Translation and cross-cultural adaptation of the Sexual Function Questionnaire (SFQ) into Brazilian Portuguese

Tradução e adaptação transcultural do Questionário de Função Sexual (SFQ) para o português do Brasil

Abstract

Introduction

Sexual dysfunction is common in patients with psychotic illness. This article describes the translation and cross-cultural adaptation of the Sexual Function Questionnaire (SFQ) into Brazilian Portuguese.

Methods

The translation and cross-cultural adaptation followed the guidelines for adapting self-report instruments proposed by the Task Force of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR). Briefly, ISPOR steps include: preparation, forward translation, reconciliation, back-translation, back-translation review, harmonization, cognitive debriefing, review of cognitive debriefing and finalization, before proofreading and final version. The original authors authorized the translation and participated in the study.

Results

There was good agreement between translations and between the back-translation and the original English version of the SFQ. The final version was prepared with certificated evaluators in the original language and in Portuguese. Few changes were necessary to the new version in Portuguese.

Conclusion

The translated and adapted Brazilian Portuguese version of the SFQ is reliable and semantically equivalent to the original version. Studies on psychotropic-related sexual dysfunction may now test the validity of the instrument and can investigate sexual dysfunction in Portuguese-speaking patients.

Sexuality; psychopharmacology; adverse effect; antipsychotics; sexual dysfunction

Resumo

Introdução

A disfunção sexual é comum em pacientes com doença psicótica. Este artigo descreve a tradução e adaptação transcultural do Questionário de Função Sexual (SFQ) para o português do Brasil.

Métodos

A tradução e a adaptação transcultural seguiram as diretrizes para a adaptação de instrumentos de autorrelato propostas pela Força-Tarefa da Sociedade Internacional de Pesquisa Farmacológica e de Resultados (International Society for Pharmacoeconomics and Outcomes Research, ISPOR). As etapas da ISPOR incluem: preparação, primeiras traduções, reconciliação, retrotradução, revisão da retrotradução, harmonização, interrogatório cognitivo, revisão do interrogatório cognitivo e finalização, antes da revisão e versão final. Os autores originais autorizaram a tradução e participaram do estudo.

Resultados

Houve boa concordância entre as traduções e entre a retrotradução e a versão original em inglês do SFQ. A versão final foi preparada com avaliadores certificados na língua original e em português. Poucas mudanças foram necessárias para a nova versão em português.

Conclusão

A versão brasileira traduzida e adaptada do SFQ é confiável e semanticamente equivalente à versão original. Estudos sobre disfunção sexual relacionada a psicotrópicos podem agora testar a validade do instrumento e investigar a disfunção sexual em pacientes brasileiros.

Sexualidade; psicofarmacologia; efeito adverso; antipsicóticos; disfunção sexual

Introduction

Sexual dysfunction is common in patients with psychotic illness,¹,²affecting up to 80% of patients.³Besides sexual dysfunction caused by the disease itself,⁴,⁵the use of antipsychotics may have direct and indirect impacts on sexual function, leading to loss of desire, erectile dysfunction, anorgasmia and ejaculatory dysfunction.¹,⁶Despite the importance of sexuality in patients’ lives and its impact on quality of life and treatment adherence, this topic is still neglected in the literature.⁷,⁸

One of the limiting aspects in the evaluation and study of antipsychotic-related sexual dysfunction is the omission of spontaneous reports by patients and the lack of investigation of the various dimensions of patient sexuality by clinicians.⁶,⁹Patients with schizophrenia also often have neurocognitive deficits and comprehension difficulties,¹⁰which makes most research instruments difficult to use. For those patients, smaller and simpler questionnaires are preferred, with clear and objective answers.⁹Despite the existence of multiple specific instruments to assess sexual dysfunction in patients on antipsychotics and with mental illness,⁷,⁹none have been translated and adapted into Brazilian Portuguese.

The aim of this article was to create and present a Portuguese version of the Sexual Function Questionnaire (SFQ)⁷– a tool especially developed to measure sexual dysfunction in mentally ill populations. Our proposal uses a standard procedure for the translation and cross-cultural adaptation of the SFQ into Brazilian Portuguese.

Methods

Team selection and patients

We selected four translators with a certificate or English proficiency test (TOEFL, Cambridge or IELTS) who did not know the scale. A professor with expertise in Portuguese language proofread the final version of the instrument. We also enrolled five patients from the psychiatric unit of Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), to perform cognitive debriefing with a translated version of the instrument.

Instrument: Sexual Function Questionnaire (SFQ)

The SFQ comprises 39 questions about libido, erection in men, vaginal lubrication in women, masturbation, orgasm, dyspareunia and ejaculation.⁷The instrument was designed for use in both men and women. It asks the user to choose the best among a number of options to describe their current conditions. The organization of the SFQ allows patients who do not currently have a partner to describe concrete aspects of their sexual functioning even though they may not be having sexual intercourse.

The SFQ has a good Cronbach alpha (0.90) and Guttman metric (0.86). Although this instrument has been used in some studies, few validation datasets are available, even in the original language.

Procedures

The procedure used for translation and cross-cultural adaptation followed guidelines for adapting self-report instruments issued by the Task Force for Translation and Cultural Adaptation of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR).¹¹Since 1999, ISPOR has stimulated discussions to create guidelines and standards for the translation and cultural adaptation of patient-reported outcomes. In clinical practice, however, different methodologies have been employed by consulting groups to perform similar tasks, making consistency and comparison difficult. At the same time, some instrument developers have issued their own translation guidelines. Furthermore, the use of different terminology to refer to the same aspects of the translation process has caused misunderstandings and impaired clarity, threatening the validity of research data and the safe aggregation of global datasets.

The ISPOR methodology has been used to translate and adapt other self-reporting instruments for psychiatric patients, into both Portuguese¹²,¹³and other languages. Following this methodology, the next ten steps were proposed:

1. Preparation: obtaining authorization from original authors; selection of translators.

2. Forward translation: production of two independent versions in Brazilian Portuguese (Translations 1 and 2).

3. Reconciliation: synthesis of Translations 1 and 2.

4. Back-translation: made by a translator who did not have any contact with the other translators.

5. Back-translation review: comparison of the new version with the original one.

6. Harmonization: comparison of back-translations of multiple language versions with each other and the original instrument to highlight discrepancies between the original and its derivative translations (consistent approach to translation problems).

7. Cognitive debriefing: instrument application to a sample.

8. Review of cognitive debriefing results and finalization.

9. Proofreading.

10. Final version

According to ISPOR rules, after obtaining authorization from the original authors (step 1), four translators with English proficiency (TOEFL, Cambridge or IELTS) were selected to make the forward translations (step 2). After the selection, translators were divided in two pairs. During this step, two independent versions were created in Brazilian Portuguese.

Reconciliation (step 3) was then made, unifying the two versions so that it could be back-translated (step 4) and compared with the original version (step 5). The harmonization step (step 6) could not be done because no other back-translated versions were available, i.e., this was the first time the SFQ was translated and adapted to another language using the principles of good practice suggested by ISPOR.

After compatibility verification, the Portuguese version was applied to five psychotic patients on antipsychotic treatment at the psychiatric unit of Hospital São Lucas – PUCRS, to complete cognitive debriefing (step 7). The intention here was to assess the understanding of the scale. A semi-structured questionnaire with questions about the scale and tips to enhance the comprehension of the instrument was used for this purpose (Table 1).

Table 1
Semi-structured questionnaire used for cognitive debriefing.

For patients
- Do you understand this item/question? (If not, please explain the difficulty.)
- If there are any difficulties, how would you rewrite this item/question?
- Can you explain what it means? (Please, ask patients what they think about the item/question.)
- Are the answer options consistent with this item? (If not, explain why and suggest how would you rewrite these options.)
For interviewers
- Please, comment on the patient’s suggestions and recommend any changes that you consider necessary.

After a review of the results (step 8), the translated instrument was proofread by an expert in Brazilian Portuguese language (step 9). The last step (step 10) consisted of the final version of the scale in Brazilian Portuguese (see below).

Ethical considerations

This study was approved by the Research Ethics Committee of PUCRS (protocol no. 42720015.0.0000.5336).

Results

Table 2presents examples of the original version, two initial translations, conciliation, back-translation and final version. The final version incorporated changes from the back-translation process and is presented at ^{Appendix 1}.

Table 2
- Original version, translations, reconciliation, back-translation and final version of the Sexual Function Questionnaire (brief format)

Original	Translation 1	Translation 2	Conciliation	Back-translation	Final version
Each statement is followed by a TRUE or FALSE answer	Cada afirmação é seguida por uma resposta de VERDADEIRO ou FALSO	Cada afirmação é seguida de uma resposta verdadeira ou falsa	Cada afirmação é seguida de uma resposta verdadeira ou falsa	Each statement is followed by a true or false answer	Cada afirmação é seguida de uma resposta verdadeira ou falsa
Read each statement carefully and decide which response best describes how you feel	Leia com atenção cada afirmação e decida qual resposta descreve melhor como você se sente	Leia atentamente cada afirmativa e decida qual resposta melhor descreve como você se sente	Leia com atenção cada afirmação e decida qual resposta descreve melhor como você se sente	Read carefully each statement and decide which answer describes best how you feel	Leia com atenção cada afirmação e decida qual resposta descreve melhor como você se sente
Put a circle around the corresponding response	Circule a resposta correspondente	Coloque um círculo em volta da resposta correspondente	Circule a resposta correspondente	Put a circle around the corresponding answer	Circule a resposta correspondente

During the reconciliation step, 20 items were easily translated, with both pairs translating them identically; the remaining items presented a few differences. All these items were discussed by the authors to achieve the maximum possible semantic equivalence with the English version.

During cognitive debriefing, two of the five patients suggested changes to questions 31 and 34. The authors discussed these suggestions and concluded that the proposed changes were not relevant did not affect semantic equivalence; therefore, no changes were made as a result of this step.

Since this was the first SFQ translation providing a back-translation of the instrument, it was not possible to carry out the harmonization step. The final version of the instrument was slightly edited to include brackets by the options, with the intention of making it easier to complete the answer and improve the layout. The original authors read and approved the final version of the instrument (^{Appendix 1}).

Discussion

This study describes the procedure of translation and cross-cultural adaptation of the original English version of the SFQ into Brazilian Portuguese language, according to ISPOR standards. To the best of our knowledge, this is the first study to adopt standardized methods to translate and adapt the SFQ cross-culturally.

Following the principles of good practice in the translation and adaptation of self-reporting instruments – including participation of the original authors – helps guarantee equivalence of the new version with the original one. A diversity of translations and adaptations of different versions of the SFQ can be found,¹⁴-¹⁶but the methodology used in those reports are poorly described and do not follow some important steps suggested by ISPOR, including cognitive debriefing. The absence of a standardized methodology for this process increases the risk of terminological inconsistence, potentially impairing the validity of the instruments.¹¹

The main limitation of this study was the impossibility to conduct the harmonization step. Although other translations are available for the SFQ, it was not possible to find other back-translations. This step can now be undertaken in future translation studies using our back-translation as a parameter.

Conclusion

The original version of the SFQ was translated and cross-culturally adapted to Brazilian Portuguese following rigid international standards. The resulting instrument is a free-use version, currently undergoing validation by the same authors. The scale is available as a free version and is available for clinical use and for studies of sexual dysfunction in Portuguese-speaking psychiatric patients.

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• Erratum

  The authors of the article entitled “Translation and cross-cultural adaptation of the Sexual Function Questionnaire (SFQ) into Brazilian Portuguese” (doi: http://dx.doi.org/10.1590/2237-6089-2016-0089), published in Trends in Psychiatry and Psychotherapy, 2017, volume 39, issue 2, pages 110-115, have identified an error in Appendix 1 (Brazilian Portuguese version of the Sexual Function Questionnaire), namely, that items 18 to 21 were missing. Below we reproduce the final, correct version of the Appendix:
  
  

Publication Dates

• Publication in this collection
  Apr-Jun 2017

History

• Received
  27 Dec 2016
• Accepted
  07 Apr 2017