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WILLIAM MICHAEL P O’LEARY, M.D., M.P.H., FLOYD J. FOWLER, PH.D., R. LENDERKING, PH.D., BETH BARBER, PH.D., PIERRE F! SAGNIER, HARRY A. GUESS, M.D., PH.D., AND MICHAEL J. BARRY, M.D.
ABSTRACT-Objectives. To develop a brief questionnaire to measure male sexual function. Methods. An initial set of questions was refined and reduced through cognitive testing and two serial vali-
dation studies. In each study, men were recruited from a sexual dysfunction clinic and a general medicine practice to complete the instrument. Test-retest reliabilities, internal consistencies, and construct validities were examined. Results. The final instrument covers sexual drive (two items), erection (three items], ejaculation (two items), perceptions of problems in each area (three items), and overall satisfaction (one item). Psychometric performance was generally very satisfactory, although self-assessments of ejaculate volume are problematic. Translations have been developed and pilot tested in a number of languages. Conclusions. The Brief Sexual Function Inventory may be useful for measuring male sexual function in practice and research. UROLGGY~ 46: 697-706, 1995.
o conduct studies of the effects of medical treatments, it is important to have good measures of the various ways that the target condition affects the patient, as well as the impact of any unwanted treatment side effects. Among the aspects of life most commonly affected by health problems and their treatments is sexuality. For example, transurethral resection of the prostate for benign prostatic hyperplasia (BPH) often produces retrograde ejaculation and has been frequently reported to cause erectile dysfunction1 although a recent controlled trial has called this common wisdom into question.2 Radical prostatectomy may cause sexual dysfunction. 3 Alpha-adrenergic blockers and the So-reductase inhibitor finasteride can both affect sexual function in a small percentage of patients with BPH,4,5 whereas androgen deprivation therapy for prostate cancer has a much more dramatic effect on sexual function6
*Supported by grants from Merck G Co., Inc. and the Agency Health Care Policy and Research (grant HS 08397). From the Department of Surgery, Harvard Medical School, and Division of Urology, Brigham and Women’s Hospital, the Center for Survey Research, University of MassachusettsBoston, the Department of Medicine, Harvard Medical School, and the Medical Practices Evaluation Center, Massachusetts General Hospital, Boston, Massachusetts; Phase V Technologies, Inc., Wellesley Hills, Massachusetts; Merck Reseat-ch Laboratories, Blue Bell, Pennsylvania, and Paris, France Reprint requests: Michael P. O’Leary, M.D., M.P.H., Division of Urology, Brigham and Women’s Hospital, 45 Francis Street,
Boston, MA 02115
Submitted [Rapid Communication): (with revisions):July 26, 199.5 uRoLOGYa 46 (51, 1995
June 19, 1995,
By its nature, sexual function is best measured by patient self-report. Although erectile function can be measured physiologically, only the patient (or a partner) is privy to information about sexual function under real-life conditions. Moreover, only patients can report on issues such as sexual interest and the extent to which sexual dysfunction has an adverse effect on their quality of life. Reviews of the published literature did not reveal any validated instruments that would allow us to measure sexual function easily in men before and after treatment of prostate disease, which has been the focus of our research. Some batteries, intended for characterizing patients whose primary complaint was sexual dysfunction-often in a psychiatric setting-were much too long and detailed for use in our clinical studies, where sexual function is not necessarily the primary concern. ‘m9Other instruments briefly measure overall sexual satisfaction but do not differentiate among the various domains of sexuality, which may be impacted on differently by prostate and other diseases and their treatments. Finally, the wording of many questions about sexual function in questionnaires we reviewed impose the assumption that lack of sexual function is problematic (for example, how much of a problem do you have getting an erection?). Our studies consistently show that men vary in how problematic they find most health states.” For clinical studies, we believe that it is essential to describe patient status in a nonevaluative way and to measure the patient’s reaction to their situation separately. 697
thought it important to evaluate questions in this area further. We separated descriptive questions. and study subjects’ comments were carefully reviewed.).O’L. For ease of response and consistency of scoring. Erectifefunction.P. erectile function.) (n = 70). 3. nevertheless. Nevertheless. In the first validation study. Clinicians sometimes consider it a sign that erectile dysfunction is psychological in origin when men have moming erections but do not respond to stimulation when awake.19 Cross-tabulations were used to evaluate inconsistencies within domains and to examine subjects’ ranges of responses. 8 on ejaculation. All our questions could be answered whether or not a respondent had a partner and whether any partner was male or female. many of which appear in the psychology literature. ejaculation. Most were believed to be more comprehensive than was necessary or practical for the purposes of routine urologic studies. Two questions were asked about the firmness of erections. we mainly used questions with five response alternatives.O’L. 11.13J4 Some of these questions were supplemented with alternative versions to determine which versions worked best with patients. is the principal fo- RATIONALEFORZTEMSELECTION Several general principles guided the selection of the items for testing in the second validation study: 1. Data compiled from this first validation study were analyzed. Pearson product-moment correlation coefficients were calculated to examine associations among variables.R. As one way of assessing the overall significance of what respondents reported in each domain. in which respondents were asked how they felt about those experiences. The identical questionnaire was then readministered by mail approximately 1 week later to examine short-term test-retest reliabilities. except for questions that had been previously validated in other response formats. 2. Based on these analyses. given the frequency with which such questions appear in the literature.t’ and intraclass correlation coefficients were calculated to assess test-retest reliabilities. some questions were added. Finally. which is familiar to most urologists and has been validated using a similar approach. Our early testing consistently found that most men did not think they could report how much semen they ejaculated. One of the authors. we describe the development and validation of a short instrument that attempts to capture the various aspects of male sexual function. we found that reports of morning erections did not correlate well with other reports of erectile function. and two senior interviewers working for the Center for Survey Research interviewed a convenience sample of patients in the sexual dysfunction practice of another author (M. The result for the next phase of testing. we tested three questions that asked respondents the extent to which they considered each specific area of sexual function UROLCGY@ 46 (5). Three questions asked about response to stimulation-the frequency with which respondents had erections when stimulated and their perception of the difficulty in getting and keeping erections. and 4 summary questions. a revised 22-item questionnaire was developed for a second validation study (Fig. A first step was to subject the questions to cognitive evaluation. 8 general and demographic questions. Questions were selected from a number of sexual function questionnaires. as it has been a time-honored way of assessing erectile function.In this article. 4.L. Moreover. This instrument had intentional redundancy that enabled us to evaluate which questions best captured the domains of interest. Study subjects in both groups were instructed to mark any questions they found confusing or difficult to answer and were debriefed by a research assistant or nurse after completing the questionnaire. The wording in the revised questionnaire used “sexual drive. men who reported they responded fully to stimulation without difficulty while awake frequently said they did not have morning erections. We tried to phrase questions so that they applied to all respondents. nor did they seem to care very much. Libido. erectile function. Four ways of asking about erectile function were examined in the first validation study. The first was a group of men presenting to the male sexual dysfunction clinic of one of the authors (M. our goal for this section was to find questions to monitor this effect. we included two questions on morning erections for further evaluation in the second validation study.). We decided to ask respondents to report their experience over the past 30 days. the first validation study. diabetes). we asked questions using the words “sexual interest” and “sexual drive. for BPH can alter the amount of semen some men ejaculate. from evaluative questions. Pilot testing was then undertaken with an initial composite instrument consisting of more than 50 carefully worded questions addressing 4 domains we believed to be conceptually separate: libido or sexual desire. A comparison group came from several general internal medicine practices at the Massachusetts General Hospital (n = 74). as is the case with sexual function and satisfaction. or deleted. the other asked respondents to describe the most erect they had become in the previous month. The performance of this revised questionnaire cus of this article. Because both surgical and medical treatments Ejaculation. Many health status measures use this reference period. those in which respondents described their experiences over the past 30 days. we considered ease of comprehension. in the first validation study. that is. Their mean age was 60 years. Problem assessments. We.15J6 Based on this evaluation. There were five broad categories of questions in the revised questionnaire: libido. 10 on erectile function. and comprehensiveness in choosing items for the second validation study. They were also younger. drive seemed to refer more directly to sexual activity. 1).” mainly because if there was a difference to respondents. revised. This self-administered questionnaire is similar in form to the American Urological Association Symptom Index for BPH. and overall satisfaction. assessment of significance of each domain (problem assessment). whether they meant to respondents what they were intended to mean. was a 41-item self-administered questionnaire that included 9 items on sexual interest. a question about waking with an erection was included. ejaculation. Its advantage is that it avoids measuring the short-term effects of acute conditions.P. In each case. This questionnaire was administered to subjects in two populations.” Both cognitive and psychometric evaluation suggested the two terms were virtually interchangeable. 1995 698 . All of these men were seeking diagnosis or treatment for a perceived problem with one or more aspects of sexual function. but individual items in these batteries were considered. ease of answering. with a mean age of 41 years. One asked the frequency with which erections were firm enough for intercourse. These men had no established diagnosis of sexual dysfunction and had no diagnoses commonly associated with sexual dysfunction (for example. as well as whether respondents could answer them. However. and overall satisfaction. The purpose of this phase was to evaluate the clarity of questions. a clinical psychologist (W.‘* Internal consistency among items in individual domains was examined with Cronbach’s alpha statistic.12 MATERIAL AND METHODS An extensive literature search was conducted to identify existing instruments that measure sexual function. and it provides a reasonable period over which to describe experiences that vary day to day.
. abilit y to get and keep erections during the nast 30 d&s? $7. Swary Fl. -*. F4. how would you rate you r level of sexual drive? :.::.... . ej. 699 .’ . Overah. : ‘j::. :.. durinn tbe nast 30 davs.....:. 82: .1:.. how much semendid you ejaculatewhen you &naxed? . Let’s defme sexual drive as a feeling that may include wanting to have a sexual experience (masturbation or intercourse). how have you felt about yoursex life? FIGURE uROLOGYB 46 61... how satisfiedhave you been with your sex life? .. ju the uas t 30 davs. . or feeling frustrated due to lack of sex. how much did you consider the amountof semenyou ejaculate to be a nroblem for vou? .. ” .. b the nast 30 davs..:. .: j ..:. “‘l‘. how.the amount of semenyou ejaculate? Jn the nast 30 days...::j . : z .jaculation Cl.. to what extent have you consideredyour abilitv to eet and keen erections to be JII the nast 30 days.:... .:i. :Aut y..I:fioiv m&h difficultv did you huve keening air erection during the past 30 davs? Section C.:: .. boy frequently did you awaken from sleep with a full erection? 33... . : .at least a partial erectian.SthlhM? ..SectionA.. ” 3 t&tiy did you awaken from sleep with . Il[c5$ did ya\i feel about your level of sexual drive u .sufficient for penetration without manual assistance Ml wtim jj: 1:...~~~? ..:. . . Durinn the nast 30 davs.capable of penetration with maflnal assistance 3 r] ‘. 9 [1 y.:lij.: j pa+ ar&+ion : trot capable of penetration even with manual assistance ~:1U..is ihe most erect (or hard) your penis has become at any time? :.u..: gait 30 davs? I?$. .: ... Revised questionnaire for second validation study..:. ... fii ’ Consider a scale from zero :to ten.. ... . on how many days have you felt sexual drive? Durinn the nast 30 davs. . where. 1.:. How much difficulty did you have nettinn an erection during the past 30 davs? < :P. .:~... during the nast 30 davs.’ &r. . . In tire nast 30 davs.. when you had erections. L.. .rieariy full &rection ....-” .. how often were they firm enough to have sexual il&XCOW? A2. .. F3... . to what extent have you consideredyour eiaculation to be a problem? Overall. .. gxutial er&t’ mn . :‘il’+‘0 Over the n&t 30 days...’.’ .I.. 1995 1. J&j& the D&t 3 0 davs.‘. Q&&&g&t 30 davec: $$it . thinking about having sex. && yM1’f&..& is no sex drive at all and ten is the highest level of sex drive a per&n could We...culation durin the past 30 days? FS... : @OF mticlram you concernedabout ...::::..: .Interest Al.tihat number would you give to your level of sex drive jn the nast . . 0 0 terribte 2’ dissatisfied IIJunhappY [f d&y Hov&“&d VW f&l about vour -. how often have you had partial or full sexual erections when you were sexually stimulated in any way? B5.. ... Section F... to what extent have you considereda lack of sex drive to be a problem? F2..‘:... . . Over the east 30 davs. how much difficulty have you had ejaculating when you have been sexually . . C%’ In the east 30 days..fl 1..I no ‘$$ion at at1 : .
France. a 5-category satisfaction question. In each area. RESULTS INDIVIDUAL SUBSCALES Sacual drive. ANALYSIS The analysis was organized around the five areas outlined: sexual drive. Italian. German. test-retest reliability. To this end.TABLE 1. respectively. transformed to a S-point scale (0 to 41. The translation and pilot testing included 2 forward translations into each of the other languages. and a rating using the 7-category delighted-terrible responses. which was scored on an 11 -point scalefrom 0 to IO. from “big problem” to “no problem. New Zealand English. summing the scores on all the questions in the domain. ‘In the past 30 days. intraclass correlation coefficient (ICC). has an important social component. and a “harmonization conference” among those responsible for translation and piloting to identify questions that posed particular difficulties and to agree on final translated versions.90 0. The latter analyses involved comparing least squares mean domain or global scores for the two patient groups in an analysis of covariance controlling for age.*O Global rating. completed a follow-up questionnaire by mail 1 week later to measure stability of responses. the 2-item index *Requests for translations of this questionnaire into the languages described in the article should be directed to the office of Catherine Acquadro.37 0. respectively.4)‘1 Measures of sexual drive Correlations Problems With Sex Drive* 0. French. and the scores are computed separately for each domain by 700 . There is a nominal handling charge to MAPI Research Institute for this service.92 0. erectile function. The goal of the analysis plan was to identify the fewest questions that appeared to describe each area reliably and validly. and Walloon. Cronbach’s alpha and test-retest values were evaluated. The basic approach was to sum the responses to alternative combinations of questions. of course.51 0. from 0 to 4. Austrian German. as measured by intraclass correlation coefficients. 69003 Lyon. South African English.) in collaboration with Dr. Swiss German. Cronbach’s alpha. We also assessed how well the resulting indices discriminated between patients being evaluated and treated for sexual dysfunction and the control patients. and ejaculation) to be a problem. a contract research organization based in Lyon. problem assessment.51 *Internal consistency. so that there would be (libido.4A3 0:98 Feelings About Sex Drives 0. M. Evaluative criteria included internal consistency. Three questions were asked about sexual drive.” and a feeling rating scale with seven ordered categories (from “delighted” to “terrible”) based on the work of Andrews and Withey. Brazilian Portugese. Sixty-four percent and 82% of respondents in the 2 groups.S.37 Indexes Summary Index Drive Drive I II Measurement Characteristics Alpha * 0. Fax (33) 72 13 66 68.88 ICC+ 0. AND PATIENT PILOTING * Parallel with evaluating the revised 24-item American English questionnaire in the two populations described. The languages in which the full process was conducted included British English. Overall satisfaction with sex life. ejaculation. The translation and pilot-testing process was taken into account to eliminate questions that were ambiguous or cumbersome to ask in one or more languages or that posed other special difficulties. was linearly equal weighting of items in the domain. we included 2 global measures. 27 rue de la Vilette. 1995 ITEM SCORING Each question is scored on a 5-point scale. and construct validity as measured by correlations with other measures to which the constructs should be related if they are valid measures.89 All Drive Items Al + A2 + . All of the preceding questions were aimed at measuring the effects of treatments or conditions on specific aspects of patients’ sexual lives. the score for question A3. in some languages a lengthy explanation was needed to make sure that Question B7 was not interpreted as asking about the ability to maintain an erection over a 30-day period.. Candidate Drive Questions Al Al + A2 +A2 + A3(. and Afrikaans. Swiss French.D. erectile function. A more limited process was used for Canadian French. the general medicine patients had no established diagnosis of sexual dysfunction and reported no health condition likely to affect sexuality. 2 back translations to ensure consistency with the source and produce an initial version for pilot testing. it is reasonable to want to have a global measure of satisfaction that reflects the net effect of all problems with sexual function as perceived by the patient. Hebrew. as measured by Cronbath’s alpha. On the one hand. to what extent have you considered a lack ofsex drive tobe a problem? §How did youfeel about your level ofsewual drive during the past 30 days? “In this summary. translation and pilot testing were carried out in a number of languages by one of us (P. The overall satisfaction question is scored separately from 0 to 4. pilot testing with 10 adult male native speakers of each language to assess cultural acceptability. On the other hand. Dutch. various ways of constructing a multi-item index were evaluated. medical treatments are not usually going to affect the social side of people’s sex lives. A 2-item and 3-item index were created. As can be seen from Table I. France. We asked these questions in two different ways: a direct problem rating. TRANSLATION. ‘Test-retest reliability. For example. CULTURAL ADAPTATION. Norwegian. MAPI Research Institute. The median ages of the 2 groups were 55 and 45 years. As in the first study. PROCEDURES A separate sample of 74 men with a chief complaint of sexual dysfunction and 60 general medicine patients were recruited from the same practices for the second validation study.P. and overall satisfaction. Spanish. Telephone (33) 72 13 66 67. UROLOGY@ 46 (51. and summary scores were correlated with two questions on how much of a problem the respondent perceived from any lack of sexual drive. Catherine Acquadro of MAPI.
88 0. the value of alpha (0.99 Candidate Indexes Erection Questions Summary Index 83 + B4 + B5 + B6 + B7 Erectile function I B3 + B6 Erectile function II B4 + B5 Erectile function III B3 + B4 Erectile function IV B3 + B4 + B7 Erectile function V 84 + B5 + 87 Erectile function VI B4 + 85 + B6 Erectile function VII *Internal consistency. Its psychometric performance was as good as any alternative. to what extent have you considered your ability “How did youfeel about your ability to get and keep erections during Measurement Characteristics Alpha * 0. However.66 0. When these two ejaculation items are combined.87 0. intraclass correlation coqfficient (ICC). asked about difficulty maintaining an erection. indicating some construct validity Thus these two questions may be grouped together as a domain. and the test-retest correlation and correlations with the 2 problem ratings are identical.85 Problems With Erections 0. the index consisting of these two questions has an acceptable test-retest reliability (0.99 0. This question could only be answered by those who had active sexual experiences in the preceding month.21 This surprising but consistent finding had been noted in the first validation study Seven alternative approaches to creating a multiitem index are presented in Table II.61 Feelings About Erection11 0. a problem that B6 avoids. confirming some of our initial impressions (Table III).96 0. As indicated earlier. Measures of erectile function Correlations All Erectile Function Items* B3 + B4 + B5 + B6 + B7 0:97 0. we had difficulty finding questions about ejaculation that met our needs. %I the past 30 days. Respondents were asked Problem assessment.96 0.96 or higher) with the full index and also score very highly on other measures of reliability and validity Our choice for a final instrument was a three-item index presented in the last row of Table II (items B4.” All of the shorter indices correlate very highly (r = 0.44 0. The questions on erectile function were analyzed similarly (Table II). B7. Erectilefinction. 1995 erections.49 0.92 0.98).96 0.TABLE II.76 0.76 0. All the questions we asked had the disadvantage of not applying to men who had not had active sexual experiences or the opportunity to ejaculate in the past month.68 0.85 0. the 2-item index was a clear choice for measurement of sexual drive.62 0. Questions Bl and B2 dealing with erections on awaking from sleep were excluded.94 0.62) is barely high enough for this measure to be considered homogenous. which is an alternative to B5 as a measure of the quality of UROLOGY@ 46 (51. based on our principle of parsimony and the psychometric data in Table I. ‘Two items dealing with morning erections excluded.77 0.” For this reason question C2 was excluded. with the sum of scores on all five items (B3-B7) being a potential “gold standard. how they felt about each of the three domains of interest in two different ways. which correlates very highly with B6.88 0. Moreover.84 0. which has been defined as erections firm enough for intercourse. B3.88 0. measures of ejaculation did not perform psychometrically as well as other measures of sexual function. the improvement is somewhat artifactual in that 27% (32 of 118) of the men either left this question blank or answered “don’t know.77 to get and keep erections the past 30 days? to be a problem? (Al plus AZ) virtually replicates the 3-item index (r = 0. Ejaculation. Furthermore.94 0. and B6). Thus. It should be noted that questions B4 and B5 alone can be used to measure erectile function almost as well as the three questions.70 0. The value of alpha is nearly as high for the 2-item index.59 0. 87% (40 of 46) of the men who reported that their erections were never firm enough for intercourse also reported no full morning erections. since a large percentage of men who reported no morning erections reported less dysfunction on all other questions dealing with erectile function. Although adding question C2 (amount of semen ejaculated) increased Cronbach’s alpha for this domain.59 0. By contrast. B5.79) and correlates reasonably well with assessments of ejaculation as a problem. Candidate indexes (based on the sums of the three items of 701 . ‘Test-retest reliability.95 ICC+ 0.99 0. Thus the questions about morning erections appear to have adequate sensitivity but very poor positive predictive value in identifying erectile impotence.87 0. 37% (23 of 63) of the men who reported no full morning erections reported that their erections were firm enough for intercourse at least some of the time. For example. had a complex set of response alternatives that proved difficult for some respondents.86 0. Cronbach’s alpha.50 0.
Cronbach’s ‘Test-retest reliability.040. - each type) were analyzed similarly to the previous domains (Table IV). intraclass correlation coefficient (ICC). DISCRIMINANT VALIDITY For each of the five subscales (drive. we chose the five response category questions on the grounds of consistency with other questions in the instrument and potential ease of administration. ejaculation. Candidate Drive Questions Fl + F2 + F3 F5 + F6 + F7 Indexes Summary.78 0. F6.67 I II Measurement Characteristics Alpha * ICC+ 0.109 patients). Domain Sexual drive Erection Ejaculation Problem assessment Satisfaction Discriminant validity using analysis of covariance: comparing least squares mean scores while controlling for age Score 0 0 1 0 0 Range* to 4 to 4 to 4 to 4 to 4 ALSMEAN+ -0. and ejaculation.TABLE Candidate Ejaculation Questions Cl +c4 Cl +c2+c4 Indexes Summary Index Ejaculation Ejaculation III.78 All Drive Items Fl + F2 + F3 *Internal consistency.least-saunres mean Gewual dysfunction ‘Ninety-jive percent confidence ink&al (CI) for ALSMEAN.301 0.0001~ 0. Index Summary problem index Summary feeling index Measures of problem assessment Correlations Overall Satisfaction With Sex Life* 0.83 *Internal consistency. The scores from the two indexes are highly correlated (r = 0.5 14. scoring. These correlate highly with each other (Y = 0. 702 The two single-item Overall satisfaction.087.000 15 *Each subject’s item scores were averaged to calculate their mean domain score. (1. whereas questions Fl. F2. 95% (-0. so results are likely to be similar. and interpretation.532 1. during the past 30 days. problem assessment uROLcGY@ 46 (5).79 0.83 . it can be seen that they correlate to a similar high degree with the two problem assessment indexes (0.87).87). The alternative index (questions FS.70 to 0.245. (0.05 level of significance. we computed the age-adjusted least squares mean difference in scores for the patients being treated for sexual dysfunction and the general medicine controls (Table V).70 0. For our final questionnaire. during the past 30 days. with good test-retest reliability (r = 0.87 0. Measures of ejaculation Correlations All Ejaculation Items Cl + c2 + c4 0.83 Overall Feeling About Sex Lifes 0.87 Measurement Characteristics Alpha * ICC+ 0.72 0. The men seeking treatment for sexual dysfunction had statistically significantly lower age-adjusted scores for erection (P = O. problem assessment. erections.87 0. as do all other items in the final questionnaire.69 0. (0. %ignificant at the two-sided 0. Cl* 0.358 0. In Table IV.Sl). intraclass ‘Overall. overall satisfaction).81 0. There is little basis for choosing between them. the latter questions give respondents seven possible responses.165 1. how satisfied have you been with your sex life? how have youfelt about your sex life? TABLE V. These questions combine well (alpha = O. and F3 deal with the extent to which the respondent considered he had a problem with drive.978) 1.89).185) 1. 1995 .73 0. correlation coefficient (ICC). Problems With Eiaculatior? 0.000 15 0.OOOl).708) 0.83 0. (-0. F2.974) P Value 0. “In the past 30 days.304 1.83). and F3 have five response categories. ?ALSMEAN = least-sauares mean keneral medicine controls) . alpha. we opted for the five-category question for the same reasons outlined in the preceding section. measures of overall feelings about one’s sex life yielded similar results. However. %verall. Cronbach’s alpha. and F7) correlates somewhat better with the two global questions on overall satisfaction with sex life and has similar values of alpha and test-retest reliability.894. Questions Fl. to what cant have you considered your gaculatton SHOW did youfeel about your ejaculation during the past 30 days? to be a problem? TABLE IV.0864 0.649) 1.58 Feelings About Eiaculation§ 0. erection.62 0. ‘Test-retest reliability.
57 0. Also.89 0. In addition.23 0.02 0. since men would be unlikely to present to a sexual dysfunction clinic for diagnosis and treatment without preserved sexual drive. This is not surprising. The key points from Table VI are that in all cases items in a given subscale correlate more highly with other items in that domain than with items from other subscales.69 0. erectile function. We consider these questions to be good measures of sexual drive.22. as opposed to performance.50 0.54 0. and ejaculation also correlate most highly with the corresponding item in the problem assessment subscale (Fl through F3).35 0.12 0.42 0. in which it appeared that men were not particularly aware of the amount of ejaculate volume and did not seem to care much about it. partners can only guess at sexual satisfaction.38 0.23 In addition.61 0.41 0. 1995 This inventory provides only a man’s own perception of his sexual function.61 0. 2).36 0.09) or drive (P = 0. Only a few questions are needed to characterize current status. The lack of statistical significance for drive is predictable.47 0.41 0. In fact.27 numbers refer A2 0.83 0. CONFIRMATION OF DOMAINS Table VI presents correlations among the 11 items chosen for the final version of the inventory (Fig. and overall satisfaction (P = O. The items designed to characterize current status with respect to sexual drive.63 0.48 0.64 0.29 0. However. while maintaining as parsimonious a question set as possible.TABLE VI.39 0. the question regarding the extent to which ejaculation is considered to be a problem 703 . it is not accurate to assume sexual dysfunction is always a problem.49 0. in view of the pilot studies already discussed.41 0. as one would expect. to avoid issues of interviewer bias that can be problematic in outcomes research. 0.57 in Figure 1.56 0.51 0. Each item was in part chosen to optimize correlation with other items in the same domain.79 0.85 0.61 0. erectile function. Indeed.41 0. Interest A2 B4 B5 B6 Cl c4 Fl F2 F3 F4 *Question Correlation Function B5 among 11 items in brief sexual function Ejaculation Cl c4 inventory * Satisfaction F4 Al 0. particularly when not all men have regular partners. the failure to discriminate between the group seeking treatment for sexual dysfunction and the general medical clinic population reflects the fact that only 11% of men in the study population identified ejaculation as a problem.28 B4 B6 Fl Problem Assessment F2 F3 0.39 0.59 0.37 0. For ejaculation. It might be argued that a more complete picture could be obtained by interviewing any sexual partners as well.64 0. Men vary greatly in the way they are affected by sexual dysfunction. Finally. the items can be used one at a time to assess their response to dysfunction in individual domains.*l We also think the three problem assessment questions are an important component of an assessment of sexual status. problem assessment. The three questions in this domain form a psychometrically sound index of how problematic respondents find their sexual status.35 0. uROLcGY@ 46 (5).32 0.28 0. The instrument was designed and has been validated for self-administration.49 0. With respect to drive and function.37 0. two questions work almost as well as three to measure erectile function. the practical and logistical problems of routinely collecting data from partners. make self-response the clear choice for measuring sexual function and satisfaction in clinical studies.38 0.65 0. although not for ejaculation (P = 0.45 0. note that question BS can be used alone to determine whether respondents meet the National Institutes of Health definition of impotence (not having erections sufficient for intercourse) . and overall sexual satisfaction.OOOl>.47 0. COMMENT These 11 sexual function and satisfaction questions were developed to capture the key areas of male sexuality as clearly and concisely as possible.52 0.58 0.38 0.33 0. the internal consistency of answers in these domains makes it clear there is a meaningful construct that people can reliably describe. several studies have documented that couples give similar replies when asked independently about their sexual behavior.OOOl).40 0.43 0.36).48 0.52 toitems (P = O.
Ovemll. some of the longer instruments available may be quite practical to use and may offer superior psychometric properties. In the past 30 days. 1995 . Over the pas( 30 bya. lo the past 30 days. when you bad crsctio~. We believe the 2 questions about ejaculation included among our 1 l-item inventory may be as good as any if one wants to assess the effects of treatments on men’s perceptions of semen volume.SEXUAL DRIVE Let’s detinc sexual drive as a feeling tlmt nuy inchIde wadng to have . A brief sexual function inventory. thinking about having sex. comparative studies are needed to address this question. reliability. Duriw your level the pall of sexual 30 days.d 30 days.t all only a few &YE I Low 1 Some 2 Medium 2 Medium 3 days Most 3 High days Ahnon every 4 High 4 day 0 not get erectiona . duniq have you been with tbc put 30 days. UROLOGY@46 (51.st 30 days. as in the treatment of sexual dysfunction. have you felt m-1 drive? on how many days No days 0 2.t all 0 I Alotof difticulty I 2 3 Little difficulty 3 4 NO difticulty 4 Some diffkulty 2 EJACULATlON 6. how much diffkulty have you bad ejaculating when you have been sexually dimulaed? Have had no sexual stimulation in pwt month 0 7. One of the uses of this inventory could be in clinical studies of men in which effects on sexu704 ality need to be monitored. to what extent have considered a lack of ssx drive to be a problem? IO. may be the best single question to ask about that domain. Its strengths include validity. Such work is under way. if sexual function is the primary outcome in a study. how &en have you M pmxiial or full sexual ere&ona when you we= wxually timulatcd in any way? 4. or foelii fnwtrated due to lack of mbx. we know from our testing that respondents are not good reporters about this aspect of their sexuality Respondents can report on their concerns and problems. to what extent have you 11. your sex life? how defied Very diaatiatied FIGURE 2. bow much the mnatnt of semen you cjwxdate for you? did you consider to be a problem A lot of difficulty 1 some diffndty 2 Medium problem 2 Little diffxulty 3 No diff&xdty 4 Did not climax 0 Big problem I Small pmblem 3 No problem 4 ?ROBLlZbi ASESMENT you Medium Very snull 8. Over the p. How erection much during difticulty dii you the past 30 days? have getting an Did Not u all 0 A few times 1 Fairly 2 often UUY 3 AIWQ? 4 . One weakness of our validation study is we have not yet assessed the responsiveness of this inventory or its subscales to clinically important changes in patients’ conditions. In the past 30 &ym. In the paat 30 bya. However. Isxlul experience (dation or intarcounc). drive? how would you rate None 0 ERECTIONS 3. and that is what we recommend asking them. how often wem they tkm enough to have sexual intewoune? 5. During the p. 1. and parsimony However.
1993. 2. J Urol 148: 1549-1557. having patients complete a brief. and Fowler FJ: The methodology for evaluating the subjective outcomes of treatment for benign prostatic hyperplasia. No. impotent. Keller AM. and Kupfer DJ: Assessment of sexual function in depressed. suggesting erectile dysfunction with intact libido.S. 705 . and Tourangeau R: Questionnaire design in the cognitive research laboratory. 5. 8. Stoner E. N Engl J Med 332: 75-79. Sherbourne CD: Social functioning: sexual problems measures. 1993. Fineman KR. U. Lynch JH: Treatment of advanced prostate cancer. 1989. J Sex Marital Ther 5: 244-281. 12. pp 194-204. and healthy men: factor analysis of a Brief Sexual Function Questionnaire for men.1991. Adv Urol 6: 83-99. Frank E. The inventory may also prove useful in the office setting to assess sexual function as part of daily care. 1992. 1986. Mebust WK. 1993. Thase ME. McClennan BL. self-administered questionnaire might well help clinicians and patients to communicate better about an area that can be uncomfortable to discuss. Bruskewitz RC. Lilienfeld SO. Gormley GJ. McConnell JD. Duke University Press. The Measurement Committee of the American Urological Association. instrument development should take place simultaneously in the languages in which the instrument will be used. 9. Studies are currently under way to evaluate further the discriminant validity of the sexual drive subscale among groups of men who should have decreased sexual drive. and Reilly NJ: Benign prostatic hyperplasia: diagnosis and treatment. McConnell JD. Mebust WK. 6. and Lessler JT: Cognitive laboratory methods: a taxonomy. an individual patient may have a high sexual drive subscale score but a low erection subscale score. Bruskewitz RC. and Cockett AT: The American Urological Association Symptom Index for benign prostatic hyperplasia. Urology 42: 622-629. 1994. 13. Bracken BR. ImperatoMcGinley J. Fowler FJ Jr. DC. 15. 1994. Holtgrewe HL. Md: Agency for Health Care Policy and Research. J Urol 148: 1546-1548. 7. Reynolds CF 3d. AHCPR Publication No. Wasson JH. 4. 16. Department of Health and Human Services. 1988. and Fowler FJ Jr: Hard measures of subjective outcomes: validating symptom indexes in urology. NC. it is not possible to generate a single score from the 11-item inventory The way to use the results is either by examining the individual questions or by creating a summary score for each of the five subscales (including the single item on overall satisfaction). Psychiatry Res 24: 231-250.In clinical practice. Durham. Lybert LE. Forsyth BH. Lange JL. O’Leary MP. but that is of importance to many men of all ages and that can be very relevant to medical treatment decisions. and Rettinger HI: Development of the male function profile/impotence questionnaire. Bruskewitz RC. since both control subjects and sexual dysfunction patients had similar scores on the sexual drive subscale. Andriole GL. Bruskewitz RC. Barry MJ. US Government Office. CONCLUSIONS This set of questions can be used by urologic researchers in the evaluation of men on treatments or with conditions that may affect sexual function. Fowler FJ Jr. Walsh PC. 1979. 8. Psycho1 Rep 68: 1151-1175. Houck PR. 1992. REFERENCES 1. 14. Arch Sex Behav 15: 157-165. 94-0582. Barry MJ. Rockville. February. and Golombok S: The Griss: a psychometric instrument for the assessment of sexual dysfunction. For example. Reda DJ. 10. Holtgrewe HL. Elinson J. Bueschen AJ. Lowe FC: Safety assessment of terazosin in the treatment of patients with symptomatic benign prostatic hyperplasia: a combined analysis. Vital and Health Statistics 6(l). This makes it important to understand the intent of the developers of the original instrument when developing translations. Groves RM. The discriminant validity of this instrument in the area of libido needs to be tested further. This inventory could serve that purpose well. and Henderson WG: A comparison of transurethral surgery with watchful waiting for moderate symptoms of benign prostatic hyperplasia. Ambiguous phrases in the language of origin of a questionnaire may require choosing one of several more precise phrases in another language. Because sexual function is multidimensional. 1992. although ejaculatory function is poorly reported by respondents. Derogatis LR. The Finasteride Study Group. Rust J. Some idioms translate poorly and translations can produce shifts in meaning with unintended consequences. 1992. Geller J. in Biemer PN. 1995. Barry MJ. Clinical Practice Guideline. Public Health Service. such as patients on androgen deprivation therapy for prostate cancer or with a diagnosis of major depression. Lu-Yao G. O’Leary MP. Two questions that appear equally acceptable in one language may represent very different levels of difficulty in achieving cultural equivalence when translated into another language. and Melisasatos N: The DSFI: a multidimensional measure of sexual functioning. and Wennberg JE: Patient reported complications and followup treatment after radical prostatectomy: the National Medicare experience: 1988-1990. Barry MJ. Whenever possible. In that way questions and response items that pose major translation difficulties can be avoided and cultural equivalence should be easier to achieve. J Fam Pratt 37: 488494. Jennings JR. Tenover JS. The inventory provides a reliable and valid yet parsimonious way to characterize sexUROLOGY~ 46 (51. Wasson J. et al: The effect of finasteride in men with benign prostatic hyperplasia. Roman A. Washington. 1995 ual function and satisfaction. in Stewart AL and Ware JE (Eds): Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Howell JR. Lessler J. Denton SE. N Engl J Med 327: 1185-1191. 3. 11. The differences in interpretation encountered during pilot testing in a number of languages make it clear that ease of translation should be considered from the beginning when developing a questionnaire for international use. Barry MJ. Urology 44: 46-51.
and Withey SB: Social Indicators of WellBeing. and Rubinstein D: Frequency of sexual dysfunction in “normal” couples. WB Saunders. Cronbach LJ: Coefficient alpha and the internal structure of tests. and Sudman S (Eds): Measurement Errors in Surveys. 23. Kleinbaum DG. New York. 22. 18. New York. New York. 1993. 1991. Plenum Press. 19. 17. Kinsey AC.Mathiowetz NA. 20. 1978. Impotence. Psychometrika 16: 297. 21. Control Clin Trials 12: 142S-159S. N Engl J Med 299: 111-115. and Morgenstern H: Epidemiologic Research: Principles and Quantitative Methods. 706 UROL~Y’ 46 (51. 1976. Lifetime Learning Publications. Pomeroy WB. and Martin CE: Sexual Behavior in the Human Male. 1991. Frank E. Kupper LL. John Wiley & Sons. and Patrick D: Reproducibility and health status measures. Anderson C. Deyo RH. NIH Consensus Conference. pp 125-128 and 235-238. p 152. 1951. Andrews FM. 1995 . pp 393-418. Diehr P. 1982. Philadelphia. JAMA 270: 83-90. 1949.
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