Section 4: Sexuality Assessment

This section will focus on two important items. First, it will present a detailed foundation overview of many of the elements of a comprehensive sexuality assessment, including:

- The criteria for effective assessment
- General strategies for sexual assessment
- Suggestions for bringing up the topic of sexuality
- Do’s and don’ts

Second, this section will begin to move into specific questions that need to be a part of a thorough assessment. This will include:

- Sexual Problem History (Abbreviated Version)
- Areas to address for an Assessment of Sexual Dysfunction
- Individual interview questions
- Conjoint interview questions
- Male interview questions, including specific sections on erectile dysfunction and premature ejaculation
- Female interview questions
- Male/female interview questions

The net effect of these materials is to provide the trainee with a relatively comprehensive guide to an assessment of sexuality.

How to Use these Assessment Materials

This section is set up so that all materials may be printed easily by the trainee. This allows you to keep the materials and refer back to them when preparing for and engaging in assessments where sexual concerns may be present. It may not be necessary for clinicians to follow these questionnaires word for word. In actuality, it is more likely that clinicians will use their clinical judgment to select which areas of sexuality are necessary to address, and will use these questionnaires as a reference point more than as a script.

It is understood that this may not be the most interesting material that the trainee is likely to read within this course. We offer our apologies up front on that matter. However, these materials are extremely functional in terms of going good preparation for specific clinical situations. They will serve you well if you print, save, read, and refer to them in actual clinical situations.

These questions are designed to be integrated into an overall biopsychosocial assessment, utilizing them to gather more specific and detailed information in circumstances where normal questioning uncovers the potential presence of a sexual concern or problem. Much as you would do if a substance abuse concern or problem is uncovered during the assessment process, you would select an appropriate time to direct the client to this more detailed questioning, always remaining conscious of the client’s level of comfort or discomfort at examining this very personal aspect of their psychological life.

Consideration must be given concerning what information from this assessment will be recorded in the client’s personal medical record. While there are obligations to create a thorough and representative record of the assessed problems, it is important to remember that a client’s record may potentially be made available to insurance companies. Certain intimate details within that record may cause clients to have some hesitations about this prospect.

Unless this issue is addressed up front, with clarity, precision, and well-managed informed consent, it may lead to a situation in which clients withhold sensitive information from the clinician. This does not serve either the client or the process of providing help. Sexuality, as a particularly sensitive topic for many clients, presents special challenges in maintaining that difficult balance between good record keeping and the client’s need for privacy. It is better for discussions in this area to be held before entering the stage where the assessment process begins to draw out sexual information.

Criteria for Effective Assessment

The criteria for effective assessment of sexuality issues in the health care setting include the following:

1. Comfort with one's own sexuality and that of others
This is considered one of the most difficult for many people to achieve, often due to lack of communication and repressive and/or sex-negative messages many have received in developmental years.
2. Awareness of values regarding sex
Having a conscious awareness is important in working with specific populations and people who practice certain sexual behaviors that may be “off-putting” (offensive) to the clinician. If the clinician knows that s/he has difficulty working with a particular issue (for example, sado-masochistic practices), it might be in the client’s best interest to refer him/her to another clinician.
3. Knowledge of sexuality
This refers to having an understanding of the basics, but does not mean the clinician has to know all of the answers. Indeed, there is NO ONE who knows all of the answers. New information about sexuality is being learned constantly. If a patient asks a question that the clinician cannot answer, it is professionally appropriate to say, “I don’t know, but I’ll find out” or “I don’t know, but I’ll find someone who does.”
4. Ability to communicate with ease regarding sex
This gets much easier with practice, and one of the suggestions for clinicians is to practice/role play with friends and colleagues. In the beginning there will likely be some anxious moments and laughter as the comfort level grows with practice. Becoming familiar with some of the more common slang terms and phrases can also be useful.
5. Knowledge of when and where to refer
If the clinician believes the situation is beyond his/her field or degree of expertise, one of the most helpful things to do is to consult a knowledgeable colleague or refer the patient to someone with advanced training in a particular area. Probably the best referral sources are through word of mouth, but if there is no one readily available through referral, the American Association of Sex Educators, Counselors, and Therapists (AASECT) website at AASECT.org is an excellent resource. AASECT is the certifying organization for sexuality professionals, and the website provides a list of certified professionals, by state and city, who are considered knowledgeable, experienced, and ethical. (Original source unknown).

General Strategies

There are several general strategies that can be useful for clinicians approaching issues of sexuality with their clients. These are shown below.

1. Go from least threatening to most threatening.
Bring up benign topics in the beginning in order to set patients/clients at ease and encourage open and honest responses. Initiating a conversation with an emotionally loaded topic such as masturbation or their current number of sexual partners will likely result in a resistant patient who is hesitant or unwilling to respond.
2. Go from past to present.
Discussing past history first is typically less threatening to clients and also lays the groundwork for the clinician to more fully understand what is currently happening. If the client presents with a sexual concern, however, hearing about present concerns may precede historical information.
3. Go from general to specific.
A general discussion about the topic of sexuality, including the clinician’s acknowledgment that sex is often a difficult subject to discuss, will help to alleviate anxiety and foster openness. (Original source unknown).

Suggestions for Bringing Up the Topic of Sexuality

The following open-ended statements and questions are useful prompts for promoting discussion.

1. “Many people have concerns about......... What are yours?”
This type of statement normalizes concerns about sexuality, lets patients/clients know that sexuality is a viable topic for discussion, and if they do have a concern, that they are not alone.
2. “What effects has this illness (or this relationship issue or whatever they are presenting to the clinician) had on your sexuality?”
This acknowledges that sexuality is a valid topic to talk about, that there are effects of illnesses, etc. on sexuality, and that this is a subject that the clinician is willing to discuss.
3. “We have information at our facility on a number of topics you might want to know about, including diet, exercise, hypertension, sexuality, etc.”
Again, this acknowledges, in a very non-threatening way, that sexuality is a relevant topic for discussion.
4. “How did you learn about.......?”
5. “How did you feel about.......?”
6. “What messages did you get regarding.......?”
Questions 4, 5, and 6 encourage discussion and exploration and can give both clinician and patient insight into what is currently happening.
7. “Research indicates that 95-99% of men masturbate. What have your experiences been with this?”
The initial statement gives important information and normalizes a behavior that the patient may be reluctant to discuss. In addition, this type of introduction to the topic is much less threatening than opening with a question such as, “What have your experiences been with masturbation?”
8. “What other information do you think might be useful for me to know in terms of your health care?” Or “Is there anything else I haven’t asked about that you’d like me to know?” These types of questions are helpful in determining if there is a topic of concern that has not been raised.

DOs and DON’Ts

1. Avoid ambiguous questions such as, “Are you sexually active?” Responses to this question have resulted in answers such as, “No—I just lie there,” “Not today,” “No, only twice a week.” One person answered “Not right before I came here.” To some people the term sexually active means having penile-vaginal intercourse and does not include oral sex, anal intercourse, masturbation or mutual masturbation, sex play with toys, or other types of sexual behaviors. Other examples of data-gathering items that might be confusing are: a) “What brought you today?” Answer: “The bus.” b) Marital status: One respondent answered, “Good, but we fight sometimes.”
2. Include both partners if possible. Sexual problems often arise within the context of a relationship and are impacting both people. While it may appear that the problem rests largely with one person, focusing on only one individual can lead to finger-pointing, blaming, and perpetuation of the problem. In reality both people are ultimately involved. Solving the problem generally requires the commitment and involvement of both. Some therapists will work with people only as couples; others will see couples together and separately; others will work with one member of the couple to address individual issues such as unresolved family of origin issues that may be impacting the relationship.
3. Be sensitive when asking questions that might be threatening to someone, such as patients who are reluctant to share their sexual orientation. For example, when asking a woman about birth control methods, the clinician might ask, “Do you use birth control?” If she says, “No,” the clinician should not assume that the patient is not having sexual intercourse. A more defining question might be to ask, “Do you have a need for birth control?”
4. Empathize with the magnitude of the client’s concern. It is sometimes hard to understand the magnitude of an individual’s or a couple’s concerns or the specific issues that evoke distress. It is important to realize that this problem is distressing to the client and to acknowledge awareness of the distress. This shows empathy with their degree of concern. A comment such as, “I can see that you’re really concerned about this” can be comforting and supportive. Letting people know that others have similar concerns, while not minimizing theirs, can also be helpful. Frequently clients will think that they are the only ones who have a particular problem.
5. Be aware of the many words that people use for body parts and sexual behaviors. Clients may tell the clinician that they are having a particular sexual problem, such as, “I have an erection problem.” An important element in establishing what is actually occurring is to say, “Tell me what happens when you have a sexual encounter. Paint me a picture.”
6. Ascertain the meaning of the experience to the individual and to his or her partner. Suggestions for specific questions to elicit this information are: “What does having this concern mean in your life?” “What has the impact been?” “If things stay the same, what do you think will happen?” These types of questions will often bring out deeper issues such as feeling inadequate, relationship struggles, or fears that a relationship may end. *(Example below)
7. Consider what brings the client(s) to treatment at this time. The clinician will often find that the problem has been going on for a lengthy period of time, sometimes years, and yet this is the first time the person or couple has sought help. Another assessment question to ask is “Why now?” What has happened that has brought the issue to the “front burner” at this time?
*Example:
In relationship to a woman’s difficulty achieving orgasm, the author has had young men say, “If she can’t have an orgasm with me, I’m leaving.” Some also say, “The other women I’ve been with haven’t had a problem.” For some men, the woman’s ability to have an orgasm is a testament to their lovemaking skills and ultimately to their sense of manhood. Other men say they know how wonderful an orgasm is and just want their partner to have the experience.

Sexual Problem History: Abbreviated Version

1. Description of Current Problem
What’s happening now? This may include the client’s “painting you a picture” of what is occurring.

2. Onset and Course of Problem
a. Onset (age, gradual or sudden, precipitating events, contingencies)
b. Course (changes over time: increase, decrease, or fluctuations in severity, frequency, or intensity; does it happen with one partner and not another, functional relationships with other variables)

3. Patient's Concept of Cause and Maintenance of Problem
This is important to know in terms of how to work with the patient to resolve the problem. Does s/he think the problem is due to unresolved issues from the past, lack of adequate information, current medical conditions or procedures, relationship issues, etc? Is there some degree of blame involved e.g. of self, of partner, of primary caretakers, or perhaps of the medical community?


4. Past Treatment and Outcome
a. Medical Evaluation- medical specialty, date, form of treatment, results; currently on any medication* for any reason.
*This is very important information, because medications can have serious sexual side effects. This will be discussed later in the course.
b. Professional Help -specialty, date, form of treatment, results.
This information provides some guidelines in terms of treatment—what worked before may be the beginning treatment approach for the current problem. Sometimes people do not recall that they had a previous effective treatment. On the other hand, if the patient is presently doing something that is ineffective, this is another valuable piece of information in terms of treatment planning.

5. Current Expectancies and Goals of Treatment
Knowing what the person expects to happen is essential in terms of the treatment approach and positive outcome. Are the expectations realistic or are they idealistic? For example, does a paraplegic male expect to be sexual in the same way he was before he sustained an injury? Does a woman expect to be orgasmic with only intercourse and no other type of stimulation? Counseling/therapy will involve helping the patient to become aware and accepting of potential realistic outcomes and to set achievable goals.

Note: An expanded history taking instrument (The Gomes Expanded History Interview Guide) is presented at the end of this course.

ASSESSMENT OF SEXUAL DYSFUNCTION


Initial Interview Questions

Intake and Nature of Problem

1. What prompted you to come at this time for therapy?
2. Who initiated seeking therapy?
3. Previous counseling or therapy?
4. Describe the nature of the problem(s).
5. How have you (or the two of you) attempted to handle the problem to date?

Consequences and Adaptive Function

1. If therapy is successful, what will you be able to do that you are unable to do now?
2. How will this change anything in your current life, relationship, personality, or partner’s personality?
3. How does the problem affect your partner’s sexual functioning?
4. What significance does the problem have with respect to your own sexual functioning?

Antecedent Events and Stimuli

1. When did the problem first occur? What was occurring in your life at that time? Concurrent events? (If there is more than one problem, or both partners have a problem): Which problem do you recall as having developed first?
2. Under what circumstances have they functioned/worked? (People, situations, circumstances, locations, time of the day, thoughts, images, feelings, sensations).
3. Where and when does the problem temporarily get better or improve?
4. Under what circumstances does the problem occur? What circumstances intensify the problem(s)?
5. Alcohol/Substance Abuse: How often and how much do you (and does your partner) drink/use? Have you ever had a blackout or memory loss while drinking/using? What medications or drugs (including over the counter drugs) do you use?

Individual Interview Questions

1. What was your major source of sex education?
2. In what ways has your religion and family background influenced your attitudes toward sex? Growing up, were you allowed to ask questions?
3. How old were you when you began petting? How many partners did you share petting with before you graduated high school? Between high school and marriage? What kinds of petting did you engage in? How would your parents respond if they had known?
4. How old were you when you first masturbated? How did you learn about masturbation? How did you feel about masturbation? With what frequency did you masturbate in your teens? What was the maximum frequency? What techniques have you used for masturbating?
5. How attractive do you feel at this point in your life? During courtship?
6. What is your current weight? What is your ideal weight?
7. Age at first intercourse, and age of partner?
8. Location and circumstances of the first intercourse? Were there any problems or difficulties? How did you feel? Were you orgasmic?
9. Premarital sexual experiences: Any problems with erection, prematurity, or delayed ejaculation? Number of premarital sexual partners, frequency of intercourse with spouse before marriage. Source of restraint for not engaging in premarital sex. Negative experiences?
10. Sexual experiences in the previous marriage.
11. Extramarital or group sex experiences?
12. What attracts, excites and stimulates you sexually? Describe the situation you find most desirable and stimulating for lovemaking.
13. Incest; illegitimate pregnancy; abortions; rape; prostitute experience; homosexual thoughts; frequency of homosexual involvements; unusual sex acts participated in or desired; non-sexual affectional relationships with a member of the opposite sex.
14. Presources and Ideals: What would you like from an ideal sexual partner, or ideally from your current partner? What would you be willing to give to such a partner?
15. How would you describe yourself? How would you describe your partner?
16. Do you tell him/her what pleases you most sexually? Displeases you?
17. What do you want most in the way of attitude, behavior, etc. from your partner that he/she does not provide you now?
18. What attitude or behavior do you receive from your partner that you value the most?
19. What trait, behavior pattern, or habit does your partner have which tends to diminish your sexual feeling or desire for him/her?
20. What trait (behavior) diminishes your feeling for him/her in non-sexual situations?
21. What attracts, excites and stimulates your partner sexually?
22. Age at puberty?
23. Any problem reactions to vaginal odors and secretions, body odor, genital odor?
24. How do you feel about your genitals, and about touching and observing your partner’s genitals?
25. Fantasy: How often do you fantasize during intercourse and while masturbating? Are they erotically stimulating? Are you comfortable with the content of your fantasies?
26. Menstrual difficulties: dysmenorrhea or amenorrhea? Discharge from nipples of your breasts? Hair loss? Hirsutism? Undescended testes? Gynecomastia? Infertility?

Conjoint Interview Questions

Marital Relationship

1. How would you describe or summarize your marriage?
2. What interests do you share and enjoy together? Independently?
3. How much time do the two of you spend together?
4. Problems and areas of conflict?
5. What is the communication like between you? Do you confide in one another?

* Does sex serve a function in the marital system? (to gain advantage or control elsewhere in the relationship; used for trade-offs elsewhere?)
** Are relational issues involved: 1) independence, activity, power, control and domination versus dependence, passivity, and submission. 2) closeness versus distance; trust versus distrust. 3) competition versus cooperation. 4) perceptual stereotypes of men, women, and the self. 5) problem-solving styles and the approach to handling differentness (communication and emotional expressiveness—under-expressiveness).

Sexual History of the Relationship

1. Frequency of intercourse recently; during first year? Did you enjoy this frequency level?
2. Time when lovemaking usually takes place, and who usually chooses the time? Privacy, noise, intrusions?
3. Verbal expressiveness. Freedom and openness during love-making.
4. When did you last have sexual relations together?
a. Who initiated? How were cues given and interpreted? What percentage of the time does each usually initiate?
b. What occurred in foreplay, and length of foreplay? Desire more or less? Level of arousal (0-10). Lubricated? Use of artificial lubrication and feeling about it.
c. What kinds of stimulation do you prefer? Do you ask for this?
d. Do you ever experience any physical discomfort during lovemaking?

***Consider the roles they take (e.g., initiator, passive, recipient, martyr, pleaser), and the ones they want their partner to take (liberator, inhibitor, playmate). Must these roles be constant, and what do they see as appropriate male/female roles?

Male Interview Questions

Assessment of Erection Problems

Taking an accurate Sexual Problem History is a prerequisite to optimal treatment of Erectile Dysfunction (ED). The history includes sociocultural, relationship, psychological, and physiological/medical aspects of the client’s situation. There is an Erection Guidelines sheet available to learners of this course for quick reference and handout for clients. Examples of interventions based on assessed clinical cases are presented. Referral for counseling to a certified sex therapist may be indicated.

Addressing the sociocultural, relationship, psychological, physiological/medical aspects of erection problems is crucial in a satisfactory resolution to each situation. When a client presents to a clinician with complaints of an erection problem, the top priority is to get a physical assessment done by a physician, ideally a sex-friendly urologist experienced in the treatment of erectile dysfunction, who is willing to consider both physical and psychological factors. The degree of physical involvement will influence the course of treatment.

There are a wide variety of medical problems that may underlie an erectile problem, some of them serious in nature. A conscientious clinician often ends up being an intermediary between the client and other medical services. This role can include educating the client on medical concerns that may be connected to erectile problems, helping to build motivation for the client to seek medical care, and facilitating a successful referral. This can also include preparing the client for what he might expect when he sees the specialist.

Assessment of physical causes will include blood pressure measurement, reflex checks to assess nervous system functioning, physical exam of penis and scrotum, and urine or blood tests to check testosterone levels (including free testosterone), blood sugar, cholesterol levels, and, if indicated, LH and prolactin levels. In addition to hematologic and biochemistry analyses, a specialist might also perform the following: vascular testing, neurological testing, and nocturnal penile tumescence and rigidity analysis.

Two additional investigations frequently used are biothesiometry (an electronic device for assessment of penile vibratory thresholds) and office injection testing (administering of an intracavernosal vasoactive agent to see if it is possible for the man to get and keep an erection (Cornell Physicians, 2007a).

Another assessment device used during sleep is a simple ring-like device called a snap gauge made up of plastic films that fit around the penis, and the films break at predetermined pressures. Most men have an erection every 90 minutes during sleep—typically 3 to 5 full erections during REM sleep. A simplified version of this test has been used by a number of men as a quick, simple, and inexpensive way to get a baseline assessment of their erectile functioning.

For three nights a strip of four to six postage stamps (with the perforations loosened by folding them beforehand) is wrapped snugly around the shaft of the penis before going to sleep. The next morning, if the stamp ring has been broken along the perforations, an erection has occurred. As most stamps today are self adhesive and are removed from a backing one at a time, this method may no longer be viable.

It is important to remember that even in cases that involve a large physical component, psychological and relational issues may still be major factors to consider. In addition, erection problems may be the first sign of an undiagnosed diabetic disorder and also of underlying cardiac disease, and evaluation of these possibilities is crucial.

Arousal and Erection Guidelines

The Arousal and Erection Guidelines have been very helpful in providing men and their partners with information and suggestions regarding erections. This information can help to allay fears and decrease performance anxiety, factors that very often contribute to erection problems, even when concurrent medical conditions exist.

The following guidelines are available for learners to copy for themselves and their clients (two pages).

AROUSAL AND ERECTION GUIDELINES

1. By age 40, 90% of males experience at least one erectile failure; this is a normal occurrence, not to be overreacted to as a sign of a major sex problem.
2. Many erection problems are caused by psychological or relationship factors as well as medical or physiological factors. To check out possible medical causes, you could consult a urologist.
3. Erection problems can be caused by a wide variety of factors including thinking too much, anxiety, depression, anger, frustration, fatigue, and just not feeling very aroused at that time or by that partner.
4. The key element is to accept the erectile difficulty as a situational problem, not to overreact and label yourself "impotent" or put yourself down as being a "failure" as a man.
5. A myth is the "male machine," ready to have an erection and intercourse at any time, with any woman in any situation. You and your penis are human, not a performance machine.
6. One of the most pervasive myths is that if a man loses his initial erection, that means he's sexually turned off and must work to regain it. In reality, it is a natural physiological process for erections to wax and wane during a prolonged pleasuring period.
7. In a typical 45 minute pleasuring session before intercourse, the male's erection will wax and wane an average of three times. Subsequent erections are usually firmer and the ensuing orgasm more pleasurable.
8. You do not need an erect penis to satisfy a woman. Orgasms achieved through manual or oral stimulation are also sexually satisfying. If you do have problems getting or maintaining an erection, the worst thing you can do is to stop the sexual interaction and put yourself down. Many women find it arousing to have the penis (erect or flaccid) used to stimulate the clitoral shaft or labia minora (inner lips).
9. A key element in potency is to actively involve yourself in the pleasurable and sexually arousing interaction. An erection is a natural result of sexual arousal.
10. You cannot will or work at getting an erection. The worst thing you can do to yourself is to passively take a "spectator" role and observe the state of your penis. Sex requires active involvement. It is not a spectator sport.
11. It makes most sense for the woman to both initiate the moment of intercourse and for her to guide your penis into her vagina. It takes pressure off you, and since the woman is the expert on her own sexuality, it is the most practical procedure.
12. You can learn to feel comfortable saying to your partner something like, "I want for sex and pleasuring to go at a pace I'm comfortable with. When I feel pressure to perform sexually, I get uptight and sex is less good for you and me. Let's make it enjoyable for us by taking it at a comfortable pace.
13. Erectile problems do not affect the ability to ejaculate. Thus, many males learn to ejaculate with flaccid or semi-flaccid penises. The male can again learn to ejaculate to the cue of an erect penis.
14. One way to learn to feel comfortable with potency is through masturbation experiences. During masturbation, you could practice gaining and losing erections, relearn to ejaculate to the cue of an erect penis, and focus on cues and fantasies which can be carried over to partner sex.
15. Morning erections should not generally be used for intercourse initiations. The morning erection can be a sign of arousal because of dreaming or because of being close to your partner; on the other hand it can be caused by a need to urinate. Too many men try to use their morning erections before they lose them. Remember arousals and erections are regainable.
16. An important component in learning to feel comfortable with arousal and potency is to make clear, direct, assertive requests (not demands) of your partner for the type of sexual stimulation you find most arousing. It is important to learn to verbally and nonverbally guide your partner in how to pleasure and arouse you.
17. Stimulating a totally flaccid penis is usually counterproductive for sexual arousal. The male simply becomes more aware of the state of his penis. Instead you could engage in sensuous, non-genital, non-demand stimulation until there is some initial arousal and erection. The male can just lie back and enjoy this stimulation rather than trying to “will an erection.”
18. Your attitude and self-thoughts can very much influence your arousal. We suggest that the key self-thought is that “sex and pleasure” go together, not “sex and performance.”
19. In thinking about a particular sexual experience, your feelings about it are best measured by your sense of pleasure and satisfaction rather than whether you got an erection, how hard it was, whether your partner was orgasmic. Accept that some sexual experiences will be great for both you and your partner, some will be better for one than the other, some will be mediocre, and some will be poor. Do not put your sexual self-esteem on the line each time.
20. It is interesting to know that when you are sleeping, you get an erection every 90 minutes--4 or 5 erections a night. Sex and arousal are natural physiological functions. Don't block them by performance anxiety or putting yourself down. Give yourself and your partner permission to enjoy sexuality (McCarthy, 1981).

Assessment of Erectile Dysfunction

1. Surgery or illness (STD, diabetes, arteriosclerosis, hypertension liver or kidney failure, Parkinson’s disease, surgery in the pelvic area, spinal cord injuries, Peyronie’s disease or priapism).
2. Do you ever experience orgasm without any fluid ejaculating?
3. Have you ever felt that you ejaculate too quickly, or are you unable to ejaculate in some circumstances?
4. Have you ever ejaculated without direct penile stimulation?
5. Do you ever have pain with intercourse or on ejaculation?
6. Have you ever ejaculated through a flaccid penis?
7. Has there been a change in your: a) libido; b) frequency of intercourse; c) frequency or firmness of morning erections?
8. Has a physician ever prescribed testosterone therapy?
9. How often do you have morning erections and nighttime erections? Grade them on a 0-10 scale.
10. Do you smoke cigarettes, and if so how many packs per day?
11. Grade the quality of erections you are able to get in the following activities (0-10 scale):
a. Various states of dress and undress?
b. When intercourse is anticipated?
c. With partner manual manipulation in foreplay?
d. With oral stimulation where a partner sucks on your penis?
e. When you are performing oral-genital sex on partner?
f. At the moment of entry for intercourse?
g. After entry?
h. With intercourse - when it is successful?
i. With extramarital intercourse or prostitute experience? Ask for changes of status and the dates these changes occurred.
12. Do you ejaculate more rapidly since the onset of impotence, or more slowly?
13. Do you have nocturnal emissions? How often, and when was the last time?
14. How often to you masturbate, and can you sustain your erection to ejaculation? Grade of erection (0-10 scale) during masturbation?
15. Does your quality of erection vary with the position used for intercourse? Who decides intercourse position used?
16. What would you estimate the size of your penis is when erect? Describe the shape of your penis when erect.
17. What are you thought processes during lovemaking? That is, what do you say to yourself, think, or wonder about during lovemaking?

Assessing Premature Ejaculation

PE can be a lifelong condition experienced from the beginning of sexual activity or it can develop at some point in a man’s life after years of satisfactory sexual activity. In clinical work it is helpful to distinguish between lifelong and acquired PE and between PE that is limited to specific situations and/or certain partners and that which is more global.

In general, knowing that a patient has a lifelong history of PE that is not specific to one partner points toward a biologic cause with a variable cognitive overlay. In contrast, knowing that PE is confined to a specific partner suggests the need to address relationship issues. (Barada & McCullough, 2004)

Questions for assessment of premature ejaculation are below.



Assessment of Premature Ejaculation

1. Do you ever ejaculate prior to entry?
2. Have you ever ejaculated so rapidly that you had no opportunity to become erect? That is, have you ever ejaculated through a flaccid penis?
3. If you were to thrust continuously after entry, how long would intercourse last?
4. Are you aware of differences in rapidity of ejaculation with position?
5. What methods of control have you previously used?
a. Anesthetic ointment applied to the penis?
b. Distracting yourself by thinking about other things?
c. Masturbating prior to intercourse?
6. How often do you masturbate, and how long do you masturbate before ejaculating?

Assessment of Female Interview Questions

Female Orgasmic Dysfunction

1. Does your partner do anything that causes physical discomfort?
2. Under what circumstances are you more interested and find sexual involvement more pleasurable? (Ambiance immediately prior, and of the day and period of time in general).
3. What could your partner do to make you more excited? Have you asked?
4. What can you do to increase your own excitement, and have you done it?
5. Conceptions of orgasm:
a. What do you believe happens to the female’s body during orgasm? Where did you get that information?
b. Fears associated with orgasm: loss of control (bladder, bowel, emotional), passing gas, grimaces or body contortions, etc.
c. What have you noticed about your partner’s face and body during his/her orgasm? How do you feel about that?
6. Individual Interview questions:
a. Masturbation and self-exploration (look, touch, to what level of arousal, with what frequency).
b. Have you ever experienced orgasm during sleep? How frequently?
c. Do you ever fake orgasms?
d. Past sexual experiences?
e. What are you thinking about during sex? Are you easily distracted during sex? What do you do to minimize distraction?
7. In what ways do you achieve orgasm?
a. Masturbation (techniques: hands, blanket-cloth, vibrator, thigh pressure, against bed, pillow, vaginal insertions, water, other).
b. With partner: manual stimulation? oral stimulation? on coitus? Percentage of time orgasmic?
8. Use of fantasy.
9. Is there a difference in the intensity or duration of your orgasms? Were these changes gradual or sudden?
10. Past sexual experiences. What made them different? (different techniques, feelings, relationship, age, life events).
11. Past surgeries and illnesses (including plastic surgery on breasts or genitals).
12. Have you ever experienced multiple orgasms? Frequency? Methods?

Assessment of Dyspareunia and Vaginismus

1. Ask antecedent questions (e.g., when first occur, under which conditions intensify or improve)?
2. What percentage of the time is intercourse painful?
3. Does it vary with position? Usual position? Which is most comfortable?
4. Describe the pain:
a. Where and when does it occur?
b. At what point in the sexual process does it occur? (at entry; during shallow or deep thrusting; with slow or rapid thrusting; with genital manipulation; at ejaculation or orgasm; after intercourse)?
c. Is it associated with increasing sexual excitement?
d. Does it have any relationship to the menstrual cycle?
e. Is the pain constant, spasmodic, episodic, occasional, or consistent? (burn, itch, ache, dull, sharp). How long does it last?
5. Birth control: new method?
6. Vaginal infections? Frequency, duration, recurring? Douche? Spray?
7. Victim of rape?
8. Constipation?
9. Retroverted uterus?
10. Surgeries? (hysterectomy, vaginal repair, episiotomy, etc.)
11. Menopause? Has she continued regular sexual activity since?
12. Medications? (antihistamines, anticholinergics; amphetamine & diet pills)
13. How often is the man unable to enter because of pain or a tight vaginal opening?
14. What is the sensation when the man inserts his finger(s)?
15. Is there any problem or pain when inserting a tampon?
16. What is the sensation like when you insert your own finger?
17. Have you had any problems during pelvic examinations?

Male/Female Interview Questions

Assessment of Hypoactive Sexual Desire and Sexual Aversion

1. How often does your partner ask for sex, and how often do you accept? Why and when do you accept or reject the invitation?
2. Do you ever initiate lovemaking? Under what circumstances?
3. Can you recall a time in the last 2-3 months when you felt interested or partially interested in sex? What were the circumstances? How do you account for the interest?
4. Environmental factors affecting interest: conversation, pleasant dinner, mate helping with children or chores, evening out, time of day, music, lighting, fire, drink, shower, degree of privacy, feeling toward partner?
5. Describe your mother; describe your father. Did you confide in them?
6. How would you ideally raise your own children? Would it be different from the way that you were raised?
7. Was affection freely shown by your parents to one another?
8. What were your parent’s attitudes towards sex?
9. Do you remember any upsetting experiences having to do with sex that occurred during childhood?
10. As a child, did you ever see anyone in intercourse or other sexual activity?
11. Were you ever caught or punished for sexual activity?
12. When did your sexual interest begin to decline? What was going on in your life and relationship at about that time? How do you account for the decline?
13. Have you felt sexual interest in your present mate in the past?
14. Do you think your partner is physically attractive? Was this a factor in your choice of him/her?
15. Masturbation, past and present.
16. What might each of you do to increase the other’s interest?
17. Were your children desired or planned?
18. How did the birth of children affect the relationship?
19. How do your children affect the relationship now?
20. Sexual interest in others, past and present?
21. Present relationship concerns that did not exist in the past?



Permission for use of all questionnaires provided above was given by Manuel Gomes.

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