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Travis Sky Ingersoll, PH.D., MSW, M.ED.

Social Work & Sexual Health Education/Consulting/Research

My Blog


Useful Educational Models to Help Cancer Patients Address Sexuality Concerns

Posted on June 2, 2016 at 7:29 AM
The information below will soon be added to Chapter 11 (Special Topics: Illness, Disability and Sexuality) in my textbook "Sexuality Concepts for Social Workers."  

Cancer patients and their significant others would undeniably benefit from counseling and comprehensive discourse pertaining to the challenges facing their sexuality. To meet these important needs, there exists a variety of curriculum available for social workers and health care professionals to utilize. The ALARM, PLEASURE, PLISSIT, and BETTER educational models can all be extremely useful to health care providers when confronted with the sexual health concerns of their patients. Common themes incorporated within these models include; bringing up and giving patients permission to discuss sexuality; explaining sexuality as an integral aspect of healthy living; communicating that issues surrounding sexuality can be brought up at any time; reviewing and combating the sexual side effects of treatment, and referring patients to sex therapists.

Useful Models for Sexual Health Assessment


The ALARM model (Anderson, 1990), which appears to incorporate and expand on Kaplan’s (1979, 1995) triphasic model of sexual response, is one useful model of communication and assessment regarding sex and the sexual activities of clients. ALARM inquires about each stage of sexual activity along with the client’s medical history. ALARM stands for Activity, Libido (desire), Arousal, Resolution, and Medical Information. The social worker (or other human service professional) begins by assessing the client’s sexual activity level prior to the point at which the identified problem or medical illness began, following up with an evaluation of changes in libido that may be causing, prolonging, or exacerbating the sexual problem the client is experiencing. Because this approach focusses primarily on the behavioral and physical aspects of sexuality, it may overlook other important domains, such as intimacy, sexual anxiety, emotional connection, and self-image (Hordern, 2008).


The PLEASURE model includes the assessment and evaluation of sexual attitudes, emotions, and activities; level of energy; current treatment and disease side effects; and incorporates the client’s understanding of actual and potential sexual dysfunctions and issues related to reproduction. Specifically, the PLEASURE model assesses the following topics and develops interventions based on identified issues and concerns: Partner, Lovemaking, Emotions, Attitudes, Symptoms, Understanding, Reproduction, and Energy (Schain, 1988).


The PLISSIT Model was designed by Annon (1976) as a step-by-step method for gathering sexual health information. PLISSIT stands for Permission, Limited Information, Specific Suggestions, and Intensive Therapy. This model has been recommended as a useful template for the assessment of sexuality and sexual health in palliative care settings (Cort, Monroe, & Oliviere, 2004; Stausmire, 2004); and Claiborne and Rizzo (2006) have asserted that PLISSIT is particularly suited for social workers. The model provides the practitioner with a general framework on how to initiate a dialogue about sexual issues and hot to continue the discussion if warranted. This approach is versatile and can be applied to a wide range of illnesses, situations, and settings – both outpatient and inpatient. According to this model, the latter levels of treatment build upon the previous ones. However, the social worker (or other human service professional) can move back and forth between the levels of treatment based on the client’s needs. The PLISSIT levels progress as follows:

  1. Permission - Permission can be interpreted to mean either asking for permission to evaluate or giving the person permission to discuss sexuality. “Would it be all right if I asked you about your sexual history?” “Is it ok if I asked you some questions about how your medication(s) has affected your sexual health?” Asking permission puts the individual in control. Such questions should be followed with a series of open-ended questions specific to sexual health: What concerns do you have? What changes have you had in your feelings about sexuality? In relation to your sexual health, what are things you’d like to have change for the better? The assessor might ask permission to have the person’s spouse or partner join the discussion as well. By doing this, social workers are offering clients and partners permission to both have and discuss sexual concerns. Giving permission not only provides opportunities for people to voice sexual concerns, it also validates and normalizes their desire to engage in, or refrain from, sexual activity (Annon, 1976).
  2. Limited Information - This step involves providing brief education to clients and partners regarding common sexual side effects associated with an illness and its treatment, including etiology, pathology, and complications. This information may be given in a short period of time or over several brief meetings to share accurate and relevant information about client and partner concerns. The health and human service professional can also provide the individual with current and accurate information regarding the factors that may be affecting their sexuality.
  3. Specific Suggestions - Based on the individual’s responses to open-ended questions the social worker or other health care professional can then make suggestions for a plan of care. For example, clients are provided with concrete suggestions on how to cope with changes in sexual function due to an illness or surgery. If a client is partnered, it may be best to see the couple together to understand the causes and dynamics of the problem and then explore possible solutions (Monturo, Rogers, Coleman, Robinson, & Pickett, 2001). Social workers may also benefit from examining how the client explored or expressed their sexuality prior to the diagnosis or presenting problem, and how sexual pleasure was achieved. Some clients or their partners may express feelings of guilt, grief, resentment, or anger resulting from the inability to achieve the level of sexual pleasure they would like to experience (Claiborne & Rizzo, 2006). This is particularly applicable during advanced disease and at the end of one’s life, as patients’ losses and recognitions of changes in their sexual selves may by exacerbated by the physical deterioration and alienation they may be experiencing.
  4. Intensive Therapy - This final level addresses ongoing concerns and may necessitate a referral to a sex therapist or relationship counselor. A small minority of cases may require this type of intervention. For example, it has been estimated that only 30 percent of people will need this last level of the PLISSIT model, since the majority of sexual function problems are resolved by providing permission, limited information, and specific suggestions (Derogatis & Kourlesis, 1981).

More recently, Tayor and Davis (2006) modified Annon’s (1976) through the development of the extended PLISSIT model (or Ex-PLISSIT). The Ex-PLISSIT model suggests that the “permission” level should involve requesting permission to discuss sexual issues as well as providing permission for a person to be a sexual being, and this should be incorporated into each level of the model (Taylor & Davis, 2006). Therefore, when assessing a client, a social worker would offer permission in conjunction with limited information, specific suggestions, and a referral to intensive therapy. Another useful application of the Ex-PLISSIT model is its integration of reflection and review by the social worker (or health care professional) after every interaction with the client. 

This step holds the practitioner accountable for their own interactions, biases, and reactions to the client. It also encourages the client to provide continual feedback and review. Incorporating these two additional steps of permission giving into each level of the PLISSIT model and designating time for reflection and review allow for practitioner accountability during a patient-centered assessment of sexual health needs.


BETTER is an acronym for Bringing up the topic of sexuality; Explaining to the client or partner that sexuality is a part of quality of life; Telling the client about resources available to them (as well as gauging the social worker’s ability and willingness to assist in addressing questions and concerns); Timing the discussion to when the patient would prefer, not only when it’s convenient for the human service practitioner; and Recording that the conversation took place and any follow-up plans to further address client concerns or questions (Mick & Cohen, 2003; Mick, Hughes, & Cohen, 2004). However, this approach may not adequately emphasize the need for psychotherapeutic interventions or referrals to specialists (e.g., Sex Therapists, Urologists, Family and Marriage Therapists, etc.).


Anderson, B. L. (1990). How cancer affects sexual functioning. Oncology, 4(6), 81-88.

Annon, J. (1976). The PLISSIT model: A proposed conceptual scheme for the behavioral
treatment of sexual problems. Journal of Sex Education and Therapy, 2(2), 1-15.

Claiborne, N., & Rizzo, V. M. (2006). Addressing sexual issues in individuals with chronic health conditions [Practice Forum]. Health & Social Work, 31, 221-224.

Cort, E., Monroe, B., & Oliviere, D. (2004). Couples in palliative care. Sexual and Relationship Therapy, 19, 337-354.

Derogatis, L, & Kourlesis, S. (1981). An approach to evaluation of sexual problems in the cancer patient. CA: A Cancer Journal for Clinicians, 31, 45-50.

Horndern, A. (2008). Intimacy and sexuality after cancer: A critical review of the literature. Cancer Nursing, 31(2), E9-E17.

Kaplan, H. S. (1979). The disorders of sexual desire. New York: Brunner/Mazel.

Kaplan, H. S. (1995). The sexual desire disorders: Dysfunctional regulation of sexual motivation. New York: Routledge.

Mick, J., & Cohen, M. Z. (2003). Sexuality and cancer: A BETTER approach to nursing
assessment of patient’s sexuality concerns. Hematology Oncology News and Issues, 2(10), 30-31.

Mick, J. A., Hughes, M., & Cohen, M. Z. (2004). Using the BETTER model to assess sexuality. Clinical Journal of Oncology Nursing, 8, 84-86.

Monturo, C. A., Rogers, P. D., Coleman, M., Robinson, J. P., & Pickett, M. (2001). Beyond sexual assessment: Lessons learned from couples post-radical prostatectomy. Journal of the American Academy of Nurse Practitioners, 13, 511-516.

Schain, W. (1988). A sexual interview is a sexual intervention. Innovative Oncological Nursing, 4(2-3), 15.

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

Categories: Sexual Health and Reproduction, Sexuality and Social Work

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Reply john
9:43 AM on August 31, 2017