A Guide To Assessments That Work - (Part VII Couple Distress and Sexual Problems)

Part VII
Couple Distress and Sexual

Problems
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Hunsley, John, and Eric J. Mash. A Guide to Assessments That Work, Oxford University Press, Incorporated, 2008. ProQuest
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20
Couple Distress
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Douglas K. Snyder
Richard E. Heyman
Stephen N. Haynes
Assessment of couple distress shares basic principles of

assessing individuals—namely, that (a) the content of
assessment methods be empirically linked to target problems
and constructs hypothesized to be functionally related; (b)
selected assessment methods demonstrate evidence of
reliability, validity, and cost-effectiveness; and (c) findings be
linked within a theoretical or conceptual framework of the

presumed causes of difficulties, as well as to clinical
intervention or prevention. However, couple assessment
differs from individual assessment in that couple assessment
strategies (a) focus specifically on relationship processes and
the interactions between individuals, (b) provide an
opportunity for direct observation of target complaints
involving communication and other interpersonal exchange,
and (c) must be sensitive to potential challenges unique to
establishing a collaborative alliance when assessing highly
distressed or antagonistic partners, particularly in a conjoint
context. Similar to the assessment process itself, our
discussion of strategies for assessing couple distress is
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necessarily selective—emphasizing dimensions empirically
related to couple distress, identifying alternative methods and
strategies for obtaining relevant assessment data, and
highlighting specific techniques within each method.
We begin this chapter by defining couple distress and noting

its prevalence and comorbidity with emotional, behavioral,
and physical health problems of individuals in both clinical
and community populations. Both brief screening measures
and clinical methods are presented for diagnosing couple
distress in clinical as well as research applications. The bulk
of the chapter is devoted to conceptualizing and assessing
couple distress for the purpose of planning and evaluating
treatment. Toward this end, we review empirical findings
regarding behavioral, cognitive, and affective components of
couple distress and specific techniques derived from clinical
interview, behavioral observation, and self-report methods. In
most cases, these same assessment methods and instruments
are relevant to evaluating treatment progress and outcome.
We conclude with general recommendations for assessing
couple distress and directions for future research.
CONCEPTUALIZING COUPLE
RELATIONSHIP DISTRESS
Defining Couple Distress
The fourth edition of the Diagnostic and Statistical Manual of

Mental Disorders-Text Revision (DSM-IV-TR; American
Psychiatric Association, 2000) defines a “partner relational
problem” as a pattern of interaction characterized by negative
or distorted communication, or “noncommunication (e.g.,
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withdrawal)” that is associated with clinically significant
impairment in individual or relationship functioning or the
development of symptoms in one or both partners. The
acknowledgment of relational problems as a “frequent focus
of clinical attention,” but their separation from other
emotional and behavioral disorders, amounts to only a
marginal improvement over earlier versions of the DSM that
all but ignored the interpersonal context of distressed lives.
What are the limitations to this conceptualization of partner

relational problems? First is an almost exclusive emphasis on
the etiological role of communication in the impairment of
functioning or development of symptoms in one or both
partners. Although group comparisons document differences
in communication between clinic versus community couples
(Heyman, 2001), and “communication problems” is the most
frequent presenting complaint of couples (Geiss & O’Leary,
1981), evidence that communication differences precede,
rather than follow, relationship distress is weak or
nonexistent. Moreover, research with community samples
indicates that some forms of “negative” communication

predict better rather than worse relationship outcomes
longitudinally (Gottman, 1993). In addition, positive changes
in relationship satisfaction following couple therapy
correspond only weakly or nonsignificantly with actual
changes in communication behavior (Jacobson, Schmaling, &
Holtzworth-Munroe, 1987; Sayers, Baucom, Sher, Weiss, &
Heyman,1991). Even the distinction between communication
and “noncommunication” seems flawed, in that most couple
and family theorists would argue that all behavior (including
withdrawal) is communicative (Fraenkel, 1997).
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In proposing a broadened conceptualization of relationship
disorders for the DSM-V, First et al. (2002, p. 161) defined
relational disorders as “persistent and painful patterns of
feelings, behavior, and perceptions involving two or more
partners in an important personal relationship . . . marked by
distinctive, mal-adaptive patterns that show little change
despite a great variety of challenges and circumstances.” Still
lacking in this conceptualization (as well as in the DSM-IV-
TR) is a recognition of “nonsymptomatic” deficiencies that
couples often present as a focus of concern, including those
that detract from optimal individual or relationship well-
being. These include deficits in feelings of security and
closeness, shared values, trust, joy, love, and similar positive
emotions that individuals typically value in their intimate
relationships. Not all such deficits reflect communication
difficulties, nor do they necessarily culminate in “clinically
significant” impaired functioning or emotional and behavioral
symptoms as traditionally conceived; yet, frequently, these
deficits are experienced as significant concerns that may
culminate in partners’ disillusion or their dissolution of the
relationship. The most positive features of the DSM’s

conceptualization of partner relational problems are its
emphasis on the interactions between partners and its
recognition that relational problems are frequently associated
with individual symptoms in one or both partners.
Prevalence and Comorbid Conditions
Clinical interventions targeting couple distress continue to

gain in stature as vital components of mental health services.
Three factors contribute to this growing recognition: (1) the
prevalence of couple distress in both community and clinic
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samples; (2) the impact of couple distress on both the
emotional and physical well-being of adult partners and their
offspring; and (3) increased evidence of the effectiveness of
couple therapy, not only in treating couple distress and related
relationship problems but also as a primary or adjunct
treatment for a variety of individual emotional, behavioral, or
physical health disorders (Snyder, Castellani, & Whisman,
2006).
Couple distress is prevalent in both community

epidemiological studies and in research involving clinical
samples. In the United States, the most salient indicator of
couple distress remains a divorce rate of approximately 50%
among married couples (Kreider & Fields, 2002), with about
half of these occurring within the first 7 years of marriage.
Independent of divorce, the research literature suggests that
many, if not most, marriages experience periods of significant
turmoil that place partners at risk for dissatisfaction,
dissolution, or symptom development (e.g., depression or
anxiety). Data on the effects of stigma, prejudice, and
multiple social stressors experienced by lesbian, gay, and

bisexual populations suggest that same-sex couples may
experience additional challenges (Meyer, 2003).
In a previous national survey, the most frequently cited causes

of acute emotional distress were relationship problems
including divorce, separation, and other marital strains
(Swindle, Heller, Pescosolido, & Kikuzawa, 2000). Other
studies have indicated that maritally discordant individuals
are overrepresented among individuals seeking mental health
services, regardless of whether or not they report marital
distress as their primary complaint (Lin, Goering, Offord,
Campbell, & Boyle, 1996). In a study of 800 employee
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assistance program (EAP) clients, 65% rated family problems
as “considerable” or “extreme” (Shumway, Wampler, Dersch,
& Arredondo, 2004).
Data from the National Comorbidity Survey indicated that, in

comparison to happily married persons, maritally distressed
partners are three times
more likely to have a mood disorder, two and a half times
more likely to have an anxiety disorder, and two times more
likely to have a substance use disorder (Whisman, 1999).
Additional findings from an epidemiological survey in
Ontario showed that, even when controlling for distress in
other relationships with relatives and close friends, marital
distress was significantly correlated with major depression,
generalized anxiety disorder, social and simple phobia, panic
disorder, and alcohol dependence or abuse (Whisman,
Sheldon, & Goering, 2000). Moreover, couple
distress—particularly negative communication—has direct
adverse effects on cardiovascular, endocrine, immune,
neurosensory, and other physiological systems that, in turn,
contribute to physical health problems (Kiecolt-Glaser &

Newton, 2001). Nor are the effects of couple distress confined
to the adult partners. Gottman (1999) cites evidence
indicating that “marital distress, conflict, and disruption are
associated with a wide range of deleterious effects on
children, including depression, withdrawal, poor social
competence, health problems, poor academic performance, a
variety of conduct-related difficulties, and markedly
decreased longevity” (p. 4).
In brief, couple distress has a markedly high prevalence, has a

strong linkage to emotional, behavioral, and health problems
in the adult partners and their offspring, and is among the
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most frequent primary or secondary concerns reported by
individuals seeking assistance from mental health
professionals.
Etiological Considerations and

Implications for Assessment
Both the aforementioned comorbidity findings and clinical

observations suggest that couple distress likely results from,
as well as contributes to, emotional and behavioral problems
in one or both partners as well as their children. However, as
a relational (vs. individual) disorder, understanding a given
couple’s distress requires extending beyond individual
considerations to pursue a broader assessment of the
relational and socioecological context in which couple
distress emerges. Snyder, Cavell, Heffer, and Mangrum
(1995) proposed a multitrait, multilevel assessment model for
assessing couple and family distress comprising five
overlapping construct domains (cognitive, affective,
behavioral, interpersonal, and structural/ developmental)
operating at five system levels (individuals, dyads, the nuclear

family, the extended family, and community/cultural
systems). Table 20.1 (from Snyder & Abbott, 2002) provides
a modest sampling of specific constructs relevant to each
domain at each system level.
The relevance of any Specific facet of this model to

relationship distress for either partner varies dramatically
across couples; hence, although providing guidance regarding
initial areas of inquiry from a nomothetic perspective, the
relation of any specific component to relationship distress for
a given individual or couple needs to be determined from a
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functional- analytic approach and applied idiographically
(Cone, 1988; Haynes, Leisen, & Blaine, 1997; Haynes &
O’Brien, 2000). Moreover, interactive effects occur within
domains across levels, within levels across domains, and
across levels and domains. For example, individual
differences in emotion regulation could significantly impact
how partners interact when disclosing personal information or
attempting to resolve conflict. Later in this chapter, we
highlight more salient components of this assessment model
operating primarily at the dyadic level as they relate to case
conceptualization and treatment planning.
ASSESSMENT FOR DIAGNOSIS
A diagnosis of couple distress is based on the subjective

evaluation of dissatisfaction by one or both partners with the
overall quality of their relationship. By comparison,
relationship dysfunction may be determined by external
evaluations of partners’ objective interactions. Although
subjective and external evaluations frequently converge,
partners may report being satisfied with a relationship

that—by outsiders’ evaluations—would be rated as
dysfunctional due to observed deficits in conflict resolution,
emotional expressiveness, management of relationship tasks
involving finances or children, interactions with extended
family, and so forth; similarly, partners may report
dissatisfaction with a relationship that to outsiders appears
characterized by effective patterns of interacting in these and
other domains. Discrepancies between partners’ subjective
reports and outside observers’ evaluations may result, in part,
from raters’ differences in personal values, gender, ethnicity,
or cultural perspectives (Tanaka-Matsumi, 2004).
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For screening purposes, a brief structured interview may be
used to assess overall relationship distress and partner
violence. Heyman, Feldbau-Kohn, Ehrensaft, Langhinrichsen-
Rohling, and O’Leary (2001) developed a structured
diagnostic interview to provide an initial assessment of
marital distress and partner aggression (SDI-MD-PA),
patterned after the Structured Clinical Interview for the DSM
(First, Gibbon, Spitzer, & Williams, 1997). An initial
evaluation of this structured interview demonstrated high
inter-rater reliability; moreover, partners’ responses to items
presented in this interview showed a high correspondence
with the same items given in the form of a questionnaire (see
Table 20.2).
TABLE 20.1 Sample Assessment Constructs Across Domains

and Levels of Couple and Family Functioning
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Source: From D. K. Snyder and B. V. Abbott (2002). Couple
distress. In M. M. Antony & D. H. Barlow (Eds.), Handbook
of Assessment and Treatment Planning for Psychological
Disorders (pp. 341–374). New York: Guilford Press.
Copyright 2002 by Guilford Press. Reprinted with
permission.
TABLE 20.2 Ratings of Instruments Used for Screening and

Diagnosis
Note: SDI-MD-PA = Structured Diagnostic Interview for

Marital Distress and Partner Aggression; DAS = Dyadic
Adjustment Scale; DAS-7 = Dyadic Adjusment Scale-7 item
version; KMSS = Kansas Marital Satisfaction Scale; CSI =
Couple Satisfaction Index Scales; RMICS = Rapid Marital
Interaction Coding System; RCISS = Rapid Couples
Interaction Scoring System; A = Adequate; G = Good; E =
Excellent; U = Unavailable; NA = Not Applicable.
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The emphasis on partners’ subjective evaluations of couple
distress has led to development of numerous self-report
measures of relationship satisfaction and global affect. There
is considerable convergence across measures purporting to
assess such constructs as marital “quality,” “satisfaction,”
“adjustment,” “happiness,” “cohesion,” “consensus,”
“intimacy,” and the like, with correlations between measures
often approaching the upper bounds of their reliability.
Differentiation among such constructs at a theoretical level
often fails to achieve the same operational distinction at the
item-content level (cf., Fincham & Bradbury, 1987, for an
excellent discussion of this issue). Hence, selection among
such measures should be guided by careful examination of
item content (i.e., content validity) and empirical fi ndings
regarding both convergent and discriminant validity.
Relatively short measures of overall relationship satisfaction

may be useful as diagnostic and screening strat egies for
couple distress. The most frequently used global measure of
relationship satisfaction in couple research is the Dyadic
Adjustment Scale (DAS; Spanier, 1976), a 32-item instrument

purporting to differentiate among four related subscales refl
ecting cohesion, satisfaction, consensus, and affectional
expression. For abbreviated screening measures of couple
distress, several alternatives are available—including a brief
(7-item) version of the DAS (Hunsley, Best, Lefebvre, &
Vito, 2001). An even briefer measure, the Kansas Marital
Satisfaction Scale (KMSS; Schumm et al., 1986), includes
three Likert items assessing satisfaction with marriage as an
institution, the marital relationship, and the character of one’s
spouse. New global measures of relationship sentiment
continue to be developed for both research and clinical
purposes—including a new set of three Couple Satisfaction
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Index (CSI) scales constructed using item response theory
(IRT) and comprising 32, 16, and 4 items each (Funk &
Rogge, in press).
Despite its widespread use, a review of psycho-metric

properties reveals important limitations to the DAS. Factor
analyses have failed to replicate its four subscales (Crane,
Busby, & Larson, 1991), and the reliability of the affectional
expression subscale is weak. There is little evidence that the
full-length DAS and similar longer global scales offer
incremental validity above the 3-item KMSS—although
preliminary evidence suggests that the new CSI scales may
offer higher precision of measurement and greater sensitivity
for detecting differences in relationship satisfaction.
Because partners frequently present for treatment together,

clinicians have the rare opportunity to observe the reciprocal
social determinants of problem behaviors without venturing
outside the therapy offi ce. Structured observations constitute
a useful assessment method because they minimize inferences
needed to assess behavior, can facilitate formal or informal

functional analysis, can provide an additional method of
assessment in a multimethod strategy (e.g., integrated with
interview and questionnaires), and can facilitate
the observation of otherwise difficult to observe behaviors
(Haynes & O’Brien, 2000; Heyman & Slep, 2004). We
discuss analog behavioral observation of couple interactions
and describe specific observational coding systems at greater
length in the following section on case conceptualization and
treatment planning. However, for purposes of initial screening
and diagnosis, we advocate two approaches to assessing
partners’ descriptions of relationship problems, expression of
positive and negative feelings, and efforts to resolve Conflicts
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and reach decisions—specifically, the Rapid Marital
Interaction Coding System (RMICS; Heyman, 2004), and the
Rapid Couples Interaction Scoring System (RCISS; Krokoff,
Gottman, & Hass, 1989). Even when not formally coding
couples’ interactions, clinicians’ familiarity with the
behavioral indicators for specific communication patterns
previously demonstrated to covary with relationship accord or
distress should facilitate empirically informed screening of
partners’ verbal and nonverbal exchanges.
When a couple presents for therapy with primary complaints

of dissatisfaction in their relationship, screening for the mere
presence of couple distress is unnecessary. However, there are
numerous other situations in which the practitioner may need
to screen for relationship distress as a contributing or
exacerbating factor in patients’ presenting
complaints—including mental health professionals treating
individual emotional or behavioral difficulties; physicians
evaluating the interpersonal context of such somatic
complaints as fatigue, chronic headaches, or sleep
disturbance, or emergency room personnel confronting

persons with severe relationship distress culminating in
physical violence and injuries. We advocate a sequential
strategy of progressively more detailed assessment when
indicators of relationship distress emerge (cf., Snyder &
Abbott, 2002, pp. 366–367):
1. Clinical inquiry as to whether relationship problems

contribute to individual difficulties such as feeling depressed
or anxious, having difficulty sleeping, abusing alcohol or
other substances, or feeling less able to deal with such
stresses as work, children and family, or health concerns.
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2. Alternatively, use of an initial brief screening measure
(e.g., the KMSS or DAS-7) having evidence of both internal
consistency and construct validity.
3. For individuals reporting moderate to high levels of global

relationship distress, following up with more detailed
assessment strategies such as semi structured interviews,
analog behavioral observation, and multidimensional
relationship satisfaction questionnaires to differentiate among
levels and sources of distress.
Overall Evaluation
When screening for either clinical or research purposes, we

advocate assessment strategies favoring sensitivity over
specificity to minimize the likelihood of overlooking potential
factors contributing to individual or relationship distress. This
implies the initial use of broad screening items in clinical
inquiry or self-report measures such as the DAS-7 or the
KMSS—along with direct observation of partner interactions
whenever possible—and subsequent use of more extensive

narrow-band or multidimensional measures described in the
following section on treatment planning to pinpoint specific
sources of concern. Initial assessment findings indicating
overall relationship distress need to be followed by
functional-analytic assessment strategies to delineate the
manner in which individual and relationship concerns affect
each other and relate to situational factors (Floyd, Haynes, &
Kelly, 1997).
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ASSESSMENT FOR CASE
CONCEPTUALIZATION AND
TREATMENT PLANNING
Conceptualizing couple distress for the purpose of planning

treatment requires extending beyond global sentiment to
assess specific sources and levels of relationship difficulties,
their individual and broader socioecological determinants,
and their potential responsiveness to various clinical
interventions. We begin our consideration of assessing couple
relationships for case conceptualization and treatment
planning with a discussion of construct domains particularly
relevant to couple distress—including relationship behaviors,
cognitions, and affect—as well as individual and broader
cultural factors. We follow this with a discussion of various
assessment strategies and techniques for evaluating specific
constructs in these domains.
Domains to Target When Evaluating

Couple Distress
Relationship Behaviors
Research examining behavioral components of couple distress

has emphasized two domains: the rates
and reciprocity of positive and negative behaviors exchanged
between partners, and communication behaviors related to
both emotional expression and decision-making. Regarding
the former, distressed couples are distinguished from
nondistressed couples by (a) higher rates of negative verbal
and nonverbal exchanges (e.g., disagreements, criticism,
hostility); (b) higher levels of reciprocity in negative behavior
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(i.e., the tendency for negativity in partner A to be followed
by negativity in partner B); (c) lengthier chains of negative
behavior once initiated; (d) higher ratios of negative to
positive behaviors, independent of their separate rates; and (e)
lower rates of positive verbal and nonverbal behaviors (e.g.,
approval, empathy, smiling, positive touch; Weiss &
Heyman, 1997). Findings suggest a stronger linkage for
negativity, compared to positivity, to overall couple distress.
Given the inevitability of disagreements arising in long-term

relationships, numerous studies have focused on specific
communication behaviors that exacerbate or impede the
resolution of couple conflicts. Most notable among these are
difficulties in articulating thoughts and feelings related to
specific relationship concerns and deficits in decision-making
strategies for containing, reducing, or eliminating conflict.
Gottman (1994) observed that expression of criticism and
contempt, along with defensiveness and withdrawal, predicted
long-term distress and risk for relationship dissolution.
Christensen and Heavey (1990) found that distressed couples
were more likely than nondistressed couples to demonstrate a

demand → withdraw pattern in which one person attempts to
engage the partner in relationship exchange and that partner
withdraws, with respective approach and retreat behaviors
progressively intensifying.
Given findings regarding the prominence of negativity,

conflict, and ineffective decision-making strategies as
correlates of relationship distress, couple assessment must
address specific questions regarding relationship
behaviors—especially communication behaviors. We list
these below, along with sample assessment methods; in
subsequent sections specifying interview, observational, and
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self-report strategies for assessing couple distress, we
describe these and related methods in greater detail.
1. How frequent and intense are the couple’s conflicts? How

rapidly do initial disagreements escalate into major
arguments? For how long do conflicts persist without
resolution? Both interview and self-report measures may
yield useful information regarding rates and intensity of
negative exchanges as well as patterns of Conflict
engagement. Commonly used self-report measures Specific to
communication include the Communication Patterns
Questionnaire (CPQ; Christensen, 1987; see Table 20.3).
Couples’ Conflict-resolution patterns may be observed
directly by instructing partners to discuss problems of their
own choosing representative of both moderate and high
disagreement, and then either formally or informally coding
these interactions using one of the behavioral coding systems
described later in this chapter.
2. What are common sources of relationship conflict? For

example, interactions regarding finances, children, sexual

intimacy, use of leisure time, or household tasks; involvement
with others including extended family, friends, or coworkers;
differences in preferences or core values? In addition to the
clinic al interview, numerous self-report measures sample
sources of distress across a variety of relationship domains.
Among those having evidence of both reliability and
construct validity are the Frequency and Acceptability of
Partner Behavior Inventory (FAPBI; Doss & Christensen,
2006) and the Marital Satisfaction Inventory-Revised (MSI-
R; Snyder, 1997)—both of which are described in greater
detail later along with other self-report measures.
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3. What resources and deficits do partners dem-3. onstrate in
problem-Identification and Conflict-resolution strategies? Do
they engage couple issues at adaptive levels (i.e., neither
avoiding nor dwelling on relationship concerns)? Do partners
balance their expression of feelings with decision-making
strategies? Are problem-resolution efforts hindered by
inflexibility or imbalances in power? Do partners offer each
other support when confronting stressors from within or
outside their relationship? As noted by others (e.g., Bradbury,
Rogge, & Lawrence, 2001; Cutrona, 1996), most of the
interactional tasks developed for use in couple research have
emphasized problem-solving and Conflict-resolution to the
exclusion of tasks designed to elicit more positive relationship
behaviors such as emotional or strategic support. Hence,
when designing interaction tasks for couples, both clinicians
and researchers should include tasks Specifically designed to
sample potential positive, as well as negative exchanges. For
example, couples might be asked to discuss a time when one
partner’s feelings were hurt by someone outside the
relationship (e.g., a friend or coworker), in order to assess
behaviors expressing understanding and caring—although

few templates with these foci have been developed and
psychometrically evaluated.
TABLE 20.3 Ratings of Instruments Used for Case

Conceptualization and Treatment Planning
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Notes: FAPBI = Frequency and Acceptability of Partner
Behavior Inventory; CPQ = Communication Patterns
Questionnaire; CTS = Conflict Tactics Scale; CTS2 =
Conflict Tactics Scale-Revised; RAM = Relationship
Attribution Measure; MSI-R = Marital Satisfaction Inventory-
Revised; ENRICH = Evaluating and Nurturing Relationship
Issues, Communication, Happiness; BARS = Behavioral
Affective Rating System; SPAFF = Specific Affect Coding

System; CRS = Conflict Rating System; CRAC = Clinical
Rating of Adult Communication Scale; IDCS = Interactional
Dimensions Coding System; KPI = Kategoriensystem für
Partnerschaftliche Interaktion; COMFI = Codebook of
Marital and Family Interaction; CST = Communication Skills
Test; DISC = Dyadic Interaction Scoring Code; LIFE =
Living In Family Environments Coding System; VTCS =
Verbal Tactics Coding Scheme; SCID = System for Coding
Interactions in Dyads; SSICS = Social Support Interaction
Coding System; A = Adequate; G = Good; E = Excellent; U =
Unavailable; NA = Not applicable.
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Relationship Cognitions
Social learning models of couple distress have expanded to

emphasize the role of cognitive processes in moderating the
impact of Specific behaviors on relationship functioning
(Baucom, Epstein, & LaTaillade, 2002). Research in this
domain has focused on such factors as selective attention,
attributions for positive and negative relationship events, and
Specific relationship assumptions, standards, and
expectancies. For example, findings indicate that distressed
couples often exhibit a bias toward selectively attending to
negative partner behaviors and relationship events and
ignoring or minimizing positive events (Sillars, Roberts,
Leonard, & Dun, 2000). Compared to non-distressed couples,
distressed partners also tend to blame each other for problems
and to attribute each other’s negative behaviors to broad and
stable traits (Bradbury & Fincham, 1990). Distressed couples
are also more likely to have unrealistic standards and
assumptions about how relationships should work,
and lower expectancies regarding their partner’s willingness
or ability to change their behavior in some desired manner

(Epstein & Baucom, 2002). Based on these findings,
assessment of relationship cognitions should emphasize the
following questions:
1. Do partners demonstrate an ability to accurately observe

and report both positive and negative relationship events? For
example, partners’ descriptions and interpretations of couple
interactions observed directly in therapy can be compared to
the clinician’s own assessment of these same exchanges.
Partners’ response-sets when completing self-report
relationship measures can also be assessed; for example, the
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Conventionalization (CNV) scale on the MSI-R (Snyder,
1997) assesses the tendency to distort relationship appraisals
in an overly positive direction.
2. What interpretation or meaning do partners impart to

relationship events? Clinical interviews are particularly useful
for eliciting partners’ subject ive interpretations of their own
and each other’s behaviors; such interpretations and
attributions also frequently are expressed during Conflict-
resolution or other interactional tasks. To what extent are
partners’ negative relationship behaviors attributed to stable,
negative aspects of the partner versus external or transient
events? Self-report measures assessing relationship
attributions include the Relationship Attribution Measure
(RAM; Fincham & Bradbury, 1992).
3. What beliefs and expectancies do partners hold regarding

both their own and the other person’s ability and willingness
to change in a manner anticipated to be helpful to their
relationship? What standards do they hold for relationships
generally?
Relationship Affect
Similar to findings regarding behavior exchange, research

indicates that distressed couples are distinguished from
nondistressed couples by higher overall rates, duration, and
reciprocity of negative relationship affect and, to a lesser
extent, by lower rates of positive relationship affect.
Nondistressed couples show less reciprocity of positive
affect, reflecting partners’ willingness or ability to express
positive sentiment spontaneously independent of their
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partner’s affect (Gottman, 1999). By contrast, partners’
influence on each other’s negative affect has been reported for
both proximal and distal outcomes. For example, Pasch,
Bradbury, and Davila (1997) found that partners’ negative
mood prior to discussion of a personal issue predicted lower
levels of emotional support they provided to the other during
their exchange. From a longitudinal perspective, couples who
divorce are distinguished from those who remain married by
partners’ initial levels of negative affect and by a stronger
linkage of initial negativity to the other person’s negative
affect over time (Cook et al., 1995). Gottman (1999)
determined that the single best predictor of couples’ eventual
divorce was the amount of contempt partners expressed in
videotaped interactions. Hence, assessment of couple distress
should evaluate the following:
1. To what extent do partners express and reciprocate

negative and positive feelings about their relationship and
toward each other? Partners’ reciprocity of affect is best
evaluated using either structured or unstructured interactions
and coded (either formally or informally) using one of the

behavioral observation systems described later in this section.
Although much of the couple literature emphasizes negative
emotions, positive emotions such as smiling, laughter,
expressions of appreciation or respect, comfort or soothing,
and similar expressions are equally import ant to assess
through observation or clinical inquiry.
2. What ability does each partner have to express his or her

feelings in a modulated manner? Problems with emotion self-
regulation may be observed either in overcontrol of emotions
(e.g., an inability to access, label, or express either positive or
negative feelings) or in undercontrol of emotions (e.g., the
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rapid escalation of anger into intense negativity approaching
rage, progression of tearfulness into sobbing, or deterioration
in quality of thought secondary to emotional overload).
Unregulated negativity culminating in either verbal or
physical aggression can be assessed through self- or partner
report using either the original or revised versions of the
Conflict Tactics Scale (CTS/ CTS2; Straus, 1979; Straus,
Hamby, Boney-McCoy, & Sugarman, 1996).
3. To what extent does partners’ negative affect generalize

across occasions? Generalization of negative affect, or
“negative sentiment override” (Weiss, 1980), can be observed
in partners’ inability to shift from negative to either neutral or
positive affect during the interview or in interactional tasks,
or in reports of distress across most or all domains of
relationship functioning assessed using self-report. In
research applications, ratings of affect by partners observing
their videotaped interactions may provide an additional means
of assessing sentiment override. For example, in a study of
the effects of relationship sentiment override on couples’
perceptions, partners used an affect-rating dial to indicate

how positively
or negatively they felt during a previously videotaped
interaction and how they thought their partner felt during the
interaction (Hawkins, Carrère, & Gottman, 2002).
Comorbid Individual Distress
As noted earlier when discussing comorbid conditions, there

is growing evidence that relationship difficulties covary with,
contribute to, and result from individual emotional and
behavioral disorders (Snyder & Whisman, 2003). Both
1273
clinician reports and treatment outcome studies suggest that
individual difficulties render couple therapy more difficult or
less effective (Allgood & Crane, 1991; Northey, 2002; Sher,
Baucom, & Larus, 1990; Snyder, Mangrum, & Wills, 1993;
Whisman, Dixon, & Johnson, 1997). Hence, when evaluating
couple distress, additional attention should be given to
disorders of individual emotional or behavioral functioning to
address the extent to which either partner exhibits individual
emotional or behavioral difficulties potentially contributing
to, exacerbating, or resulting in part from couple distress.
Given the association of couple distress with affective
disorders and alcohol use, initial interviews of couples should
include questions regarding suicidality and alcohol or other
substance use—as well as brief screening for previous
treatment of emotional or behavioral disorders.
When clinical interview suggests potential interaction of

relationship and individual dysfunction, focused and brief
measures (e.g., the Beck Depression Inventory-II [BDI-II];
Beck, Steer, & Brown, 1996, or the Symptom
Checklist-90-Revised [SCL-90-R]; Derogatis & Savitz, 1999)

should be considered. It is equally important to assess
couples’ strengths and resources across intrapersonal,
relationship, and broader social system levels. These include
partners’ ability to limit the impact of individual or couple
dysfunction despite overwhelming stressors, or containing the
generalization of distress to other family members.
Finally, establishing the direction and strength of causal

relations among individual and relationship disorders, as well
as their linkage to situational stressors or buffers, is crucial
for determining both the content and sequencing of clinical
interventions. In many cases, such functional relations are
1274
reciprocal—supporting interventions at either end of the
causal chain.
Cultural Differences in Couple Distress
Consistent with our conceptual framework, cultural

differences in the development, subjective experience, overt
expression, and treatment of couple distress are critical to
evaluate. By this we refer not only to cross-national
differences in couples’ relationships, but also to cross-cultural
differences within nationality and consideration of
nontraditional relationships including gay and lesbian
couples. There are important differences among couples as a
function of their culture, religious orientation, economic level,
and age. These dimensions can affect the importance of the
couple relationship to a partner’s quality of life, their
expectancies regarding marital and parenting roles, typical
patterns of verbal and nonverbal communication and
decision-making within the family, the behaviors that are
considered distressing, sources of relationship Conflict, the
type of external stressors faced by a family, and the ways that

partners respond to couple distress and divorce (e.g., Diener,
Gohm, Suh, & Oishi, 2000; Gohm, Oishi, Darlington, &
Diener, 1998; Jones & Chao, 1997). For example, Haynes et
al. (1992) found that parenting, extended family, and sex were
less strongly related to marital satisfaction whereas health of
the spouse and other forms of affection were more important
factors in marital satisfaction in older (i.e., over 55 years)
compared to younger couples. Similarly, Bhugra and De Silva
(2000) suggested that relationships with extended family
members might be more important in some cultures. Also,
when partners are from different cultures, cultural differences
1275
and Conflicts can be a source of relationship dissatisfaction
(e.g., Baltas & Steptoe, 2000). An important implication of
such findings is that measures shown to be valid for one
population may be less so for another.
Assessment Strategies and Specific Techniques

for Evaluating Couple Distress
Assessment strategies for evaluating relationships vary across

the clinical interview, observational methods, and self- and
other-report measures. In the sections that follow, we discuss
empirically supported techniques within each of these
assessment strategies. Although Specific techniques within
any method could target diverse facets of individual, dyadic,
or broader system functioning, we emphasize those more
commonly used when assessing couple distress.
The Clinical Interview
The pretreatment clinical interview is the first step in

assessing couples. It can aid in identifying a couple’s

behavior problems and strengths, help specify a couple’s
treatment goals, and be used to acquire data that are useful for
treatment outcome evaluation. The assessment interview can
also serve to strengthen the client–clinician relationship,
identify barriers to treatment, and increase the chance that the
couple will participate in subsequent assessment and
treatment tasks. Furthermore, it is the primary means of
gaining a couple’s informed consent about the assessment–
treatment process. Data from initial assessment interviews
also guide the clinician’s decisions about which additional
assessment strategies may be most useful; for example,
1276
Gordis, Margolin, and John (2001) used an interview to select
topics for discussion during an analog behavioral observation
of couple communication patterns. Perhaps most importantly,
the assessment interview can provide a rich source of
hypotheses about factors that may contribute to the couple’s
distress. These hypotheses contribute to the case formulation
which, in turn, affects decisions about the best treatment
strategy for a particular couple.
The interview can also be used to gather information on

multiple levels, in multiple domains, and across multiple
response modes in couple assessment. It can provide
information on the Specific behavioral interactions of the
couple, including behavioral exchanges and violence;
problem-solving skills, sources of disagreement, areas of
satisfaction and dissatisfaction, each partner’s thoughts,
beliefs, and attitudes; and their feelings and emotions
regarding the partner and relationship. The couple assessment
interview can also provide information on cultural and family
system factors and other events that might affect the couple’s
functioning and response to treatment. These factors might

include interactions with extended family members, other
relationship problems within the nuclear family (e.g., between
parents and children), economic stressors, and health
challenges. The initial assessment interview can also provide
information on potentially important causal variables for
couple distress at an individual level, such as a partner’s
substance use, mood disorder, or problematic personality
traits.
Moreover, the clinical interview can be especially useful in

identifying functional relations that may account for
relationship difficulties. The functional relations of greatest
1277
interest in couple assessment are those that are relevant to
problem behaviors, feelings, and relationship enhancement.
Identifying functional relations allows the assessor to
hypothesize about “why” a partner is unhappy or what
behavioral sequences lead to angry exchanges. Clinicians are
interested, for example, in finding out what triggers a
couple’s arguments and what communication patterns lead to
their escalation. What does one partner do, or not do, that
leads the other partner to feel unappre ciated or angry?
In the previous section on screening and diagnosis, we

identified a brief structured interview for identifying overall
relationship distress and partner aggression. Various formats
for organizing and conducting more extensive assessment
interviews with couples have been proposed (cf., Epstein &
Baucom, 2002; Gottman, 1999; Karpel, 1994; L’Abate, 1994;
Snyder & Abbott, 2002). For example, Karpel (1994)
suggested a four-part evaluation that includes an initial
meeting with the couple together, followed by separate
sessions with each partner individually, and then an additional
conjoint meeting with the couple. Snyder and Abbott (2002)

recommended an extended initial assessment interview lasting
about 2 hours in which the following goals are stated at the
outset: (a) first getting to know each partner as an individual
separate from the marriage; (b) understanding the structure
and organization of the marriage; (c) learning about current
relationship difficulties, their development, and previous
efforts to address these; and (d) reaching an informed
decision together about whether to proceed with couple
therapy and, if so, discussing respective expectations.
However, none of the comprehensive interview structures

proposed for couples has been subjected to the rigorous
1278
development and psychometric evaluation that have
characterized other couple assessment methods such as self-
report questionnaires or behavioral observation techniques.
Moreover, the limited research on couple-based interviews
has shown lower rates of endorsement for sensitive or socially
undesirable behaviors (e.g., infidelity) when assessed by
interview in comparison to alternative self-report methods
(Whisman & Snyder, 2007).
The clinical literature reflects considerable divergence on the

issue of whether initial assessment of couple distress should
be conducted with partners con-jointly or should also include
individual interviews with partners separately. Arguments for
the latter include
considerations of both veridicality and safety—particularly
when assessing such sensitive issues as partner violence,
substance abuse, or sexual interactions (Haynes, Jensen,
Wise, & Sherman, 1981). Research indicates that couples
experiencing domestic violence often do not disclose a
partner’s violent behavior in early interviews due to
embarrassment, minimization, or fear of retribution

(Ehrensaft & Vivian, 1996). Moreover, risks of retaliatory
aggression against one partner by disclosing the other’s
violence in conjoint interview argue for the importance of
conducting inquiries concerning partner violence in individual
interviews.
Arguments against individual interviews when assessing

couple distress emphasize potential difficulties in conjoint
therapy if one partner has disclosed information to the
therapist about which the other partner remains uninformed.
Of particular concern are disclosures regarding partner
violence (Aldarondo & Straus, 1994; Rathus & Feindler,
1279
2004) and sexual infidelity (Snyder & Doss, 2005; Whisman
& Wagers, 2005). Hence, if separate interviews are conducted
with partners as a prelude to conjoint couple therapy, the
interviewing clinician needs to be explicit with both partners
ahead of time regarding conditions under which information
disclosed by one partner will be shared with the other, and
any criteria for selecting among individual, conjoint, or
alternative treatment modalities.
Observational Methods
As noted previously in this chapter, couple assessment offers

the unique opportunity to observe partners’ complaints
involving communication and other interpersonal exchanges
directly. Like interviews and self-report methods, analog
behavioral observation (ABO) describes a method of data
collection; Specifically, it involves a situation designed,
manipulated, or constrained by a clinician that elicits both
verbal and nonverbal behaviors of interest such as motor
actions, verbalized attributions, and observable facial
reactions (Heyman & Slep, 2004, p. 162). We earlier

identified both the RMICS and RCISS as rapid observational
methods particularly useful for initial screening and diagnosis
of couple distress. Detailed descriptions and psychometric
reviews of additional couple coding systems have been
published previously (cf., Heyman, 2001; Kerig & Baucom,
2004). Although these systems vary widely, in general they
reflect six major a priori classes of targeted behaviors:
1. Affect (e.g., humor, affection, anger, criticism, contempt,

sadness, anxiety). Examples include the Behavioral Affective
Rating System (BARS; Johnson, 2002) and the Specific
1280
Affect Coding System (SPAFF; Gottman, McCoy, Coan, &
Collier, 1996; Shapiro & Gottman, 2004).
2. Behavioral engagement (e.g., demands, pres-2. sures for

change, withdrawal, avoidance). An example is the Conflict
Rating System (CRS; Heavey, Christensen, & Malamuth,
1995).
3. General communication skills (e.g., involve-3. ment,

verbal and nonverbal negativity and positivity, information
and problem description). Examples include the Clinician
Rating of Adult Communication (CRAC; Basco, Birchler,
Kalal, Talbott, & Slater, 1991), the Interactional Dimensions
Coding System (IDCS; Kline et al., 2004), and the
Kategoriensystem für Partnerschaftliche Interaktion (KPI;
Hahlweg, 2004).
4. Problem-solving (e.g., self-disclosure, valid-4. ation,

facilitation, interruption). Examples include the Codebook of
Marital and Family Interaction (COMFI; Notarius, Pellegrini,
& Martin, 1991), the Communication Skills Test (CST;

Floyd, 2004), the Dyadic Interaction Scoring Code (DISC;
Filsinger, 1983), the Living in Family Environments (LIFE)
coding system (Hops, Davis, & Longoria, 1995), and the
Verbal Tactics Coding Scheme (VTCS; Sillars, 1982).
5. Power (e.g., verbal aggression, coercion, attempts to

control). An example is the System for Coding Interactions in
Dyads (SCID; Malik & Lindahl, 2004).
6. Support/intimacy (e.g., emotional and tangible support,

attentiveness). An example is the Social Support Interaction
1281
Coding System (SSICS; Pasch, Harris, Sullivan, & Bradbury,
2004).
Psychometric characteristics for the 15 couple coding systems

summarized in Tables 20.2–20.4 indicate considerable
variability in the extent to which information regarding
reliability, validity, and treatment sensitivity for each system
has been accrued. For example, only 3 of 15 coding systems
report data concerning internal consistency—although this
likely reflects systems’ emphasis on Specific behaviors rather
than broader constructs. When superordinate classes of
behavior (e.g., positive or negative) are of interest, internal
consistency should be evaluated by using either Cronbach’s
alpha or indices derived from factor analysis (Heyman, Eddy,
Weiss, & Vivian, 1995). Stable estimates of behavioral
frequencies may require extended observation depending on
the base-rate of their occurrence—for example, as few as 2
minutes for frequent behaviors, but 30 minutes or longer for
infrequent behaviors (Heyman et al., 2001). Inter-rater
reliability for nearly all coding systems reviewed here was
adequate or better following coder training—although the

more comprehensive or complicated the system, the more
difficult it is to obtain high inter-rater reliability. Few studies
have been conducted on the temporal stability of observed
couple behaviors across tasks or settings. However, the
limited evidence suggests that couples’ interactions likely
vary across topic (e.g., high- vs. low-Conflict), setting (e.g.,
home vs. clinic or research laboratory), and length of
marriage (with longer married couples exhibiting more
enduring patterns; Gottman & Levenson, 1999; Lord, 1999;
Wieder & Weiss, 1980).
1282
TABLE 20.4 Ratings of Instruments Used for Treatment
Monitoring and Treatment Outcome Evaluation
Note: KMSS = Kansas Marital Satisfaction Scale; DAS =

Dyadic Adjustment Scale; MSI-R = Marital Satisfaction
Inventory-Revised; RMICS = Rapid Marital Interaction
Coding System; GAS = Goal Attainment Scaling; A =
Adequate; G = Good; E = Excellent; U = Unavailable; NA =
Not applicable.
Although varying in their emphasis, each of the couple coding

systems reviewed here clearly assesses constructs related to
communication and other domains of partner interaction
relevant to relationship functioning and couple distress. Many
of the coding systems can trace their origins to the Family
Interaction Coding System (Patterson, Ray, Shaw, & Cobb,
1969; Reid, 1978) that was developed from naturalistic

observations of family members’ behaviors in the home.
Nearly all coding systems have accrued evidence of
discriminative validity and relatedness to independent
measures of similar constructs, and only the most recently
developed systems have yet to accrue evidence of validity
generalization. Pre and posttreatment data for couple
behavioral coding systems are limited, in part because of
fewer funded clinical trials of couple therapy during recent
years in which these systems were developed. However, the
Marital Interaction Coding System (MICS) and Couples
Interaction Scoring System (CISS) have evidence of
treatment sensitivity; it is reasonable to infer that their quicker
1283
versions (RMICS and RCISS) and coding systems that
measure similar constructs (i.e., most of the communication-
oriented systems) would demonstrate similar levels of
treatment sensitivity.
Concerns have been raised about the clinical utility of analog

behavioral observations (e.g., Mash & Foster, 2001), because
nearly all coding systems require extensive observer training
to reach adequate levels of inter-observer agreement. Even
after observers are certified as reliable, a great deal of energy
is required to maintain reliability (e.g., weekly meetings with
regular feedback on agreement). Thus, even if clinicians
expended a great deal of time learning a system to the point of
mastery (i.e., meeting the reliability criterion), their reliability
would naturally decay without ongoing efforts to maintain
agreement. Such a requirement is likely not reasonable for
most clinicians.
However, even if not striving to code behavioral observations

in the manner required for scientific study of couple
interactions, the empirically informed use of behavioral

observations should be standard in clinicians’ assessment of
couple distress. That is, collecting communication samples is
an important part of couple clinical assessment because
“communication is the common pathway to relationship
dysfunction because it is the common pathway for getting
what you want in relationships. Nearly all relationship-
relevant Conflicts, emotions, and neuroses are played out via
observable communication—either verbally or nonverbally”
(Heyman, 2001, p. 6).
If questionnaire or interview assessments suggest that an

interactive task may place one or both partners in danger
1284
(e.g., if there is a history of serious physical or emotional
abuse, indications of severe power or control dynamics, or
threats conveyed to the assessor), analog behavioral
observation would be contraindicated. However, if it seems
reasonable that it is safe to
proceed, then the clinician should hypothesize which classes
of behaviors seem most highly connected to the target
problems. Wherever possible, analog behavioral observations
should be video-recorded so that the sample can be reviewed
later with an eye toward a class of behaviors other than what
was the assessor’s primary focus during the in vivo ABO.
Furthermore, unless the clinician can rule out a plausible
connection between Conflict communication and the couple’s
problems, we recommend that a Conflict communication
ABO be collected. Based on findings from observational
research with couples, Heyman (2001) suggested that
clinicians use behavioral observations in assessing couple
distress to address the following:
1. How does the conversation start? Does the level of anger

escalate? What happens when it does? Does the couple enter

repetitive negative loops?
2. Do partners indicate afterward that what occurred during

the conversations is typical? Is their behavior stable across
two or more discussions?
3. Do partners’ behaviors differ when it is her topic versus

his? Do they label the other person or the communication
process as the problem?
4. What other communication behaviors—either positive

(e.g., support, empathic reflection) or negative (e.g., criticism,
1285
sneers, turning away)—appear functionally related to
partners’ ability to discuss relationship issues effectively?
Self- and Other-Report Methods
The rationale underlying self-report methods in couple

assessment is that such methods (a) are conveni ent and
relatively easy to administer, (b) are capable of generating a
wealth of information across a broad range of domains and
levels of functioning germane to clinical assessment or
research objectives including those listed in Table 20.1, (c)
lend themselves to collection of data from large normative
samples which can serve as a reference for interpreting data
from individual respondents, (d) allow disclosure about
events and subjective experiences respondents may be
reluctant to discuss with an interviewer or in the presence of
their partner, and (e) can provide important data concerning
internal phenomena opaque to observational approaches
including thoughts and feelings, values and attitudes,
expectations and attributions, and satisfaction and
commitment.
However, the limitations of traditional self-report measures

also bear noting. Specifically, data from self-report
instruments can (a) reflect bias in self- and other-presentation
in either a favorable or unfavorable direction, (b) be affected
by differences in stimulus interpretation and errors in
recollection of objective events, (c) inadvertently influence
respondents’ nontest behavior in unintended ways, and (d)
typically provide few fine-grained details concerning
moment-to-moment interactions compared to analog
behavioral observations. Because of their potential
1286
advantages and despite their limitations, self-report
techniques of couple and family functioning have
proliferated—with published measures numbering well over
1000 (Touliatos, Perlmutter, Straus, & Holden, 2001).
However, relatively few of these measures have achieved
widespread adoption. Chun, Cobb, and, French (1975) found
that 63% of measures they reviewed had been used only once,
with only 3% being used 10 times or more. Fewer than 40%
of marital and family therapists regularly use any
standardized instruments (Boughner, Hayes, Bubenzer, &
West, 1994). Contributing to these findings is the inescapable
conclusion that the majority of measures in this domain
demonstrate little evidence regarding the most rudimentary
psychometric features of reliability or validity, let alone clear
evidence supporting their clinical utility (Snyder & Rice,
1996).
We describe below, and summarize in Table 20.3, a small

subset of self-report instruments selected on the basis of their
potential clinical utility and at least moderate evidence of
their reliability and validity. In some domains (e.g.,

relationship cognitions and affect), well-validated measures
are few. Additional measures identified in previous reviews
(cf., Epstein & Baucom, 2002; Sayers & Sarwer, 1998;
Snyder, Heyman, & Haynes, 2005) or in comprehensive
bibliographies of self-report couple and family measures (e.g.,
Corcoran & Fischer, 2000; Davis, Yarber, Bauserman,
Schreer, & Davis, 1998; Fredman & Sherman, 1987;
Grotevant & Carlson, 1989; Jacob & Tennenbaum, 1988;
L’Abate & Bagarozzi, 1993; Touliatos et al., 2001) may be
considered as additional clinical resources; however, the data
they generate should generally be regarded as similar to other
self-reports derived from interview—namely, as subject to
1287
various biases of observation, recollection, interpretation, and
motivations to present oneself or one’s partner in a favorable
or unfavorable light.
A variety of self-report measures has been developed to

assess couples’ behavioral exchanges including
communication, verbal and physical aggression, and physical
intimacy. The Frequency and Acceptability of Partner
Behavior Inventory (FAPBI; Doss & Christensen, 2006)
assesses 20 positive and negative behaviors in 4 domains
(affection, closeness, demands, and relationship violations)
and possesses excellent psychometric characteristics. As a
clinical tool, the FAPBI has the potential to delineate relative
strengths and weaknesses in the relation-ship—transforming
diffuse negative complaints into Specific requests for positive
change.
Among self-report measures Specifically targeting partners’

communication, one that demonstrates good reliability and
validity is the Communication Patterns Questionnaire (CPQ;
Christensen, 1987). The CPQ was designed to measure the

temporal sequence of couples’ interactions by soliciting
partners’ perceptions of their communication patterns before,
during, and following Conflict. Scores on the CPQ can be
used to assess characteristics of the demand → withdraw
pattern frequently observed among distressed couples.
Assessing relationship aggression by self-report measures

assumes particular importance because of some individuals’
reluctance to disclose the nature or extent of such aggression
during an initial con-joint interview. By far the most widely
used measure of couples’ aggression is the Conflict Tactics
Scale (CTS). The original CTS (Straus, 1979) included 19
1288
items assessing three modes of Conflict resolution including
reasoning, verbal aggression, and physical aggression. The
revised instrument (CTS2; Straus, Hamby, Boney-McCoy, &
Sugarman, 1996) adds scales of sexual coercion and physical
injury as well as additional items to better differentiate
between minor and severe levels of verbal and physical
aggression. An additional measure of relationship aggression,
the Aggression (AGG) scale of the Marital Satisfaction
Inventory-Revised (MSI-R; Snyder, 1997), comprises 10
items reflecting psychological and physical aggression
experienced from one’s partner. Advantages of the AGG
scale as a screening meas ure include its relative brevity and
its inclusion in a multidimensional mea-sure of couples’
relationships (the MSI-R) described below.
Earlier we noted the importance of evaluating partners’

attributions for relationship events. The Relationship
Attribution Measure (RAM; Fincham & Bradbury, 1992)
presents hypothetical situations and asks respondents to
generate responsibility attributions indicating the extent to
which the partner intentionally behaved negatively, was

selfishly motivated, and was blameworthy for the event. Both
causal and responsibility attributions assessed by the RAM
have evidence of good internal consistency and test–retest
reliability, as well as convergence with partners’ self-reported
overall relationship satisfaction and observed affect.
For purposes of case conceptualization and treatment

planning, well-constructed multidimensional measures of
couple functioning are useful for discriminating among
various sources of relationship strength, Conflict, satisfaction,
and goals. Widely used in both clinical and research settings
is the MSI-R-(Snyder, 1997), a 150-item inventory designed
1289
to identify both the nature and intensity of relationship
distress in distinct areas of interaction. The MSI-R includes
two validity scales, one global scale, and ten Specific scales
assessing relationship satisfaction in such areas as affective
and problem-solving communication, aggression, leisure time
together, finances, the sexual relationship, role orientation,
family of origin, and interactions regarding children. More
than 20 years of research have supported the reliability and
construct validity of the MSI-R scales (cf., Snyder & Aikman,
1999). The instrument boasts a large representative national
sample, good internal consistency and test–retest reliability,
and excellent sensitivity to treatment change. The Global
Distress Subscale (GDS) of the MSI-R has been shown to
predict couples’ likelihood of divorce 4 years following
therapy (Snyder, 1997). A validation study using a national
sample of 60 marital therapists supported the overall accuracy
and clinical utility of the computerized interpretive report for
this instrument (Hoover & Snyder, 1991). Recent studies
suggest the potential utility of Spanish and German
adaptations of the MSI-R for cross-cultural application with
both clinic and community couples (Snyder et al., 2004), as

well as use of the original English version with nontraditional
(e.g., gay and lesbian) couples (Means-Christensen, Snyder,
& Negy, 2003).
Additional multidimensional measures obtaining fairly

widespread use are the PREPARE and ENRICH inventories
(Fowers & Olson, 1989, 1992; Olson & Olson, 1999),
developed for use with premarital and married couples,
respectively. Both of these measures
include 165 items in 20 domains reflecting personality (e.g.,
assertiveness, self-Confidence), intrapersonal issues (e.g.,
marriage expectations, spiritual beliefs), interpersonal issues
1290
(e.g., communication, closeness), and external issues (e.g.,
family and friends). A computerized interpretive report
identifies areas of “strength” and “potential growth” and
directs respondents to Specific items reflecting potential
concerns. The ENRICH inventory has a good normative
sample and has ample evidence supporting both its reliability
and validity.
Overall Evaluation
Couples presenting for therapy vary widely in both the

content and underlying causes of their individual and
relationship problems. Conceptualizing partners’ distress and
planning effective treatment requires careful assessment of
behavioral, cognitive, and affective components of
relationship functioning conducted across multiple modalities
including interview, analog behavioral observation, and self-
report measures. Effective intervention depends upon
assimilating assessment findings within an overarching
theoretical framework linking individual and relationship
difficulties to presumed etiologies as well as to clinical

intervention. Toward this end, assessment of couple distress
requires going beyond nomothetic conclusions derived from
standardized measures of relationship functioning to integrate
idiographic findings from clinical interview and behavioral
observation in a functional-analytic approach (Floyd et al.,
1997; Haynes et al., 1997).
1291
ASSESSMENT FOR TREATMENT
MONITORING AND TREATMENT
OUTCOME
In principle, assessment strategies relevant to case

conceptualization and treatment planning are also germane to
monitoring treatment progress and evaluating outcome. It
would be difficult to imagine ad equate assessment of
partners’ changes in individual and relationship functioning
not including clinical inquiry about alterations in behavioral,
cognitive, and affective domains outside of treatment
sessions; repeated analog behavioral observations to track the
acquisition and use of targeted communication skills; and
integration of self-report measures profiling changes across
diverse domains and providing information in sensitive areas.
Several caveats moderate this general conclusion. First, the

use of repeated assessments to evaluate changes attributable
to treatment requires measures demonstrating temporal
reliability in the absence of clinical intervention. Although
obvious as a precondition for interpreting change, information

regarding the temporal reliability of couple-based assessment
techniques is remarkably sparse. Second, treatment effects are
best assessed by using measures both relevant and Specific to
aspects of individual and relationship functioning targeted by
clinical interventions. Finally, treatment monitoring across
sessions imposes pragmatic constraints on measures’ length,
thus suggesting enhanced utility for reliable and valid
measures distinguished by their brevity (e.g., the KMSS as a
measure of global affect or the FAPBI to assess more Specific
dyadic behaviors). Table 20.4 provides ratings on several
relevant instruments.
1292
Changes in individualized treatment goals can be quantified
using goal attainment scaling (GAS; Kiresuk, Smith, &
Cardilo, 1994) as described previously for use in couple
therapy by Whisman and Snyder (1997). When adopting the
GAS method, the issues that will be the focus of treatment are
first identified, and then each problem is translated into one or
more goals. The expected level of outcome is then specified
for each goal, along with the “somewhat more” and “much
more” than expected levels of outcome, as well as the
“somewhat less” and “much less” expected levels. Each level
of outcome is assigned a value on a 5-point measurement
scale ranging from –2 for much less than expected level of
outcome, to +2 for much more than expected level of
outcome. Levels of outcome can then be rated during or
following treatment, and the ratings across goals can be
averaged to provide a summary score for evaluating the
degree to which treatment helped the couple attain their own
individualized goals.
Overall Evaluation
Gains or deterioration in individual and relationship

functioning should be evaluated using techniques sensitive
and Specific to treatment effects across assessment modalities
incorporating interview, behavioral observation, and self-
report methods. Conclusions drawn from nomothetic
approaches (such as the DAS or MSI-R) should be
complemented by idiographic methods, ideally incorporating
observational assessment as well as goal attainment scaling or
similar procedures.
1293
CONCLUSIONS AND FUTURE
DIRECTIONS
Recommendations for Assessing

Couple Distress
Assessment strategies and Specific methods for assessing

couple distress will necessarily be tailored to partners’ unique
constellation of presenting difficulties, as well as Specific
resources of both the couple and the clinician. However,
regardless of the Specific context, the following
recommendations for assessing couple distress will generally
apply.
1. Given empirical findings linking couple distress to

individual disorders and their respective impact in moderating
treatment outcome, assessment of couple functioning should
be standard practice when treating individuals. Screening for
couple distress when assessing individuals may involve a
brief interview format shown to relate to relevant indicators
of couple interactions (e.g., the SDI-MD-PA; Heyman et al.,

2001) or a brief self-report measure exhibiting prior evidence
of discriminative validity (e.g., the KMSS or short-form
DAS). Similarly, when treating couples, partners should be
screened for individual emotional or behavioral difficulties
potentially contributing to, exacerbating, or resulting in part
from couple distress.
2. Assessment foci should progress from broad to

narrow—first identifying relationship concerns at the broader
construct level and then examining more Specific facets of
couple distress and its correlates using a finer-grained
1294
analysis. The Specific assessment methods described in this
review vary considerably in their overall breadth or focus
within any Specific construct domain and, hence, will vary
both in their applicability across couples and their placement
in a sequential exploratory assessment process.
3. Within clinical settings, certain domains should always be

assessed with every couple either because of their robust
linkage to relationship difficulties (e.g., communication
processes involving emotional expressiveness and decision-
making) or because the Specific behaviors, if present, have
particularly adverse impact on couple functioning (e.g.,
physical aggression or substance abuse).
4. Couple assessment should integrate findings across

multiple assessment methods. Self- and other - report
measures may complement findings from interview or
behavioral observation in generating data across diverse
domains both central or conceptually related to the couple’s
difficulties, or across those domains potentially more
challenging to assess because of their sensitive nature or their

not being amenable to direct observation. However, special
caution should be exercised when adopting self- or other-
report measures in assessing couple distress. Despite their
proliferation, most measures of couple functioning described
in the literature have not undergone careful scrutiny of their
underlying psychometric features. Among those instruments
for which some evidence concerning reliability and validity
has been garnered, evidence often exists only for overall
scores and not at the level of subscales or smaller units of
analysis at which interpretations may be made.
1295
5. At the same time, assessment of couple distress should be
parsimonious. This objective can be facilitated by choosing
evaluation strategies and modalities that complement each
other and by following a sequential approach that uses
increasingly narrow-band measures to target problem areas
that have been identified by other assessment techniques.
6. Psychometric characteristics of any assessment

technique—whether from interview, analog behavioral
observation, or self-report measure—are conditional upon the
Specific population and purpose for which that assessment
method was developed. Given that nearly all measures of
couple distress were developed and tested on white, middle-
class, married couples, their relevance to and utility for
assessing ethnic couples, gay and lesbian couples, and low-
income couples is unknown. This caveat extends to content-as
well as criterion-related validity. Hence, any assessment
measure demonstrating evidence of validity with some
couples may not be valid, in part or in whole, for any given
couple, thus further underscoring the importance of drawing
upon multiple indicators across multiple methods for

assessing any Specific construct.
Recommendations for Further Research
Future directions for assessment research germane to the field

generally also apply to research in assessing couple distress
Specifically, including the need for greater attention to (a)
psychometric underpinnings of various measurement methods
and instruments, (b) factors moderating reliability and validity
across populations differing in sociocultural characteristics as
well as in clinical functioning, (c) the assessment process
1296
including initial articulation of assessment goals, selection of
assessment method and instruments, and methods of
interpreting data and providing feedback, and (d) the
functional utility of assessment findings in enhancing
treatment effectiveness (Hayes, Nelson, & Jarrett, 1987).
In considering the implications of these directives for

assessing couple distress, considerably more research is
needed before a comprehensive, empirically based couple
assessment protocol can be advocated. For example, despite
the ubiquitous use of couple assessment interviews, virtually
no research has been conducted to assess their psychometric
features. Observational methods, although a rich resource for
generating and testing clinical hypotheses, are less frequently
used and present significant challenges to their reliable and
valid application in everyday practice.
Questionnaires—despite their ease of administration and
potential utility in generating a wealth of data—frequently
suffer from inadequate empirical development and, at best,
comprise only part of a multimethod assessment strategy.
We would recommend, as a research roadmap, that clinical

researchers consider adapting the Institute of Medicine stages
of intervention research cycle (Mrazek & Haggerty, 1994).
Stage 1 involves identifying the disorder and measuring its
prevalence. Despite being so basic a need, there currently
exists no gold standard for discriminating distressed from
nondistressed couples; the questionnaires typically used for
such Classifications are of limited sensitivity and specificity
(Heyman et al., 2001). Stage 2 involves delineating Specific
risk and protective factors. As noted above, some replicated
factors have been identified, although this research could be
sharpened by defining groups more carefully (via Stage 1
1297
above). Stage 3 (efficacy trials) would involve tightly
controlled trials of the efficacy of a multimethod assessment
in clinical practice. Stage 4 (effectiveness trials) would
involve controlled trials of the outcome of this assessment in
more real-world clinical environments. Only then would
testing broad-scale dissemination (Stage 5) of empirically
based couple assessment be appropriate.
This research roadmap reflects an ambitious agenda unlikely

to be met by any single investigator or group of investigators.
However, progress toward evidence-based assessment of
couple distress will be enhanced by research on Specific
components targeting more notable gaps in the empirical
literature along the lines recommended below.
1. Greater attention should be given to expanding the

empirical support for promising assessment instruments
already detailed in the literature than to the initial (and
frequently truncated) development of new measures.
Proposals for new measures should be accompanied by
compelling evidence for their incremental utility and validity

and a commitment to programmatic research examining their
generalizability across diverse populations and assessment
contexts. Research needs to delineate optimal structured
2. and semistructured interview formats for assessing

couples. Such research should address (a) issues of content
validity across populations and settings, (b) organizational
strategies for screening across diverse system levels and
construct domains relevant to couple functioning (similar to
branching strategies for the Structured Clinical Interview for
the DSM [First et al., 1997] and related structured interviews
for individual disorders), (c) relative strengths and limitations
1298
to assessing partners separately versus conjointly, (d) factors
promoting the disclosure and accuracy of verbal reports, (e)
relation of interview findings to complementary assessment
methods (as in generating relevant tasks for analog behavioral
observation), and (f) the interview’s special role in deriving
functional-analytic case conceptualization.
3. Although laboratory-based behavioral obser-3. vation of

couple interaction has considerably advanced our
understanding of couple distress, generalization of these
techniques to more common clinical settings has lagged
behind. Hence, researchers should develop more macro-level
coding systems for quantifying observational data that
promote their routine adoption in clinical contexts while
preserving their psychometric fidelity.
4. Research needs to attend to the influences of culture at

several levels. First, there has been little attention to
developing measures directly assessing domains Specific to
relationship functioning at the community or cultural level
(e.g., cultural standards or norms regarding emotional

expressiveness, balance of decision-making influence, or
boundaries governing the interaction of partners with
extended family or others in the community). Hence,
assessment of such constructs currently depends almost
exclusively on the clinical interview, with no clear guidelines
regarding either the content or format of questions. Second,
considerably more research needs to examine the moderating
effects of sociocultural factors on measures of couple
functioning, including the impact of such factors as ethnicity,
age, socio economic status, or sexual orientation. Third, work
needs
1299
to proceed on adapting established measures to alternative
languages. In the United States, the failure to adapt existing
instruments to Spanish or to examine the psychometric
characteristics of extant adaptations is particularly striking
given that (a) Hispanics are the largest and fastest-growing
ethnic minority group, and (b) among U.S. Hispanic adults
age 18 to 64, 28% have either limited or no ability to speak
English (Snyder et al., 2004).
Adapting existing measures to alternative contexts (i.e.,

differing from the original development sample in language,
culture, or Specific aspects of the relationship such as sexual
orientation) should proceed only when theoretical or clinical
formulations suggest that the construct being measured does
not differ substantially across the new application. Detailed
discussions of both conceptual and methodological issues
relevant to adapting tests to alternative languages or culture
exist elsewhere (e.g., Butcher, 1996; Geisinger, 1994).
Because clinicians and researchers may fail to recognize the
inherent cultural biases of their conceptualization of couple
processes, the appropriateness of using or adapting tests

cross-culturally should be evaluated following careful
empirical scrutiny examining each of the following:
• Linguistic equivalence including grammatical, lexical, and

idiomatic considerations.
• Psychological equivalence of items across the source and

target cultures.
• Functional equivalence indicating the congruence of

external correlates in concurrent and predictive criterion-
related validation studies of the measure across applications.
1300
• Scalar equivalence ensuring not only that the slope of
regression lines delineating test–criterion relations be parallel
(indicating functional equivalence) but also that they have
compar able metrics and origins (zero points) in both cultures.
Finally, research needs to examine the process, as well as the

content, of couple assessment. For example, little is known
regarding the impact of decisions about the timing or
sequence of Specific assessment methods, the role of the
couple in determining assessment objectives, or the provision
of clinical feedback on either the content of assessment
findings or their subsequent effect on clinical interventions.
Although assessment of couples has shown dramatic gains in

both its conceptual and empir ical underpinnings over the past
25 years, much more remains to be discovered. Both
clinicians and researchers need to avail themselves of recent
advances in assessing couple distress and collaborate in
promoting further development of empirically based
assessment methods.
ACKNOWLEDGMENTS Portions of this chapter were adapted

from Snyder, Heyman, and Haynes (2005). Richard
Heyman’s work on this chapter was supported by National
Institute of Child Health and Human Development grant R01
HD046901-01. The authors express their appreci ation to
Brian Abbott, Danielle Provenzano, and Dawn Yoshioka for
their contributions to Tables 20.1–20.4.
1301
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1319
21
Sexual Dysfunction
___________________
Marta Meana
Yitzchak M. Binik
Lea Thaler
The question of assessment in sexuality has always been a

complex one. Arguably more than with other phenomena
covered in the Diagnostic and Statistical Manual of Mental
Disorders (DSM), the Classification of sexuality has been
complicated by changing notions of normality, the subjective
nature of the sexual experience, gender differences, and
significant social, economic, and political investment from

parties with opposing ideologies. The last decade has
evidenced a series of challenges to extant definitions of
sexual dysfunction in general and, more Specifically, to the
legitimacy of certain dysfunctions. The current DSM-IV-TR
(American Psychiatric Association [APA], 2000)
Classification has been critiqued for (a) medicalizing
sexuality by discounting the diversity of sexual expression in
favor of categorical distinctions between health and disorder
(Tiefer, 2002), (b) using an androcentric conceptualization of
the sexual response that inadequately accounts for female
sexuality (Basson et al., 2004), (c) ignoring questions of
sexual and relationship satisfaction (Byers, 1999), and (d)
1320
decontextualizing the sexual experience (Laumann & Mahay,
2002). The validity of Specific dysfunctions has also been
questioned with recent theoretical and empirical challenges to
the diagnoses of Hypoactive Sexual Desire Disorder (HSDD;
Basson, 2002), Dyspareunia (Binik, 2005), and Vaginismus
(Reissing, Binik, Khalife, Cohen, & Amsel, 2004).
Our aim in this chapter is not to determine what rises to the

level of a disorder and what does not. Rather, we aim to
describe and discuss different ways of measuring subjective
and physiological sexual phenomena related to global sexual
function as well as to the nine sexual dysfunctions defined in
the DSM-IV-TR: HSDD, Sexual Aversion Disorder (SAD),
Female Sexual Arousal Disorder (FSAD), Male Erectile
Disorder (ED), Female and Male Orgasmic Disorders,
Premature Ejaculation (PE), Dyspareunia, and Vaginismus.
After a brief description of the nature of these sexual
problems, we will describe global sexual function measures
suitable for the purposes of diagnosis, case conceptualization
and treatment planning, and treatment monitoring and
outcome. A description of assessments Specific to each of the

aforementioned sexual dysfunctions will follow, concluding
with a discussion of future directions.
THE NATURE OF SEXUAL DYSFUNCTION
One of the reasons clinicians and researchers debate the very

notion of sexual dysfunction is the ubiquity of sexual
complaints in our society. Despite wide variation in
prevalence rates for all sexual dysfunctions depending on the
population and methodology in question (Simons & Carey,
2001), the numbers remain staggering. With general
1321
prevalence figures for sexual dysfunction in the United States
estimated at 43% in women and 31% in men (Laumann, Paik,
& Rosen, 1999), sexual difficulties seem close to normative.
Once relegated strictly to sex therapists and sexologists, the
assessment of sexual function is increasingly considered an
integral part of an overall health assessment (Parish, 2006).
However,
it is important to distinguish a fleeting sexual complaint from
a more pervasive problem. Most people will experience
difficulty with sex at some point in their lives. The DSM-IV-
TR restricts diagnosis to cases characterized by a persistence
of the problem and significant associated distress for the
individual or couple. The DSM-IV-TR further classifies
sexual dysfunctions as (a) generalized or situational, (b)
lifelong or acquired, and (c) due to psychological or
combined factors. Exclusion criteria are other Axis I disorders
other than another sexual dysfunction (except dyspareunia for
which vaginismus is an exclusion criterion), medical
conditions and/or use of substances that could account for or
induce the dysfunction.
The exact determination of the DSM-IV-TR inclusion/

exclusion criterion relating Specifically to etiology is
particularly complicated in any individual case. It is often
difficult to determine whether the sexual problem emanates
from psychological disturbances alone or whether there is
organic involvement. Considering the sexual response
necessarily involves both peripheral and central nervous
system activity, one could argue that every sexual problem
either originates or is perpetuated by both psychological and
physiological factors. Clearly, a degree of dualism persists in
the DSM-IV-TR, with its insistence on the distinction
1322
between physical and psychological etiologies, despite its nod
to the possibility of combined effects.
The overall organization of the sexual dysfunctions in the

DSM-IV-TR integrates seven of the nine dysfunctions within
three phases of the sexual response cycle (desire, arousal, and
orgasm), concluding with the sexual pain disorders. There are
no dysfunctions listed that relate to the resolution phase of the
cycle. This may change in future editions given recent support
for the existence of Persistent Sexual Arousal Syndrome in
women (Goldmeier & Leiblum, 2006; Leiblum & Nathan,
2001). The comorbidity of sexual dysfunctions other than the
presenting one is almost a given. A problem at any stage of
the sexual response cycle is likely to engender difficulties at
other stages. In the absence of much sound data on
comorbidity, we must remain cognizant of the close
relationship of all phases of the sexual response cycle and the
possible effects of deficits in one phase on other phases. A
brief description of the known features of each of the sexual
dys-functions listed in the DSM-IV-TR follows.
Hypoactive Sexual Desire Disorder
defined by the DSM-IV-TR as an absence or deficiency of

sexual fantasies and desire for sexual activity, HSDD is the
most common presenting problem in couples seeking help for
sexual difficulties and far more prevalent in women than in
men (Seagraves & Seagraves, 1991). The best estimate of the
prevalence rate of HSDD in the general population is 5% of
men and 22% of women, with rates and gender ratios varying
with age (Laumann et al., 1999).
1323
Considering the large gender ratios, it is imperative to tease
apart true HSDD from desire that fails to rise to a partner’s
wishes or to a societal, oppressive ideal. Barring medical
conditions, pain syndromes, or medication side-effects, the
most oft-cited biological factor implicated in HSDD has been
hormones. Administration of exogenous testosterone has
shown effects in the desire of hypo- and eugonadal men with
erectile dysfunction (Carani et al., 1990; Schiavi, White,
Mandeli, & Levine, 1997) and there is accumulating evidence
that androgen replacement increases sexual desire in many
surgically postmenopausal women (Sherwin, 1988; Shifren et
al., 2000). Psychosocially, many negative emotional states
and life experiences have been linked to low desire, including
stress, depression, anxiety, cognitive set, self-esteem, trauma,
and relational and financial difficulties (for reviews, see Beck,
1995; Wincze & Carey, 2001).
Sexual Aversion Disorder
Individuals with SAD experience extreme aversion to sexual

activity and generally avoid genital sexual contact with a

partner. Although some consider SAD and HSDD to exist on
a continuum of desire (e.g., Winzce & Carey, 2001), the
DSM-IV-TR makes a categorical distinction between the
indifference of HSDD and the phobic nature of SAD. Its
prevalence is unknown, but SAD is believed to be more
common in women than in men. Although questions of
etiology are largely unanswered (Crenshaw, 1985), SAD
appears to be related to state and trait anxiety, fear of negative
evaluation, and number and intensity of fears (Katz &
Jardine, 1999). The more severe psychosocial factors
associated with HSDD (e.g., sexual trauma) are likely to be
1324
implicated in SAD. Biologically, it has been linked to the
neurochemistry of anxiety and panic disorder (Figueira,
Possidente, Marques, & Hayes, 2001).
Female Sexual Arousal Disorder
FSAD is defined as the persistent or recurrent inability to

attain or maintain an adequate lubrication-swelling response
of sexual excitement during sexual activity. Without teasing
apart comorbidity, the prevalence of FSAD is approximately
14% (Laumann et al., 1999; Rosen, Taylor, Leiblum, &
Bachman, 1993). Biologically, FSAD has been most often
been linked to aging (Laumann et al., 1999), vascular and
neurological impairments (Wincze & Carey, 2001), and
treatments for reproductive cancers (Jensen et al., 2004), all
processes that interfere with hormone availability. Similar to
HSDD, negative mood states (e.g., Dunn, Croft, & Hackett,
1999), negative expectancies, relationship factors (e.g.,
McCabe & Cobain, 1998), and sexual trauma (Loeb et al.,
2002; van Berlo & Ensink, 2000) have been linked to arousal
problems.
Male Erectile Disorder
The persistent or recurrent, partial or complete inability to

attain or maintain an erection sufficient for penetration is how
arousal problems generally manifest themselves in men. A
prevalence rate of 5% was found by Laumann and colleagues
(1999) in men under 60, while others have found rates of 17%
for moderate erectile difficulties at age 40 and 34% at age 70
(Feldman, Goldstein, Hatzichristou, Krane, & McKinlay,
1994). Biologically, the role of testosterone remains unclear
1325
as the administration of testosterone has often proven
ineffective in enhancing erectile function (e.g., Schiavi, et al.,
1997). Vascular and neurological diseases or damage are
associated with ED as are lifestyle behaviors (e.g., smoking,
alcohol abuse, inactivity) that affect the vascularization and
innervation necessary for erection and/or the stamina
necessary to sustain the physical exertion of penetration
(Wincze & Carey, 2001). Some antidepressants,
antihypertensives, and drugs that block the conversion of
testosterone into dihydro-testosterone (DHT), commonly used
to treat male pattern hair loss and benign prostatic hyperplasia
(Ekman, 1999; Papatsoris & Korantzopoulos, 2006; Weiner
& Rosen, 1997), have also been implicated. Psychosocially,
performance demands, arousal underestimation, negative
affect during sex, self-critical attributions, depressive
symptoms, and relationship problems have all been linked to
ED (Araujo, Durante, Feldman, Goldstein, & McKinlay,
1998; Barlow, 1986; McCabe & Cobain, 1998; Weisberg,
Brown, Wincze, & Barlow, 2001).
Female Orgasmic Disorder
As per the DSM-IV-TR, a diagnosis of female orgasmic

disorder (FOD) requires a persistent or recurrent delay in, or
absence of, orgasm following a normal sexual excitement
phase. Because of the wide variation in the type or intensity
of stimulation that triggers orgasm, clinicians are left to judge
that the woman’s orgasmic capacity be less than expected for
her age, sexual experience, and stimulation received. North
American prevalence estimates range from 10% in women
ages 51 to 61 (Johannes & Avis, 1997) to 24% in women
under 60 (Laumann et al., 1999). Endocrine disruptions have
1326
been associated to FOD, albeit unreliably (e.g., Davis,
Davison, Donath, & Bell, 2005). Neurophysiological and
vascular disruptions, as well as side effects from serotonin
reuptake inhibitors have also been implicated (Goldstein &
Berman, 1998; Heiman, 2000; Margolese & Assalian, 1996).
It is, however, more common that women with FOD have
none of these factors present. Psychosocial etiologic factors
mirror those associated with HSDD, including personality,
relationship quality, and socioeconomic status and
educational level (Meston, Levin, Sipski, Hull, & Heiman,
2004).
Male Orgasmic Disorder
Orgasm difficulties in men present as delayed, absent,

incomplete (emission or contractile phase disorders such as
squirtless seminal dribble and retrograde ejaculation; Kothari,
1984) and anaesthetic response (Dekker, 1993). General
population prevalence estimates in recent studies range from
0% to 8%, with significantly higher estimates in homosexual
samples (for a review, see Richardson, Nalabanda, &

Goldmeier, 2006). The most common physiological etiologies
are select disease processes associated with aging, such as
heart disease, and benign prostatic hyperplasia/lower urinary
tract symptoms, although pelvic surgeries, diabetes,
neurological disturbances, and antidepressants and alpha
blockers have been linked to MOD. Theorized psychosocial
etiologic pathways include fear, performance anxiety,
hostility, guilt, low desire for the partner, and inadequate
stimulation (Richardson et al., 2006).
1327
Premature Ejaculation
The most common of the male dysfunctions with a North

American prevalence rate of 29% (Laumann, Gagnon,
Michael, & Michaels, 1994), PE is defined in the DSM-IV-
TR as persistent or recurrent ejaculation with minimal sexual
stimulation before, on, or shortly after penetration and before
the person wishes it. The onus is on the clinician to judge
whether conditions described are adequate for most men to
delay ejaculation until desired. Waldinger, Zwinderman,
Berend, and Schweitzer (2005) have suggested intravaginal
ejaculatory latency times (IELT; stopwatch measured) of less
than 1 minute for a diagnosis of “definite” PE and 1 to 1.5
minutes for “probable” PE. In addition to innate physiological
predispositions to ejaculate quickly, genitourinary,
cardiovascular, and neurologic diseases have also been
implicated (Metz & Pryor, 2000). Psychosocial factors
hypothesized to contribute to PE include negative mood
states, unrealistic expectancies, sexual misinformation, poor
sexual skills and sensory awareness, maladaptive arousal
patterns, and relational problems (Metz & Pryor, 2000;

Perelman, 2006).
Dyspareunia
Primarily a female sexual dysfunction, dyspareunia is

currently defined in the DSM-IV-TR as recurrent or persistent
genital pain associated with sexual intercourse that is not
caused exclusively by vaginismus or lack of lubrication.
General North American prevalence rates in women have
been estimated at 14%, whereas in men they are
approximately 3% (Laumann et al., 1999). Higher rates have
1328
been reported in men who engage in receptive anal
intercourse (Rosser, Metz, Bockting, & Buroker, 1997). There
is considerable debate as to whether dyspareunia is better
characterized as a disorder of sexual function or as a pain
syndrome that interferes with sexual functioning only
incidentally (Binik, 2005; Binik, Meana, Berkley, & Khalife,
1999; Meana, Binik, Khalife, & Cohen, 1997a). Biologically,
dyspareunia can arise from (a) congenital malformations of
the genital tract, (b) acute and chronic diseases, (c)
nonSpecific inflammatory or nerve dysfunction processes,
such as vestibulodynia, (d) postmenopausal decreases in
estrogen, and (e) iatrogenic damage from genital surgeries/
procedures (Meana & Binik, 1994). Until recently, there was
a robust tendency to attribute the etiology of dyspareunia
directly to psychogenic factors of a developmental, traumatic,
or relational nature. There is, however, slim support for the
primacy of any one psychosocial etiology as most women
with dyspareunia do not differ from controls on psychosocial
factors (Meana, Binik, Khalife, & Cohen, 1997b), with the
possible exception of a hypersensitivity and hyper-vigilance
to pain in general (Payne, Binik, Amsel, & Khalife, 2005).
Vaginismus
Vaginismus might simply be the severe, phobic end of the

dyspareunia continuum (Meana & Binik, 1994; Reissing, et
al., 2004), as it is difficult to distinguish between painful
intercourse and vaginismus (van Lankveld et al., 2006). The
DSM-IV-TR, however, makes a categorical distinction
between the two sexual pain disorders by attributing the
interference in vaginismus to a spasm of the outer third of the
vagina. Either way, vaginismus is characterized by a fear that
1329
rises to the level of a phobia (Reissing et al., 2004) and
population-based estimates have been reported at 1% or less
(Fugl-Meyer & Sjogren Fugl-Meyer, 1999). Although
vaginismus is primarily associated with a psychosocial
etiology, biological factors implicated in some cases are
essentially similar to those hypothesized for dyspareunia. The
very same anatomic, disease, or iatrogenic factors may instate
a conditioning process complete with classical processes
(intercourse paired with pain) and operant ones (avoidance
reinforced by relief of anticipatory anxiety). More purely
psychological etiologies proposed have included religiously
based inhibitions, sexual trauma, partner dysfunction, and
relational problems. Fear, however, appears to be the defining
characteristic rather than pain itself (Reissing, Binik, Khalife,
Cohen, & Amsel, 2003).
PURPOSES OF ASSESSMENT
The latest edition of the Handbook of Sexuality-Related

Measures (Davis, Yarber, Bauserman, Schreer, & Davis,
1998) contains 214 self-administered questionnaires that

relate to sexuality. The comprehensiveness of this reference
text is deceiving, however, as it creates the impression that
the field of human sexuality is rich in assessment tools. In
terms of sexual function and its clinical assessment, quite the
opposite is true. Only a small subset of the measures in the
Handbook focuses on sexual function and possesses adequate
psychometric properties. The assessment of sexual function
using extensively validated instruments is actually in its
infancy, although growing at an unprecedented rate in the last
decade as a consequence of the emerging need to assess
1330
outcomes in pharmaceutical clinical trials (Daker-White,
2002).
TABLE 21.1 Ratings of Instruments Used for Diagnosis
Note: DISF = Derogatis Interview for Sexual Functioning;

GRISS = Golombok–Rust Inventory of Sexual Satisfaction;
BISF-W= Brief Index of Sexual Functioning for Women;
FSFI = Female Sexual Function Index; MFSQ = McCoy
Female Sexuality Questionnaire; SFQ = Sexual Function
Questionnaire; SDM = Structured Diagnostic Method; BSFI-
M = Brief Sexual Function Inventory-Male; IIEF =
International Index of Erectile Function; MSHQ = Male

Sexual Health Questionnaire; SAS = Sexual Aversion Scale;
L = Less Than Adequate; A = Adequate; G = Good; E =
Excellent; U = Unavailable; NA = Not Applicable.
This chapter is limited to the description and evaluation of

measures that (a) aim to assess sexual function in clinically
useful ways and (b) have adequate or better psychometric
properties. The list of measures covered could arguably have
been longer, as the multifactorial conceptualization of sexual
problems could conceivably include assessments of myriad
aspects of an individual’s life. On the other hand, the list
could have been shorter, as many of the measures included
1331
are in the preliminary stages of validation. Our choice was
guided by objective indices of reliability and validity and by
our subjective assessment of a measure’s promise of clinical
utility. We first present multidimensional measures of global
sexual function or related constructs (satisfaction, distress,
relationship adjustment) adequate for diagnosis, case
conceptualization, and treatment monitoring. This will be
followed by a discussion of assessment tools Specific to each
of the nine sexual dysfunctions. Some of the measures
selected are applicable to men, women, and/or couples,
whereas others are gender-Specific. Critical evaluations of the
psychometric properties of all measures (global and
dysfunctionSpecific) by assessment purpose (diagnosis, case
conceptualization, treatment monitoring) are provided in
Tables 21.1–21.3 and listed in the order in which they appear
in the text.
GLOBAL ASSESSMENT OF SEXUAL

FUNCTION
Concerns about the growing medicalization of the field have

engendered appeals to integrative conceptualizations of
sexual dysfunctions that encompass individual, family of
origin, relational, social, and cultural factors (Leiblum &
Rosen, 2000; Weeks, 2005). This multifactorial approach,
however, represents a daunting challenge to assessment and
treatment, as it requires the simultaneous consideration of
multiple factors. It also calls for assessment of other Axis I
and II disorders that may impact on sexual function and for
assessment of the comorbidity of other sexual dysfunctions in
the client and his or her partner.
1332
Note: Abbreviations for instruments in alphabetical order;

DAS = Dyadic Adjustment Scale; DISF = Derogatis
Interview for Sexual Functioning; GRISS = Golombok-Rust
Inventory of Sexual Satisfaction; DSFI = Derogatis Sexual
Functioning Inventory; ISS = Index of Sexual Satisfaction;
SII = Sexual Interaction Inventory; FSDS = Female Sexual
Distress Scale; SSS-W = Sexual Satisfaction Scale for
Women; SDI = Sexual Desire Inventory; SIDI-F = Sexual
Interest and Desire Inventory; PFSF = profile of Female
Sexual Function; MSIQ = Menopausal Sexual Interest

Questionnaire; SAS = Sexual Aversion Scale.
A = Adequate; G = Good; E = Excellent; NA = Not
Applicable; L = Less Than Adequate; U = Unavailable.
The assessment of global sexual function gener ally involves

a clinical interview and/or self-administered questionnaires,
depending on the context of the evaluation. General
practitioners who want to screen for sexual dysfunction in the
context of a busy medical practice will depend primarily on
brief screening questionnaires. Sex therapists and other
mental health professionals more directly involved in the
treatment of sexual dysfunction will almost invariably start
1333
with an extended clinical interview, possibly followed by
questionnaires.
Assessment for Diagnosis
As there is no diagnostic category of global sexual

dysfunction, there is no such diagnosis. The “diagnostic”
assessment of global sexual function is thus conducted for
one of two reasons: to get a general sense of the person’s
sexual adjustment multidimensionally defined as function,
satisfaction, distress, and relationship quality, or as a screen
for the existence of a Specific dysfunction which will then be
investigated further. Because the DSM-IV-TR criteria depend
heavily on clinician judgment rather than on
operationalizations of dysfunction, the clinical interview is
the main diagnostic tool. Self-report measures of global
sexual function and Specific dysfunctions are generally
considered diagnostic adjuncts.
Clinical Interview
The clinical interview remains the mainstay of sexual

dysfunction diagnostic assessment. Clinician judgment is
central to the determination of whether a client meets DSM-
IV-TR criteria for sexual dysfunction. However, there is no
widely used, standardized interview that has been
psychometrically validated, as is the case for other Axis I and
Axis II disorders. Neither the extensively tested Diagnostic
Interview Schedule (DIS) nor the Structured Clinical
Interview for DSM-IV Disorders (SCID) covers the sexual
dysfunctions (Compton & Cottler, 2004; First & Gibbon,
2004). Several authors have proposed clinical interview
1334
outlines and recommendations about coverage of topics and
process (e.g., see Bach, Wincze, & Barlow, 2001; Maurice,
1999; McConaghy, 2003; Wincze & Carey, 2001). briefly, the
clinical interview typically starts with the individual
describing the nature of the problem and the reasons for
seeking treatment at the time. Following an open-ended
characterization of the difficulty, the clinician then might start
asking more operationally Specific questions about the extent
of the problem and the conditions under which it occurs. This
is ideally followed by questions covering the myriad
biological, psychological, and social problems that might be
implicated.

Note: DISF = Derogatis Interview for Sexual Functioning;

GRISS = Golombok-Rust Inventory of Sexual Satisfaction;
ISS = Index of Sexual Satisfaction; SII = Sexual Interaction
Inventory; CSFQ = Changes in Sexual Function
Questionnaire; BISF-W = Brief Index of Sexual Functioning
for Women; FSDS = Female Sexual Distress Scale; FSFI =
Female Sexual Function Index; MFSQ = McCoy Female
Sexuality Questionnaire; IIEF/IIEF-5 = International Index of
1335
Erectile Function; SDI = Sexual Desire Inventory; MSIQ =
Menopausal Sexual Interest Questionnaire; A = Adequate; G
= Good; E = Excellent; U = Unavailable; NA = Not
Applicable.
From a broadly biological perspective, it is important to

assess and take into account age, general health status (e.g.,
body-mass index, energy levels, sense of physical well-
being), lifestyle factors (e.g., diet, cigarette smoking, alcohol
use, exercise), hormone levels, chronic pain syndromes (e.g.,
vulvodynia, interstitial cystitis), vascular diseases (e.g.,
hypertension, atherosclerosis, impaired cardiac function),
conditions that affect nervous system function (e.g., diabetes,
neuropathy), and pelvic or perineum trauma. It is also
important to assess for the potentially iatrogenic influence of
surgeries that may interfere with the musculature and
innervation of the genital area, as well as its cosmetic
appearance. Antidepressants, antipsychotics, and
antihypertensives can also have a deleterious effect on desire,
arousal, and orgasm and should be inquired about. Often,
assessment of many of these factors will require referral to the

appropriate medical professional.
In terms of individual psychological factors, depression and

anxiety are often comorbid with sexual dysfunction.
Treatment for sexual difficulties that does not simultaneously
target mood disturbances and anxiety is unlikely to meet with
much success. Substance abuse disorders can also have a
major impact on sexual functioning, as can certain mal-
adaptive cognitive sets and negative emotional reactions that
interfere with sexual function, although they may not rise to
the level of a disorder. These may arise from past trauma,
negative experiences, or learned sexual scripts. Often
1336
individuals simply lack knowledge of physiology or of sexual
techniques.
From a relational/social perspective, family of origin attitudes

regarding sexuality can be instated early on and create the
conditions for the development of sexual dysfunction.
Assessing the quality of the individual’s current relationship
cannot be stressed enough. Although sexual difficulties can
occur in the happiest of relationships, couple disharmony can
be a cause and/or consequence of sexual problems and needs
to be addressed. Relational issues important to assess include
anger, distrust, discrepancies in drive and preferences,
communication, and physical attraction. It is usually
recommended that both partners be interviewed together and/
or separately to gather as much information as possible. The
comorbidity of partner sexual dysfunction is common and
crucial to assess. Finally, ethnocultural and religious attitudes
and beliefs are important as they can be implicated in the
development and maintenance of sexual difficulties. Also,
these beliefs need to be respected in order to successfully treat
the individual or the couple.
In summary, the presence of any one or combination of the

aforementioned factors does not necessarily result in
dysfunction. Failing to assess for them, however, may
interfere with otherwise reasonable treatment efforts.
Although the unstructured clinical interview undeniably
provides maximum flexibility to explore the specifics of an
individual’s sexual problem and profile, the addition of a
shorter, structured interview and/or self-administered
questionnaires is likely to enhance the accuracy and utility of
the overall assessment.
1337
Self-Report Measures of Global Sexual Function
Table 21.1 provides a listing of self-report measures of global

sexual function helpful in diagnostic assessment. The first
two of these measures are designed to be applicable to men,
women, and couples, whereas the rest are gender-Specific. A
description of these measures follows.
The Derogatis Interview for Sexual Functioning (DISF/DISF-

R; Derogatis, 1997, 1998) is a 26-item interview designed to
assess sexual functioning multidimensionally as a whole and
in terms of each of five domains: sexual cognition/fantasy,
sexual arousal, sexual behavior/experience, orgasm, and
sexual drive/ relationship. There is also a distinct self-report
version (DISF-R) consisting of 26 items. Items are responded
to on 9- and 5-point adjectival scales and both formats take 15
to 20 minutes to complete, with the DISF-R taking a few
minutes less than the interview version. Both formats have
separate gender-keyed versions for men and women and were
designed to be administered repeatedly to monitor treatment
outcome or solely at pre and postintervention. Standard scores

allow for meaningful comparisons with the normative
community sample. There are, however, no clinical
norms at this time. This limits its use for diagnostic purposes,
although there is some evidence that scores distinguish
between groups with and without dysfunction. The measure
has been translated and is available in eight languages other
than English.
The Golombok-Rust Inventory of Sexual Satisfaction

(GRISS; Rust & Golombok, 1985, 1986, 1998) is a 56-item
self-report measure of sexual function and of relationship
1338
quality in heterosexual relationships. With 28 items Specific
to men and 28 Specific to women, the GRISS yields scores on
five dimensions for women, five for men, and two common
dimensions. Female-Specific dimensions pertain to orgasmic
difficulties, vaginismus, nonsensuality, avoidance, and
dissatisfaction. Male-Specific dimensions pertain to erectile
dysfunction, PE, nonsensuality, avoidance and dissatisfaction.
The two common dimensions pertain to infrequency and
noncommunication. Items are responded to on 5-point
adjectival scales. Scores on the 12 dimensions are
transformed into standardized scores and can be plotted to
provide a profile. The GRISS also provides a global score
indicative of overall relationship quality and the couple’s
sexual function that can be useful in case conceptualization
and treatment planning. Although there is some support for its
use as a diagnostic tool, the GRISS was designed primarily as
an evaluation tool for sex and marital therapy and for cross-
treatment efficacy comparisons. Its clinical utility lies in its
ease of administration (approximately 10 minutes to
complete) and its simultaneous assessment of both sexual
function and relationship quality.
The Brief Index of Sexual Functioning for Women (BISF-W;

Rosen, Taylor, & Leiblum, 1998; Taylor, Rosen, & Leiblum,
1994) is a 22-item scale developed to measure global sexual
function for the purposes of large-scale clinical trials. A
scoring algorithm provides an overall score for sexual
function and on seven dimensions: thoughts/desire, arousal,
frequency of sexual activity, receptivity/initiation, pleasure/
orgasm, relationship satisfaction, and problems affecting
sexual function. Items are responded to in a variety of formats
from adjectival frequency scales, to multiple choice, to yes/no
options. It takes 15 to 20 minutes to administer and some
1339
dimensions and overall score have been shown to be sensitive
to treatment targeted at women (transdermal testosterone) and
their partners (sildenalfil; Rosen et al., 2006; Shifren et al,
2000).
The Female Sexual Function Index (FSFI; Rosen et al., 2000)

is a brief, 19-item self report measure of female sexual
function yielding a total score, as well as scores on five
domains: desire, arousal, lubrication, orgasm, satisfaction,
and pain. Items are responded to on 5- to 6-point adjectival
scales and in reference to the past 4 weeks. The FSfitakes
approximately 15 minutes to administer and is scored such
that higher scores denote more difficulty. Cross-validation of
this instrument has supported its use as a screening tool or
diagnostic aid, but not as the sole basis of diagnosis (Meston,
2003; Wiegel, Meston, & Rosen, 2005). Because it does not
address questions of onset, duration, etiological or
maintaining factors, or situational specifics, it is not as useful
in the conceptualization of cases and treatment planning as in
screening and measurement of treatment outcome. There are
some data to suggest that it can detect treatment-related

changes (e.g., Nappi et al., 2003).
The McCoy Female Sexuality Questionnaire (MFSQ; McCoy

& Matyas, 1998) is a 19-item measure that assesses a
woman’s general level of sexual interest and response in the
preceding 4 weeks. It was designed to serve as a diagnostic
aid and as an assessment capable of measuring changes in
sexual functioning over time. The first 11 questions relate to
general sexual enjoyment, arousal, interest, satisfaction with
partner, and feelings of attractiveness; the remaining 8
questions cover intercourse frequency and enjoyment, orgasm
frequency and pleasure, lubrication, pain with intercourse,
1340
and the impact of partner’s erectile difficulties. With the
exception of one item inquiring about overall frequency of
heterosexual intercourse, all items are answered on a 7-point
adjectival scale. Time to administer is approximately 10
minutes. Although in its current form the measure is intended
for women in heterosexual relationships, the authors suggest
removal of the intercourse items to make the measure
applicable to lesbian women. It has not, however, been
validated with that population. Until recently, the MFSQ had
only been used with menopausal women, but an Italian
translation of the measure has provided support for its use as
a valid measure of dysfunction in women ages 18 to 65
(Rellini et al., 2005).
The Sexual Function Questionnaire (SFQ; Quirk et al., 2002;

Quirk, Haughie, & Symonds, 2005) is a 34-item self-report
instrument developed to assess multiple dimensions of female
sexual function and sexual satisfaction for women in sexual
pharmacology
clinical trials. The eight Specific dimensions targeted are
desire, arousal-sensation, arousal-lubrication, subjective

arousal, enjoyment, orgasm, pain, and partner relationship.
The SFQ Specifically distinguishes between subjective and
genital aspects of FSAD. It takes 15 to 20 minutes to
complete, with items answered in reference to the preceding 4
weeks on 5-point adjectival scales. The intention of the
authors was that the SFQ be used diagnostically to determine
the likelihood of a sexual problem and the phases of the
sexual response cycle (and/or pain) affected. The 4-week
reference period also makes the measure suitable for the
tracking of treatment progress, although no data supporting its
use for treatment outcome has yet been made available. The
SFQ has been developed and validated in 16 languages.
1341
The Structured Diagnostic Method (SDM; Utian et al., 2005)
is a novel method designed to aid health-care providers who
are not sexuality experts determine a diagnosis of female
sexual dysfunction in postmenopausal women. The SDM
consists of four self-report measures, followed by a clinical
interview. The four questionnaires administered in the order
that follows are the Life Satisfaction Checklist (Fugl-Meyer,
Lodnert, Branholm, & Fugl-Meyer, 1997), the first seven of
the nine questions of the sexual component of the Medical
History Questionnaire (Pfeiffer & Davis, 1972), the Female
Sexual Distress Scale (FSDS; Derogatis, Rosen, Leiblum,
Burnett, & Heiman, 2002), and the SFQ (Quirk et al., 2002).
The combination covers overall life satisfaction (including
sexual), decline in sexual function as well as its onset,
sexually related distress, and sexual function. The measures
are followed by a structured interview based on a guide to
diagnostic assignment outlined by Utian and colleagues
(2005). The administration of the SDM is lengthy and not
suitable for primary care clinic use, but it can be clinically
useful in both clinical trials and sex therapy practice. The
authors have not provided an algorithm or guidelines to

combine results from the measures and interview to arrive at a
diagnosis.
The Brief Sexual Function Inventory-M (BSFI-M; O’Leary et

al., 1995) is an 11-item measure of male sexual function
covering sexual drive, erection, ejaculation, subjective
problem assessment of drive, erection and ejaculation, and
overall satisfaction. Responses are given on 5-point adjectival
scales with higher scores indicating better function. The
reference period for responses is the last 30 days. Although
the initial intent was for this measure to provide a
multidimensional measure of sexual function in men, more
1342
recent validation of the measure suggests that it is most
efficacious as a unidimensional tool for general screening
purposes (Mykletun, Dahl, O’Leary, & Fossa, 2005). The
measure was intended to be suitable whether partners of the
male respondents were male or female.
The International Index of Erectile Function (IIEF; Rosen et

al., 1997) is a brief self-administered measure of erectile
function designed to detect treatment-related changes in
patients with erectile dysfunction, although it is also a useful
diagnostic adjunct. The 15 items address 5 domains of sexual
function: erec-tile function, orgasmic function, sexual desire,
intercourse, and overall satisfaction. Response options consist
of 5- or 6-point adjectival scales and the time reference is the
prior 4 weeks. It takes less than 15 minutes to complete and is
easy to administer in most settings. The IIEF has been
validated linguistically in many languages.
The Male Sexual Health Questionnaire (MSHQ; Rosen,

Catania, et al., 2004) is a 25-item self-administered measure
designed Specifically to assess sexual function and

satisfaction in aging men with urogenital concerns often
associated with heart disease, prostate cancer, benign
prostatic hyperplasia/lower urinary tract symptoms. Disorders
of ejaculation are common in men with these age-related
physical problems, yet erectile function measures such as the
IIEF do not focus Specifically on problems such as delayed or
retrograde ejaculation and diminished sensation, force, or
pleasure. The MSHQ thus addresses three domains of sexual
function: erection, ejaculation, and satisfaction with the
sexual relationship. The questionnaire is suitable for both
heterosexual and homosexual men as it does not assume
heterosexual intercourse to be the sole or even central sexual
1343
activity. Although initial reliability and validity for this
measure is promising, it is new and requires further
validation.
Assessment for Case Conceptualization

and Treatment Planning
Again, the richest tool for case conceptualization and

treatment planning is the clinical interview, with its capacity
to investigate multiple areas of functioning both in the client
and in their partner. One important area to assess in the
formulation of a treatment plan
is the existence of other Axis I and Axis II disorders, if these
are suspected to be present. Other chapters in this text
elaborate on the assessment of these and thus these
assessment tools will not be covered here. The other area
crucial to case conceptualization and treatment planning is the
assessment of the nonsexual aspects of the client’s primary
relationship. Table 21.2 provides a listing of self-report
measures suitable as adjuncts in case conceptualization and
treatment planning.
Ideally, the assessment of sexual function should include the

client’s partner if he/she has one and if they are willing to
participate. There are multiple functions to partner
assessment, including a general assessment of relationship
adjustment, the partner’s perception of the sexual difficulty,
and the presence of partner sexual dysfunction. This couple
assessment can be enhanced with self-administered measures
of marital adjustment.
1344
The Dyadic Adjustment Scale (DAS; Spanier, 1976), is the
most widely used instrument for the measurement of
relationship quality. It consists of 32 items in a variety of
response formats that are summed to create a total score
ranging from 0 to 151, with higher scores indicating better
dyadic adjustment. The items also break down into four
subscales which can be used independently as they have also
shown good reliability and validity: Dyadic Consensus (13
items), Dyadic Satisfaction (10 items), Dyadic Cohesion (5
items), and Affective expression (4 items). Total DAS scores
have been shown to discriminate between distressed and
nondistressed couples and to identify at-risk marriages. The
measure has also been used with gay and lesbian couples
(Kurdek, 1992). It is easy to administer (10 to 15 minutes)
and provides information about the marital context within
which the sexual dysfunction exists.
Because of the multidimensionality of most measures of

global sexual function, many are appropriate for use in case
conceptualization and treatment planning. Of the measures
already covered in the preceding diagnosis section, both the

DISF and the GRISS can be useful as they cover corollary
cognitions and behaviors, as well as satisfaction and
relationship quality. Other measures include:
The Derogatis Sexual Functioning Inventory (DSFI;

Derogatis, 1998; Derogatis & Melisaratos, 1979) is a
multidimensional measure that assesses constructs associated
with sexual functioning and general well-being. It consists of
254 items and arranged into 10 subscales. The response
format is a mixture of yes/no answers and multipoint
adjectival scales. The 10 dimensions addressed by the scales
are information, experiences, drive, attitudes, psychological
1345
symptoms, affect, gender role definition, fantasy, body image,
and sexual satisfaction. Each scale provides a separate score
and the linear combination of the 10 scales yields the Sexual
Functioning Index. A second global score, The Global Sexual
Satisfaction Score, assesses the individual’s subjective
perception of their sexual function. The psychometric
soundness of the measure varies by subscale.
The Index of Sexual Satisfaction (ISS; Hudson, 1998;

Hudson, Harrison, & Crossup, 1981) is a 25-item self-report
measure of dissatisfaction in the sexual aspects of a couple’s
relationship from the perspective of the respondent. In the
original measure items were responded to on 5-point
adjectival scales describing relative frequency. The newer
version has seven-point scales and minor item revisions. The
measure takes 5 to 7 minutes to complete.
The Sexual Interaction Inventory (SII; LoPiccolo & Steger,

1974; Reinhardt, 1998) is a self-report inventory designed to
assess the heterosexual couple’s sexual relationship with
regard to functioning and satisfaction. Unlike most other

measures designed for one respondent, the SII requires
responses from both partners. It is a lengthy measure, with
102 questions covering 17 heterosexual behaviors, and is
divided into 11 scales: Frequency Dissatisfaction—Male,
Female; Self Acceptance—Male, Female; Pleasure—Male,
Female; Perceptual Accuracy—Male of Female, Female of
Male; Mate Acceptance—Male of Female, Female of Male;
Total Disagreement. The item scales are 6-point adjectival
with some items inquiring about frequency and others about
pleasure. The inventory is completed in approximately 30
minutes.
1346
The Female Sexual Distress Scale (FSDS; Derogatis et al.,
2002) is designed to measure sexually related distress in
women. Although the FSDS requires additional independent
testing, it shows significant promise. Initially a 20-item
measure with frequency and intensity versions, analyses of
pilot studies reduced it to one 12-item measure with four-
point adjectival scales. The ascertainment of distress over
sexual difficulties can be integral to case conceptualization
and treatment planning and the FSDS has been shown to be
sensitive to treatment changes. It has also demonstrated
reliability and validity with different
populations (Dennerstein, Alexander, & Kotz, 2003; ter
Kuile, Brauer, & Laan, 2006).
The Sexual Satisfaction Scale for Women (SSS-W; Meston &

Trapnell, 2005) is a promising new measure of sexual
satisfaction in women along personal and relational
dimensions. The 30 items in the scale are responded to on
5-point scales anchored at “strongly agree” and “strongly
disagree” in reference to the respondent’s situation at the time
of administration. It consists of five domains of satisfaction

(communication, compatibility, contentment, relational
concern, and personal concern) with 6 items relating to each.
Despite its brevity, it provides the most detailed breakdown
available of satisfaction into separate components. This may
be particularly helpful in clarifying the sometimes confusing
relationship between satisfaction/distress and sexual difficul-
ties in women. Clearly not intended as a diagnostic measure,
the SSS-W could prove invaluable in case conceptualization
and the holistic measurement of treatment outcome,
regardless of the presenting sexual dysfunction.
1347
Assessment for Treatment Monitoring and
Treatment Outcome
Treatment monitoring and outcome is the one assessment

purpose for which the clinical interview is not optimal. This
assessment purpose requires the quantification that only
standardized measurement can provide. The recent explosion
in clinical trials for pharmacotherapeutic agents targeting
sexual dys-function has happily resulted in the development
of a number of measures designed Specifically for the
assessment of treatment monitoring and outcome. The
validation of treatment sensitivity in these measures is in its
infancy but finally there are actually measures to validate.
Table 21.3 provides a listing of measures suitable to treatment
monitoring and the assessment of treatment outcome.
In terms of measures applicable to men, women, and couples,

there is data to support that the DISF, GRISS, ISS, and SII
can detect changes attributable to treatment effects.
Additionally there is one other instrument Specifically
designed to measure changes in sexual function associated

with psychiatric illness and medication effects.
The Changes in Sexual Functioning Questionnaire (CSFQ,

CSFQ-14: Clayton, McGarvey, & Clavet, 1997; Clayton,
McGarvey, Clavet, & Piazza, 1997; Keller, McGarvey, &
Clayton, 2006) can be clinician-administered as a structured
interview (CSFQ-I) or self-administered as a gender-Specific
questionnaire (CSFQ-F or CSFQ-M). It measures five
dimensions of sexual functioning (frequency of sexual
activity, sexual desire, pleasure, arousal, orgasmic capacity),
as well as comorbid conditions, current medications, alcohol
1348
and substance use, and relationship status. The first 21 items
of the questionnaire apply to both men and women and are
followed by 36 male-Specific and 35 female-Specific items,
answered primarily on 5-point Likert-type scales. The CSFQ
has been found more valid and reliable in female than in male
samples and most of the psychometric data available
emanates from the self-administered version. Recently
abbreviated into a Short Form, the CSFQ-14 also has gender-
Specific versions and is self-administered. It yields scores for
three scales corresponding to desire, arousal, and orgasm, as
well as for the five scales in the original long form. The
available psychometric data for the newly introduced
CSFQ-14 are very promising and appear to improve on the
reliability and validity of the long form, especially with
regard to men. The addition of a short form enhances its
clinical utility, as it can be administered quickly in busy
practices and is amenable to immediate clinician feedback.
Although designed with psychiatric patients in mind, the
CSFQ has also been tested in nonclinical populations and
been found suitable for general use.
In terms of measures Specific to female sexual dys-function,

the BISF-W, FSDS, FSFI, and the MSFQ have all been found
sensitive to treatment effects. Far more data is needed to raise
Confidence about the use of these measures for treatment
monitoring and outcome, but they are promising and
represent a significant advance from a decade ago when none
existed. In terms of measures Specific to male sexual
dysfunction, the IIEF has demonstrated treatment sensitivity
and the MSHQ requires further validation but was designed
for this purpose and is a promising new measure Specifically
for older men.
1349
DYSFUNCTION-SPECIFIC ASSESSMENT
The assessment of any one sexual dysfunction is largely

dependent on the clinical interview. However, the
administration of one or more of the aforementioned self-
administered measures of global sexual
function that contain a domain pertinent to the dysfunction in
question can be a useful adjunct. Dysfunction-Specific
measures will be described in the following section and they
are included in Tables 21.1 to 21.3 as appropriate. As those
tables illustrate at a glance, there are very few such
dysfunction-Specific measures and diagnosis is still almost
completely dependent on the clinical interview. When a client
presents with symptoms of a Specific dysfunction, assessment
is more likely to involve physiological assessment strategies
than self-report measures. Although few of these
psychophysiological measures have been validated for the
assessment of sexual dysfunction, they will be discussed
briefly in the following section to introduce the reader to
promising additions to the multidisciplinary assessment
toolkit.
Hypoactive Sexual Desire Disorder
HSDD is perhaps the most difficult sexual dysfunction to

diagnose in both men and women as it is not anchored in the
absence or disturbance of an expected discrete event (e.g.,
erection, lubrication, orgasm) or in the presence of an
unexpected one (pain during intercourse). Diagnostic
assessment is usually based on the presenting complaint of
distress about desire level, taking into account natural
discrepancies between members of a couple. In addition to the
1350
clinical interview, an operationalization of the severity of the
problem can be facilitated by self-administered measures.
Global sexual function measures for use with either men or
women that have domains Specific to desire are the CFSQ,
DISF, DSFI, and the GRISS. Female-Specific global
measures that address desire levels are the BISF-W, FSFI,
MFSQ, SFQ, and, for postmenopausal women, the SDM.
Male-Specific measures with desire scales are the BSFI-M
and the IIEF. The advantage of these multidimensional
measures of desire is that they may also be helpful for the
purpose of case conceptualization as they provide information
on the existence of comorbid sexual dysfunctions, can also be
administered to the partner, and, in some cases, provide
information about relationship quality and satisfaction. There
are, however, only a handful of desire-Specific self-
administered measures with acceptable psychometric
properties and clinical utility. All of them are more applicable
to case conceptualization than to diagnosis and two of them
were designed to track treatment progress although we await
data to validate their use for this purpose.
The Sexual Desire Inventory (SDI; Spector, Carey, &

Steinberg, 1996) is a 14-item self-report measure of dyadic
and solitary desire for use with men and women. Its focus is
primarily on cognitive rather than behavioral dimensions of
desire. Each item is responded to according to the intensity of
feeling or frequency of occurrence on seven- or eight-point
adjectival scales and yields scores for dyadic desire, solitary
desire, as well as a total score. It has been validated in a
handful of studies (e.g., Conaglen & Evans, 2006) and has
been found sensitive to treatment effects in women with
HSDD (van Anders, Chernick, Chernick, Hampson, & Fisher,
2005). Because of its cognitive emphasis, it can be
1351
particularly useful in cognitive-behavioral case
conceptualizations.
The Sexual Interest and Desire Inventory (SIDI-F; Clayton et

al., 2006; Sills et al., 2005;) is a new, 13-item clinician-
administered instrument designed to quantify the severity of
symptoms in premenopausal women diagnosed with HSDD
and to track symptom changes in response to treatment. The
13 items cover the following areas: relationship-sexual,
receptivity, initiation, desire-frequency, affection, desire-
satisfaction, desire-distress, thoughts-positive, erotica,
arousal–frequency, arousal-ease, arousal-continuation,
orgasm. Based on the client’s response, the clinician chooses
among four, five, or six possible answers for most questions,
but six of the questions use a grid system that simultaneously
rates both intensity and frequency, allowing up to thirteen
possible responses. Although more validation is needed, this
scale shows higher specificity than the FSFI and CSFQ in
assessing the severity of HSDD symptoms. Yet to be tested
for inter-rater or test–retest reliability, it holds promise as a
brief measure of HSDD severity.
The profile of Female Sexual Function (PFSF; Derogatis et

al., 2004; McHorney et al. 2004) is a new 37-item self-report
instrument designed Specifically for the measurement of
sexual desire and associated symptoms in naturally and
surgically menopausal women with HSDD. The aim of the
measure was to capture the experience of HSDD in this
population by inquiring about its effects on the woman’s
feelings, thoughts, and behavior. It covers seven domains of
sexual function as follows: desire, arousal, orgasm, pleasure,
sexual concerns, responsiveness, and self-image. It has been
1352
used internationally, although little data are available on its
sensitivity to treatment effects.
The Menopausal Sexual Interest Questionnaire (MSIQ;

Rosen, Lobo, Block, Yang, Zipfel, 2004) is a 10-item scale
designed to assess sexual function in postmenopausal women
in three domains: desire, responsiveness and satisfaction.
Prior to the administration of these items, there are four
questions assessing whether the woman perceives a decline in
her level of sexual desire as a consequence of meno-pause.
The MSIQ is meant to be administered at the start of
treatment and repeatedly thereafter to track treatment-related
changes. Questions are asked in reference to the present or the
week preceding and are responded to on 7-point adjectival
scales. The construct validity of this measure looks very
promising but awaits independent validation.
In the absence of psychological, relational, situational, or

disease-related factors that could account for a decline in
desire, clinicians are increasingly turning to the assessment of
sex hormone levels as aids in the case conceptualization and

treatment planning of HSDD. The link between testosterone
and sexual desire is stronger than that of estrogen (Bachman
et al., 2002) and there is accumulating evidence that
androgens impact sexual desire in surgically menopausal
women (Shifren et al., 2000). It is important to note that no
single estrogen or androgen level has been found predictive of
low desire in either sex (Davis et al., 2005; Schiavi et al.,
1997).
1353
Sexual Aversion Disorder
Although some clients will disguise their phobic reactions to

sex as disinterest, the aversion usually surfaces early in the
process of any standard treatment for HSDD, especially once
exposure to sexual situations is introduced. In terms of self-
report measures, clients with SAD will register disturbances
of desire on the desire-Specific domains of the global sexual
function measures or in the unidimensional desire measures,
but it is unlikely that these will detect the severity of the
problem. There is only one self-administered measure directly
designed to assess sexual fear and avoidance.
The Sexual Aversion Scale (SAS; Katz, Gipson, Kearly, &

Kriskovich, 1989; Katz, Gipson, & Turner, 1992) is a 30-item
questionnaire designed to assess fears and phobic avoidance
of sexual contact theorized by the authors to be associated to
sexual trauma, guilt, social inhibitions, and fear of sexually
transmitted diseases (STDs). The 30 items are responded to
on four-point adjectival scales. Although this instrument has
been used primarily for research purposes, it could be useful

in the diagnosis of SAD, despite the fact that it has only been
normed with college samples. It might reduce delays in the
discovery that what presented as low desire is actually
something more intense. It could also prove useful in
conceptualization of a case as it can identify the source of the
aversion.
Female Sexual Arousal Disorder
In terms of self-administered measures, the CSFQ, BISF-W,

and MFSQ all inquire about arousal in general terms and in
1354
terms of lubrication, but the inquiry is limited to one or two
questions. Arousal questions can also be found in desire-
Specific measures such as the PFSF and the SIDI-F, but the
assessment of sexual arousal remains relatively brief. The two
measures that engage in a more detailed assessment of arousal
are the FSFI and the SFQ. The FSFI has four questions about
general sexual arousal and four about lubrication. The SFQ
also has eight questions devoted to arousal, and it
distinguishes between genital and subjective arousal.
Unlike the clinical assessment of male erectile dysfunction

which has long made use of physiological measures, the
assessment of female sexual arousal has relied almost
exclusively on self-report, despite evidence that women are
relatively unaware of their genital arousal (Laan, Everaerd,
van der Velde, & Geer, 1995). After years of relative neglect,
there is now a flurry of investigative activity on objective
genital arousal assessment instruments, with some of these
instruments holding as yet unfulfilled promise for clinical use.
Attempts to measure lubrication, clitoral engorgement, and

uterine contractions have met with little success for a variety
of reasons (see Meston, 2000; Prause & Janssen, 2006).
Vaginal blood flow has been most amenable to measurement,
and the most frequently used instrument is the vaginal
photoplethysmograph (VPP), a tampon-like, light-emitting
device that measures vasocongestion via the amount of light
reflected back from the vaginal walls. Pulsed-wave Doppler
clitoral ultrasonography appears to distinguish between
women with and without sexual dysfunction, although
questions as to its specificity to sexual arousal remain
(Bechara et al., 2003; Kukkonen et al., 2006; Nader,
Maitland, Munarriz, &
1355
Goldstein, 2006). The heated oxygen electrode measures
blood flow as a function of the power necessary to keep a
heated oxygen electrode placed on the vaginal wall by suction
at a constant temperature (Levin, 2006). The vaginal
thermistor measures changes in blood flow via a
thermoconductive probe mounted on a diaphragm ring which
telemetrically sends a signal to a receiver outside the body
(Meston, 2000). The labial thermistor clip is a surface
temperature probe fastened to the labia minora and it has been
found to correlate with VPP results while improving
correlations with subjective arousal (Janssen, 2001; Payne &
Binik, 2006). Thermal imaging technology produces thermal
images indicating the average temperature of less than a
millimeter of skin with a precision of .07°C rapidly
(Kukkonen, Binik, Amsel, & Carrier, 2007). Magnetic
resonance imaging is now also being applied to the
measurement of genital vasocongestion, as well as brain
activation during sexual arousal (Maravilla, 2006). These
psychophysiological instruments lack validation and their
clinical utility is constrained by the necessity of sexual
arousal induction, equipment, trained technicians, and

interpretive problems. However, these limitations have not
hampered the clinical use of similar techniques in the clinical
assessment of male erectile dysfunction (Levin, 2004).
Male Erectile Disorder
The comprehensive assessment of ED requires a thorough

clinical interview that includes both medical and
psychosexual history, physical examination, and laboratory
testing. More specialized diagnostic tests may be indicated in
some cases and these may include Doppler ultrasound and
1356
nocturnal penile tumescence tests (NPT). Self-report
measures may be helpful in the diagnosis of the problem,
although they are rarely sufficient. General sexual function
measures that inquire about ED are CSFQ, DISF-R, and
GRISS. Male-Specific measures that explore the existence of
ED in more detail are the BSFI-M and the IIEF and IIEF-5.
The International Index of Erectile Function-5 (IIEF-5;

Rosen, Cappelleri, Smith, Lispky, & Pena, 1999) consists of
five items from the IIEF that Specifically measure erectile
function and intercourse satisfaction. It is easy to administer
in the context of busy general practices, although it does not
provide information about other aspects of the patient’s
sexual function. It was designed to tag erectile difficulties and
track treatment-related changes. The response options are on
5-point adjectival scales and the reference period is 6 months.
Specialized techniques to assess for ED include NPT, penile

strain gauges, the RigiScan Monitor and the Doppler
ultrasound. The most commonly used psychophysiologic
procedure in the diagnosis of ED is NPT, based on the

assumption that the erections during the REM phase of the
sleep cycle rule out substantial organic etiology. Usually
measured in sleep labs with penile strain gauges that measure
circumferential changes, NPT has demonstrated both validity
and clinical utility (Shvartzman, 1994). The RigiScan
Monitor, a small computerized device, improves on NPT by
addressing the issue of rigidity, in addition to tumescence and
duration of erectile episodes (Ackerman & Carey, 1995).
Finally, intracavernosal injection testing and penile duplex
ultra-sonography have been found clinically useful in the
detection of arterial inflow abnormalities and veno-occlusions
(Goldstein, 2004).
1357
Once ED has been adequately diagnosed, case
conceptualization can be greatly enhanced by a sexual,
medical, and psychosocial history to assess for general sexual
functioning, medical, pharmacologic, surgical, and lifestyle
risk factors, as well relationships and general psychological
well-being. The physical examination should focus on
genitourinary, neurologic, and vascular systems with
laboratory tests focused on endocrine dysfunction (Goldstein,
2004).
Female Orgasmic Disorder
Within a clinical interview, women with lifelong orgasmic

difficulty will typically report either never having had an
orgasm or difficulty attaining one. Alternately, they may
complain of having lost orgasmic capacity over time or a lack
of pleasure or intensity during orgasm or even not knowing
whether or not they have had an orgasm. Almost all of the
self-administered measures of general and female-Specific
sexual function covered in this chapter inquire directly about
orgasm. Although these measures can be helpful in indicating

a potential problem, the questions embedded in these global
sexual function questionnaires are not sufficient to establish a
nuanced clinical picture of the many variations possible in
female orgasmic difficulty. The clinical interview remains the
best diagnostic tool for the assessment of orgasmic difficulties
in women. Mah and Binik’s (2002) Orgasm Rating Scale
(ORS) is an interesting recent addition to the assessment of
orgasm for both men and women. It is not designed to assess
anorgasmia per se, but rather the cognitive-affective and
sensory components of orgasm. Although it needs further
validation, this measure may be useful in identifying
1358
determinants of orgasmic pleasure as part of a treatment
program for women or men who are not completely
anorgasmic.
Male Orgasmic Disorder
Most global sexual function measures inquire about the

occurrence of orgasm and satisfaction with ejaculatory
latency and sensation, but instruments designed Specifically
for male sexual dysfunction tend to more adequately
investigate the range of problems that fall under MOD. The
IIEF and the BSFI contain one question addressing the
occurrence of and difficulty with ejaculation; the IIEF adds
one more item on the pleasurable sensation of orgasm and the
BSFI-M asks directly about satisfaction with the amount of
ejaculate emitted. The best coverage of orgasmic problems in
men, however, is provided by the MSHQ which has seven
questions devoted to ejaculation, its occur-rence, delay,
volume, force, pain or discomfort, and pleasure, as well as the
occurrence of retrograde ejaculation. Although the MSHQ
was designed for aging men, it can be useful for patients of

any age who report orgasm problems.
Retrograde ejaculation and emission phase disorders will

likely have a physiological cause and, thus, a careful medical
history and referral to a physician is important to assess for
potential disease or other biological processes (see Segraves
& Segraves, 1993, for a list of these). Whether or not
biological factors are implicated, a psychosexual history is
necessary to assess psychological and relational factors
contributing to the problem or consequential to it as this can
1359
be helpful for the purpose of case conceptualization and
treatment planning.
Premature Ejaculation
The assessment of PE has been complicated by variations in

what is considered a normal ejaculatory latency by expert
opinions and by the patient himself. In clinical trials, IELT is
usually assessed by means of a stopwatch; however, this is
not a viable assessment technique in clinical practice.
Because PE depends not only on objective measurement but
also on patient distress, most clinicians do not use IELT cut-
off points to assess for PE. Assessment usually relies more on
clinical impression and patient distress gathered from the
clinical interview (Perelman, 2006). There is no self-
administered measure that taps directly into PE in sufficient
detail to be helpful in assessment.
The clinical interview should assess whether the PE is likely

to be attributable to neurologic factors, psychological traits,
distress, psychosexual skills deficits, relationship problems,

physical illness or injury, and/or medication side effects
(Metz & Pryor, 2000). Metz and Pryor (2000) provided a
useful decision tree for the aforementioned Classifications
and potential etiologic pathways. Perelman (2006) stressed
the importance of assessing whether the patient is able to
detect premonitory sensations (bodily changes reflecting
arousal/impending ejaculation), as this is necessary in order to
choose to ejaculate or to delay ejaculation.
1360
Dyspareunia and Vaginismus
An understanding of both dyspareunia and vaginismus

requires the assessment of sexual function and of pain. A
number of self-administered sexual function measures, such
as the CSFQ, GRISS, MFSQ, and the BISF-W, contain one
question to assess the existence and frequency of pain with
intercourse. The SFQ and the FSFI have questions related to
frequency and intensity of the pain and the FSFI has been
found to have good discriminant validity in the assessment of
chronic vulvar pain (Masheb, LozanoBlanco, Kohorn,
Minkin, & Kerns, 2004).
Pain measures found to be useful in the conceptualization and

treatment planning of dyspareunia are the McGill Pain
Questionnaire (MPQ; Melzak, 1975), the Pain
Catastrophizing Scale (PCS; Sullivan, Bishop, & Pivik,
1995), as well as visual analog scales and pain diaries (Payne,
Bergeron, Khalife, & Binik, 2006). In addition to a large
number of studies attesting to the reliability and validity of
the MPQ for a wide range of pain experiences, it has been

shown to distinguish between different subtypes of
dyspareunia (Meana et al., 1997a). The PCS, another widely
validated general pain measure, is useful for determining the
amount of distress incurred by intercourse pain and in
formulating cognitive treatment strategies. Pain-related
distress is particularly germane
to women with vaginismus as they recall past intercourse
attempts with significant distress (Reissing et al., 2004), and
to those with vestibulodynia (VVS) who catastrophize
intercourse pain (Pukall, Binik, Khalife, Amsel, & Abbott,
2002).
1361
The clinical interview for dyspareunia should contain
questions on the history, onset, location, quality, duration, and
intensity of the pain, as these pain characteristics have been
found to have discriminant validity in the differentiation of
different dyspareunia subtypes (Meana et al., 1997a). Impact
of the pain on sexual activity, relationships, and psychological
functioning are also important to cover (Meana et al., 1997b).
A physical examination that aims to replicate the pain
experienced with attempts at intercourse is a necessary
component of assessment. The physical examination should
include a cotton-swab palpation of the vulva and a pelvic
examination. Pukall, Binik, and Khalife (2004) recently
introduced an instrument called the vulvalgesiometer to
standardize palpation pressure. The palpation serves to both
locate the pain precisely and establish the sensitivity of the
hyperalgesic area, if one is identified. Assessment of vulvar
or pelvic diseases is another important goal of medical
referral. Recently, the assessment of pelvic floor tonicity has
gained wider acceptance, as it has been shown to discriminate
between women with and without vestibulodynia (Reissing,
Brown, Lord, Binik, & Khalife, 2005). Pelvic floor

physiotherapy has shown promising outcomes in women with
sexual pain (Bergeron et al., 2002; Rosenbaum, 2005) and
women with vaginismus have been found to have higher
vaginal/pelvic muscle tonicity and lower muscle strength
(Reissing et al., 2004).
CONCLUSIONS AND FUTURE

DIRECTIONS
The multidimensionality of sexual function and its problems

poses a formidable challenge to both research and clinical
1362
practice. With lengthy laundry lists of potential etiologies for
all of the nine sexual dysfunctions, the isolation of any one
predominating factor or even of a reasonably articulated
system of interdependent factors is exceedingly difficult. It is
against this backdrop of complexity that clinicians are left to
diagnose, conceptualize, and treat. No single measure of
sexual function can provide sufficient information regarding
the affective, cognitive, behavioral, relational, and social
contexts within which the sexual difficulties have arisen or
are perpetuated. Only the clinical interview has the flexibility
to encompass an individual client’s Specific circumstances,
yet it is compromised by reliability and validity deficiencies
and by the fact that instrumental details affecting the sexual
difficulties tend to trickle out long after the initial intake. For
this reason, assessment needs to be an integrated component
of treatment at all stages, to track efficacy and to revise
strategies as information and conditions change.
Despite their limitations, self-administered measures and

psychophysiological tests can be useful in diagnosis, case
conceptualization, and the monitoring of treatment progress.

The clinical interview does not lend itself well to
readministration or to the operationalization of changes in
sexual function. Regardless of complexities in the etiology
and maintenance of sexual difficulties, simple measures of
drive, frequency, pleasure, or pain can tag improvement,
stasis, or deterioration. Elaboration on the meaning of the
changes can follow, but their quantification is essential to the
client’s and clinician’s evaluation of progress. Self-
administered measures are also integral to screening of sexual
function in health-care settings. After decades of urging the
medical profession to attend to sexual health as a primary
1363
component of an overall health assessment, it is up to sex
researchers to provide them with the tools to do so accurately.
And therein lies the rub. The majority of sexual function

measures require additional psychometric validation. There is
a paucity of independent validation and data supporting long-
term test–retest reliability, validity generalization, treatment
sensitivity, and clinical benefit. Achieving high psychometric
standards is an important research goal that will increase our
Confidence in the continued use of these measures and
encourage other disciplines to engage in the assessment of
sexual function. There is currently a very encouraging trend
toward the sound development and validation of clinically
useful measures. The concerning move toward medicalization
has had the unexpected benefit of promoting the development
of measures for use in clinical trials. We must remain vigilant
that the originating drive for the development of these
measures does not result in reductionist assessment tools that
miss the forest for the trees, or that neglect to address the
Specific concerns of minority populations. As we endeavor to
expand and refine our assessment toolbox, it is

important that we also turn our attention to the traditionally
neglected issues of sexual orientation, disability, and
ethnocultural diversity.
Most sexual function measures are penile–vaginal intercourse

centered and validated with predominantly Caucasian,
heterosexual, abled populations. There is little research on
culturally informed assessment and treatment for sexual
difficulties over and above concerns about high-risk
behaviors (Lewis, 2004). Cultural norms are important to
prevent sexual function measures from pathologizing groups
that fall outside of mainstream expectations. The recent cross-
1364
national validation of some sexual function measures
designed for clinical trials, as well as Laumann et al.’s (2006)
recent foray into the sexual well-being of older adults in 29
countries are good examples of this culturally informed
direction. Despite the occasional mention that a questionnaire
could be applicable to sexual minorities, little data supports
the generalizability of any of these self-administered
assessment tools. Additionally, the sexual health of
individuals with disabilities or chronic illness has also been
neglected. The norming of existing measures, as well as the
development and validation of measures Specific to
ethnocultural groups, sexual minorities, and individuals with
disabilities is long overdue.
Finally, it should be noted that the much needed corrective

trend toward the investigation of female sexual dysfunction
may now need to be matched by one that revisits the
complexity of male sexual function. There are now many
more measures for the assessment of female than of male
sexual function. The “age of Viagra” may have reduced male
sexual function to a medically produced erection. Although

the male sexual response may be more predictable than the
female one, we risk simplifying and doing a disservice to
male sexual function.
In conclusion, sexual health as defined by the World Health

Organization (WHO) is a state of physical, emotional, mental,
and social well-being related to sexuality, which is respectful
and free of coercion and discrimination (Edwards &
Coleman, 2004). Clearly, this encompasses much more than
the absence of dysfunction but it includes it. Our endeavors to
develop effective assessment strategies are instrumental in the
promotion of sexual health. We cannot address problems
1365
without the proper tools to identity them. Insuring that these
strategies are both accurate and inclusive is essential.
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22
Paraphilias
___________________
Michael C. Seto
Carolyn S. Abramowitz
Howard E. Barbaree
This chapter provides an overview of methods for assessing

paraphilias. Paraphilias are intense and persistent sexual
interests in atypical targets or activities; thus, the focus of a
person’s sexual thoughts, fantasies, urges, and arousal are
targets other than sexually mature humans, or activities that
are highly unusual among individuals who prefer sexually
mature partners. Better known examples of target paraphilias

include pedophilia (prepubescent children), fetishism
(nonliving objects), or partialism (body parts such as hands or
feet); examples of activity paraphilias include sadism
(physical or psychological suffering of others), masochism
(being humiliated, bound, or otherwise made to suffer),
exhibitionism (exposing one’s genitals to an unsuspecting
stranger), or voyeurism (observing an unsuspecting stranger
engaged in normally private activities). Other paraphilias are
extremely rare, and have only been described in case reports.
A target or activity is considered to be an exclusive paraphilia
when it is essential for someone to be sexually gratified (e.g.,
First, 2004; Moser & Levitt, 1987).
1388
Money (1984) has described a complex descriptive typology
of paraphilias, and Freund (1990) proposed that certain
activity paraphilias—exhibitionism, voyeurism, frotteurism,
and preferential rape—reflected disturbances in the species-
typical male courtship process. Money’s typology and
Freund’s notion of courtship disorder are descriptive rather
than explanatory. We do not have a satisfactory theory to
explain why some targets and activities appear to be more
likely to become the focus of paraphilias than other targets or
activities. For example, fetishistic interest in synthetic
materials such as rubber or vinyl is much more likely to occur
than fetishism for natural materials such as wood or feathers.
Mason (1997) has observed that fetish categories may be
stable, but the objects in those categories change (e.g., a
fetishistic interest in clothing materials has been observed for
more than a hundred years, but interests in velvet or silk in
the 19th century have largely been displaced by interests in
vinyl, rubber, or leather).
The majority of this review deals with pedophilia, which has

received the most research attention because of public and

professional concerns about sexual offenses committed
against children. Individuals with other paraphilias that lead
to criminal behavior if acted upon, such as exhibitionism,
voyeurism, or nonconsensual sadism, are also more likely to
be referred to clinical or forensic settings than individuals
with other paraphilias and therefore more likely to be studied
by researchers. Clinicians are unlikely to see other paraphilias
in their practices unless the person is greatly troubled by their
paraphilic sexual interests or it causes relationship or other
personal difficulties.
1389
Reliable and valid assessment methods are needed for
effective clinical practice and for scientific research. In this
chapter, we review empirically supported methods for
assessing paraphilias, including self-report through interview
or questionnaire; behavioral history, including sexual offense
history; and laboratory tasks involving viewing time or the
assessment of penile response (phallometry).
NATURE OF THE DISORDER
In the most recent edition of the Diagnostic and Statistical

Manual of Mental Disorders (DSM-IV-TR; American
Psychiatric Association [APA], 2000), the primary
nosological system used by mental health professionals in
North America, the diagnostic criteria for paraphilias are (a)
recurrent and intense sexual fantasies, urges, or behaviors
directed toward body parts or nonhuman objects, suffering or
humiliation of either partner in a sexual situation, or sexual
activity with a nonconsenting person; and (b) these fantasies,
urges, or behaviors cause clinically significant distress or
impairment in functioning. The DSMIV-TR Specifically

mentions a number of the more commonly known paraphilias.
The paraphilias listed in the 10th revision of the International
Classification of Mental and Behavioural Disorders (ICD-10:
World Health Organization, 1997) are generally quite similar
in content to the DSM-IV-TR.
Paraphilic individuals are a heterogeneous group and there is

little evidence to suggest they differ from nonparaphilic
individuals in most sociodemographic characteristics.
However, no large-scale comparative studies have been
conducted. The prevalence of paraphilias is unknown, as
1390
epidemiological surveys regarding persistence and intensity
of sexual interests have not been conducted. It is generally
accepted, however, that paraphilias are much more likely to
manifest in males. Retrospective studies suggest that
paraphilias emerge in early adolescence. Phenomenologically,
the experience may be similar to the emerging awareness of
one’s sexual orientation around the time of puberty; this
awareness typically precedes identifying oneself as
heterosexual or homosexual, and also typically precedes
engaging in sexual behavior with opposite-sex or same-sex
persons, respectively (McClintock & Herdt, 1996; Remafedi
et al., 1992; Savin-Williams & Diamond, 2000).
Abel, Becker, Mittelman, and Cunningham (1987) found that

one quarter to one half of their groups of sex offenders with
child victims reported an onset of sexual interests in children
before the age of 18. Freund and Kuban (1993) surveyed 76
adult sex offenders with child victims who admitted being
sexually interested in children and recalled that they were first
aware of a curiosity to see nude children as young
adolescents. Zolondek, Abel, Northey, and Jordan (2001)

reported data from 485 adolescent males between the ages of
11 and 17 referred for assessment or treatment of possibly
paraphilic interests or behavior. The adolescents completed a
questionnaire about their sexual interests and experiences as
part of their evaluation. Of these 26% acknowledged
engaging in fetishistic behavior, 17% acknowledged
voyeuristic behavior, and 12% acknowledged exhibitionistic
behavior. The average age of onset across these paraphilic
behaviors was between 10 and 12.
There is evidence that paraphilias are comorbid with mood

disorders, so nonforensic practitioners who specialize in
1391
seeing clients with mood disorders may occasionally see
individuals with paraphilias in their practice. For example,
Dunsieth et al. (2004) reported high prevalence rates for
mood and anxiety disorders in a sample of 113 male sex
offenders seen at a residential treatment facility; 58% met
diagnostic criteria for a mood disorder and 23% met
diagnostic criteria for an anxiety disorder. The paraphilic sex
offenders, half of whom were pedophiles, were more likely to
have been diagnosed for any mood disorder, anxiety disorder,
or impulse control disorder than the nonparaphilic sex
offenders. Kafka (1997, 2003) has argued that paraphilias and
mood disorders share an underlying deficit in serotonin
regulation, and thus antidepressant medications that increase
serotonin may have positive effects on both mood and
paraphilic sexual fantasies, thoughts, urges, and behavior.
In addition to complaints of mood problems, paraphilic

individuals may come to the attention of clinicians because of
relationship difficulties, which can result if the person cannot
confide in their partner (e.g., if they have a stigmatized
paraphilia such as pedophilia) or if the person’s partner is

aware and distressed by the paraphilic interest (e.g., a
transvestic fetishist whose spouse is upset about his cross-
dressing or a masochist whose spouse does not want to
engage in sadomasochistic activities).
There is evidence from several studies that paraphilic

behaviors tend to co-occur, for example, some pedophiles
have also engaged in exhibitionistic behavior, or some
voyeurs have also engaged in fetish-istic or sadistic behavior
(Abel, Becker, CunninghamRathner, Mittelman, & Rouleau,
1988; Bradford, Boulet, & Pawlak, 1992; Freund & Seto,
1998; Freund, Seto, & Kuban, 1997; Smallbone & Wortley,
1392
2004). Thus, clients referred because of concerns about one
paraphilia should also be assessed regarding their sexual
interests in other atypical targets or activities.
PURPOSES OF ASSESSMENT
In the following sections, we focus our review on assessments

for the purpose of (a) diagnosis, (b) case conceptualization
and treatment planning, and (c) treatment monitoring and
evaluation. See Seto (2008) for a review of cognitive science
and neuroim-aging paradigms adapted to the assessment of
sexual interests, particularly pedophilia, in research.
ASSESSMENT FOR DIAGNOSIS
We expect most practitioners will conduct assessments for

paraphilias in one of two clinical contexts. First, evaluators
will use these assessments in forensic settings where the
suspected paraphilia is associated with criminal conduct (e.g.,
pedophilia and sexual offenses against children, sexual
sadism and rape, exhibitionism and indecent exposure). The

individual will have criminal charges or convictions for
sexual crimes, and the main clinical questions will be about
the presence or absence of paraphilias, given the implications
of this diagnosis for treatment, management, and risk to
sexually offend again. Referrals may come from the courts
upon sentencing, parole boards considering a release from
custody, or treatment providers considering a candidate for
participation in a sex offender treatment program.
The second context involves nonforensic clinical settings

where paraphilias that are not usually associated with criminal
1393
conduct are encountered. For example, clinicians may be
asked to assess someone for paraphilias because that person is
distressed about his or her sexual thoughts, fantasies, urges, or
behavior, whereas sex or marital therapists may see someone
because his or her sexual interests are causing difficul-ties in
relationships or other aspects of interpersonal functioning.
Clinicians in settings providing care to individuals with
obsessive–compulsive disorder (OCD) may be asked to
conduct these assessments with individuals who have
obsessive thoughts about atypical targets or activities, for
example, reporting recurring and seemingly uncontrollable
thoughts about molesting a child (Freeman & Leonard, 2000;
Gordon, 2002). Usually, these assessments are done to rule
out a paraphilia and to reassure the OCD client concerning the
unlikelihood of their acting upon their thoughts. The
differential diagnosis is made by determining if the person’s
thoughts are associated with sexual arousal or pleasure,
instead of anxiety or disgust, and by inquiring about other
symptoms of obsessive–compulsive disorder.
There is often a substantial difference in the quality and

breadth of information that is available in forensic versus
nonforensic evaluations of paraphilias. Forensic evaluators
benefit from the availability of justice records regarding
criminal sexual behavior (e.g., previous allegations and
charges of sexual offenses), previous assessment reports, and
information from health and school authorities. At the same
time, individuals facing criminal sanctions may be
understandably reluctant to disclose paraphilic thoughts,
fantasies, urges, or behavior, and thus the information that can
be obtained through self-report may be limited or invalid.
Nonforensic evaluators do not usually have access to the
same breadth of collateral information as their forensic
1394
counterparts, but they can often obtain more information
through self-report as the client is self-referred and
presumably more willing to talk about potentially paraphilic
sexual interests, though still very reluctant to disclose highly
stigma-tized paraphilias (e.g., someone complaining of their
masochistic sexual interests because it causes relationship
difficulties may not be willing to disclose sexual thoughts,
fantasies, or urges regarding prepubescent children). Table
22.1 summarizes the psychometric properties of a selection of
relevant measures used for the purpose of diagnosis.
Self-Report
Sexual histories are typically obtained through clinical

interview. Respondents are asked questions pertaining to their
sexual thoughts, interests, and behaviors, as well as
relationship history. Comprehensive interviews also include
questions to help clinicians rule out other explanations for
potentially paraphilic sexual thoughts, urges, fantasies, or
behavior. No validated semistructured or structured
interviews are available.
Interviews can be quite informative, but there are potential

problems with recall and other report biases in gathering data
on sexual behavior in this way (see Wiederman, 2002, for a
review of research on the impact of self-report methods to
study sexuality). Another limitation is the face validity of
interview questions (e.g., “Do you ever have sexual fantasies
about hurting someone?” “Are you sexually attracted to
children?”). Individuals may understandably lie because of
embarrassment about sexual matters, or concerns about the
1395
legal or social sanctions they could face in acknowledging
illegal sexual behavior.
TABLE 22.1 Ratings of Instruments Used for Diagnosis
Note: SICQ = Sexual Interest Cardsort Questionnaire; MASA

= Multidimensional Assessment of Sex and Aggression; MSI
= Multiphasic Sex Inventory; SSPI = Screening Scale for
Pedophilic Interests; L = Less Than Adequate; A = Adequate;
G = Good; E = Excellent; U = Unavailable; NA = Not
Applicable.
One way to reduce the reluctance of individuals to disclose

paraphilic sexual interests or behavior in face-to-face
interviews is to administer questionnaires. A number of
questionnaires have been developed to assess paraphilias, for
example, the Multiphasic Sex Inventory (MSI: Nichols &

Molinder, 1984), and the Multidimensional Assessment of
Sex and Aggression (MASA: Knight, Prentky, & Cerce,
1994). Manuals are available for these two questionnaires; the
first is commercially available and the second is available
from the lead developer.
The MSI contains 200 items, organized into 20 scales,

tapping different aspects of conventional and paraphilic
sexuality, including six validity scales and a scale assessing
attitudes regarding treatment. A number of studies have
reported on its psychometric properties, which appear to be
1396
good to excellent in terms of the internal consistency of scales
and test– retest reliability (Day, Miner, Sturgeon, & Murphy,
1989; Kalichman, Henderson, Shealy, & Dwyer, 1992;
Simkins, Ward, Bowman, & Rinck, 1989). A revised version
of this measure, the MSI-II, has been developed but there is
only one peer-reviewed study of this version, and its scoring
algorithms cannot be independently verified because tests
must be submitted to a scoring service. Thus, we include only
the MSI in this review. Day et al. (1989) reported that MSI
scores explained more of the variance in past criminal sexual
behavior than phallometrically assessed sexual arousal, and
several studies have shown that MSI scores can distinguish
between types or subgroups of sex offenders (Baldwin &
Roy, 1998; Barnard, Robbins, Tingle, Shaw, & Newman,
1987; Craig et al., 2006; Kalichman et al., 1989).
The MASA has undergone repeated evaluation and revision.

It was developed to assess adult male sex offenders, but
recent studies have examined its performance in the
assessment of adolescent male sex offenders (e.g., Daversa,
2005). It contains items drawn from existing questionnaires

and generated by a panel of clinicians, assessing domains
such as antisocial behavior, social competence, anger and
aggression, paraphilias, sexual preoccupation and
compulsivity, offense planning, sexual attitudes, and
pornography use. Of most relevance to the current chapter are
the items pertaining to sadism and other paraphilias. The
sadism and paraphilias scales have good internal
consistencies and good test–retest reliabilities, and the sadism
items have figured in the testing of theoretical models of
sexual offending against women (Knight & Sims-Knight,
2003).
1397
The Sexual Interest Cardsort Questionnaire (SICQ; Holland,
Zolondek, Abel, Jordan, & Becker, 2000) contains 75
descriptions of explicit sexual acts that are relevant to
different paraphilia diagnoses. Respondents rate each
description on a seven-point scale in terms of their sexual
interest. The measure is called a cardsort because it was
originally developed as a set of cards that were sorted by
respondents. Holland et al. (2000) reported that SICQ
responses were significantly correlated with group
Classification made by clinicians in a sample of 371 males
seeking assessment or treatment because of their paraphilic
interests or sexual offending. Holland et al. also reported on
the development of a shorter version of the SICQ that
contains only 45 descriptions. Laws,
Hanson, Osborn, and Greenbaum (2000) reported that the
SICQ could distinguish between offenders who victimized
only boys from offenders who victimized only girls. Hunter,
Becker, and Kaplan (1995) reported on the administration of a
modification of the SICQ to 38 adolescent sex offenders, but
no other published data are available on this adolescent
version.
Several promising measures are not included in Table 22.1.

The Clarke Sexual History Questionnaire-Revised (SHQ-R:
Langevin & Paitich, 2002) is intended for adults and contains
508 items divided into 17 sections, tapping different aspects
of conventional and paraphilic sexuality, including early
childhood experiences, sexual dysfunction, fantasies,
exposure to pornography, and behavior. Langevin, Lang, and
Curnoe (1998) compared 201 male sex offenders to 72
controls (50 nonsex offenders and 22 heterosexual volunteers)
and found that only one third of the sex offenders admitted to
having paraphilic sexual fantasies, and in fact were less likely
1398
to report having fantasies of any kind than the controls.
Curnoe and Langevin (2002) found that the SHQ-R could be
used to distinguish sex offenders who admit to having
paraphilic sexual fantasies from those who do not. The SHQ-
R was not included in Table 22.1 because it has poor
test–retest reliability, and similar measures are available.
The Sexual Fantasy Questionnaire was developed for

adolescents and contains items about sexual fantasies
involving sex with children under the age of 12, as well as
items about other atypical sexual fantasies. The Sexual
Fantasy Questionnaire is promising because it is suitable for
adolescents and assesses a variety of paraphilic interests, but
it has only been examined in a single peer-reviewed article so
far (Daleiden, Kaufman, Hilliker, & O’Neil, 1998).
Finally, the Wilson Sexual Fantasy Questionnaire is a 40-item

questionnaire that includes a scale assessing sadomasochistic
sexual fantasies (other scales assess the frequency of fantasies
with intimate, exploratory, or impersonal themes). This
questionnaire is distinguished from many of the other

measures we have listed because it has been used with both
men and women (e.g., Baumgartner, Scalora, & Huss, 2002;
Gosselin, Wilson, & Barrett, 1991). Gosselin et al. found that
a group of 87 sadomasochistic women scored higher on the
items pertaining to sadomasochistic fantasies than a
comparison group of 50 nonparaphilic women. Other
researchers have examined the Wilson Sexual Fantasy
Questionnaire in samples of male sex offenders. Thornton and
Mann (1997) found that sex offenders who scored higher on
the questionnaire also scored higher on measures of attitudes
and beliefs tolerant of sexual offending. Smith, Wampler,
Jones, and Reifman (2005) found that 114 adolescent sex
1399
offenders rated as high risk because of their criminal histories
and antisocial behavior also scored higher on all four scales of
the Wilson Sexual Fantasy Questionnaire.
Like interviews, questionnaires are vulnerable to self-report

biases because many of their items are face valid, although
both the Clarke SHQ-R and the MSI contain validity scales to
detect lying. It is worth noting here that the SICQ study
reported by Holland et al. (2000) excluded men who denied
their sexual offenses. One would expect that men who denied
their sexual offenses would not admit to any paraphilic sexual
interests, rendering their responses invalid. Because of
concerns about the limitation of self-reports, especially in
forensic evaluations, there is a great deal of clinical and
research interest in measures that draw on other sources of
information. In some cases, useful information can be
obtained from other sources, such as a past or current sexual
partner. Questions can be asked of partners about the client’s
sexual behavior and what he has disclosed in the past about
his sexual thoughts, fantasies, and urges.
Behavioral History
Clinicians have used information about sexual victim

characteristics that are empirically related to pedophilic
sexual interests to make the diagnosis of pedophilia. Among
adult sex offenders with child victims, those who have
multiple victims, very young victims, boy victims, or victims
outside the offender’s immediate family are more likely to be
pedophilic than those who do not. This information has
typically been combined in a subjective and unstructured
fashion in clinical judgments. In response, Seto and
1400
Lalumière (2001) developed a 4-item scale, the Screening
Scale for Pedophilic Interests (SSPI), to summarize an
offender’s sexual victim characteristics and identify those
who were more likely to be pedophilic in their sexual arousal
in terms of their penile responses to depictions of children
relative to their responses to depictions of adults.
The SSPI was developed in a large sample of primarily adult

men who had been convicted of at least
one sexual offense against a child (total N = 1,113 offenders,
including 40 adolescent sex offenders). Four major correlates
of pedophilia identified from the empirical literature
independently contributed to the prediction of
phallometrically assessed sexual arousal to children. Having
boy victims explained approximately twice the variance of
sexual arousal, and, thus, was given twice the weight of the
other variables. These four variables were scored as present or
absent, using all available information about sexual offenses:
having any male victims, having more than one victim,
having a victim aged 11 or younger, and having an unrelated
victim. Total SSPI scores range from 0 to 5. File information

such as police synopses or probation/parole reports are
preferred over self-report as a means of obtaining information
about sexual offense history, unless the individual reported
sexual offenses that were not previously known.
Sex offenders who have higher scores on the SSPI are much
more likely to be pedophilic than are sex offenders with lower
scores. Approximately one in five sex offenders with a score
of zero showed greater sexual arousal to children than to
adults when assessed phallometrically, whereas
approximately three in four sex offenders with a score of five
showed this pattern of sexual arousal. Recent studies have
1401
demonstrated that the SSPI is also valid for adolescent sex
offenders with child victims (Madrigano, Curry, & Bradford,
2003; Seto, Murphy, Page, & Ennis, 2003). Moreover, SSPI
scores predict new serious (nonsexually violent or sexual)
offenses among adult male sex offenders with child victims
(Seto, Harris, Rice, & Barbaree, 2004).
A disadvantage of the SSPI is that it requires a history of

sexual contact with a child, thus a pedophile who has never
acted upon his sexual attraction to children cannot be scored.
On the other hand, the SSPI does not rely on self-report.
Similar behavioral history scales have not yet been developed
for other paraphilias.
Viewing Time or Visual Reaction Time
Unobtrusively recorded viewing time of pictures of children

and adults is correlated with self-reported sexual interests and
phallometric responding in samples of nonoffending male
volunteers recruited from the community (Quinsey, Ketsetzis,
Earls, & Karamanoukian, 1996; Quinsey, Rice, Harris, &

Reid, 1993; but not Gaither, 2001). The basic viewing time or
visual reaction time procedure for assessing age preferences
involves showing a series of pictures depicting girls, boys,
women, or men; these pictures can depict clothed,
semiclothed, or nude figures. Respondents are either asked to
examine the pictures to answer later questions, or they are
asked to rate each picture on certain attributes (e.g., how
attractive the person is, how sexually interesting he or she is).
Respondents are instructed to proceed to the next picture at
their own pace and are supposed to be unaware that the key
1402
dependent measure is the amount of time they spend looking
at each picture.
Several studies have shown that adult sex offenders with child
victims can be distinguished from other men by the amount of
time they spend looking at pictures of children relative to
pictures of adults (Harris, Rice, Quinsey, & Chaplin, 1996) or
by a combination of viewing time and self-reported sexual
interests, arousal, and behavior (Abel, Jordan, Hand, Holland,
& Phipps, 2001; Abel, Lawry, Karlstrom, Osborn, &
Gillespie, 1994). Viewing time can also distinguish sex
offenders with boy victims from those with only girl victims
(Abel, Huffman, Warberg, & Holland, 1998; Abel et al.,
2004; Worling, 2006).
However, Smith and Fischer (1999) were not able to

demonstrate discriminative validity in a study of adolescent
sex offenders and nonoffenders using the viewing time
component of the Abel Assessment of Sexual Interest
(AASI), a commercially available measure of paraphilas. The
AASI includes both a viewing time component and a

computer-administered questionnaire that is completed by
clients (see www.abelscreen.com, retrieved on March 1,
2007). No published studies have yet demonstrated that
scores on viewing time measures, whether alone or in
combination with self-report ratings, predict recidivism
among sex offenders.
A potential problem for viewing time measures is that they

may become vulnerable to faking once the client learns that
viewing time is the key variable of interest (e.g., see
www.innocentdads.org/abel.htm, retrieved on March 1,
2007). No published studies have reported on the ability of
1403
participants to manipulate their responses on viewing time
measures or the ability of examiners to detect such efforts at
deception. Normative data are available for the AASI-2, but
the algorithms are considered to be proprietary knowledge
and thus test results must be submitted to a scoring service
(see Abel et al., 1994). The AASI developers claim their
measure combining viewing
time and self-report can assess other paraphilias, such as
fetishism and sadism, but there are no published data
regarding this claim, and this claim cannot be verified by
independent researchers. Other viewing time measures that
allow users to score responses are available (e.g., Harris et al.,
1996; Worling, 2006).
Phallometry
Phallometry involves the measurement of penile responses to

stimuli that systematically vary on the dimensions of interest,
such as the age and sex of the figures in a set of pictures.
Phallometry was developed as an assessment method by Kurt
Freund, who first showed that it could reliably discriminate

between homosexual and heterosexual men (Freund, 1963),
and then showed it could distinguish between sex offenders
against children and other men (Freund, 1967). Greater detail
is provided in this chapter about phallometry because of the
clinical utility of phallometry in the assessment of paraphilias
among sex offenders, and because several decades of research
is available.
Phallometric responses are recorded as increases in either

penile circumference or penile volume; bigger increases in
circumference or volume reflect greater sexual arousal to the
1404
presented stimulus. Circumferential gauges, typically a
mercury-in-elastic strain gauge placed over the mid-shaft of
the penis, are the most commonly used phallometric devices.
Although volumetric devices are more sensitive than
circumferential gauges at very low levels of arousal, they
show very high agreement above a threshold of
approximately 10% of full erection (Kuban, Barbaree, &
Blanchard, 1999). Changes in the electrical conductance of
the mercury represent changes in penile circumference and
can be calibrated to give a precise measure of penile erection.
Erectile response (except for erections that occur during
sleep) is Specifically sexual, unlike other psychophysiological
responses such as pupillary dilation, heart rate, and skin
conductance (Zuckerman, 1971). Phallometric responses
correlate positively and significantly with viewing time and
self-report among nonoffenders (Harris et al., 1996) and with
AASI scores among sex offenders (Letourneau, 2002).
Phallometric data are optimally reported as the relative

response to the category of interest, for example, penile
response to pictures of prepubescent children minus penile

response to pictures of adults; more positive scores indicate
greater sexual interest in children. Relative responses are
more informative than absolute penile responses because the
former take individual differences in responsivity into
account. Responsivity can vary for a variety of reasons,
including the man’s age (Blanchard & Barbaree, 2005),
health, and the amount of time since he last ejaculated. To
illustrate the value of relative response scoring, the
observation that an individual exhibits a 10 mm increase in
penile circumference in response to pictures of children is
more interpretable when we know whether he exhibits a 5
mm or 20 mm increase in response to pictures of adults. The
1405
first pattern of responses indicates someone who is more
sexually aroused by pictures of children compared to pictures
of adults, indicating a sexual preference for children; the
second pattern of responses indicates someone who is
relatively more responsive in the laboratory, but who is more
sexually aroused by pictures of adults relative to pictures of
children, indicating a sexual preference for adults.
Discriminative Validity
Indices of relative phallometric responding can discriminate

sex offenders against children from other men. Sex offenders
with child victims respond relatively more to stimuli
depicting children than men who have not committed such
sexual offenses, including sex offenders with adult victims,
nonsex offenders (e.g., men convicted of nonsexual assault),
and nonoffenders (e.g., Barbaree & Marshall, 1989; Freund &
Blanchard, 1989; Quinsey, Steinman, Bergersen, & Holmes,
1975). Moreover, phallometric responses are associated with
victim choice, such that men who have offended against girls
tend to respond relatively more to stimuli depicting girls, and

those who have offended against boys tend to respond
relatively more to stimuli depicting boys (Harris et al., 1996;
Quinsey et al., 1975). Rapists respond relatively more to
depictions of sexual aggression than nonrapists (see
Lalumière & Quinsey, 1994, for a quantitative review; see
Lalumière, Quinsey, Harris, Rice, & Trautrimas, 2003, for a
recent update), and other investigators have shown that
phallometric test results can distinguish men who admit to
sadistic fantasies, men who cross-dress, or men expose their
genitals in public from other groups of men (Freund, Seto, &
1406
Kuban, 1995; Marshall, Payne, Barbaree, & Eccles, 1991;
Seto & Kuban, 1996).
The discriminative validity of phallometry can be improved in

several ways. Using standardized scores to calculate indices
of relative responding and using indices based on differences
in the responses to different stimulus categories increases
discrimination between male sex offenders and other men
(Earls, Quinsey, & Castonguay, 1987; Harris, Rice, Quinsey,
Chaplin, & Earls, 1992). The addition of a tracking task in
which participants push buttons when they see or hear violent
or sexual content increases their attention to the stimuli and
subsequently increases the discriminative validity of
phallometry for sex offenders (Harris, Rice, Chaplin, &
Quinsey, 1999; Proulx, Côté, & Achille, 1993; Quinsey &
Chaplin, 1988). Response artifacts can also be used to detect
attempts to manipulate test results (Freund, Watson, &
Rienzo, 1988). Tactics to reduce faking are important in
phallometry because some men can voluntarily control their
penile responses during sessions (Quinsey & Bergersen,
1976; Quinsey & Carrigan, 1978). The use of audiotaped

descriptions of sexual scenarios also yields very good
discrimination (e.g., Chaplin, Rice, & Harris, 1995; Quinsey
& Chaplin, 1988).
At the level of individual diagnosis, the sensitivity of

phallometric tests, defined as the proportion of paraphilic
individuals identified as such on the basis of their
phallometric responses, can be calculated after setting a
suitable cut-off score (e.g., showing greater arousal to an
atypical target or activity than to depictions of sexual
intercourse with adults). Given the potentially negative
consequences of being identified as a paraphilic individual,
1407
cut-off scores providing high Specificities are typically used
in clinical settings. specificity is defined as the percentage of
nonparaphilic controls who are identified as not being
sexually interested in an atypical target or activity. In a
sample of 147 sex offenders with unrelated child victims,
using a cut-off score that produced 98% specificity,
sensitivity was 50% in Freund and Watson (1991). In a
sample of sex offenders with child victims who denied being
sexually interested in children, Blanchard, Klassen, Dickey,
Kuban, and Blak (2001) reported that sensitivity was 61%
among men with many child victims, and specificity was 96%
among men with many adult victims and/or adult sexual
partners. The average sensitivity across the studies reviewed
by Lalumière et al. (2003) was 63% (63% of rapists showed
greater sexual arousal to depictions of rape than to mutually
consenting sex) with a corresponding specificity of 87% (87%
of volunteers showed greater sexual arousal to depictions of
mutually consenting sex than to depictions of rape).
If one considers admission of pedophilia to be a suitable

standard, then the sensitivity of phallometry is very high. In a

series of three studies, Freund and his colleagues reported on
the results of phallometric testing for a total of 137 sex
offenders with child victims who admitted to having
pedophilia; the sensitivity of phallometric testing in this group
of self-admitted pedophiles was 92% (Freund & Blanchard,
1989; Freund, Chan, & Coulthard, 1979; Freund & Watson,
1991).
1408
Predictive Validity
Phallometry has good predictive validity. A recent meta-

analysis of 10 studies, with a combined sample size of almost
1278 sex offenders, found that phallometrically measured
sexual arousal to children was one of the single best
predictors of sexual recidivism among sex offenders (Hanson
& Morton-Bourgon, 2004, 2005); its correlation with sexual
recidivism was similar to the correlations obtained by
measures of psychopathy or prior criminal history, and both
psychopathy and prior criminal history are strong and robust
predictors of recidivism across types of offenders (Gendreau,
Little, & Goggin, 1996; Hanson & Morton-Bourgon, 2004;
Hare, 2003).
Reliability
Phallometric testing has been criticized for its lack of

reliability. Traditional internal consistency and test–retest
analyses suggest the reliability of phallo-metric testing is
acceptable, at best (Barbaree, Baxter, & Marshall, 1989;

Davidson & Malcolm, 1985; Fernandez, 2002; but see
Gaither, 2001). The validity of a test is constrained by its
reliability, yet the discriminative and predictive validities of
phallometric testing are quite good, suggesting that it must be
reliable. This apparent contradiction in test properties
suggests the discriminative and predictive effect sizes that
have been obtained for phallometry are conservative
estimates of its validity and would be even higher if reliability
were higher.
1409
One possible explanation for phallometry’s low test–retest
reliability is that individuals become familiar with the
procedure and use tactics to voluntarily control their sexual
arousal over sessions. Evidence for this comes from Rice,
Quinsey, and Harris (1991),
who found that initial phallometric test results were more
strongly related to recidivism than subsequent phallometric
test results, and Barbaree et al.’s (1989) finding that nonrapist
controls showed a signficant change in their responses from
the first to second session. Freund et al. (1988) discussed
signs of attempts to manipulate penile response and Quinsey
and Chaplin (1988) described a method for reducing faking.
Because of phallometry’s clinical utility in the assessment of
paraphilias and sex offenders, it is included in Table 22.1
despite its relatively low test–retest reliability. The purposeful
modification of sexual arousal patterns is discussed later in
this chapter when we consider the use of phallometry to
assess treatment change.
Criticisms
Despite the consistent evidence supporting the clinical and

research use of phallometry to assess paraphilias, there is
disagreement about the utility of this assessment method, and
the number of phallometric laboratories has declined over the
past 10 to 15 years (Howes, 1995; McGrath, Cumming, &
Burchard, 2003). Critics such as Launay (1999) and Marshall
and Fernandez (2000) have discussed their practical and
ethical objections to phallometry. One of the main criticisms
of phallometric testing is its lack of standardization in stimuli,
procedures, and data analysis (though it seems to us that this
is more a criticism of how phallometric testing is conducted
1410
in practice than the methodology itself). Howes (1995)
identified a great deal of heterogeneity in methodologies in a
survey of 48 phallometric laboratories operating in Canada
and the United States. For example, laboratories vary on the
number and nature of stimuli they present, duration of
stimulus presentations, and the minimum arousal level
accepted for clinical interpretation of individual response
profiles. Unfortunately, many phallometric laboratories do not
use validated procedures and scoring methods.
Standardization of procedures is needed because some

phallometric testing procedures have been validated, but
others that are currently in use have not been subjected to
empirical scrutiny. Standardization would also facilitate the
production of normative data and thereby aid in the
interpretation and reporting of phallometric test results.
Unfortunately, repeated calls for standardization in the field
have resulted in very little progress. Progress on
standardization has been slowed by ethical and legal concerns
regarding the production and distribution of stimulus material
that may constitute child pornography, and other nonscientific

reasons. There is empirical evidence to guide decisions about
these methodological issues, such as the number and kinds of
stimuli to present, the use of circumferential or volumetric
devices, and the optimal transformations of data for
interpretation (see Lalumière & Harris, 1998; Quinsey &
Lalumière, 2001).
1411
Inter-Rater Reliability and Diagnostic Agreement
Between Methods
Other issues that need to be addressed in the assessment of

paraphilias is the inter-rater reliability of paraphilia diagnoses,
and agreement between diagnostic measures. As this review
has shown, there are reliable and valid methods for assessing
paraphilias, especially pedophilia, yet the diagnostic criteria
of paraphilias have been challenged. O’Donohue, Regev, and
Hagstrom (2000) and Marshall (2006) have pointed out
problems with DSM-IV diagnostic criteria for paraphilias
such as pedophilia and sadism, including the absence of data
on inter-rater reliability (the extent to which two clinicians
would agree in assigning the diagnosis) and test–retest
reliability (whether someone diagnosed as having a paraphilia
at Time 1 would continue to be identified as such at Time 2).
Consistent with these critiques, Levenson (2004) reported
diagnostic reliability in a sample of 295 adult male sex
offenders (three quarters of the sample had committed sexual
offenses against minors) and found that the inter-rater
reliability for a diagnosis of pedophilia was only acceptable.

Wilson, Abracen, Picheca, Malcolm, and Prinzo (2003)
compared the Classification provided by different measures
of pedophilia—sexual history, strict application of DSM-IV
criteria, phallometric responding, and an expert’s
diagnosis—and found that scores on these measures were not
highly correlated in a sample of sex offenders against
children, suggesting each was identifying different groups of
pedophiles.
Though the criteria seem straightforward, the inter-rater

reliability of the diagnosis of pedophilia is constrained
1412
because of the subjective way in which information about
sexual interests is typically combined; in addition, this
information is usually inferred from behavior, because many
individuals are unwilling to admit to sexual thoughts,
fantasies, or urges regarding prepubescent children. Thus, one
of the
complications in reviewing the literature on pedophilia is the
fact that different assessment methods (and operational
definitions of pedophilia) have been used, and thus the groups
that have been studied are not equivalent.
An unpublished analysis of the data reported in Seto, Cantor,

and Blanchard (2006) found that self-reported sexual
interests, sexual history, and possession of child pornography
independently contributed to the prediction of phallometric
responding. These results suggest that the most accurate
Identification of pedophiles would come from using multiple
sources of information. Given the challenges in subjectively
combining different pieces of information, creating an
algorithm that incorporates various valid measures of
pedophilia—self-report, sexual history, and phallometric

responding—might be the best approach (Grove, Zald,
Lebow, Snitz, & Nelson, 2000; Ægisdóttir, Spengler, &
White, 2006).
Overall Evaluation
The above review suggests that assessments of paraphilia

(predominantly pedophilia) can be ranked according to their
level of empirical support and their practical utility. The
assessment approach that has the greatest amount of empirical
support in the literature is phallometry. The disadvantages of
1413
phallometry include the need for expensive equipment and its
intrusiveness. The assessment approach that uses official
offence history data has less empirical support, but the
support that is available is encouraging. Potential advantages
of the behavioral history over phallometry are that the
measure is not intrusive and it is not subject to faking by the
individual being assessed (unless they are able to falsify
official records).
Assessments based on viewing time are accumulating

empirical support in terms of their reliability and validity, but
seems to be weakened by the potential that the individual
being assessed will discover or discern the purpose of the
assessment and thereafter be able to fake their responses.
Finally, some self-report measures have adequate empirical
support regarding their reliability and validity, but suffer from
a lack of Confidence in forensic assessment due to the ease
with which the individual can fake their responses.
Further research should focus on developing reliable and

valid structured or semistructured interviews, gathering

further psychometric evaluations of self-report questionnaires
such as the SHQ-R and MSI, developing behavioral history
measures for paraphilias other than pedophilia, and further
phallometric research on paraphilias other than pedophilia
and sadism. More research is also needed on the assessment
of paraphilias among women, including female sex offenders.
Most of the research cited in this chapter has been drawn
from research on male samples. There have been case reports
of female sex offenders who clearly meet diagnostic criteria
for a paraphilia; for example, Chow and Choy (2002)
described the case of a female pedophile who admitted to
sexual fantasies about sex with prepubescent children and
1414
committed sexual offenses against two young children.
Wiegel, Abel, and Jordan (2003) analyzed questionnaire data
from a sample of 242 women who admitted to committing a
sexual offense. The majority (70%) had sexually offended
against a child, and the rest had engaged in obscene telephone
calls, or acts of bestiality, exhibitionism, or voyeurism.
Approximately a third of the women reported being sexually
aroused by male or female children, with slightly more
admitting to an interest in boys than in girls.
It remains to be seen if laboratory measures of paraphilic

sexual arousal can be developed for women, given recent
results reported by Chivers, Rieger, Latty, and Bailey (2004).
These investigators found that, unlike men, women could not
be accurately classified according to their sexual orientation
on the basis of their genital responses to sexual stimuli
depicting males or depicting females. Similarly, Gaither
(2005) found that, unlike men, women could not be
accurately classified according to their sexual orientation on
the basis of the time they spent looking at pictures of men and
women.
ASSESSMENT FOR CASE

CONCEPTUALIZATION AND
TREATMENT PLANNING
Once a paraphilia diagnosis has been made, clinicians will

need to assess other factors for the purposes of case
conceptualization and treatment planning. There is a widely
(though not universally) held assumption that paraphilias are
stable preferences, akin to sexual orientation, that cannot be
changed or that are highly unlikely to change (see Seto,
1415
2004). Thus, the focus of case conceptualization and
treatment planning is to assist the person in better managing
his or her paraphilia. Factors to be considered in case
conceptualization and treatment planning include (a)
antisocial tendencies; (b) denial or minimization of personal
responsibility for sexual offenses, when applicable; (c)
attitudes and beliefs that are supportive of sexual offending;
(d) sexual and general self-regulation skills; and (e) risk to
sexually reoffend among identified sex offenders. A brief
overview of these related assessment domains is provided
below.
Although an exhaustive review of measures in each domain is

far beyond the scope of this chapter, Table 22.2 summarizes
the psychometric properties of a selection of measures of
relevant domains. These measures include self-report
questionnaires assessing denial or minimization of responsibi
lity (Facets of Sex Offender Denial, FoSOD), attitudes and
beliefs tolerant of sexual offending (MSI, Abel and Becker
Cognitions Scale, Bumby MOLEST scale), phallometric
assessment of sexual arousal patterns, and measures of static

(PCL family, Static-99, and SSPI) or dynamic risk
(Stable-2000).
Validated measures of risk to reoffend are available for adult

male sex offenders (see Doren, 2002, and Hanson et al., 2003,
for reviews). There is some encouraging work on risk
instruments for adolescent sex offenders (e.g., Parks & Bard,
2006), but similar measures are not yet available for female
sex offenders or paraphilic individuals with no known history
of sexual offending.
1416
Antisocial Tendencies
Antisocial tendencies are important to assess because of their

robust association with criminal behavior across different
demographic groups; individuals who score higher on
measures of antisocial tendencies are more likely to offend,
whether based on self-report or official records (Lalumière,
Harris, Quinsey, & Rice, 2005; Quinsey, Book, & Skilling,
2004; Quinsey, Harris, Rice, & Cormier, 2006). Paraphilic
sex offenders who score higher in antisocial personality traits,
antisocial attitudes and beliefs, and associations with criminal
peers are more likely to offend again than those who do not
(Hanson & Morton-Bourgon, 2004, 2005).
Many reliable and valid measures of antisocial tendencies are

available, including measures of antisocial personality traits,
antisocial attitudes and beliefs, and associations with criminal
peers. Of particular relevance is psychopathy, a condition
characterized by a lack of empathy or conscience,
manipulativeness, deceitfulness, and impulsive and
irresponsible behavior. One of the Psychopathy Checklist

family of measures (PCL-R for offenders and forensic
patients, PCL-SV for nonoffenders and civil psychiatric
patients, and PCL-YV for adolescent offenders) can be rated
by a clinician on the basis of an interview and file
information, and psychopathy scores are robustly associated
with future criminal behavior, including violent or sexual
offending (Hare, 2003).
1417
Denial or Minimization of Personal
Responsibility for Sexual Offending
Among sex offenders, denial or minimization of

responsibility can be a problem in treatment planning because
an individual who denies committing the offense, or greatly
minimizes his responsibility for the offense, may not be able
to participate meaningfully in treatment designed to teach him
how to refrain from future offending by analyzing past
offenses and the sequences of events that lead up to them.
(This does not mean denial or minimization of personal
responsibility is a risk factor for recidivism, however, because
studies have not found such a relationship; see Hanson &
Bussière, 1998).
Measures of denial or minimization include scales of the MSI,

the Denial and Minimization Checklist (Barbaree, 1991) and
the Facets of Sex Offender Denial measure (FoSOD:
Schneider & Wright, 2001). These measures assess different
aspects of denial or minimization, which can include denial
that a sexual offense ever occurred (e.g., claiming there was

no sexual contact), denial of personal responsibility (e.g.,
claiming the victim initiated the sexual contact), and
minimization of different aspects of the sexual offense, such
as victim impact, planning, paraphilia as a motive, and
potential for reoffense. The FoSOD is a 65-item questionnaire
completed by offenders against children. Schneider and
Wright reported that the questionnaire was significantly
correlated with other measures of denial, and was also
significantly associated with treatment progress, in that sex
offenders in an advanced stage of treatment had lower scores
1418
than those in an early stage of treatment (Schneider & Wright,
2001; Wright & Schneider, 2004).
Attitudes and Beliefs Tolerant of Sexual

Offending
Cognitions are considered to be important because individuals

who espouse tolerant attitudes (e.g., that children can benefit
from sexual contacts with adults, that women secretly enjoy
being sexually dominated) may be more likely to commit
sexual offenses (Hanson & Harris, 2000). A variety of
measures of attitudes and beliefs about sexual offending are
available, but most have not been evaluated or have only been
evaluated in only one or two relatively small-scale studies.
Measures of attitudes and beliefs tolerant of sexual offending
with adequate empirical support are the Cognitive Distortion
and Immaturity scale and Justification scale of the MSI, the
Abel and Becker Cognitions Scale (Abel, Becker, &
Cunningham-Rathner, 1984), and the Bumby MOLEST scale
(Bumby, 1996). The MOLEST scale was adapted from the
Abel and Becker Cognitions Scale, has excellent internal

consistency and acceptable test–retest reliability, and was
only modestly correlated with a measure of social desirability.
Two studies have shown that the MOLEST scale can
distinguish sex offenders from children from groups of other
offenders or nonoffending men (Arkowitz & Vess, 2003;
Marshall, Marshall, Sachdev, & Kruger, 2003). However, a
companion measure, the RAPE scale, did not discriminate
rapists from other groups of men.

1419
Note: MSI = Multiphasic Sex Inventory; CDI = Cognitive
Distortion and Immaturity Scale; J = Justification Scale;
FoSOD = Facets of Sexual Offender Denial; PCL =
Psychopathy Checklist; SSPI = Screening Scale for
Pedophilic Interests; L = Less Than Adequate; A = Adequate;
G = Good; E = Excellent; U = Unavailable; NA = Not
Applicable.
Attitudes and beliefs tolerant of sexual offending can also be

assessed through a single three-point rating on the
Stable-2000, a dynamic measure of risk to reoffend developed
for adult male sex offenders as part of the Sex Offender Need
Assessment Rating (Hanson & Harris, 2000). Men who
reoffended during the follow-up period received a higher

rating on this item, indicating they endorsed many attitudes
and beliefs tolerant of sexual offending.
Sexual and General Self-Regulation
Difficulties with sexual and general self-regulation have been

identified as a risk factor for sexual offending by different
theorists (e.g., Bickley & Beech, 2002; Ward, Hudson, &
Keenan, 1998). The logic is that individuals who are less able
to control their sexual impulses are more likely to act upon
their paraphilia.
1420
The Stable-2000 includes an item pertaining to sexual self-
regulation deficits; sex offenders receive a higher rating if
they make statements or engage in behavior indicating they
have a high sex drive, feel entitled to sex, or they are
preoccupied with paraphilic thoughts or fantasies. Similarly,
the Stable-2000 contains an item pertaining to general self-
regulation deficits; sex offenders receive a higher rating if
they are not compliant with supervision or treatment
requirements, or engaging in other antisocial behavior.
Hanson and Harris (2000) found that men who violently or
sexually reoffended had a higher rating on these two items.
One could also measure general self-regulation through
measures of personality traits such as impulsivity, risk-taking,
and sensation seeking.
Assessment of Risk to Sexually Offend
For some paraphilic individuals, case conceptualization and

treatment planning will focus on risk for future sexual
offending. Risk is an important concern because the intensity
of interventions should match the risk posed by the

individual, with more expensive, higher-intensity
interventions reserved for higher-risk individuals (Andrews &
Bonta, 2006).
Static and Dynamic Risk
A distinction is made in sex offender risk assessments

between static and dynamic risk factors. Actuarial risk
instruments such as the Static-99 are comprised of static risk
factors, meaning the factors are historical and therefore
cannot change (e.g., prior criminal history, history of alcohol
1421
abuse) or they are highly stable and very unlikely to change,
if they can be Modified at all (e.g., having a diagnosis of
paraphilia, psychopathy). In contrast, dynamic risk factors
are, in principle, changeable (e.g., attitudes and beliefs
tolerant of sex with children) or temporally fluctuating (e.g.,
level of alcohol intoxication), and could therefore be targets
of intervention. Another example of a dynamic risk factor
would be access to potential victims (Hanson & Harris,
2000).
Paraphilia and Risk
Unfortunately, little is known about the risk posed by

individuals with a paraphilia but no history of sexual
offending involving some kind of contact with victims. A
relevant study was reported by Seto and Eke (2005), who
followed a sample of men convicted of child pornography
offenses to determine how many of these men would later
commit sexual offenses involving children. Seto, Cantor, and
Blanchard (2006) demonstrated that a majority of child
pornography offenders are likely to be pedophiles on the basis

of their phallometrically assessed sexual arousal. As predicted
by Seto and Eke, criminal history was a risk factor: child
pornography offenders
with a history of other kinds of offenses were significantly
more likely to commit a contact sexual offense. However, this
study was of individuals who had already come into contact
with the criminal justice system for possession or distribution
of child pornography. No published studies have examined
the risk posed by self-identified pedophiles, or individuals
who admit to other paraphilias, without any known history of
sexual offending.
1422
A paraphilia diagnosis is important to consider when
assessing sex offenders because of the evidence that
paraphilic sex offenders are at higher risk to reoffend than
nonparaphilic sex offenders (Hanson & Bussière, 1998;
Hanson & Morton-Bourgon, 2005). In particular, there is
strong and consistent data that pedophilia is associated with
risk to offend among sex offenders. Many diagnostic
indicators of pedophilia predict sexual recidivism, including
phallometrically assessed sexual arousal to children, having a
boy victim, and having unrelated victims. In fact, these
paraphilia-related variables are among the strongest predictors
of sexual recidivism studied so far (Hanson & Bussière, 1998;
Hanson & Morton-Bourgon, 2004).
Phallometric responding to depictions of children predicts

sexual offending against children in groups of sex offenders
other than those who have already victimized children.
Rabinowitz, Firestone, Bradford, and Greenberg (2002)
followed a sample of 221 men who had been criminally
charged and who met diagnostic criteria for exhibitionism.
None of these offenders were known to have committed a

contact sexual offense at the time they were assessed.
Nonetheless, among this group of exhibitionistic offenders,
phallometrically assessed sexual arousal to children
distinguished those who subsequently committed contact
sexual offenses from those who committed noncontact sexual
offenses again during the average follow-up of almost 7
years.
1423
Actuarial Risk Assessment
Perhaps the most significant advance in sex offender risk

during the past 20 years has been the development and
dissemination of actuarial instruments that can significantly
predict violent or sexual offending among adult male sexual
offenders (Doren, 2002; Hanson, 1998; Quinsey, Harris, Rice,
& Cormier, 2006). In a recent meta-analysis of sex offender
recidivism studies, Hanson and Morton-Bourgon (2004)
identified four commonly used actuarial instruments: the Sex
Offender Risk Appraisal Guide (SORAG; Quinsey, et al.,
2006), the Rapid Risk Assessment of Sexual Offense
Recidivism (RRASOR; Hanson, 1997), the Static-99 (Hanson
& Thornton, 1999), and the Minnesota Sex Offender
Screening Tool-Revised (MnSOST-R; Epperson et al., 1998).
These four risk instruments incorporate paraphilia-related

variables (e.g., the RRASOR, Static-99, MnSOST-R, and
SORAG all contain items regarding the age and gender of
sexual victims and the SORAG has an item pertaining to
phallometrically assessed sexual arousal). These instruments

are referred to as actuarial risk instruments because they
include a set of empirically identified risk factors that are
objectively scored and provide probabilistic estimates of risk
based on the established empirical relationships between the
individual items and the outcome of interest. Only items that
independently contribute to the prediction of recidivism, in
combination with the other instrument items, are retained.
Probabilistic estimates indicate the proportion of people with
the same score who reoffend during a specified period of
opportunity.
1424
Actuarial assessments of risk are well established in such
disparate areas of practice as determining insurance premiums
and predicting survival times for progressive stages of
cancers. In a similar vein, the SSPI is an actuarial measure for
determining the likelihood that a sex offender with child
victims will show a sexual preference for children over adults
when assessed phallometrically (and, serendipitously, the
SSPI is a significant predictor of recidivism among adult male
sex offenders with child victims; Seto et al., 2004).
Because the sex offender risk assessment literature has grown

so large over the past 15 years, we focus on one actuarial
instrument, the Static-99, in Table 22.2. We chose the
Static-99 because it is relatively easy to score given adequate
records, its predictive validity has been independently
replicated numerous times, and it has the largest number of
peer-reviewed studies supporting it among the most common
actuarial instruments (see Hanson, Morton, & Harris, 2003).
The Static-99 was developed for adult males who are known
to have committed at least one sexual offense, and was
designed to predict violent or specifically sexual recidivism.

Clinicians or other professionals rate 10 items, each of which
was selected to independently contribute to the prediction of
new offenses. Individual scores range from 0 to 12, and sex
offenders are assigned to
one of seven risk categories based on their score (individuals
with scores of six or more are combined into one group
because of the small frequencies of offenders with such
scores in the development sample). Static-99 scores
consistently produce accurate predictions regarding future
sexual offending (e.g., Barbaree, Seto, Langton, & Peacock,
2001).
1425
Overall Evaluation
Measures of additional domains other than paraphilias

become more salient when assessment of paraphilias
addresses case conceptualization and treatment planning. In
this section, we identified antisocial personality traits and
other antisocial tendencies, denial or minimization of personal
responsibility for sexual offending, attitudes and beliefs
tolerant of sexual offending, sexual and general self-
regulation, and assessments of risk to violently or sexually
reoffend as important to assess when there is concern about
someone engaging in paraphilic behavior that is illegal (e.g.,
having sexual contacts with children, sexual assaults of
nonconsenting persons).
ASSESSMENT FOR TREATMENT

MONITORING AND TREATMENT
OUTCOME EVALUATION
As we noted in the previous section, there is a widely held

assumption among clinical sexologists and forensic

practitioners that paraphilias cannot be changed. Thus, the
focus of treatment and other interventions is to assist the
individual in managing their paraphilic sexual interests, to
reduce personal distress, improve relationship and other
functioning, and refrain from engaging in illegal sexual
behavior.
In cases where the paraphilia is particularly strong,

distressing, or likely to place the person at risk of engaging in
criminal behavior (e.g., frequent and intense sadistic fantasies
that the person feels he cannot control), anti-androgen
1426
medications such as cyproterone acetate may be prescribed to
reduce sex drive (for reviews, see Gijs & Gooren, 1996; Seto,
2008). Changes in sex drive can be assessed through self-
report and by interviewing others, whereas changes in sexual
responsivity can be assessed using phallometry.
In other cases, it may be possible to teach individuals how to

change their attitudes and beliefs about sexual offending, gain
voluntary control over their sexual arousal, and regulate their
sexual behavior, and thereby refrain from engaging in
problematic paraphilic behavior. Thus, measures of attitudes
and beliefs tolerant of sexual offending, sexual arousal
patterns, and sexual and general self-regulation, and antisocial
tendencies can be valuable in monitoring treatment change
and evaluating treatment outcome. All of these domains are
relevant for both nonforensic and forensic assessments,
though not all of these measures have been evaluated for
nonforensic clients. Among sex offenders, denial or
minimization of personal responsibility for their sexual
offenses may interfere with treatment compliance, and thus
may be an initial treatment target.
Table 22.3 summarizes the psychometric properties of

measures that may be sensitive to treatment change. These
include self-report measures of attitudes and beliefs tolerant
of sexual offending (all but one already mentioned in Table
22.2), clinician rating scales of changes on dynamic risk
factors (SOTRS and Stable-2000), and phallometric
assessment of changes in sexual arousal patterns.
1427
Attitudes and Beliefs Tolerant of Sexual
Offending
A number of studies have shown that some MSI scales can

distinguish sex offenders who admit responsibility for their
crimes from those who deny responsibility, and sex offenders
who complete treatment from those who do not (Simkins et
al., 1989; Waysliw, Haywood, Grossman, Johnson, & Liles,
1992). Simkins et al., for example, reported that MSI scales
could explain between 30% and 47% of treatment response.
Marques, Wiederanders, Day, Nelson, and van Ommeren
(2005) reported that sex offenders who completed treatment
had lower scores on MSI items pertaining to attitudes and
beliefs about sexual offending (Cognitive Distortions and
Immaturity scale).
Hanson and Harris (2000) compared the records of 208 sex

offenders who committed another violent or sexual offense
while under community supervision and 201 sex offenders
who did not violently or sexually reoffend. Those who
reoffended were distinguished by more expressions of

antisocial attitudes and association with criminal peers,
intimacy deficits, endorsement of attitudes and beliefs tolerant
of sexual offending, and problems with sexual and general
self-regulation.

1428
Note: MSI = Multiphasic Sex Inventory; CDI = Cognitive
Distortion and Immaturity Scale; J Scale = Justification Scale;
SO Scale = Sexual Obsession Scale; FoSOD = Facets of
Sexual Offender Denial; SOTRS = Sex Offender Treatment
Rating Scale; A = Adequate; G = Good; E = Excellent; NA =
Not Applicable; U = Unavailable.
Changes in Sexual Arousal
In the behavioral treatment of paraphilias, aversion techniques

are used to suppress sexual arousal to atypical targets or
activities, whereas masturbatory reconditioning techniques
are used to increase sexual arousal to sexual activities
involving consenting adults. Treatment progress is monitored
through self-report and phallometry. In aversive conditioning

procedures, unpleasant stimuli such as mild electric shock or
ammonia are paired with repeated presentations of sexual
stimuli depicting children. Aversive conditioning techniques
were used as early as the 1950s and 1960s for the treatment of
paraphilias such as fetishism and transvestic fetishism (e.g.,
Marks & Gelder, 1967; Raymond, 1956). The efficacy of
behavioral approaches for changing sexual arousal patterns
has been reviewed in detail by Barbaree, Bogaert, and Seto
(1995) and Barbaree and Seto (1997). In sum, the research
suggests that behavioral techniques can have an effect on
sexual arousal patterns, as assessed by phallometry, but it is
1429
unclear how long these changes are maintained and whether
they result in actual changes in interests, as opposed to greater
voluntary control over paraphilic sexual arousal (e.g.,
Lalumière & Earls, 1992).
Sexual Self-Regulation
Hanson and Harris (2000) found that sex offenders who

committed a violent or sexual reoffense while under
community supervision differed from those who did not
violently or sexually reoffend by being more likely to view
themselves as having a strong sex drive, entitled to sex, and
likely to become frustrated or feel deprived if they were not
able to satisfy their sexual urges. Similarly, Craig et al. (2006)
found that the Sexual Obsessions scale of the MSI
distinguished sex offenders who reoffended from those who
did not.
Relapse prevention is currently a popular approach for

teaching individuals how to regulate their sexual behavior.
This approach is cognitive-behavioral in orientation and is

adapted from the addictions field (Marlatt & Gordon, 1985).
It is currently the most common psychological treatment
provided to adult sex offenders (McGrath et al., 2003). The
relapse prevention strategy involves (a) identifying situations
in which the individual is at high risk for relapse; (b)
identifying lapses, that is, behaviors that do not constitute
full-fledged relapses but do constitute approximations to the
problem behavior; (c) developing strategies for avoiding
high-risk situations; and (d) developing coping strategies
which are used in high-risk situations that cannot be avoided
and in responding to lapses that do occur. As applied to
1430
paraphilias, lapses could include masturbating to paraphilic
sexual fantasies, viewing pornography depicting paraphilic
content, or engaging in paraphilic activity once, whereas
relapses would be a full return to paraphilic activity. High-
risk situations could include stressful situations in which
paraphilic thoughts and fantasies are more likely to occur as a
means of coping.
Whether sex offender treatment is effective in reducing

recidivism is hotly debated (e.g., Hanson et al., 2002; Rice &
Harris, 2003). Several studies have examined the relationship
between treatment performance and outcomes among sex
offenders participating in programs espousing cognitive-
behavioral and relapse prevention principles. Marques et al.
(2005) conducted the largest and most relevant randomized
clinical trial comparing the reoffense rates of offenders
treated in an inpatient relapse prevention program with the
rates of untreated control groups. No significant differences
were found in their rates of sexual or violent reoffending over
an 8-year follow-up period. However, post hoc analyses
suggested that high-risk sex offenders against children who

met the treatment goals were less likely to reoffend than high-
risk sex offenders who did not meet these goals (10% vs.
50%).
Marques et al. (2005) assessed treatment goals using multiple

measures: (a) scores on questionnaire scales pertaining to
attitudes and beliefs about sexual offending; (b) changes in
phallometrically assessed sexual arousal to children or to
coercive sex; and (c) ratings of written homework exercises
regarding the offender’s understanding of the costs and
benefits of offending versus abstaining, the sequence of
cognitions and behaviors that preceded their sexual offenses,
1431
and the strategies they could use to intervene in this offense
sequence. However, two additional studies of sex offenders
participating in cognitive-behavioral treatment programs did
not find a significant and positive relationship between ratings
of relapse prevention knowledge and skills (in addition to
other treatment goals) and recidivism (Barbaree, 2005;
Looman, Abracen, Serin, & Marquis, 2005; see also Seto,
2003).
General Self-Regulation and Antisocial

Tendencies
There is good evidence that certain kinds of cognitive-

behavioral treatments are effective in reducing reoffending
among offenders in general (see Andrews & Bonta, 2006).
These treatments are matched to offenders according to their
risk to reoffend and focus on dynamic risk factors, including
self-regulation in areas such as anger management, problem-
solving, and substance use. Thus, treatments that strengthen
self-regulation skills and reduce exposure to disinhibiting
influences such as alcohol or other drugs might be very

helpful in assisting paraphilic sex offenders from sexually
reoffending, and assisting paraphilic individuals from
engaging in illegal sexual behavior.
Assessing Treatment Outcome
Research on treatment outcome for individuals with

paraphilias and for paraphilic sex offenders would be boosted
by the development of psychometrically sound measures of
treatment change. Specific measures for paraphilias are not
available, other than self-reported changes in paraphilic
1432
thoughts, fantasies, urges, or behavior, and self-reported and
phallometrically assessed changes in sexual arousal. Among
sex offenders, treatment change has been assessed using
specific measures of relapse prevention knowledge and skills,
such as the Relapse Prevention Knowledge Questionnaire
(Beckett, Fisher, Mann, & Thornton, 1997) and Sex Offender
Treatment Rating Scale (SOTRS: Anderson, Gibeau, &
D’Amora, 1995), and using general measures of treatment
change adapted for this purpose, such as Goal Attainment
Scaling (Barrett, Wilson, & Long, 2003; Stirpe, Wilson, &
Long, 2001).
As an example of a measure developed for sex offenders,

Anderson et al. (1995) developed the 54-item SOTRS as a
therapist-rated measure of six aspects of treatment
performance: (1) insight into their offending in terms of
motives and underlying attitudes and beliefs; (2) atypical
sexual fantasies and urges; (3) awareness of situational risk
factors; (4) motivation for personal change through treatment;
(5) empathy for sexual victims; and (6) disclosure of
offending patterns and details. In a sample of 122 adult male

sex offenders, Anderson et al. reported the SOTRS had
excellent internal consistencies, and good inter-rater
reliability and test–retest reliability. Levenson and Macgowan
(2004) found that SOTRS ratings were significantly and
inversely correlated with offender denial of responsibility for
his offenses, and positively correlated with a measure of
group therapy engagement in a sample of 61 offenders against
children. Ricci, Clayton, and Shapiro (2006) found the
SOTRS could detect significant changes over the course of
treatment in a small group of 10 offenders against children;
moreover, changes on the scales assessing atypical sexual
fantasies, motivation for change, and victim empathy were
1433
positively correlated with changes on phallometrically
assessed sexual arousal.
As an example of a general measure adapted for use with sex

offenders, Barrett et al. (2003) used Goal Attainment Scaling
to assess the following aspects of motivation to change in a
sample of 101 sex offenders: acceptance of guilt for the
offense, acceptance of personal responsibility for the offense,
disclosure of personal information, motivation to change
behavior, and participation in treatment. Motivation to change
significantly increased from an intake assessment and
following institutional treatment, but then decreased upon
release to the community and did not recover following 12
weeks of treatment in the community. Stirpe et al. (2001)
monitored treatment progress using GAS scores. Offenders
were classified as low, moderate, or high in risk for
recidivism. Low- and moderate-risk offenders received better
GAS scores, and only low- and moderate-risk offenders
showed a steady improvement in ratings of relapse prevention
targets and motivation to change from pretreatment to release
to the community.
Demonstrating that treatment can have an impact on these

targets does not mean that the treatment is effective in
reducing sexual offending, which is the ultimate goal of
treatments for (paraphilic) sex offenders or paraphilic
individuals who are considered to be at great risk of acting
upon their interests and thereby committing sexual crimes.
Thus, assessment of treatment outcome should ideally include
the recording of new offenses, which can be obtained through
self-report and through official records of new arrests,
charges, and convictions.
1434
Overall Evaluation
Some of the paraphilia measures identified in the diagnosis

section are also useful in the assessment of treatment change
and outcome. Focusing on the
paraphilia, changes in the frequency or intensity of paraphilic
thoughts, fantasies, urges, arousal, and behavior can be
assessed through self-report, either by interview or through
questionnaires. When appropriate, treatment change can be
corroborated by interviewing others (e.g., the client’s sexual
partner) and objective assessment of sexual arousal patterns
using phallometry.
For some paraphilic individuals, assessment of treatment

change and outcome should also focus on potentially
changeable factors associated with risk to offend (dynamic
risk factors) if the paraphilia is acted upon. These dynamic
risk factors include attitudes and beliefs tolerant of sexual
offending, sexual and general self-regulation, and general
antisocial tendencies such as antisocial attitudes and beliefs
and association with criminal peers. Paraphilias of particular

concern are pedophilia and sadism because they are
associated with sexual offenses against children and violent
sexual offenses, respectively, but frotteurism, exhibitionism,
and voyeurism are also of concern. Other paraphilias—though
distressing to the client or disruptive to his or her
relationships and other functioning—are unlikely to involve
criminal behavior if acted upon.
1435
OVERALL SUMMARY AND
FINAL COMMENTS
As demonstrated in this review, a number of reliable and

valid measures are available for the diagnosis of paraphilias,
but more research is needed. No standardized semistructured
or structured interview formats for assessing specific
paraphilias have been developed and validated, and interview
questions and questionnaire items are mostly face valid and
therefore vulnerable to socially desirable responding.
Questionnaires such as the MSI or SHQ-R contain validity
scales, but more studies are needed on the ability of these
validity scales to detect socially desirable or exaggerated
responding. In addition, the majority of measures that have
been developed focus on paraphilias that result in criminal
conduct if acted upon, particularly pedophilia and sadism, and
to a lesser extent exhibitionism and voyeurism. More work is
needed on self-report measures of other paraphilias,
particularly those that are not usually associated with criminal
conduct.
As we have already mentioned, it would be very beneficial to

develop behavioral history measures similar to the SSPI, but
designed to assess other paraphilias. Development of these
measures will require a better understanding of the behavioral
correlates of these other paraphilias, just as research on sexual
offending against children has identified having boy victims,
multiple victims, younger victims, and unrelated victims as
being associated with pedophilia. Of particular interest would
be behavioral correlates among nonoffending individuals with
paraphilias. There is a great deal of support for the use of
phallometry in the assessment of paraphilias. However, more
1436
research is needed to develop valid stimulus sets for
paraphilias other than pedophilia and biastophilia (a sexual
preference for rape), as only a limited number of studies have
examined exhibitionism, transvestism, and fetishism. Finally,
more work is needed on the development of reliable and valid
assessment methods—self-report, behavioral history, and
behavioral testing—for women, and age-appropriate measures
for adolescents.
Nonforensic evaluators are likely to rely on self-report for

assessment of paraphilias, but can benefit from objective
measures when they are available. The Association for the
Treatment of Sexual Abusers, a large international
organization of professionals who assess and treat sex
offenders, maintains a membership directory and can identify
laboratories that use viewing time or phallometry to assess
sexual interests (see www.atsa.com). Some of these
laboratories accept referrals of nonoffending individuals who
may have paraphilias. Training is required to conduct such
assessments in a reliable and valid fashion. Forensic
evaluators will use both self-report and objective methods,

and will also be able to draw upon information they obtain
regarding sexual offense histories.
Measures that do not rely on self-report but are less intrusive

than genital assessment—including viewing time, adaptations
of other cognitive science paradigms such as choice reaction
time, evoked potential recordings, and brain imaging—would
be particularly useful for both clinical and research purposes.
Research on paraphilias would also benefit from the
development of scales suitable for large-scale epidemiological
surveys, in order to address fundamental questions about
1437
paraphilias with regard to prevalence, biographic correlates,
and developmental course.
Some of the assessment measures used in the diagnosis of

paraphilias are suitable for case conceptualization, treatment
planning, and monitoring of treatment change and outcome,
particularly certain MSI scales and phallometry. Because
there is no
evidence that paraphilic sexual interests can be altered,
treatment planning and monitoring focuses on related factors
that are believed to be associated with the likelihood of
paraphilic sexual behavior, though changes in the frequency
and intensity of paraphilic thoughts, fantasies, urges, arousal,
and behavior should also be assessed. Some of the related
factors are relevant for both nonforensic and forensic
evaluations, such as antisocial tendencies, attitudes and
beliefs tolerant of sexual offending, and sexual self-regulation
problems. Factors associated with risk to reoffend—as
represented in items of actuarial risk scales such as the
Static-99—are particularly germane for men who are already
known to have committed sexual offenses.
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A Guide To Assessments That Work - (Part VII Couple Distress and Sexual Problems)

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Part VII

Couple Distress and Sexual

Assessment of couple distress shares basic principles of

linked within a theoretical or conceptual framework of the

We begin this chapter by defining couple distress and noting

couple distress and directions for future research.

Defining Couple Distress

The fourth edition of the Diagnostic and Statistical Manual of

What are the limitations to this conceptualization of partner

indicates that some forms of “negative” communication

relationship. The most positive features of the DSM’s

Prevalence and Comorbid Conditions

Clinical interventions targeting couple distress continue to

Couple distress is prevalent in both community

multiple social stressors experienced by lesbian, gay, and

In a previous national survey, the most frequently cited causes

Data from the National Comorbidity Survey indicated that, in

contribute to physical health problems (Kiecolt-Glaser &

In brief, couple distress has a markedly high prevalence, has a

Etiological Considerations and

Both the aforementioned comorbidity findings and clinical

operating at five system levels (individuals, dyads, the nuclear

The relevance of any Specific facet of this model to

ASSESSMENT FOR DIAGNOSIS

A diagnosis of couple distress is based on the subjective

partners may report being satisfied with a relationship

TABLE 20.1 Sample Assessment Constructs Across Domains

TABLE 20.2 Ratings of Instruments Used for Screening and

Note: SDI-MD-PA = Structured Diagnostic Interview for

Relatively short measures of overall relationship satisfaction

Adjustment Scale (DAS; Spanier, 1976), a 32-item instrument

Despite its widespread use, a review of psycho-metric

Because partners frequently present for treatment together,

needed to assess behavior, can facilitate formal or informal

When a couple presents for therapy with primary complaints

disturbance, or emergency room personnel confronting

1. Clinical inquiry as to whether relationship problems

3. For individuals reporting moderate to high levels of global

When screening for either clinical or research purposes, we

whenever possible—and subsequent use of more extensive

Conceptualizing couple distress for the purpose of planning

Domains to Target When Evaluating

Research examining behavioral components of couple distress

Given the inevitability of disagreements arising in long-term

were more likely than nondistressed couples to demonstrate a

Given findings regarding the prominence of negativity,

1. How frequent and intense are the couple’s conflicts? How

2. What are common sources of relationship conflict? For

example, interactions regarding finances, children, sexual

behaviors expressing understanding and caring—although

TABLE 20.3 Ratings of Instruments Used for Case

Affective Rating System; SPAFF = Specific Affect Coding

Social learning models of couple distress have expanded to

or ability to change their behavior in some desired manner

1. Do partners demonstrate an ability to accurately observe

2. What interpretation or meaning do partners impart to

3. What beliefs and expectancies do partners hold regarding

Similar to findings regarding behavior exchange, research

1. To what extent do partners express and reciprocate

and coded (either formally or informally) using one of the

2. What ability does each partner have to express his or her

3. To what extent does partners’ negative affect generalize

perceptions, partners used an affect-rating dial to indicate