205
Journal of Parkinson’s Disease 4 (2014) 205–210 DOI 10.3233/JPD-130271 IOS Press
Research Report
The Arizona Sexual Experiences Scale: A Validity and Reliability Assessment of the Thai Translation (ASEX-Thai) in Parkinson’s Disease Onanong Jitkritsadakula , Priya Jagotaa and Roongroj Bhidayasiria,b,∗ a Chulalongkorn
Center of Excellence on Parkinson Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand b Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Abstract. Introduction: Cultural sensitivities tend to limit assessments of sexual dysfunction (SD) in Parkinson’s disease (PD). Objective: To assess the validity and reliability of the Thai translation (ASEX-Thai) of the Arizona Sexual Experiences Scale (ASEX). Method: The validity and reliability of ASEX-Thai were assessed with a random sample of 40 PD patients. Back translation and cross-cultural modifications assured content validity. Criterion validity used DSM-IV-TR criteria and receiver operating characteristics (ROC) analysis was calculated for cutoff points plus sensitivity and specificity. Internal consistency was assessed with Cronbach’s alpha coefficient. Test-retest reliability was assessed by Pearson’s correlation at baseline and at a 2-month follow-up. Result: Criterion validity was conducted with a positive correlation between the clinical diagnosis of SD and DSM-IV-TR (r = 0.601; p < 0.001). The ROC analysis differentiated between SD and non-SD patients (p < 0.001). The cutoff point of ASEXThai at ≥16 points effectively screened for SD (sensitivity 96.2%, specificity 92.9%). Reliability was documented with the Cronbach’s alpha of all items at baseline and at a 2-month follow-up with values of 0.948 and 0.962 respectively. The Pearson’s correlation also showed highly significant test–retest reliability [Item 1 (r = 0.959, p < 0.001), Item 2 (r = 0.914, p < 0.001), Item 3 (r = 0.944, p < 0.001), Item 4 (r = 0.992, p < 0.001), Item 5 (r = 0.930, p < 0.001), and total ASEX-Thai score (r = 0.883, p < 0.001)]. Conclusion: ASEX-Thai is a valid and reliable instrument for the assessment of sexual dysfunction in Thai PD patients. Keywords: Arizona sexual experiences scale, ASEX-Thai, Parkinson’s disease, sexual dysfunction
INTRODUCTION Sexual dysfunction (SD) is a common non-motor manifestation of Parkinson’s disease (PD) but has ∗ Correspondence
to: Roongroj Bhidayasiri, MD, FRCP, FRCPI, Chulalongkorn Center of Excellence on Parkinson Disease & Related Disorders, Chulalongkorn University Hospital, 1873 Rama 4 Road, Bangkok 10330, Thailand. Tel.: +662 256 4627; Fax: +662 256 4630; E-mail: [email protected].
tended to be under-recognized and neglected by neurologists [1–5]. The prevalence of SD in the PD population is reported to be 65 percent in males and 36 percent in females [6]. According to Bronner et al., there are different patterns of SD among PD patients [3, 7]. In males the predominant manifestations of SD are erectile dysfunction, sexual dissatisfaction, and premature ejaculation, whereas the predominant symptoms occurring in females are difficulty with arousal,
ISSN 1877-7171/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
206
O. Jitkritsadakul et al. / The Arizona Sexual Experiences Scale
difficulty with reaching orgasm and low sexual desire. SD among PD patients is of concern because it usually coexists with depression, may contribute to low self-esteem and may affect the intimate relationship with the spouse. The assessment of this problem is quite limited because most patients are too embarrassed to discuss this intimate issue and are reluctant to share their concern with their neurologists even though it is a significant source of stress. In addition, many neurologists are reluctant to probe this personal area of functioning because they tend to give higher priority to motor symptoms than sexual problems [7]. Sexuality and sexual expressions are basic aspects of the human condition, are important for a healthy life and require the balanced functioning of the motor, sensory, and autonomic systems [8, 9]. In patients with a chronic medical illness such as PD, the balance is disrupted leading to SD. Many factors contribute to SD in PD patients such as PD itself, psychiatric complications such as clinical depression in about 50% of PD patients and side effects of medication [7]. Motor deterioration such as rigidity, immobility, tremor, and impaired movements can directly affect sexual intercourse and masked facies are sometimes misinterpreted as lacking desire [2, 10]. Moreover, sleep disturbances in PD, especially REMsleep behavioral disorders, often lead to sleeping in separate beds which decreases the opportunities for intimacy [2, 7, 10]. Finally, significant sexual problems (both hypo- and hypersexuality) can occur from not only dopaminergic medication, but also antidepressants (especially, Selective Serotonin Reuptake Inhibitors (SSRIs)), antipsychotics, and anticholinergics [3, 11–16]. Because many aspects of sexual dysfunction affect both patients and their families, it is important that this problem be identified. Although a psychiatrist’s assessment in accordance with DSMIV-TR criteria is the current standard for diagnosis, this service is not very accessible in regular outpatient services [17]. Given the realities noted above, a validated and user-friendly tool to identify SD among PD patients is needed. ASEX is a 5-item, self-administered questionnaire with a 6-point Likert scale designed to assess the core components of SD: drive, arousal, penile erection, vaginal lubrication, ability to achieve orgasm and orgasmic satisfaction. Total ASEX scores range from 5 to 30 with a higher score correlating with greater sexual impairment [18]. Total ASEX scores of 19 or greater, three or more items with individual scores of 4 and any individual item score of either 5 or 6 correlate
with sexual dysfunction [18]. This tool has been used to assess sexual dysfunction among SSRI users, endstage renal disease, diabetes mellitus, schizophrenia and PD patients [11, 19–21]. ASEX has been validated and tested for reliability in psychiatric patients and ESRD patients and showed excellent results [18, 22]. However, the original ASEX in English was never validated and tested for reliability for self-administration among Thai patients. Hence, this study was designed to estimate the validity and reliability of the Thai version of ASEX (ASEX-Thai) in Thai PD patients and is the first effort to measure the results of using this tool in this population. METHOD The original ASEX questionnaire was first translated into the Thai language by the Chalermprakiat Center of Translation and Interpretation, Faculty of Arts, Chulalongkorn University. Comprehension of all items after translation was refined by five specialist doctors (Two neurologists who specialize in movement disorders (RB and PJ), one neurologist who specializes in dementia (IT), and two psychiatrists (CR and CT)) for content validity by using the IOC index (Index of Item-objective Congruence). For each item, a mean value on the IOC index was above 0.6, indicating positive content validation. As a pilot trial, the questionnaire was first given to 10 literate PD patients to test whether they understood the meanings and the instructions. Minor revisions were made on wording of the questionnaire after this pilot trial. Backward translation into English was conducted by two neurologists (PP and OJ) who were not involved in the forward translation. Another movement disorders neurologist (ST) compared the backward translation with the original English version. Given that the meaning of the backward translation is very similar to the original English version, the translated Thai version was accepted. The study was approved by the Ethics Committee of Chulalongkorn University Hospital, Bangkok, Thailand. The reliability of ASEX was assessed by administering the test to 40 randomly selected PD patients who satisfied the United Kingdom Parkinson’s Disease Society Brain Bank clinical criteria [23] and visited the Movement Disorders Outpatient Clinic of Chulalongkorn Hospital during the period of August to October 2012. Patient characteristics are described in Table 1. The eligibility criteria included: age between 18–70 years, being able to comprehend and complete the self-rating questionnaire, and being clinically stable without a history of dementia or psychiatric
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Table 1 Patient demographics Mean age Presence of previous medical Illnesses Presence of depression determined by HDRS No depression Mild depression Moderate depression Mean HDRS total score Mean TMSE score Mean ASEX score Hoehn-Yahr Stage 1 Stage 1.5 Stage 2 Stage 2.5 Stage 3 Stage 4 Stage 5
Female (n = 13)
Male (n = 27)
p-value
55.62 ± 9.215 4 (10)
57.74 ± 9.634 9 (22.5)
0.512ϕ 1.000δ 0.512χ
6 (15) 7 (17.5) 0 (0) 7.77 ± 2.682 27.85 ± 1.625 21.69 ± 8.22
16 (40) 10 (25) 1 (2.5) 7.67 ± 2.961 28.00 ± 1.209 17.26 ± 4.809
2 (5) 3 (7.5) 3 (7.5) 1 (2.5) 3 (7.5) 1 (2.5) 0 (0)
0.916ϕ 0.738ϕ 0.090ϕ 0.862χ
2 (5) 5 (12.5) 5 (12.5) 4 (10) 10 (25) 1 (2.5) 0 (0)
HDRS: Hamilton Depression Rating Scale; TMSE, Thai Mini Mental State Examination. ϕ Independent sample t-test, δ Fisher’s Exact test, χ Chi-squared test. Percentages are shown in parentheses.
problems. Consent for participating in the study was obtained from all participants. Data on participants included the following: 1) demographic data and medical history; 2) PD severity scale obtained by the Hoehn and Yahr scale at baseline; 3) ASEX-Thai score at baseline and at 2-month follow-up; and 4) The results of the Thai-Mini Mental Status Examination (TMSE) for dementia assessment that was administered at baseline (Table 1). TMSE scores range from 0 to 30 with a score of less than 24 indicating dementia [24]. 5) The Hamilton Depression Rating Scale (HDRS) for depression assessment was used at baseline. The total scores are in 5 categories: no depression, mild depression, less than major depression, major depression and more than major depression [25]. Statistical analysis was performed using SPSS version 17 (Chicago, Illinois.). Internal consistency of ASEX-Thai was assessed with Cronbach’s alpha coefficient. Test-retest reliability was performed by Pearson’s correlation at baseline and at a 2-month follow-up. Criterion validity for sexual dysfunction of ASEX-Thai was assessed by using DSM-IV-TR criteria and convergent validity was assessed with HDRS question number 14 (HDRS-14) which assesses genital symptoms [17, 25]. For criterion validity, receiver operating characteristics (ROC) analysis was performed and calculated for cutoff points in addition to sensitivity and specificity. The confidence interval (CI) was 95% for all analyses. RESULTS 40 PD patients participated in the study-27 male and 13 female patients. The mean ages of female,
male and all patients combined were 55.62 ± 9.215, 57.74 ± 9.634 and 57.05 ± 9.435 years respectively. None of the participants met the dementia criteria for exclusion. All of them could complete the self-administered questionnaire on their own. There were no statistical differences in mean TMSE scores between female and male groups. The H&Y staging of 25 patients (62.5%) were less than 3, which reflected the mild to moderate disease severity without postural instability among the majority of the patients. There were only a few severe patients in H&Y stages 4 or 5. We found that almost half of our patients (45%) presented with depressive symptoms as assessed by the HDRS, but none of them presented with severe depression. Although the mean age, and the HDRS and TMSE scores among female and male patients were no different, the total ASEX-Thai scores tended to be higher in the female group though not statistically significant. We found that all patients were able to complete this self-administered questionnaire in less than 5 minutes. ASEX-Thai validity and reliability tests (Tables 2 and 3) After the content validity of ASEX-Thai was accepted, the test was validated in 40 PD patients. The diagnosis of SD using the DSM-IV-TR criteria revealed the presence of SD in 26 patients (65%). The criterion validity compared clinical diagnosis of SD between ASEX-Thai and DSM-IV-TR criteria, Pearson’s correlation showed good correlation for clinical diagnosis of SD by ASEX and DSM-IV-TR criteria
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O. Jitkritsadakul et al. / The Arizona Sexual Experiences Scale Table 2 The internal consistency and the test-retest reliability of ASEX
Cronbach’s alpha of all items of ASEX Pearson’s correlation for Test-retest reliability in each items Item 1 Item 2 Item 3 Item 4 Item 5 Total ASEX score Pearson’s correlation Sexual dysfunctionχ and DSM-IV-TR Sexual dysfunctionχ and HDRS-14ϕ Sexual dysfunctionχ and total HDRS score Total ASEX score and total HDRS score
Baseline 0.948
2 months follow-up 0.962
r 0.959 0.914 0.944 0.992 0.930 0.883
p-value
Journal of Parkinson’s Disease 4 (2014) 205–210 DOI 10.3233/JPD-130271 IOS Press
Research Report
The Arizona Sexual Experiences Scale: A Validity and Reliability Assessment of the Thai Translation (ASEX-Thai) in Parkinson’s Disease Onanong Jitkritsadakula , Priya Jagotaa and Roongroj Bhidayasiria,b,∗ a Chulalongkorn
Center of Excellence on Parkinson Disease & Related Disorders, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand b Department of Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
Abstract. Introduction: Cultural sensitivities tend to limit assessments of sexual dysfunction (SD) in Parkinson’s disease (PD). Objective: To assess the validity and reliability of the Thai translation (ASEX-Thai) of the Arizona Sexual Experiences Scale (ASEX). Method: The validity and reliability of ASEX-Thai were assessed with a random sample of 40 PD patients. Back translation and cross-cultural modifications assured content validity. Criterion validity used DSM-IV-TR criteria and receiver operating characteristics (ROC) analysis was calculated for cutoff points plus sensitivity and specificity. Internal consistency was assessed with Cronbach’s alpha coefficient. Test-retest reliability was assessed by Pearson’s correlation at baseline and at a 2-month follow-up. Result: Criterion validity was conducted with a positive correlation between the clinical diagnosis of SD and DSM-IV-TR (r = 0.601; p < 0.001). The ROC analysis differentiated between SD and non-SD patients (p < 0.001). The cutoff point of ASEXThai at ≥16 points effectively screened for SD (sensitivity 96.2%, specificity 92.9%). Reliability was documented with the Cronbach’s alpha of all items at baseline and at a 2-month follow-up with values of 0.948 and 0.962 respectively. The Pearson’s correlation also showed highly significant test–retest reliability [Item 1 (r = 0.959, p < 0.001), Item 2 (r = 0.914, p < 0.001), Item 3 (r = 0.944, p < 0.001), Item 4 (r = 0.992, p < 0.001), Item 5 (r = 0.930, p < 0.001), and total ASEX-Thai score (r = 0.883, p < 0.001)]. Conclusion: ASEX-Thai is a valid and reliable instrument for the assessment of sexual dysfunction in Thai PD patients. Keywords: Arizona sexual experiences scale, ASEX-Thai, Parkinson’s disease, sexual dysfunction
INTRODUCTION Sexual dysfunction (SD) is a common non-motor manifestation of Parkinson’s disease (PD) but has ∗ Correspondence
to: Roongroj Bhidayasiri, MD, FRCP, FRCPI, Chulalongkorn Center of Excellence on Parkinson Disease & Related Disorders, Chulalongkorn University Hospital, 1873 Rama 4 Road, Bangkok 10330, Thailand. Tel.: +662 256 4627; Fax: +662 256 4630; E-mail: [email protected].
tended to be under-recognized and neglected by neurologists [1–5]. The prevalence of SD in the PD population is reported to be 65 percent in males and 36 percent in females [6]. According to Bronner et al., there are different patterns of SD among PD patients [3, 7]. In males the predominant manifestations of SD are erectile dysfunction, sexual dissatisfaction, and premature ejaculation, whereas the predominant symptoms occurring in females are difficulty with arousal,
ISSN 1877-7171/14/$27.50 © 2014 – IOS Press and the authors. All rights reserved
206
O. Jitkritsadakul et al. / The Arizona Sexual Experiences Scale
difficulty with reaching orgasm and low sexual desire. SD among PD patients is of concern because it usually coexists with depression, may contribute to low self-esteem and may affect the intimate relationship with the spouse. The assessment of this problem is quite limited because most patients are too embarrassed to discuss this intimate issue and are reluctant to share their concern with their neurologists even though it is a significant source of stress. In addition, many neurologists are reluctant to probe this personal area of functioning because they tend to give higher priority to motor symptoms than sexual problems [7]. Sexuality and sexual expressions are basic aspects of the human condition, are important for a healthy life and require the balanced functioning of the motor, sensory, and autonomic systems [8, 9]. In patients with a chronic medical illness such as PD, the balance is disrupted leading to SD. Many factors contribute to SD in PD patients such as PD itself, psychiatric complications such as clinical depression in about 50% of PD patients and side effects of medication [7]. Motor deterioration such as rigidity, immobility, tremor, and impaired movements can directly affect sexual intercourse and masked facies are sometimes misinterpreted as lacking desire [2, 10]. Moreover, sleep disturbances in PD, especially REMsleep behavioral disorders, often lead to sleeping in separate beds which decreases the opportunities for intimacy [2, 7, 10]. Finally, significant sexual problems (both hypo- and hypersexuality) can occur from not only dopaminergic medication, but also antidepressants (especially, Selective Serotonin Reuptake Inhibitors (SSRIs)), antipsychotics, and anticholinergics [3, 11–16]. Because many aspects of sexual dysfunction affect both patients and their families, it is important that this problem be identified. Although a psychiatrist’s assessment in accordance with DSMIV-TR criteria is the current standard for diagnosis, this service is not very accessible in regular outpatient services [17]. Given the realities noted above, a validated and user-friendly tool to identify SD among PD patients is needed. ASEX is a 5-item, self-administered questionnaire with a 6-point Likert scale designed to assess the core components of SD: drive, arousal, penile erection, vaginal lubrication, ability to achieve orgasm and orgasmic satisfaction. Total ASEX scores range from 5 to 30 with a higher score correlating with greater sexual impairment [18]. Total ASEX scores of 19 or greater, three or more items with individual scores of 4 and any individual item score of either 5 or 6 correlate
with sexual dysfunction [18]. This tool has been used to assess sexual dysfunction among SSRI users, endstage renal disease, diabetes mellitus, schizophrenia and PD patients [11, 19–21]. ASEX has been validated and tested for reliability in psychiatric patients and ESRD patients and showed excellent results [18, 22]. However, the original ASEX in English was never validated and tested for reliability for self-administration among Thai patients. Hence, this study was designed to estimate the validity and reliability of the Thai version of ASEX (ASEX-Thai) in Thai PD patients and is the first effort to measure the results of using this tool in this population. METHOD The original ASEX questionnaire was first translated into the Thai language by the Chalermprakiat Center of Translation and Interpretation, Faculty of Arts, Chulalongkorn University. Comprehension of all items after translation was refined by five specialist doctors (Two neurologists who specialize in movement disorders (RB and PJ), one neurologist who specializes in dementia (IT), and two psychiatrists (CR and CT)) for content validity by using the IOC index (Index of Item-objective Congruence). For each item, a mean value on the IOC index was above 0.6, indicating positive content validation. As a pilot trial, the questionnaire was first given to 10 literate PD patients to test whether they understood the meanings and the instructions. Minor revisions were made on wording of the questionnaire after this pilot trial. Backward translation into English was conducted by two neurologists (PP and OJ) who were not involved in the forward translation. Another movement disorders neurologist (ST) compared the backward translation with the original English version. Given that the meaning of the backward translation is very similar to the original English version, the translated Thai version was accepted. The study was approved by the Ethics Committee of Chulalongkorn University Hospital, Bangkok, Thailand. The reliability of ASEX was assessed by administering the test to 40 randomly selected PD patients who satisfied the United Kingdom Parkinson’s Disease Society Brain Bank clinical criteria [23] and visited the Movement Disorders Outpatient Clinic of Chulalongkorn Hospital during the period of August to October 2012. Patient characteristics are described in Table 1. The eligibility criteria included: age between 18–70 years, being able to comprehend and complete the self-rating questionnaire, and being clinically stable without a history of dementia or psychiatric
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Table 1 Patient demographics Mean age Presence of previous medical Illnesses Presence of depression determined by HDRS No depression Mild depression Moderate depression Mean HDRS total score Mean TMSE score Mean ASEX score Hoehn-Yahr Stage 1 Stage 1.5 Stage 2 Stage 2.5 Stage 3 Stage 4 Stage 5
Female (n = 13)
Male (n = 27)
p-value
55.62 ± 9.215 4 (10)
57.74 ± 9.634 9 (22.5)
0.512ϕ 1.000δ 0.512χ
6 (15) 7 (17.5) 0 (0) 7.77 ± 2.682 27.85 ± 1.625 21.69 ± 8.22
16 (40) 10 (25) 1 (2.5) 7.67 ± 2.961 28.00 ± 1.209 17.26 ± 4.809
2 (5) 3 (7.5) 3 (7.5) 1 (2.5) 3 (7.5) 1 (2.5) 0 (0)
0.916ϕ 0.738ϕ 0.090ϕ 0.862χ
2 (5) 5 (12.5) 5 (12.5) 4 (10) 10 (25) 1 (2.5) 0 (0)
HDRS: Hamilton Depression Rating Scale; TMSE, Thai Mini Mental State Examination. ϕ Independent sample t-test, δ Fisher’s Exact test, χ Chi-squared test. Percentages are shown in parentheses.
problems. Consent for participating in the study was obtained from all participants. Data on participants included the following: 1) demographic data and medical history; 2) PD severity scale obtained by the Hoehn and Yahr scale at baseline; 3) ASEX-Thai score at baseline and at 2-month follow-up; and 4) The results of the Thai-Mini Mental Status Examination (TMSE) for dementia assessment that was administered at baseline (Table 1). TMSE scores range from 0 to 30 with a score of less than 24 indicating dementia [24]. 5) The Hamilton Depression Rating Scale (HDRS) for depression assessment was used at baseline. The total scores are in 5 categories: no depression, mild depression, less than major depression, major depression and more than major depression [25]. Statistical analysis was performed using SPSS version 17 (Chicago, Illinois.). Internal consistency of ASEX-Thai was assessed with Cronbach’s alpha coefficient. Test-retest reliability was performed by Pearson’s correlation at baseline and at a 2-month follow-up. Criterion validity for sexual dysfunction of ASEX-Thai was assessed by using DSM-IV-TR criteria and convergent validity was assessed with HDRS question number 14 (HDRS-14) which assesses genital symptoms [17, 25]. For criterion validity, receiver operating characteristics (ROC) analysis was performed and calculated for cutoff points in addition to sensitivity and specificity. The confidence interval (CI) was 95% for all analyses. RESULTS 40 PD patients participated in the study-27 male and 13 female patients. The mean ages of female,
male and all patients combined were 55.62 ± 9.215, 57.74 ± 9.634 and 57.05 ± 9.435 years respectively. None of the participants met the dementia criteria for exclusion. All of them could complete the self-administered questionnaire on their own. There were no statistical differences in mean TMSE scores between female and male groups. The H&Y staging of 25 patients (62.5%) were less than 3, which reflected the mild to moderate disease severity without postural instability among the majority of the patients. There were only a few severe patients in H&Y stages 4 or 5. We found that almost half of our patients (45%) presented with depressive symptoms as assessed by the HDRS, but none of them presented with severe depression. Although the mean age, and the HDRS and TMSE scores among female and male patients were no different, the total ASEX-Thai scores tended to be higher in the female group though not statistically significant. We found that all patients were able to complete this self-administered questionnaire in less than 5 minutes. ASEX-Thai validity and reliability tests (Tables 2 and 3) After the content validity of ASEX-Thai was accepted, the test was validated in 40 PD patients. The diagnosis of SD using the DSM-IV-TR criteria revealed the presence of SD in 26 patients (65%). The criterion validity compared clinical diagnosis of SD between ASEX-Thai and DSM-IV-TR criteria, Pearson’s correlation showed good correlation for clinical diagnosis of SD by ASEX and DSM-IV-TR criteria
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O. Jitkritsadakul et al. / The Arizona Sexual Experiences Scale Table 2 The internal consistency and the test-retest reliability of ASEX
Cronbach’s alpha of all items of ASEX Pearson’s correlation for Test-retest reliability in each items Item 1 Item 2 Item 3 Item 4 Item 5 Total ASEX score Pearson’s correlation Sexual dysfunctionχ and DSM-IV-TR Sexual dysfunctionχ and HDRS-14ϕ Sexual dysfunctionχ and total HDRS score Total ASEX score and total HDRS score
Baseline 0.948
2 months follow-up 0.962
r 0.959 0.914 0.944 0.992 0.930 0.883
p-value
