0022-5347/99/1626-1999/0

THE JOURNAL OF UROLOGY® Vol. 162, 1999 –2002, December 1999

Copyright © 1999 by AMERICAN UROLOGICAL ASSOCIATION, INC.® Printed in U.S.A.

A COMPARISON OF PATIENT AND PARTNER RESPONSES TO A BRIEF

SEXUAL FUNCTION QUESTIONNAIRE
SUSAN D. MATHIAS, MICHAEL P. O’LEARY, JAMES M. HENNING, DAVID J. PASTA,
SUSAN FROMM AND RAYMOND C. ROSEN
From Lewin-TAG, Inc., San Francisco, California, Brigham and Women’s Hospital, Boston, Massachusetts, TAP Holdings, Inc., Deerfield,
Illinois, and Robert Wood Johnson Medical School, Piscataway, New Jersey

ABSTRACT

Purpose: Patient self-administered questionnaires have recently been developed to assess sexual
function in men with erectile dysfunction. However, it may also be important to assess satisfaction
with and any improvements in sexual function from the perspective of the female partner. We report
the results of a brief 3-item questionnaire developed for the female partner and its association with
an 11-item questionnaire developed for men with erectile dysfunction.
Materials and Methods: Men and their female partners each self-administered a brief sexual
function questionnaire several times during a clinical trial of an experimental treatment for
erectile dysfunction. Items addressed the frequency and firmness of erection, and satisfaction
with sex life on a 5-point Likert scale with responses ranging from 0 to 4. We compared mean
values of the 3 items common to each questionnaire by respondent, and also analyzed item and
scale correlations using weighted kappa statistics and/or the Pearson correlation coefficient.
Results: Data from 389 pairs were available. Generally patient results were fairly consistent
with those of partners. Men reported slightly more frequent erection (1.6 versus 1.5), identical
firmness of erection (1.2) and less satisfaction (1.2 versus 1.4) than partners. Weighted kappas of
the 3 items ranged from 0.47 to 0.61, representing good agreement. The Pearson correlations
were slightly higher. Internal consistency reliability using Cronbach’s a of the 3-item scale was
0.69 (0.77 for patient and 0.81 for partner).
Conclusions: These data support the use of patient and partner assessments of sexual function
in clinical trials of erectile dysfunction.
KEY WORDS: impotence; sexual partners; sexual dysfunction, psychological; questionnaires

Erectile dysfunction is estimated to affect 30 million men
in the United States.1, 2 This condition is defined as the
inability to achieve or maintain erection enabling sexual
intercourse.2– 4 As well as affecting sexual function, many
men with erectile dysfunction also report decrements in self-
esteem and interpersonal sensitivity, and decreases in phys-
ical and role function as well as increased depression and
mental distress.3, 5 Erectile dysfunction also affects the inter-
personal relationship of a man and his sexual partner.5–7
Since erectile dysfunction affects sexual behavior and expe-
riences between sexual partners, there is an impact on the
sexual satisfaction of the man and his female partner.5, 8
Areas of sexual function within a relationship that may affect
each partner include anorgasmia, infrequency of sexual ac-
tivity, noncommunication between partners, sexual dissatis-
faction, nonsensuality and avoidance of sexual encounters.8
With the advent of new therapies to treat men with erectile
dysfunction, self-administered questionnaires have been de-
veloped to assess sexual function and satisfaction.1, 4, 5, 9, 10
Many questionnaires are designed to be completed only by
the man with erectile dysfunction. Some studies ask men
about perceived acceptance by the sexual partner without
measuring sexual partner satisfaction directly.11 Recently
questionnaires have been developed for men with erectile
dysfunction and for their sexual partners. These measures
typically assess sexual function, including duration of erec-
tile dysfunction, frequency of intercourse, premature ejacu-
lation, quality of erection and sexual satisfaction.4, 8, 12–14
Accepted for publication July 23, 1999.
Supported by TAP Holdings, Inc., Deerfield, Illinois.
Presented at annual meeting of American Urological Association,
San Diego, California, May 30-June 4, 1998.
1999
Occasionally these measures are used in conjunction with
more general mental health measures, such as those assess-
ing self-esteem, anxiety and depression.12 We assessed sex-
ual function and satisfaction from the perspective of the man
with erectile dysfunction and his female partner. We evalu-
ated the responses of men and women separately with an
emphasis on similarities and differences in male patients and
their partners.
METHODS
The study was performed as part of an 8-week, multicenter,
double-blind, randomized, placebo controlled crossover phase
III clinical trial of apomorphine SL, a new oral treatment for
erectile dysfunction.15 Healthy heterosexual men 18 to 70 years
old who had the confirmed diagnosis of erectile dysfunction with
no major organic component (controlled hypertension and dia-
betes were acceptable) were enrolled in the study. Study criteria
included a stable heterosexual relationship at least 6 months in
duration, and the physical ability to attain and maintain partial
erection on at least 1 night of nocturnal penile erection testing.
In addition, each patient agreed to attempt to engage in sexual
intercourse with the partner at least twice weekly during the
study. All study materials were reviewed and approved by in-
stitutional review boards at each participating institution. Pa-
tients and partners provided written informed consent before
participating in the study.
An 11-item sexual function questionnaire10 was completed
by all men during the clinical trial at baseline, at the close of
the initial treatment period and at the end of the second
treatment period (study end). Sexual partners of each en-
rolled study participant also completed an abbreviated
2000 COMPARISON OF PATIENT AND PARTNER RESPONSES TO SEXUAL FUNCTION QUESTIONNAIRE
3-item version of this questionnaire at the same times. Pa-
tients and partners were blinded to each other’s responses.
Study sites were instructed to have patients and partners
self-administer the questionnaire at the clinic before being
seen at the regularly scheduled visit. Investigators and study
coordinators were asked not to assist the respondents in
interpreting questions but to encourage them to answer each
question to the best of their ability.
The sexual function questionnaire contains items covering
the specific areas of sexual drive, erection, ejaculation, sexual
problem assessment and overall satisfaction. The time frame
for all items was the last 30 days. A 5-point response scale
was used for each item. There were established data on
reproducibility at 1 week and internal consistency reliability
as well as construct validity (relationships among the sub-
scales) and discriminant validity (comparing scores for pa-
tients treated versus those of controls).10 The 3-item abbre-
viated partner version of the questionnaire was developed
specifically for use in this study (see Appendix). It includes 1
item each on the frequency and firmness of erection, and on
overall satisfaction with sex life, as rated on a scale of 0 —less
to 4 — greater. Corresponding items were included as part of
the patient questionnaire. These 3 items were selected from
the 11-item sexual function questionnaire because of rele-
vance to women. The frequency and firmness questions were
worded to refer specifically to the husband/partner, while the
satisfaction item addressed overall female satisfaction with
her sex life with her partner.
To evaluate the concordance between the responses of male
patients and their partners we calculated 2 measures of
reliability. The Pearson R correlation coefficient is a familiar
measure of agreement, although it may overestimate the
degree of concordance in groups with large mean differenc-
es.16 We also calculated the weighted version of Cohen’s
kappa.17 The weighted kappa, appropriate for responses that
are ordinal or continuous, weights disagreement according to
how many categories separate the 2 responses. A weighted
kappa .0.70 is acceptable, while a value ^0.80 indicates
redundancy.
We also calculated a summary score for the 3 items as the
simple sum of the items. We determined an average response
for each of the 3 items and the summary score by gender, and
compared the values using a paired t test statistic. Internal
consistency reliability is a measure of the similarity of individ-
ual responses across several items, indicating the homogeneity
of a scale and the extent to which the scale is free of random
error. Cronbach’s coefficient a provides an estimate of reliability
based on all possible correlations among items collected at any
time point.18
Finally, we categorized patients by treatment success, de-
fined as an erection firm enough for intercourse more than
50% of the time. We then compared mean values of each of
the 3 items and the summary score for those successfully
versus those unsuccessfully treated. For study purposes we
pooled data regardless of treatment. All statistical analyses
were completed with commercial software.
RESULTS
A total of 389 patient and partner pairs completed the
questionnaire at baseline and at the end of the initial treat-
ment period, that is after 4 weeks of active treatment or
placebo. Male study participants had a mean age plus or
minus standard deviation of 53.8 6 9.9 and 87% were white.
All responding partners were female.
Data for the end of treatment period 1 yielded the same
conclusions as those for the end of treatment period 2. The
only material differences in the 2 periods were that the
sample size was decreased to 341 pairs, and scores on all
items were slightly lower for each respondent at the end of
treatment period 2. Therefore, we present results for the end
of treatment period 1 only.
When we evaluated the concordance between men and
women at the end of treatment period 1, there was generally
good agreement (see table). For each measure of concordance
there was the least agreement on frequency of erections and
satisfaction with sex life. Weighted kappa coefficients were
also lower than the Pearson correlations for each item and
the summary score. We noted asymmetry in subsequent
analyses of the difference in kappa. For example, for the item
regarding frequency of erections we noted that 18 pairs
(4.6%) responded “not at all” when asked how often they or
their partners had a partial or full erection when sexually
stimulated. However, when 1 member of the pair responded
“not at all,” 7 women (1.8%) responded “a few times,” “fairly
often,” “usually” or “always” compared with 31 men (8.0%).
Likewise 130 pairs (33.8%) responded “a few times” when
asked how often they or their partners had an erection firm
enough for sexual intercourse. When 1 member of the pair
responded “a few times,” 26 women (6.8%) responded “fairly
often,” “usually” or “always” versus 31 men (8.1%). However,
the opposite pattern was noted for satisfaction with sex life.
For example, 35 pairs (9.0%) responded “neutral or mixed”
when asked how satisfied they had been with sex life. When
1 member of the pair responded “neutral or mixed,” 23
women (5.9%) responded “mostly satisfied” or “very satisfied”
in contrast to 10 men (2.6%).
Figure 1 shows mean values per respondent for each item
and the summary score. Women reported significantly
greater mean satisfaction with sex life than their male coun-
terparts (1.44 6 1.10 versus 1.17 6 1.01, p ,0.001). Coupled
with the comparable reports of frequency and firmness, the
significant difference in satisfaction resulted in borderline
statistically significant differences between respondents for
the summary score (p 5 0.060).
When men were categorized into those who were success-
fully versus not successfully treated, trends of the pooled
analysis of all respondents still persisted. In each instance
women reported significantly greater satisfaction than men.
In addition, there was a trend toward women reporting more
frequent erections than men in the group not successfully
treated (1.06 6 0.93 versus 1.18 6 0.83, p 5 0.069). As
expected, lower scores on all items were reported by those
who did not versus those who did receive successful treat-
ment (for all items p ,0.001).
Cronbach’s a, a measure of the extent to which items
within a scale correlate with each other to constitute a multi-
item scale, was calculated and found to be acceptable (a 5
0.77 in men and 0.81 in women). Figures 1 and 2 show values
for the summary score by respondent.
Finally, we explored the possibility that the 6 items (3 per
respondent) constituted a scale. As an initial approximation, we
observed that the 6 items measured the same construct. In fact,
Cronbach’s a for such a 6-item scale is 0.86, which was a higher
value than that calculated for each of the 2 individual summary
scores. Some may find such a summary score more convenient
as a single end point. However, doing so does not permit exam-
ination of the data by respondent.
DISCUSSION
Extensive research is under way on developing outcome meas-
ures to document the decrement in sexual function accompany-
Indicators of concordance
Pearson R Weighted Kappa
Frequency 0.59 0.48
Firmness 0.72 0.61
Satisfaction 0.64 0.47
Summary score 0.73 0.54
 COMPARISON OF PATIENT AND PARTNER RESPONSES TO SEXUAL FUNCTION QUESTIONNAIRE
FIG. 1. Mean values by respondent with lower value representing less frequency, firmness or satisfaction
FIG. 2. Mean values by respondent with lower value representing less frequency, firmness or satisfaction
ing erectile dysfunction and the potential benefits resulting
from successful treatment. However, few studies have been
performed that systematically evaluate the responses of sexual
partners. While a few questionnaires are currently being de-
vised for assessing partner responses, only 1 published study to
date has investigated the concordance between the responses of
male patients and their partners.19 If concordance were high, it
may be argued that the collection of such data would be redun-
dant. On the other hand, low concordance rates may raise
concerns about the validity of patient or partner responses. The
results of our study suggest that, in addition to evaluating the
responses of male patients, future research studies of erectile
dysfunction, as well as individual clinical treatment and coun-
seling sessions, should include the systematic assessment of
partner responses.
Magaziner20 and Dorevitch21 et al reported that proxies
tend to overestimate disability, particularly in regard to ac-
tivities of daily living. However, we noted that generally men
and women provided consistent estimates of the frequency
and firmness of erections. Women reported significantly
greater satisfaction with sex life with the male partners than
was reported by men. Measures of concordance indicate good
agreement. While we report our findings for each respondent
separately, evidence suggests that a composite score combin-
ing responses from each individual may be of value. Assess-
ment of sexual function has been shown to be feasible in
clinical settings. Unlike the recent study of Goldstein et al in
which only 25% of the partners completed an optional ques-
2001
tionnaire,22 96% of partners completed our questionnaire,
which was administered in the waiting room of a physician
office.
Our finding that women consistently report greater satis-
faction with sex life than men is not altogether surprising. In
light of the results that indicate fairly comparable values on
the 2 items of frequency and firmness of erection, certain
hypotheses are suggested. It is possible that men define sex
life as the ability to maintain an erection that results in
sexual intercourse. On the other hand, women may have a
more comprehensive outlook when considering sex life. For
example, women may include nongenital touching by the
sexual partner when evaluating the quality of the sexual
relationship. A related hypothesis is that sexual intercourse
may not be as important for women as it is for their male
partners. Therefore, the inability to maintain an erection
sufficient for sexual intercourse may not decrease sexual
satisfaction to the same degree in women.
The results of our study should be interpreted in light of
several limitations. As part of the entry criteria, patients
were required to be in a stable heterosexual relationship at
least 6 months in duration and attempt sexual intercourse
at least twice weekly during the 8-week study. Therefore, for
the most part couples in this study knew each other well. As
in any other study of this nature, it is also possible that
individuals may have shared questionnaire responses with
each other, increasing the likelihood of concordance. It would
also be of interest to solicit information about pre-erectile
2002 COMPARISON OF PATIENT AND PARTNER RESPONSES TO SEXUAL FUNCTION QUESTIONNAIRE
dysfunction levels of satisfaction with sex life to determine
whether they also differed. In addition, sexual function is just
1 area of relevance when rating relationship satisfaction and
overall quality of life. Other questionnaires should be devel-
oped and/or adapted to address other domains, such as mar-
ital function.
CONCLUSIONS
Our data suggest that there is substantial concordance
between assessments of sexual function by male patients
with erectile dysfunction and their partners. However, there
is not enough overlap to suggest redundancy. Based on
these findings, researchers and clinicians should consider
collecting data from each individual when performing clinical
trials of erectile dysfunction.
APPENDIX: PARTNER VERSION OF QUESTIONNAIRE
In the past 30 days:
1. How often has your husband/partner had partial
or full sexual erections when he was stimulated in
any way? (FREQUENCY)
2. When your husband/partner had erections, how
often were they firm enough to have sexual inter-
course? (FIRMNESS)
3. Overall, how satisfied have you been with your
sex life with your husband/partner? (SATISFAC-
TION)
REFERENCES
1. Feldman, H. A., Goldstein, I., Hatzichristou, D. G., Drane, R. J.
and McKinlay, J. B.: Impotence and its medical and psychos-
ocial correlates: Results of the Massachusetts Male Aging
Study. J. Urol., 151: 54, 1994.
2. Linet, O. I. and Ogrine, F. G.: Efficacy and safety of intracaver-
nosal alprostadil in men with erectile dysfunction. New Engl.
J. Med., 334: 873, 1996.
3. Impotence. National Institutes of Health Consensus Develop-
ment Panel on Impotence. J.A.M.A., 270: 83, 1993.
4. Rosen, R. C., Riley, A., Wagner, G., Osterloh, I. H., Kirkpatrick,
J. and Mishra, A.: The International Index of Erectile Func-
tion (IIEF): a multidimensional scale for assessment of erectile
dysfunction. Urology, 49: 822, 1997.
5. Willke, R.: Quality of life effects of alprostadil therapy for erec-
tile dysfunction. J. Urol., 157: 2124, 1997.
6. Gheorghiu, S., Godschalk, M., Gentili, A. and Mulligan, T.: Qual-
ity of life in patients using self-administered intracavernous
injections of prostaglandin E1 for erectile dysfunction. J. Urol.,
156: 80, 1996.
7. Carroll, J.: Evaluation of sexual satisfaction in partners of men
experiencing erectile failure. J. Sex. Marital Ther., 16: 70, 1990.
8. Rust, J. and Golombok, S.: The Golombok-Rust Inventory of Sexual
Satisfaction (GRISS). Brit. J. Clin. Psychol., 24: 63, 1985.
9. Fineman, K. R. and Rettinger, H. I.: Development of the male
function profile/impotence questionnaire. Psychol. Rep., 68:
1151, 1991.
10. O’Leary, M. P., Fowler, F. J., Lenderking, W. R., Barber, B.,
Sagnier, P. P., Guess, H. A. and Barry, M. J.: A brief male
sexual function inventory for urology. Urology, 46: 697, 1995.
11. Limoge, J.: Minimally invasive therapies in the treatment of
erectile dysfunction in anticoagulated cases: a study of satis-
faction and safety. J. Urol., 155: 1277, 1996.
12. Althof, S. E.: Through the eyes of women: the sexual and psy-
chological responses of women to their partner’s treatment
with self-infection or external vacuum therapy. J. Urol., 147:
1024, 1992.
13. McLaren, R. H.: Patient and partner satisfaction with the AMS
700 penile prosthesis. J. Urol., 147: 62, 1992.
14. Speckens, A. M.: Psychosexual functioning of partners of men
with presumed nonorganic erectile dysfunction: cause or con-
sequence of the dysfunction. Arch. Sex. Behav., 24: 157, 1995.
15. Padma-Nathan, H., Fromm-Freeck, S., Ruff, D. D., McMurray,
J. G. and Rosen, R. C.: Efficacy and safety of apomorphine SL
vs placebo for male erectile dysfunction (MED). J Urol., part 2,
159: 261, abstract 920, 1998.
16. Deyo, R. A., Diehr, P. and Patrick, D. L.: Reproducibility and
responsiveness of health status measures: Statistics and strate-
gies for evaluation. Control Clin. Trials, suppl., 12: 142S, 1991.
17. Cohen, J.: A coefficient of agreement for nominal scales. Educ.
Psychol. Meas., 20: 37, 1960.
18. Cronbach, L. J.: Coefficient alpha and the internal structure of
tests. Psychometrika, 16: 297, 1951.
19. Glick, H. A., McCarron, T. J., Althof, S. E., Corty, E. W. and
Willke, R. J.: Construction of scales for the Center for Marital
and Sexual Health (CMASH) sexual functioning question-
naire. J. Sex. Marital Ther., 23: 103, 1997.
20. Magaziner, J., Simonsick, E. M., Kashner, T. M. and Hebel, J. R.:
Patient-proxy response comparability on measures of patient
health and functional status. J. Clin. Epidemiol., 41: 1065, 1988.
21. Dorevitch, M. I., Cossar, R. M., Bailey, F. J., Bisset, T., Lewis,
S. J., Wise, L. A. and MacLennan, W. J.: The accuracy of self
and informant ratings of physical functional capacity in the
elderly. J. Clin. Epidemiol., 45: 791, 1992.
22. Goldstein, I., Lue, T. F., Padma-Nathan, H., Rosen, R. C., Steers,
W. D. and Wicker, P. A.: Oral sildenafil in the treatment of
erectile dysfunction. Sildenafil Study Group. New Engl.
J. Med., 338: 1397, 1998.