Development and validation of a sexual functioning measure for use in diverse women's health outcome studies

doi:10.1016/j.ajog.2008.03.036

American Journal of Obstetrics and Gynecology

Volume 198, Issue 6, June 2008, Pages 710.e1-710.e11

Presented at the 74th Annual Meeting of the Pacific Coast Obstetrical and Gynecological Society, Henderson, NV, Oct. 10-14, 2007.

https://doi.org/10.1016/j.ajog.2008.03.036 Get rights and content

Objective

The objective of the study was to evaluate the psychometric properties of the Sexual Health Outcomes in Women Questionnaire (SHOW-Q).

Study Design

SHOW-Q was developed to assess the impact of pelvic problems on sexual desire, frequency, satisfaction, orgasm, and discomfort. A total of 1833 English- or Spanish-speaking women enrolled in 5 studies across the United States completed relevant items at baseline and, for 4 studies, periodically thereafter. Participants also completed measures of pelvic symptomatology and health-related quality-of-life including mental and physical component scales (MCS, PCS).

Results

Factor analysis revealed a 12-item scale with high internal consistency reliability (Cronbach's α = 0.86) and 4 reliable subscales (α = 0.73 to 0.84). Among sexually active women, SHOW-Q scores showed statistically significant correlations (P < .001) with MCS (0.267), PCS (0.378), body image (.360), and symptom resolution (.237). The SHOW-Q subscales were also correlated with these other measures at baseline and over time.

Conclusion

SHOW-Q is a reliable, valid, and sensitive measure of sexual functioning for use in diverse women's health outcome studies.

Section snippets

Materials and Methods

Our analyses included data accumulated from 1833 English- or Spanish-speaking women sampled within 1 of 5 women's health studies: the Medicine or Surgery (Ms) randomized trial; the Total or Supracervical Hysterectomy (TOSH) randomized trial; the prospective observational Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives (SOPHIA); the Ultra Low Dose Transdermal estRogen Assessment (ULTRA) osteoporosis prevention trial; and an observational study of women with heavy menstrual

Results

Initially, we fit exploratory factor analysis models to the data from baseline assessments of all 15 sexual function items among 886 sexually active women with complete data on all items. Given the multiple theoretical domains of sexual functioning represented in the item pool, we did not assess the fit of a 1 factor model. The item measuring frequency of experiencing vaginal dryness had factor loadings less than 0.40 in all models and was thus dropped from consideration. Further analyses found

Comment

Our analyses demonstrate the internal consistency and concurrent validity of SHOW-Q as a measure of sexual functioning in sociodemographically diverse premenopausal women seeking care for a variety of pelvic problems. In all 5 women's health studies we examined, the Cronbach's α coefficients of the 12-item SHOW-Q and its subscales were consistently high. Furthermore, in all but the ULTRA trial, SHOW-Q scores were closely correlated with HRQOL and symptom measures at baseline, and in SOPHIA,

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Cited by (31)

Ethnic Minority Representation in Female Sexual Dysfunction Questionnaire Validation: A Scoping Review
2022, Journal of Sexual Medicine
Female sexual dysfunction (FSD) is a significant cause of distress for an estimated 12–24% of women, and over the past 5 decades several questionnaires have been developed for clinical practice.
The purpose of this scoping review is to evaluate the ethnic representation of sample populations used in the studies to validate FSD questionnaires.
A scoping review was performed using electronic databases, including PubMed and Scopus, to identify FSD questionnaires validated between 1976 and 2021. Weighted averages from the combined ethnicity data were compared to population data from 2019 US census data and 2018 healthcare workforce reports to evaluate epidemiologic diversity. Ethnicity data from each questionnaire were also investigated longitudinally to evaluate trends in representation over the past 50 years.
Our outcome of interest was comparison of the weighted averages for ethnicity categories from validation populations to the US female general population, US female health care workforce, and US census data.
48 validation studies were reviewed and showed that the average ethnic representation of the study populations relative to the US general population and US female health care workforce, respectively, was: Caucasian (83.7% vs 62.7% and 68.5%), Black (7.8% vs 13.3% and 8.3%), Hispanic (3.6% vs 16.0% and 9.6%), Native American (0.1% vs 0.8% and 0.3%), Asian (0.6% vs 6.4% and 6.2%), and Other (3.1% vs 0.7% and 1.4%).
FSD questionnaires are relied upon in research and clinical settings, so lack of diversity in validation populations could lead to under recognition and undertreatment in ethnic minority women.
Our results are dependent on the quality of data available from previously published validation studies. We attempted to account for biases in lack of data and size of validation populations by using weighted averages for making comparisons. We chose the US general population and female healthcare workforce for comparison and analyzed validation populations across multiple decades and geographic locations. Many of the validation studies were performed at least 10 years ago and may not reflect the current state of FSD and potential of questionnaire responses of ethnic minority women. This manuscript raises critical awareness regarding the lack of validated instruments for FSD in ethnically diverse women.
Study populations used to validate FSD questionnaires demonstrate a trend of ethnic minority underrepresentation relative to the US female general and healthcare workforce populations.
Battle CR, Rubin RS, Kingsberg SA, et al. Ethnic Minority Representation in Female Sexual Dysfunction Questionnaire Validation: A Scoping Review. J Sex Med 2022;19:1824–1838.
Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study
2022, Journal of Sexual Medicine
Citation Excerpt :
Most studies looking at sexual function after surgery for DE, focus on colorectal resections for bowel DE.24,25 One study, assessing sexual function 6 months after surgery with the Sexual Health Outcomes in Women Questionnaire26 for patients with all types of DE showed improvement in desire and satisfaction after surgery but not in orgasm.27 In our study, desire has shown a long term improvement but orgasm improved only at 6 months and satisfaction was unchanged.
Deep endometriosis (DE) may significantly affect women's quality of life. Limited data exists on the effect of surgery on the several domains of sexual function.
To prospectively compare various domains of sexual function before and after laparoscopic surgery for DE.
A prospective observational cohort study in a tertiary university-affiliated referral center. Patients with suspected DE who were planned to undergo laparoscopic surgery completed the Female Sexual Function Index questionnaire before surgery. The same questionnaire was completed by the participants 6 weeks, 6 months, and 12 months after surgery. Rate of sexual dysfunction over time was compared using multilevel logistic regression. Summary scores were then compared at each time point to the corresponding score before surgery using multilevel linear regression. Multivariable analysis was performed of potential confounders.
Change in desire, arousal, orgasm, lubrication, satisfaction and pain summary scores as well as in the full-scale score between before and after surgery.
We followed 149 patients with surgically confirmed DE. Sexual dysfunction rate as per the full-scale score was 75.5% before surgery and remained over 60% to 12 months after. The full-scale sexual function score improved at 6 (change in score = 2.8 ± 9.5, P = .004) and 12 months (change in score = 2.1 ± 9.9, P = .03). None of the summary scores improved at 6 weeks. Desire score (P < .001), arousal score (P = .02), and pain score (P = .01) improved at 6 months. Desire score (P = .03) and pain score (P = .01) also improved at 12 months, as compared to before surgery. On multivariable multilevel analysis, scores before surgery significantly contributed to the scores after surgery (P < .001).
While sexual function improved after surgery, dysfunction rate remained substantial. Proper preoperative counseling should address sexual function measures and clinical and research attention should be given to seek ways to further reduce sexual dysfunction.
The main strengths of our study are the prospective design, the relatively long follow-up and the use of a detailed validated questionnaire allowing assessment of a large variety of clinically relevant sexual function domains and scores as well as a full-scale score. Among our limitations are the lower response rate at 12 months and the limited generalizability as this is a single center study.
Sexual function is a major and often under reported domain of quality of life. Further research is needed to identify the specific populations who may improve, not change or experience deterioration in their sexual functioning after surgery.
Dior UP, Reddington C, Cheng C, et al. Sexual Function of Women With Deep Endometriosis Before and After Surgery: A Prospective Study. J Sex Med 2022;19:280–289.
What Sexual Behaviors Relate to Decreased Sexual Desire in Women? A Review and Proposal for End Points in Treatment Trials for Hypoactive Sexual Desire Disorder
2017, Sexual Medicine
Counts of satisfying sexual events (SSEs) per month have been criticized as an end point in treatment trials of women with hypoactive sexual desire disorder (HSDD) but grounding improvement in sexual desire by assessing changes in sexual behavior remains of some importance.
We conducted a literature review to find validated measurements that are specific sexual behavioral correlates of low sexual desire. We compared expert-proposed criteria for dysfunctional desire, expert-developed sets of scale items, and self-rated scales developed before issuance of, or in accordance with, the Food and Drug Administration’s guidance on developing patient-reported outcomes. Behavioral measurements of HSDD were isolated from these sets of criteria or scales.
We outline a plan to evaluate such behavioral measurements of HSDD with reference to SSEs.
Eleven rating scales, four expert-originated and seven self-rated scales mainly derived from patient input were identified as well validated and relevant to HSDD. Three recent sets of diagnostic criteria for conditions such as HSDD were compared with the scales. Twenty-four different symptoms were found in the scales. Content found relevant to HSDD during development of the rating scales varied highly among measurements, including the self-rated scales developed in conformity with current recommendations for patient-reported outcome measurements. The only item on all sets was desire for sexual activity. Four other items were in approximately at least half the sets: sexual thoughts or fantasies, frequency of sexual activity, receptivity, and initiations. Sexual thoughts or fantasies were in every expert-derived set but in only three of the seven patient-derived sets. Receptivity was in five of the seven expert-derived sets vs two of the seven patient-derived sets. Frequency of sexual activity was in one of the seven expert-derived sets but in five of the patient-derived sets. Initiation was in approximately half the two sets. All other items were on one to three sets each. We identified three sexual behaviors of validated specificity for female HSDD: frequency of sexual activity, receptivity, and initiations. Six or seven items are relevant and informative. The item on frequency of sexual activity in the Changes in Sexual Functioning–Female scale is the only item that covers frequency of dyadic and solitary sexual activity. An item in the Female Sexual Desire Questionnaire (FSDQ) covers the intuitively relevant topic of frequency of sexual activity motivated by the woman’s desire. Three FSDQ items on initiations and two items on receptivity reflect expert opinion on the sexual behaviors of most relevance to HSDD, but the FSDQ has not been validated in women with HSDD.
SSEs have been discredited as the primary measurement in clinical trials of women with HSDD, but it would be meaningful to include at least one sexual behavioral symptom specific to HSDD as an end point. Expert-recommended sexual behaviors specifically related to HSDD are irregularly represented in self-rating scales whether developed as in the Food and Drug Administration guidance on patient-reported outcomes or not. Six or seven items on sexual behavior in self-rated scales can be recommended for relevance to women with HSDD in clinical trials. Items on female sexual behavior should be tested in comparison with SSEs in women with HSDD for relevance and for treatment sensitivity, and responder and functional and dysfunctional cutoffs should be determined before incorporation into large-scale clinical trials.
Pyke R and Clayton A. What Sexual Behaviors Relate to Decreased Sexual Desire in Women? A Review and Proposal for End Points in Treatment Trials for Hypoactive Sexual Desire Disorder. Sex Med 2017;5:e73–e83.
Validation of the Turkish Version of the Sexual Health Outcomes in Women Questionnaire (SHOW-Q) in Turkish-Speaking Women
2016, Sexual Medicine
Citation Excerpt :
More than two thirds of women with chronic pelvic pain have sexual problems related to pain symptoms.8,9 The Sexual Health Outcomes in Women Questionnaire (SHOW-Q) was developed by Learman et al10 in 2008. This questionnaire is designed to assess the sexual life of women for satisfaction, orgasm, desire, and pelvic problem interference.
The Sexual Health Outcomes in Women Questionnaire (SHOW-Q) is designed to evaluate the sexual life of women for satisfaction, orgasm, desire, and pelvic problem interference. The SHOW-Q is important for evaluating worsening of sexual life for patients with pelvic problems and the management of these women to improve their sexual life.
To validate the Turkish versions of the SHOW-Q for Turkish-speaking women.
The Turkish version of the SHOW-Q was generated by two independent professional English-to-Turkish translators. The translated version of the SHOW-Q was reverse translated by two bilingual translators whose native language was English. Women with at least one symptom related to pelvic problems (n = 71) and those with no symptoms (n = 38) were included in the present study.
Test-retest reliability analysis, content-face validity, internal consistency reliability, item-total correlations, convergent validity, construct validity, and factorial validity were performed to assess the psychometric properties of the Turkish versions of the SHOW-Q.
Test-retest reliability demonstrated good correlation for all subscales. Cronbach α values ranged from 0.735 to 0.892 and indicated high internal consistency. There was a strong correlation for the corresponding subscales between the SHOW-Q and the Female Sexual Function Index. The mean score of each SHOW-Q subscale showed significant differences between symptomatic and asymptomatic patients.
The Turkish version of the SHOW-Q is a valid and reliable instrument that can be used to evaluate the sexual life of Turkish-speaking women with different pelvic problems.
Applying the RE-AIM Framework to Evaluate Integrative Medicine Group Visits Among Diverse Women with Chronic Pelvic Pain
2015, Pain Management Nursing
The purpose of this study was to evaluate group medical visits using an integrative health approach for underserved women with chronic pelvic pain (CPP). We implemented an integrative medicine program to improve quality of life among women with CPP using Centering, a group-based model that combines healthcare assessment, education, and social support. Patients were from university-affiliated and public hospital-affiliated clinics. We evaluated the program with qualitative and quantitative data to address components of the RE-AIM framework: Reach, Effectiveness, Adoption, Implementation, and Maintenance. Participants of the Centering CPP Program participants (n = 26) were demographically similar to a sample of women with CPP who sought care at Bay Area hospitals (n = 701). Participants were on average 40 years of age, a majority of whom were racial/ethnic minorities with low household income (76%). Women who attended four or more sessions (n = 16) had improved health-related quality of life, including decreases in average number of unhealthy days in the past month (from 24 to 18, p < .05), depressive symptoms (from 11.7 to 9.0, p < .05), and symptom severity (from 4.2 to 3.1, p < .01). Sexual health outcomes also improved (30.5 to 50.3, p = .02). No improvements were observed for pain catastrophizing. Our pilot program provides preliminary data that an integrative health approach using a group-based model can be adapted and implemented to reach diverse women with CPP to improve physical and psychological well-being. Given these promising findings, rigorous evaluation of implementation and effectiveness of this approach compared with usual care is warranted.
Using an FSDS-R Item to Screen for Sexually Related Distress: A MsFLASH Analysis
2015, Sexual Medicine
Citation Excerpt :
It is possible that the strength of correlations we observed may have varied based on a woman's sexual activity. For example, correlations between the Sexual Health Outcomes in Women Questionnaire (SHOW-Q) and health-related quality of life, body image, and symptom scales varied based on whether or not a woman was sexually active [19]. Limitations include the following.
The Female Sexual Distress Scale-Revised (FSDS-R) was created and validated to assess distress associated with impaired sexual function, but it is lengthy for use in clinical practice and research when assessing sexual function is not a primary objective.
The study aims to evaluate whether a single item from the FSDS-R could be identified to use to screen midlife women for bothersome diminution in sexual function based on three criteria: (i) highly correlated with total scores; (ii) correlated with commonly assessed domains of female sexual functioning; and (iii) able to differentiate between women reporting high and low sexual concerns during the prior month.
Data from 93 midlife women were collected by the Menopause Strategies Finding Lasting Answers to Symptoms and Health (MsFLASH) research network.
Women completed the FSDS-R, Female Sexual Function Index (FSFI), and Menopausal Quality of Life Scale (MENQOL). Those who reported a change in the past month on the MENQOL sexual were categorized into a high sexual concerns group, while all others were categorized into a low sexual concerns group.
Women were an average of 54.6 years old (SD 3.1) and mostly Caucasian (77.4%), college educated (60.2%), married/living as married (64.5%), and postmenopausal (79.6%). The FSDS-R item number 1 “Distressed about sex life” was: (i) highly correlated with FSDS-R total scores (r = 0.90); (ii) moderately correlated with FSFI total scores (r = −0.38) and FSFI desire (r = −0.37) and satisfaction domains (r = −0.40); and (iii) showed one of the largest mean differences between high and low sexual concerns groups (P < 0.001). Other FSDS-R items met one or two, but not all three of the prespecified criteria (i, ii, iii).
A single FSDS-R item may be a useful screening tool to quickly identify midlife women with sexually related distress when it is not feasible to administer the entire scale, though further validation is warranted. Carpenter JS, Reed SD, Guthrie KA, Larson JC, Newton KM, Lau RJ, Learman LA, and Shifren JL. Using an FSDS-R item to screen for sexually related distress: A MsFLASH analysis. Sex Med 2015;3:7–13.

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Cite this article as: Learman LA, Huang AJ, Nakagawa S, et al. Development and validation of a sexual functioning measure for use in diverse women's health outcome studies. Am J Obstet Gynecol 2008;198:710.e1-710.e11.

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Meeting paperPCOGS paperDevelopment and validation of a sexual functioning measure for use in diverse women's health outcome studies

Objective

Study Design

Results

Conclusion

Section snippets

Materials and Methods

Results

Comment

J Urol

Maturitas

Obstet Gynecol

Obstet Gynecol

Sexual dysfunction in the United States: Prevalence and predictors

JAMA

Sexual function problems and help seeking behaviour in Britain: National probability sample survey

BMJ

Sexual activity and function in postmenopausal women with heart disease

Obstet Gynecol

Sexual activity and function in middle-aged and older women

Obstet Gynecol

Problems with sexual function in people attending London general practitioners: Cross sectional study

BMJ

The DSFI: A multidimensional measure of sexual functioning

J Sex Marital Ther

The GRISS: A psychometric instrument for the assessment of sexual dysfunction

Arch Sex Behav

The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function

J Sex Marital Ther

Randomized trial comparing hysterectomy with endometrial ablation for dysfunctional uterine bleeding; psychiatric and psychosocial aspects

BMJ

Hysterectomy and sexual functioning

JAMA

Outcomes after total versus subtotal abdominal hysterectomy

N Engl J Med

Meeting paper
PCOGS paper
Development and validation of a sexual functioning measure for use in diverse women's health outcome studies