REVIEW

A Systematic Review of Sexual Distress Measures

Pablo Santos-Iglesias, PhD,1 Bijan Mohamed, BSc,2 and Lauren M. Walker, PhD, RPhysch3,4

ABSTRACT

Background: Sexual distress is an important component of sexual dysfunction and quality of life and many
different measures have been developed for its assessment.
Aim: To conduct a literature review of measures for assessing sexual distress and to list, compare, and highlight
their characteristics and psychometric properties.
Methods: A systematic review was conducted using Scopus and PubMed databases to identify studies that
developed and validated measures of sexual distress. The main characteristics and psychometric properties of each
measure were extracted and examined.
Outcomes: Psychometrically validated measures of sexual distress and a summary of relative strengths and
limitations.
Results: We found 17 different measures for the assessment of sexual distress. 4 were standalone questionnaires
and 13 were subscales included in questionnaires that assessed broader constructs. Although 5 measures were
developed to assess sexual distress in the general population, most were developed and validated in very specific
clinical groups. Most followed adequate steps in the development and validation process and have strong
psychometric properties; however, several limitations were identified.
Clinical Translation: This literature review offers researchers and clinicians a list of sexual distress measures and
relevant characteristics that can be used to select the best assessment tool for their objectives.
Strengths and Limitations: A thorough search procedure was used; however, there is still a chance that
relevant articles might have been missed owing to our search methodology and inclusion criteria.
Conclusion: This is a novel and state-of-the-art review of assessment tools for sexual distress that includes
valuable information measure selection in the study of sexual distress and sexual dysfunction. Santos-Iglesias P,
Mohamed B, Walker L. A Systematic Review of Sexual Distress Measures. J Sex Med 2018;XX:XXXeXXX.
Copyright
2018, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Sexual Distress; Sexual Dysfunction; Literature Review; Assessment; Validation

INTRODUCTION anxiety, frustration, bother, or feelings of inadequacy, that people

The study of sexual dysfunction is an important topic of experience associated with their sexuality and their sexual func-
investigation in sexual health research because sexual dysfunction tion5,6 and that ultimately exert a negative impact on overall
acts as a barrier to optimal sexual health and quality of life by well-being and quality of life.7 Although sexual distress is gaining
affecting various aspects of an individual’s sexual more attention in research and clinical fields, it remains a
relationships.1e3 Of particular interest in the study of sexual relatively understudied concept.8
dysfunction is the construct of sexual distress.4 Sexual distress The importance of considering sexual distress is underscored
refers to different negative emotional responses, such as worry, by its inclusion as a criterion for the diagnosis of sexual
dysfunctions in the Diagnostic and Statistical Manual of Mental
Disorders, 5th Edition (DSM-5).9 Nonetheless, there are several
Received September 28, 2017. Accepted February 23, 2018.
1 other reasons for why it is helpful to evaluate sexual distress as a
Department of Oncology, University of Calgary, Calgary, AB, Canada;
2 separate construct in the context of sexual dysfunction. The way
Department of Psychology, University of Calgary, Calgary, AB, Canada;
3
in which researchers choose to assess sexual health and problems
Department of Oncology, University of Calgary, Calgary, AB, Canada;
4
greatly influences the prevalence estimates of sexual disorders.
Department of Psychosocial Resources, Tom Baker Cancer Centre, Calgary,
AB, Canada
For example, estimates of sexual dysfunction decrease when
sexual distress measurements are taken into account,10 suggesting
Copyright ª 2018, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved. that sexual distress should be assessed to prevent overestimates of
https://doi.org/10.1016/j.jsxm.2018.02.020 sexual dysfunction. Unfortunately, sexual distress has been

J Sex Med 2018;-:1e20 1

2 Santos-Iglesias et al
missed by widely used sexual function assessments such as the
Female Sexual Function Index (FSFI)11 and the International
Index of Erectile Function (IIEF).12,13 The sole assessment of
sexual function in the absence of distress, using tools such as the
FSFI and IIEF, provides a singular perspective of sexual
dysfunction. For example, by determining the presence of sexual
dysfunction based on a cutoff score, such measures imply that
function alone is the only relevant aspect of sexual dysfunction.
In contrast, sexual dysfunction is more likely accurately described
as a biopsychosocial phenomenon.14 Furthermore, exclusive
assessment of functional status does not typically consider how
people feel about their sexual problems, despite evidence that
people’s subjective evaluation about their problems has a large
influence on their quality of life.15
Ultimately, there is clinical and practical value in considering
the assessment of sexual distress in the context of sexual
dysfunction and sexual health. For instance, people experiencing
sexual distress are more likely to discuss their sexual problems
with their physician and to seek treatment16 than those not
experiencing sexual distress. That is, a sexual problem that is not
perceived as distressing is unlikely to motivate treatment-seeking
behavior. Furthermore, there are relevant changes in the relation
between distress and function that come with age. Bancroft
et al17 and Shifren et al18 noted that although sexual problems
were more common in older women, younger women were more
likely to be distressed by them. These points underscore the
importance of being aware of the differences between sexual
function and distress and demonstrate the value of assessing
sexual distress separate from and in addition to impairments in
sexual function.
In the context of sexual health research, it is as important to
assess sexual distress as a separate, distinct construct as it is to
assess it accurately. Scale development and validation is a
continuous process that involves defining the construct to be
assessed, in addition to its components or dimensions, devel-
oping a pool of items, testing their psychometric properties, and
accurately reporting the entire process.19,20 Among all desirable
properties that are relevant when considering the strength of
certain measures, researchers largely focus on reliability (ie, the
degree to which a test score is free of error of measurement)21
and validity (ie, “the degree to which evidence and theory sup-
port the interpretation of test scores for proposed use of tests”).19
However, other relevant aspects of the construction and valida-
tion process should be considered when selecting assessment
tools,22,23 because reliability and validity are not immutable
qualities of the measure itself.24 A common challenge among
researchers and clinicians is choosing the most appropriate
assessment tool among many available options23,25; therefore, an
examination of characteristics and validation of the measures is
essential. This systematic review should facilitate this decision-
making process by providing a comprehensive list of sexual
distress measures and their characteristics and psychometric
properties. Although there are various reviews of measures used
to assess sexual function,23,25,26 there is not yet a comparable
review for measures that assess sexual distress. The purpose of the
present article is to review the measures available for assessing
sexual distress and to list, compare, and highlight their charac-
teristics and psychometric properties to assist researchers and
clinicians in choosing the measures that best meet their needs.
METHODS
Literature Search
To identify measures assessing sexual distress, a literature
search was conducted from June through November 2016
through the Scopus (within health and social sciences journals
only) and PubMed databases. This search was limited to the title
and abstract of original studies and literature reviews that were
published or in press in English without any year restriction.
Different relevant synonyms for sexual distress, such as sexual
bother, concern, or worry, were used in the search because past
research found that these words also reflect patients’ negative
psychological responses relating to sex.27 Proximity operators
were used to limit the allowed adjacency to 3 words between the
search terms for the searches in Scopus (eg, sex* w/3 distress*).
Because PubMed did not allow for this function, the search
terms were entered as phrases (eg, sexual distress). The purpose of
using all these limitations was 2-fold: (i) to restrict the large
volume of results that appeared when searching more broadly
and (ii) to retain publications that focused on measuring the
specific state of sexual distress (rather than general emotional
distress or other types of distress). In addition, an exploratory
search conducted in the context of a related research project led
to the discovery of additional records that were considered for
inclusion during the screening of articles.
Inclusion Criteria, Screening, and Data Extraction
After the initial search, abstracts were reviewed to screen for
measures that specifically assessed sexual distress. If this was
unclear from the abstract, then the full text was retrieved to check
this criterion. Articles that were retained after the initial screen
were further assessed to determine whether they included vali-
dated measures that assess sexual distress. Inclusion criteria
consisted of the following: (i) the authors qualified sexual distress
in a manner fitting the proposed definition of sexual distress in
the Introduction; (ii) the authors provided a complete psycho-
metric validation of a sexual distress measure; (iii) the measure
must have been a full scale for assessing sexual distress or must
have included a specific separate subscale for assessing sexual
distress; and (iv) the measure must have been developed and
validated in English. A list of the research investigations that used
the instruments also was retained to determine the frequency of
usage for each measure. Once a measure was accepted according
to the inclusion criteria, a 2nd search was conducted to identify
all potential articles that had examined the psychometric prop-
erties of each measure by (i) searching for articles using the name
J Sex Med 2018;-:1e20
Sexual Distress Measures 3

Table 1. List of characteristics extracted from each measure
1 Name of measure, authors, and year of
publication
2 Definition and operationalization of sexual
distress used by the authors
3 Measure development procedure
4 Samples used in creation and validation
5 Number of items
6 Response scale and scoring system
7 Evidence of reliability:
Internal consistency (eg, Cronbach a)
Test-retest
8 Evidence of validity according to groupings of
the AERA, APA, and NCME19:*
Evidence based on test content
Evidence based on internal structure
Evidence based on relations to other variables
9 Existence of cutoff scores or norms
10 Existence of translations and validations
AERA ¼ American Educational Research Association; APA ¼ American
Psychological Association; NCME ¼ National Council on Measurement in
Education.
*Because none of the measures found had included evidence of validity
based on response processes, this category was not included in the analysis.
of the measure (eg, Female Sexual Distress Scale) and (ii) iden-
tifying the original validation article for each measure and
looking through all the articles that had cited the original
validation article. In this 2nd search, articles were retained if their
main goal was to provide a further psychometric validation of the
measure. For each measure, its characteristics and psychometric
properties (Table 1) were reviewed and compiled into a table.
Disease Questionnaire (PDQ; n ¼ 3), and Profile of Female
Sexual Function (PFSF; n ¼ 2).
The most frequently used measures were the FSDS, Female
Sexual Distress ScaleeRevised (FSDS-R; n ¼ 201), and the
Expanded Prostate Cancer Index Composite (EPIC; n ¼ 58;
Tables 2e6). Each of the included scales or subscales is described
below. Their main characteristics are presented in Tables 2 to 6.
Measures for the General Population
Female Sexual Distress Scale
The FSDS4 is a full scale that assesses sexual distress in women
that is not specific to domains of sexual function or sexual
conditions (eg, “Distressed about your sex life”). The FSDS was
developed by a panel of experts and although the authors
provided justifications for most of the decisions about the scale
construction (eg, number of items, response scale, dimension-
ality, etc), no details about how the actual items were generated
were provided. The scale was validated using samples of sexually
functional and dysfunctional women. The scale showed good
internal consistency and test-retest reliability (more details about
the reliability of scales and subscales are presented in Table 2).
The authors did not test or did not provide details about content
validity. The internal structure was tested using principal
component analysis and the results showed that the items loaded
on a single factor. Higher scores on the FSDS were correlated to
greater psychological distress and negative mood and lower
positive mood. Scores on the FSDS were highly correlated to
daily reports of sexual distress, showed responsiveness to

RESULTS
After the initial screening, 2,726 documents were retained. Of
these, 1,715 were excluded because they did not assess sexual
distress but rather other types of distress, leaving 1,011 articles to
be screened for eligibility. Another 961 documents were
excluded because they did not refer to a measure of sexual
distress, leaving 50 full-text articles to be assessed for inclusion.
After a thorough review of each document, another 34 were
excluded for the following reasons: failure to meet the definition
of sexual distress adopted in this literature review (n ¼ 17),
sexual distress items did not constitute a separate scale or subscale
(n ¼ 11), no psychometric validation was provided for the sexual
distress items (n ¼ 4), or the measure was not developed and
validated in English (n ¼ 2; Figure 1).
4 scales and 13 subscales were included in the review. 5
assessed sexual distress in the general population, whereas 12
were designed to assess sexual distress in specific populations,
such as men with sexual dysfunction (n ¼ 5), women with sexual
dysfunction (n ¼ 2), patients with cancer (n ¼ 4), and aging
men (n ¼ 1). The 2nd search found additional validation articles
for the Female Sexual Distress Scale (FSDS; n ¼ 4), Peyronie’s Figure 1. Flowchart. Adapted from Moher et al.28

J Sex Med 2018;-:1e20

 4
Table 2. Sexual distress measures for general population
Translations and
Reliability Validity validations

Scale or Internal Times

Name subscale Population Items Response scale Scoring IC TR Content structure Other variables Cutoff Translations Validations used, n

Female Sexual Scale Women 12 0 (never)e4 0e48 (higher 0.86e0.96 0.74e0.92 Not assessed 1 factor (pca) Psychological 15 Dutch 113
Distress Scale (always) score ¼ (1e4 wk) or reported distress (rr);
(FSDS) greater mood (rr); daily
distress) measures of
distress (rr);
sexual desire (rr);
responsiveness to
treatment;
discriminates high
vs low libido;
discriminates
sexual function vs
dysfunction
Female Sexual Scale Women 13 0 (never)e4 0e52 (higher 0.88e0.97 0.75e0.93 Content Daily measures of 11 Korean, 88
Distress Scalee (always) score ¼ (1e4 wk) distress (rr); Polish,
Revised greater discriminates Iranian,
(FSDS-R) distress) sexual function vs Turkish
dysfunction
Sexual Distress Scale Men 12/13 0 (never)e4 0e48/0e52 0.93e0.94 0.80e0.85 content 1 factor (CFA); Sexual bother and 18.5/
Scale (SDS)/ (always) (higher (35 d) invariant concerns (rr); 19.5
Sexual Distress score ¼ sexual function (rr);
ScaleeRevised greater mood (rr); sexual
(SDS-R) distress) attitudes (r);
discriminates
sexual function vs
dysfunction
Sexual Satisfaction Subscale Women 6 1 (strongly 6e30 (higher 0.81e0.90 0.72e0.83 Not assessed 1 factor (FA) Sexual satisfaction (rr); 11
Scale for Women (personal) disagree)e6 score ¼ (4e5 wk) or reported marital adjustment
(SSS-W) (strongly agree) greater (rr); discriminates
distress) sexual function vs
dysfunction
Subscale Women 6 1 (strongly 6e30 (higher 0.80e0.88 0.72e0.86 Not assessed 1 factor (FA) Sexual satisfaction (rr); 11
(relational) disagree)e6 score ¼ (4e5 wk) or reported marital adjustment
(strongly agree) greater (rr); discriminates
distress) sexual function vs
dysfunction

(continued)
J Sex Med 2018;-:1e20

Santos-Iglesias et al
 Table 2. Continued
J Sex Med 2018;-:1e20

Sexual Distress Measures

Translations and
Reliability Validity validations

Scale or Internal Times

Name subscale Population Items Response scale Scoring IC TR Content structure Other variables Cutoff Translations Validations used, n

Multidimensional Subscale Men and 5 0 (not at all 0e20 (higher 0.83 0.58e0.68 Not assessed 1 factor (FA) Sexual esteem, 1
Sexuality (anxiety) women characteristic of score ¼ (3 wk) or reported preoccupation,
Questionnaire me)e4 (very greater motivation,
(MSQ) characteristic of distress) assertiveness,
me) depression,
monitoring,
satisfaction, fear of
sexual relations,
internal and external
sexual control,
exchange approach
to sex, sexual
attitudes, and sexual
experience (rr)
Subscale Men and 5 0 (not at all 0e20 (higher 0.92 0.68e0.71 Not assessed 1 factor (FA) Sexual esteem, 1
(depression) women characteristic of score ¼ (3 wk) or reported preoccupation,
me)e4 (very greater anxiety,
characteristic of distress) assertiveness,
me) depression,
monitoring,
satisfaction, fear of
sexual relations,
internal and external
sexual control,
exchange approach
to sex, sexual
attitudes,
and sexual
experience (rr)

CFA ¼ confirmatory factor analysis; FA ¼ factor analysis; IC ¼ internal consistency; PCA ¼ principal components analysis; r ¼ weak correlation between the main construct assessed by the scale and the
constructs listed (divergent validity); rr ¼ significant moderate to high correlation between the main construct assessed by the scale and the constructs listed (convergent validity); TR ¼ test-retest reliability.

5
 6
Table 3. Sexual distress measures for men with sexual dysfunction
Reliability Validity Translations and validations

Scale or Response Internal Times

Name subscale Population Items scale Scoring IC TR Content structure Other variables Cutoff Translations Validations used, n
Index of Subscale Men with pe 2 Extremely enot No details 0.86e0.91 0.70e0.72 Content 1 factor (FA) Sexual distress (rr); Czech, Dutch, 3
Premature at all (lower (7e10 d) intravaginal Finnish, French,
Ejaculation distressed score ¼ ejaculatory German,
(IPE) greater latency time (rr); Hebrew,
distress) discriminates Hungarian,
sexual function vs Italian,
dysfunction Norwegian,
Polish,
Portuguese,
Spanish, US
Spanish
Peyronie’s Subscale Men with PD 6 0e4 (extreme 0e16 (lower 0.70e0.78 0.89 Not assessed 1 factor (CFA) Penile curvature (rr); 1
Disease bother) score ¼ (7 d) or reported pain on erection (rr);
Questionnaire greater distress over PD (rr);
(PDQ) distress) sexual function (rr);
(only 4 improvement in PD
items are symptoms (rr);
scored) discriminates
between levels of PD;
responsiveness to
treatment
Sexual Quality of Scale Men with PE 11 1 (completely 0e100 (higher 0.82e0.93 0.77e0.90 Content 1 factor (FA) Sexual function (rr); Danish, English, Persian 3
LifeeMale and ED agree)e6 score ¼ less (7e10 d) sexual satisfaction French, German,
(SQOL-M) (completely distress) (rr); sexual distress Italian,
disagree) (rr); discriminates Norwegian,
sexual function vs Swedish, Turkish
dysfunction
Brief Male Sexual Subscale Men with SD 3 0 (big problem)e 0e12 (higher 0.81 0.87 Not assessed Inter-item Satisfaction with sex life British English, Norwegian 2
Function Index 4 (no problem) score ¼ less (1 wk) or reported correlations (rr); feelings about French, German,
(BMSFI) distress) sex life (rr); Italian, Spanish
discriminates sexual Hebrew, Dutch,
function vs Norwegian,
dysfunction Brazilian,
Portuguese,
Afrikaans
Quality of Lifee Scale Men with ED 18 1 (not at all)e 0e100 (higher 0.94e0.96 0.78e0.91 Content Psychological well-being US, UK, 1
Erectile 4 (very much) score ¼ less (2 wk) (rr); physical German
Dysfunction distress) functioning (rr);
(QOL-ED) social functioning
(rr); mental health
(rr); discriminates
J Sex Med 2018;-:1e20

between levels of

Santos-Iglesias et al
perceived disease
severity

CFA ¼ confirmatory factor analysis; ED ¼ erectile dysfunction; FA ¼ factor analysis; IC ¼ internal consistency; PCA ¼ principal components analysis; PD ¼ Peyronie disease; PE ¼ premature ejaculation; r ¼
weak correlation between the main construct assessed by the scale and the constructs listed (divergent validity); rr ¼ significant moderate to high correlation between the main construct assessed by the
scale and the constructs listed (convergent validity); SD ¼ sexual dysfunction; TR ¼ test-retest reliability.
J Sex Med 2018;-:1e20

Sexual Distress Measures

Table 4. Sexual distress measures for women with sexual dysfunction
Translations and
Reliability Validity validations

Scale or Response Internal Times

Name subscale Population Items scale Scoring IC TR Content structure Other variables Cutoff Translations Validations used, n
Profile of Female subscale oophorectomized 3 1 (always)e6 0e100 (higher 0.74e0.96 0.57e0.85 content 1 factor (FA, sexual fantasies (rr); English, Canadian 15
Sexual Function women with (never) score ¼ less (2e4 wk) CFA) sexual arousal French, Dutch,
(PFSF) low desire; distress) (rr); sexual German,
young men pleasure (rr); Italian, US
and women sexual Spanish
responsiveness
(rr); orgasm (rr);
sexual self-image
(rr); sexual desire
(rr); discriminates
low libido vs
controls
Sexual Desire scale women with 17 0 (never 0e68 (higher 0.97e0.98 0.89 (2 wk) content 1 factor (FA) sexual distress (rr); 2
Relationship HSDD distressed score ¼ frequency of sex
Distress Scale or bothered)e4 greater (rr); satisfaction
(SDRDS) (very often distress) with sexual
distressed or activities (rr);
bothered) frequency of sexual
desire (rr); level of
sexual desire (rr);
depression (r);
discriminates
HSDD vs controls;
decreases in sexual
activity,
satisfaction, and
desire
associated with
changes in sexual
distress

CFA ¼ confirmatory factor analysis; FA ¼ factor analysis; HSDD ¼ hypoactive sexual desire disorder; IC ¼ internal consistency; PCA ¼ principal components analysis; r ¼ weak correlation between the main
construct assessed by the scale and the constructs listed (divergent validity); rr ¼ significant moderate to high correlation between the main construct assessed by the scale and the constructs listed
(convergent validity); TR ¼ test-retest reliability.

7
 8
Table 5. Sexual distress measures for patients with cancer
Translations and
Reliability Validity validations

Scale or Response Internal Times

Name subscale Population Items scale Scoring IC TR Content structure Other variables Cutoff Translations Validations used, n
Expanded Subscale Men with PCa 4 0 (mo problem)e4 0e100 (higher 0.84 0.78 Not assessed Sexual Sexual function (rr); Japanese, 58
Prostate (big problem) score ¼ les (2e4 wk) or reported function urinary European
Cancer Index distress) and bother function (r); Spanish,
Compositee in 1 factor urinary bother (r); Korean,
Sexual Bother (FA) bowel function (r); Brazilian,
(EPIC-SB) bowel bother (r) French
Prostate Cancere Subscale Men with PCa 6 1 (no problem)e5 0e100 (higher 0.87e0.92 0.87 Usability Health-related quality 1
Quality of Life (big problem) score ¼ less (2 wk) of life (rr); life
(PC-QoL) distress) satisfaction (rr);
negative affect (rr);
sexual function (rr);
sexual bother (rr);
urinary function (r);
urinary bother (r);
urinary limitations
(r); bowel function
(r); bowel bother (r);
bowel limitations (r)
Prostate Cancer- Subscale Men with PCa 3 Never or no problem 0e100 (higher 0.83 0.77 (4 wk) Not assessed 1 factor (PCA) Erectile function (rr); 2
Specific to most of the score ¼ less or reported urinary
Instrument time or big distress) incontinence (r);
(PCSI) problem sexual desire (r);
intercourse
satisfaction (r);
bowel pain/
constipation (r);
frequency diarrhea
(r); rectal bleeding
(r); urinary bother (r);
bowel bother (r);
cancer worry (r);
treatment regret (r);
treatment
satisfaction (r);
physical health (r);
mental health (rr);
does not
discriminate
between treatment
groups
J Sex Med 2018;-:1e20

Santos-Iglesias et al
(continued)
 Sexual Distress Measures 9

treatment, and discriminated between sexually functional and

by the scale and the constructs listed (divergent validity); rr ¼ significant moderate to high correlation between the main construct assessed by the scale and the constructs listed (convergent validity);
CFA ¼ confirmatory factor analysis; FA ¼ factor analysis; IC ¼ internal consistency; PCa ¼ prostate cancer; PCA ¼ principal components analysis; r ¼ weak correlation between the main construct assessed
Cutoff Translations Validations used, n
Times
dysfunctional women. The authors found that a score of at least

1
15 discriminated between these 2 groups.
In 2008, Derogatis et al29 developed a revised version of the
FSDS (ie, FSDS-R) that included the addition of a 13th item to
Translations and

assess sexual distress specifically related to low sexual desire in

women (eg, “Are you bothered by low sexual desire?”). There-
validations

fore, the fundamental difference of this revision is that the

13-item scale assesses sexual distress that is more specific to a
component of sexual function (ie, sexual desire). The authors did
not provide any details about how this new item was generated.
The FSDS-R was validated using samples of sexually dysfunc-
orgasm (rr); pain (rr);

tional women (including those with hypoactive sexual desire

function (rr); sexual
problems (rr); body

(r); physical health

due to cancer (rr);

image (rr); fatigue

sexual desire (rr);

(r); mental health

disorder and other female sexual dysfunctions) and sexually

Changes in function
Other variables

satisfaction (rr);
lubrication (rr);

adjustment (r)
overall sexual

functional women. The FSDS-R showed good internal consis-

(rr); dyadic

tency and test-retest reliability. Evidences of content validity

were provided in a later study, showing that the items were
sufficient to assess sexual distress and they were clear and
understandable to respondents.30 Similar to the FSDS, the
1 factor (FA)
structure

FSDS-R was highly correlated to daily reports of sexual distress

Internal

and moderately correlated to measures of sexual desire. A score of

11 discriminated between sexually functional and dysfunctional
women.
Content
Validity

Usability

Recently, the FSDS and FSDS-R were validated in samples of

men31 (Sexual Distress Scale [SDS] and Sexual Distress
ScaleeRevised [SDS-R]). After conducting a content validity
0.71e0.91 0.77e0.86
(18 d)

test, the authors found that the items of the SDS and SDS-R
adequately represented the construct of sexual distress in male
TR

samples. The 1-factor structure was confirmed using confirma-

Reliability

tory factor analysis and the scales were found to be invariant

across sex and sexual function status (ie, sexually functional men
IC

vs sexually dysfunctional men). The internal consistency and

score ¼ less
1 (almost always or 6e36 (higher

test-retest reliabilities were excellent. Higher scores on the SDS

distress)
Scoring

and SDS-R were strongly associated with higher sexual bother

and concern scores, moderately associated with sexual function
and mood scores, and not correlated to sexual attitudes. The SDS
(almost never or

and SDS-R discriminated men with from those without sexual

always)e6

dysfunction and scores of at least 18.5 and 19.5 discriminated

Response

never)

these 2 groups, respectively.

subscale Population Items scale

Strengths and limitations. One of the main advantages of the

6

FSDS is that it assesses sexual function independent of specific

Women with

sexual function domains (eg, orgasm, erectile function), making

cancer
breast

it more sensitive to the assessment of other sources of sexual

distress (eg, relationship problems).32 It is the sexual distress
measure that has been exposed to a larger extent of psychometric
Scale or

TR ¼ test-retest reliability.
Subscale

scrutiny in different samples and, as such, it has been found to be

Table 5. Continued

a reliable and valid tool for many different assessment purposes.

Although it has been used to assess sexual distress in women with
Function Index
Female Sexual

and without sexual dysfunction, the presence of measurement

(FSFI-BC)
eBreast
Cancer

bias or differential item functioning has never been tested across

Name

these 2 groups. Because of its single-factor structure, the scale

could benefit from an item reduction.

J Sex Med 2018;-:1e20

10 Santos-Iglesias et al

Sexual Satisfaction Scale for Women

construct assessed by the scale and the constructs listed (divergent validity); rr ¼ significant moderate to high correlation between the main construct assessed by the scale and the constructs listed
CFA ¼ confirmatory factor analysis; FA ¼ factor analysis; HSDD ¼ hypoactive sexual desire disorder; IC ¼ internal consistency; PCA ¼ principal components analysis; r ¼ weak correlation between the main
Cutoff Translations Validations used, n
Times
The Sexual Satisfaction Scale for Women (SSS-W)33 was
developed as a general scale to assess sexual satisfaction in

4
women. Sexual distress is assessed by 2 different subscales relating
to relational concern (eg, “I’ve disappointed my partner”) and
personal concern (eg, “My sexual difficulties are frustrating to
Translations and

me”). The distress items were developed after interviews with

sexually dysfunctional women and further refined based on the
validations

results of factor analyses. The SSS-W was validated using samples

of sexually functional and dysfunctional women. The 2 subscales
have good internal consistency and test-retest reliability. To our
knowledge, there is no evidence of content validity. The items
corresponding to each subscale loaded onto different factors and
the 2 subscales discriminated women with from those without
changes in sexual

masturbation (r);

sexual dysfunction. Greater sexual and relational distresses were

Sexual function (rr);

satisfaction with
Other variables

erectile function
depression (rr);

satisfaction (r);
(rr); frequency

discriminates

associated with poorer sexual satisfaction and marital adjustment.

between age
function (rr);

sex life (rr);

relationship

No cutoff scores were provided.

groups

Strengths and limitations. The SSS-W can be used for the

assessment of not only sexual distress but also relational distress.
1 factor (PCA)

This distinction is important because women often complain

structure
Internal

about aspects of their relationships that are not related to their

sexual function.17 Some limitations are related to the lack of a clear
conceptual framework supporting the factor structure. They also
or reported
Not assessed

could benefit from validation studies that provide evidence about

Content
Validity

the interpretability of the scale scores in addition to clinical use.

Multidimensional Sexuality Questionnaire

(2 wk)

The Multidimensional Sexuality Questionnaire (MSQ)34 was

0.82
Reliability

TR

developed to assess a series of tendencies, such as sexual esteem,

sexual preoccupation, sexual anxiety, that influence the sexual
0.88
IC

relationships of men and women. Snell et al34 included separate

0e20 (higher

sexual anxiety and sexual depression subscales, whose definitions

distress)
score ¼
greater
Scoring

(“The tendency to feel tension, discomfort, and anxiety about the

sexual aspects of one’s life” and “The tendency to feel depressed
about the sexual aspects of one’s life,” respectively) and content
distressed)e
4 (extremely

(eg, “I feel anxious when I think about the sexual aspects of my

distressed)
worried or

worried or
Response

0 (not at all

life” and “I am depressed about the sexual aspects of my life,”

subscale Population Items scale

respectively) resemble those of sexual distress. Items were written

Table 6. Sexual distress measures for aging men

according to definitions of sexual anxiety and depression and

were narrowed to 5 items per subscale by the 1st author. The 2
(convergent validity); TR ¼ test-retest reliability.

subscales were validated using samples of male and female uni-

5

versity students. The internal consistency reliabilities were good;

Aging men

however, test-retest reliabilities after 3 weeks were suboptimal.

Content validity was not reported as assessed by the authors. A
factor analysis showed that the sexual anxiety and sexual
depression items loaded on to a single factor, indicating that they
Scale or

Subscale

likely do not measure distinct constructs. Sexual anxiety and

depression showed significant associations with other related
constructs, such as sexual self-esteem, internal sexual control,
Questionnaire
Ageing Study

(EMAS-SFQ)
European Male

sexual consciousness, sexual depression, external sexual control,

Function
eSexual

sexual monitoring, fear of sexual relations, sexual preoccupation,

Name

sexual assertiveness, exchange approach to sex, and sexual

permissiveness. No cutoff score exists for this subscale.

J Sex Med 2018;-:1e20

Sexual Distress Measures
Strengths and limitations. Perhaps the only strength of the
MSQ is the multitude of evidences of validity based on relations
with other variables. Although the authors started with a clear
conceptual definition of the 2 constructs, the item development
and refinement strategy did not produce good results because
there is a great overlap between the 2 domains. Furthermore,
some psychometric properties are less than ideal (eg, test-retest
reliability, lack of content validation).
Measures for Men With Sexual Dysfunction
Index of Premature Ejaculation
The Index of Premature Ejaculation (IPE)27 was developed to
assess the overall experience of men with premature ejaculation
(PE). It includes a subscale that assesses sexual distress about
ejaculating prematurely (eg, “How distressed [frustrated] were
you by how long you lasted before you ejaculated?”). Items were
generated through face-to-face interviews with 2 sex therapists. It
was validated using samples of men with PE and control samples
of sexually functional men. The scale demonstrated excellent
internal consistency reliability and good test-retest reliability.
The IPE was thoroughly tested for content validity and the
results showed that, after a few minor changes, the existing items
adequately captured the experience of PE and the items were
clear and easy to understand. Items related to sexual distress were
grouped together in confirmatory factor analysis. The scale could
differentiate men with from those without PE, and higher scores
on sexual distress were correlated to poorer sexual quality of life
and shorter intravaginal ejaculation latency times. Cutoff scores
were not provided by the authors. The authors also indicated the
scale had been translated and is publicly available in Czech,
Dutch, Finnish, French, German, Hebrew, Hungarian, Italian,
Norwegian, Polish, Portuguese, Spanish, and US Spanish.
Strengths and limitations. The IPE was carefully developed
and tested through a series of studies. The authors examined the
content validity of the scale and all the psychometric properties
are good to excellent. The scale validity could be improved for
clinical use if evidences of responsiveness to treatment and cutoff
scores were provided.
Peyronie’s Disease Questionnaire
The PDQ35 was developed to specifically assess the psycho-
sexual impact of Peyronie’s disease (PD) in men. It includes a
subscale that assesses PD symptom bother (eg, “Thinking about
the last time you looked at your erect penis, how bothered were
you by the way your penis looked?”). The scale was developed by
a board of experts starting from a conceptual model and refined
through a series of focus groups, cognitive interviews, expert
opinions, and psychometric assessments. The final validation was
conducted on samples of men with PD. The internal consistency
of the scale was acceptable and the test-retest reliability was
excellent.36 Although the PDQ was developed after a series of
J Sex Med 2018;-:1e20
11
focus groups and cognitive interviews, no evidence of content
validity was mentioned. The items assessing sexual distress
loaded onto the same factor. Higher scores on sexual distress
were associated with more severe PD symptoms (ie, self-reported
penile curvature, pain on erection, and distress over PD) and
poorer erectile function and sexual satisfaction (convergent),
whereas they showed weak correlations to investigator-measured
degree of penile curvature and sexual desire (divergent). The
distress scale also discriminated patients with moderate to severe
PD from those with no or mild PD and different levels of the
global assessment of PD. 2 studies examined responsiveness to
treatment37,38 and found a moderate to large effect size change
after treatment. These studies also found that improvements in
penile curvature and erectile function were associated with less
PD bother. No cutoff scores were reported.
Strengths and limitations. The PDQ is a good instrument
that has been thoroughly tested in different studies. Therefore, it
is valid for the assessment of PD bother and it can be clinically
used to assess changes related to treatment. Its interpretability
could be improved if cutoff scores were developed.
Sexual Quality of LifeeMale
The Sexual Quality of LifeeMale (SQOL-M)39 is a scale
designed to assess emotional well-being related to sexual life in
men with PE and erectile dysfunction (ED; eg, “When I think
about my sexual life, I feel frustrated”). At review of the items, it
was determined that this scale of sexual quality of life matched
our proposed definition of sexual distress. The SQOL-M is an
adaptation of the female version of the SQOL40 (the female
version was excluded because the sexual distress items did not
constitute a separate subscale). After discussions with experts,
literature review, and interviews with men with ED or PE, the
authors determined that only 1 item of the female version needed
modification to assess sexual quality of life in men. The male
version was validated using samples of men with ED or PE and
control groups of sexually functional men. The scale showed
good internal consistency and test-retest reliability. The authors
tested the content validity of the scale but no detailed results
were provided. All items loaded on a single factor. The scale
could discriminate sexually functional from sexually dysfunc-
tional men. Greater sexual distress was associated with poorer
sexual function and satisfaction and greater distress (assessed by
the bother subscale of the IPE). No cutoff scores were provided.
The authors indicated that the SQOL-M was translated into
Danish, English, French, German, Italian, Norwegian, Spanish,
Swedish, and Turkish.
Strengths and limitations. The SQOL-M is an instrument
with adequate psychometric properties that assesses sexual
distress not related to sexual function domains. However, it
needs further validation with clinical samples to improve its
clinical utility: cutoff scores are necessary to improve the
12
interpretability of the scale and, because the scale was designed to
be used in men with sexual dysfunction, its responsiveness to
treatment also could be examined.
Brief Male Sexual Function Inventory
The Brief Male Sexual Function Inventory (BMSFI)41 was
developed to have a short instrument to capture the various
aspects of sexual function in urology practice. It includes 4
subscales that assess sexual drive, erectile function, ejaculation,
overall satisfaction, and problem assessment, that is, the extent to
which different areas of sexual function (ie, sex drive, erection,
and ejaculation) are considered a problem (eg, “To what extent
have you considered your lack of sex drive to be a problem?”).
The scale was developed in 2 stages. (i) Questions were drawn
from previous questionnaires and refined using cognitive in-
terviews with sexually functional and dysfunctional men. (ii) The
resulting items were reduced to a shorter 22-item list using
samples of men with and without sexual dysfunction. The final
3-item version of the scale was validated using a sample of
sexually dysfunctional men and a control group of sexually
functional men. The internal consistency and test-retest reli-
ability were good. As part of content validity, item clarity and
understandability were assessed in the initial stages of question-
naire development, but the authors did not provide results of
these tests. The internal structure of the BMSFI was not tested
using factor analysis; however, the authors showed that within
each domain, items were highly correlated, but they were weakly
correlated across domains. The subscales discriminated between
sexually dysfunctional and functional men. Less sexual distress
was associated with greater satisfaction with sex life and overall
feelings about sex life. The authors did not provide cutoff scores.
According to the authors, the BMSFI was translated to British
English, French, German, Italian, Spanish, Hebrew, Dutch,
Norwegian, Brazilian, Portuguese, and Afrikaans.
Strengths and limitations. The BMSFI only narrowly
assesses sexual distress, because it focuses only on distress that is
related specifically to sexual function. The approach to exam-
ining the dimensionality of the scale is quite basic and the
authors could have improved their validation if they had
conducted a factor analysis. Although the psychometric proper-
ties tested are satisfactory, the scale still needs more evidence
before it can be used reliably in research and clinical contexts.
Quality of Life for Men With Erectile Difficulties
The Quality of Life for Men with Erectile Difficulties (QOL-
ED)15 was developed as a quality-of-life measure that assesses
the emotional consequences of erectile difficulties in men (eg, “I
feel frustrated because of my erection problem”). Items were
developed after a series of semistructured interviews with men
with ED in the United States and United Kingdom and then
reviewed for content validity by another sample of men with
ED. The scale was validated using samples of men with ED.
Santos-Iglesias et al
Psychometric analyses conducted with the scale showed good
internal consistency and test-retest reliability. The authors
stated that the scale was refined after examining content val-
idity; however, they did not provide details about these results.
The SQOL-ED differentiated among patients with different
levels of self-perceived illness severity and it was correlated to
indicators of general well-being (health concerns, energy, and
anxiety) and indicators of health (mental health, physical and
social functioning; convergent). No cutoff scores were provided
for the scale.
Strengths and limitations. The SQOL-ED is a rather large
instrument for the assessment of sexual distress. Since the orig-
inal development and validation, the scale has been used infre-
quently. Although the authors created the scale from a solid
theoretical model, they did not examine the internal structure of
the scale, which raises questions about the remaining psycho-
metric properties. The psychometric properties need to be
examined more carefully before recommending its use.
Measures for Women With Sexual Dysfunction
Profile of Female Sexual Function
The PFSF42 was developed to assess sexual function in
women who underwent bilateral oophorectomy (ie, surgical
removal of ovaries). The overall scale is composed of 7 different
domains, with concerns about sexual life being a domain (eg, “I
was frustrated about my sex life”). The scale was carefully
developed after a series of focus groups and interviews with
menopausal women with low sexual desire and interviews with
physicians. Content validity and item understanding were
tested through a series of cognitive interviews with menopausal
women, and cognitive interviews were conducted to assess the
linguistic validity of the scale across different countries. Despite
this careful process, the authors did not report details or results
about the content validity beyond a few examples of ambiguous
items that were deleted. The PFSF was validated using samples
of surgically menopausal women with low desire and control
groups of non-oophorectomized women with normal desire
from the United States, Canada, Australia, and Europe (United
Kingdom, Holland, France, Italy, and Germany).42,43 Later,
the scale was validated in samples of young men and women.44
Results showed good internal consistency of the sexual concerns
subscale and weak to good test-retest reliability. The sexual
distress items loaded on a single factor. Greater sexual distress
was associated with lower sexual desire, pleasure, responsive-
ness, arousal, and self-image. The sexual distress subscale
differentiated sexually functional from dysfunctional women,
and the scale showed good sensitivity and specificity to differ-
entiate these 2 groups; however, no cutoff scores were provided.
A brief version of the PSFS exists,45 but because the sexual
distress items are not a separate subscale, it was not included in
this review.
J Sex Med 2018;-:1e20
Sexual Distress Measures
Strengths and limitations. The PFSF is a good measure for
the assessment of sexual distress in surgically menopausal
women. Examinations of responsiveness to treatment and
interpretability would help strengthen the scale. Although
Kalmbach et al44 did test the factor structure separately in men
and women, they did not test whether the scale was invariant,
which limits its use regarding the comparability of the scores
between men and women.
Sexual Desire Relationship Distress Scale
The Sexual Desire Relationship Distress Scale (SDRDS)46 was
developed to assess sexual distress associated with hypoactive
sexual desire disorder in women. Items were generated from
focus groups with pre- and postmenopausal women with hypo-
active sexual desire disorder or lowered sexual desire. The
SDRDS is composed of 17 items that assess personal distress (eg,
“Having decreased sexual desire”) and relationship distress (eg,
“Not fulfilling your partner’s sexual needs”). The SDRDS was
validated using samples of pre- and postmenopausal women with
hypoactive sexual desire disorder and sexually functional con-
trols. Reliability (internal consistency and test-retest reliability
after 2 weeks) was good. Regarding evidence based on content, a
group of 21 women reported that instructions, item content, and
response scales were well understood. All items loaded onto a
single factor. Greater sexual distress, as assessed by the SDRDS,
was associated with greater sexual distress, frequency of sex,
satisfaction with sexual activities, frequency and levels of desire,
and changes in these variables were associated with changes in
sexual distress. The scale could differentiate women with from
those without sexual dysfunction, but the authors did not pro-
vide cutoff scores for the scale.
Strengths and limitations. One of the strongest points of the
SDRDS is that it assesses sexual and relationship distress, instead
of just focusing on distress related to sexual function. However,
the scale is lengthy, adding burden to respondents and making it
less suitable for clinical use. Furthermore, to improve interpret-
ability of the scale, the authors could have provided cutoff scores.
Measures for Patients With Cancer
Expanded Prostate Cancer Index Composite
The EPIC47 was developed to assess quality of life in men with
prostate cancer (PCa) and assesses function and bother on 3 main
domains: urinary, bowel, and sexual function. Items were drawn
from the original UCLA Prostate Cancer Index (UCLA-PCI).48
These items were refined after the results of a literature review
and a panel of experts and patients suggested the need to increase
the number of items to capture additional concerns. The sexual
bother domain is composed of 4 items assessing overall bother and
bother associated with desire, erection, and orgasm (eg, “Overall,
how big of a problem has your sexual function or lack of sexual
function been for you during the last 4 weeks?”). The EPIC was
J Sex Med 2018;-:1e20
13
validated using samples of men with PCa. The subscale showed
good internal consistency and test-retest reliability after 2 to 4
weeks. Content validity was not tested by the authors. A factor
analysis showed that items belonging to the same domain (ie,
urinary, bowel, or sexual) were grouped together. That is, the
sexual bother and sexual function items loaded on the same factor,
which is not a strong indicator of validity for the sexual bother
subscale. The sexual bother subscale was strongly correlated to
sexual function but weakly correlated to urinary function and
bother and bowel function and bother. No cutoff scores were
provided for this subscale. 26-item and 16-item versions of the
EPIC have been developed,49,50 but in these 2 brief versions the
sexual function and bother items were collapsed into a single
domain and no longer offer a separate bother score.
Strengths and limitations. The EPIC has been extensively
used in research with patients with PCa and an advantage of the
sexual bother subscale is its shortness. Despite its frequent use, it
has been subject to very little psychometric scrutiny and, as such,
it has several weak points: it exclusively assesses sexual distress
related to sexual function, the content validity of the scale was
not tested, and the factor structure does not separate sexual
function and sexual bother items.
Prostate CancereQuality of Life
Similar to other quality-of-life instruments for patients with
PCa, the Prostate CancereQuality of Life (PC-QOL)51 was
developed to assess a wide variety of symptoms (ie, bowel, uri-
nary, and sexual) and their associated bother in patients with
PCa. It also includes a sexual bother subscale that assesses how
much patients are bothered or distressed by their sexual function
in general without any mention of specific sexual function
domains (eg, “Overall, how big of a problem has your sexual
function been for you during the last 4 weeks?”). Items were
drawn from previous scales and after consultation with PCa
health professionals and patients and were further refined with
feedback provided by patients with PCa. The scale was validated
in men with PCa. The sexual bother subscale showed good in-
ternal consistency and test-retest reliability. As part of content
validity, the authors tested the usability of the scale and found
that the entire PC-QOL took approximately 15 minutes to
complete and that no patients refused to complete the sexual
subscales. The sexual bother subscale was strongly correlated to
sexual function but weakly correlated to urinary function and
bother and bowel function and bother. Further evidence of
validity showed that the sexual bother subscale was strongly
correlated to the UCLA-PCI sexual bother scale. Greater sexual
bother was correlated to poorer health-related quality of life,
poorer satisfaction with life, and greater negative affect. No cutoff
scores were provided.
Strengths and limitations. As with other sexual distress
measures, an advantage of the PC-QOL is that the assessment of
14
distress is not tied to just sexual function domains; therefore, this
measure offers a broader assessment of sexual distress. However,
the scale has been poorly validated: no evidences of the internal
structure were provided by the authors and it still needs more
evidence to guarantee its clinical utility.
Prostate Cancer-Specific Instrument
The Prostate Cancer-Specific Instrument (PCSI)52 was
created as a scale to assess quality of life in patients with PCa. It
includes a subscale that assesses how much patients are both-
ered or distressed by their sexual function without any reference
to specific domains of sexual function (eg, “How often have
you felt embarrassed or ashamed because of poor sexual func-
tion?”). Items were developed based on a literature review and
the expertise of a group of PCa professionals. The authors
stated the items were further refined by PCa health pro-
fessionals and patients who judged their wording and face and
content validity; however, any results of this refinement were
not reported. The PCSI was validated using a sample of men
with PCa. The sexual bother subscale showed good internal
consistency and test-retest reliability after 4 weeks. All sexual
bother items loaded together on a single factor. No statistically
significant differences were found among the different treat-
ment groups (ie, external beam radiation, brachytherapy, and
prostatectomy) on sexual bother. Similar to other scales
developed for men with PCa, the sexual bother subscale was
strongly correlated to erectile function but weakly correlated to
urinary and bowel function and urinary and bowel bother.
Similarly, sexual bother was not associated with treatment
regret, treatment satisfaction, or physical health, although it
was moderately correlated to mental health. No cutoff scores
were provided by the authors.
Strengths and limitations. As with the PC-QOL, the
advantage of the PCSI is that it assesses sexual distress not related
to sexual function domains. Similarly, the scale needs further
psychometric validation (eg, discriminant validity, cutoff scores,
treatment responsiveness) before it can be used reliably in clinical
contexts.
Female Sexual Function IndexeBreast Cancer
The Female Sexual Function IndexeBreast Cancer (FSFI-
BC)53 was developed as a validation of the FSFI11 in women
with breast cancer. To address a few shortcomings of the FSFI
in the breast cancer population, the FSFI-BC included several
subscales relating to sexual health, 1 of which assesses sexual
functioning-related distress. The authors did not provide details
about how the additional items were created. This subscale is
composed of 6 items: 1 assessing sexual distress related to
overall sex life and 5 related to different domains of sexual
function (ie, desire, arousal, orgasm, lubrication, and pain; eg,
“How often did you feel distressed, bothered or frustrated about
your sexual desire?”). The scale was validated in samples of
Santos-Iglesias et al
sexually active and sexually inactive women with breast cancer.
The scale showed excellent Cronbach a values and good test-
retest reliability. Participants examined user acceptability (ie,
comfort with questions, relevance of questions, and length of
questionnaire). Sexually active and inactive women with breast
cancer provided good feedback about the user acceptability of
the FSFI-BC. The sexual distress domain emerged as a sepa-
rated subscale using factor analysis. Higher scores on sexual
distress were moderately to highly correlated to poorer overall
sexual function, sexual desire, lubrication, orgasm, satisfaction
with sex life, body image and mental health, and greater sexual
pain. No correlations or weak correlations were found between
sexual distress scores and fatigue, physical health, and dyadic
adjustment. The authors did not provide information about
cutoff scores.
Strengths and limitations. The FSFI-BC is the only instru-
ment (to our knowledge) for the assessment of sexual distress in
women with breast cancer. The scale was developed and
validated carefully for the assessment of sexual distress, although
the authors still need to provide more evidences of its clinical
utility.
Measures for Aging Men
European Male Ageing StudyeSexual Function Questionnaire
The European Male Ageing StudyeSexual Function Ques-
tionnaire (EMAS-SFQ)54 is a subscale that assesses sexual
function, masturbation, changes in sexual functioning, and
sexual distress in aging men. The scale was developed as part of
a larger assessment of aging on various aspects of the lives of 40-
to 79-year-old men. The overall EMAS scale was developed
after a comprehensive literature review. Different sexual distress
items were generated to the questionnaire (eg, “Are you worried
or distressed by your current orgasmic experience?”). The
overall EMAS was validated in aging men. The internal con-
sistency and test-retest reliability were good. No evidence of
content validity was provided. All sexual distress items loaded
onto the same dimension. The sexual distress subscale
discriminated between different age groups, with younger men
(ie, 40e49 years) being less distressed than older men (ie, 50
years). Greater sexual distress was associated with poorer sexual
function, more depression, and less satisfaction with sex life and
relationship satisfaction. No cutoff scores were provided for this
scale.
Strengths and limitations. The EMAS-SFQ might be the
only measure that has been specifically validated for use in older
men. The psychometric properties are good, indicating good
construct validity. The sexual distress subscale is short and should
not represent a burden to respondents. However, it would
benefit from further validation and more evidences of clinical
utility.
J Sex Med 2018;-:1e20
Sexual Distress Measures
DISCUSSION
Our systematic review showed a broad range of measures
available for the assessment of sexual distress among a wide va-
riety of populations and clinical conditions. Although some of
these measures exist in the form of standalone questionnaires,
most are subscales within a questionnaire assessing broader
constructs such as quality of life or sexual function. Our decision
to include various synonyms for distress in our search terms was
affirmed, because the results of the search demonstrated that
researchers label the construct of sexual distress differently, with
words such as concern, anxiety, depression, and bother used to
conceptualize the psychological experience of sexually related
distress. Other variabilities in the characteristics and psycho-
metric properties of these measurements and variances in how
these results were reported provide meaningful insight into the
development and validation of these measures and into their
strengths and weaknesses.
This literature review yielded 17 different measures that can
be used for the assessment of sexual distress. Notably, each
measure was developed and validated in different contexts, from
the assessment of sexual distress in the general population (eg,
FSDS)4 to instruments aimed at very specific populations (eg,
men with PD,35 ED,15 or PE27 or women with low sexual
desire46). Similarly, there were multiple sexual distress scales
designed for the cancer population (1 for patients with breast
cancer53 and 3 for patients with PCa47,51,52). Given that these
scales assess specific types of sexual dysfunction, specific sub-
scales assessing sexual distress associated with aspects of sexual
function are optimal and suggest that the authors understand
that a diagnosis of sexual dysfunction is not complete without
the presence of sexual distress.6,55 Furthermore, such different
measures when used alongside measures of specific aspects of
sexual function will provide more accurate prevalence estimates
of sexual dysfunction.10 However, in many cases the assessment
of sexual distress, although assessed as a separate subscale, is still
tied to specific aspects of sexual function. For example, the
EPIC links assessments of sexual bother to specific aspects of
sexual function (eg, orgasm, erection, desire, etc), but such an
approach overlooks distress associated with other aspects of
one’s sexual life. In the PCa population, a group for whom
improvements in those aspects of their sexual function are much
delayed and in some cases unlikely56 and for whom impaired
sexual function increases concerns about intimacy with their
partners or even their sense of masculinity,57,58 these measures
of sexual distress might be less helpful. In the general popula-
tion, such tools also might be less useful because individuals
might not experience impairments in those particular aspects of
function but might have distress about other aspects of their
sexual lives. In fact, a study conducted with a large represen-
tative sample of American women found that more women
showed marked distress about their sexual relationships in
general (19.8%) than about their own sexuality (14.7%).17 One
exception to this finding is the original 12-item FSDS, which
J Sex Med 2018;-:1e20
15
does not include any items directly linked to sexual function.
Depending on the nature of the research question or the pur-
pose of the clinical assessment, assessing sexual distress inde-
pendent of sexual function could be an important feature and
scales such as the FSDS (or similarly, the PSCI or SQOL-M)
might offer a more suitable selection.32
The length of the scales and subscales was highly variable and
ranged from 1 to 18 items. Most scales tend to be short, which is
a desirable property of the scale to make it more useful for re-
spondents and administrators.59,60 However, some scales might
actually contain too few items and might not actually be useful in
accurately assessing sexual distress (eg, PFSF sexual distress
subscale).61 In contrast, scales such as the QOL-ED and the
SDRDS, that assess 1 single domain with a large number of items
(18 and 17 items, respectively), would likely be more useful if
they were reduced to essential items, thus decreasing burden and
fatigue for respondents and administrators.59
In general, it appears that most of the authors followed
appropriate steps for developing each of the scales and sub-
scales.61 Although only a few authors opted to generate their
items solely based on proposed definitions of sexual distress (ie,
MSQ)34 or recurrent themes in the literature (ie, SSS-W),33 most
are the result of extensive work that combined literature reviews
and drawing items from previous questionnaires, focus groups
and cognitive interviews with clinical populations, and discus-
sions with professionals and/or patients. For example, the PDQ
and the PFSF are the result of intensive work through several
stages involving qualitative and quantitative approaches,35,42
which resulted in well-grounded questionnaires that met the
standards for scale development proposed by different organiza-
tions, such as the Food and Drug Administration20 or the
American Educational Research Association, American Psycho-
logical Association, and National Council on Measurement in
Education.19
Performing a robust psychometric validation is a key step in
making sure a scale is appropriate for its intended use.62
Regarding reliability, internal consistency (and more specif-
ically, Cronbach a), and test-retest reliability were tested and
reported for most measures included in this review. Most scales
reached desired levels of internal consistency and test-retest
reliability, with only a few exceptions such as the rather low
internal consistency of the PDQ.35 Different types of reliability
are preferred depending on the type of scale, underlying mea-
surement model, characteristics, and intended use63; therefore,
systematically testing internal consistency and test-retest reli-
ability should not be regarded as the norm. For example, when
score reproducibility is important (eg, when assessing the same
construct over time), test-retest reliability should be provided.63
Along the same lines, it is surprising that despite the criticism
that Cronbach a has gathered over years (eg, it relies on a
s-equivalent model that is hardly met and is strongly affected by
the length of the scale)64e67 and the availability of other more
appropriate reliability estimators (eg, McDonald u, greatest
16
lower bound),64,66 Cronbach a is still used as the default
reliability estimator.63,64
Regarding validity, only half the studies mentioned evidences
of validity based on content (SQOL-M, IPE, QOL-ED, FSDS-
R, PFSF, SDRDS, PC-QOL, FSFI-BC), whether it was through
a quick assessment of scale usability or more intensive assess-
ments about the clarity and understandability of the items or
patient and expert assessments of the validity and applicability of
the items and their responses for a particular population, whereas
the other half did not conduct tests of content validity (eg, MSQ)
or did not report the results (eg, PSCI). Only the IPE provided
detailed results about the content validity study.27 Testing con-
tent validity is a crucial step in scale development68 and it has
important implications for the clinical judgements made from
the scores obtained.69 As a result of the overall poor content
validation, some scales included in this review showed problems
with the factorial solution (eg, MSQ, EPIC), or even included
items that were not strictly assessing sexual distress but other
related constructs (eg, sexual confidence; eg, SQOL-M). Other
evidences of validity were reported, although not consistently.
Very common were evidences of validity based on the internal
structure of the scale and evidences based on relations to other
variables. Regarding internal structure, all scales and subscales
emerged as separate dimensions except for the 2 MSQ subscales
(ie, sexual anxiety and depression) and the EPIC sexual bother
subscale. In the MSQ, all items on the sexual depression (5
items) and sexual anxiety (5 items) subscales loaded onto the
same factor, and thus these items likely assess a more general
construct of sexual distress, rather than distinct concepts of sexual
depression and sexual anxiety. For the EPIC, the sexual bother
and sexual function items loaded on the same factor, which in-
dicates the presence of a more general sexual domain. These are 2
instances of where further refinement to improve a scale’s
internal structure and, hence, its construct validity are likely
warranted. A large proportion of scales examined validity based
on differences between groups, demonstrating that these mea-
sures discriminated well between clinical and non-clinical groups.
However, in this regard, there are 2 aspects that are worth
mentioning. (i) Despite the authors putting in the effort of
collecting large clinical and control samples, the large majority
did not provide cutoff scores for their scales, although these
measures were primarily designed for clinical groups; the
exceptions are the different versions of the FSDS.4,29 Also, none
of the measures included in this review have norms. Proposing
and including norms would provide a helpful guideline for
practitioners wanting to use the scales by serving as a standard-
ized value for helping to diagnose sexual dysfunctions. These 2
aspects are especially relevant given that the interest in sexual
distress emerged from its inclusion as a diagnostic criterion for
sexual dysfunction9; therefore, having indicators (ie, cutoff scores
and/or norms) that can be used to interpret the scores and
determine what constitutes clinically significant levels of sexual
distress is paramount. (ii) None of the scales that compared
Santos-Iglesias et al
between groups reported any test of measurement invariance,
which is a necessary condition to conduct meaningful compari-
sons between groups.70e72 Only 2 measures examined treatment
responsiveness (eg, FSDS and PDQ) and, in general, they
showed good results. Given that most of these measures were
designed to be used in clinical populations and that they could be
used to assess improvements in clinical conditions after treatment
or even be used as outcomes in clinical trials, it is surprising that
most of these measures did not test responsiveness to treatment.
A final step in questionnaire development and validation is the
process of reporting.22 In this regard, we found some articles
missed relevant information. For example, many articles had
incomplete information justifying the type of response scale that
was chosen, and a few others did not provide clear and precise
information about the response scale or information about how
to obtain scores.27 In general, very little attention is given to
reporting the qualitative parts of scale development (eg, focus
groups or interview results), by providing too limited or no de-
tails about how these qualitative tests were conducted. For
example, articles stated only that content validity had been
assessed, but results were not provided. These omissions make it
more difficult to evaluate the quality of the instrument and its
appropriateness for someone’s work.22
GUIDANCE IN SELECTING AN APPROPRIATE
MEASURE
This systematic review shows there are many different options
for measures to assess sexual distress, some of which are more
appropriate than others depending on the assessment question.
The population should be considered. When assessing those with
a specific type of sexual dysfunction, several specific measures of
good quality were identified (eg, men with PD or ED, men and
women affected by PE, women with low sexual desire or surgi-
cally induced menopause, or populations with PCa or breast
cancer). If the population to be assessed is more general, then
other measures could prove more useful, such as the BMSFI or
the SQOL-M for men with different types of sexual dysfunction
or the EMAS-SFQ, for an aging male population. If the popu-
lation is more general, then the SSS-W or the FSDS could be
considered. Of these 2, the [Female] Sexual Distress Scale stands
out as an ideal scale to select because the items are gender neutral,
and it has been used73e76 and validated31 with men.
Other important considerations in measure selection include
frequency of use, clinical application, breadth of focus of the
study, and definition of distress. (i) Questionnaires that have
been used infrequently can make it very difficult to make
comparisons across studies. If the primary purpose is to draw
comparisons across a large volume of studies, then the more
popular scales might prove most useful. These include the FSDS,
FSDS-R, and EPIC. (ii) When the assessment question includes
an aim to assist with clinical diagnosis or to determine clinical
severity, measures containing a cutoff score (such as the FSDS)
J Sex Med 2018;-:1e20
Sexual Distress Measures
are ideal. (iii) If assessing sexual distress is 1 of several aims,
selecting a measure that includes a sexual distress subscale as part
of a larger full scale might be the best option (eg, sexual distress
as a component of overall quality of life). (iv) It also is important
to ensure that the definition of sexual distress is not too narrow.
For example, for the PCa population, 3 subscales were identified,
ranging from assessing only bother associated specifically with
sexual function (ie, EPIC) to a broader assessment of impact on
intimate relationships, general feelings, degree of concern, worry
about pleasing a partner, shame, and interference with enjoying
life (ie, PC-QOL). This narrow assessment of sexual distress (as
used in the EPIC) excludes other relevant aspects of sexual
distress that are independent of specific function (eg, aspects of
the intimate relationship).
LIMITATIONS AND FUTURE RESEARCH
Although a thorough search and documentation approach was
used, there is a chance that relevant articles might have been
missed. Because we restricted our searches to English-language
journals, we could have missed other language validations.
Although we came across validations of some scales across
different languages and cultures, in the future it could be valuable
to look further into questions regarding the cross-cultural suit-
ability and sensitivity of sexual distress scales.
The findings from this research suggest several recommenda-
tions future research directions. (i) Researchers should strive to
more completely validate their measures and provide full
disclosure of their results, so that there is a more robust account
of the psychometric properties related to the scale.25 (ii) Given
that the validation process never ends and that the psychometric
properties of the scale depend on the samples and use of the
scale,21,62,63 authors need to consider the strengths, weaknesses,
and characteristics of the scale and determine whether they suit
their needs or if, on the contrary, further tests and validations are
necessary.
CONCLUSIONS
The results of this investigation have many implications in
clinical and research realms. In the context of research applica-
tions, our results provide a consistent reference point for re-
searchers who are interested in assessing sexual distress in their
studies. This literature review informs clinicians and researchers
of the variety of tools for assessing sexual distress. Because the
measures we found were extremely diverse, it is not practical to
provide an endorsement for a “gold standard” measure for
assessing sexual distress. Rather, professionals should use their
discretion to decide which measure is most appropriate for their
purpose, based on the specific population and the question of
interest. They can use the information provided in this article to
ascertain whether the psychometric properties, practicality, and
scope of the scales fit within the niche of their objectives. The
availability of this comprehensive list of validated measures for
J Sex Med 2018;-:1e20
17
the assessment of sexual distress allows clinicians to more validly
and reliably make diagnoses of sexual dysfunction in a manner
that adheres to the information outlined in the DSM-5.9 This is
important because asking about the psychological aspects of
sexual problems has been shown to be beneficial in making more
holistic and accurate determinations about the presence of sexual
dysfunction and for avoiding overdiagnosis of sexual dysfunc-
tion.77 Ultimately, this article provides valuable information for
empowering sexual health researchers and clinicians to consider
and evaluate sexual distress more accurately, thereby facilitating
advancements in the study of the psychological aspects of sexual
health and dysfunction.
Corresponding Author: Pablo Santos-Iglesias, PhD, Tom
Baker Cancer Centre, Psychosocial Oncology, 2202 2nd Street
SW, Calgary, AB T2S 3C1, Canada. Tel: 403-698-8001; Fax:
403-355-3206; E-mail: pablo.santos@ahs.ca
Conflicts of Interest: The authors report no conflicts of interest.
Funding: This research was funded by a Prostate Cancer Canada
grant to Dr Walker and the Markin Undergraduate Student
Research Program in Health and Wellness to Bijan Mohamed.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Pablo Santos-Iglesias; Bijan Mohamed; Lauren Walker
(b) Acquisition of Data
Pablo Santos-Iglesias; Bijan Mohamed
(c) Analysis and Interpretation of Data
Pablo Santos-Iglesias; Bijan Mohamed; Lauren Walker
Category 2
(a) Drafting the Article
Pablo Santos-Iglesias; Bijan Mohamed; Lauren Walker
(b) Revising It for Intellectual Content
Pablo Santos-Iglesias; Lauren Walker
Category 3
(a) Final Approval of the Completed Article
Pablo Santos-Iglesias; Lauren Walker
REFERENCES
1. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the
United States: prevalence and predictors. JAMA 1999;
281:537-544.
2. World Health Organization. Developing sexual health pro-
grammes. A framework for action. Geneva: World Health
Organization; 2010.
3. Rosen R. Prevalence and risk factors of sexual dysfunction in
men and women. Curr Psychiatry Rep 2000;2:189-195.
4. Derogatis L, Rosen R, Leiblum S, et al. The Female Sexual
Distress Scale (FSDS): initial validation of a standardized scale
for assessment of sexually related personal distress in women.
J Sex Marital Ther 2002;28:317-330.
18
5. Stephenson KR, Meston CM. Differentiating components of
sexual well-being in women: are sexual satisfaction and
sexual distress independent constructs? J Sex Med 2010;
7:2458-2468.
6. Pescatori ES, Giammusso B, Piubello G, et al. Journey into the
realm of requests for help presented to sexual medicine spe-
cialists: introducing male sexual distress. J Sex Med 2007;
4:762-770.
7. Dennerstein L, Guthrie KA, Hayes RD, et al. Sexual function,
dysfunction and sexual distress in a prospective, population-
based sample of mid-aged, Australian-born women. J Sex
Med 2008;5:2291-2299.
8. Abdo CH. The impact of ejaculatory dysfunction upon the
sufferer and his partner. Transl Androl Urol 2016;5:460-469.
9. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders. 5th ed. Arlington, VA: American
Psychiatric Publishing; 2013.
10. Hayes RD, Dennerstein L, Bennett CM, et al. What is the
“true” prevalence of female sexual dysfunctions and does the
way we assess these conditions have an impact? J Sex Med
2008;5:777-787.
11. Rosen R, Brown C, Heiman J, et al. The Female Sexual
Function Index (FSFI): a multidimensional self-report for the
assessment of female sexual function. J Sex Marital Ther
2000;26:191-208.
12. Rosen R, Riley A, Wagner G, et al. The International Index of
Erectile Function (IIEF): A multidimensional scale for assess-
ment of erectile dysfunction. Urology 1997;49:822-830.
13. Forbes MK, Baillie AJ, Schniering CA. Critical flaws in the
Female Sexual Function Index and the International Index of
Erectile Function. J Sex Res 2014;51:485-491.
14. McCabe M, Althof SE, Assalian P, et al. Psychological and
interpersonal dimensions of sexual function and dysfunction.
J Sex Med 2010;7:327-336.
15. Wagner TH, Patrick DL, McKenna SP, et al. Cross-cultural
development of a quality of life measure for men with erection
difficulties. Qual Life Res 1996;5:443-449.
16. Evangelia N, Kirana PS, Chiu G, et al. Level of bother and
treatment-seeking predictors among male and female in-
patients with sexual problems: a hospital-based study. J Sex
Med 2010;7:700-711.
17. Bancroft J, Loftus J, Long JS. Distress about sex: A national
survey of women in heterosexual relationships. Arch Sex
Behav 2003;32:193-208.
18. Shifren JL, Monz BU, Russo PA, et al. Sexual problems and
distress in United States women. Obstet Gynecol 2008;
112:970-978.
19. American Educational Research Association, American Psy-
chological Association, National Council on Measurement in
Education. The standards for educational and psychological
testing. Washington, DC: AERA Publications; 2014.
20. Food and Drug Administration. Guidance for industry patient-
reported outcome measures: use in medical product devel-
opment to support labeling claims. Available at: https://www.
fda.gov/downloads/Drugs/GuidanceComplianceRegulatory
Information/Guidances/UCM193282.pdf. Published 2009.
Santos-Iglesias et al
21. Price LR. Psychometric methods: theory into practice. New
York: Guilford Press; 2017.
22. Streiner DL, Kottner J. Recommendations for reporting the
results of studies of instrument and scale development and
validation. J Adv Nurs 2014;70:1970-1979.
23. Meston C, Derogatis LR. Validated instruments for assessing
female sexual function. J Sex Marital Ther 2002;28:155-164.
24. Urbina S. Essentials of psychological testing. 2nd ed. Hobo-
ken, NJ: John Wiley & Sons; 2014.
25. Giraldi A, Rellini A, Pfaus JG, et al. Questionnaires for
assessment of female sexual dysfunction: a review and
proposal for a standardized screener. J Sex Med 2011;
8:2681-2706.
26. Derogatis L. Assessment of sexual function/dysfunction via
patient reported outcomes. Int J Impot Res 2008;20:35-44.
27. Althof S, Rosen R, Symonds T, et al. Development and vali-
dation of a new questionnaire to assess sexual satisfaction,
control, and distress associated with premature ejaculation.
J Sex Med 2006;3:465-475.
28. Moher D, Liberati A, Tetzlaff J, et al. The PRISMA Group.
Preferred reporting items for systematic reviews and meta-
analyses: the PRISMA statement. PLoS Med 2009;
6:e1000097.
29. Derogatis L, Clayton A, Lewis-D’Agostino D, et al. Validation of
the Female Sexual Distress ScaleeRevised for assessing
distress in women with hypoactive sexual desire disorder.
J Sex Med 2008;5:357-364.
30. Derogatis L, Pyke R, McCormack J, et al. Does the Female
Sexual Distress ScaleeRevised cover the feelings of women
with HSDD? J Sex Med 2011;8:2810-2815.
31. Santos-Iglesias P, Mohamed B, Danko A, et al. Psychometric
validation of the Female Sexual Distress Scale in male sam-
ples. Arch Sex Behav. In press.
32. Santos-Iglesias P, Mohamed B, Danko A, et al. It is not only
about function! Assessment of sexual distress with four
standardized scales. Presented at: Canadian Sex Research
Forum; Fredericton, Canada; October 2017.
33. Meston C, Trapnell P. Development and validation of a five-
factor sexual satisfaction and distress scale for women: the
Sexual Satisfaction Scale for Women (SSS-W). J Sex Med
2005;2:66-81.
34. Snell WE, Fisher TD, Walters AS. The Multidimensional
Sexuality Questionnaire: an objective self-report measure of
psychological tendencies associated with human sexuality.
Ann Sex Res 1993;6:27-55.
35. Hellstrom WJG, Feldman R, Rosen RC, et al. Bother and
distress associated with Peyronie’s disease: validation of the
Peyronie’s Disease Questionnaire. J Urol 2013;190:627-634.
36. Coyne KS, Currie BM, Thompson CL, et al. The test-retest
reliability of the Peyronie’s Disease Questionnaire. J Sex
Med 2015;12:543-548.
37. Coyne KS, Currie BM, Thompson CL, et al. Responsiveness of
the Peyronie’s Disease Questionnaire (PDQ). J Sex Med 2015;
12:1072-1079.
J Sex Med 2018;-:1e20
Sexual Distress Measures
38. Hellstrom WJG, Feldman RA, Coyne KS, et al. Self-report and
clinical response to Peyronie’s disease treatment: Peyronie’s
Disease Questionnaire results from 2 large double-blind, ran-
domized, placebo-controlled phase 3 studies. Urology 2015;
86:291-299.
39. Abraham L, Symonds T, Morris MF. Psychometric validation of
a sexual quality of life questionnaire for use in men with
premature ejaculation or erectile dysfunction. J Sex Med
2008;5:595-601.
40. Symonds T, Boolell M, Quirk F. Development of a question-
naire on sexual quality of life in women. J Sex Marital Ther
2005;31:385-397.
41. O’Leary MP, Fowler FJ, Lenderking WR, et al. A brief male
sexual function inventory for urology. Urology 1995;
46:697-706.
42. McHorney CA, Rust J, Golombok S, et al. Profile of Female
Sexual Function: a patient-based, international, psychometric
instrument for the assessment of hypoactive sexual desire in
oophorectomized women. Menopause 2004;11:474-483.
43. Derogatis L, Rust J, Golombok S, et al. Validation of the Profile
of Female Sexual Function (PFSF) in surgically and naturally
menopausal women. J Sex Marital Ther 2004;30:25-36.
44. Kalmbach DA, Ciesla JA, Janata JW, et al. The validation of the
Female Sexual Function Index, Male Sexual Function Index, and
Profile of Female Sexual Function for use in healthy young
adults. Arch Sex Behav 2015;44:1651-1662.
45. Rust J, Derogatis L, Rodenberg C, et al. Development and
validation of a new screening tool for hypoactive sexual desire
disorder: the Brief Profile of Female Sexual Function (B-PFSF).
Gynecol Endocrinol 2007;23:638-644.
46. Revicki DA, Margolis MK, Fisher W, et al. Evaluation of the
Sexual Desire Relationship Distress Scale (SDRDS) in women
with hypoactive sexual desire disorder. J Sex Med 2012;
9:1344-1354.
47. Wei JT, Dunn RL, Litwin MS, et al. Development and validation
of the Expanded Prostate Cancer Index Composite (EPIC) for
comprehensive assessment of health-related quality of life in
men with prostate cancer. Urology 2000;56:899-905.
48. Litwin MS, Hays RD, Fink A, et al. The UCLA Prostate Cancer
Index: development, reliability, and validity of a health-related
quality of life measure. Med Care 1998;36:1002-1012.
49. Szymanski KM, Wei JT, Dunn RL, et al. Development and
validation of an abbreviated version of the Expanded Prostate
Cancer Index Composite instrument for measuring health-
related quality of life among prostate cancer survivors.
Urology 2010;76:1245-1250.
50. Chang P, Szymanski KM, Dunn RL, et al. Expanded Prostate
Cancer Index Composite for clinical practice: development and
validation of a practical health related quality of life instrument
for use in the routine clinical care of patients with prostate
cancer. J Urol 2011;186:865-872.
51. Giesler RB, Miles BJ, Cowen ME, et al. Assessing quality of life
in men with clinically localized prostate cancer: development of
a new instrument for use in multiple settings. Qual Life Res
2000;9:645-665.
J Sex Med 2018;-:1e20
19
52. Befort CA, Zelefsky MJ, Scardino PT, et al. A measure of
health-related quality of life among patients with localized
prostate cancer: results from ongoing scale development. Clin
Prostate Cancer 2005;4:100-108.
53. Bartula I, Sherman KA. Development and validation of the
Female Sexual Function Index adaptation for breast cancer
patients (FSFI-BC). Breast Cancer Res Treat 2015;
152:477-488.
54. O’Connor DB, Corona G, Forti G, et al. Assessment of sexual
health in aging men in Europe: development and validation of
the European Male Ageing Study sexual function question-
naire. J Sex Med 2008;5:1374-1385.
55. Basson R, Berman J, Burnett A, et al. Report of the interna-
tional consensus development conference on female sexual
dysfunction: definitions and classifications. J Urol 2000;
163:888-893.
56. Rabbani F, Schiff J, Piecuch M, et al. Time course of re-
covery of erectile function after radical retropubic prosta-
tectomy: does anyone recover after 2 years? J Sex Med
2010;7:3984-3990.
57. Bokhour BG, Clark JA, Inui TS, et al. Sexuality after treatment
for early prostate cancer: exploring the meanings of “erectile
dysfunction.” J Gen Intern Med 2001;16:649-655.
58. Clark JA, Wray N, Brody B, et al. Dimensions of quality of life
expressed by men treated for metastatic prostate cancer. Soc
Sci Med 1997;45:1299-1309.
59. Bowling A. Techniques of questionnaire design. In: Bowling A,
Ebrahim S, eds. Handbook of health research methods.
Investigation, measurement, and analysis. New York: Open
University Press; 2005. p. 394-427.
60. Rust J, Golombok S. Modern psychometrics. The science of
psychological assessment. 3rd ed. New York: Routledge;
2009.
61. Kline TJB. Psychological testing. A practical approach to
design and evaluation. Thousand Oaks, CA: Sage; 2005.
62. Sireci SG. On the validity of useless tests. Assess Educ 2016;
23:226-235.
63. Danner D, Blasius J, Breyer B, et al. Current challenges, new
developments, and future directions in scale construction. Eur
J Psychol Assess 2016;32:175-180.
64. Sijtsma K. On the use, the misuse, and the very limited
usefulness of Cronbach’s alpha. Psychometrika 2009;
74:107-120.
65. Cortina JM. What is coefficient alpha? An examination of
theory and applications. J Appl Psychol 1993;78:98-104.
66. Dunn TJ, Baguley T, Brunsden V. From alpha to omega: a
practical solution to the pervasive problem of internal con-
sistency estimation. Br J Psychol 2014;105:399-412.
67. Streiner DL. Being inconsistent about consistency: when co-
efficient alpha does and doesn’t matter? J Pers Assess 2003;
80:217-222.
68. Rubio DM, Berg-Weger M, Tebb SS, et al. Objectifying content
validity: conducting a content validity study in social work
research. Soc Work Res 2003;27:94-104.
20
69. Haynes SN, Richard DCS, Kubany ES. Content validity in
psychosocial assessment: a functional approach to concepts
and methods. Psychol Assess 1995;7:238-247.
70. Dimitrov DM. Testing for factorial invariance in the context of
construct validation. Meas Eval Couns Dev 2010;43:121-149.
71. Meredith W, Teresi JA. An essay on measurement and factorial
invariance. Med Care 2006;44:S69-S77.
72. Vandenberg RJ, Lance CE. A review and synthesis of the
measurement invariance literature: suggestions, practices, and
recommendations for organizational research. Organ Res
Methods 2000;3:4-70.
73. Jern P, Santtila P, Johansson A, et al. Indicators of premature
ejaculation and their associations with sexual distress in a
population-based sample of young twins and their siblings.
J Sex Med 2008;5:2191-2201.
Santos-Iglesias et al
74. Park ES, Villanueva CA, Viers BR, et al. Assessment of sexual
dysfunction and sexually related personal distress in patients
who have undergone orthotopic liver transplantation for end-
stage liver disease. J Sex Med 2011;8:2292-2298.
75. O’Sullivan LF, Brotto LA, Byers ES, et al. Prevalence and
characteristics of sexual functioning among sexually expe-
rienced middle to late adolescents. J Sex Med 2014;
11:630-641.
76. O’Sullivan LF, Byers ES, Brotto LA, et al. A longitudinal study
of problems in sexual functioning and related sexual distress
among middle to late adolescents. J Adolesc Health 2016;
59:318-324.
77. Roos AM, Sultan AH, Thakar R. Sexual problems in the gy-
necology clinic: are we making a mountain out of a molehill?
Int Urogynecol J 2012;23:145-152.
J Sex Med 2018;-:1e20