Intersystem Assessment of Sexual Disorders

General Principles

The assessment of sexual problems is a comprehensive, continuous, and fluid process that can be masterfully comingled with treatment throughout the duration of therapy. It begins with the initial contact, continues during the preliminary interviews and ends with the last session. Intersystem assessment is particularly comprehensive because all facets of the client system are evaluated, including individual characteristics, relationship patterns, intergenerational factors, contextual and sociocultural constituents, and so on. Assessment can be used to direct areas of inquiry and eventually contribute to establishing sexual, relational, or individual diagnoses. Ultimately, assessment helps in the formulation or conceptualization of a case and also provides the basis for treatment planning and modifications. With any assessment, it is important to determine the following:

• • The couple’s perception of the problem(s)
• • Current baseline of individual and relational functioning
• • Physical status of each partner
• • The couple’s expectations or goals at the end of treatment
• • Realistic treatment goals
• • Level of sexual desire/interest for each partner
• • Perceived degree of sexual satisfaction
• • Level of distress experienced because of the sexual problem
• • Impact of the sexual problem on the intimate relationship
• • The function of sex in their relationship

As treatment progresses, the assessment should help to direct the structure of the sessions to follow (when to use individual or conjoint). Finally, as therapy culminates, assessment is used to more precisely determine treatment outcomes and, toward the end of therapy, relapseprevention strategies. For sex therapists, assessment of sexual problemstypically relies on information originating from a variety of sources, including self and partner reports, structured interviews and collaborative data from medical and psychological practitioners.

The Biphasic Assessment Process

Phase 1

The first phase of Intersystem assessment is designed to acquire general information about the presenting problem and the health histories of each partner. The therapist usually initiates assessment by asking about the nature of the sexual problem. Sensitivity must be used in eliciting information because the material is often of a delicate nature. It is useful to begin with broad, open-ended, general questions about sexual satisfaction and dissatisfaction while using normalizing statements to help reduce anxiety and to obtain more information. The subsequent questions can be more specific, such as a precise description of the sexual problem. Depending on the information gathered, the therapist can ask about other aspects of sexual functioning, such as adequate foreplay, creating an environment favorable to sex, preferences and dislikes, and so on. The therapist should assume that sexual complaints are often underreported; some couples might be reluctant to reveal one or more sexual problems, and others simply do not recognize a problem as a problem.

Phase 2

The second phase of the assessment process enlarges the perspective to include questions about the couple’s overall relationship and broader contextual material such as environmental stressors and religious, historical, financial, or other sociocultural factors. Additionally, in the second phase, the therapist gathers more detailed information about etiologic factors and how the sexual difficulties are impacting each partner. These focused questions are essential, but certainly not all inclusive or exhaustive of the information that needs to be gathered. In the present discussion, we include only the most common sexual problems the therapist is likely to see. Fundamentally, the therapist is going through a checklist of possible sexual difficulties in order to rule them out. The following areas of concentration should be addressed during the assessment:

• • The who, what, where, when, and duration of the sexual problem. This information can be acquired through a series of conversations between the therapist and partners. How do they view the problem? Is there agreement? What measures have they taken to resolve the problem on their own? The therapist should avoid “why” questions as they are of little value since clients do not often know how to accurately explain the answer.
• • Level of distress on the individual and the relationship. How are the partners feeling about the problem? Who is more upset? Are they able to discuss their feelings about the sexual difficulty? Pessimism is a common emotion that results from attempting to repair sexual problems and failing to find solutions. Are the partners skeptical that the other wants to solve the problem or that treatment will work? Are they anxious, angry, or giving up hope?
• • History of the problem. Did the difficulty begin prior to or during the current relationship? Was the onset sudden or gradual? When did they first notice the symptoms? How has the couple managed the sexual issue and their feelings related to it? Does the sexual issue occur when alone, or with the partner, or in both situations?
• • The overall couple relationship. The therapist acquires an overview of how the couple perceives strengths and weaknesses in their relationship (Weeks & Fife, 2014). Some of the most common relationship issues present as intimacy fears, anger, communication problems, and so on. These conflicts can have a direct and indirect influence on sexual satisfaction. Determine if the couple recognizes a connection between their sexual and relationship problems and vice versa. Many couples cannot comprehend that sexual and relational issues are often comingled, and each impacts the other. The therapist encourages systemic thinking by explaining that most sexual problems do not occur in a vacuum and that sex affects the relationship and vice versa (Mark & Jozkowski, 2013). It is critical to make these connections in order for the partners to believe the therapist is working on the correct issues and in the proper sequence.
• • Level of affection in the relationship. Many couples with sexual concerns view affection as a precursor to sex. Sex and affection have become fused together for many couples. Eventually, expressions of affection are avoided. Ask the couple to work together to compile a list of behaviors that they define as affectionate and whether they view each of these behaviors as a precursor to sex. If they believe an exchange of affection must lead to sex, they will begin to avoid affection too in many cases. Do the partners believe they share the same level of affection in the relationship? Is sharing the same level of affection important?
• • The level of sensuality in their relationship. Sensuality should not be confused with sexual expression. Sensuality involves giving and receiving physical sensual exchanges. Does the level of sensuality change when other factors in the relationship fluctuate, such as with stress on one or both partners? Does one partner generally have a tendency to be more sensual than another? If so, does the more sensual partner expect a certain level of reciprocity with regard to sensual behaviors?
• • Communication skills. Do the partners talk to each other about sex? How do they communicate about sex, verbally and nonverbally? Can they ask for what they want to give and get from each other during a sensual and sexual encounter? Do they cease communication during sex or express themselves in ways that sabotage the experience?
• • Is there anything else the therapist needs to know? Couples may have other significant problems they do not want to discuss, other than the sexual problem. For example, an alcoholic man may not want to discuss his drinking, but just focus on his erectile problems. Eventually, the therapist must provide opportunities for partners to share secrets such as previous sexual abuse, Internet compulsivity, addictions, paraphilias, or affairs that they do not want to reveal in the presence of the partner. Often, these secrets are revealed in individual sessions. The therapist must be vigilant for undisclosed secrets that will interfere with treatment.