that tend to avoid discussing them. By modeling an ability to move past
personal feelings of anxiety around discussing a subject, clinicians assist both clients and their
families in having these conversations despite feelings of vulnerability or discomfort. The same
can be said of the benefit of modeling healthy boundary setting with clients when sexual topics
or feelings arise. One participant spoke to the importance of modeling this when clients develop
romantic or sexual feelings towards them: “I have also found that many of my clients with
disabilities develop romantic or sexual feelings towards me, their therapist. This can be a great
opportunity to model healthy boundaries and to discuss these topics further, if appropriate.”
A commonly agreed upon stance amongst participants was the importance of and desire
to advocate for clients’ ability to access and discuss sexual topics. The literature in related fields
overwhelmingly supported the view that advocacy is sorely needed in a variety of areas (Burnes
et al., 2017; Eisenberg et al., 2015; Harris & Hays, 2008; Hanzlik & Gaubatz, 2012; McDaniels
& Fleming; Turner & Crane, 2016). Turner and Crane (2016) spoke to the importance of directly
assisting in as well as advocating for disabled people’s physical and emotional access to pleasure
in terms of sexuality and intimacy:

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43

“Adults with ID rely on others for advocacy in many areas of community
integration…Including sex and relationships as rights would challenge advocates for
those with disabilities to step into the role of sexuality advocate, viewing access to
pleasure as a social justice issue. Access to dating partners depends on one’s support
system, thus transportation and freedom of movement without supervision must also be
provided.”
While this sentiment was widely shared among participants, many also spoke to the possibility of
caregivers pulling clients out of therapeutic services as a result of clinically engaging in topics
they did not want discussed in therapy. To that end, many echoed the need to measure risk versus
reward to the client. As one participant stated:
“I think the question about caregivers deeming sexual topics inappropriate is difficult. In
a previous work setting, part of our funding came from these caregivers. While
therapeutic work shouldn't be about money, employee livelihood unfortunately is. Such a
discussion could result in the client being pulled out of therapy and a potentially more
affirming space. So, whether or not to discuss sexuality is intermingled with client
advocacy and employee salaries, the decision becomes a little more complex.”
In reflecting on these possibilities, it is important to consider what is ultimately best for the client
in the big picture rather than imposing ideas which could lead to clients having decreased access
to valuable areas of support and care.
Limitations, design reflections and future considerations
There were multiple limitations noted in this research, the first being the expansive nature
of “disability” and “sexual topics” in terms of definition. Because both of these terms cover so
much complex ground, it may have been confusing for participants to fully consider the breadth

MUSIC THERAPISTS’ ATTITUDES TOWARDS DISABILITY AND SEXUALITY

44

of their intersection, particularly in a survey predominantly composed of Likert scale-style
questions. One participant pointed out:
“How someone experiences and processes their sexuality, sexual urges/impulses or sexual
desires is inherently going to vary based on their disability status. Is it a physical
disability? Is it a new disability that has changed their perception of their
body/self-image? Is it a cognitive disability that potentially impacts their ability to
consent? Do they have a history of being victimized by perpetrators who took advantage
of them because of their disability? All of this plays into how/if I would bring sexuality
into the session…”
This issue is further complicated by the clear indication that sexual topics in general are not
uniformly taught to music therapists. To expect clinicians who have not been trained in a
complex area of experience to apply that experience to as complex a subject as disability is not a
reasonable task.
To that point, several participants indicated frustration regarding this style of question in
reference to such extensive topics and cited a desire for additional short answer space to verbally
reflect. As one participant stated:
“This is an immensely complex issue concerning intersectionality that cannot be
answered in a Likert fashion. The lived experience of every individual is unique within
the context of their community and as they interact within and across other systems
throughout their lifetime. Then to consider one’s sexuality as an additional
variable—which may include different aspects of trauma and multiple layers that impact
mental health.”

MUSIC THERAPISTS’ ATTITUDES TOWARDS DISABILITY AND SEXUALITY

45

Furthermore, I mistakenly neglected to include operational definitions for these terms in the
survey cover letter as originally intended. This led to participants using their own discernment to
define them, which adds an additional layer of variables and could potentially skew data in
considering participants’ responses. There were also several instances where the wording of the
survey questions used the terms “sexuality” and “sexual topics” interchangeably, which could
have further skewed data based on participants’ perception of these terms.
Another aspect of the survey which was pointed out as a limitation by numerous
participants was the wording of question nineteen. Participants were asked how they would
respond if the caregiver or legal guardian of their client did not want them discussing sexual
topics, which prompted many to reference the differences between these two terms. These
participants pointed out that while a “caregiver” has certain levels of authority over those in their
care, a “guardian” has the legal right to make decisions on behalf of the client. Not only can this
lead to discontinuation of services with the client, but it could possibly open therapists up to
litigation should they not comply with the guardian’s requests. One participant noted the need for
more concise definitions: “I think you should more clearly define terms. This is exceptionally
subjective; caregiver and legal guardian aren't the same....difficult to answer the previous
questions in that a legal guardian can make binding demands.”
Future Research
Given that this is one of the first studies examining music therapists’ attitudes on
addressing sexual topics with disabled adults, it would be worthwhile for a more thorough
examination of this subject with tighter, more concise terms and definitions. I strongly suggest
that more studies take place on the subject of the ways in which music therapy can play a role in
disability-affirmative sexual education, support and empowerment of clients as they navigate

MUSIC THERAPISTS’ ATTITUDES TOWARDS DISABILITY AND SEXUALITY

46

intimate areas of their lives. The role of supervision in these conversations could also be a
valuable study. Additionally, the perspectives of disabled people should be studied in continuing
to study this subject and gain firsthand knowledge from those directly impacted by the issues
highlighted in this paper.
Conclusion
Disability and sexual topics have in common that they are both often viewed as taboo
and/or sensitive subjects within a multitude of cultures. As a result, disabled people often have
limited access to a) appropriate sexual education and sources of knowledge b) support systems in
the context of their intimate lives and c) the quality of life associated with these aspects of
experience. To quote Tepper (2000), “pleasure in an affirmation of life… (and sexual pleasure) is
particularly powerful in making one feel alive” (p. 288). This is an area of life everyone should
have access to regardless of disability status. As music therapists, the addressing of sexual topics
may not be our niche or specialization. That said, it is an area of the human experience in which
every person has a unique and distinct connection, and to deny our responsibility in addressing
these areas as we would with any other area of humanity is misguided at best and dangerous at
worst. In a profession where we are considered qualified to provide baseline levels of support in
the realms of spiritual and psychosocial domains, we have a responsibility to learn the same skill
sets as they pertain to sexual topics, despite cultural attitudes and norms. The field-wide
hesitation to discuss sexual topics as a whole contributes to disabling limitations placed on
disabled people’s access to support in these areas, which is antithetical to our roles as therapists
and advocates. It is on all of us as clinicians to continue moving toward liberatory practices that
aid disabled people in living lives of their choosing.

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47

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APPENDIX A:
Recruitment email:
Dear music therapist or music therapy intern,
My name is Francesca Miller (she/her) and I am an MMT student at Slippery Rock University. I
am conducting my thesis, “Exploring music therapists’ attitudes towards disability and
sexuality,” under the direction of Susan Hadley, Ph.D, MT-BC with the approval of SRU’s IRB.
Participants are invited to take a 19 question survey, which will take about 15 minutes to
complete, and can be filled out via computer or smartphone. In order to participate, you must be
a US-based music therapist or music therapy intern who has had experience working with
disabled clients ages 18 and older. Music therapists and music therapy interns of all ages above
21, backgrounds and levels of education are eligible.
If you are interested in participating, please click the link below to be directed to the survey. If
you have any additional questions, please contact the researcher and co-researcher at
susan.hadley@sru.edu or fjmiller92@gmail.com.

Sincerely,
Francesca Miller, MT-BC, Co-researher, MMT candidate Slippery Rock University
Follow this link to the survey:
Or paste this URL into your browser:

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56

Recruitment facebook post:
Hi all,
My name is Francesca Miller (she/her) and I am an MMT student at Slippery Rock University. I
am conducting my thesis, “Exploring music therapists’ attitudes towards disability and
sexuality,” under the direction of Susan Hadley, Ph.D, MT-BC with the approval of SRU’s IRB.
Participants are invited to take a 19 question survey, which will take about 15 minutes to
complete, and can be filled out via computer or smartphone. In order to participate, you must be
a US-based music therapist or music therapy intern who has had experience working with
disabled clients ages 18 and older. Music therapists and music therapy interns of all ages above
21, backgrounds and levels of education are eligible.
If you are interested in participating, please click the link below to be directed to the survey. If
you have any additional questions, please contact the researcher and co-researcher at
susan.hadley@sru.edu or fjmiller92@gmail.com
Thank you!

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57

APPENDIX B:
Informational Letter

Exploring music therapists’ attitudes
towards disability and sexuality
Start of Block: Informational letter
Informational letter
Susan Hadley, PhD, MT-BC
Professor, Director of Music Therapy
101 Central Loop, Suite 225
Slippery Rock, PA 16057-1326
724-738-2446 office
724-738-4469 fax
e-mail: susan.hadley@sru.edu
http://www.sru.edu/depts/artsci/music/index.htm
RESEARCH PARTICIPANT INFORMATIONAL LETTER
Exploring music therapists’ attitudes towards disability and sexuality
Francesca Miller, fxm1007@sru.edu; Susan Hadley, susan.hadley@sru.edu
Invitation to be Part of a Research Study
You are invited to participate in a research study. In order to participate, you must be a
US-based music therapist or music therapy student (at internship level) who work or have
worked with disabled clients ages 18 and up. Taking part in this research project is voluntary.
Important Information about the Research Study
Things you should know:
● The purpose of this survey is to examine music therapists' personal beliefs and biases
around addressing sexuality in music therapy with disabled clients. If you choose to participate,
you will be asked to complete an anonymous online survey. This will take approximately 10-25
minutes.
● We do not anticipate any outside of potential personal discomfort from this research.
● The study may benefit you directly in shifting your perspective on addressing sex as a topic
with disabled clients or disability in general. It may benefit disabled clients who have not

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58

previously had the opportunity to explore this subject with clinicians increased access to such
conversations.
● Taking part in this research project is voluntary. You do not have to participate and you can
stop at any time.
Please take time to read this entire form and ask questions before deciding whether to take part
in this research project.
What is the Study About and Why are We Doing it?
The purpose of this survey is to examine music therapists' personal beliefs and biases around
addressing sexuality in music therapy with disabled clients.
What Will Happen if You Take Part in This Study?
If you agree to take part in this study, you will be asked to complete a 23 question anonymous
online survey containing 20 multiple choice and 3 short answer questions. We expect this to
take about 10-25 minutes.
How Could You Benefit From This Study?
The study may benefit you directly in shifting your perspective on addressing sex as a topic
with disabled clients or disability in general. It may benefit disabled clients who have not
previously had the opportunity to explore this subject with clinicians increased access to such
conversations. It will ideally encourage clinicians to think more critically about this topic to the
benefit of their disabled clients.
What Risks Might Result From Being in This Study?
While we do not anticipate risks or discomforts associated with this study, it is possible that you
may experience some emotional discomfort when answering questions regarding your feelings
around the topic of ableism and how it relates to a variety of subjects including individual
perception, training, clinical experience. We have taken precautions to eliminate or reduce these
risks by developing an anonymous survey. We also want to assure you that participation in the
research is completely voluntary and that declining to participate will not negatively affect you in
any way. You can withdraw from the study at any time if you feel discomfort.
How Will We Protect Your Information?
We plan to publish the results of this study. To protect your privacy, we will not include any
information that could directly identify you. Your survey responses will not be connected with
your email address.
What Other Choices do I Have if I Don’t Take Part in this Study?
If you choose not to participate, there are no alternatives.
Your Participation in this Research is Voluntary
It is totally up to you to decide to be in this research study. Participating in this study is
voluntary. Even if you decide to be part of the study now, you may change your mind and stop at

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59

any time. You do not have to answer any questions you do not want to answer. If you decide to
withdraw before this study is completed, just exit the survey.
Contact Information for the Study Team and Questions about the Research
If you have questions about this research, you may contact Francesca Miller,
fxm1007@sru.edu.
Contact Information for Questions about Your Rights as a Research Participant
If you have questions about your rights as a research participant, or wish to obtain information,
ask questions, or discuss any concerns about this study with someone other than the
researcher(s), please contact the following:
Institutional Review Board
Slippery Rock University
104 Maltby, Suite 302
Slippery Rock, PA 16057
Phone: (724)738-4846
Email: irb@sru.edu
Your Consent
Before agreeing to be part of the research, please be sure that you understand what the study
is about. You can print a copy of the document for your records. If you have any questions about
the study later, you can contact the study team using the information provided above.
I understand what the study is about and my questions so far have been answered. I agree to
take part in this study. I understand that I can withdraw at any time. You indicate your voluntary
agreement to participate by clicking BEGIN SURVEY.
End of Block: Informational letter

MUSIC THERAPISTS’ ATTITUDES TOWARDS DISABILITY AND SEXUALITY
APPENDIX C:
Survey Questions
Start of Block: Pre-survey question block
Pre-survey 1 Do you work with disabled clients?

o Yes (1)
o No (2)
Pre-survey 2 Do you work with disabled clients over the age of 18?

o Yes (1)
o No (2)
End of Block: Pre-survey question block
Start of Block: Default question block
1 Check all the apply in regards to your racial identity:

▢

American Indian or Alaska Native (1)

▢
▢

Black or African American (3)

▢
▢

Asian (2)

Hispanic or Latino (4)

Native Hawaiian or Other Pacific Islander (5)

60

MUSIC THERAPISTS’ ATTITUDES TOWARDS DISABILITY AND SEXUALITY

▢

White or Caucasian (6)

2 Check the age group of which you are a part:

▢

▢

20-35 (1)

▢

36-45 (2)

▢

46-59 (3)

60 and above (4)

3 Do you identify as disabled?

o Yes (1)
o No (2)
4 Do you identify as cisgender?

o Male (1)
o Female (2)
o Non-binary / third gender (3)
o Prefer not to say (4)

61

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5 Do you identify as heterosexual?

o Yes (1)
o No (2)
6 I believe that sexual experiences and sexual identity are fundamental rights for all people,
regardless of their disability status.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
7 I believe it is the responsibility of the therapist to initiate conversations around sociocultural
identities, which include sexuality and sexual personhood.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)

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63

o Strongly agree (5)
8 Has any part of your training, either inside or outside of the field, included education around
addressing sexual identity and topics with disabled clients?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

9 I wait for clients to bring sexual topics before discussing them rather than initiating the topic
myself.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
10 I feel comfortable discussing sexual topics in social, non-clinical situations.

o Strongly disagree (1)
o Somewhat disagree (2)

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o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)

11 I feel comfortable engaging with music with sexual themes in clinical situations with clients.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
12 I feel comfortable clinically addressing romantic themes within music, but not explicitly
sexual themes.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)

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o Strongly agree (5)
13 I feel comfortable clinically addressing sexually explicit themes, but not romantic themes.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
14 I believe that using music containing sexual themes or references in clinical situations is
generally inappropriate and seldom has any therapeutic value.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)

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15 I believe that using music containing sexual themes or references in clinical situations can be
clinically relevant and of therapeutic value depending on the context.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)

16 My comfort level in clinically addressing sex as a topic in therapy remains the same
regardless of a client's disability status.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
17 I initiate clinically-relevant sexual topics with with all clients regardless of disability status.

o Strongly disagree (1)

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o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
18 I initiate clinically-relevant sexual topics with speaking disabled clients, but not with
non-speaking disabled clients.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)
o Somewhat agree (4)
o Strongly agree (5)
19 While there are similarities, the ways in which I support disabled and non-disabled clients in
processing their sexuality are ultimately different given the lived experience of disability and the
impact of ableism on community members.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)

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o Somewhat agree (4)
o Strongly agree (5)
20 Please elaborate your thoughts on question 19.
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21 If the caregiver or legal guardian of an adult-age disabled client considered clinically-relevant
sexual topics emerging in therapy to be inappropriate, I would no longer engage in discussing
that topic with the client.

o Yes (1)
o No (2)
22 If the caregiver or legal guardian of an adult-age disabled client considered clinically-relevant
sexual topics emerging in therapy to be inappropriate, I would advocate for the client.

o Strongly disagree (1)
o Somewhat disagree (2)
o Neither agree nor disagree (3)

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o Somewhat agree (4)
o Strongly agree (5)
23 What are some thoughts and reflections that came up for you while answering these survey
questions?
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