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SEXUAL BEHAVIOR HISTORY QUESTIONNAIRE
Answer the following questions as they pertain to you. If a question does not pertain to you, just put "not applicable." If the question does apply, a "yes" answer is not enough. An explanation is necessary and expected. Your responses to this questionnaire will be verified through a polygraph examination. Please answer this questionnaire as thoroughly as possible. An accurate representation of your sexual history and behavior is necessary for proper treatment and management. If you run out of room for a question, you can continue a question on another paper, but please put the question number along with your answer. REMEMBER, sexual contact means any contact with another person’s genitals or your own genitals ("private parts"). It does not just mean sexual intercourse. Ask your counselor for any help you need.
Sexual Knowledge/Early Experience/Masturbation
1. Where, when and how did you learn about sex? Describe in detail, how you learned about sex, what happened, how did it happen, who was involved, and how old you were.
2. Describe your first physical sexual contact with another person. What was it? How old were you? What was the age and sex of the other person? Was the sexual contact consensual or abusive?
3. List the locations, other than your home, where you have engaged in sexual activities. Describe the activities, your age at the time, who was involved in the activity.
4. How old were you when you first engaged in masturbation? Identify the location and frequency of masturbation and your thoughts/fantasies associated with masturbation.
5. Describe times when the frequency of your masturbatory behaviors either increased or decreased. Identify the ages at which the increase of decrease occurred. Also describe the places where you would engage in masturbatory behaviors.
6. How often do you currently masturbate? List the current places you masturbate. Describe the thoughts/fantasies associated with your masturbation.
7. Describe what stimulus you have utilized when you masturbate (i. e. , magazines, stories, videos, movies.)
8. Describe the sexual activities you have engaged in over the last three years prior to incarceration.
9. Identify the sexual activities that you have been involved in over the last 12 months.
10. Describe the sexual activities you have engaged in since you have been in prison.
11. Identify each marriage or live-in relationship with an adult that you have been involved in. For each relationship identify your age at the beginning, sex practices within the relationship, frequency of sex, any affairs during the relationship by either partner, and why the relationship ended. Circle his or her to identify the gender of your partner.
(NOTE: THERE IS A TABLE INSERTED HERE THAT I DID NOT INCLUDE.)
12.Describe any sexual interaction you have had with relatives. This would include brothers, sisters, parents, cousins, grandparents, step-relatives. Describe your age, your relatives age, sex and relationship with you, the type of sexual activity engaged in, frequency and why it ended.
(NOTE: THERE IS A TABLE INSERTED HERE THAT I DID NOT INCLUDE.)
13.What is the total number of consenting adult sexual partners that you have had over your sexually active life time? Describe these contacts by describing your age, your partner’s age, sex, relationship with you , length of time you had know the person, the type of activity engaged in, and the frequency of the sexual contacts.
14. Was there ever at time when non-relatives or extended family lived wit you? If yes, was there sexual contact with that or those people? Please describe.
15. How often have you had sexual contact with someone who was drunk or high on drug?
Alternative/Deviant/Criminal Sexual Behavior
Masturbation
16.Have you ever masturbated in public? List all the locations you have ever masturbated.
17. What age and gender of person do you prefer to masturbate in front of?
18. Have you ever masturbated in front of children? Describe.
19. Have you ever taken pictures of yourself masturbating?
20. Did you send these pictures to anyone? If yes, who?
Sexual Contact with Animals
21. How many times have you ever had or tried to have sexual contact with animals?
22. Please complete the following: Type of animal, Your age, # of contacts, Types of Sexual/Attempted Sex Acts
23. Were any animals hurt during the acts? Explain how, if so, and if it were on purpose.
24. How many time have you had sex with dead animals? Describe.
25. Did you kill the animals before you had sex with them? How?
Fetish Objects/Fetishism
26. Have you ever dressed in the clothing of the opposite sex? Describe.
27. Describe any other clothing you used to provide sexual stimulation such as wearing diapers, leather, nail polish, wigs, makeup, high heels, stockings, or other things especially for sexual stimulation.
28. How many times have you stolen an item of clothing from someone or their home? What was it? Why did you take it? Include family members and whether the clothing was dirty.
29. How many times have you cut up, burnt, or mutilated stolen or another’s clothing?
30. What did you do to the clothing? Why?
31. How many times have you ever masturbated into stolen clothing? When was the last time?
32. Describe times you were sexually aroused to a specific type of object or material. This includes undergarments, footwear, personal possessions of another person, bicycle seats, leather, or other things.
33. Describe any particular body part of another person that is very arousing to you, sometimes exclusively arousing (e. g. breasts, hair, feet).
34. Describe times when you participated in or attempted, sexual activity when urine or feces was involved. This includes any times you have urinated or defecated on someone or had them urinate or defecate on you, and includes whether or not you have become excited and/or aroused when you observed or smelled someone urinating or defecating.
35. What about this excited you?
36. Describe times you used objects for sexual stimulation of yourself or another person. This includes dildos, vibrators, candles, food.
Photography/Video/Pornography
37. Describe when you have taken pictures of your own or other’s genitals.
38. Describe times you have taken, or attempted to take, pictures or videos of anyone involved in sexual activity or posing in a sexual manner with their consent.
39. Describe when you have taken pictures or videos of others without their permission. Include the approximate age and gender of the person, the location, the situation, what you took (video or photo) and your reason for doing it.
40. Describe your use of erotica an pornography. This includes magazines/books, photographs, catalogues, advertisements, and or videos. Identify age at time of involvement, frequency of use, and or activity while utilizing this material.
41. What have you used to stimulate yourself that is not typical pornography, like children’s television show or clothing catalogue?
42. Have you ever posted pictures of people that were not your family in you home? Describe.
43. Have you ever manipulated a computer image or photograph to look in a way that was more stimulating for you? Describe what it was and what you did to the image.
44. Have you ever put any pornography on the Internet? What?
45. Have you ever traded or been involved with trading pornography? What?
46. Have you ever seen Child pornography? How many times? Describe whether it was a magazine or computer and describe the pornography.
47. Have you ever purchased child pornography? Describe.
48. How many time have you made child pornography (taken pictures or videos of nude children or children engaged in sexual acts)? Describe.
49. Have you ever gone to another country to obtain any type of pornography? Describe.
50. Have you used any pornography displaying violence or death? Describe in detail
51. Have you ever seen a "snuff"film? Describe.
Adult Consensual Activity
52.Describe times you have, or attempted to have, sex with more than one person at a time.
53. How many times have you been in topless bars, adult theaters and sex shows? Describe your activities and your reason for going.
54. How man times have you been in an adult bookstore? Describe your reason for going and your activities in the bookstore.
55. How many times have you had anonymous sex? Describe this, including location, situation, and gender of the other person
56. Describe times you paid someone for sex or offered to pay for sex.
57. Describe times you were paid for sex, or been offered pay for sex. Have you ever traded drugs for sex? Describe.
58. How man affairs have you had outside a committed relationship?
Frontage (Bumping or rubbing against people sexually)
59. How old were you when you first rubbed against people in a sexual way?
60. How many times have you done this? Estimate: per day, per week, per year.
61. What are the situations were this usually takes place (elevator, bus, etc.)? Describe.
62. How many victims of each of the following groups have you had?
Adult females____ adult males____ teenage females__ teenage males___ girls under 12__ boys under 12__ females over 70__ males over 70__ authority figures__
63.When and where did you masturbate after these times?
Obscene Phone Calls/Sexual Calls or Internet Use
64. How old were you when you made your first obscene phone call?
65. How many obscene phone calls have you made in your lifetime?
66. What do you say or do when the person answers the phone? Describe in detail.
67. Do you ever threaten the person or get him or her to do things on the phone? Describe.
68. How do you pick the people you call/
69. How many of your victims do you call repeatedly? ___% What determines whether you will call them again or not.
70. How many in each category do you have? Boys__ girls__ men __ women__
71. How many time have you called 900 numbers or other types of sex lines?
72. How much money have you spent on them in your lifetime?
73. There was no question listed, most likely due to typo error.
74. What type of sexual behavior or fantasies do you participate in when you call?
75. Do you call men, women, or both/
76. Have these phone calls ever caused problems between you and others? Describe. Did you stop after the problems started.
77. Describe any sexual contact, writing, or "chat" that you have had on the Internet
78. Have you ever sent obscene e-mail to someone?
79. Have you ever used the internet or a chat room to contact other sexual offenders or people with the same sexual interest as you? Describe how, what you were looking for and the response.
80. Describe times you have responded to or placed an ad in a newspaper, magazine, the internet, or a dating service to try to establish a friendship, romantic relationship or sexual relationship.
Exhibitionism
81. How old were you when you first exposed you genitals to someone other than your sexual partner? Who was it?
82. Describe what you have done or do to expose yourself and where. (Include dropping your pants, leaving the bathroom door open, urinating in public.)
83. When was the last time you exposed yourself?
84. How many times have you exposed yourself in your lifetime/
85. How many victims do you have in each group? Boys__ girls __ men __ women __.
86. What have you done to cover or hide your behavior (e. g. pretend you don’t know, lure, put holes in your clothes)?
87. What do you like best about exposing yourself to others?
Voyeurism/Stalking
88. How old were you when you first peeped on someone? Who and where was it/
89. Describe what you have done or do to try to peep on other people. Include looking in a window, shower, open door, urinal, or other things in public or private.
90. When was the last time you peeped on someone?
91. How many times have you peeped in your lifetime?
92. How many victims do you have in each group? Boys __ girls __ men __ women __
93. What have you done to cover or hide your behavior?
94. What do you like best about peeping? What are you looking for?
95. Have you ever followed someone in order to peep on them? Describe.
96. Have you ever followed anyone in order to find out more information about them or have contact with them? Describe.
97. Have you ever followed anybody who became a victim to you (of any crime)? Describe.
Sexual Contact with Children
98. How many children have you had some from of sexual contact with in your lifetime? Include anyone under 16 who was 3 or more years younger than you at the time.
99. Please complete the following. Attach other pages if necessary.
Your Age Vict. Age F/F Mo/yr 1st time Freq. Per wk. Relation to Vic. Type of sexual Act. Type of force or Manipulation used. (THERE WAS A FULL PAGE CHART INCLUDED FOR THIS QUESTION)
100. How many children have you physically forced? Describe what you did.
101. How many children have you threatened with a weapon for sexual activity? Describe.
102. How many children have you threatened to beat, spank, or hurt with your hand/body to get them to be sexual with you? Describe.
103. How many children have you bribed for sexual activity? Describe.
104. How many children have you talked into or groomed for sexual activity? Describe.
105. What kind of rewards have you used for children for sexual behavior?
106. What kinds of lies have you told children to get them to perform sexually for you?
107. Did you ever use pornography with any of your child victims? If yes, describe.
108. Did you ever use cigarettes, drugs or alcohol w/ any of your child victims? Describe.
109. Did you ever drink or use before, during, or after your offenses with child victims? Describe.
110. How many times have you had contact with children at any place where you did not have to wear clothes, like a nudist or naturalist club?.
111. How many times have you been involved with groups of adults who traded children for sex? Describe.
112. How many times have you had sexual contact with children with adults present?
113. How many times have you watched other adults have sexual contact with children? Describe.
114. How many other adults do you know (outside of treatment) who have been sexual with children? Describe.
115. How many times have you had sexual contact with children in other countries?
Coerced/Forced Sex with Adults
Forced sex with an adult includes many situations-when someone told you "no" or that s/he did not want to continue, when you placed any kind of weapon in sight of the person, when you blocked someone’s exit or ability to leave (like taking the person to remote places in our car or a stranger’s house), or when you have been or are a danger to the person (like right after you beat or assaulted them). In essence, forced sex in any time the person did not actively agree to sex with you of his or her own free will without threats (implied or not), show of force or actual physical force.
116. How many time have you forced sex with an adult? %Men__ %Women__
117. How many times have you had contact with someone who was drunk? Describe.
118. How many time have you bribed someone with drugs or alcohol for sex? Describe
119. How many times have you had sex with someone unconscious? Describe.
120. How many time have you had sex with someone sleeping? Describe.
121. How many time have you had sex with someone bedridden? Describe.
122. How many time have you had sex with someone handicapped? Describe.
123. How many times have you had sex with someone who was your employee? Describe.
124. How many time have you had sex with a patient, student, or parishioner? Describe.
Complete the below for all adult victims:
Your age. Vict. Age. M/F Type of Sexual Acts Types of Force used.
Sadism
126. Describe your sexual activities where you caused pain or deliberately hurt a person during a sexual act.
127. How many times have you caused physical pain or hurt someone during a physical act?
128. How many time have you beaten or hit a person before, during, or after sex?
129. Does physical violence sexually arouse you?
130. How many times have you tied, handcuffed, or bound someone up?
131. Describe the bindings that you used.
132. How many times were against that person’s will?
133. Describe your sexual activities where you tried to humiliate, degrade, or shame that person, before, during, or after sexual contact.
134. Describe any sexual contact you have used as a punishment for a person.
135. How many times have you tortured someone? Include intensive punishment (kneeling on rice for hours). Was it sexually arousing? Describe.
136. Describe any sexual behavior you have forced your partner to do that s/he did not want to (watch pornography, do a threesome, have anal sex.)
137. What is the worst thing you have ever done to someone to inflict pain. Describe.
138. Have you ever killed someone during or after sex?
139. How many times have you tortured an animal? Describe.
140. Have you ever had sex with a dead person? Describe.
141. Have you ever had sex with a dead animal? Describe.
Fantasies/Masturbation
142. Describe your most exciting sexual thought or fantasy not yet experienced.
143. Describe the thoughts and fantasies you have masturbated to of holding someone captive and/or torturing him or her.
144. Describe any thoughts, fantasies, or images you have masturbated to of anyone struggling to breath or cutting of his/her air supply.
145. Describe any thoughts, fantasies, or images you have masturbated to of killing someone.
146. Have you ever masturbated during or after cutting off your own air supply? Describe.
147. Have you ever set fires for sexual arousal or masturbated to fantasies about setting fires? Describe any actions or fantasies.
Miscellaneous
148. Describe times you have written to movie or TV stars or joined a fan club.
149. Describe your involvement with nudist camps or members of a nudist camp.
150. Describe organizations and literature received from any organization whose primary function revolved around sexual behavior. (Examples would be Nambla, Guion, Diaper Pail, sexual interest clubs.)
151. Describe your involvement in sexual activity associated with occult, ritualistic, or religious groups.
152. Describe your involvement in sexual activity as part of a gang activity or initiation.
153. Have you ever engaged in sexual behavior as part of a gang activity or initiation? Describe.
154. Describe any type of sexual encounters not covered by the previous questions. This might include group masturbation, massage parlors. Be specific.
155. Have you ever committed a sexual abuse/assault with a co-participant? Describe.
156. Describe any sexual abuse/assaults that you have thought about or planned that you have not successfully initiated or completed.
157. Did you ever ask your victims if the enjoyed the sexual acts you committed?
158. Describe times you have felt guilty about your sexual behavior and what you did to feel less guilty.
159. Have you ever cross-dress during a sex offense? At any other time?
160. Do you have thoughts or interest in being a member of the opposite sex?
161. Have you ever committed the following behaviors: Murder, assault, child abuse, substance abuse.
162. Have you ever been violent in a relationship? Physical violence including slapping? Non physical controlling tactics (controlling money, access to transportation, friendships? Sexual abuse?
163. List any other criminal activity you have ever engaged in.
Cognition about your sexual behavior
164. Did you think your victims ever enjoyed the sexual acts you committed on them? Rate on a ten point scale.
165. Rate the level of satisfaction you felt during your sex crimes. Rate on a ten point scale
166. Did you ever experience sexual dysfunction during your sex crimes? Describe.
167. Did you think your consenting sexual partners ever enjoyed the sexual activity with you? Ten point scale.
168. Rate the level of satisfaction you felt during consenting sexual activity. Ten point scale.
169. Did you experience sexual dysfunction during consenting sexual activity? Describe.
170. List any other relevant information you think will be useful to your treatment.
Have you withheld, omitted or misrepresented anything in your answers to these questions? Is this a complete and accurate account of your sexual history/
Do you understand that this history is going to be verify with polygraph examination?
Please make any comments or questions below.
Signature________________________________ Date______________
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Sexual Behavior History Questionnaire (Read 32028 times)
