Sexual History and assessment paper

Sexual History and assessment paper

©Philip G. Monroe, PsyD, 2009 | Sex Therapy Assessment Questionnaire 1

Sex Therapy Assessment Questionnaire Directions: Sexual problems in marriage can be complex and multi-faceted. This survey will help us assess the nature of your problem and more quickly focus therapy to your needs. Your responses will be held in confidence and only shared with your spouse with your permission. Please answer questions by checking the box the most fits your current feelings and experiences.



Years married?

Previously married?

Typical frequency of sex?

Strongly Agree Agree Neutral Disagree

Strongly Disagree

1. I find thoughts about sex with my spouse pleasant. 0 1 2 3 4

2. When my spouse asks to have sex I readily agree. 0 1 2 3 4

3. When I think about sex I have unpleasant memories. 4 3 2 1 0

4. Sex disgusts me. 4 3 2 1 0

5. Sex feels like a chore most of the time. 4 3 2 1 0

6. It is easy for me to become aroused. 0 1 2 3 4

7. I am usually able to stay aroused throughout sex. 0 1 2 3 4

8. I am often distracted by other thoughts during sex. 4 3 2 1 0

9. Our sexual activity is rarely rushed. 0 1 2 3 4

10 Planning time to have sex seems undesirable to me. 4 3 2 1 0

11. I regularly satisfy my spouse’s sexual desires. 0 1 2 3 4

12. My spouse regularly satisfies my sexual desires. 0 1 2 3 4

13. I wish my spouse would be more adventurous in bed. 4 3 2 1 0

14. I feel pressured to try new things during sex. 4 3 2 1 0

15. We both usually orgasm during sex. 0 1 2 3 4

16. My spouse takes a long time to orgasm. 4 3 2 1 0

17. I take too long to orgasm. 4 3 2 1 0

18. I am able to orgasm alone but not with my spouse. 4 3 2 1 0

Alexandra Slater


15 No

Once a week



















©Philip G. Monroe, PsyD, 2009 | Sex Therapy Assessment Questionnaire 2

19. My spouse orgasms too quickly. 4 3 2 1 0

20. I orgasm too quickly. 4 3 2 1 0

21. It is a big problem if I or my spouse fails to orgasm. 4 3 2 1 0

22. Our sex activity usually includes vaginal penetration. 0 1 2 3 4

23. Vaginal penetration is difficult and/or painful. 4 3 2 1 0

24. We agree on what makes for good sexual activity 0 1 2 3 4

25. We cannot talk about sexual matters without fighting. 4 3 2 1 0

26. Overall, I am satisfied with our sex life. 0 1 2 3 4

27. Overall, our marriage relationship is very strong. 0 1 2 3 4

Additional comments, questions, or problems not yet noted (e.g., known physiological problems (e.g., diabetes, heart disease, menopause), medication side effects, current or past infidelity, history of child sexual abuse, addictions, domestic violence, etc.):










I have suffered in my past from domestic violence. I also have diabetes. I don’t believe either of those affect my sex life. My husband sometimes during sex gets a pain in his genital area. He believes it has something to do with an accident he had years ago on a motorcycle.

©Philip G. Monroe, PsyD, 2009 | Sex Therapy Assessment Questionnaire 3

Sex Therapy Assessment Questionnaire Administration and Scoring/interpretation Directions

This survey has not been statistically evaluated. Scores are calculated only to guide clinicians in treatment decisions by eliciting information in an efficient manner. At the start, provide copies of the survey questions to each spouse ask them to respond independent of each other. Respondents are to answer questions according to their current experiences and feelings. Encourage each to write any additional concerns, problems, and questions related to their struggles in the final comments box. Once completed, score the survey by noting:

1. Total Score: Sum the total score of the 27 items. Totals may range from a low of zero to a high of 108. High scores suggest significant sexual difficulties. Respondents choosing the neutral answer for every question would receive a score of 54 while admitting a problem for each item would receive a score of 81. Thus, clinical judgment suggests totals scores of 81-108 have very serious sexual dysfunction and may need other interventions prior to engaging in sex therapy proper. Total scores between 54 and 81 may suggest significant sexual dysfunction. Scores below 27 may suggest the respondent does not perceive any significant or repetitive sexual dysfunction.

2. Domain Scores: Examine the items in the five domains assessed in the survey: Desire (#1-5), Arousal (#6-10), Technique satisfaction (#11-14), Orgasm (#15-21), Pain (#22-23), and Relationship (#24-27). The following chart provides possible interpretation of domain scores

Domain Minimal Problem Likely Problem Significant Problem

Desire 0-5 6-14 15-20

Arousal 0-5 6-14 15-20

Technique satisfaction 0-4 5-12 13-16

Orgasm 0-6 7-18 19-24

Pain 0 1-3 4-8

Relationship 0-4 5-12 13-16

3. Critical Items: Examine the responses to items 4 (disgust), 14 (pressure), 25 (fighting about sex) and 27 (overall marriage satisfaction). Dialog with the respondent about their responses if their choice acknowledges problems in this area. Also, make note of any serious issues acknowledged in the comments section of the survey. If concerns about child sexual abuse, active addictions, domestic violence, imminent divorce, coercion, etc. are present, sex therapy may not be appropriate at this time since therapy is based on a trust relationship between the couple.

4. Couple Differences: Note significant differences between spouse responses. Review these discrepancies with the couple (with permission) if confident that exposing such differences will not risk harm to either spouse.

Possible exploratory questions regarding common sexual dysfunction

Desire 1. What are your feelings about sex? If experiencing negative emotions about sex, when did they first

begin? 2. Have you ever experienced positive sexual desire for your spouse? For a previous mate? 3. What, if anything, helps increase your desire for sex with your spouse? What hinders it? 4. What efforts have you made to try to cultivate appropriate sexual desire? What worries you about

trying to cultivate desire?


©Philip G. Monroe, PsyD, 2009 | Sex Therapy Assessment Questionnaire 4

1. Have you difficulty achieving and/or maintaining arousal through sexual activity? No. What happens when you lose your arousal? That has not happened with my husband.

2. What is necessary to achieve physical or emotional arousal for sex? With my husband I get aroused very easily. A simple kiss, touch, or even sometimes the way he looks at me gets me aroused.

3. Who initiates sex? How? Planned? Spontaneous? Frequency? We both initiate sex. We sometimes just give each other a sexy look. We have been married for 15 years we know how to read each other. Sometimes we just say “Want to?” The initiation is mostly spontaneous but we do have a deal that we keep our sex life alive so one of us initiates it at least once a week.


1. What sexual activities provide you the greatest pleasure? I seem to get the most pleasure during the old fashion missionary position. I love to feel my husbands body on top of me and him looking down on me with his pleasure smile.

2. Does your spouse know this? Is he/she able and/or willing to provide this activity? He does know that is my favorite and is willing and able anytime.

3. Do you know what pleases your spouse most and are you able/willing to provide it? My husband loves for me to perform oral sex on him. I am willing to do it anytime even if our sexual encounter ends there.

4. What constitutes foreplay? How quickly do you move to the genitals? To penetration? We take our time. Foreplay is the best part sometimes. We have even made each other beg to move to the genital area. There are times when in the genital area we wait until right before orgasm to move to penetration but other times we just want each other so bad we go to penetration after the teasing foreplay.

5. Do you attempt to have simultaneous orgasms? We have attempted it at times but it is a difficult task sometimes.

6. Are any activities or body-parts off limits for one spouse that frustrates the other? No. I do not enjoy anal sex but my husband doesn’t mind either. He doesn’t really like it that much either.

Orgasm 1. Do both achieve satisfactory orgasm? If not, why not? I always thought satisfactory orgasm was

all orgasms. With each other every orgasm is a minimum of satisfactory. 2. Does orgasm take too long? Too premature? How much time? For me orgasm takes a long time.

It always had. My husband goes fast but not to fast and he can keep going after about a minute break. A long time to me is 20 minutes. If i do not orgasm within the first 10 then I think I am not going to. We have tried up to 20 minutes before. My husband can go in 3 – 5 minutes but he does wait for me most of the time unless I dont want him to wait.

Pain 1. Presence of pain and/or distracting sensations that hinder sexual activity or satisfaction?

Sometimes my husband has pain in his scrotum area and loses his erection. 2. Vaginal tightness hindering penetration? History of penetration? No 3. Lubrications used? Sometimes KY Jelly but mostly none used.


1. Has your spouse ever violated your trust in regards to sexual matters? No 2. Do you feel coerced to try new things relating to sex? No 3. Do you feel you have the right to refuse sex because of interest, emotions, tiredness, etc.? Yes 4. What happens when you talk about your sexual feelings? When your spouse talks about sexual

feelings? My spouse and I have a great relationship and can talk about anything. We share everything. If there is a problem we do not have any problem communicating the problem. If we want to try something new there are no barriers and we feel comfortable and trust each other enough to ask.


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