PLISSIT

1. Introduction

Version followed: Annon's original four-level PLISSIT model (Jack S. Annon, psychologist, Honolulu), plus the Extended PLISSIT (Ex-PLISSIT) revision by Bridget Taylor and Sally Davis where stated. What has been verified: the journal statement is Annon 1976, Journal of Sex Education and Therapy 2(1):1–15 (citation confirmed in Sharratt and in Cicek Ozdemir et al. 2024; text not drawn on). The book The Behavioral Treatment of Sexual Problems appeared as Vol. 1 Brief Therapy (Honolulu: Kapiolani Health Services / Enabling Systems, 1974) and Vol. 2 Intensive Therapy (Honolulu: Enabling Systems, first limited printing 1975, second printing 1976), with a Harper & Row Medical Department edition of Vol. 1 (Hagerstown, MD, c1976; some papers cite it as 1977) [source: Wellcome Collection and NYPL catalogue records; AbeBooks listings; Nho 2013]. The 1974 date in the MND Association handout therefore matches the first Honolulu printing of Vol. 1 [inference]. Annon also wrote a PLISSIT chapter for Corsini's psychotherapy handbook (German edition 1983) [source: Spektrum Lexikon der Psychologie]. Ex-PLISSIT: Taylor & Davis 2006, Nursing Standard 21(11):35–40 (proposed as a tool for primary-care nurses), and 2007, Sexuality and Disability 25(3):135–139 (acquired disability and chronic illness); abstracts only [source: RCNI; ProQuest]; a fuller account is the chapter Davis & Taylor 2006, "From PLISSIT to Ex-PLISSIT", in Davis (ed.), Rehabilitation: the use of theories and models in practice (Elsevier), cited by Sharratt, not drawn on. Annon's own paper and books are not drawn on in full text, so level-by-level detail rests on secondary accounts and on catalogue and contents descriptions [uncertain].

PLISSIT is a conceptual framework for grading sexual-health interventions, not a single therapy. Its name lists four levels of increasing depth: Permission, Limited Information, Specific Suggestions, Intensive Therapy. Each level requires more knowledge, confidence and skill from the clinician [source: Ramanathan & Redelman 2020; Sharratt]. Its idea of change: many sexual concerns are sustained by silence, guilt, worry about being abnormal and misinformation, so a large share of clients improve once a professional opens the topic, normalises it and corrects facts; a smaller group needs tailored behavioural suggestions; only the remainder needs (or should be referred for) intensive, individualised therapy. The first three levels together were framed as "brief therapy" able to address most clients' problems [source: Almeida et al. 2019; Wikipedia; Ramanathan & Redelman 2020]: they form Annon's Vol. 1 Brief Therapy, which a bookseller's description says covers permission, limited information and specific suggestions for male and female problems [source: AbeBooks listing], and a German psychology lexicon describes the model as behaviour-therapy based, graded by severity of the problem, and intended as brief therapy of one to a few sessions [source: Spektrum Lexikon der Psychologie]. It has since been adopted widely by nurses, midwives, GPs, rehabilitation and oncology teams as well as therapists [source: Wikipedia; SIECCAN; QSCIS; Cicek Ozdemir et al. 2024].

For a psychotherapist, PLISSIT does two jobs: (a) a way to raise and handle sexual concerns inside any therapy; (b) a self-check on which level you are competent to offer and when to refer. Formal sex therapy techniques used at the Intensive Therapy level (e.g. sensate focus) are separate modalities and are not described in full here [synthesis].

2. Framework

PLISSIT has levels, not timed phases. In Annon's conception the first three levels are brief therapy of one to a few sessions [source: Spektrum Lexikon der Psychologie]; no source gives Annon's own time estimates or a fixed session count [uncertain]. Published nurse-led programmes ran four or five sessions (see the group and couple formats below).

[source: SIECCAN; Sharratt; Almeida et al. 2019; QSCIS; Ramanathan & Redelman 2020]

Original vs extended versions. In original PLISSIT the levels are a stepped sequence: problems not resolved at the first three levels go on to IT [source: Almeida et al. 2019; Spektrum Lexikon]. Ex-PLISSIT keeps the four levels but (1) makes explicit permission-giving a core feature of each of the other stages rather than a one-off first step, (2) requires review of all interactions with the client, and (3) uses reflection to build the practitioner's self-awareness by challenging assumptions [source: Taylor & Davis 2007 abstract]. Later accounts add that movement between levels is non-linear or cyclical, answering the criticism that the original was linear and lacked review and reflection [source: Cicek Ozdemir et al. 2024; Sharratt; SIECCAN; QSCIS]. Scope of IT. In Annon's version IT was a treatment level, not just referral: when specific suggestions do not succeed in the short term, a more intensive treatment built on behaviour-therapy techniques follows [source: Spektrum Lexikon]. His Vol. 2 Intensive Therapy is described as covering a conceptual scheme, treatment difficulties, assessment procedures and worked case applications, with appendices of self-study programmes, questionnaires, relaxation procedures and covert techniques [source: AbeBooks listing of Vol. 2]. In later nursing and medical use IT is usually framed as referral to a specialist (sex therapist, sexual-rehabilitation or psychology service) [source: Cicek Ozdemir et al. 2024; Wikipedia; Almeida et al. 2019; Sharratt], or as therapy delivered where it is within the clinician's training, with referral otherwise [source: QSCIS]. This guide follows the last reading: deliver IT only if trained for it, otherwise refer [synthesis].

Criteria for moving between levels (gathered across sources): the client's own wishes about how far to go [source: Sharratt; Rev Port Med Geral Fam letter]; whether the concern is answered at the current level; the clinician's knowledge and skill limits [source: Sharratt; SIECCAN]; complexity, e.g. multifactorial causes or significant psychological comorbidity, which signals IT [source: SIECCAN]. In Annon's scheme, specific suggestions come only after a fuller account of the problem and of what the client has already tried, and IT follows when specific suggestions fail in the short term [source: Spektrum Lexikon]. Duration can help gauge seriousness: one GP source distinguishes a sexual difficulty (under six months) from a dysfunction (over six months) [source: Ramanathan & Redelman 2020]. A rushed fix may relapse or create new problems [source: Ramanathan & Redelman 2020].

Group and couple formats (published operationalisations, not Annon's). A Brazilian nurse-and-sexologist programme for breast-cancer survivors ran five weekly group sessions of about two hours: session 1 permission, 2 limited information, 3 specific suggestions, 4 integration of the first three levels, 5 recap plus referral of those needing IT to the sexologist [source: Almeida et al. 2019]. A Korean nurse-led programme for women with gynaecological cancer and their husbands ran four 90-minute sessions over four weeks [source: Nho 2013]; its session-by-session contents were in a table not readable on the page [uncertain]. Trials pooled in a 2024 review mostly delivered PLISSIT or Ex-PLISSIT counselling through trained midwives, counsellors or supervised students [source: Cicek Ozdemir et al. 2024].

3. Guiding principles

• Silence gives a message. If you never raise sexuality, clients assume it is off-limits; make permission explicit. Practice: ask, don't wait to be asked [source: Sharratt].
• Permission is continuous (Ex-PLISSIT). Practice: re-open the door at every level and every visit, not just at intake [source: SIECCAN; Sharratt; QSCIS].
• Non-judgemental, inclusive stance. Practice: use language that makes no assumptions about orientation, relationship status, partner gender or practices [source: SIECCAN; Sharratt].
• The client sets the depth. Practice: offer, don't push; the client may decline to discuss sex and that is respected [source: Sharratt; Rev Port Med Geral Fam letter].
• Least intensive sufficient intervention. Practice: start with permission and information; many concerns need nothing more [source: Wikipedia; Almeida et al. 2019; Ramanathan & Redelman 2020].
• Stay within competence. Each level demands more knowledge, training and skill; your competence sets the limit of your involvement and signals referral. Practice: know which levels you can offer and have a referral pathway ready before you need it [source: Sharratt; SIECCAN; Ramanathan & Redelman 2020].
• Find out before you inform. Practice: ask what the client already knows and wants to know before giving facts [source: SIECCAN; Wikipedia].
• Relevance over completeness. Information is "limited" — directly tied to the concern raised. Practice: answer the question asked; avoid lectures [source: SIECCAN; Sharratt].
• Biopsychosocial framing. Practice: explain that sexual problems usually arise from a mix of biological, psychological and social factors [source: SIECCAN].
• Tailoring. Practice: fit suggestions to culture, socioeconomic and educational level, orientation and actual sexual practices [source: SIECCAN].
• Informed choice. Practice: give benefits and side effects of each option, citing evidence where possible [source: SIECCAN].
• Review and reflect (Ex-PLISSIT). Practice: ask the client how things have gone and what is left; examine your own comfort and beliefs, alone or in supervision [source: SIECCAN; Sharratt; Wikipedia].
• Flexibility. The model is a guide that can be adapted to individual needs and settings [source: Almeida et al. 2019].
• Verify whom you refer to. Practice: check the competence and credentials of sex therapists before referring, as the title may be unprotected (Australia example) [source: Ramanathan & Redelman 2020].

4. Intervention inventory

PLISSIT supplies a structure; the procedures below are those the sources describe at each level. Annon's own per-level procedures (Vol. 1 for P, LI and SS; Vol. 2 for IT) are known only from catalogue and contents descriptions and a lexicon summary [uncertain]. All example language is illustrative unless quoted.

Level P – Permission

4.1 Setting up a permission-giving environment

• Purpose / when: Before and throughout contact; signals that sexuality may be raised here [source: SIECCAN; Ramanathan & Redelman 2020].
• Steps: (1) See clients in a private, confidential room. (2) Put leaflets, posters or simple diagrams on sexual health in the waiting area; a desk notice is an option. (3) Keep at least one sexual-health book in the room. (4) Use inclusive intake forms and wording (partner rather than husband/wife) [source: SIECCAN; Ramanathan & Redelman 2020; Sharratt].
• Example language: On intake forms or at first meeting: "Some people bring questions about sex or intimacy here; you're welcome to, whenever it feels right." (illustrative)
• Watch for: Clients referring to the materials or raising the topic unprompted suggests the signals are working [synthesis].

4.2 Routine, open inquiry built into assessment

• Purpose / when: At intake and at reviews, especially when depression, medication, chronic illness, surgery, cardiac disease or diabetes are present [source: Ramanathan & Redelman 2020; MND Association handout].
• Steps: (1) Add one or two sexual-function questions to your standard history, so it is routine rather than singling the client out. (2) Preface with a sentence that this is asked of everyone. (3) Ask permission to continue. (4) Use open questions so the client can name what matters to them [source: Sharratt citing McInnes 2003; Ramanathan & Redelman 2020; SIECCAN].
• Example language: The GP article's direct question: "Have you noticed any changes with your sexual function?" [source: Ramanathan & Redelman 2020]. Also: "Would you like to talk about how this has affected you sexually or in your relationship?" (illustrative, after SIECCAN's sample prompts).
• Watch for: A clear "no" is respected and the door left open for later [synthesis].

4.3 Normalising and generalising statements

• Purpose / when: When a client hesitates, or after a concern is disclosed, to reduce shame and the fear of being abnormal [source: Sharratt citing McInnes 2003; Almeida et al. 2019].
• Steps: (1) State that the concern is common in people in the client's situation. (2) Where you have reliable figures, add them. (3) Follow with an open question about the client's own experience [source: Sharratt; Rev Port Med Geral Fam letter].
• Example language: "Many people with [condition / on this medication] notice changes in desire or arousal. How has it been for you?" (illustrative)
• Watch for: Visible relief, more detailed disclosure. Avoid normalising something that warrants medical review (e.g. new pain) [synthesis].

4.4 Bridging from a related topic

• Purpose / when: When sex is not the presenting issue but sits next to a topic already being discussed [source: Sharratt].
• Steps: Extend a conversation about sleep, body image, closeness, mood or the relationship to include sexual activity, e.g. moving from sleeping arrangements to sex [source: Sharratt].
• Example language: "You mentioned you and your partner now sleep apart. Has that changed things between you physically as well?" (illustrative)
• Watch for: The client taking up or declining the bridge; either is fine [synthesis].

4.5 Non-judgemental listening and explicit permission

• Purpose / when: Once the client is talking; many need only this level [source: Wikipedia].
• Steps: (1) Listen without evaluating. (2) Reflect back the concern. (3) Explicitly affirm that the thought, feeling, wish or behaviour described is acceptable and not cause for guilt, where that is true and safe. (4) Give permission, as appropriate, to feel comfortable with it, to change something, or to seek medical help [source: Wikipedia; Almeida et al. 2019]. In Annon's sense, permission means reassuring clients that their sexual practices are fine as long as they enjoy them; coming from an expert this relieves many people, and often nothing further is needed [source: Spektrum Lexikon]. Read "enjoyed" as wanted and consensual for everyone involved [synthesis]. In Ex-PLISSIT, affirm the person as a sexual being, including after illness or disability [source: Wikipedia; QSCIS].
• Example language: "Nothing you've described sounds wrong or unusual to me. It makes sense you'd worry, and it sounds like it's been hard to say out loud." (illustrative)
• Watch for: Permission must not extend to behaviour that is harmful, non-consensual or illegal; then shift to risk and safeguarding [synthesis]. Signs it is working: reduced guilt, the client resuming an activity they had stopped, or no further need to discuss it [source: Almeida et al. 2019 (resuming behaviour)].

Level LI – Limited Information

4.6 Eliciting knowledge and wishes before informing

• Purpose / when: At the start of LI; prevents irrelevant or over-detailed information [source: SIECCAN; Wikipedia].
• Steps: (1) Ask what the client already understands about the concern, including their ideas about its cause. (2) Ask what they want to know. (3) Pitch to their health literacy [source: SIECCAN; Ramanathan & Redelman 2020].
• Example language: "What have you read or been told about why this happens?" (illustrative)
• Watch for: Misbeliefs to correct and the exact question to answer [synthesis].

4.7 Targeted factual information, including normal ranges

• Purpose / when: When worry rests on a mistaken idea of "normal" or on missing facts [source: Ramanathan & Redelman 2020].
• Steps: (1) Give accurate information directly relevant to the concern, in question-and-answer style. (2) Where the issue is a perceived abnormality, give the normal range. (3) Check understanding [source: Ramanathan & Redelman 2020]. Example from the source: a man distressed by an ejaculatory latency of about seven minutes was reassured that the usual range is roughly two to six minutes, so his experience is not a medical problem; this information alone can be therapeutic [source: Ramanathan & Redelman 2020]. Annon-style examples include survey data on how common a particular practice is, and information on risks such as HIV [source: Spektrum Lexikon]. Other typical topics: effects of illness, ageing, medication and treatment on sexual function [source: Rev Port Med Geral Fam letter; MND Association handout; Cicek Ozdemir et al. 2024].
• Example language: "Lots of people think X; in fact the usual range is Y. What you describe sits within that." (illustrative)
• Watch for: Keep to facts you are sure of; if unsure, say so and find out or refer [synthesis].

4.8 Biopsychosocial explanation

• Purpose / when: When a client fixes on one cause ("it's all in my head" / "it's purely physical") [source: SIECCAN].
• Steps: Explain that sexual problems usually arise from a mix of biological, psychological and social factors, and link the explanation to the client's own factors [source: SIECCAN].
• Example language: "Your body, your stress, and what's happening between you two all feed into this. Let's look at each." (illustrative)
• Watch for: Reduced self-blame; openness to a combined plan [synthesis].

4.9 Visual aids and anatomical models

• Purpose / when: When explaining anatomy or physiology [source: Almeida et al. 2019].
• Steps: Use pelvic and genital anatomical models or diagrams to explain anatomy; invite questions [source: Almeida et al. 2019; SIECCAN (diagrams)].
• Watch for: Comfort; offer printed versions to take away [synthesis].

4.10 Signposting to resources, with follow-up

• Purpose / when: To extend information beyond the session [source: SIECCAN; Sharratt].
• Steps: (1) Offer vetted leaflets, evidence-based websites, patient advocacy or support groups, and education seminars or counselling. (2) Do not treat a leaflet as the whole intervention; Ex-PLISSIT was partly a response to clinicians jumping to handing out leaflets without permission-giving. (3) Arrange to revisit the topic so the client can raise further concerns [source: SIECCAN; Sharratt; Wikipedia]. Vetted online resources for private browsing are one current form [source: Wikipedia].
• Example language: "Here's a reliable site on this. Have a look, and next time we can talk about anything it raises." (illustrative)
• Watch for: Whether the client used the resource and what questions followed [synthesis].

4.11 Anonymous question box (group format)

• Purpose / when: In groups, where people are reluctant to ask aloud [source: Almeida et al. 2019].
• Steps: Participants write questions anonymously on paper; the facilitator answers them in the group at a later session [source: Almeida et al. 2019].
• Watch for: Questions that reveal individual needs for SS or IT; follow these up individually [synthesis].

Level SS – Specific Suggestions

4.12 Focused problem history and goal setting

• Purpose / when: Before giving any specific suggestion; suggestions need adequate context [source: Sharratt; Almeida et al. 2019; MND Association handout ("full evaluation of the presenting problem")].
• Steps: (1) Take a more detailed history of the specific problem: what happens, since when, in what situations, how the client and partner respond. (2) Identify the challenges. (3) Explore the client's goals and expectations. (4) Agree a goal [source: Sharratt]. In Annon's scheme, suggestions follow a detailed account of the problem and of the client's own attempts to help themselves [source: Spektrum Lexikon], so ask what has already been tried and with what result. Annon is widely reported to have used a structured "sexual problem history" at this level, but its items are unconfirmed [uncertain]. Assess duration (difficulty under six months versus dysfunction over six months) and possible medical or medication contributors [source: Ramanathan & Redelman 2020].
• Example language: "Let's get a clearer picture. When did you first notice it? What happens, step by step? What would you like to be different?" (illustrative)
• Watch for: Red flags for medical causes (new pain, sudden onset, bleeding, medication change): arrange medical review before behavioural suggestions [synthesis].

4.13 Tailored practical suggestions

• Purpose / when: For a defined, relatively straightforward problem within your competence [source: SIECCAN].
• Steps: (1) Generate options suited to the client's culture, socioeconomic and educational level, sexual orientation and actual practices. (2) Explain benefits and side effects of each, citing evidence where possible. (3) Let the client choose. (4) Agree how it will be tried [source: SIECCAN]. Examples in the sources: changing sexual positions when a partner has joint pain; explaining when to use a lubricant versus a vaginal moisturiser for dryness; presenting treatment options for premature ejaculation with their effects and side effects [source: SIECCAN]; trying devices or lubricant for comfort; exploring other forms of intimacy beyond intercourse [source: Rev Port Med Geral Fam letter]; for breast-cancer survivors, lubricants, sex toys, lingerie and erotic material [source: Almeida et al. 2019]. In Annon's model this level also includes direct instruction in specific sex-therapy techniques for problems such as erectile difficulties or pain during intercourse [source: Spektrum Lexikon]; those techniques are separate methods not described here [synthesis]. Medication changes belong to a prescriber [source: Rev Port Med Geral Fam letter; synthesis].
• Example language: "One option is X. It tends to help with Y; the downside is Z. Would you like to try it this week and tell me how it went?" (illustrative)
• Watch for: Suggestions the client finds embarrassing or that conflict with their values; renegotiate rather than insist [synthesis]. Working: the client reports trying it and some change.

4.14 Behavioural rehearsal of difficult conversations

• Purpose / when: When the barrier is interpersonal, e.g. telling a new partner about a hidden visible difference [source: Sharratt].
• Steps: Use social-skills training: plan what to say, rehearse in session, then try it in life [source: Sharratt]. Extending the same rehearsal to talking with a partner about needs, pain or changes after illness is [synthesis].
• Example language: "Let's practise. I'll be your new partner. How would you start?" (illustrative)
• Watch for: Anxiety in rehearsal; grade the task down if needed [synthesis].

4.15 Evaluating the strategy

• Purpose / when: At follow-up after any suggestion [source: Sharratt].
• Steps: (1) Ask what was tried and what happened. (2) Compare with the goal. (3) Keep, adjust or drop the strategy. (4) If no progress or new complexity emerges, consider IT [source: Sharratt; Almeida et al. 2019].
• Watch for: Partial improvement can justify another SS cycle; repeated failure signals IT [synthesis].

4.16 Group experiential exercises (one published group protocol)

• Purpose / when: In a PLISSIT-structured group; these activities come from one nurse/sexologist protocol and are not part of Annon's model [source: Almeida et al. 2019].
• Steps: As reported: role-reversal introductions and a film scene on life after mastectomy to open discussion of body image, sex life, partner relationship and mood (Permission session); a self-image drawing activity (SS session); an exercise in which participants build a story using provided objects to integrate the first three levels [source: Almeida et al. 2019]. Session-by-session facilitation details were not given [uncertain].
• Watch for: Group members disclosing more than they later feel comfortable with; set ground rules on confidentiality and the right to pass [synthesis].

Level IT – Intensive Therapy

4.17 Referral to specialist sex therapy or sexual medicine

• Purpose / when: When problems are multifactorial, involve significant psychological comorbidity, or exceed your skills [source: SIECCAN].
• Steps: (1) Keep an up-to-date list of reputable sex therapists, sexual-medicine and relevant medical services, including remote ones. (2) Check the provider's competence, as "sex therapist" may not be a protected title. (3) Frame the referral so it does not sound like rejection or a judgement of severity. (4) Offer a couple-based referral where a partner is involved [source: SIECCAN; Ramanathan & Redelman 2020].
• Example language: "This has several strands, physical and emotional, and a specialist in sexual health can work on all of them together. I'd like to refer you, and I'm happy to keep seeing you alongside." (illustrative)
• Watch for: Whether the client attends; check at the next contact [synthesis].

4.18 Delivering intensive therapy within your scope

• Purpose / when: When specific suggestions have not worked in the short term or the problem is complex, and only if you hold sex-therapy training [source: Spektrum Lexikon; QSCIS].
• Steps: IT is individualised specialist work. In Annon's version it was behaviour therapy [source: Spektrum Lexikon]; his Vol. 2 is described as covering assessment procedures, treatment difficulties and case applications, with appendices of self-study programmes, questionnaires, relaxation procedures and covert techniques [source: AbeBooks listing of Vol. 2]. Its procedures are not given here [uncertain]. Current sources name IT components as cognitive-behavioural interventions, mindfulness techniques, systems or couple interventions and psychotherapy, with education, strategies and exercises done at home [source: Ramanathan & Redelman 2020], and specialist CBT or ACT for intimacy concerns linked to visible difference [source: Sharratt]. Specific protocols (e.g. sensate focus, dysfunction-specific programmes) are separate methods and are not described here. The 1975 volume reflects 1970s behaviour therapy; check any historical treatment aim against current ethics (for example, professional bodies reject treating sexual orientation as something to change) [synthesis].
• Watch for: Staying within training; seek supervision [synthesis].

Ex-PLISSIT additions

4.19 Review with the client

• Purpose / when: At the end of each contact and at the start of the next [source: SIECCAN; Wikipedia; Sharratt].
• Steps: (1) Ask the client to reflect on the conversation. (2) Ask how things have gone since last time. (3) Ask what has not yet been covered. (4) Consider the partner's perspective [source: SIECCAN; Wikipedia].
• Example language: "How was it to talk about this today? Is there anything we haven't touched on that matters to you?" (illustrative)
• Watch for: New concerns that signal moving up, down or across levels [source: Sharratt (non-linear movement)].

4.20 Practitioner self-reflection

• Purpose / when: After contacts, and regularly in supervision [source: SIECCAN; Sharratt].
• Steps: (1) Examine your comfort with sexual topics and how your beliefs shape care. (2) Challenge assumptions you made (e.g. about age, disability, orientation). (3) Identify knowledge gaps and fill them. (4) Do this alone or in clinical supervision [source: SIECCAN; Wikipedia].
• Watch for: Topics you avoid or rush; these are training priorities [synthesis].

5. Handling problems

The sources say little about problems in use. Unless a source tag is given, the guidance below is [synthesis].

• Client declines to discuss sex. Respect it; the client sets the depth [source: Sharratt]. Say once that the offer stands, and reopen it lightly at a later review, as Ex-PLISSIT treats permission as ongoing [source: SIECCAN; QSCIS]. Do not push.
• Clinician discomfort or avoidance. The Ex-PLISSIT reflection step is the response: name your discomfort, take it to supervision, and practise opening questions [source: SIECCAN; Sharratt]. A common failure, skipping permission and just handing over a leaflet, is what Ex-PLISSIT was designed to correct [source: Wikipedia].
• Stuck at LI/SS (information or suggestions don't help). Re-take the history (4.12); look for missed medical, medication, relational or trauma factors; if the problem is multifactorial or entrenched, move to IT rather than piling on suggestions [source: SIECCAN for multifactorial → refer; rest synthesis].
• Non-adherence to suggestions. Ask what got in the way: embarrassment, partner reluctance, value conflict, lack of privacy, or a suggestion that did not fit the client's practices. Revise the plan to fit (tailoring principle [source: SIECCAN]) or step back to Permission to address shame.
• Over-reassurance. Normalising can hide something that needs assessment. If symptoms are new, painful, worsening or physically unexplained, arrange medical review before or alongside psychological work.
• Overwhelm or distress when the topic opens. Slow down, return to Permission, validate, check what the client wants to do now, and offer to pause. Distress may point to sexual trauma: screen gently, do not probe for detail, and move to trauma-informed care or IT referral as needed.
• Disclosure of abuse, coercion or risk. Permission never extends to non-consensual, exploitative or illegal behaviour. Follow your safeguarding and mandatory-reporting duties; this overrides the PLISSIT sequence.
• Partner dynamics. One partner wanting to discuss sex and the other not, or desire discrepancy, often goes beyond brief levels; consider the partner's perspective at review [source: SIECCAN] and refer for couple-based therapy where needed [source: Ramanathan & Redelman 2020].
• Rupture after an assumption (e.g. assuming heterosexuality, or that an older or disabled client is not sexually active). Acknowledge it plainly, apologise, ask how the client would prefer you to speak, and log it for reflection [source: SIECCAN and Sharratt on inclusive language; repair steps synthesis].
• Referral felt as rejection. Frame referral as adding expertise, not as "too much for me"; offer continued contact and check the referral was taken up [source: SIECCAN on framing; rest synthesis].
• No specialist available. Specialist services can be scarce (one source names a single NHS service for intimacy and visible difference) [source: Sharratt]. Use remote services [source: SIECCAN], vetted online resources [source: Wikipedia], and work at SS level within competence with supervision.
• Cultural or religious conflict with suggestions. Tailor to the client's culture and values [source: SIECCAN]; ask what is acceptable before suggesting, and do not frame the client's values as the problem.
• Groups. Over-disclosure, or someone needing individual help: set confidentiality and right-to-pass rules, use anonymous questions [source: Almeida et al. 2019], and refer individuals for IT at the end [source: Almeida et al. 2019].
• Rushing. Problems addressed in a rushed way may relapse or produce new problems [source: Ramanathan & Redelman 2020]; book adequate time or a dedicated follow-up.

Sources

Sources:

• When to Refer Your Patient with Sexual Difficulties to a Sexual Health Specialist (SIECCAN)
• Sharratt N. Being Ex-PLISSIT: Addressing Visible Difference and Intimacy with Patients (UWE repository)
• PLISSIT model – Wikipedia
• Almeida NG et al. PLISSIT model: sexual counseling for breast cancer survivors. Rev Bras Enferm 2019;72(4):1109–13
• Ramanathan V, Redelman M. Sexual dysfunctions and sex therapy: the role of a general practitioner. Aust J Gen Pract 2020;49(7)
• Queensland Spinal Cord Injuries Service: Sexual health and sexuality after SCI – approach to supporting sexuality
• Cavaco JP et al. Letter to the editor on sexuality in older adults, with reply. Rev Port Med Geral Fam 2026;42:265–6
• MND Association: PLISSIT Model of Addressing Sexual Functioning (handout)
• Annon JS (1971). The extension of learning principles to the analysis and treatment of sexual problems. PhD thesis, University of Hawaii (record only; predates PLISSIT)
• Cicek Ozdemir S, Dogan Gangal A, Senturk Erenel A (2024). The effect of sexual counseling based on PLISSIT and EX-PLISSIT models on sexual function, satisfaction, and quality of life: a systematic review and meta-analysis. Archives of Sexual Behavior
• Taylor B, Davis S (2007). The Extended PLISSIT model for addressing the sexual wellbeing of individuals with an acquired disability or chronic illness. Sexuality and Disability 25(3):135–139 (ProQuest abstract)
• Taylor B, Davis S (2006). Using the Extended PLISSIT model to address sexual healthcare needs. Nursing Standard 21(11):35–40 (RCNI abstract)
• Wellcome Collection catalogue: Annon JS, The behavioral treatment of sexual problems, v. 1 Brief therapy (Honolulu: Kapiolani Health Services, 1974–)
• NYPL catalogue: Annon JS, Behavioral treatment of sexual problems, v. 1 Brief therapy (Hagerstown, MD: Medical Dept., Harper & Row, c1976)
• AbeBooks listings of Annon's volumes (printings, dates and contents descriptions of Vols. 1 and 2)
• PLISSIT-Modell. Lexikon der Psychologie, Spektrum Akademischer Verlag, 2000
• Nho JH (2013). Effect of PLISSIT model sexual health enhancement program for women with gynecologic cancer and their husbands. J Korean Acad Nurs 43(5):681–689

Further reading (full text not drawn on; abstracts or catalogue records only where noted above) [uncertain]:

• Annon JS (1976). The PLISSIT model: a proposed conceptual scheme for the behavioral treatment of sexual problems. Journal of Sex Education and Therapy, 2(1), 1–15.
• Annon JS (1974–1976). The Behavioral Treatment of Sexual Problems, Vol. 1: Brief Therapy (Honolulu: Kapiolani Health Services / Enabling Systems, 1974; Hagerstown, MD: Harper & Row, c1976); Vol. 2: Intensive Therapy (Honolulu: Enabling Systems, 1975; second printing 1976). Dates from catalogue and bookseller records.
• Taylor B, Davis S (2006). Using the Extended PLISSIT model to address sexual healthcare needs. Nursing Standard, 21(11), 35–40. doi:10.7748/ns2006.11.21.11.35.c6382 (abstract only).
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