Sexual Health Assessment Models

Sexuality Concepts for Social Workers
Dr. Travis Sky Ingersoll

Dr. Brent Satterly
Chapter 11 Special Topics: Illness, Disability, and Sexuality
p. 282 UPDATE! Paragraph 2 mentions the Sexual Health
Assessment models outlined below. The following additional
information was requested by a number of students.
Useful Models for Sexual Health Assessment

ALARM
The ALARM model (Anderson, 1990), which appears to incorporate and
expand on Kaplans (1979, 1995) triphasic model of sexual response, is one
useful model of communication and assessment regarding sex and the
sexual activities of clients. ALARM inquires about each stage of sexual
activity along with the clients medical history. ALARM stands for Activity,
Libido (desire), Arousal, Resolution, and Medical Information. The social
worker (or other human service professional) begins by assessing the clients
sexual activity level prior to the point at which the identified problem or
medical illness began, following up with an evaluation of changes in libido
that may be causing, prolonging, or exacerbating the sexual problem the
client is experiencing. Because this approach focusses primarily on the
behavioral and physical aspects of sexuality, it may overlook other important
domains, such as intimacy, sexual anxiety, emotional connection, and selfimage (Hordern, 2008).
PLEASURE
The PLEASURE model includes the assessment and evaluation of sexual
attitudes, emotions, and activities; level of energy; current treatment and
disease side effects; and incorporates the clients understanding of actual
and potential sexual dysfunctions and issues related to reproduction.
Specifically, the PLEASURE model assesses the following topics and develops
interventions based on identified issues and concerns: Partner, Lovemaking,
Emotions, Attitudes, Symptoms, Understanding, Reproduction, and Energy

(Schain, 1988).
PLISSIT
The PLISSIT Model was designed by Annon (1976) as a step-by-step method
for gathering sexual health information. PLISSIT stands for Permission,
Limited Information, Specific Suggestions, and Intensive Therapy. This
model has been recommended as a useful template for the assessment of
sexuality and sexual health in palliative care settings (Cort, Monroe, &
Oliviere, 2004; Stausmire, 2004); and Claiborne and Rizzo (2006) have
asserted that PLISSIT is particularly suited for social workers. The model
provides the practitioner with a general framework on how to initiate a
dialogue about sexual issues and hot to continue the discussion if warranted.
This approach is versatile and can be applied to a wide range of illnesses,
situations, and settings both outpatient and inpatient. According to this
model, the latter levels of treatment build upon the previous ones. However,
the social worker (or other human service professional) can move back and
forth between the levels of treatment based on the clients needs. The
PLISSIT levels progress as follows:
1. Permission - Permission can be interpreted to mean either asking
for permission to evaluate or giving the person permission to
discuss sexuality. Would it be all right if I asked you about your
sexual history? Is it ok if I asked you some questions about how
your medication(s) has affected your sexual health? Asking
permission puts the individual in control. Such questions should be
followed with a series of open-ended questions specific to sexual
health: What concerns do you have? What changes have you had in
your feelings about sexuality? In relation to your sexual health, what
are things youd like to have change for the better? The assessor
might ask permission to have the persons spouse or partner join
the discussion as well. By doing this, social workers are offering
clients and partners permission to both have and discuss sexual
concerns. Giving permission not only provides opportunities for
people to voice sexual concerns, it also validates and normalizes
their desire to engage in, or refrain from, sexual activity (Annon,
1976).
2. Limited Information This step involves providing brief
education to clients and partners regarding common sexual side
effects associated with an illness and its treatment, including

etiology, pathology, and complications. This information may be
given in a short period of time or over several brief meetings to
share accurate and relevant information about client and partner
concerns. The health and human service professional can also
provide the individual with current and accurate information
regarding the factors that may be affecting their sexuality.
3. Specific Suggestions - Based on the individuals responses to
open-ended questions the social worker or other health care
professional can then make suggestions for a plan of care. For
example, clients are provided with concrete suggestions on how to
cope with changes in sexual function due to an illness or surgery. If
a client is partnered, it may be best to see the couple together to
understand the causes and dynamics of the problem and then
explore possible solutions (Monturo, Rogers, Coleman, Robinson, &
Pickett, 2001). Social workers may also benefit from examining how
the client explored or expressed their sexuality prior to the
diagnosis or presenting problem, and how sexual pleasure was
achieved. Some clients or their partners may express feelings of
guilt, grief, resentment, or anger resulting from the inability to
achieve the level of sexual pleasure they would like to experience
(Claiborne & Rizzo, 2006). This is particularly applicable during
advanced disease and at the end of ones life, as patients losses
and recognitions of changes in their sexual selves may by
exacerbated by the physical deterioration and alienation they may
be experiencing.
4. Intensive Therapy This final level addresses ongoing
concerns and may necessitate a referral to a sex therapist or
relationship counselor. A small minority of cases may require this
type of intervention. For example, it has been estimated that only
30 percent of people will need this last level of the PLISSIT model,
since the majority of sexual function problems are resolved by
providing permission, limited information, and specific suggestions
(Derogatis & Kourlesis, 1981).
More recently, Tayor and Davis (2006) modified Annons (1976) through the
development of the extended PLISSIT model (or Ex-PLISSIT). The ExPLISSIT model suggests that the permission level should involve
requesting permission to discuss sexual issues as well as providing
permission for a person to be a sexual being, and this should be incorporated
into each level of the model (Taylor & Davis, 2006). Therefore, when
assessing a client, a social worker would offer permission in conjunction with

limited information, specific suggestions, and a referral to intensive therapy.
Another useful application of the Ex-PLISSIT model is its integration of
reflection and review by the social worker (or health care professional) after
every interaction with the client. This step holds the practitioner accountable
for their own interactions, biases, and reactions to the client. It also
encourages the client to provide continual feedback and review.
Incorporating these two additional steps of permission giving into each level
of the PLISSIT model and designating time for reflection and review allow for
practitioner accountability during a patient-centered assessment of sexual
health needs.
BETTER
BETTER is an acronym for Bringing up the topic of sexuality; Explaining to
the client or partner that sexuality is a part of quality of life; Telling the client
about resources available to them (as well as gauging the social workers
ability and willingness to assist in addressing questions and concerns);
Timing the discussion to when the patient would prefer, not only when its
convenient for the human service practitioner; and Recording that the
conversation took place and any follow-up plans to further address client
concerns or questions (Mick & Cohen, 2003; Mick, Hughes, & Cohen, 2004).
However, this approach may not adequately emphasize the need for
psychotherapeutic interventions or referrals to specialists (e.g., Sex
Therapists, Urologists, Family and Marriage Therapists, etc.).
References
Anderson, B. L. (1990). How cancer affects sexual functioning. Oncology,
4(6), 81-88.
Annon, J. (1976). The PLISSIT model: A proposed conceptual scheme for the
behavioral
treatment of sexual problems. Journal of Sex Education and Therapy, 2(2),
1-15.
Claiborne, N., & Rizzo, V. M. (2006). Addressing sexual issues in individuals
with chronic health
conditions [Practice Forum]. Health & Social Work, 31, 221-224.

Cort, E., Monroe, B., & Oliviere, D. (2004). Couples in palliative care. Sexual
and Relationship
Therapy, 19, 337-354.
Derogatis, L, & Kourlesis, S. (1981). An approach to evaluation of sexual
problems in the cancer
patient. CA: A Cancer Journal for Clinicians, 31, 45-50.
Horndern, A. (2008). Intimacy and sexuality after cancer: A critical review of
the literature.
Cancer Nursing, 31(2), E9-E17.
Kaplan, H. S. (1979). The disorders of sexual desire. New York:
Brunner/Mazel.
Kaplan, H. S. (1995). The sexual desire disorders: Dysfunctional regulation
of sexual motivation.
New York: Routledge.
Mick, J., & Cohen, M. Z. (2003). Sexuality and cancer: A BETTER approach to
nursing
assessment of patients sexuality concerns. Hematology Oncology News
and Issues, 2(10),
30-31.
Mick, J. A., Hughes, M., & Cohen, M. Z. (2004). Using the BETTER model to
assess sexuality.
Clinical Journal of Oncology Nursing, 8, 84-86.
Monturo, C. A., Rogers, P. D., Coleman, M., Robinson, J. P., & Pickett, M.
(2001). Beyond sexual
assessment: Lessons learned from couples post-radical prostatectomy.
Journal of the
American Academy of Nurse Practitioners, 13, 511-516.
Schain, W. (1988). A sexual interview is a sexual intervention. Innovative

Oncological Nursing, 4(2-3), 15.
Stausmire, J. M. (2004). Sexuality at the end of life. Journal of Hospice and
Palliative Care, 21,
33-39.
Taylor, B., & Davis, S. (2006). Using the extended PLISSIT model to address
sexual health care
needs. Nursing Standard, 21(11), 35-40.

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Sexuality Concepts for Social Workers

Dr. Travis Sky Ingersoll

Useful Models for Sexual Health Assessment

Emotions, Attitudes, Symptoms, Understanding, Reproduction, and Energy

effects associated with an illness and its treatment, including

assessing a client, a social worker would offer permission in conjunction with

conditions [Practice Forum]. Health & Social Work, 31, 221-224.

Schain, W. (1988). A sexual interview is a sexual intervention. Innovative

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