SELF ESTEEM
1. I feel dirty, like there's something wrong with me. --Always
2. Sometimes I think I'm crazy. --Always
3. I feel ashamed. --Always
4. I'm different from other people. --Always
5. I feel powerless. --Usually
6. If people really knew me, they'd leave.--Always
7. I want to die. --Sometimes
8. I want to kill myself. --Rarely
9. I hate myself. --Usually
10. I have a hard time taking care of myself.--Rarely
11. I don't deserve to be happy. --Usually
12. I don't trust my intuition or my feelings.--Usually
13. I'm often confused. --Sometimes
14. I don't know how to set goals and follow through on them. --Usually
15. I'm scared of success.--Usually
16. I'm a failure. I don't feel capable of doing a good job. --Usually
17. I use work to make up for empty feelings inside. --Never
18. I'm a perfectionist. --Sometimes
19. I've made up a lot of stories about my life.--Rarely
20. I've done a lot of shoplifting. --Never
MY FEELINGS
1. I don't think feelings are very important.--Rarely
2. I usually don't know what I'm feeling. --Sometimes
3. I can't tell one feeling from another. --Sometimes
4. I only experience one or two emotions. --Rarely
5. I have a hard time expressing my feelings. --Usually
6. I have a hard time crying freely. --Sometimes
7. I cry all the time. --Usually
8. I get uncomfortable when I feel too happy. --Usually
9. I get nervous when things are relaxed and calm. --Sometimes
10. I feel enraged a lot of the time. --Rarely
11. I'm rarely angry. Anger scares me. --Rarely
12. I get depressed a lot. --Usually
13. I have a lot of nightmares. --Sometimes
14. I have panic attacks. --Sometimes
15. If I really let myself go, my feelings would be out of control. --Sometimes
16. I've been violent. --Sometimes
17. I haven't been violent yet, but I'm worried I might be. --Rarely
MY BODY
1. I'm not "in my body" a lot of the time. --Rarely
2. I frequently space out. --Rarely
3. My body often feels numb. --Rarely
4. I feel as if my body is separate from the rest of me. --Rarely
5. I don't pay too much attention to my body's signals (hunger, tiredness, pain). --Usually
6. I think my body is ugly. --Always
7. I hide my body. --Usually
8. I'm dyslexic. I had learning disabilities when I was growing up. --Never
9. I use drugs or alcohol more than I think I should. --Rarely
10. I often eat compulsively. --Sometimes
11. I keep myself from eating, or eat and throw up. --Sometimes
12. I hurt myself on purpose (cut, burn or injure myself) --Always
13. I have illnesses I think are related to my abuse. --Rarely
14. I've worked out to make my body strong so I wouldn't feel like a victim. --Sometimes
15. I've had flashbacks of the abuse during surgery or other medical procedures. --Sometimes
16. I'm scared to go to the dentist. I hate the feeling of things in my mouth. --Sometimes
17. (For women) I'm scared to go to the gynecologist. --Usually
INTIMACY
1. I often feel alienated from other people, as if I'm from another planet. --Rarely
2. Most of my relationships just don't work. --Rarely
3. I don't have many friends. --Sometimes
4. I'm okay with my friends, but I just can't work things out with a lover. --Rarely
5. I think I'm really meant to be alone. --Usually
6. I'm not sure I deserve to be loved. --Always
7. I don't know what love is. --Never
8. I find it hard to trust people. --Rarely
9. I think people are going to leave me. --Always
10. I test people a lot. --Usually
11. It's hard for me to be nurtured or to nurture someone else. --Rarely
12. I'm clingy with people I'm close to. I'm afraid to be alone. --Rarely
13. I'm scared of making commitment. When people get too close, I panic.--Always
14. I have a hard time saying no. --Always
15. People take advantage of me in relationships. --Sometimes
16. I get involved with people who are inappropriate or inaccessible. --Sometimes
17. I've had relationships with people who remind me of my abuser. --Never
18. I'm struggling a lot with my partner. --Usually
19. Sometimes I think my partner is my abuser. --Rarely
20. Sexual abuse is really creating problems in my relationship. --Never
SEXUALITY
1. I avoid sex. Deep down, I wish I never had to deal with sex again. --Rarely
2. I am celibate. I haven't had sex in years. --Never
3. I really think sex is disgusting. --Sometimes
4. I don't feel sexual desire. I think there's something basically wrong with it. --Never
5. Sex isn't pleasurable for me. I usually have sex to make the other person happy. --Sometimes
6. I try to use sex to meet most of my needs. --Rarely
7. It really feels like I'm "oversexed" --Rarely
8. Sex and aggression are really connected for me. --Usually
9. I find it hard to be close in nonsexual ways. It just isn't satisfying. --Never
10. I frequently go after sex I really don't want. --Sometimes
11. Sex is the thing I'm best at. --Sometimes
12. I've sold myself for sex. --Usually
13. I've had sex with people who don't respect me. --Usually
14. I need to control everything about sex. --Rarely
15. I have a hard time staying present when I make love. I'm numb a lot during lovemaking. --Rarely
16. When I am sexual, I have terrifying, scary feelings I don't understand. --Rarely
17. I often have flashbacks of my abuse while making love. --Sometimes
18. I get sexually aroused when I read or talk about sexual abuse. --Never
19. Violent, sadistic fantasies turn me on. --Never
20. I'm ashamed of my sexuality. --Sometimes
21. I've sexually abused others. --Never
CHILDREN AND PARENTING
1. I feel awkward and uncomfortable around children. --Usually
2. I have a hard time being affectionate with kids. --Sometimes
3. I have a hard time setting boundaries with kids. --Sometimes
4. I have a hard time balancing children's needs with my own. --Always
5. (For parents) I feel inadequate as a parent. --Always
6. I have trouble protecting children I take care of. --Never
7. I tend to be overprotective. --Usually
8. I've successfully protected children. --Always
9. I'm scared I'll be abusive. --Sometimes
10. I have abused children. --Never
11. My kids have been abused (by someone else). --Never
MY FAMILY OF ORIGIN
1. I have strained relationships with my family. --Sometimes
2. Members of my family have rejected me (or vice versa) --Rarely
3. I have a hard time setting limits with my family. --Usually
4. People in my family invalidate my feelings and experiences. --Usually
5. I feel crazy when I'm around my family. --Usually
6. I can't be honest with the people in my family. --Usually
7. My abuse is still a secret in my family. --Sometimes
8. I'm waiting for people in my family to come around and support me. --Usually
If many of the statements on this list were familiar to you, you may feel overwhelmed right now. Put the purpose of this assessment is not to overwhelm you; it's to show you that there's a reason why you experience the things you do. It's to point out the areas that need healing. It is possible to dramatically alter your life so that your answers two years from now will bear little resemblance to your answers today.
1. When I look over my responses, I feel...
like I have a LOT to work on.
2. I've been most strongly affected in the areas of...
I think self esteem
3. I was least affected in the areas of...
I think sexuality
4. The hardest statements for me to acknowledge were...
I don't know
5. I feel the most hopeful about making changes in...
I don't know
6. I already made major strides in the following areas...
I don't know
7. I feel the most hopeless about changing...
Everything
8. I was surprised by...
the fact that I don't know much
9. I learned...
That I have a lot to learn.

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