Relationship Survey

This survey is designed to be the first of several surveys. Our goal is to create a model of therapy that will enhance the cultural competency of clinicians who provide couples counseling for the LGBTQQI community.

Relationship Defined

For the purposes of this survey, relationship will be defined as: an intimate, affectionate and sexual connection between two or more adult individuals.

Basic Information

* How do you identify?

(check all that apply)

* What is your gender identity?

Female

Male

GenderQueer

* Ethnicity:

(check all that apply)

* Age:

* Primary Language:

* Your Salary:

* Couple's/Relationship's Combined Salary (write in N/A if currently single/couple does not share expenses):

* Total approximate number of relationships to date:

* Average Length of Relationships:

* HIV Status:

* Partner's HIV Status:

* Have you been in a traditional,

hetero-normative relationship?

Yes

No

If so, have you been married?

Yes

No

If so, have you been divorced?

Yes

No

N/A

* How long have you identified as LGBTQQI?

* If you are out, how long have you been out?

* Are you currently in a relationship(s)?

Yes

No

What is the length of your current relationship?

.

Below are a number of questions designed to identify many of the issues that may arise in LGBTQQII relationships. Please select as many of the following that you have experienced in your relationships:

Self Identity

Some working definitions:

Homophobia

An irrational fear or intolerance of love, affection, and erotic behavior between people of the same gender.

Internalized Homophobia

The belief that same-gender sexual orientation are inferior to heterosexual orientation which results in the internalization of negative messages, feelings about oneself and one’s group, and beliefs about how one should be treated.

*

	Strongly Agree	Somewhat Agree	Neutral	Somewhat Disagree	Strongly Disagree	Not Applicable
Externalized homophobia has impacted my relationship/s
Internalized homophobia has impacted my relationship/s
Sexual orientation is something one is born with
Sexual orientation is something that one learns
My relationship/s have been influenced by my religious beliefs
I am comfortable expressing affection in front of my family
I am comfortable expressing affection out in public
I am comfortable expressing my orientation at work
My partner is comfortable expressing his/her orientation at work
Relationships that mirror my own can last a long time

Level of Support

*

	Strongly Agree	Agree	Somewhat Agree	Neutral	Somewhat Disagree	Disagree	Strongly Disagree	Not Applicable
I consider myself to be out in my life
I consider my partner to be out in life
I consider myself to be out at work
I consider my partner to be out at work
I have friends that support my relationship/s
My family supports my relationship/s
My coworkers support my relationship/s
My religious community supports my relationship/s
I have friends with intimate relationships that mirror mine
I have support in place for assisting with conflicts in my intimate relationship/s
My relationship/s have been influenced by society/government discrimination

Gender Expression

*

	Strongly Agree	Agree	Somewhat Agree	Neutral	Somewhat Disagree	Disagree	Strongly Disagree	Not Applicable
I fit the stereotype of my birth assigned gender (e.g., are you a "male" that looks "male" or "female" that looks "female")

Children

* How many children do you have?

* How many children do you care for?

* Do you have legal rights to your children?

Yes

No

Not Applicable

* Are you planning on having children/more children?

Yes

Maybe

No

Don't Know

If so, please check the methods you are most likely to use:

* Does your sexual identity impact your desire/decision to have children?

Yes

No

* Do you have grief/loss of not having biological children with your partner of choice?

Yes

No

Not Applicable

Exclusivity in Current Relationships

If you are not currently in a relationship, please continue to the following section.

How would you describe your relationship?

(check all that apply)

Exclusivity in Previous Relationships

How would you describe your past relationship(s)?

(check all that apply)

Relationship Challenges

* Do you think that domestic violence is an issue in LGBTQQI relationships?

Yes

No

Don't Know

Is domestic violence an issue in your current relationship?

Yes

No

Don't Know

N/A

If yes, are others aware of the domestic violence?

Yes

No

Don't Know

N/A

* Has domestic violence been an issue in your past relationships?

Yes

No

Don't Know

Definition of Abuse:
Use of alcohol or drug in which one needs an increasing amount in order to get the same effects, uses despite efforts to stop, and/or use causes social or occupational impairment.

*

	Yes	No	Don't Know	N/A
Do you use alcohol or drugs?
Are you currently abusing alcohol or drugs?
Have you ever abused alcohol or drugs?
Does your current partner abuse alcohol or drugs?
Did any of your past partners abuse alcohol or drugs?
Do you believe that alcohol or drug use is impacting your relationship?
Do you believe that alcohol or drug use impacted any of your past relationships?

Relationship Satisfaction

Please rate how happy/satisfied you are in your current relationship, if applicable.

* Are you currently in couples counseling?

Yes

No

If currently in a relationship, have you and your partner(s) been in couples counseling?

Yes

No

* Have you been in couples counseling in past relationships?

Yes

No

If yes to any of the above questions, do you feel that the counselor was aware of issues pertinent to your sexual orientation/gender identification?

Yes

Somewhat

No

The following questions should be based on your current or most recent relationship.

* I am satisfied with...

	Strongly Agree	Agree	Somewhat Agree	Neutral	Somewhat Disagree	Disagree	Strongly Disagree	Not Applicable
The frequency of which my partner and I engage in sex
The quality of the sex we have
The level of affection in my relationship/s
The level of intimacy in my relationship/s
The level of emotional support in my relationship/s
The quality of communication
The quality of shared interests
The task division/chores
The division of power
How money/finances are handled
Our shared parenting responsibilities
Our discipline styles
Our caretaking responsibilities towards pets
Our shared desire for children in the relationship
The support I receive from my friends
The support I receive from my family
The support I receive from my religious community

Final Thoughts

Please share your challenges of being in a same sex relationship.

NOTE:
Further participaton is not necessary to submit information on this survey.

All email addresses are private and confidential and will not be linked to the current survey information.

Would you be willing to participate in our follow-up survey?

Yes

No

If yes, please provide an email address.

* Indicates Response Required

Gay	Lesbian
Bisexual	Transgender
Gender Queer	Intersex
Queer	Other

African American/Black	Asian
Caucasian	Hispanic/Latino
Middle Eastern	Native American/Alaskan
Other	Pacific Islander

Monogamous	Non-Monogamous
Open	Polyamorous
Other

	Always	Sometimes	Never	Don't Know
Have you been unfaithful?
Are you currently unfaithful?
Has your partner been unfaithful?
Is your partner currently unfaithful?

Monagomous	Non-Monagomous
Open	Polyamorous
Other

	Always	Sometimes	Never	Don't Know
Have your partners been unfaithful?
Have you been unfaithful?