Turkish validity and reliability of the Sexual Complaints Screener for Women

ABSTRACT OBJECTIVE: The Sexual Complaints Screener for Women (SCS-W) is a brief, practical and up-to-date scale which assesses sexual problems parallel with the current diagnostic manuals. The SCS-W consists of 10 questions which assess a variety of sexual dysfunctions and potential distress experienced at the time of and the last six months leading to the evaluation. This study aims to assess the validity and reliability parameters of the Turkish version of the SCS-W. METHODS: Cross-sectional study included 352 women between the ages of 18 and 25 who voluntarily completed the survey, 316 of which were included in the analysis. Data was collected through specific questionnaires including the Female Sexual Function Index, the Short Form Health Survey (SF-36), the Turkish translation of SCS-W, and a sociodemographic form. The Cronbach Alpha Test was used to calculate the internal consistency and the Pearson Correlation Test was used for total score correlations as well as to determine cross-validity. An explanatory factor analysis was applied to identify the validity of the scale. RESULTS: The average age of participants in the study was 21.17 ± 1.87. The Cronbach alpha internal consistency coefficient of the scale was 0.895, and the correlation coefficient for most of the items was found to be higher than 0.50. Correlation analysis between the SCS-W and the FSFI total score and subscales were statistically significant. CONCLUSION: The SCS-W has credible psychometric values for validity and reliability to screen and evaluate sexual complaints. To sum up, the SCS-W is a practical assessment tool with the considerable advantages of delivering cost-effective evaluation of female sexual problems in clinical settings, research, and daily practice.


Introduction
Human sexuality is a diverse phenomenon influenced by interactions between global, cultural, social, biological, physiological, relational and psychological contexts [1]. The human sexual response cycle involves desire, arousal, orgasm and resolution [2], and bases on a linear sexual response model formed of consecutive stages of these domains [3]. However, today, the new circular model of female sexual functioning views the absence of spontaneous sexual desire as a variant of normal sexual functioning and defines "responsive sexual desire," following sexual arousal [4,5]. All components of sexual functioning can be hindered by relational, psychological, psychiatric problems, significant life changes, chronic illnesses or other medical conditions [6]. The Turkish prevalence rates for female sexual dysfunctions (FSDs) were found to be 41%, 53.1% and 67.9% between 18-30, 31-45 and, 46-55 year-olds, respectively. 48.3% of females had low desire, 35.9% had arousal problems, 40.9% had lubrication issues, 42.7%, had difficulty reaching orgasm, 45% reported having the low sexual satisfaction, and 42.9% reported experiencing pain during or before penetration [7]. The most common female sexual dysfunction was low desire, which was consistent with international [8] and Turkish findings [9]. Assessing female sexual functioning is a requirement of routine medical and psychological evaluations and primary health care. There are a few reliable and validated female sexual function assessment tools in Turkish. The Female Sexual Function Index (FSFI) [10], the Golombok Rust Inventory of Sexual Satisfaction (GRISS) [11] and the Arizona Sexual Experiences Scale (ASEX) [12] are the most commonly used tools for the evaluation of female sexual problems. The FSFI has been widely acknowledged and used worldwide as the internationally to assess female sexual functioning. The FSFI consists of 19 items in its original version and assesses six sexual function domains including desire, arousal, lubrication, orgasm, satisfaction, and pain [10]. The total score of the FSFI items evaluate overall Female Sexual Dysfunction (FSD) and differentiates between those with or without sexual dysfunction in all subdomains. The FSFI was chosen in the current study to compare and correlate.
Brief assessment tools consistent with the current diagnostic guidelines may have a considerable advantage of delivering cost-effective clarification sexual problems, preliminary assessment of current and past sexual functioning, assessment of the necessity of additional evaluation and may ease the individuals' efforts to complete it. The International Society for Sexual Medicine (ISSM) has established the Sexual Complaint Scale for Women (SCS-W) as one of the tools that would serve as a brief screener to assess sexual problems [13]. The SCS-W is a comprehensive self-administered screener for sexual functioning that is easy to administer even by clinicians who are less familiar with sexual problems. This screener assesses all main aspects of female sexual functioning including sexual interest/desire, subjective and objective arousal, orgasm, dyspareunia, vaginismus, persistent genital arousal, sexual satisfaction, and distress. The SCS-W consists of 10 items and has some advantages such as assessing sexual experiences during the six months leading to the assessment date and personal distress which are concurrent with the current DSM-5 [1].
The SCS-W has only been tested for its validation in German so far [14]. The current study aims to evaluate the SCS-W for its validity and reliability in the Turkish language.

Participants
The current study is a cross-sectional study which was initially conducted by the European Federation of Sexology's Youth Committee between December 2015 and March 2016 as an online survey which took approximately 20-25 minutes. Women between the ages of 18 and 25 were recruited, and sex and age were the only inclusion parameters identified. Data was collected online through validated self-reporting questionnaires. 352 women between the ages of 18 and 25 voluntarily completed the survey, and of those, 316 were included in the study. Eleven participants declined to participate in the study by checking "no" under the informed consent page, and an additional 25 questionnaires were excluded for being incomplete. During the recruitment stage, no further inclusion or exclusion criteria were used to represent the targeted population other than the age range. The validity and reliability testing of the scale required there be at least a hundred participants (ten times the number of questions presented on the scale) which were accomplished [15].

Operation
The original authors of the screener were contacted through e-mail to get approval for translation and use of the original screener. The current study was carried out in accordance with the Helsinki Declaration standards. Approval from the Institutional Review Board was received on January 21, 2015, with the protocol number 2/2015. Four professionals experienced in the field of sexual health, three of whom are psychiatrists and one a sexologist, fluent in English translated the original text from English to Turkish. After the initial translation, a psychiatrist blind to the research and procedure translated the Turkish text back to English. Next, a psychiatrist specializing in sexual dysfunctions and sex therapy translated the latter English version into Turkish for the second time. Once the translations were completed, a final review was concluded by the research team leading to the final Turkish version. Twenty volunteers participated in the pilottest after which no revisions were required due to a lack of negative feedback. After the pilot test was completed, the questionnaire was made accessible to the public.
Female participants between the ages of 18 and 25 were recruited through social media announcements, word of mouth. Participation in the study was voluntary. In order to ensure a diverse sample, no further inclusion or exclusion criteria were applied. The introduction page in the dedicated link presented the aim of the study, types of questions included in the questionnaire, and information on anonymity and confidentiality, the voluntary nature of participation and the option of withdrawing from participating in the study at any time. In order to consent to take part in the study, participants were asked to electronically tick a box which stated "accept" to initiate the questionnaire. The informed consent piece would not allow participants to pass to the questionnaire section unless the "accept" box was clicked on. Upon accepting to participate, participants were directed to a sociodemographic information page, the FSFI Form, the Quality of Life Form (SF36) and the SCS-W Form in that order. Participants' ethical rights were protected in accordance with the Declaration of Helsinki.

Data collection tools
Using an online data collection method allowed efficiency for collection and processing of the data, and anonymity which was critical due to the content of the questionnaire and scales.
The socio-demographic form; was developed to assess demographic information including age, sexual orientation, sex, marital status, level of education, psychiatric and medical history, and alcohol and substance use. None of the questions in the socio-demographic form asked participants to disclose information that would jeopardize their anonymity.
Sexual Complaints Screener for Women (SCS-W); a screener developed by the Standards Committee of the International Society for Sexual Medicine. The SCS-W consists of 10 questions which assess a variety of sexual dysfunction experienced in the six months leading to the assessment date. The first seven items on the scale are made up of two parts. The first parts of the questions are labeled "a", and assess sexual dysfunction. The second parts are labeled "b", assess sexual distress that may be caused by dysfunctions. Both part "a" and part "b" are evaluated on a five-point Likert Scale. A six-point Likert scale (0 = "very unsatisfying" to 5 = "very satisfying") was used to rate the eight-question, and the ninth item is an open-ended question to allow participants to share further information about their sex lives. The tenth and final question is designed to be used as a gateway question to foster dialogue between clinicians and their patients about sexual health [13]. The tool is a sex-specific screening tool that assesses those whose sex were assigned female at birth, and measures these complaints in seven different parameters: sexual desire, sexual arousal, lubrication, orgasm, vaginismus, persistent arousal, and sexual life satisfaction. Seventeen items on the scale are on a Likert scale, and one is an open-ended question.
The Female Sexual Function Index (FSFI); was developed by Rosen [10] and colleagues, designed to assess desire, arousal, lubrication, orgasm, satisfaction and pain experienced by female participants in the month leading to the assessment. The highest score on the scale is 36.0, and the lowest score is 2.0. The Turkish validity and reliability tests of the FSFI were conducted in 2005 by Aygın and Aslan [16] and had been validated for online use [17].
The Quality of Life Questionnaire Short-Form 36 (SF36); was designed to measure the quality of life [18]. The SF-36's Turkish version was validated by Koçyiğit et al. [19]. The form is a self-administered form containing thirty-six items measuring the quality of life during the four weeks leading up to the date of assessment. The subscales identified in the scale were physical limitations, non-physical limitations experienced due to physical problems, experienced pain, general self-perception on health, level of energy/vitality, social functioning, limitations experienced due to emotional problems, and mental health.

Statistical analysis
The Cronbach Alpha Test was used to calculate the internal consistency of the scale and the Pearson Correlation Test was used to calculate the total score correlations as well as to determine cross-validity. A convergent validity analysis was conducted to test the construct validity. To test the convergent validity of the scale, the Pearson correlation analysis was performed between the SCS-W subscale score and the FSFI subscale and total scores. In addition, a correlation analysis was performed between the SF36 subscale scores and the SCS-W total score. Correlation coefficients higher than 0.30 were considered adequate [20].
The 8-factor structure of the scale was tested. For verification of the 8-factor structure of the SCS-W, an exploratory factor analysis was conducted with a principal component analysis for estimation of factors. Kaiser-Meyer-Olkin's sampling adequacy criterion was used to assess the inclusion of the data in factor analysis. The Kaiser-Meyer-Olkin values greater than 0.80 were considered optimal, and those less than 0.5 were not included. The Varimax rotation method was used for eigenvectors to rotate the axes. Collected data was evaluated by the IBM SPSS Statistics 20 package programme. In the analyses, p ≤ 0.05 was considered statistically significant.

Results
The mean age of participants included in the current study was 21.17 ± 1.87. The SCS-W was examined for both reliability and validity. Reliability is the consistency of the measurement and its ability to measure without errors. The reliability of the SCS-W in our study was evaluated with internal consistency and item consistency. The internal consistency was assessed by the Cronbach alpha consistency coefficient and was calculated with the internal consistency coefficient. The scale's Cronbach alpha internal consistency coefficient was 0.895. Furthermore, the item-total test correlation coefficients were found to be higher than the cut-off point of 0.30. Additionally, the correlation coefficients for the majority of the items were found to be higher than 0.50. These values showed that the Turkish form of the scale had high internal consistency and item consistency (Table 1).
Validity shows the degree of the test measurement what it alleges to measure. The construct and content validity of the current study had been evaluated. A correlation analysis between the SCS-W, the FSFI, and the subscales were found to be statistically significant ( Table 2). According to these results, the convergent validity of the SCS-W can be accepted for orgasm, satisfaction, dyspareunia, desire, lubrication, arousal, and the total questionnaire score while it was not found to be acceptable for vaginismus ( Table 2). The correlations between the SCS-W and the SF-36 subscales were not significantly correlated (Table 3).
Construct validity of the SCS-W was examined via an explanatory factor analysis. Analytical suitability of the data was evaluated by Barlett Sphericity and Kaiser-Meyer-Olkin (KMO) tests. The sample suitability coefficient was 0.868, and the Barlet-Sphericity test had the Chi-square value of 927.662, indicating that the results obtained were suitable for factor analysis. For the SCS-W, an un-rotated principal component analysis resulted in 8 factors with only 1 having eigenvalues higher than 1 (Table 4). Although factors 4, 5, 6, 7, and 8 showed low eigenvalues, they were included in the exploratory factor analysis because of the results of subsequent Varimax rotation and suggested an 8-factor model as the most robust (Table 5). According to this 8-factor varimax result, no elements with complex overloads for the SCS-W had been identified. As  Table 1.

Discussion
The current study aimed to adapt the Sexual Complaints Screener for Women (SCS-W) to Turkish and to test and validate it as a reliable assessment tool for sexual problems in women. The reliability of the SCS-W was calculated by the Cronbach Alpha Internal Consistency Coefficient (CAICC). A minimum CAICC measurement of 0.70 was required to reach internal consistency [21]. The scale's CAICC was calculated at 0.895. The total correlation analysis and the interpretation of the items were expected to be .30 or higher to distinguish the measured parameters significantly [20]. The item-total test correlation coefficients were higher than the 0.30 cut-off point for all items, and the majority of the questions had correlation coefficients higher than 0.50, which indicated a very high internal consistency. The construct validity of the SCS-W was examined via an exploratory factor analysis which concluded the data collected in the current study to be suitable for factor analysis. The FSFI and the SF-36 were used in the correlation analysis for the validity of the SCS-W. All the subscales of the FSFI and the SCS-W were significantly correlated, whereas none of the subscales of the SF-36 and the SCS-W had a significant correlation.
Furthermore, the correlation analysis between all subscales of the SCS-W and the FSFI were significantly higher than .30 except in the vaginismus subscale. The dyspareunia domain, one of the SCS-W's two domains, was correlated with the FSFI pain domain with the correlation coefficient higher than .30. The vaginismus domain was also associated with the FSFI pain domain, yet the correlation coefficient with the FSFI pain was found to be lower than .30. The FSFI did not explicitly discriminate between the pain (dyspareunia) and vaginismus domains. One of the possible reasons could have been the FSFI's lack of differentiation between the pain experienced due to penile-vaginal penetration and difficulties allowing vaginal penetration to occur. The correlation coefficient between the SCS-W pain domain and the FSFI pain domain was higher than .30 which was consistent with the results of Burri and Porst's research [14]. The inconsistency mentioned was expected since there the FSFI did not constitute of items that specifically evaluated vaginismus. All in all, the current study concluded the Turkish version of the SCS-W to be valid.
The lack of correlation between sexual functions and quality of life in females in the study may be due to the cultural context in which the study was conducted, other factors, such as intimacy, emotional closeness, attachment, love, acceptance, and tolerance may have been more directly associated with sexual proximity [4,5] thus being more directly associated with quality of life. From a sociocultural perspective, considering the current study's population, physical expressions of sexuality, whether auto-eroticism or partnered sexual expression, may not be as frequent and not perceived to be an essential component of life quality when compared to their male counterparts.
Even though sexual problems are more prevalent among females than males, there is an urgent need for further research due to inconsistent findings on the prevalence of female sexual dysfunctions. Two of the leading causes of such inconsistencies are methodological discrepancies and the usage of different diagnostic criteria and tools for assessment of female sexual problems [22]. The prevalence of at least one sexual dysfunction in females has been estimated at between 40% and 50%, irrespective of age [23].
To ensure safe access to treatment and adequate referrals, there is a great need for the assessment of female sexual dysfunctions in standard medical and clinical practices. Providing clinicians with efficient and practical female sexual functioning assessment tools would allow for more comprehensive data to be collected, and the assessment of data to lead to more accurate diagnoses, and actions for treatment and referral. The SCS-W was designed as a brief, practical and updated tool to enable clinicians of all backgrounds to incorporate the assessment of sexual health into their routine evaluations similar to the Sexual Complaints Screener for Men [24]. The use of the SCS-W holds the potential to create a space for patients to share sexual health issues and histories in a more detailed and comprehensive manner. Additionally, this scale can be of great use to researchers aiming to evaluate sexual health issues and dysfunctions in larger populations.
Some of the limitations of the current study need mentioning. The participants were recruited on a voluntary basis and not random sampling which is a limiting factor on the generalizability of the outcomes. A limiting age group may have created another sample bias due to its generalizability. The results of the current study were not counterchecked with clinical sexual dysfunction diagnoses but have been evaluated through a comparison with the FSFI.
In summary, the SCS-W was validated as a reliable questionnare for assessing of the sexual complaints while at the same time presenting as a beneficial supplement to the short screening tools used for the evaluation of female sexual issues. This scale has acceptable psychometric values, a modest number of questions enabling the efficient and effective screening of female sexual problems. It is important for the scale not to be considered as a stand-alone comprehensive diagnostic tool used to diagnose sexual dysfunctions. The properties of this scale are expected to enable clinicians and researchers to reach larger samples in a shorter time allowing for faster assessment of data.