Arch Sex Behav DOI 10.1007/s10508-014-0356-5

ORIGINAL PAPER

Sexual Compulsivity Scale, Compulsive Sexual Behavior Inventory, and Hypersexual Disorder Screening Inventory: Translation, Adaptation, and Validation for Use in Brazil Marco de T. Scanavino • Ana Ventuneac • H. Jonathon Rendina • Carmita H. N. Abdo • Hermano Tavares • Maria L. S. do Amaral • Bruna Messina • Sirlene C. dos Reis • Joa˜o P. L. B. Martins • Marina C. Gordon Julie C. Vieira • Jeffrey T. Parsons

•

Received: 1 October 2013 / Revised: 19 February 2014 / Accepted: 10 March 2014  Springer Science+Business Media New York 2014

Abstract Epidemiological, behavioral, and clinical data on sexual compulsivity in Brazil are very limited. This study sought to adapt and validate the Sexual Compulsivity Scale (SCS), the 22-item version of the Compulsive Sexual Behavior Inventory (CSBI-22), and the Hypersexual Disorder Screening Inventory (HDSI) for use in Brazil. A total of 153 participants underwent psychiatric assessment and completed self-reported measures. The adaptation process of the instruments from English to Portuguese followed the guidelines of the International Society for Pharmacoeconomics and Outcomes Research. The reliability and validity of the HDSI criteria were evaluated and the construct validity of all measures was examined. For the SCS and HDSI, factor analysis revealed one factor for each measure. For the CSBI-22, four factors were retained although we only calculated the scores of two factors (control and violence). All scores had good internal consistency (alpha[.75), presented high

temporal stability ([.76), discriminated between patients and controls, and presented strong (q[.81) correlations with the Sexual Addiction Screening Test (except for the violence domain = .40) and moderate correlations with the Impulsive Sensation Seeking domain of the Zuckerman Kuhlman Personality Questionnaire(q between .43and .55). The sensitivityof the HDSI was 71.93 % and the specificity was 100 %. All measures showed very good psychometric properties. The SCS, the HDSI, and the control domain of the CSBI-22 seemed to measure theoretically similar constructs, as they were highly correlated (q[.85). The findings support the conceptualization of hypersexuality as a cluster of problematic symptoms that are highly consistent across a variety of measures.

M. T. Scanavino
M. L. S. Amaral
B. Messina
S. C. Reis
J. P. L. B. Martins
M. C. Gordon
J. C. Vieira Department and Institute of Psychiatry (IPq), Clı´nicas’ Hospital (HC), University of Sa˜o Paulo Medical School (FMUSP), Sao Paulo, Brazil

J. T. Parsons HealthPsychologyDoctoralProgram,TheGraduateCenteroftheCity University of New York (CUNY), New York, NY, USA

A. Ventuneac
H. J. Rendina
J. T. Parsons Center for HIV/AIDS Educational Studies and Training (CHEST), New York, NY, USA H. J. Rendina
J. T. Parsons Basic and Applied Social Psychology Doctoral Program, The Graduate Center of the City University of New York (CUNY), New York, NY, USA

Keywords Sexual compulsivity
Hypersexual disorder
Compulsive sexual behavior
HIV
Psychometric properties

J. T. Parsons The CUNY School of Public Health at Hunter College, New York, NY, USA M. T. Scanavino (&) Rua Mato Grosso, 306, conj. 614, Sao Paulo, SP 01239-040, Brazil e-mail: [email protected] C. H. N. Abdo
H. Tavares Department of Psychiatry, University of Sa˜o Paulo Medical School (FMUSP), Sao Paulo, Brazil

J. T. Parsons Department of Psychology, Hunter College and the Graduate Center of the City University of New York (CUNY), New York, NY, USA

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Introduction Sexual compulsivity (SC) is increasingly being recognized as an important phenomenon among researchers and clinicians. Generally characterized as sexual fantasies, urges, and behaviors (e.g., excessive masturbation, excessive use of pornography, multiple casual sex partners) that increase in intensity and frequency over time and lead to negative outcomes, such as unemployment, financial problems, divorce, social isolation, and sexually transmitted infections (Black, 2000; Goodman, 2001; Kafka, 2010; Kalichman & Rompa, 1995; Kuzma & Black, 2008; Morgenstern et al., 2011; Muench et al., 2007; Parsons, Grov, & Golub, 2012; Parsons, Kelly, Bimbi, Muench, & Morgenstern, 2007; Raymond, Coleman, & Miner, 2003), researchers have drawn on impulse control, emotion regulation, compulsivity, and addiction models of behavior to obtain epidemiological evidence for SC and its correlates (Kafka, 2010). The utility of standardized instruments and rating scales has become paramount for research conducted in the United States. In the context of public health, it was critical to examine the association between SC and an increased risk for HIV transmission in different sample populations, such as HIV-positive men and women (Benotsch, Kalichman, & Pinkerton, 2001; Kalichman & Rompa, 2001), heterosexual college students (Dodge, Reece, Cole, & Sandfort, 2004), and male escorts (Parsons, Bimbi, & Halkitis, 2001). In the clinical context, SC rating scales make it possible to differentiate clinical and non-clinical samples, with regard to SC (Coleman, Miner, Ohlerking, & Raymond, 2001; Delmonico, Bubenzer, & West, 1998; Silveira, Vieira, Palomo, & Silveira, 2000), and to evaluate the effect of an intervention in a clinical trial (Wainberg et al., 2006). Research literature on SC conducted outside of the U.S. is sparse. There are a few case reports (e.g., Gulzun, Gulcat, & Aydin, 2007; Scanavino, Torres, Abdo, Rego, & Fernandez, 2009) and population-based studies (e.g., Langstrom & Hanson, 2006). Most of SC measures are not translated and adapted to other languages, with just a couple of exceptions such as the Sexual Compulsivity Scale (SCS) (Kalichman et al., 1994) and the 22-item version of the Compulsive Sexual Behavior Inventory (CSBI) (Miner, Coleman, Center, Ross, & Rosser, 2007). The validated Spanish version of the SCS was investigated in a sample of college students in Spain (Ballester Arnal, Go´mez Martı´nez, Gil Llario, & Salmero´n Sa´nchez, 2012), while the Spanish version of CSBI-22 was investigated in a sample of Latino men in the U.S. (Miner et al., 2007). The SCS and CSBI22 are widely used, and their psychometric properties have been evaluated in several different samples (Hook, Hook, Davis, Worthington, & Penberthy, 2010). The main difference between them is that the SCS is a unidimensional measure developed to evaluate trends of repetitive sexual thoughts and behaviors, while the CSBI-22 is a multidimensional measure that investigates control over sexual behavior and sexual aggression and violence.

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In the U.S., new efforts to establish an operational definition of SC for researchersandclinicianswithcriteria forthe diagnosis of hypersexual disorder were underway recently in order to provide evidence for consideration for inclusion in the DSM-5 (Kafka, 2010, 2013; Womack, Hook, Ramos, Davis, & Penberthy, 2013). The main criteria of hypersexual disorder were supported by data that emerged from studies using standardized instruments.Inparticular,thecriteriaregardingsignificantamounts of time consumed by sexual behaviors, increases in sexual behavior when experiencing stressful life events, difficulties in controlling sexual behavior, risk taking behaviors associated with sexual activity, and clinical distress or impairment in important areas of functioning were supported by findings from previous studies using the SC rating scale (Kalichman & Rompa, 1995, 2001; Kalichman & Cain, 2004; McBride, Reece, & Sanders, 2008; Miner et al., 2007). The proposal to include hypersexual disorder in the DSM-5 was recently rejected because there was not sufficient empirical evidence to support its inclusion as a disorder (American Psychiatric Association, 2012). Nevertheless, the newly developed measure, the Hypersexual Diagnostic Screening Inventory (HDSI), drafted based on the preliminary recommendations for DSM-5 diagnostic criteria for hypersexual disorder, was shown to be highly reliable in a sample of gay and bisexual men in the U.S. (Parsons et al., 2013). In Brazil, epidemiological, behavioral, and clinical data on SC remain very limited. A search of PubMed and the‘‘Biblioteca Virtual em Sau´de’’ [Virtual Health Library] databases, which include Medline, Lilacs, and the Cochrane Library, for studies on SC conducted in Brazil did not identify any clinical or population-based studies that investigated SC and its connections with HIV or sexually risky behavior. Recently, authors of this paper worked together on the first empirical study to examine SC in a treatment-seeking sample in Sa˜o Paulo, Brazil. We set out to investigate the psychometric properties of three measures, the SCS, the CSBI-22, and the HDSI, in a sample composed of sexually compulsive and non-sexually compulsive individuals in Sa˜o Paulo, Brazil. Adaptation and validation of SC rating scales for use in Brazil will make it possible to investigate epidemiological data on SC in another culture, in particular the connections between SC and sexual risk behavior for HIV transmission, the prevalence of SC symptoms in the clinical context, and the impact of interventions on SC symptoms. The data may be compared with previous studies conducted in the United States, and may increase our inter-cultural understanding of the SC. The goals of the current study were to (1) adapt the measures (the SCS, the 22-item CSBI, and the HDSI) from English to Portuguese (spoken in Brazil), and provide evidence for their research utility in Brazil; (2) examine the correspondence between previously well-utilized measures (SCS and CSBI) and the newly proposed HDSI; and (3) examine the correspondence between previously utilized SC diagnostic criteria and the diagnostic criteria purported to be investigated by HDSI.

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Method Translation and Cultural Adaptation The International Society for Pharmacoeconomics and Outcomes Research (ISPOR) guidelines for the translation and cultural adaptation of self-report instruments were used (Wild et al., 2005). We began by obtaining permission from the authors of the original versions of the SCS, CSBI, and HDSI to adapt their scales. Two Brazilian psychiatrists who were fluent in English produced two independent versions of each measure in Portuguese. We reconciled the two translated versions, resolving any discrepancies between the versions. A native English speaker, who had lived in Brazil for the previous eleven years and who had not worked with the original instrument or either of the two translated versions, conducted the back translation of the reconciled versions into English. A researcher in the U.S., who was familiar with the measures, reviewed and compared the back translation to the original instruments. To assess question comprehension, a clinical sample of SC patients reviewed the questions and indicated whether each question was difficult, confusing, or caused embarrassment. To check each patient’s level of understanding, we administered a sliding rating scale (Clark, Lavielle, & Martı´nez, 2003), in which the patients were asked to give a score from 1 (did not understand anything) to 5 (understood everything), including decimals (e.g., 1.1, 1.2), to represent their level of understanding. The results of the debriefing were analyzed in order to make final changes, and then final proofreading was performed. Regarding the SCS, there were no major discrepancies upon reconciliation of the two translated versions. In the process of reviewing the back translation by the American researcher, one discrepancy of meaning was found between the back translation and the original version. The American researcher noticed that one of the alternatives to the answer‘‘slightly like me’’had been translated to ‘‘not like me.’’ The mistake was corrected to ‘‘applies a little to me.’’The final version was administered to 17 sexually compulsive individuals for cognitive debriefing. The majority (15 of to 17) did not consider any items confusing, difficult,orembarrassing.A slidingscaleranging from 1 to 5was used to evaluate the level of understanding of the whole test; the mean was 4.82 (SD = .29), with a minimum of 4.0 and a maximum of 5.0. No major discrepancies were found among the forward translated versions of the CSBI-22. In the process of reviewing the back translation, a discrepancy was noticed regarding the meaning of the ninth statement‘‘How often have you developed excuses and reasons to justify your sexual behavior,’’ where ‘‘developed excuses and reasons’’ had been translated to ‘‘gave excuses.’’It was noted that‘‘to give excuses’’means to justify to other people but to ‘‘develop excuses and reasons’’ means a cognitive process of self-justification. We amended the Portuguese version based on this observation. The final version was

administered to 17 sexually compulsive individuals for cognitive debriefing. The majority (15–17) did not consider any items to be confusing, difficult, or embarrassing. A sliding scale ranging from 1 to 5 was used to evaluate the level of understanding of the whole assessment; the mean score was 4.94 (SD = .03), with a minimum of 4.86 and a maximum of 5.0. During reconciliation of the HDSI, the expression ‘‘risky sexual behavior,’’which was used in the fifth A criteria (i.e., item A.5), was changed to‘‘sexual risk behavior’’in the target translated version, as this is more commonly used by Brazilian health professionals. No other major discrepancies were found among the forward translated versions during the reconciliation process or among the back translation and the original version during review of the back translation. The final version was administered to 14 sexually compulsive individuals for cognitive debriefing. The majority (12 of 14) did not consider any item confusing, difficult, or embarrassing. A sliding scale ranging from 1 to 5 was used to evaluate the level of understanding of whole assessment; the mean was 4.80 (SD = .29), with a minimum of 4.0 and a maximum of 5.0. Participants and Procedure This article presents data from a study conducted at the Institute of Psychiatry of the Clı´nicas’ Hospital (HC) of the University of Sa˜o Paulo Medical School (FMUSP), a public university-based medical center in Sa˜o Paulo. Participants were recruited through advertisements for the research study via several media outlets, including radio, magazines, and journals. The research study was also advertised inside Clı´nicas’ Hospital by e-mail and on wall posters. Individuals who answered the advertisements were eligible for the study if they were classified as having an excessive sexual drive based on the tenth revision of the International Classification of Diseases (ICD-10) criteria F52.7 (World Health Organization, 1992) and met the criteria for sex addiction based on Goodman’s (2001) criteria. If the individuals did not meet these criteria, they were eligible to serve as controls. In addition, the participants had to be 18 years of age or older, and literate in Portuguese. In order to reduce the effects of comorbid psychopathology, the exclusion criteria for the study included a diagnosis of any of the following disorders: preference disorder (ICD-10 F65), gender identity disorder (ICD-10 F64), schizophrenia, schizotypal, and delusional disorders (ICD-10 F20F29), current manic episode (ICD-10 F30) or other mental disorders related to brain dysfunction, injury, or physical disease (ICD-10 F0.6). In total, 326 individuals responded to the advertisements, of whom 273scheduled an in-person screening interview. Ofthese, 207 (75.8 %) appeared for the in-person screening interviews, and 196 individuals were considered eligible for this study. Twenty-four individuals (11.6 %) did not return for assessment. A total of 172 (153 male and 19 female) individuals completed

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all of the study assessments from October 2010 until December 2011. Given that our competency to make any statistical analysis based on only 19 women enrolled in this study was limited, we dropped data from women from our analyses. In this article, we report data from the 153 men enrolled in the study. The HDSI became available for use a few months after the onset of the study; thus, 32 individuals who were enrolled at the beginning of the study were not assessed using the HDSI. As a result, we evaluated data from the 121 men who completed the HDSI. Participants provided informed consent and completed a 3-h assessment that consisted of standardized self-report measures and a psychiatric assessment. A nurse asked the participants to report their sociodemographic characteristics and explained the research process. The participants completed the measures on their own using a paper and pencil. Trained staff members oversaw the process of answering the self-report measures and provided clarification to participants as requested. Two psychiatrists who were familiar with screening people seeking SC treatment, and with conducting the treatment of those who met criteria, were trained by the principal investigator to assess possible cases of SC based on the HDSI algorithm score, namely, at least four A criteria and one B criteria (see Method section). The training happened with SC patients under treatment, who were assessed and discussed by the psychiatrist team. Most of the discrepancies were about participants presenting high severity of symptoms but who did not get at least four A criteria. In these occasions, we decided to keep the directions given by the DSM5 taskforce and these patients were not assigned as a possible case of SC. The training stopped when we observed a minimum of discrepancies between the psychiatrist team. When we began data collection, the psychiatrists conducted the clinical interviews in order to assess Goodman’s criteria for sexual addiction (Goodman, 2001) and the diagnostic criteria for excessive sexual drive, as well as the diagnostic criteria for the ICD-10 conditions that were used as exclusion criteria (World Health Organization, 1992). They also reviewed the HDSI scores to identify which participants met the screening criteria for hypersexual disorder. The psychiatrists also determined whether the questions seemed to be well understood by the participants, and if the questions were not understood, the psychiatrists provided clarification. Finally, following the algorithm recommended by the DSM-5 taskforce, the psychiatrists determined who did and did not meet criteria as a possible case of SC. Individuals with SC were offered treatment, and individuals without SC were offered financial incentives to cover their transportation costs. The second wave of data collection began in the Spring of 2011. Of the 153 participants, 99 responded the measures a second time with 2 weeks of interval. All 54 nonresponders were SC individuals (i.e., patients), and a greater proportion of them identifiedas gay andbisexual,than those who answered the retest. No differences on age, race, marital status, income, and years of education were found among who answered and did not answer the retest.

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This study was reviewed and approved by the Ethics Committee at of the HC-FMUSP. Measures Participant Characteristics Participants were asked to report their age, gender, legal marital status, race, years of education, and sexual orientation. Sexual Compulsivity The SCS (Kalichman et al., 1994; Kalichman & Rompa, 1995) consists of 10 statements (e.g.,‘‘I have to struggle to control my sexual thoughts and behavior.’’) that are rated using a 4-point scale, ranging from 1 (not at all like me) to 4 (very much like me). Total scores can range from 10 to 40, with higher scores indicating higher levels of SC symptomology. Some authors (Benotsch et al., 1999; Cooper, Delmonico, & Burg, 2000; Parsons et al., 2001) have used a cutoff score of 24 or higher to indicate SC (Hook et al., 2010). A recent review of SC instruments found high levels of internal consistency (Cronbach’s a) for the SCS across 30 samples, and that the SCS demonstrated good reliability and validity (Hook et al., 2010). Compulsive Sexual Behavior The CSBI (Coleman et al., 2001) originated from a 42-item scale that was based on the clinical experiences of individuals with SC. In previous studies, factor analysis has been used and identified three factors, namely, control over sexual behavior, sexual violence, and sexual abuse. However, subsequent studies have used different versions of this scale (Miner et al., 2007; Muench et al., 2007). Given that many of the items that comprise the abuse domain are outdated and that studies have failed to identify significant differences between SC subjects and controls (Coleman et al., 2001), we utilized the more commonly used 22-item version (CSBI-22) (Miner et al., 2007). Participants answer each item of the CSBI-22 using a 5-point Likert-type scale, ranging from 1 (very often) to 5 (never). In the CSBI-22, the scores can range from 22 to 110, with lower scores representing more severe rates of SC (Miner et al., 2007). The CSBI22 assesses two factors: control (13 items), which measures the ability to control sexual behavior, and violence (9 items), which measures theexperience ofsexual violence. Investigationsofthe psychometric properties of the CSBI show good reliability and validity (Hook et al., 2010). Hypersexual Disorder The HDSI is a dimensional and diagnostic screening measure. Hypersexual disorder had been proposed for inclusion in the

Arch Sex Behav

DSM-5 as a diagnosis for patients who report a period of 6 months or more of recurrent and intense sexual fantasies, sexual urges, and sexual behavior that cause significant distress or impairment. There are seven core diagnostic criterion questions included in the HDSI (five A and two B criteria). Each criterion item is rated on a five-point severity index ranging from 0 (never true) to 4 (almost always true) with a resulting total score ranging from 0 to 28 points that can be used as a dimensional measure of overall severity. To screen positive for a probable diagnosis of hypersexual disorder, an individual must score three or four points on at least four of the five A criteria and at least one of the two B criteria. Part C contains a list of six domains of problematic sexual behaviors (e.g., masturbation, sexual behavior with consenting adults, cybersex) and participants were asked to report which types of behaviors had caused them problems in the prior6 months(American PsychiatricAssociation, 2010; Kafka, 2010). This measure was recently found to be highly reliable in discriminating differing levels of hypersexual disorder symptomology in a non-clinical sample of highly sexually active gay and bisexual men in the United States (Parsons et al., 2013). Following the first directions given by the Task Force group for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association, in this article we investigated the both ways of applying HDSI, as a dimensional measure (the sum of the scores) and as a diagnosticcriteriameasure(at least fourA criteria and oneB criteria). Convergent Validity Measures We used the Sexual Addiction Screening Test (SAST) (Carnes, 1989) and the Zuckerman Kuhlman Personality Questionnaire (ZKPQ) (Zuckerman, Kuhlman, Joireman, Teta, & Kraft, 1993) to investigate convergent validity. The SAST (Carnes, 1989) is used to screen for possible cases of sexual addiction and was adapted and validated for use in Brazil by Silveira et al. (2000). It consists of 25 questions, which are answered either Yes or No. Research with a sample of men with and without sexual addiction showed that the SAST had a single factor and high internal consistency (Carnes, 1989). The Brazilian version of the scale was tested in a sample of six sexual addicts, 10 alcohol-dependent patients, 17 drugdependent outpatients, and 38 healthy controls. The internal consistency was .89 (Cronbach’s a) (Silveira et al., 2000). The ZKPQ (Zuckerman et al., 1993) consists of 99 pairs of self-completion questions in which the subject has to choose the statement from each pair that best describes him/herself. The ZKPQ has been translated into several languages, including Spanish (Aluja, Garcı´a, Cuevas, & Garcı´a, 2007; Goma`-i-Freixanet & Valero Ventura, 2008), Chinese (Wang et al., 2003), and Portuguese (Souza, Omar, & Formiga, 2006). We administered only the 19 items of the Impulsive Sensation Seeking (ImpSS) domain, which investigates the provision for novelty seeking and non-planning impulsivity. This domain presents an

internal consistency of .77 (Cronbach’s a) (Zuckerman et al., 1993). Data Analysis We performed separate factor analyses of the SCS, HDSI, and CSBI using principal components extraction with orthogonal rotation (Varimax method) for those scales in which more than one factor was extracted. We relied on Catell’s scree test to evaluate evidence of a meaningful factor in addition to Eigenvalues of at least 1 and meaningful item loadings. The items with factor loadings of 0.50 or more were considered to meaningfully load onto a factor. The internal consistency was evaluated using Cronbach’s a coefficient. Reliability was assessed using the Wilcoxon test, the intra-class correlation coefficient (rintra-class), and Bland–Altman graphs. Convergent validity was evaluated using Spearman correlations between the scores of each of the questionnaires and the scores of the SAST and the ImpSS. To verify the discriminant construct validity, we compared the mean scores between the patients and the controls. In this analysis, we used the Mann–Whitney test, and we hypothesized that the patients would have higher mean scores than the controls. To evaluate the criterion validity (sensitivity, specificity, positive, and negative predictive value) of the HDSI, we used the provisional diagnostic criteria for Sexual Addiction from the DSM IV (Goodman, 2001) as a diagnostic reference (gold standard). This reference has been previously used by Silveira et al. (2000) to validate the SAST for use in Brazil. We tested the HDSI against the Goodman’s criteria using a two by two table for calculating the prevalence of true positive (number of individuals meeting Goodman’s criteria and positive on HDSI), false positive (number of individuals not meeting Goodman’s criteria and positive on HDSI), false negative (number of individuals meeting Goodman’s criteria and negative on HDSI), and true negative (number of individuals not meeting Goodman’s criteria and negative on HDSI) cases. Then, we assessed the sensitivity (number of true positives by the total with SC), specificity (number of true negatives by the total without SC), positive predictive value (number of true positives by the total of positives on HDSI), and negative predictive value (number of true negatives by the total of negatives on HDSI). Statistical analyses were performed using STATA 10, and we considered statistical significance when p\.05.

Results Participant Characteristics The sociodemographic characteristics of the participants are shown in Table 1. The majority of the participants were White (71 %) and heterosexual (69 %). Approximately half of the participants were sexually compulsive and single. The mean age

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Arch Sex Behav Table 1 Sociodemographic characteristics of male participants who provided full data and those who completed the Hypersexual Disorder Screening Inventory (HDSI) Full sample (n = 153)

Sample with HDSI (n = 121)

n

n

%

Sexually compulsive 89

58.2

41

33.9

No

64

41.8

80

66.1

White

110

70.9

86

71.1

African descent

40

27.3

32

26.4

Other

3

1.8

3

2.5

Gay/bisexual

105

68.6

85

70.2

48

31.4

36

29.8

57

37.3

43

35.6

Divorced

15

9.8

13

10.7

Single

81

52.9

65

53.7

M Age Years of education

36.4 13.9

SD 10.2 4.1

M 36.3 13.8

1

0.7695 0.9063 0.8936

0.9191 0.9376 0.8643

0.9067

b

b

b

0.9162

b

b

b

0.7449

b

b

b

b

b

4

0.8508

0.9138

0.9019

b

5

0.8234

0.8679

0.8872

b

b

b

0.9161

b

b

b

0.8938

b

b

b

0.6501

b

b

b

b

b

6

0.7951

7

0.9329

0.9133

0.9137

0.9034

a

0.8695

a

0.7766

b

10

0.5886

a

0.7424

b

b

b

11

a

a

0.6534

b

b

b

12

a

a

0.7184

b

b

b

13

a

a

0.8624

b

b

b

14 15

a

a

b

b

b

b

a

a

b

b

b

0.7302

16

a

a

b

b

b

b

10.5

17

a

a

b

0.6628

b

b

4.0

18

a

a

b

0.7868

b

b

19

a

a

b

0.7264

b

b

20

a

a

b

b

0.7904

b

21

a

a

b

0.6398

b

b

22

a

a

b

b

b

0.6369

0.82

0.41

0.11

0.08

0.08

8 9

SD

and years of education of the participants were 36 and 14 years, respectively. Psychometric Properties We conducted an independent factor analysis for each scale (SCS, HDSI, and CSBI-22). The factor analyses of the SCS and the HDSI each extracted a single factor that met our criteria. The extracted factor explained 69.23 % of the variance for the SCS and 81.77 % for the HDSI. Therefore, in keeping with prior research, we calculated the scores of the SCS and HDSI as the total sum of the item responses. The scores of the SCS ranged from 10 to 40, and the scores of the HDSI ranged from 0 to 28. The factor analysis of CSBI-22 revealed four factors that had an eigenvalue greater than 1 that explained a cumulative variance of 67.35 %. However, after examining the Catell’s scree test and the factor loading patterns, we determined that only the first two factors met the criteria for being substantially meaningful factors—the third and fourth factors contained only one or two items with strong loadings and did not deviate from the scree line. The first factor consisted of questions 1–13 and the second factor consisted of questions 17, 18, 19, and 21. With regards to the two factors that were ultimately dropped, the third factor consisted of question 20; and the fourth factor consisted of questions 15 and 22. Questions 14 and 16 did not load on to any factor.

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CSBI

Factor 1 Factor 1 Factor 1 Factor 2 Factor 3 Factor 4

3

Marital status Married

HDSI

Scale item number

2

Race

Sexual orientation Straight

Factor loadings SCS

%

Yes

Table 2 Exploratory factor analysis of the SCS, HDSI, and CSBI Scales

% variance 0.6923 explained

SCS sexual compulsivity scale, HDSI hypersexual disorder screening inventory, CSBI compulsive sexual behavior inventory a

Not applicable—no relevant scale item

b

Item loading was less than 0.50. Factors 3 and 4 from the CSBI scale were excluded from further analyses

These two factors accounted for a cumulative variance of 51.71 % of all 22 items, and 68.30 % considering just the 17 items retained (1–13; 17–19; 21). We calculated mean scores for each factor to allow for comparison between them despite different numbers of items. Based on their respective items, we determined that the first factor related to control (control domain) and second factor related to violence (violence domain) (see Table 2). The results of the reliability and validity analyses are presented in Table 3. As can be seen, the SCS, HDSI, and two CSBI subscales all demonstrated strong internal consistency, with all alpha coefficients exceeding 0.75 and most exceeding 0.90. With regards to discriminant validity, patients had significantly higher scores on all four variables when compared to controls. Additionally, statistically significant correlations were found between all the scores and the SAST. The correlations were high

Arch Sex Behav Table 3 Summary of the reliability and validity statistics for the SCS, HDSI, and CSBI scales Scale

Internal consistency

Discriminant validity

A

M

SD

Control

Patient M

Sig. SD

Convergent validity

Test–retest reliability

SAST

ImpSS

Time 1

Time 2

q

q

M

SD

M

z

Sig.

ICC

SD

SCS

0.95

15.3

5.4

32

4.9

***

0.81***

0.53***

19.5

8.1

19.3

7.6

0.7

ns

0.77***

HDSI

0.96

2.6

3.3

21.2

5.6

***

0.81***

0.50***

7.2

7.7

7.3

8.0

-0.8

ns

0.80***

CSBI-control CSBI-violence

0.97 0.75

57.3 19.6

7.1 1.0

26.2 18.6

8.2 2.1

*** ***

-0.87*** -0.36***

-0.48*** -0.41***

48.6 19.4

14.3 1.3

48.8 19.4

13.8 1.3

-0.5 -0.7

ns ns

0.81*** 0.92***

* p\.05. ** p\.01. *** p\.001 Table 4 Correlation matrix from the SCS, HDSI, and CSBI Scales Scale

1. q

2. q

3. q

1. SCS

–

2. HDSI

0.87***

–

3. CSBI-control

-0.86***

-0.86***

–

4. CSBI-violence

-0.33***

-0.43***

0.33***

* p\.05. ** p\.01. *** p\.001

(q[.81) for all domains except the violence domain (q = .36), where the correlation was moderate. The correlations between the scores and the ImpSS were statistically significant for all domains. The correlations between the scores and the ImpSS were moderate, ranging from .50 to .55. However, for the violence domain, the correlations were moderate but smaller (q = .42). The correlations among the scores are also presented in Table 4. The SCS, the HDSI, and the control domain of the CSBI-22 are highly correlated (q[.85). The violence domain showed moderate correlations with the other scores (q[.32). Ninety-nine individuals completed the questionnaire a second time, which corresponded to 64.70 % of the individuals who answered the SCS and the CSBI and 81.81 % of the individuals who answered the HDSI. There were no differences between the means of the scores obtained at the two time points. Moreover, there was a high correlation between the scores obtained at test and at retest (ricc[.76 for all). The Bland–Altman plots of all the scores are presented in Fig. 1, showing a random distribution of points around the means, which suggested that there were no specific differences between the scores of the test–retest when compared tothemean differences. Only a limited numberof data points fell outside of the limits of the standard deviation. The sensitivity and specificity of the HDSI, when tested against the Goodman’s criteria (gold standard), were 71.93 and 100 %, respectively. Therefore, the probability that a participant who screened positive for hypersexual disorder using the HDSI had a hypersexual disorder (positive predictive value) was 100 %. In contrast, the probability that a participant who did not screen positive for hypersexual disorder in the HDSI did not have the disorder (negative predictive value) was 80 %.

Discussion Our factor analysis of the SCS retained all 10 statements in one single factor, indicating that a single factor represented the SC construct. As factor analysis was not performed in the original studies (Kalichman et al., 1994; Kalichman & Rompa, 1995), there were no previous suggestions as to how many factors should comprise the factor analysis. The study by Kalichman and Cain (2004), which used a sexually transmitted infection treatment-seeking sample population, identified two factors, social disruptiveness (Items 1–4) and personal discomfort (Items 5–10), for use in the factor analysis (Kalichman & Cain, 2004). A Spanish study of college students also identified two factors, interference of sexual behavior (Items 1–4, 10) and failure to control sexual impulses (Items 5–9) (Ballester Arnal et al., 2012). The two factor models in these studies accounted for of 60 and 50 % of the variance, respectively. Our model with one factor accounted for greater proportion of the variance when all 10 statements were included in the analysis. Furthermore, the internal consistency of our study was high, in accordance with previous studies using samples of gay men, inner city men and women, persons seeking treatment for sexually transmitted infections, and HIV-positive men and women, which found, respectively, alphas values of .86, .87, .88, .89, and .92 (Kalichman & Cain, 2004; Kalichman & Rompa, 1995, 2001). Our test– retest coefficient was also high, and in accordance with a study of 106 gay men which reported a two week temporal stability coefficient of .95, while the 3 month temporal stability coefficients ranged from .64 (community sample of same-gender sexually active men) to .80 (sample of inner city men and women) (Kalichman & Rompa, 1995). The SCS showed significant evidence of convergent validity with the SAST, which also measures SC, and the construct convergent validity also tested searching correlation with sensation seeking. We tested the ImpSS domain of the ZKPQ and found a significant correlation with sensation seeking, which is consistent with several previous studies. Some of these studies used a specific measure of sexual sensation seeking and found correlation coefficients ranging from .50 (sample of undergraduate students) (Gullette & Lyons, 2005) to .70 (community sample of same-gender sexually active men) (Kalichman & Rompa, 1995). Similar to our results, other studies have

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Fig. 1 Bland-Altman graphs for SCS, HDSI, CSBI-control, and violence domain

investigated correlations with general sensation seeking and have found correlations coefficients ranging from .43 (sample of inner city men and women) to .57 (community sample of samegender sexually active men) (Kalichman & Rompa, 1995). In previous studies, the SCS was used to distinguish between several characteristics, such as age orincome (Hook et al., 2010), whereas in our study, the SCS enabled discrimination between SC patients and the controls. We did not find any previous studies that examined this type of discriminant validity of the SCS. Our factor analysis of the CSBI-22 replicated the control domain of the original factor analysis (Coleman et al., 2001; Miner et al., 2007), retaining all 13 statements regarding control in one single factor. However, we only partly replicated the results for the violence domain, retaining four of the nine statements regarding violence. Despite this result, we decided to test two of the four retained factors because the total cumulative variance was close to the 58 % cumulative variance reported in the original study (Coleman et al., 2001). We examined the psychometric properties of the CSBI-control and

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violence domains and found that the internal consistency was high. Previous studies have reported that the internal consistency of the total scores ranges from .67 to .87 (Hook et al., 2010) and that the internal consistency was .96 for the control domain and was .88 for the violence domain (Coleman et al., 2001), which are similar to our results. Furthermore, our test– retest coefficient was high for the CSBI domains, in accordance with an online study of 1,026 Latino men who have sex with men, which reported a seven- to ten-day stability coefficient of .86 (Miner et al., 2007). The CSBI-control domain showed high evidence of convergent validity with the SAST, and the convergent validity with the ImpSS was moderate, which is similar to the results reported above for the SCS. The violence domain showed significant convergent validity with the SAST and the ImpSS, although the degree was moderate. Similar to the study by Coleman et al. (2001), where participants who self-identified with pedophilia and sexual addiction scored lower on the CSBI than the control group, the CSBIcontrol and violence domains could be used to differentiate between patients and controls in the current study.

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Reid et al. (2012) investigated the reliability and validity of the criteria for hypersexual disorder in a sample of 207 patients seeking treatment for SC (152), general psychiatric conditions (35), and substance-related disorders (20) using a structured diagnostic interview. They found high inter-rater reliability (among the team of interviewers), good stability over time, and good sensitivity and specificity (Reid et al., 2012). In contrast to Reid et al., we assessed the symptoms of hypersexual disorder using the HDSI as a self-report measure, and we assessed the diagnostic criteria for hypersexual disorder using a psychiatric assessment based on the HDSI diagnostic criteria. As we employed a different study design and methodology, our dimensional and diagnostic criteria results positively validate the criteria for hypersexual disorder, as previously proposed by the DSM-5 and by the study by Reid et al. (2012). In our study, the HDSI showed very good psychometric characteristics. The factor analysis enrolled all seven statements in one single factor, accounting for a high proportion of variance. The internal consistency, reproducibility, and convergent and discriminant construct validity were good and were similar to those reported for the SCS and the CSBI-control domain. The HDSI psychometric properties found in the current study are in accordance with the study of Parsons et al. (2013) which confirmed that a uni-dimensional structure was an adequate fit to the measure, and also demonstrated the validity of the measure and its associations with other scales of similar constructs. Regarding the limitations of the current work, our findings showedthat theHDSIproduceda 28 % rateof falsenegatives but hadno false positiveswhen usedto predict thegold standard(i.e., Goodman’s criteria). As such, using the HDSI in clinical settings to screen for possible cases of SC may lead to under-diagnosis of cases who would meet Goodman’s diagnostic criteria. Typically, screening measures are designed to maximize sensitivity (i.e., minimize the rate of false negatives) at the expense of specificity (i.e., inflating the rate of false positives) in order to refer all potential cases for further diagnostic screening. That is not the case of HDSI in our study. However, it is worth noting that to reach the Goodman’s criteria one needs to endorse 3 out of 7 of the criteria, while to reach the Hypersexual Disorder criteria, one needs to endorse 4 out of 5 of the A criteria and 1 out of 2 of the B criteria (i.e., 5 total criteria). These findings suggest that the HDSI may utilize more rigorous screening criteria than the Goodman’s and may identify those at an even higher level of risk than Goodman’s criteria. Goodman proposed the provisional criteria for SC in 2001, adapting from the criteria of substance dependence from the DSM-IV. On the other hand, the HDSI was created in 2010 to assess the criteria of Hypersexual Disorder, which was developed without regard for a specific underlying etiology or treatment approach (i.e., without regard forwhether it was an impulse disorder, compulsive disorder, addiction, etc.). Despite the fact that currently there is no SC diagnosis within the DSM, patients still regularly seek treatment for sexual behavior which they feel

is beyond their control and causing them distress (i.e., the characteristic features of SC). In this context, an updated and scientific-based measure, such as HDSI, can help the clinician to make decisions regarding the treatment. The HDSI also can be very useful in the research field currently, because of the need of searching for more evidences to SC. Another limitation is that our study enrolled 153 male participants who answered research advertisements in Sa˜o Paulo, Brazil. Therefore, caution should be exercised in attempting to generalize our findings to other populations. Sa˜o Paulo is a large city with ten million inhabitants, including many immigrants who are responsible for the important socio-cultural diversity. We also analyzed correlations between the scales and found high correlations, except for the violence domain. Therefore, we can conclude that the SCS, the HDSI, and the CSBI-control domain seem to measure theoretically similar constructs of SC. Furthermore, all three assessments will be useful for prospective or intervention studies, as they demonstrated high test–retest coefficients. Because all three assessments had good convergent validity with sensation seeking and because SC and both constructs are associated with sexual risk behavior related to HIV transmission, we also consider that all three assessments will be important measures for studies of the impact of SC on HIV risk behavior in Brazil. The CSBI includes a violence domain, which the SCS and the HDSI do not include; therefore, when measures of sexual violence are one of the goals of a study (for example, involving sexual offenders), the CSBI is the most appropriate tool. In contrast, for studies in clinical settings, the HDSI can be used as a diagnostic screening instrument, as this tool simplifies the recognition of SC in clinical environments and therefore enables proper treatment. Acknowledgments This study was supported by Grants from the Sa˜o Paulo Research Foundation (FAPESP), Grant 2010/15921-6.

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