Sexual Problems Self-Assessment Questionnaire (Version H)

This questionnaire is part of a research and development project; it is unfinished and there are no scoring norms. It is being explored as a tool to aid in making a comprehensive assessment of sexual issues in women and men.

This information is intended for two uses:

In order to submit the results, please specify that you are taking this survey to provide feedback to your service provider (and provide their email address) or agree to have a report sent to Seattle Institute for Sex Therapy, Education, and Research. Or, if you want to explore the questionnaire for your own use, please print out a blank questionnaire and fill it out by hand.

If you are a client or patient, know that you have the right to decline to answer all or part of the questionnaire and it will not negatively affect standard practice of treatment.

IMPORTANT NOTE: If you are can see this text, you need to enable JavaScript for the Survey to work correctly. This can probably be done using the yellow bar at the top of your screen, but it may be more involved than that (depending on your security settings).



GENERAL QUESTIONS
    1. FEEDBACK
      1. Yes
        No
        Skipped
        1. Enter that person's name.
          Skipped
        2. Enter the five (5) character "nickname" for yourself that you and your provider have agreed upon. Or, create your code number with the first letter of your mother's maiden name and the last four digits of your Social Security Number. Or you may, instead, create another 5-character code that you will remember.
          Skipped
        3. To send your survey to your provider, enter his/her email address.
          NOTE: email addresses are verified when you move to another question or press <Enter>.
          (INVALID EMAIL ADDRESS) Checking Provider Email. Please feel free to answer other questions. Unable to confirm Provider Email. Please re-input it below. Your Service Provider hasn't signed up to receive surveys. Valid Service Provider Email Address
          Please re-enter your service provider's email.
          (DIFFERENT EMAIL ADDRESS) (Same Email Address)
          Skipped
    2. DEMOGRAPHICS
      1. Sex
        Female
        Male
        Other
        Skipped
      2. Age
        Skipped
      3. I am currently in a relationship.
        I have been in a sexual relationship previously.
        I have never been in a sexual relationship.
        Skipped
        1. How long has your current relationship lasted?How long did your longest previous relationship last?
          Skipped
    3. INSTRUCTIONS AND SAMPLE QUESTION

      Answer each question by clicking or tapping in the spot or dragging the cursor to the answer area that best describes how you feel.

      To go back and change any answer, move the cursor to the spot that better describes how you feel.

      To skip an answer, click or tap in the checkbox which says "Skip." To change your mind and answer the question, first click or tap in the checkbox which says "Skipped" to clear it.

      Experiment with the sample question below.

      1. I feel that I have adequate access to chocolate.
        Yes No
        Skipped

OVERALL SATISFACTION

    1. In general, I am satisfied with my sex life.
      Very Not At All
      Skipped
    2. In general, I am satisfied with the emotional intimacy in my life.
      Very Not At All
      Skipped
  1. SOCIO-CULTURAL, POLITICAL, OR ECONOMIC FACTORS
    1. I feel uninformed about sexuality due to inadequate sex education.
      Yes No
      Skipped
    2. I think my vocabulary is adequate to describe subjective or physical sexual experience.
      Yes No
      Skipped
    3. I have adequate information about human sexual biology and women's changes with age.
      Yes No
      Skipped
    4. I have adequate information about human sexual biology and men's changes with age.
      Yes No
      Skipped
    5. I think I lack information about how gender roles influence men's and women's sexuality.
      Yes No
      Skipped
    6. I have adequate access to information and services for birth control.
      Yes No
      Skipped
    7. I have adequate access to information and services for prevention and treatment of sexually transmitted infections.
      Yes No
      Skipped
    8. I have adequate access to information and services for rape or sexual trauma.
      Yes No
      Skipped
    9. I have adequate access to information and services for domestic violence.
      Yes No
      Skipped
    10. I have adequate access to emotional support in my life, such as friends, family, etc.
      Yes No
      Skipped
    11. I avoid having sex or experience distress during sex because I feel I don't live up to the ideals of my culture regarding sexuality or desirability.
      Yes No
      Skipped
    12. I feel anxiety or shame about my body, sexual attractiveness, or sexual responses.
      Yes No
      Skipped
    13. I feel confusion or shame about my sexual orientation or identity.
      Yes No
      Skipped
    14. I feel confusion or shame about my sexual fantasies, desires, and preferences.
      Yes No
      Skipped
    15. I feel that there are conflicts between my sexual values and those of my partner.
      Yes No
      Skipped
    16. I feel that there are conflicts between my sexual values and those of my peer group.
      Yes No
      Skipped
    17. I feel that there are conflicts between my sexual values and those of the mainstream culture.
      Yes No
      Skipped
    18. I feel a lack of interest, fatigue, or lack of time for sex due to family, work, or other obligations.
      Yes No
      Skipped
    19. I feel inhibited about communicating preferences or initiating, pacing, or shaping sexual activities.
      Yes No
      Skipped
  2. RELATIONSHIPS
    Please answer the following questions based on your current relationship.
    Please answer the following questions based on your previous experience in sexual relationship.
    These questions only apply to people who have been in a sexual relationship. To enable them, appropriately answer the "Relationship Status" question.
    1. I experience sexual inhibition, avoidance, or distress because of betrayal by or dislike of my partner.
      Yes No
      Skipped
    2. I experience sexual inhibition, avoidance, or distress because I fear my partner.
      Yes No
      Skipped
    3. I experience sexual inhibition, avoidance, or distress because of abuse by my partner.
      Yes No
      Skipped
    4. I experience sexual inhibition, avoidance, or distress arising from unequal power between myself and my partner.
      Yes No
      Skipped
    5. I experience sexual inhibition, avoidance, or distress because of my partner's negative communication patterns.
      Yes No
      Skipped
    6. In ANOTHER RELATIONSHIP, I have experienced sexual inhibition, avoidance, or distress arising from betrayal, dislike, fear or abuse.
      Yes No
      Skipped
      This question only applies to people CURRENTLY in a relationship, but you indicated otherwise in the "Relationship Status" question.
    7. There are discrepancies between myself and my partner in frequency of desire for sexual activity.
      Yes No
      Skipped
    8. There are discrepancies between myself and my partner in preferences for various sexual activities.
      Yes No
      Skipped
    9. I trust my partner to be sensitive to my wants.
      Yes No
      Skipped
    10. I have lost sexual interest as a result of conflicts with my partner over commonplace issues such as money, schedules, or relatives.
      Yes No
      Skipped
    11. I have experienced loss of sexual interest due to traumatic experiences, such as infertility or the death of a child.
      Yes No
      Skipped
    12. My partner's health and/or sexual problems interfere with my sexual arousal, enjoyment, or spontaneity.
      Yes No
      Skipped
    13. I experience sexual aversion, mistrust, or inhibition of sexual pleasure due to my partner's problem with rejection.
      Yes No
      Skipped
    14. I experience sexual aversion, mistrust, or inhibition of sexual pleasure due to my partner's problem with co-operation.
      Yes No
      Skipped
    15. I experience sexual aversion, mistrust, or inhibition of sexual pleasure due to my partner's problem with closeness.
      Yes No
      Skipped
    16. I experience sexual aversion, mistrust, or inhibition of sexual pleasure due to my partner's criticalness.
      Yes No
      Skipped
    17. I experience sexual aversion, mistrust, or inhibition of sexual pleasure due to my partner's depression.
      Yes No
      Skipped
    18. I experience sexual aversion, mistrust, or inhibition of sexual pleasure due to my partner's anxiety.
      Yes No
      Skipped
  3. PSYCHOLOGICAL FACTORS
    1. I experience inhibition of sexual pleasure or response due to my history of physical, sexual, or emotional trauma.
      Yes No
      Skipped
    2. I avoid sexual activity or fail to experience sexual pleasure because of my fears about rejection.
      Yes No
      Skipped
    3. I avoid sexual activity or fail to experience sexual pleasure because of my fears about intimacy.
      Yes No
      Skipped
    4. I avoid sexual activity or fail to experience sexual pleasure because of my anger toward my partner.
      Yes No
      Skipped
    5. I practice masturbation or other forms of self-pleasuring.
      Frequently Never
      Skipped
    6. I experience sexual aversion, mistrust, or inhibition of sexual pleasure due to my depression.
      Yes No
      Skipped
    7. I experience sexual aversion, mistrust, or inhibition of sexual pleasure due to my anxiety.
      Yes No
      Skipped
    8. I experience sexual inhibition due to my fear of sexual acts or their possible consequences, for example, pain during intercourse, pregnancy, sexually transmitted infections, etc.
      Yes No
      Skipped
    9. I limit my sexual feelings due to my fear of losing my partner.
      Yes No
      Skipped
    10. I engage in sexual behavior that feels inappropriate and out of control.
      Yes No
      Skipped
  4. PHYSICAL FACTORS
    1. I experience pain or lack of physical response during sexual activity due to medical condition(s) affecting my body.
      Yes No
      Skipped
    2. I believe that my sexual experience and pleasure are limited by a medical condition.
      Yes
      No
      Skipped
      1. Please be as specific about the medical condition(s) such as diabetes, multiple sclerosis, Parkinson's disease, lupus, headaches, epilepsy, arthritis, etc. Please note that you will be automatically limited to 255 characters.
        You have characters left.
        Skipped
    3. (men) I have been treated for prostate cancer.
      Yes
      No
      Skipped
    4. (women) I have had a hysterectomy or had my ovary(ies) removed.
      Yes
      No
      Skipped
    5. At some time in my life, I have taken hormones (such as estrogen, testosterone, progesterone, DHEA, birth control pills, etc.).
      Frequently Never
      Skipped
    6. I experience pain or lack of physical response during sexual activity due to the following medical conditions:
      1. Pregnancy
        Yes No
        Skipped
      2. Childbirth
        Yes No
        Skipped
      3. Menopause
        Yes No
        Skipped
      4. Sexually Transmitted Disease
        Yes No
        Skipped
      5. Physical Injury
        Yes No
        Skipped
      6. Side effects of drugs, medications, or treatment for a medical condition.
        Yes No
        Skipped
      7. (women): Involuntary contractions of the vagina (vaginismus).
        Yes No
        Skipped
    7. I am satisfied with my ability to control my ejaculation/orgasm.
      Yes No
      Skipped
    8. I experience pain during arousal (erection, lubrication).
      Yes No
      Skipped
    9. I experience pain during orgasm.
      Yes No
      Skipped
    10. I experience pain during intercourse or other sexual contact for undiagnosed reasons.
      Yes No
      Skipped
    11. I take medication/substance(s) (prescribed, herbal, or illegal) to enhance my sexual experience
      Yes No
      Skipped
    12. I lead a physically healthy lifestyle.
      Yes No
      Skipped
    13. I smoke.
      Yes No
      Skipped
    14. I drink more than 1 alcoholic beverage per day (women) or more than 2 drinks per day (men).
      Yes No
      Skipped
    15. Regarding my weight, I am...
      Too Thin Too Fat
      Skipped
    16. I am exposed to solvents or volatile substances, e.g., exhaust, chemical odors, etc.
      Daily Rarely
      Skipped
    17. I regularly engage in vigorous physical exercise.
      Daily Rarely
      Skipped

Thank you for filling out the survey!

GENERAL QUESTIONS
    1. FEEDBACK
      1. For Service Provider
        1. Service Provider Name:
        2. Service Provider Client Code:
        3. Service Provider Email:
      2. Research Consent
    2. DEMOGRAPHICS
      1. Sex
      2. Age
      3. Relationship
        1. Relationship Years
    3. INSTRUCTIONS AND SAMPLE QUESTION
      1. chocolate
OVERALL SATISFACTION
    1. Satisfied Sex Life
    2. Satisfied Emotional Intimacy
  1. SOCIO-CULTURAL, POLITICAL, OR ECONOMIC FACTORS
    1. Info on Sex Ed
    2. Info on Vocabulary
    3. Info on Female Aging
    4. Info on Male Aging
    5. Info on Gender Roles
    6. Info Svcs re Birth Control
    7. Info Svcs re STDs
    8. Info Svcs re Rape
    9. Info Svcs re Domestic Violence
    10. Access to Emotional Support
    11. Avoid Distress Cultural Ideals
    12. Anxiety Shame of Body or Responses
    13. Confusion Shame re Identity
    14. Confusion Shame re Wants
    15. Sex Value Conflict Partner
    16. Sex Value Conflict Peers
    17. Sex Value Conflict Society
    18. Disinterested Obligations
    19. Inhibited Communication
  2. RELATIONSHIPS
    1. Inhibit Betrayal or Dislike
    2. Inhibit Fear of Partner
    3. Inhibit Partner Abuse
    4. Inhibit Unequal Power
    5. Inhibit Neg Communication
    6. Inhibit Another Relationship
    7. Discrepancy In Frequency
    8. Discrepancy In Activities
    9. Partner Sensitivity
    10. Lost Interest from Mundania
    11. Lost Interest from Trauma
    12. Partner Health or Sex Probs
    13. Aversion Partner Problem with Rejection
    14. Aversion Partner Problem with Co-operation
    15. Aversion Partner Problem with Closeness
    16. Aversion Partner Criticalness
    17. Aversion Partner Depression
    18. Aversion Partner Anxiety
  3. PSYCHOLOGICAL FACTORS
    1. Inhibition History of Trauma
    2. Avoid / Fail Fear Rejection
    3. Avoid / Fail Fear Intimacy
    4. Avoid / Fail Anger at Partner
    5. Self-Pleasuring
    6. Aversion Own Depresssion
    7. Aversion Own Anxiety
    8. Inhibition Consequences
    9. Limit Fear of Losing Partner
    10. Behavior Feels Inapp Uncontrolled
  4. PHYSICAL FACTORS
    1. Pain or LPR from Medical Condition:
    2. Medical Limit:
      1. Medical Limit Specific Condition(s):
    3. History of Prostate Cancer
    4. History of Ovariectomy
    5. History of Hormones
    6. SOURCE OF PAIN OR LACK OF PHYSICAL RESPONSE
      1. Pain or LPR from Pregnancy
      2. Pain or LPR from Childbirth
      3. Pain or LPR from Menopause
      4. Pain or LPR from STD
      5. Pain or LPR from Physical Injury
      6. Pain or LPR from Drugs or Meds
      7. Pain or LPR from Vaginismus
    7. Control of Ejac/Orgasm
    8. Pain Arousal
    9. Pain Orgasm
    10. Pain Undiagnosed
    11. Substances Enhancement
    12. Physically Healthy Lifestyle
    13. Smoking
    14. Alcohol
    15. Weight odd thin to even fat
    16. Solvents or Volatiles
    17. Vigorous Exercise

SURVEY COMPLETED:

This questionnaire has been derived from the diagnostic classification system created by The Working Group on a New View of Women's Sexual Problems* and developed by Seattle Institute for Sex Therapy, Education and Research (Elizabeth Rae Larson, M.S., D.H.S.; Malcolm McKay, M.Ed.; Laura Tsang, M.S.; Ann Manly, Editor; and Ian K. Hagemann, B.A./B.S., Computer Design), with gratefully acknowledged critical feedback and generous assistance from Joy Davidson, Ph.D.; Leonore Tiefer, Ph.D.; Gerald Weeks, Ph.D.; Marilyn McIntyre, M.S.W.; Jack Morin, Ph.D.; and Marty Klein, Ph.D. An earlier version of the SPSAQ was published in the Handbook of Sexuality-Related Measures, Third Edition, edited by Terri D. Fisher, Clive M. Davis, William L. Yarber, and Sandra L. Davis (New York: Routledge, 2010). Please direct any questions about the SPSAQ to questionnaire@sextx.com.

* The New View of Women's Sexual Problems (2000) Working Group members: Linda Alperstein, M.S.W.; Carol Ellison, Ph.D.; Jennifer R. Fishman, B.A.; Marny Hall, Ph.D.; Lisa Handwerker, Ph.D., M.P.H.; Heather Hartley, Ph.D.; Ellyn Kaschak, Ph.D.; Peggy J. Kleinplatz, Ph.D.; Meika Loe, M.A.; Laura Mamo, B.A.; Carol Tavris, Ph.D.; and Leonore Tiefer, Ph.D.

The Web Survey was designed by Ian K. Hagemann using the jQuery JavaScript Library version 1.4.4 and the jQuery User Interface version 1.8.9. JQuery code was used as provided, but all other client-side JavaScript was validated with JSLint Edition 2011-05-01 using "The Good Parts." In accordance with JQuery licensing requirements, this project is released under the GNU General Public License, version 2. Please direct any questions about the survey web design to ianh@sextx.com.

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