Translation and cross-cultural adaptation of the Arizona Sexual Scale ( ASEX ) into Portuguese

Introdução: A disfunção sexual é comum em indivíduos com doenças psiquiátricas e sob o uso de medicações como antidepressivos e antipsicóticos. Várias escalas foram desenvolvidas para avaliar a função sexual desses doentes. A Arizona Sexual Scale (ASEX) é uma escala de cinco itens de avaliação que quantifica desejo sexual, excitação, lubrificação vaginal/ereção peniana, capacidade para atingir o orgasmo e satisfação com o orgasmo. Este artigo descreve o processo de tradução e adaptação transcultural da escala ASEX para a língua portuguesa, com o objetivo de contribuir para a avaliação da função sexual dos doentes medicados com fármacos psicotrópicos nos vários países onde se utiliza essa língua. Métodos: A tradução e a adaptação transcultural seguiram de forma detalhada os passos recomendados pelo grupo de trabalho da International Society for Pharmacoeconomics and Outcomes Research (ISPOR), nomeadamente: preparação, tradução inicial, reconciliação, retroversão, revisão da retroversão, harmonização, teste cognitivo, revisão do teste cognitivo, finalização, leitura final e versão final. Resultados: O processo foi completado com sucesso, e não foram observadas diferenças grandes entre as fases de tradução, reconciliação e retroversão, tendo sido feitos apenas pequenos ajustes. Conclusão: A tradução da escala ASEX foi bem-sucedida, seguindo orientações internacionais de referência. A aplicação dessas orientações é a garantia de uma versão em língua portuguesa que é qualitativa e semanticamente equivalente à versão original da escala. A existência desta nova versão da escala permitirá estudos que avaliem a função sexual dos doentes em países nos quais se fale a língua portuguesa. Estudos futuros poderão atestar a validade da escala para essas populações. Descritores: Disfunção sexual, ASEX, psicofarmacologia, antipsicóticos, antidepressivos, esquizofrenia, depressão. Abstract


Introduction
The concept of sexual dysfunction includes the multiple ways in which an individual is unable to participate in a sexual relationship as he or she would wish, as a result of impaired psychological and/or somatic processes -according to criteria from the International Classification of Diseases, 10th revision (ICD-10). 17][8] It includes every aspect of sexual function, including desire, arousal, erection, ejaculation and orgasm. 9Although sexual dysfunction is common in psychiatric patients, its quantification is limited by several factors, such as relevant clinical information, time constraints and explicit sexual questions that could contribute to patient noncompliance. 9In clinical settings, the use of smaller and simpler questionnaires with clear and objective answers should be prioritized.However, there is a paucity of validated, user-friendly scales. 9e Arizona Sexual Scale (ASEX) is a five-item rating scale that quantifies sex drive, arousal, vaginal lubrication/penile erection, ability to reach orgasm, and satisfaction from orgasm.The total score ranges from 5 to 30 points, with higher scores indicating higher degrees of sexual dysfunction. 9This assessment tool was designed to be self-or clinician-administered, and it is adapted to either heterosexual or homosexual populations, regardless of the existence of a sexual partner. 9It is also validated for patients medicated with either antipsychotics 10 or antidepressants, 9 which is the target population in need of a more pertinent, expedient and less intrusive method of evaluating sexual dysfunction. 9Despite not covering all stages of sexual functioning, the ASEX is a simple and effective approach to determine and quantify sexual function impairment in psychiatric patients. 10Also, even though it is currently not possible to establish the etiology of sexual dysfunction, the ASEX has shown internal consistency, reliability, validity and sensitivity to accurately assess sexual dysfunction, if present. 9The ASEX has also been successfully used in the evaluation of particular populations, such as subjects with Parkinson's disease, 11 epilepsy 12 or undergoing dyalisis. 13veral studies have used ASEX to determine sexual functioning in psychotic patients.Uçok et al., using ASEX, concluded that 52.6% of patients with schizophrenia had sexual dysfunction, and that disease severity was correlated with the scale's total score. 14t the moment, the ASEX has only been translated into three other languages: Thai, 15 French 16 and Arabic. 17 addition, very few related scales have been validated in the Portuguese language, and only very recently was the Sexual Function Questionnaire (SFQ) translated into Portuguese. 18 this study, we aim to describe the translation and validation process of the ASEX into the Portuguese language.

Selection of research team and patients
We enrolled 20 patients from Hospital de Magalhães Lemos, followed up at an outpatient clinic and receiving psychotropic medication, to perform the proofreading step of the scale translation process.All patients signed a written consent form before being involved in the translation process.

Instrument: Arizona Sexual Experience Scale (ASEX)
The ASEX measures each of its five items in a relatively nonintrusive bimodal fashion, using a 6-point Likert-type scale ranging from hyperfunction (1) to hypofunction (6). 9 An open comment section is included for the expression of individual concerns and feedback.The male and female versions differ on the third question, which refers to penile erection or vaginal lubrication, accordingly. 9is methodology focuses on 10 steps to translate a scale: 1) Preparation: obtaining authorization from original authors and selecting translators.
2) Forward translation: production of two independent versions in Portuguese (translations 1 and 2).
3) Reconciliation: synthesis of translations 1 and 2. Informed consent was obtained in writing.Table 1 shows the cognitive debriefing questions used for patients and interviewers.After reviewing the results (step 8), the final version of the document was proofread by an expert in Portuguese-English translation (step 9).
The final version of the translated scale is presented as an Appendix to this paper (step 10).

Ethical considerations
This study was approved by the ethics committee of Centro Hospitalar Psiquiátrico de Lisboa, Lisboa, Portugal.

Results
Table 2 presents examples of the original version of the scale, the initial translations, the result of the reconciliation stage, the back-translation and the final version -the latter was defined using both the initial translations and the back-translation (Escala ASEX © ).No significant differences were found between translators in the third step of the translation.
From the total sample size of 20 patients who participated in the cognitive debriefing process, only one patient mentioned a relevant comment regarding the understanding of the scale.The authors opted to review the translation process as a whole, but no changes were made.This fact, added to the non-existence of other translations using the ISPOR guidelines, made the harmonization step impossible to perform.

Discussion
To our knowledge, this is the first study to describe the translation and cross-cultural adaptation of the ASEX to the Portuguese language.The translation was performed according to ISPOR criteria so that we could obtain a final version as accurate as possible.The use of this methodology warranted a solid final translation, as close to the original as possible, maintaining accuracy in the assessment of patients.
The ASEX is one of the scales most widely used for the assessment of sexual dysfunction in psychosis.We were only able to find three published translations of the English version of the scale, into Thai, 15 French 16 and Arabic. 17Those translations, however, did not follow the ISPOR guidelines, and therefore the harmonization step was not performed.
The Portuguese version of the ASEX will be an

Conclusions
The original version of the ASEX was translated into

4 ) 7 ) 8 )9) Proofreading. 10 )
Back-translation: performed by a translator who did not have previous contact with the other translators.5) Back-translation review: comparison between the original and the new version of the scale.6) Harmonization: assessment of discrepancies between different translations of the same instrument made prior to the translation process under way, with the objective of minimizing distinct results.Cognitive debriefing: instrument application to a sample.Review of cognitive debriefing results and finalization.Final report.To follow this 10-step guidelines, we contacted the author of the original scale (step 1).Then, four translators with English proficiency were selected to participate in the translation process (step 2).Reconciliation of the scale was done using the first two translation versions (step 3), and a back-translation was made afterwards and compared to the original version (steps 4 and 5).The harmonization stage (step 6) was not possible to carry out, as no other languages had translations that would match the ISPOR criteria, making this the first translation to assure those principles.Cognitive debriefing (step 7) was completed by administering a compatible version of the scale to 20 psychiatric patients medicated with either antidepressants, antipsychotics or both.
important and useful instrument to assess the sexual function of patients who are under psychotropic medication.The final result (Escala ASEX © ) is presented in this article as an Appendix.With regard to limitations, the main one was the unavailability of other ISPOR-compliant translations, which prevented the harmonization step from being performed.

Table 1 -
Questions used for cognitive debriefing of the Arizona Sexual Scale (ASEX)

Table 2 -
Translation process of the Arizona Sexual Scale (ASEX) from English into Portuguese The Arizona Sexual Scale (ASEX) in Portuguese -Prata Ribeiro et al.