J Head Trauma Rehabil

Vol. 28, No. 3, pp. 164–170

Copyright c 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins

Assessment of Sexuality Following

Traumatic Brain Injury: Validation of
the Brain Injury Questionnaire of
Sexuality
Renerus J. Stolwyk, DPsych; Marina G. Downing, PhD; John Taffe, PhD;
Jeffrey S. Kreutzer, PhD; Nathan D. Zasler, PhD; Jennie L. Ponsford, PhD

Background: The importance of effectively identifying and managing sexuality issues following acquired brain
injury is being increasingly recognized within clinical and research domains. However, a tool specifically developed
to measure sexuality following brain injury is yet to be validated. Objectives: In this study, the reliability and
validity of the Brain Injury Questionnaire of Sexuality (BIQS) was evaluated. Method: Eight hundred and sixty-five
people who had sustained traumatic brain injury participated in this study. All participants completed the BIQS,
and a subsample also completed the Derogatis Interview for Sexual Functioning—Self-Report version (DISF-SR).
Results: Exploratory factor analysis supported a 3-subscale structure of the BIQS, which aligns with contemporary
conceptual models of sexuality in chronic disease. All subscales of the BIQS demonstrated very good internal
consistency. Convergent and divergent validity of all BIQS subscales was also demonstrated. Conclusions: Results
from the study support the reliability and validity of the BIQS, which shows promise as a measurement tool for
future traumatic brain injury sexuality research. Further validation work including evaluation for potential clinical
applications is encouraged. Key words: assessment, reliability, sexual function, sexual well-being, sexuality, traumatic brain
injury, validity

T RAUMATIC BRAIN INJURY (TBI) is a leading

cause of disability in young people.1 A multitude
of motor, sensory, cognitive, emotional, and behavioral
functions may be impaired following TBI. These im-
pairments can compromise engagement in meaningful
activities and participation in important life roles many
years postinjury.2 Sexuality is an important part of hu-
Author Affiliations: School of Psychology and Psychiatry, Monash
University (Drs Stolwyk, Downing, Taffe, and Ponsford),
Monash-Epworth Rehabilitation Research Centre (Drs Downing and
Ponsford), and National Trauma Research Institute (Dr Ponsford),
Melbourne, Victoria, Australia; and Virginia Commonwealth University
Medical Center (Dr Kreutzer), Concussion Care Centre of Virginia, Ltd
(Dr Zasler), Tree of Life Services, Inc (Dr Zasler), and Department of
Physical Medicine and Rehabilitation, Virginia Commonwealth
University (Dr Zasler), Richmond, Virginia.
This project was funded by the Transport Accident Commission through the
Institute for Safety, Compensation and Recovery Research.
The authors thank all participants involved in this project who generously gave
their time.
The authors declare no conflicts of interest.
Corresponding Author: Renerus J. Stolwyk, DPsych, School of Psychology
and Psychiatry, Monash University, Bldg 17, Clayton Campus, Melbourne,
Victoria, Australia 3800 (rene.stolwyk@monash.edu).
DOI: 10.1097/HTR.0b013e31828197d1
man life and is a significant determinant of relationship
health and quality of life.3 It is understood that healthy
sexual function is mediated by a range of physical and
psychological factors, many of which are compromised
following TBI. However, despite these facts, little re-
search has been conducted investigating how TBI im-
pacts sexuality and how this restricts participation in the
role of a spouse/partner.4
A universally agreed conceptualization of sexual-
ity does not currently exist within the literature,
which presents as a challenge for both researchers and
clinicians.5 However, it is generally accepted that sexual-
ity is a complex and multidimensional construct involv-
ing a range of biological, psychological, relational, and
sociocultural factors.6 An integrated conceptual frame-
work of sexuality within chronic disease was recently
developed by Verschuren and colleagues.7 Within this
model, 2 core aspects of sexuality are described: sexual
functioning, referring to physiological aspects of sex-
ual performance (eg, sexual arousal, orgasm); and sexual
well-being, referring to a person’s subjective experience
of sexuality (eg, satisfaction, perceived sexual appeal).
Key factors, including physical/psychological symptoms
and treatment effects, whereby disease compromises

164

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

sexuality are also described. This framework is poten-
tially helpful to both clinicians and researchers in con-
ceptualizing and studying sexuality following TBI.
Disinhibited sexual behavior following TBI has re-
ceived significant attention within research literature,
particularly within the context of challenging behav-
ior. However, more comprehensive studies of sexuality
following TBI have highlighted reduced frequency and
quality of sexual activity as the predominant complaints
by patients and their partners.8,9 A number of sexual
functions, including sexual drive, arousal, and ability
to orgasm, are reportedly compromised in 30% to 50%
of TBI survivors.10–15 Furthermore, reduced sexual well-
being has been reported, including dissatisfaction with
sexual experience, reduced perceived sexual appeal, and
poor sexual communication with partners.11–13 How-
ever, as noted in a review by Sandel and colleagues,16
our understanding of the specific sexual impairments
associated with TBI and potential physical, psychologi-
cal, and sociocultural contributors to these impairments
remains limited.
Previous research examining sexuality following TBI
has been limited by numerous methodological prob-
lems. One of the most pertinent of these is the lack
of a validated tool to measure sexuality following TBI.
Some previous studies have used established sexuality
measures such as the Golombok Rust Inventory of Sex-
ual Satisfaction,12,17,18 Personal Assessment of Intimacy
in Relationships Scale,19,20 and Derogatis Interview for
Sexual Functioning—Self Report version (DISF-SR)15,21
to measure sexual function following TBI. However,
there are disadvantages associated with use of these es-
tablished measures. First, item content relating to sexual
function and well-being was not derived from TBI sur-
vivors, limiting content validity within the TBI popu-
lation. Second, in addition to comparison with healthy
controls, comparison of current function with prein-
jury function is of major interest within TBI research.
The format of the aforementioned measures does not al-
low this preinjury comparison. Third, most established
measures were originally designed for healthy people in
established relationships. Thus, they do not easily ac-
commodate those people who are single or in casual
relationships, which is the case for many TBI survivors.
Finally, because of the explicit nature of some measures,
such as the DISF-SR, response compliance can be an is-
sue.
Other previous studies have developed measures
specifically for persons with brain injury. Kreutzer
and Zasler11 developed the Psychosexual Assessment
Questionnaire (PAQ) specifically for male patients with
TBI. The content of this scale was based on TBI patient
interviews and sexual function questionnaires used in
other populations. Items were grouped into 3 sections
(Sexual Behaviour, Affect and Self-Esteem, and Rela-
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Assessment of Sexuality Following TBI 165
tionship Characteristics). Kreuter et al10 developed the
Sexual Adjustment Questionnaire (SAQ), as well as a
Sexual Interest and Satisfaction (SIS) scale, where items
were adapted from a spinal cord injury questionnaire.
More recently, Ponsford13 adapted the PAQ, SAQ, and
the SIS scale to create the Sexuality Questionnaire (SQ).
The original PAQ sections were retained; however, items
were added and language was modified to accommodate
both males and females. Ponsford13 also added separate
questions about sexual relationships, current and before
injury, and reasons why sexual changes may have oc-
curred since the injury. The SQ has the advantage that
content was developed specifically for a TBI popula-
tion and allows comparison of sexuality pre/post TBI.
It accommodates both males and females in addition
to people who are not necessarily in long-term relation-
ships. However, unfortunately, little scale-development
work has been conducted on the SQ and limited psy-
chometric information is available.
On the basis of research discussed earlier, TBI and
its associated consequences appear to compromise as-
pects of sexuality in a significant proportion of survivors.
However, previous studies have used a number of differ-
ent tools to measure sexuality, none of which have been
validated for use within the TBI population. This limits
the reliability and validity of research findings and can
hinder future research within this field. This study forms
the basis of a broader research program longitudinally
investigating the prevalence, causes, and consequences
of reduced sexuality following TBI. However, as a first
step, the primary aim of this study was to validate a
measure of sexual function and well-being in people
with TBI to justify its use. More specifically, we aimed
to establish the factor structure of the SQ. We also ex-
amined internal consistency and convergent validity of
this measure within the TBI population.
METHODS
Participants
A total of 865 participants were recruited for this study
from 2311 consecutive admissions to a TBI rehabilita-
tion program in the context of a no-fault accident com-
pensation system. All patients treated in this program are
routinely invited to attend a follow-up clinic at 1, 2, 3,
5, 10, and 20 years postinjury. Thus, the sample used in
this study was not biased toward participants seeking on-
going assistance. Demographic and injury information
for participating and nonparticipating TBI survivors
who attended follow-up is presented in Table 1.
With regard to the participating group, as expected
within TBI research, the sample comprised more males
than females. Severity of TBI was measured by length of
posttraumatic amnesia, according to criteria established
by Jennett and Teasdale22 (see Table 1). Severity of
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166 JOURNAL OF HEAD TRAUMA REHABILITATION/MAY–JUNE 2013

TABLE 1 A comparison of demographic forms for each partner. Thus, single participants were
not required to complete it.
and injury information between TBI
survivors who participated in this study
and those who did not Sexuality Questionnaire
As noted earlier, the SQ13 was developed by Pons-
Study Non-
participants participants
ford in 2003 and was adapted from the PAQ,11 the
(N = 865) (N = 1157) SAQ,10 and the SIS scale.10 The SQ requires respon-
dents to compare postinjury aspects of their sexuality
Age at injury,a mean 31.2 (12.6) 34.6 (17.1) (eg, sex drive, sex appeal, communication with sexual
(SD)
Sex, % sample partner) with their preinjury status on a 5-point Lik-
Male 70.3 70.8 ert scale (1 = greatly decreased, 5 = greatly increased).
Female 29.7 29.2 Items, except 12 (level of depression) and 13 (preoc-
Length of PTA, mean 27.6 (30.6) 26.2 (42.5) cupation with problems), are positively expressed; so
(SD), d these 2 are reverse scored so that higher scores on
TBI severity, % sample
Mild (PTA < 24 h) 3.2 5.4 all items represent improvement. The original section
Moderate (PTA 1-7 d) 24.1 27.6 headings of the PAQ (Sexual Behaviour, Affect and
Severe (PTA 8-28 d) 40.3 35.8 Self-Esteem, Relationship Characteristics) were retained
Very severe (PTA 32.3 31.3 within the SQ. Separate questions about sexual rela-
> 28 d) tionships, current and before injury, and reasons why
Within established
relationship, % sexual changes may have occurred since the injury
sample are also included. See original version of the SQ in
Yes 32.4 36.0 Appendix 1.
No 67.6 64.0
Years postinjury,a %
sample Derogatis Interview for Sexual Functioning—Self-Report
1 47.9 46.2 Version
2 15.6 26.9
3 9.5 16.0 This is a 25-item self-report questionnaire that pur-
5 9.6 8.0 ports to measure level of sexual activity and overall qual-
10 15.4 2.9 ity of sexual functioning during the past 30 days. Five
20 2.1 0.1
domains are included: sexual cognition/fantasy, sexual
arousal, sexual behavior/experience, orgasm, and sexual
Abbreviations: d, days; PTA, posttraumatic amnesia; TBI, trau- drive/relationship, with distinct sex-keyed versions.23
matic brain injury. Most scales of the DISF-SR relate to sexual function-
a P ≤ .05.
ing, with the exception of the drive/relationships do-
injury ranged from mild to severe; however, the major- main. Norms are based on several hundred community-
ity of the sample sustained severe TBI. Approximately based nonpatient respondents, and favorable psycho-
one-third of participants reported being either married metric properties have been reported in various medical
or in a relationship. populations.21
A between-groups comparison found that the 865
TBI patients who completed the SQ were significantly Procedure
younger at injury (t(2019) = 5.23, P < .001) and were more
years postinjury (χ 2 (1, 2022) = 161.60, P < .001) than the Ethical approval for this study was obtained from
1157 who did not participate. However, there was no the Epworth Hospital human research ethics commit-
difference in sex (χ 2 (1, 2022) = 0.06, P > .05), length of tee. All patients attending their follow-up appointment
posttraumatic amnesia (t(1996) = −0.81, P > .05), or rela- were invited to participate in this study, and a full writ-
tionship status (χ 2 (1, 1988) = 2.79, P > .05) between the ten explanation of the research was provided. The ethics
groups (see Table 1). committee required the questionnaires to be presented
in a sealed envelope with a warning that the contents
might be offensive. Those who agreed to participate in
Measures
the study signed a consent form. Participants were then
All participants completed the SQ. Participants who invited to complete the SQ. Those who were married or
reported being married or in a relationship were also within a relationship were also invited to complete the
invited to complete the DISF-SR. The DISF-SR was de- DISF-SR. Demographic and injury information was ob-
veloped for use with couples and comprises 2 separate tained from interview with patients and medical records.

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Assessment of Sexuality Following TBI 167

RESULTS Injury Questionnaire of Sexuality (BIQS) to highlight

the scale’s specific measurement of sexuality following
Factor structure
brain injury. The BIQS is included in Appendix 2.
The factor analysis was based on responses to
15 Likert scale scored items from the SQ provided by
the 635 TBI patients who completed them all. For these Item completion
data, the Kaiser-Meyer-Olkin measure of sampling ade-
quacy was high at 0.92 and the Bartlett’s test of sphericity As noted earlier, of the 865 TBI survivors who par-
significant (P < .001). The SQ has 15 items, so 2-, 3-, ticipated in this research, only 635 responded to every
and 4-factor solutions were investigated. In each of these, item of the BIQS. In light of these completion rates,
the 2 reverse-scored items (12 and 13) formed a separate item-by-item counts of missing data were calculated to
factor, leaving the first factor in the 2-factor solution investigate whether nonresponse was an issue for spe-
too diffuse and inducing another 2-item factor in the cific items. Completion rates for almost all the BIQS
4-factor solution, which was not ideal; so we decided items were between 90% and 95%. The only exceptions
on the 3-factor solution (see Table 2) arrived at by prin- were items 4, 10, and 13, where completion rates re-
cipal factoring with an oblique promax rotation. Item duced to 82% to 86%. These items differ from the rest
factor loading cut-off was set at 0.4. No items loaded of the BIQS items in that they relate to interaction with
on more than one factor using this criterion. On initial a partner.
extraction, the 3 factors explained 65.3% of the variance
and communalities after extraction averaged 0.65 with a
standard deviation of 0.10. Internal consistency
Factor 1 is associated with a range of sexual functions Internal consistency was evaluated by calculating
and behaviors (frequency, drive, importance, partner Cronbach’s α for the total BIQS score and the 3 BIQS
satisfaction, engagement, enjoyment, arousal, climax) subscales. Cronbach’s α for the total BIQS score was
and has been labeled “sexual functioning.” Factor 2 is 0.92. The value of α was 0.94 for the Sexual Functioning
associated with sexual well-being and partner relation- scale, 0.86 for the Relationship Quality and Self-Esteem
ships (opportunity for sex, self-confidence, sex appeal, scale, and 0.81 for the Mood scale.
communication with partner, relationship quality) and
has been labeled “relationship quality and self-esteem.”
Factor 3 is associated with feelings of depression
Convergent validity
and worry in a sexual context (preoccupation with
problems, depression) and has been labeled “mood.” To investigate convergent validity, we investigated
On the basis of these results, items from the original whether the BIQS significantly correlated with another
SQ have been organized into Sexual Functioning, established scale purporting to measure sexual function,
Relationship Quality and Self-Esteem, and Mood the DISF-SR. A subsample of 62 participants completed
subscales. This measure has been renamed the Brain the DISF-SR in addition to the SQ. Pearson’s correlation
coefficients between the BIQS scales and the DISF-SR
scores were calculated and are presented in Table 3.
TABLE 2 Factor analysis pattern matrix As expected, significant correlations were found be-
tween the BIQS Sexual Functioning scale and most
Item Short name Factor 1 Factor 2 Factor 3 DISF-SR scales, as these scales all purport to measure
1 Importance 0.68 functioning aspects of sexuality. Not surprisingly, the
2 Opportunity 0.53 Relationship Quality and Self-Esteem and Mood sub-
3 Drive 0.82 scales of the BIQS were not significantly correlated with
4 Frequency 0.52 most DISF-SR subscales. This likely reflects that most
5 Satisfaction 0.56 subscales of the DISF-SR focus on sexual function rather
6 Engage 0.64
7 Enjoy 0.80 than sexual well-being. Interestingly, the only DISF-SR
8 Arouse 0.91 scale that purports to measure sexual relationships, the
9 Climax 0.82 Drive/Relationships subscale, did indeed significantly
10 Confidence 0.42 correlate with the Relationship Quality and Self-Esteem
11 Appeal 0.45 subscale of the BIQS. The correlation between the BIQS
12 Mood 0.82
13 Problems 0.82 Relationship Quality and Self-Esteem subscale and the
14 Communication 0.83 DISF-SR Orgasm scale was also significant. Overall,
15 Quality 0.84 the aforementioned pattern of correlation data supports
both convergent and divergent validity of the BIQS.
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168 JOURNAL OF HEAD TRAUMA REHABILITATION/MAY–JUNE 2013

TABLE 3 Correlations between the BIQS An evaluation of the psychometric properties of the
BIQS gave generally positive results. Internal consis-
and the DISF-SR subscales tency of all 3 subscales and the total score of the BIQS
were all considered very good.24 Convergent validity was
BIQS subscales
supported by significant correlations between the BIQS
Relationship and DISF-SR Sexual Functioning subscales. Divergent
Sexual quality and validity was also supported by the nonsignificant cor-
functioning self-esteem Mood relations between the BIQS Relationship Quality and
DISF-SR subscales Self-Esteem and Mood subscales and the DISF-SR Sex-
Sexual 0.11 0.08 0.01 ual Functioning subscales. A significant correlation be-
Cognition/ tween the BIQS Relationship Quality and Self-Esteem
Fantasies
subscale and the DISF-SR Orgasm scale was also found.
Sexual Arousal 0.44a 0.27 0.04
Sexual 0.32b 0.30 − 0.06 This was unexpected and requires further consideration.
Behaviour/ We have established subscales for the BIQS, which are
Experiences consistent with recognized constructs of sexuality within
Orgasm 0.68a 0.42a − 0.001 chronic disease. These factors provide a solid conceptual
Drive/ 0.64a 0.36b − 0.11
framework of sexuality following brain injury, which
Relationships
will support future, theoretically driven research in this
field. Furthermore, the BIQS is not sex specific, does
Abbreviations: BIQS, Brain Injury Questionnaire of Sexuality; not assume that respondents are in long-term relation-
DISF-SR, Derogatis Interview for Sexual Functioning—Self-
ships, and allows preinjury comparison, which addresses
Report version.
a P < .01. weaknesses of previous sexuality measures used follow-
b P < .05. ing brain injury. This study forms the foundation for
an ongoing research program investigating sexuality fol-
lowing TBI. Current findings have provided important
psychometric information to justify use of the BIQS
DISCUSSION
within our ongoing investigations of prevalence, causes,
The primary aim of this study was to establish the and consequences of reduced sexuality following TBI.
factor structure of the SQ. In addition, we evaluated key Of the 865 participants in this study, only 635 com-
aspects of the scale’s reliability and validity. Previous pleted all the BIQS items. Closer examination revealed
tools used to measure sexuality following TBI have not that missing data was most problematic for items relating
been specifically developed for TBI, and their psycho- to interaction with a sexual partner. The fact that only
metric properties have not been evaluated within a TBI one-third of our sample considered themselves in a rela-
population. This is the first study of its kind to evalu- tionship may explain this pattern of missing data. These
ate the psychometric properties of a sexuality measure findings further highlight the utility of the BIQS within
specifically developed for TBI. TBI research. Other established sexuality measures often
Original SQ items were largely derived from TBI pa- assume the presence of a regular partner and thus may
tient interviews (during PAQ development) and other result in nonresponse when used in TBI research and
sexuality questionnaires, which supports the content va- clinical practice.
lidity of the SQ (and in turn the BIQS). Although 3 With regard to limitations of this study, although
sections of the PAQ and SQ were originally developed, best efforts were made to consecutively recruit partic-
this organization had not previously been empirically ipants, a significant proportion did not participate. Un-
validated. The present factor analysis results establish a fortunately, reason for nonparticipation could not be
new 3-subscale structure and the SQ has been renamed recorded by the research team because of ethics re-
the BIQS to reflect the scales’ specific measurement of quirements for respondent privacy. It may relate to the
sexuality following brain injury. The BIQS subscales sensitive nature of the study. While those who partici-
measure 3 key constructs of sexuality following brain in- pated in this study were of similar sex and TBI severity
jury: sexual behavior and functioning, relationship and to those who did not, our study sample were slightly
self-esteem aspects of sexuality, and feelings of depres- younger and were more years postinjury than those who
sion and worry about problems with sexuality following did not participate. Furthermore, our sample comprised
brain injury. The BIQS subscales are largely consistent predominantly moderately to severely injured people.
with key components of the Verschuren et al7 concep- These factors should be considered when interpreting
tual framework of sexuality in chronic disease (sexual the aforementioned results. With regard to the conver-
functioning, sexual well-being, and sexual relationships) gent validity analysis, only a subsample of participants
discussed earlier. who were in established relationships and completed the

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

DISF-SR were included. Unfortunately, no specific cri-
teria were provided to assist participants’ description of
relationship status, which may have impacted reliability
of relationship reporting. No significant between-group
differences regarding age, sex, length of posttraumatic
amnesia, and BIQS scores were found between the con-
vergent validity analysis subsample and the wider study
sample (all t test and χ 2 analyses were nonsignificant at
0.05 α level). However, it is acknowledged that we can-
not assume that the convergent validity results will gen-
eralize to a wider sample of TBI survivors who are not in
relationships. Finally, participants were not asked regard-
ing their sexual orientation, and thus further validation
work incorporating sexual preference is warranted.
There is scope for further scale development of the
BIQS. Research evaluating aspects of criterion-related
validity of the BIQS, such as predictive validity,
would be particularly helpful to investigate expected
consequences of sexuality issues following TBI. It is also
recognized that the BIQS is currently developed for pa-
tient use only. Other existing scales of sexuality comprise
2 forms, which allow comparison of responses between
sexual partners. For those TBI participants in relation-
ships, it would be useful to develop a partner version of
the BIQS. Considering reduced insight and communi-
cation are commonly reported following TBI, it would
be interesting to compare responses between partners
to investigate whether they are sharing a common
experience of their sexual relationship following TBI.
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Assessment of Sexuality Following TBI 169
While between 30% and 50% of TBI survivors re-
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Answer the following for now compared to prior to
Did you have a sexual relationship/s prior to your your injury on the following scale:
injury? Yes/No  Greatly decreased  Decreased  Same Increased
a. Are you in a sexual relationship now? Yes/No  Greatly increased
b. Do you have the opportunities to engage in sexual Sexual Functioning
activities with yourself or others? Yes/No 1. The importance of sexuality
Answer the following for now compared to prior to 2. Your sex drive
your injury on the following scale: 3. The frequency with which you engage in sex
 Greatly decreased  Decreased  Same Increased 4. Your ability to give your partner sexual satisfac-
 Greatly increased tion/enjoyment/fulfilment
Sexual Behaviour 5. Your ability to engage in intercourse
1. The importance of sexuality 6. Your ability to enjoy sex yourself
2. Your opportunity to engage in sex 7. Your ability to stay aroused during sex
3. Your sex drive 8. Your ability to climax
4. The frequency with which you engage in sex Relationship Quality and Self-Esteem
5. Your ability to give your partner sexual satisfac- 9. Your opportunity to engage in sex
tion/enjoyment/fulfilment 10. Your ability to verbally communicate with your
6. Your ability to engage in intercourse sexual partner
7. Your ability to enjoy sex yourself 11. Your self-confidence
8. Your ability to stay aroused during sex 12. Your sex appeal
9. Your ability to climax 13. The quality of your relationship with your sexual
Affect and Self-Esteem partner
10. Your self-confidence Mood
11. Your sex appeal 14. Level of depression
12. Level of depression 15. Level of preoccupation with problems
13. Level of preoccupation with problems What do you think are the reasons for any changes
Relationship Characteristics you have noticed?
14. Your ability to verbally communicate with your (You may tick more than one.)
sexual partner No changes Behaviour problems
15. The quality of your relationship with your sexual Decreased mobility Low confidence
partner Loss or decrease in sensitivity Feeling unattractive
What do you think are the reasons for any changes Pain Decline in
you have noticed? relationship
(You may tick more than one.) Tiredness/fatigue Difficulties in
No changes Behaviour problems communicating
Decreased mobility Low confidence Arousal/sex drive problems Limited access to
Loss or decrease in sensitivity Feeling unattractive intimate social
Pain Decline in contact
relationship Other, please specify _____________

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