A Comprehensive Perspective on Treating Victims of Human Trafficking

Kathryn Marburger, Sheri Pickover

Providing treatment to survivors of human trafficking requires mental health professionals to understand complex layers of multiple traumas. These layers include an understanding of how trafficking occurs; what gender, ages, sexual orientations, life circumstances, and ethnicities are most at risk to be trafficked; the lasting impact of trafficking on human development, mental health, and family relationships; and the stigma victims face from their own families, communities, and mental health providers. These survivors suffer from physical ailments and post-traumatic stress disorder, and they are at high risk for developing comorbid disorders such as depression and addiction disorders. Integrated treatment options to alleviate these concerns, including cognitive behavioral therapy, trauma-focused therapy, ecologically focused therapy, and family therapy, are presented.

Keywords: human trafficking, trauma, post-traumatic stress disorder, addiction disorder, sexual orientation

Human trafficking is often referred to as modern-day slavery and is found in every corner of the globe (Cecchet & Thoburn, 2014; Department of Homeland Security [DHS], n.d.; Gerassi, 2015; Hardy et al., 2013; Hodge, 2014; Litam, 2017; Polaris, n.d.-b; Sanchez & Stark, 2014; Zimmerman & Kiss, 2017). The United Nations defines trafficking as:

the recruitment, transportation, transfer, harbouring or receipt of persons, by means of the threat or
use of force or other forms of coercion, of abduction, of fraud, of deception, of the abuse of power or
of a position of vulnerability or of the giving or receiving of payments or benefits to achieve the
consent of a person having control over another person, for the purpose of exploitation. (Office of the
High Commissioner for Human Rights, 2000, article 3, para. 1)

The International Labour Office (2017) has estimated that 40.3 million people are victims of modern-day slavery throughout the world. This means that one person in every 1,000 is being victimized through modern-day slavery. Offering high rewards with minimal risk, human trafficking is a profitable and fast-growing criminal enterprise. Human trafficking profits surpass illegal arms trafficking and are second only to drug trafficking (Busch-Armendariz et al., 2014; Greer & Davidson Dyle, 2014; UNICEF USA, 2017). The International Labour Office (2014) has estimated that the profits from human trafficking are $150 billion a year, of which $99 billion comes from sexual exploitation.


The DHS reported that the crime of human trafficking is often hidden in plain sight in both legal and illegal industries; victims can be any gender, sexual orientation, age, and nationality, including documented or undocumented immigrants (DHS, n.d.; Rothman et al., 2017). However, statistics on human trafficking within the United States are lacking (DHS, n.d.; Gerassi, 2015; Miller-Perrin & Wurtele, 2017; Varma et al., 2015), and a uniform system of collecting data to identify victims currently does not exist, which increases the difficulty of obtaining accurate data (Gerassi, 2015; Miller-Perrin & Wurtele, 2017). Additional factors that contribute to the underreporting of human trafficking include legal and social services that are not readily accessible to victims, fear of punishment from traffickers, and fear or distrust of law enforcement. Moreover, some victims may not even recognize themselves as being the victims of human trafficking (De Chesnay, 2013; Miller-Perrin & Wurtele, 2017).


Human trafficking is a crime that inflicts complex layers of trauma on victims and survivors. The goal of this article is to provide mental health professionals with a systemic view of this crime from various perspectives so that they can implement wraparound-focused treatment plans. The perspectives adopted include how individuals become trafficked, sociocultural factors, the impact on the victims’ development and mental health, family relationships, and the stigma victims face from communities and their families. Having knowledge of these complex factors will allow mental health professionals to devise trauma-sensitive approaches to treat survivors of human trafficking. For the purpose of this paper, the term victims refers to individuals who are actively under the control of the trafficker, and the term survivors refers to individuals who are no longer being exploited.


Sexual exploitation and forced labor are two of the most common forms of human trafficking (Busch-Armendariz et al., 2014; De Chesnay, 2013; Greer & Davidson Dyle, 2014; Hodge, 2014; Martinez & Kelle, 2013; Miller-Perrin & Wurtele, 2017; U.S. Department of State, 2017). Human Rights First (2017) reported that 19% of human trafficking victims are trafficked for sex, and yet sex trafficking accounts for 66% of trafficking profits worldwide. Sex trafficking includes a wide variety of traditionally accepted forms of labor, including commercial sex, exotic dancing, and pornography. It is a form of oppression placing men, women, and children throughout the world at risk of sexual exploitation (Litam, 2017; Polaris, n.d.-a; Zimmerman & Kiss, 2017).


Traffickers treat victims’ bodies as resources to be used and repeatedly sold for money or goods such as pornography, cigarettes, drugs, clothing, and shelter (Busch-Armendariz et al., 2014; Greer & Davidson Dyle, 2014; Litam, 2017; Miller-Perrin & Wurtele, 2017; Sanchez & Stark, 2014). International trafficking often receives more attention; however, most trafficking occurs domestically within the same country (Martinez & Kelle, 2013; Zimmerman & Kiss, 2017). Furthermore, trafficking does not have to include crossing a state line, nor does it necessarily involve moving locations (Busch-Armendariz et al., 2014). Domestic minor sex trafficking is flourishing in every region, state, and community in the United States (Countryman-Roswurm & Bolin, 2014), with Midwestern cities showing increased rates of recruitment; such cities have access to several highways to transport victims to destination cities, including Detroit, Chicago, and Las Vegas, where demand for sexual exploitation is highest (Litam, 2017).


Sex trafficking has been linked not only to escort and massage services, strip clubs, and pornography, but also to major sporting events, entertainment venues, truck stops, business meetings, and conventions (Busch-Armendariz et al., 2014; Hardy et al., 2013; Litam, 2017). As long as demand exists, the opportunity for traffickers to sell victims is limitless. The internet increases the convenience and reduces the risk for traffickers and consumers. For instance, although Backpage.com was shut down by the U.S. government in 2017 for participating in and profiting from sex trafficking advertisements, and other websites like Craigslist began to censor and remove sex advertisements (Anthony et al., 2017; Leary, 2018; Peterson et al., 2019), numerous websites are used by traffickers not only to lure victims but also to advertise and sell to consumers. These websites include Eros.com, Bedpage.com, and social media platforms such as Instagram, Facebook, Twitter, Tinder, and Grindr (Jordan et al., 2013; Litam, 2017; Moore et al., 2017; O’Brien, 2018). The physical and psychological abuse victims experience from both traffickers and consumers leaves victims traumatized (Graham et al., 2019; Greer & Davidson Dyle, 2014; Litam, 2017; Moore et al., 2017; Zimmerman & Kiss, 2017).


The Victims of Trafficking


One out of every four victims of human trafficking is a child (International Labour Office, 2017), and these children are often found in the child welfare and juvenile justice systems, and runaway and homeless youth shelters (Moore et al., 2017; U.S. Department of State, 2017). In 2016, it was estimated that one out of six runaways was a victim of sex trafficking and 86% had been in foster care or social services when they ran away (Polaris, n.d.-a). Runaway youth are usually approached by traffickers within 48 hours of living on the street (Jordan et al., 2013). Traffickers recruit runaway or homeless children into trafficking rings, exposing them to extreme forms of abuse that result in many being killed from the violence inflicted or from diseases acquired through sexual abuse (Litam, 2017).


Sex trafficking is prevalent throughout the world, affecting men, women, children, families, and communities. Individuals also are trafficked for various other purposes, including domestic service, agricultural work, commercial fishing, the textile industry, construction, mining, factory work, and petty crime (U.S. Department of State, 2017; Zimmerman & Kiss, 2017). Although men have been confirmed to be victims in all areas of trafficking, they are disproportionately subjected to forced labor, whereas women and children account for the majority of sexually exploited victims (International Labour Office, 2017). Although trafficking occurs in all parts of the world and can affect anyone, several factors increase the risk of trafficking, including gang activity, a history of childhood abuse, and poverty. Substance abuse also plays a key role (De Chesnay, 2013; Moore et al., 2017; O’Brien, 2018).



Substance abuse within families is a risk factor for children becoming the victims of trafficking (Hardy et al., 2013; Miller-Perrin & Wurtele, 2017). Parents or other family members with an addiction can force youth into sexual exploitation, selling or trading them to support their drug addiction (De Chesnay, 2013; Litam, 2017). Traffickers often force substance use on victims in order to control and sexually exploit them (De Chesnay, 2013; Gerassi, 2015; Hodge, 2014; Hom & Woods, 2013; Litam, 2017; Moore et al., 2017). Substance abuse also may be a way for trafficking victims to cope with the abuse they endure (Miller-Perrin & Wurtele, 2017).


Trafficking victims who engage in substance abuse usually experience detrimental personal outcomes, including an increased likelihood of engaging in high-risk behaviors (i.e., unprotected sex), infection from needles, and overdosing (Gerassi, 2015; Zimmerman et al., 2011). They often commit drug-related crimes for their trafficker and are therefore at risk of arrest and conviction for prostitution and drug offenses (Litam, 2017; Miller-Perrin & Wurtele, 2017; Zimmerman et al., 2011). Arrests, drug charges, substance abuse, and violent clients can trap trafficking victims in a vicious circle of re-traumatization by their traffickers, their potentially abusive consumers, and the criminal justice system (Gerassi, 2015; Zimmerman et al., 2011).


Impact on Physical and Mental Health

A concern for children who fall prey to sex trafficking is the impact these experiences have on their development. Not only are victims affected by educational deprivation, but trafficking also causes serious harm to their psychological, spiritual, and emotional development (Miller-Perrin & Wurtele, 2017; Rafferty, 2008; Sanchez & Stark, 2014). Child victims suffer from an increased risk of several emotional problems such as guilt, shame, anxiety, hopelessness, and loss of self-esteem (Miller-Perrin & Wurtele, 2017; Rafferty, 2008). Some of the mental health consequences for child victims include depression, dissociation, post-traumatic stress disorder (PTSD), eating disorders, somatization, poor attachment, antisocial behaviors, substance use disorders, self-harm, and suicidality (Kiss et al., 2015; Miller-Perrin & Wurtele, 2017; Rafferty, 2008). Furthermore, because of the exposure to the violence and sexual assault linked to trafficking, child victims have been found to be at higher risk of sexually transmitted infections, reproductive health problems from unsafe abortions, fractures, genital lacerations, malnutrition, and dental problems (Miller-Perrin & Wurtele, 2017).


Trafficking poses significant risk to child victims’ long-term mental health. Survivors trafficked in childhood report a high prevalence of mental health problems such as depression, anxiety, and PTSD. These mental health problems also affect adult victims (Hom & Woods, 2013; Oram et al., 2016). Among women who have survived trafficking, there are increased rates of anxiety and stress disorders, disassociation, depression, personality disorders, low self-esteem, suicidal ideation, and poor interpersonal relationships (Sanchez & Stark, 2014). Additionally, somatic symptoms such as headaches, fainting, and memory problems are commonly reported among women who are victims of trafficking (Oram et al., 2016). A high prevalence of sexually transmitted infections has been reported in both men and women (Hom & Woods, 2013; Oram et al., 2016; Sanchez & Stark, 2014). Borschmann et al. (2017) found high rates of self-harm among adult victims of human trafficking.


Pregnancy is a common occurrence for trafficked women (Bick et al., 2017; Gerassi, 2015; Hom & Woods, 2013; Oram et al., 2016; Sanchez & Stark, 2014). Several barriers to maternity services have been identified for pregnant victims, including traffickers preventing women from seeking care and the victims feeling reluctant because they might not have valid documents (Bick et al., 2017). Additionally, children and family members are often used by traffickers to threaten and coerce victims, which further isolates victims and distances them from their families (Hardy et al., 2013; Hodge, 2014; Juabsamai & Taylor, 2018; Sanchez & Stark, 2014).


Sex trafficking often involves the exploitation of victims by force, and the brutal nature of the crime can cause complex mental health problems for victims (Gerassi, 2015; Greer & Davidson Dyle, 2014; Hodge, 2014; Hom & Woods, 2013; Litam, 2017). Victims endure high levels of trauma, and survivors show increased rates of depression, anxiety, PTSD, and substance use disorders (Gerassi, 2015). The goal of traffickers is to physically and psychologically break victims down into subservience (Hodge, 2014). Not only are victims forced to engage in humiliating sexual acts and use substances, but traffickers also use recurrent beatings, rape, and even murder as tactics to control their victims (De Chesnay, 2013; Gerassi, 2015; Hodge, 2014; Hom & Woods, 2013; Litam, 2017). Victims may believe that the traffickers have their best interests in mind and develop significant bonds with their traffickers, similar to Stockholm syndrome, and may be reluctant to escape (De Chesnay, 2013; Hodge, 2014; Hom & Woods, 2013; Litam, 2017). In addition, victims of sexual exploitation have not only endured physical and emotional abuse from their traffickers, but there also is a strong correlation with childhood abuse (Gerassi, 2015; Miller-Perrin & Wurtele, 2017). However, issues of physical and mental health tend to be exacerbated by issues of economic deprivation and racial inequality. These factors may act as a catalyst for putting individuals more at risk of human trafficking (Greer, 2013).


Multicultural Considerations

Sex traffickers often target vulnerable individuals, including runaway and homeless youth; victims of domestic abuse or sexual assault; victims of war; and individuals who experience social discrimination, including gender, racial, ethnic, and socioeconomic inequality (Anthony et al., 2017; Miller-Perrin & Wurtele, 2017). For example, LGBTQ homeless youth account for 20% of the homeless youth population in the United States, yet 58.7% of homeless LGBTQ youth are victims of sex trafficking (Martinez & Kelle, 2013). Martinez and Kelle (2013) further noted that this figure is significantly higher than the 33.4% of the heterosexual homeless youth. Furthermore, LGBTQ youth are more than seven times more likely to experience acts of violence than their cisgender peers (Anthony et al., 2017). Trafficking often affects victims of poverty. Studies of sexual exploitation and domestic sex trafficking also have reported higher rates of violence against women of color, especially African American women, and undocumented immigrants (Gerassi, 2015; Zimmerman & Kiss, 2017).


Finally, individuals with intellectual disabilities are at risk because of an unfamiliarity with sexual activities and an inability to understand the nature of sexual abuse and exploitation (Reid, 2018). As a result, such individuals are at a higher risk of becoming victims of trafficking (Greer & Davidson Dyle, 2014; Hodge, 2014; Miller-Perrin & Wurtele, 2017; Reid, 2018).


Returning Home

Women who have been victims of trafficking have often been found to come from abusive households (Gerassi, 2015; Hom & Woods, 2013; O’Brien, 2018; Oram et al., 2016). As a result, once victims are free from their traffickers, they have often been found to not only lack social support but also lack basic needs such as shelter and financial support (Hom & Woods, 2013; Le, 2017; Oram et al., 2016). Reconciliation with supportive family often plays a key role for trafficking survivors; however, because of stigma, some victims are met with shame and judgment from their families and are not welcomed (Hom & Woods, 2013; Juabsamai & Taylor, 2018; McCarthy, 2018; Zimmerman & Kiss, 2017).


Unfortunately, it is not uncommon for victims to be exploited by someone they know and love. Oftentimes a trafficker is a family member, intimate partner, friend, or acquaintance (Gerassi, 2015; Hardy et al., 2013; Hom & Woods, 2013; Le, 2017; Miller-Perrin & Wurtele, 2017; Moore et al., 2017), which further complicates survivors’ ability to establish trusting relationships. Moreover, law enforcement may charge adult victims with prostitution. Not only is the victim caught in legal limbo, but they are re-victimized by law enforcement (Sanchez & Stark, 2014). Finally, female survivors who socialize with men after being freed from their traffickers have reported being triggered with memories of their abusive experiences, further affecting their ability to develop healthy, stable relationships and social support (Hom & Woods, 2013).


Victims of human trafficking have often been robbed of their identities, had their self-esteem demolished, and already experienced physical and psychological abuse before they became victims of human traffickers. Once they leave their traffickers, survivors have a variety of immediate, short-, and long-term needs that must be addressed to help promote resiliency while they are reintegrating into the community (Busch-Armendariz et al., 2014; Graham et al., 2019; Hom & Woods, 2013; Le, 2017; McCarthy, 2018; O’Brien, 2018; Twigg, 2017). Immediate needs include ensuring safety; finding medical care, food, shelter, clothing, and counseling; and acquiring identification, language interpretation services, and legal and immigration assistance (Busch-Armendariz et al., 2014; Graham et al., 2019; Hom & Woods, 2013; McCarthy, 2018; Polaris, n.d.-a; Twigg, 2017). Education, employment, and establishing friendships have been identified as vital ongoing needs to successfully alleviate stress while reintegrating into the community (Hom & Woods, 2013; McCarthy, 2018; O’Brien, 2018; Polaris, n.d.-a; Twigg, 2017). However, it is important to note that survivors are often met with substantial challenges while seeking basic services. For instance, many programs may be underfunded or ill-equipped to handle the high demand for services (Polaris, n.d.-a). This reaffirms the crucial need to meet survivors with empathetic and nonjudgmental attitudes to help prevent re-victimization and a return to traffickers (Anthony et al., 2018; Hodge, 2014; Hom & Woods, 2013; McCarthy, 2018).


Family support can provide survivors with significant protection while reintegrating into the community. Reconnecting with family typically increases the likelihood of a sustainable return process (McCarthy, 2018; Twigg, 2017). However, reconciliation might require a careful approach, as the process can be met with difficulties, including stigma, dysfunctional family environments, or the family’s direct involvement with the victim’s trafficking (Le, 2017; McCarthy, 2018; Twigg, 2017; Zimmerman & Kiss, 2017). In some cases, shame within a cultural context is a prohibitive factor for many to return to their families because of the association with prostitution or having been trafficked (Hom & Woods, 2013). As a result, it is necessary to provide comprehensive, culturally sensitive interventions for trafficking survivors (Hodge, 2014; Hom & Woods, 2013; Le, 2017; McCarthy, 2018). Family continues to be essential to survivors’ sense of identity, and, upon return, cultural beliefs and values that previously formed their self-concept remain influential to survivors (Le, 2017). Many women have noted that marriage and children play an integral role in successfully reintegrating into their community and gaining acceptance from family members (McCarthy, 2018). However, issues of economic deprivation and racial inequality act as a barrier to successful community reintegration and put an individual at higher risk for trafficking (Greer, 2013).


This brief literature review has confirmed that victims of human trafficking suffer from a wide array of mental health concerns, including PTSD, depression, anxiety, and substance abuse, and from stigma associated with being victims of human trafficking. Mental health treatment should address these complex concerns and provide for comprehensive assessment and treatment planning.

Treatment Challenges

Working with trafficked clients poses a series of challenges for counselors because an intervention modality specific to sex-trafficked survivors has yet to be developed (Hopper et al., 2018; Jordan et al., 2013). Treatments are borrowed from evidence-based interventions initially developed for PTSD, domestic violence, and captivity, and a holistic approach is essential (De Chesnay, 2013; Hom & Woods, 2013; Jordan et al., 2013). Four essential practices for providers include ensuring safety and confidentiality, engagement of trauma-informed care, performing a comprehensive needs assessment, and delivery of comprehensive case management that coordinates physical and mental health and legal services. As a result of the multiple traumas trafficking victims endure, the path to restoring wellness is often long and complex, requiring additional time and patience from mental health counselors (Hodge, 2014; Hom & Woods, 2013).


Mental health counselors should conduct a needs assessment to identify the physical, emotional, and spiritual needs of trafficking survivors (Hodge, 2014; Hom & Woods, 2013). Survivors are often in need of medical treatment, as traffickers do not bother with preventative care or what they may consider minor treatment and only allow victims to seek treatment when a condition interferes with earning money (De Chesnay, 2013). Similarly, survivors are often resistant to seek help from mental health providers because of fear of physical violence or threats of retaliation from their traffickers if they disclose their circumstances (De Chesnay, 2013; Hodge, 2014; Litam, 2017). Survivor-centered approaches are recommended initially to acknowledge and validate the survivor’s experience, give the survivor control, and build a sense of safety and trust (Hodge, 2014; Hom & Woods, 2013; Twigg, 2017).


However, after months or years of abuse, trafficking survivors often need a wide array of services to meet their distinctive needs (Hodge, 2014; Hom & Woods, 2013; McCarthy, 2018; Polaris, n.d.-a). The U.S. government has enacted several policies to help victims of trafficking, including the Victims of Trafficking and Violence Protection Act of 2000, which allows victims who have been trafficked from abroad to be issued visas, enabling them to reside in the United States (Davy, 2016; Hodge, 2014). Survivors need to be met with nonjudgmental attitudes, acceptance, understanding, and genuine concern, and they should be slowly encouraged to take on risks associated with leaving their traffickers (Hodge, 2014; Hom & Woods, 2013; McCarthy, 2018). Providing survivors with emotional support and encouragement opposes the isolated world created by their trafficker. Survivors have explained that street outreach programs can play an essential role in establishing contact, allowing victims to become aware of the resources available and begin breaking down the sense of isolation (Hom & Woods, 2013). Additionally, it is vital to empower survivors so that they can understand they are in control (Anthony et al., 2018; Hodge, 2014; Hom & Woods, 2013; Twigg, 2017). Research on resiliency has found creativity, humor, flexibility, and movement are important factors in improving self-esteem, prosocial behaviors, and hope among traumatized individuals (Litam, 2017).


Evidence-Based Treatment
     Counselors working with trafficking survivors should be equipped to use several trauma-sensitive interventions to assist with the individual needs of each survivor (Busch-Armendariz et al., 2014; De Chesnay, 2013; Hardy et al., 2013; Hodge, 2014; Hom & Woods, 2013; Litam, 2017; Miller-Perrin & Wurtele, 2017; Twigg, 2017). Trauma-sensitive interventions recognize safety as the foundation for working with individuals to end self-harm, develop trusting relationships, overcome obstacles, leave dangerous situations, and promote wellness (Hopper et al., 2018). Although it may be painful for trafficking survivors to verbalize their traumatic experiences, creative therapies offer alternative methods of communication and expression (De Chesnay, 2013; Litam, 2017).


Although evidence-based practices for treating sex-trafficking survivors are not widespread, counseling techniques exist that have been shown to be effective with child sex abuse victims, including trauma-focused cognitive behavioral therapy and dialectical trauma-focused cognitive behavior therapy (De Chesnay, 2013; Twigg, 2017). Similarly, participating in group counseling can empower survivors of sex trafficking and provide them with an opportunity to share their experiences, generating a sense of community and support (Hopper et al., 2018). Peer support has been noted to be a vital component of intervention, both as a motivating factor to remain in treatment and as help in the prevention of survivors returning to their traffickers (De Chesnay, 2013; Litam, 2017; Twigg, 2017). Furthermore, discussing stigmatized topics within group settings can help reduce shame, as it is common for trafficked survivors to feel that no one else has gone through similar situations (Hickle & Roe-Sepowitz, 2014; Litam, 2017). Having a setting to address the shame can help survivors recognize the commonality of their experiences and build support (Countryman-Roswurm & Bolin, 2014; Litam, 2017).

Family Therapy

As human trafficking affects individuals, families, and communities, it is necessary to adopt treatment models that engage families and communities as well as individual-based treatment models. Twigg (2017) found that survivors require and benefit from therapeutic support in order to achieve successful family and community reunification. However, like individual treatment, family therapy models specific to human trafficking survivors do not exist, but current family therapy models developed around trauma could be adapted for use with human trafficking survivors. Apsche et al. (2008) developed Family Mode Deactivation Therapy, a cognitive behavior family therapy model for use with youth and families in residential treatment that uses ongoing assessment and community skill development to reduce the behavioral symptoms associated with trauma. The researchers found this model reduced recidivism more effectively than a non–family-based approach. Hughes (2017) developed an attachment-focused family treatment for children who have experienced developmental trauma. This two-phase treatment provides therapy to a caregiver first, then transitions to joint sessions to reframe the trauma experience.


Similarly, using ecologically based family therapy with individuals involved in sex trafficking has been found to improve outcomes for sobriety and depression (Murnan et al., 2018). Agani et al. (2010) recommended the use of the linking human systems community resilience model, which is based on transgenerational and ecosystemic structural family therapies. This model focuses on identifying the strengths of community and family members, bringing them together to encourage their competency and using community leaders to solve problems. Other novel approaches to working with survivors of crime include the Family Group Project, which involves group therapy aimed at recreating a family environment to re-integrate survivors into the community (Allen et al., 2015).

A Survivor’s Story

Research provides one perspective on the plight of human trafficking victims and survivors, but a first-person account provides insight to the worldview of an actual survivor. One of the authors met with a human trafficking advocate in order to gain further perspective on the needs of survivors. The advocate, who requested that the author provide no identifying information beyond her gender, disclosed during the interview that she was a survivor who had been trafficked by her husband. Her trafficker had been blackmailing a John, a term commonly used for an exploitive consumer. She was arrested during a raid and remained in jail for 3 months because she refused to say anything. She explained that it took her a year to build up the strength and courage to testify in court because her trafficker blackmailed her. He threatened to tell her family about the exploitative acts and substance use, which he forced her to engage in. He would say, “Do you really want your family to know what you have been up to?” However, once her family was notified of her predicament, she reported that her family members provided emotional support. She explained that it was through their support she was able to come forward and testify.


Although she came forward and testified against her trafficker, she was not viewed as a victim, and she was charged with prostitution. As she explained, advocates are trying to change the legislation and work with police in her local area so that human trafficking victims are not charged with crimes. For instance, not only was she charged with prostitution, but she also had to pay the John $3,000, the money her trafficker had stolen from him. Despite never having seen the money, she was ordered to repay it and was placed on a repayment schedule. Even more disheartening, her trafficker made a plea deal and did not have to repay any money and the charges of trafficking were dropped. All these events provide an example of how the legal system can re-victimize a survivor. Although she had been the victim of trafficking, which stigmatized her, she also was told that she owed money to someone her trafficker had stolen from, thus re-victimizing her.


The charge of prostitution remained on her record and became something she had to explain to potential employers. With the support of her family and by attending therapy, she was able to rebuild her life. She had a bachelor’s degree in social work when she met her ex-husband and was able to obtain her limited license. She decided to pursue a master’s degree and was once again faced with the challenge of disclosing the charge on her record and reliving the trauma of explaining what happened. The first university she applied to denied her application, and this placed her in a deep depression; however, she was accepted at another university and after graduating became an advocate for survivors of human trafficking. She also shared that although it took time to be able to trust someone again, she has established an intimate relationship and will soon be married.




Counselors treating a human trafficking survivor need to develop a wide-ranging view of assessment, treatment, case management, support, advocacy, and termination from counseling. Human trafficking survivors suffer from a complex variety of developmental, mental health, and social issues that require counselors to not only engage the individual in treatment, but also to act as an advocate against stigma within their family and the community.


The myriad of issues faced by these individuals, from navigating the criminal justice system, coping with multiple layers of physical and emotional trauma, overcoming substance abuse, overcoming family and community alienation, coping with dual stigmas of human trafficking and mental health diagnoses, to finally reintegrating into daily work and life, require counselors to be vigilant in the assessment process. Counselors need to consider assessment an ongoing extensive process that should occur throughout every session and focus not just on mental health needs, but also on physical health and basic needs, and career support. Counselors will need to assess risk of the individual returning to the trafficker and have referrals ready to help the client stay safe. Human trafficking survivors will need a counselor able to quickly identify short-term crisis needs during long-term treatment.


When entering the treatment phase, counselors need to research multiple treatment modalities that may not directly relate to human trafficking but may support the client. For example, a counselor will need to navigate working with substance use, trauma, family issues, and career concerns. Counselors will need to widen their view of their role within the therapeutic relationship. Human trafficking survivors may require case management services more than long-term counseling when first entering care, yet the need to build a strong therapeutic relationship is paramount for ongoing treatment. The counselor should consider taking on the case management role as needed to promote consistency in the treatment process. As an advocate, the counselor will need to engage multiple individuals and systems into the treatment process to ensure comprehensive care. Counseling skills aimed at engaging families, law enforcement personnel, legal personnel, and medical professionals in treatment are essential for treating survivors. Counselors would also benefit from strength-based approaches with this population, as research indicates survivors most benefit from being able to identify their own qualities of self-protection and resiliency, which empowers their recovery process. This empowerment also allows for a supportive termination process, ensuring that the survivor has ongoing access to a support network in order to facilitate long-term recovery.


Conflict of Interest and Funding Disclosure
The authors reported no conflict of interest
or funding contributions for the development
of this manuscript.



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Kathryn Marburger is a graduate student at the University of Detroit Mercy. Sheri Pickover, PhD, LPC, is an associate professor at Central Michigan University. Correspondence can be addressed to Sheri Pickover, 195 Ojibway Court, Mt. Pleasant, MI 48859, picko1s@cmich.edu.

An Exploratory Factor Analysis of the Sexual Orientation Counselor Competency Scale: Examining the Variable of Experience

Shainna Ali, Glenn Lambie, Zachary D. Bloom

The Sexual Orientation Counselor Competency Scale (SOCCS), developed by Bidell in 2005, measures counselors’ levels of skills, awareness, and knowledge in assisting lesbian, gay, or bisexual (LGB) clients. In an effort to gain an increased understanding of the construct validity of the SOCCS, researchers performed an exploratory factor analysis on the SOCCS with a sample of practicing counselors who were members of the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) and counselors-in-training (N = 155) enrolled in four Council for Accreditation of Counseling & Related Educational Programs (CACREP)-accredited counseling programs. The data analyses resulted in a 4-factor model, 28-item assessment that explained 56% of the variance. In acknowledging the loading of the fourth factor, this result highlights the need to focus on involvement and engagement in clinical practice in order to maintain best practice standards. Furthermore, the fourth factor of experience adds a compelling perspective to consider when understanding, improving, and maintaining sexual orientation counselor competence.

Keywords: sexual orientation, counselor competence, exploratory factor analysis, best practice standards, SOCCS

In order for counselors to be ethical and effective professionals, they must be competent in providing services to sexual minority clients (Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling [ALGBTIC], 2013). The American Counseling Association’s (ACA) 2014 ACA Code of Ethics requires that counselors honor the uniqueness of clients in embracing their worth, potential, and dignity. Additionally, counselors should actively attempt to understand client identity, refrain from discrimination, and utilize caution when assessing diverse clients (ACA, 2014). Furthermore, the Council for Accreditation of Counseling and Related Educational Programs (CACREP) 2009 Standards for Accreditation assert that counselors should understand identity development, develop self-awareness, promote social justice, and strive to eliminate prejudices, oppression, and discrimination. Therefore, it is both ethical and essential to empirically explore competence assessments in order to improve overall counseling competence.

Sexual minority clients are at risk for a myriad of concerns such as shame, depression, risky behaviors, self-harm, abuse, and suicide (Cooper, 2008; Degges-White & Myers, 2005; Human Rights Campaign, 2014; McDermott, Roen, & Scourfield, 2008). In order to align with the intended population of the Sexual Orientation Counselor Competency Scale (SOCCS; Bidell, 2005), sexual minority clients are defined as individuals who identify as lesbian, gay, or bisexual (LGB). Since the 1970s, researchers have identified the importance of counseling for LGB individuals, as these clients have a higher propensity for suicide and substance abuse as compared to heterosexual populations (Cass, 1983; Cooper, 2008; Degges-White & Myers, 2005; McCarn & Fassinger, 1996; Troiden, 1979, 1989). Furthermore, at the turn of the 21st century, researchers began to note the importance of competence in providing effective counseling services to sexual minority clients (Bidell, 2005; Brooks & Inman, 2013; Graham, Carney, & Kluck, 2012; Grove, 2009; Israel & Selvidge, 2003).

Bidell (2005) developed the SOCCS in an effort to measure counselors’ awareness, skill, and knowledge competencies in assisting LGB clients. Initial research findings supported the criterion, concurrent, and divergent validity, and the internal consistency and test-retest reliability of the SOCCS with the norming population; however, the factor structure (construct validity) of the SOCCS with the norming population was questionable (i.e., 40% of the variance explained by the 29-item SOCCS). Therefore, additional research is warranted to examine the construct validity of the SOCCS with a different sample of counseling professionals, as construct validity provides a central understanding to whether or not the assessment: (a) measures the intended competencies, (b) is adequately explicated by a 3-factor structure, and (c) is best comprised of 29 items (Gall, Gall, & Borg, 2006). Consequently, the purpose of the present study was to examine the factor structure of the SOCCS with a sample of counseling practitioners and counselors-in-training to gain an increased understanding of the construct validity of the SOCCS. The findings of the present study add a new perspective, as the results display a potential 4-factor structure that warrants consideration in the literature.

Sexual Orientation Counselor Competency Scale

The SOCCS (Bidell, 2005) is a 29-item instrument designed to measure counselors’ level of competence in working with clients identifying as LGB. The SOCCS was developed based on the LGB-affirmative counseling and multicultural counseling competencies (Sue, Arredondo, & McDavis, 1992) and included an item pool of 100 items that was reduced to 42 items with 12 items pertaining to skills, 12 items to awareness, and 18 items to knowledge. Bidell (2005) examined the factor structure of the SOCCS using exploratory factor analysis (EFA) with a principal axis factoring (PAF) and an oblique rotation, identifying a 3-factor structure: (a) Factor 1: Skills (11 items, 24.91% of the variance explained), which assesses counseling skills in working with LGB clients; (b) Factor 2: Awareness (10 items; 9.66% of the variance explained), which measures counselors’ awareness of biases and attitudes about LGB individuals; and (c) Factor 3: Knowledge (8 items, 5.41% of the variance explained), which assesses counselors’ understanding about the LGB population.

Factor Analysis

Bidell (2005) also examined the criterion, convergent, and divergent validity of the SOCCS with his sample. Criterion validity of the SOCCS was examined using participants’ education level and self-identified sexual orientation. A positive relationship was identified between the participants’ SOCCS subscale scores and their level of education and sexual orientation. Convergent validity was examined by measuring the relationship between SOCCS subscale scores and participants’ Attitudes Toward Lesbians and Gay Men Scale (Herek, 1998), the knowledge subscale of the Multicultural Counseling Knowledge and Awareness Scale (Ponterotto et al., 1996), and the skills subscale of the Counselor Self-Efficacy Scale (Melchert, Hays, Wiljanen, & Kolocek, 1996). The results of the correlational analyses supported the convergent validity of the SOCCS. Discriminant validity was examined by comparing the mean social desirability scores with the SOCCS subscale scores, and results supported the divergent validity of the SOCCS within the norming sample.

Norming Population of the SOCCS

The norming population for the SOCCS (Bidell, 2005) consisted of 312 mental health students, providers, and educators from across the United States. The majority of the sample was comprised of females (n = 235) and the average age was 31.9 years old. Individuals were recruited from 13 public and three private universities. More than 80% of the population included students: (a) 47 were undergraduates from an undergraduate introduction to counseling course, (b) 154 were master’s- level students in school or community counseling programs accredited by CACREP, (c) 32 were doctoral students from a CACREP-accredited counselor education program, and (d) 30 were from university internship sites approved by the American Psychological Association. The non-student portion of the population was comprised of 49 doctoral-level counselor education supervisors. A majority of the population (85.5%) identified as heterosexual, 12.2% identified as LGB, and 2.5% chose to not identify. Bidell (2005) noted the limited gender variance in the development of the SOCCS, as it is possible that individuals within the 2.5% may identify on the gender continuum. More than half of the norm group (n = 191) identified as European American or White, 41 as Latino, 32 as Asian American, 22 as African American or Black, seven as biracial or mixed, and four as Native American. Fourteen individuals identified as “other,” and this may have been because of rigid racial denominations provided in the demographics.

Interpretation of the SOCCS

The SOCCS (Bidell, 2005) is a criterion-referenced measure consisting of rating scales. The SOCCS provides respondents with a range of seven choices to self-report on the three subscale domains (Skills, Awareness, and Knowledge): from (a) not at all true, to (b) moderately true, and to (c) totally true. Eleven of the 29 SOCCS items (2, 10, 11, 15, 17, 21, 22, 23, 27, 28, and 29) are reverse scored, and overall competence is interpreted by the sum of the items divided by the total number of items (29) to form a percentage score. Bidell (2005) does not provide information on criteria to determine low, moderate, or high competence; however, inferences can be made from interpreting the overall and subscale scores (Farmer, Welfare, & Burge, 2013).

The overall mean SOCCS (Bidell, 2005) score in the norm group was 4.64 (SD = 0.89). Subscale mean SOCCS scores included 2.94 (SD = 1.53) for Skills, 6.49 (SD = 0.79) for Awareness, and 4.66 (SD = 1.05) for Knowledge. Graham, Carney, and Kluck (2012) sampled 234 counseling students and found mean SOCCS averages for competence were 3.88 for Factor 1: Skills, 6.52 for Factor 2: Awareness, 4.67 for Factor 3: Knowledge, and 5.01 for overall SOCCS scores. Follow-up studies continue to support the original theme in which individuals believe they are more aware but less knowledgeable; furthermore, individuals believe they have less skills than knowledge pertaining to sexual minority counselor competencies (Bidell, 2012; Farmer et al., 2013; Grove, 2009; Rutter, Estrada, Ferguson, & Diggs, 2008).

In addition, Graham and colleagues (2012) also assessed for potential differences in SOCCS scores between individuals who have or have not attended a conference presentation, workshop, or training pertaining to LGB issues. No difference in SOCCS scores was identified between participants reporting that they attended a conference presentation with subject matter pertaining to LGB counseling or not; however, individuals who attended a workshop had higher competency scores in Skills, F (1, 225) = 61.03, p < .001; Awareness, F (1, 225) = 4.42, p < .05; and Knowledge, F (1, 225) = 4.34, p < .05. Additionally, individuals who attended a training session had higher scores in the domains of Skills, F (1, 225) = 32.07, p < .001; Awareness, F (1, 225) = 33.62, p < .001; and Knowledge, F (1, 225) = 33.62, p < .001; and when compared to individuals who did not attend similar trainings. Furthermore, more experience with LGB clients yielded higher competency scores. A Tukey’s post hoc analysis identified that individuals who had never provided counseling services to LGB clients had lower SOCCS scores (M = 4.43, SD = 0.72) than individuals who had provided services to one to five LGB clients (M = 4.99, SD = 0.66), six to 10 LGB clients (M = 5.57, SD = 0.55), 11 to 15 LGB clients (M = 5.59, SD = 0.57), or more than 15 LGB-identified clients (M = 5.78, SD = 0.50). Therefore, the differences in SOCCS scores suggest that more exposure and experience with LGB clients could improve sexual minority counseling competence.

Factor Analysis of the Original Instrument

The SOCCS (Bidell, 2005) coefficient alpha for internal consistency reliability was found to be .90. The subscale scores for internal consistency were .91 for Skills, .88 for Awareness, and .71 for Knowledge. A subsection of the sample (n = 101) including students and supervisors was used for test-retest reliability. One-week test-retest reliability was found to be .84 for the overall instrument, .83 for the Skills subscale, .85 for the Awareness subscale, and .84 for the Knowledge subscale (Bidell, 2005). In addition, Bidell (2013) investigated the potential for SOCCS scores to change after implementation of an LGB counseling course six weeks into the program, and identified that the participants’ scores were significantly higher on the overall and subscale scores. Bidell’s (2013) findings identified the ability for education to promote SOCCS scores in counseling students but challenged the test-retest reliability of the SOCCS. No published data was identified related to the inter-rater reliability or alternate forms of the SOCCS.

Additional Factor Analysis of the SOCCS

Carlson, McGeorge, and Toomey (2013) examined the factor structure of the SOCCS with a sample of 248 master’s and doctoral students in couple and family therapy and identified a 2-factor solution: (a) Factor 1: Awareness and (b) Factor 2: Knowledge and Skills. Further, three SOCCS items (i.e., 5, 24, 25) did not load into the combined Knowledge and Skills subscale and were removed. The second examination resulted in an acceptable model fit x2 (df = 8) = 20.65, p < .01; however, it should be noted that five SOCCS item stems (i.e., 3, 4, 7, 8, 19) were altered and the 7-point scale was adapted to a 6-point scale. Therefore, based on the modifications made to the SOCCS, it is difficult to compare the factor structure results to other investigations using the unmodified SOCCS.

Counseling Competency With Sexual Minority Clients

Researchers have utilized the SOCCS in an effort to further their understanding of counseling competencies related to working with sexual minority clients (Brooks & Inman, 2013; Graham et al., 2012; Grove, 2009). Grove (2009) provided counseling students (n = 56) with the SOCCS, and an ANOVA identified that years in training provided a significant difference in scores for Skills (p = .002), Awareness (p = .05), and Knowledge (p = .001). Although analyses were not conducted to determine the differences between subscales, Grove noted high scores in the Awareness subscale. Although individuals have strong, affirmative attitudes, they may lack the knowledge and subsequent skills necessary to effectively aid LGB clients. These SOCCS scores may be interpreted to show a variety of concerns such as inflated confidence, potential lack of training, and low competency. Graham and colleagues (2012) utilized the SOCCS with counselor education and counseling psychology graduate students (n = 234) and yielded similar results to Grove. Participants scored highest on the Awareness subscale, followed by the Knowledge and Skills subscale scores. These research findings identify that counselor trainees may not be receiving the necessary knowledge and skills to become competent counselors in working with sexual minority clients.

Advances have been made in the counseling field regarding the understanding of competency in aiding sexual minority clients (Bidell, 2005; Graham et al., 2012; Grove, 2009); however, additional research is warranted. The commonly utilized SOCCS is a self-report measure; therefore, there is potential for participants to provide socially desirable answers. Further, because the SOCCS was created to measure counselors’ level of confidence (self-efficacy) in providing counseling services to LGB clients, the literature has followed this narrow lead (Bidell, 2013; Carlson et al., 2013; Grove, 2009) . The SOCCS was created prior to ALGBTIC’s (2013) guidelines; therefore, the items may not align with the essential aspects of the guidelines. Considering this potential gap, it is essential to explore the psychometric properties of the SOCCS (Bidell, 2005). Nevertheless, the SOCCS is the most used assessment instrument for examining LGB counselor competence in training and research; hence, it is important to explore the reliability and validity of the instrument in order to support continued exploration of LGB counselor competence. Therefore, we aimed to examine the factor structure of the SOCCS with a sample of counselor trainees and practitioners in order to gain an increased understanding of the psychometric properties of this assessment. The following research questions guided our investigation:

Research Question 1. What is the factor structure of the SOCCS with a sample of practicing counselors and counselors-in-training?

Research Question 2. What is the internal consistency reliability of the SOCCS with a sample of practicing counselors and counselors-in-training?



We aimed to examine the factor structure of the SOCCS with a sample of practicing counselors and counselors-in-training. The data used for this investigation were part of a larger study regarding counselors’ preparedness to assist clients in the coming-out process. Because online surveys tend to have a lower response rate (Shih & Fan, 2009), we decided to use additional intentional data collection methods in our sampling to achieve a sample of counselors-in-training and practicing professionals. The data collection assessments were distributed through ALGBTIC in order to acquire a national sample of counseling professionals and to include individuals who may perceive themselves as competent to work with sexual minority individuals. In addition, the data collection assessments were distributed to counselors-in-training enrolled in four CACREP-accredited counseling programs in four different southeastern states with the assumption that the student population would help to cover the domain of individuals who do not believe they are competent to assist sexual minority clients in counseling. We received a total of 200 responses, which gave us a response rate of 28.41%. However, because of missing data, 45 participants were eliminated, leaving 155 (22.02%) usable cases. Although the response rate was less than the weighted average Van Horn, Green, and Martinussen (2009) noted in their meta-analysis of counseling and clinical psychology journals (49.6%), we decided our response rate was adequate to continue because of the necessity of research on the factor structure of the SOCCS and the potential value of the implications on improving counseling services for sexual minority clients. Additionally, the demographics of the sample mirrored the overall population (i.e., a majority of the participants identified as white and female), which is presented in Table 1 (U.S. Census Bureau, 2016).


Our university’s institutional review board approved this study prior to any data collection and recruitment. We implemented the Tailor Design Method (Dillman, Smyth, & Christian, 2009) in our recruitment and data collection (e.g., invitation, survey). We utilized Qualtrics, an electronic survey research tool, to assemble our informed consent, data collection instruments, and demographic questionnaire online. Qualtrics permitted us to collect anonymous data. After data collection, Statistical Package for the Social Sciences (Windows Version 20) was used for data cleaning and analysis.

Data Screening

 Before we analyzed our data, we screened our dataset. First, we needed to remove responses with at least one incomplete item from the overall data set to promote consistency (Warner, 2013). Listwise deletion resulted in the removal of 45 cases, resulting in 155 completed data collection packets for the investigation. SOCCS item scores were converted to standardized z-scores to determine if outliers

Table 1

Participants’ Demographic Characteristics                                                               

Characteristic                                                              n                        Total Percent           


Female                                                             121                              82.9

Male                                                                              24                              16.4

Ethnic Background

African American/African/Black                                  14                                 9.7

Asian/Asian American                                                    6                                 3.9

Biracial/Multiracial                                                          9                                 5.8

Caucasian (Non-Hispanic)                                          105                              67.7

Hispanic/Latina/Latino                                                   7                                 4.5

Other                                                                               2                                 1.3

Chose not to specify                                                       2                                 1.3

Sexual Orientation

Bisexual                                                                          8                                 5.2

Gay                                                                                 5                                 3.2

Heterosexual                                                                 71                              45.8

Lesbian                                                                            7                                 4.5

Other                                                                               3                                 1.9

Professional Status

Student                                                                       102                              61.5

Clinician                                                                        43                              33.3


Accredited                                                                    73                              46.8

Not Accredited                                                             20                              12.8


21–25                                                                            70                              45.2

26–30                                                                            27                              17.4

31–35                                                                            16                              10.3

36–40                                                                            13                                 8.4

41–45                                                                              4                                 2.6

46–50                                                                              7                                 4.5

51–55                                                                              1                                   .6

56–60                                                                              6                                 3.9

61–65                                                                              1                                   .6

            66–70                                                                              1                                   .6

Note. N = 155

existed in the data, and the results identified that no scores were greater than +4 or less than -4; therefore, no outliers were identified (Hair, Black, Babin, Anderson, & Tatham, 2010). Next, we examined the appropriateness of the sample size to conducting an EFA. Smaller sample sizes are suitable for EFA if several solutions have high loading variables (above .80; Tabachnick & Fidell, 2013). In addition, rather than sample size, the ratio of assessment items to participant may be used to determine appropriateness of data for EFA (Dimitrov, 2012; Nunnally, 1978; Tabachnick & Fidell, 2013), with a five participant cases-to-item ratio deemed acceptable. Because there were more than five cases per SOCCS item (5.34:1), we determined this sample size was appropriate for EFA. Our next step was to examine the normality of the data and determine the most appropriate method of extraction. To assess for normality of our data, we checked the univariate normality of each SOCCS item, and if item univariate normality was satisfied, we checked multivariate normality using the Mardia test (Mvududu & Sink, 2013). We identified several SOCCS items that were not normally distributed; therefore, multivariate normality was not examined because univariate normality is a necessary condition of multivariate normality (Mvududu & Sink, 2013). In addition, our histograms, boxplots, and Q-Q Plots results identified that multiple SOCCS items were non-normally distributed; hence, we assumed the data was non-normally distributed, which can occur in social science research (Mvududu & Sink, 2013).

Data Analysis

After screening the dataset for missing data and assessing for normality, we conducted an EFA to examine the factor structure of the SOCCS with our sample of counseling practitioners and counselors-in-training. Because of the non-normality of the data (Costello & Osborne, 2005), PAF was used for extraction with an oblimin rotation with Kaiser Normalization. A significant value (p < .001) was identified for Bartlett’s test of sphericity (Bartlett, 1954), and a value of .83 was obtained for Kaiser-Meyer-Olkin sampling adequacy for the SOCCS. Next, we examined internal consistency reliability of SOCCS using Cronbach’s α, thus assessing the degree of correlation between SOCCS items.


To examine the factor structure of SOCCS, we used EFA, employing PAF analysis. All SOCCS items displayed a factor loading of at least .3 and were initially retained (Floyd & Widaman, 1995; Hair et al., 2010). However, SOCCS items were reduced following classical test theory in order to reduce items with poor measurement properties and to increase internal consistency reliability (Crocker & Algina, 2006; DeVellis, 2003). As noted in Table 2, The PAF results identified the presence of six SOCCS factors with eigenvalues exceeding one, explaining 62% of the variance. However, the first three factors produced eigenvalues of greater than 2.8, whereas the remaining three were all less than 1.5. The three factors accounted for 49% of the variance. As noted in Figure 1, the scree plot, a preferred method for identifying factor solutions in EFA (Hair et al., 2010), identified a steep decline including three factors, a break near the fourth factor, and a significant plateau at the fifth factor, supporting a 3- or 4-factor model solution for the SOCCS with these data. The factor matrix showed loadings of more than .4 for the first three factors, and less than .4 for the fourth through sixth factors. The first three SOCCS factors paralleled Bidell’s conceptually based factors of Skills, Awareness, and Knowledge. In the essence of EFA, we examined the potential construct being measured by the fourth factor and determined that all items (i.e., 4, 7, 8, 12 and 18) pertained to experience. Originally, these SOCCS items were included in the Skills subscale; however, we determined that the presence of these items together shows promise for a fourth SOCCS subscale of Experience. The model with four subscales accounted for 54% of the variance.

The Knowledge subscale was the only subscale that loaded as intended with eight items, accounting for 9.90% of variance as compared to 5.41% of variance in the original analysis (Bidell, 2005). Six SOCCS items loaded onto the Skills subscale, accounting for 27.5% of the variance as compared to 24.91% of variance in the original analysis. The remaining five SOCCS items that did not load onto the Skills subscale loaded together onto the fourth subscale, which is the Experience subscale. The Experience subscale accounted for 5.11% of the variance. Five SOCCS items loaded onto

the Awareness subscale. Of the remaining items, three loaded onto both fifth and sixth factors (i.e., 11, 15, and 17). Unlike the Awareness subscale, which was theoretically justified, a fifth factor was not theoretically justified; therefore, we decided to keep these three items with the Awareness subscale.

Table 2Total Variance Explained

  Initial Eigenvalues

Extraction Sums of

Squared Loadings

Rotation Sums of Squared Loadings a


% of Variance

Cumulative %


% of Variance

Cumulative %














































































































































Note: Extraction Method: Principal Axis Factoring.

a. When factors are correlated, sums of squared loadings cannot be added to obtain a total variance.

Figure 1.

Eigenvalues from 28-item SOCCS Factor Analysis

Because SOCCS items 10 and 23 only loaded onto factors five and six and no other factor, we decided to remove these items for parsimony. Therefore, the Awareness subscale now has eight items, accounting for 13% of the variance. Further information on factor loadings can be seen in Table 3.

Internal Consistency Reliability of the SOCCS

The second research question examined the internal consistency reliability of the SOCCS with a sample of counselors-in-training and practicing counselors. The original 29-item SOCCS displayed a strong reliability score with a Cronbach’s α of .90 (Leech, Onwuegbuzie, & O’Connor, 2011). As a 27-item assessment, the Cronbach’s α for the overall SOCCS was .894; although slightly lower than the original assessment, the reliability of the revised SOCCS displays strong internal consistency (Leech et al., 2011). Original SOCCS subscale reliability scores were .91 for Skills, .88 for Awareness, and .76 for Knowledge. Our item analysis of the SOCCS data identified strong internal consistency reliability with a Cronbach’s α of (a) Total SOCCS scores .893, (b) SOCCS Knowledge subscale scores .807, (c) SOCCS Skills subscale scores .877, (d) SOCCS Awareness subscale scores .814, and (e) SOCCS Experience subscale scores .872 (Ponterotto & Ruckdeschel, 2007).

Table 3
Factor Loadings for a 4-Factor Solution






I have received adequate clinical training and supervision to counsel lesbian, gay, and bisexual (LGB) clients.





I check up on my LGB counseling skills by monitoring my functioning/competency—via consultation, supervision, and continuing education.





I feel competent to assess the mental health needs of a person who is LGB in a therapeutic setting.





I have done a counseling role-play as either the client or counselor involving an LGB issue.





Currently, I do not have the skills or training to do a case presentation or consultation if my client were LGB.





The lifestyle of an LGB client is unnatural or immoral.





I believe that being highly discreet about their sexual orientation is a trait that LGB clients should work toward.





I believe that LGB couples don’t need special rights (domestic partner benefits, or the right to marry) because that would undermine normal and traditional family values.





It would be best if my clients viewed a heterosexual lifestyle as ideal.





I think that my clients should accept some degree of conformity to traditional sexual values.





I believe that LGB clients will benefit most from counseling with a heterosexual counselor who endorses conventional values and norms.





Personally, I think homosexuality is a mental disorder or a sin and can be treated through counseling or spiritual help.





I believe that all LGB clients must be discreet about their sexual orientation around children.





When it comes to homosexuality, I agree with the statement: “You should love the sinner but hate or condemn the sin.”





LGB clients receive less preferred forms of counseling treatment than heterosexual clients.





I am aware some research indicates that LGB clients are more likely to be diagnosed with mental illnesses than are heterosexual clients.





Heterosexist and prejudicial concepts have permeated the mental health professions.





There are different psychological/social issues impacting gay men versus lesbian women.





I am aware of institutional barriers that may inhibit LGB people from using mental health services.





I am aware that counselors frequently impose their values concerning sexuality upon LGB clients.





Being born a heterosexual person in this society carries with it certain advantages.





I feel that sexual orientation differences between counselor and client may serve as an initial barrier to effective counseling of LGB individuals.





At this point in my professional development, I feel competent, skilled, and qualified to counsel LGB clients.





I have experience counseling lesbian or gay couples.





I have experience counseling lesbian clients.





I have been to in-services, conference sessions, or workshops which focused on LGB issues (in Counseling, Psychology, Mental Health).





I have experience counseling bisexual (male or female) clients.






The purpose of this research was to explore the factor structure and reliability of the SOCCS with a sample of counselor trainees and practitioners in the United States. Our results identified a 4-factor SOCCS model, including the subscales of Skills, Awareness, Knowledge, and Experience. The 4-factor SOCCS structure identified with these substantiate the three previous factors of Skills, Awareness, and Knowledge; however, an additional factor is noted. The fourth factor, Experience, echoes Graham and colleagues’ (2012) findings, which note improved competence with practice. Hence, the results of this study should encourage researchers to explore beyond the 3-factor model and promote measurement versatility with counselor trainees and clinicians. Overall, our results identified a 4-factor SOCCS model with strong internal consistency, offering counselor educators and practitioners a sound method for assessing sexual orientation counselor competence.

Implications for Counselors and Counselor Educators

Counselor competency with sexual minority clients is essential in counselor education (ACA, 2014; ALGBTIC, 2013; CACREP, 2009). Our findings support the use of the SOCCS as a valid and reliable measure of sexual orientation counselor competency. Therefore, we suggest that the SOCCS may be implemented in counselor training programs to assess trainees’ levels of competency in providing services to sexual minority clients. Our results identified that in addition to the previously suggested areas of importance in sexual orientation counselor competence (i.e., Skills, Awareness, Knowledge), experience may be an important factor to consider. Counselor educators may consider methods of facilitating experiences within training in order to foster increases in competence. Further, the SOCCS may be used as a pedagogical intervention strategy in counselor education programs. For example, the SOCCS may be given to students to prompt reflection on overall and subscale competence levels regarding counseling sexual minority clients. The SOCCS may also be used beyond counselor education programs to assure that practicing counselors not only have, but also maintain necessary components of competence in order to aid sexual minority clients. Additionally, the results of our study help to further sexual minority counselor competence literature. The SOCCS (Bidell, 2005) is an effective measure for researchers to employ to examine counselors’ self-perceived levels of competence in working with LGB clients; however, the SOCCS also offers educators and practitioners a tool to support best practices in counseling and counselor education. Our SOCCS data yielded a potential fourth factor (i.e., Experience) that was not delineated as an essential component of counselors’ competence in working with LGB clients in prior research. Therefore, this study prompts researchers, counselor educators, and counselors to consider the factor of counselors’ experience in providing services to LGB clients as a necessary domain of counselor competence.

Recommendations for Future Research

The SOCCS is an effective instrument in assessing sexual orientation counselor competence. At this time, there is no indication of cutoff scores that determine appropriate levels of counselor competence (e.g., counselor is competent or not competent to provide services to sexual minority clients). Hence, we recommend that future researchers investigate levels of competence that should be assessed as benchmarks for counselors-in-training prior to graduating from their graduate programs. To our knowledge, other than the SOCCS creator (Bidell, 2005), Carlson and colleagues (2013) are the only researchers to explore the factor structure of the SOCCS. However, Carlson and colleagues altered SOCCS item stems (i.e., 3, 4, 7, 8, and 19) in their investigation and transformed the 7-point scale to a 6-point scale. Their results displayed a 2-factor model that differs from the 3-factor model recommended by Bidell (2005); however, the amendments to the instrument make the SOCCS results difficult to compare to other studies. Further, to our knowledge, we are the only researchers to explore the factor structure of the SOCCS without altering the instrument prior to exploration. Moreover, our 4-factor SOCCS model results accounted for a larger percent of variance (56%) than the original 3-factor SOCCS model (40%; Bidell, 2005). We recommend that future researchers conduct confirmatory factor analyses with their data to determine if the four factors found in our results are consistent with other samples and populations.


We recognize that our study has limitations. The SOCCS is a self-report instrument, making the data vulnerable to social desirability bias (Gall et al., 2006). Our response rate may have contributed to our sampling and data collection methods (e.g., online survey), influencing the external validity of our findings. Because of recruitment from ALGBTIC, it is possible that there may have been bias, as members of this group may not have competence levels that are equivalent to the general counseling population. Additionally, because of an error in the original Qualtrics survey, complete SOCCS answers were not required, thus causing issues in missing data. Furthermore, our sample size was limited, affecting the interpretation of our findings. Nevertheless, our study examined an area warranting further investigation (counselors-in-training’s and counselors’ competency in providing service to sexual minority clients) and offered meaningful findings (e.g., a 4-factor SOCCS model).


The social climate for sexual minorities is changing, and it is imperative for counselors to be competent to serve this population. Because of constant societal change, it is important for measures to be relevant in order to measure sexual minority counselor competence. The SOCCS (Bidell, 2005) is the most current and related instrument to measure sexual minority counselor competence. It fulfills an area of need in counselor training and development. This study provides helpful data to expand on the reliability and validity data of this useful assessment.

Moreover, the findings from the study present the case for a potential fourth subscale of Experience to be considered in addition to Skills, Awareness, and Knowledge. The existence of an additional factor pertaining to involvement and engagement in practice holds considerable implications for counselor training and effective practice with LGB clients.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.


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Shainna Ali, NCC, is an instructor at the University of Central Florida. Glenn Lambie is a professor at the University of Central Florida. Zachary D. Bloom is an assistant professor at Northeastern Illinois University. Correspondence can be addressed to Shainna Ali, 4000 Central Florida Blvd., Orlando, FL 32816, Shainna.ali@ucf.edu.