Spinal cord injury (SCI) is a common, debilitating
physical condition. Data from the United
States indicates that there are approximately
12000 new cases each year (
To address the quality of sexual lives of SCI patients,
a number of instruments have been developed
The Emotional Quality of the Relationship Scale
(EQR) was developed and validated by Kreuter et al.
This study reported the sexual health measures developed and validated for Iranian individuals with SCI who presented to the Brain and Spinal Injury Research Center (BASIR) in Imam Khomeini Hospital. This research aimed to create culturally appropriate and practical tools that could be used to investigate sexual health among Iranian patients with SCI.
Approval for this cross-sectional study was obtained from the Ethics Committee of Tehran University of Medical Sciences in 2009. Convenience sampling was used to recruit patients (N=68) from a larger study for health promotion of Iranian SCI patients. Participants completed the questionnaires while they were admitted for medical care and treatment follow-up. The written consent of participation was obtained prior to data collection.
To be included, participants had to be at least
18 years of age and have no medical diseases
other than SCI that affected sexual health. Patients
were evaluated based on the ASIA impairment
scale (AIS) (
The population on which questionnaires were
tested comprised of two subgroups; 32 males aged
25-52 years (mean age: 35.69 ± 8.14) and 8 females
aged 26-46 years (mean age: 34.29 ± 6.80).
The mean age of all patients was 35.4 ± 7.8 years.
Almost half (48.7%) of the participants were married.
The average number of years of marriage
was14.4 ± 8.5. The average number of years of
SCI was 10.2 ± 8.5 years (
Internal consistency of the subscales and validation instruments
Distribution of participants based on ASIA Impairment Scales (AIS)
As there were no existing sexual health questionnaires in the Farsi language to assess SCI patients, this study investigated six different multiple-choice questionnaires with a minimum of 7 to a maximum of 23 questions, which were designed in Farsi. Extensive literature review, opinions of 12 experts from various disciplines that included sexologists, urologists, epidemiologists, psychiatrists, midwifes, general practitioners and religious leaders, in addition to informal encounters with SCI patients were used to generate the instruments. Our intention was to develop a measure that could be used to assess sexual-related social life (questions 1-8), sexual adjustment after SCI (questions 9-19), sexual activities (questions 20-32), sexual thoughts (questions 33-39), performance partnership satisfaction (questions 40-55), and sexual functions (questions 56-65). Sexual-related social life characterizes the social component of a person’s sexuality, including interpersonal relationships.
In the current study, as with a study by Kreuter
et al. (
The total score in each subscale was calculated by summing the items after which we transformed the total score using linear transformation
Face validity, defined as whether the scale appears to measure what it is supposed to measure, and content validity, or the extent to which a measure comprehensively covers domains of interest were examined by an expert committee. Construct validity was assessed by examining convergent validity and hypothesizing that each sex subscale would be significantly negatively correlated with age and positively correlated with other subscales.
We computed Cronbach’s alpha to assess internal
consistency of items as a function of the
mean inter-item correlation among the six measures.
A high Cronbach’s alpha value (>0.7), the
standard criterion of acceptability, is the result
of a high inter-item correlation which indicates
that the items measure the same underlying
Correlation matrix based on Pearson’s product-
moment correlation (
To assess the test-retest reliability of the questionnaires, participants were asked to complete the questionnaire again, two to four weeks after initial participation. Reliability testing was performed separately for each measure.
Test-retest reliability of the subscales by Intraclass Correlation Coefficient
The hypothesized significant negative correlation
between the questionnaire subscales
and age was supported. As expected, there was
a significant positive correlation observed between
subscales of the questionnaire (
Internal consistency was determined using
Cronbach’s alpha for each of the seven
measures. High scores were eminent for all
measures (0.73 and higher). Cronbach’s alpha
ranged from 0.73 for the sexual activity measure
to 0.904 for the sexual adjustment measure
Test-retest reliability was determined using the ICC for each of the seven measures. ICCs ranged from 0.653 for sexual function (female) to 0.836 for sexual activity.
Correlation of each sex domain with age and other domains
All correlations were significant at the 0.01 significance level.
The primary purpose of the current study was to
develop and validate sexual health measures for
Iranian patients with SCI. Internal consistency was
documented for each of the six measures. Cronbach’s
alpha was 0.73 or higher which showed
good internal consistency. Thus, it indicated that
the items measured the same underlying construct.
These high correlations were comparable to those
reported by Meston (
However internal consistency in this study was
lower than reported from some other studies. For
example, Alexander et al. (
ICC from test-retest reliability in the current
study was 0.65 or higher which suggested satisfactory
stability. The only exception was in
female sexuality function measures, though
ICC in the other measures was greater than
78%, which indicated near to excellent agreement.
These results were comparable with ICC
reported from other studies. Alexander et al.
found an ICC between 0.79 and 0.86, in their
The results suggested that a questionnaire with this level of sensitivity should be completed in male patients that have male assistants. Although we achieved significant results with this small sample size, we recommend that future studies be conducted with larger numbers of participants.
The rehabilitation services do not have adequate, comprehensive sexual well-being programs in Iran. One reason for this deficit is the lack of culturally appropriate instruments to examine related variables and measure the interested outcomes among SCI patients.
Although a number of measures have been pubpublished
concerning sexuality matters in SCI patients
To address this insufficiency we have aimed not only at the cognitive component of sexual health attitudes but also the behavioral component. Our study has shown that it was possible to construct measures with good psychometric characteristics regarding the quality of social life, sexual adjustment, sexual activities, sexual thoughts, partnership satisfaction and sexual function (males and females). The sexual health measures provided a valid assessment of sexuality-related matters in this sample of patients with SCI, which has suggested that it may be useful for evaluation of sexual well being in clinical trials. Overall, the studied sexual health measures have shown good internal consistency and test-retest reliability. This is the first study to validate a measure of sexuality-related matters on a sample of patients with SCI in Iran. Future research is needed to examine this measure in a larger study population.