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Reliability and validity of the Arizona Sexual Experiences Scale-Arabic version in Tunisian patients with schizophrenia Jaafar Nakhli a,⁎, Yousri El Kissi a , Saoussen Bouhlel a , Badii Amamou a , Thouraya Ajmi Nabli b , Selma Ben Nasr a , Bechir Ben Hadj Ali a a
Psychiatric department, Farhat Hached University Hospital, Sousse, Tunisia b Faculty of Medicine Ibn Jazzar, Sousse, Tunisia
Abstract Background: Sexual dysfunction is frequent in patients with schizophrenia compared to the general population. Screening for this dysfunction seems essential, and a scale such as the Arizona Sexual Experience (ASEX) Scale may help practitioners. The aim of this study was to assess the validity of the Arabic version of the ASEX scale. Method: Arabic translation of the ASEX scale was obtained by the “forward/backward translation” method. Adaptations were made after a pre-test including ten outpatients with schizophrenia. For validation, one hundred outpatients with schizophrenia were recruited in the psychiatric department in Sousse (Tunisia) during a period of three months. Internal consistency was assessed by Cronbach alpha coefficient and test-retest was conducted by use of Pearson correlation. For factor analysis, principal components analysis and Varimax rotation were adopted. Results: The study of internal consistency between the 5 Items was found to be good (α = 0.82). The test-retest reliability was satisfactory (r = 0.92, p b 10 −3). Regarding construct validity, factor analysis revealed one factor that was responsible for 83.7% of the variance. Conclusion: This study assessed the reliability and validity of the Arabic version of the ASEX scale. These findings demonstrate the highly acceptable psychometric properties of ASEX in patients with schizophrenia. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Schizophrenia is a chronic and disabling mental illness. Its prevalence ranges from 0.4 to 0.7% in the general population [1,2]. All sexual dysfunctions can be observed in schizophrenia. They are due to: a decrease in the subject's ability to think and desire the opposite sex, withdrawal and precarious situation of these patients, the cognitive and emotional development deficit and finally the side effect of antipsychotics. In the literature, the frequency of sexual dysfunctions in these patients varies between 50 and 85% . At present, there are three scales available to assess sexual dysfunctions in patients with schizophrenia under antipsychotic treatment: the Dickson and Glazer Scale for the
Assessment of Sexual Functioning Inventory (DGSFi) , the Arizona Sexual Experience (ASEX) Scale  and the Psychotropic-Related Sexual Dysfunction (PRSexDQSALSEX) . Unlike the more traditional and lengthy scales for assessing sexual dysfunctions, the ASEX can be completed in approximately 5 minutes and it was designed to be self or clinician-administered . It was validated in outpatients with schizophrenia and schizoaffective disorders . To our knowledge, in Tunisia, as well as in other Arabic countries there is not yet any validation of the ASEX scale. The aim of the present study was to translate into Arabic and validate the ASEX scale.
2. Methods ⁎ Corresponding author at: Psychiatric department, Farhat Hached University Hospital, Rue Ibn Jazzar Sousse, 4002, Tunisia. Tel: +216 73221411. E-mail address: [email protected]
(J. Nakhli). 0010-440X/© 2014 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.comppsych.2014.04.006
2.1. The ASEX scale The ASEX is designed to assess five major aspects of sexual dysfunction: drive, arousal, penile erection/vaginal
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lubrication, ability to reach orgasm, and satisfaction from orgasm. Items are measured on a 6-point scale (1–6), with higher scores reflecting impaired sexual function. The female and male versions of ASEX differ on the gender-specific question 3 addressing erection/lubrication . This scale allows rapid detection of sexual dysfunction. Sexual dysfunction was defined as 1) a total ASEX score of ≥19, 2) any one item with a score of ≥5, or 3) any three items with a score of ≥4 . ASEX scale can be used in heterosexual and homosexual populations and it is appropriate for use in those with and without sexual partners. It evaluates sexual activity that includes two partner sexual activity or masturbation . These attributes are important for persons with schizophrenia who are less likely to have a sexual partner . Based on samples of patients with depressive or anxiety disorders , those at end-stage renal disease , those with schizophrenia and schizoaffective disorders  and with Parkinson disease , the ASEX scale has good internal reliability and construct validity. 2.2. Translation and adaptation We applied to the original version of ASEX scale forward/ backward translation procedure. Firstly, we obtained the consent and the permission of the University of Arizona Psychiatry to validate the ASEX scale in Arabic language. For translation and adaptation, we refer to the manual of the “Mapi Research Institute” (MAPI) . The translation was made from English to Arabic language by two bilingual translators and all participants discussed the translated version to find the most appropriate terms. The second stage was the back-translation made by a bilingual translator of the translated version from Arabic to English and the verification of the similarity of the five items with the original scale. 2.3. Pre-testing A pre-testing process was conducted in which the translated Arabic version was administrated to ten outpatients and their literal answers given were collected. Based on these, the investigators agreed on the wording of the questions and the ability of each patient to understand all the five items. All these patients were randomly selected and not part of the validation study. 2.4. Sample This study was approved by the ethics committee of the Faculty of Medicine in Sousse. We have performed this study with one hundred first outpatients with a diagnosis of schizophrenia (DSM-IV TR criteria)  from the outpatient psychiatric service of Farhat Hached Hospital in Sousse. The study was held between first September and 30 November 2013. All patients meet the remission criterion developed by “The Working Group Remission in schizo-
phrenia”  and were taking antipsychotic medication at the time of assessment. Patients in remission have a score less than or equal to 90 at the Positive and Negative Syndrome Scale (PANSS)  and had no history of hospitalization during the last six months . We excluded schizophrenic patients with other comorbidity such as: mental retardation, personal history of depressive disorder, alcohol and/or substance abuse in the preceding six months. We administered to the one hundred outpatients a record exploring demographic characteristics, the PANSS scale and ASEX scale translated into Arabic language. 2.5. Reliability Cronbach's alpha coefficient (α) was used to evaluate internal consistency of ASEX scale. Pearson's coefficient (r) was used to evaluate test-retest reliability. It is calculated with the administration of the scale at baseline and at 15 days. It had concerned twenty outpatients from the same sample of one hundred outpatients. 2.6. Validity For content validity, we applied a factorial analysis to verify if the Arabic version of ASEX scale had a similar factorial structure to the original version. We performed principal components analysis (considering Eigen values N1) with VARIMAX rotation and Kaiser Normalization.
3. Results 3.1. Translation and pre-testing After the forward/backward translation and meeting for all participants, we found that the Arabic version of the ASEX scale is similar to the original version. For pre-testing, all comments of patients with schizophrenia and their difficulties to understand terms are taken into consideration. A final corrected version was adopted by all the investigators. 3.2. Subjects' demographic and clinical characteristics (Table 1) The mean age of our sample was 37.6 years (SD = 10.2). The sex ratio was 2.3 and 27% of them had professional activity. The mean age of illness onset was 24.8 (SD = 6.1). 43% of them received second generation antipsychotics. The mean ASEX total score was 17.7 (SD = 5.6) and the mean PANSS total score was 51.8 (SD = 12.8). 55% of outpatients with schizophrenia have sexual dysfunction. 3.3. ASEX reliability In regard to internal consistency of the ASEX scale, Cronbach's alpha coefficient was 0.82 for the total sample. It was 0.81 for males and 0.83 for females. Lower coefficient
J. Nakhli et al. / Comprehensive Psychiatry xx (2014) xxx–xxx Table 1 Demographic and clinical characteristics of the sample (n = 100). Age (years) Male Education (years) Professional activity (%) Age of onset illness (years) Second generation antipsychotics ASEX total score PANSS Total Score Sexual dysfunction
37.6 ± 10.2 70% 8.1 ± 4.2 27% 24.8 ± 6.1 43% 17.7 ± 5.6 51.8 ± 12.8 55%
was 0.81 (arousal) and higher coefficients were 0.89 (penile erection/vaginal lubrication and ability to reach orgasm). The five items of ASEX were correlated with p b 10 −3. Tables 2 and 3 shows the mean of each item by gender and correlation between the five items. The test-retest reliability calculated with the administration of the ASEX scale at baseline and at 15 days on a subsample of twenty patients was r = 0.92 (p b 10 −3). It was between 0.63 (arousal) and 0.87 (penile erection/vaginal lubrication) (Table 4). 3.4. ASEX validity Keiser-Meyer-Olkin index (KMO) in our study was 0.44 and Bartlett's sphericity test was significant (p b 10 −3). The factorial analysis showed one factor that explained 83.7% of the variance of the scores.
4. Discussion 4.1. Translation In our validation study, we followed the protocol of the “The Mapi Research Institute” (MAPI) which consists of three steps: translation, back-translation and pre-testing . In this method, we only need three translators (two for translation and one for the back-translation). This seems to be advantageous over other methods because it can solve the problem of non-availability of experts. Translators must have a good knowledge of the source language and the target language and experience the culture [15–17]. For many authors, we can administer scale into ten to twenty patients for pre-test to check the clarity of items. Afterward, these patients must be excluded from the different steps of the validation. Investigators are allowed to change incomprehensible expressions [15,18]. 4.2. Reliability A good internal consistency between the five items of the ASEX Arabic version was found with Cronbach's α coefficient of 0.82. It was 0.81 in males and 0.83 in females. We also found a positive correlation between the five items one by one and with the ASEX total score. Pearson “r” coefficients ranged from 0.66 to 0.91 with p b 10 −3.
In the original validation of ASEX scale, McGahuey et al., found excellent internal consistency in 107 control subjects and 58 psychiatric patients, with Cronbach α coefficient of 0.90. The sensitivity of this scale in the detection of sexual dysfunction was 82% and specificity 90%. They concluded that a total ASEX score ≥19, or any one item with a score ≥5, or any three items with a score ≥4, was strongly associated with sexual dysfunction . Similarly, the reliability of the ASEX Chinese version have been established among patients with major depressive disorder with a Cronbach's alpha of 0.89 and a sensitivity and specificity for predicting sexual dysfunction of 0.74 and 0.84, respectively . Soykan, in his study of reliability and validity of ASEX scale for end-stage renal disease patients undergoing hemodialysis in Turkey, had found a coefficient α of 0.92 for women and 0.81 for men . Similarly, Nunes et al., in their study of 137 patients with schizophrenia or schizoaffective disorders found Cronbach's α coefficient of 0.81 and mean Pearson's correlation for the five ASEX items was 0.47. The sensitivity and specificity of the ASEX in relation to DGSFi were: 80.8% (95% CI = 70.0– 88.5%) and 88.1% (95% CI = 76.5–94.7%) . In the study of sexual dysfunction in outpatients with schizophrenia and schizoaffective disorder, Byerly et al., noted that internal reliability by using Cronbach's α coefficient were very high for the ASEX scale (overall sample, α = 0.90; for females, α = 0.91; for males, α = 0.88). Factor loadings ranged from 0.80 to 0.88 for the overall sample, from 0.82 to 0.91 for females, and from 0.76 to 0.85 for males . In the French validation study of ASEX scale, Briki et al. noted that the five items are all significantly correlated. Furthermore, the results of the analysis of Cronbach's α coefficient indicated that ASEX has excellent internal consistency (α = 0.94) . In the Thailand validation study in a sample of 40 Parkinson's disease patients, Cronbach's alpha of all items at baseline and at a 2-month follow-up were 0.94 and 0.96 respectively . The test-retest reliability in our study for two weeks was excellent (r = 0.92). In the original validation study, Pearson's coefficient was 0.8 in the patient group and 0.89 for the control group . In the French validation study, the Table 2 Internal consistency of the ASEX scale-Arabic version. Items of the ASEX scale
Cronbach's Cronbach's Cronbach's alpha alpha (male) alpha (female) (total sample)
1. Sexual drive 2. Arousal 3. Penile erection/ vaginal lubrication 4. Ability to reach orgasm 5. Satisfaction from orgasm Total ASEX
0.87 0.74 0.87
0.86 0.89 0.88
0.87 0.81 0.89
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Table 3 Correlation between items of ASEX scale-Arabic version. ASEX (Item 1) ASEX (Item 1) ASEX (Item 2) ASEX (Item 3) ASEX (Item 4) ASEX (Item 5)
ASEX (Item 2)
ASEX (Item 3)
ASEX (Item 4)
r = 0.81⁎⁎
r = 0.77⁎⁎ r = 0.75⁎⁎
r = 0.75⁎⁎ r = 0.69⁎⁎ r = 0.82⁎⁎
ASEX (Item 5) r r r r
= = = =
0.75⁎⁎ 0.66⁎⁎ 0.78⁎⁎ 0.81⁎⁎
ASEX Total r r r r r
= = = = =
0.89⁎⁎ 0.85⁎⁎ 0.91⁎⁎ 0.91⁎⁎ 0.90⁎⁎
⁎⁎ p b 10 −3.
test-retest reliability of the ASEX scale was performed on both populations (patients with major depressive disorder and controls), at first day and after two weeks. No significant difference was observed for the ASEX total score between the two times evaluation for both patients with major depressive disorder and controls . Similarly, in the test-retest reliability investigation of ASEX scale for Turkish end-stage renal disease patients undergoing hemodialysis, Pearson's correlation coefficients between baseline and 6-month scores were calculated. Correlation coefficients revealed highly significant correlations statistically for Item 1 (r = 0.69, p = 0.001), Item 2 (r = 0.79, p = 0.001), Item 3 (r = 0.72, p = 0.001), Item 4 (r = 0.76, p = 0.001), Item 5 (r = 0.84, p = 0.001) and total ASEX score (r = 0.88, p = 0.001) . In the Thailand validation of ASEX scale, authors found highly significant test-retest reliability  4.3. Validity In our study, factorial analysis of ASEX scale showed one factor that explained 83.7% of the variance of the scores. In the English original version, the ASEX was a bimodal scale able to diagnose reduced or enhanced sexual function . Byerly et al., during their validation of ASEX scale among outpatients with schizophrenia or schizoaffective disorder had also noted one principal factor in the Principal Component Analysis, measuring sexual dysfunction. Factor loadings ranged from 0.80 to 0.88 for the overall sample, from 0.82 to 0.91 for females, and from 0.76 to 0.85 for males . 5. Conclusion It is important to assess sexual dysfunction in patients with schizophrenia. This exploration needs using of Table 4 Test-retest reliability. Items of ASEX scale
“r” Pearson's coefficient
ASEX (Item 1) ASEX (Item 2) ASEX (Item 3) ASEX (Item 4) ASEX (Item 5) ASEX Total
0.71 0.63 0.87 0.67 0.71 0.92
0.001 0.002 b10 −3 b10 −3 0.001 b10 −3
validated tools such as ASEX scale. In this study, the Arabic version of the ASEX scale presented good internal consistency, excellent inter-rater reliability for the total score. Factor analysis showed one factor structure similar to the English original version. These findings demonstrate the highly acceptable psychometric properties of ASEX in patients with schizophrenia independently of their culture.
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