The accuracy of the Arizona Sexual
Experience Scale (ASEX) to identify sexual dysfunction in patients of
the schizophrenia spectrum
A acurácia da Escala de Experiência
Sexual do Arizona (ASEX) para identificar
disfunção sexual em pacientes do espectro da esquizofrenia
Luciana Vargas Alves Nunes1,
Luiz Henrique Junqueira Dieckmann2, Fernando Sargo Lacaz2,
Rodrigo Bressan3, Tiemi Matsuo4,
Jair de Jesus Mari
M.D, MSc. Student, Department of Psychiatry, Universidade Federal de
São Paulo, São Paulo, Brazil*.
2 M.D., Department of Psychiatry,
Universidade Federal de São Paulo, São Paulo, Brazil.
3 M.D, PhD., Department of Psychiatry,
Universidade Federal de São Paulo, São Paulo, Brazil.
4 PhD, Department of Statistics,
Universidade Estadual de Londrina, Londrina, Paraná, Brazil.
5 M.D., PhD, Department of Psychiatry,
Universidade Federal de São Paulo, São Paulo, Brazil.
Honorary Visiting Professor, Health Services and Population Research
Department, Institute of Psychiatry, King’s College, University
Recebido: 21/1/2009 –
is frequent in patients with schizophrenia, it is reported as one of
the most distressing antipsychotic’s adverse effects and it is
directly related to treatment compliance. Objectives:
a) to evaluate the accuracy of the Arizona Sexual Experience Scale (ASEX)
to identify sexual dysfunction; b) to assess the frequency of sexual
dysfunction in a sample of outpatients with schizophrenia and schizoaffective
disorder under antipsychotic therapy; and c) to investigate the effect
of different antipsychotics on sexual function. Method:
Outpatients with schizophrenia or schizoaffective disorder were asked
to fulfill both the ASEX and the Dickson Glazer Scale for the Assessment
of Sexual Functioning Inventory (DGSFi) at a single interview. Results:
137 patients were interwied. The sensitivity and specificity of the
ASEX in relation to DGSFi were: 80.8%, (95% CI = 70.0%-88.5%) and 88.1%
(95% CI = 76.5%-94.7%), and the misclassification rate was 9.5%. The
ROC curve comparing the ASEX and the DGSFi scores revealed a value of
0.93 (CI = 0.879-0.970), with the optimum cut-off point of ASEX being
14/15. Sexual dysfunction measured was higher in females (79.2%) than
in males (33.3%) (2
= 27.41, d.f. = 1, p < 0.001). Discussion: Patients
under antipsychotic treatment showed a high level of sexual complaints,
and the ASEX proved to be an accurate instrument to identify sexual
dysfunction in an outpatient sample of patients with schizophrenia spectrum.
Females showed a higher frequency of sexual dysfunctions and sexual
drive and ability to reach orgasm were the most affected areas. The
use of antipsychotics, especially the combinations, was more likely
to impair sexual functioning.
Nunes LVA, et al. / Rev Psiq Clín. 2009;36(5):182-9
Keywords: Schizophrenia, sexual
dysfunction, antipsychotics, ASEX.
sexual é frequente entre pacientes com esquizofrenia, sendo relatada
como um dos mais incômodos efeitos adversos dos antipsicóticos,
e está diretamente relacionada com adesão ao tratamento.
a) avaliar a acurácia da Escala de Experiência Sexual do
Arizona (ASEX) para identificar a disfunção sexual; b)
avaliar a frequência da disfunção sexual em uma
amostra de pacientes do espectro da esquizofrenia em tratamento com
antipsicóticos; e c) investigar o efeito dos diferentes antipsicóticos
na função sexual. Método: Pacientes
ambulatoriais com esquizofrenia ou transtorno esquizoafetivo foram entrevistados
por meio de questionários: ASEX e escala Dickson-Glazer (DGSFi)
para avaliação do funcionamento sexual, em uma única
entrevista. Resultados: Cento e trinta e sete pacientes foram entrevistados.
A sensibilidade e a especificidade da ASEX em relação
à DGSFi foram: 80,8% (95%
IC = 70,0%-88,5%) e 88,1% (95% IC = 76,5%-94,7%), e a taxa de classificação
incorreta foi 9,5%. A curva ROC comparando a pontuação
da ASEX e da DGSFi revelou valor de 0,93 (IC = 0,879-0,970) com o ponto
de corte da ASEX encontrado sendo 14/15. A disfunção sexual
foi mais alta entre as mulheres (79,2%) que nos homens (33,3%) (2
= 27,41, gl = 1, p < 0,001). Conclusão: Os
pacientes em tratamento com antipsicóticos mostraram alta frequência
de queixas sexuais e a ASEX provou ser um instrumento eficaz para identificar
disfunção sexual em amostra de pacientes ambulatoriais
do espectro da esquizofrenia. As mulheres apresentaram frequência
mais alta de disfunção, e desejo sexual e habilidade para
alcançar orgasmo foram as áreas mais afetadas. O uso de
antipsicóticos, principalmente o uso de combinações,
foi associado com piora do funcionamento sexual.
Nunes LVA, et al. / Rev Psiq Clín. 2009;36(5):182-9
Palavras-chaves: Esquizofrenia, disfunção sexual,
Long term treatment is indicated for all patients
with schizophrenia1. Antipsychotic
drugs can be of great benefit for a wide range of psychotic disorders,
although treatment can be associated with potential and unpleasant adverse
effects2. Antipsychotic drugs
may restore sexual desire lost for patients with schizophrenia, but
they can also impair the patient’s sexual performance3-5.
Antipsychotics can cause sexual dysfunction through multiple mechanisms,
including sedation, hyperprolactinaemia (wich can cause sexual dysfunction
directly and indirectly by causing secondary hypogonadism) and antagonism
of a-adrenergic, dopaminergic, histaminic and muscarinic receptors2.
Moreover, there are many other factors that may cause sexual problems
for patients with schizophrenia, including concomitant medications,
the effect of the disease itself, comorbidity with other psychiatric
disorders and various endocrine, vascular or genitourinary diseases6.
Negative symptoms of the disorder, such as anhedonia, avolition and
blunted affect related to hypodopaminergic activity in the frontal cortex,
severely harm the ability to enjoy sexual life. These patients face
difficulties in establishing relationships due to recurrent psychotic
episodes, obesity and low self-steem7.
It is noteworthy that a recent study conducted by Plevin et al.8 reported
that 73% of men presented complaints in at least one area of antipsychotic-induced
sexual dysfunction: a) erectile, ejaculatory, and orgasmic dysfunction9-16
b) low sexual desire11,13-16
and c) priapism12. Although fewer studies have been conducted with females,
there is evidence of sexual dysfunctions in the following areas: a)
lack of orgasm11,13,17,18 b)
low lubrification13,19 c) loss
of libido14,19 and d) amenorrhea11.
Sexual dysfunctions induced by antipsychotic treatment can be responsible
for non-adherence to treatment20
and non compliance is one of the main obstacles to an adequate control
of the symptoms present in patients with schizophrenia2. Moreover, sexual
dysfunction is rated as one of the most distressing adverse effects
of antipsychotic treatment22,23
and experienced by patients as significantly more distressing than sedation,
or extrapyramidal side effects22.
At present, there are three scales available to asses sexual dysfunctions
in patients under antipsychotic treatment: a) the Dickson and Glazer
Scale for the Assessment of Sexual Functioning Inventory (DGSFi)24;
b) the Arizona Sexual Experience Scale (ASEX)25,
c) the Psychotropic-Related Sexual Dysfunction (PRSexDQ-SALSEX)26.
Unlike the more traditional and lengthy scales for assessing sexual
dysfunctions, the ASEX can be completed in approximately 5 minutes27
and it was designed to be self- or clinician-administered. In addition,
the ASEX questionnaire can be used for heterossexual and homossexual
populations, as well as for those without sexual partners28.
Antipsychotic-induced sexual dysfunctions are poorly recognized, and
not properly investigated by most clinicians29.
Thus, it is very important to have accurate tools to aid clinicians
in the diagnosis of antipsychotic-induced sexual dysfunctions28.
The main aims of this paper are threefold: a) to evaluate the accuracy
of the ASEX to identify sexual dysfunction; b) to assess the frequency
of sexual dysfunction in a sample of outpatients with schizophrenia
and schizoaffective disorder under antipsychotic therapy; and c) to
investigate the effect of different antipsychotics on sexual function.
A cross-sectional study of sexual function was
conducted with 1-year consecutive outpatients from the Schizophrenia
Program of the Universidade Federal de São Paulo (Proesq), from
February 2007 to January 2008. The study was submitted and approved
by the Ethics Committee of the Universidade Federal de São Paulo,
and participants signed a written informed consent to participate. Eligible
subjects recruited were stabilized outpatients who met DSM-IV criteria
for schizophrenia and schizoaffective disorder under antipsychotic therapy
for at least four weeks. The patients were currently receiving a fixed
dose of a first- or second-generation antipsychotic (risperidone was
analyzed separately since it is an antipsychotic that frequently causes
hyperprolactinaemia), or a combination of first- and second-generation
antipsychotics, or a combination of antipsychotics and antidepressants.
Patients consecutively attending the outpatient clinic were asked to
fulfill a questionnaire comprising information on social and demographic
characteristics, clinical symptoms, pharmacologic treatment, substance
use disorders, sexual function, presence of partner, and time of disease
onset, followed by the application of the ASEX and the DGSFi.
The DGSFi was developed by Ruth Dickson and Willian Glazer in the University
of Calgary, Canada, to assess sexual dysfunctions in patients suffering
from schizophrenia spectrum disorders. It is a computerized assessment,
categorical and qualitative, of sexual functioning and was developed
to be easy for the researcher to obtain detailed information reducing
embarrassment and discomfort for patients. The DGSFi is a computerized
self-report questionnaire of sexual functioning with parallel versions
developed for males (32 questions) and females (41 questions). It is
a multiple choice questionnaire aiming to assess sexual activity frequency,
desire, arousal, and orgasm for both solitary and partner sexual activities
and perceptions of medication side effects for the prior 2 weeks24.
A Brazilian version of the DGSFi was adapted and used by Costa et
al.30 to compare the frequency
of sexual dysfunction between first-generation antipsychotic treatment
The ASEX was developed by McGahuey et al. in the University
of Arizona in response to the need for evaluating psychotropic drug-induced
sexual dysfunction. Initially, the scale was tested to assess sexual
dysfunction among selective serotonin reuptake inhibitor (SSRI)-treated
subjects25 and end-stage renal
disease31. Byerly et al.
tested the psychometric properties of ASEX in patients with schizophrenia
and schizoaffective disorder and demonstrated that ASEX represents an
easy-to-administer tool for assessing sexual dysfunction in this population28.
The ASEX is a brief 5-item questionnaire designed to measure sexual
functioning in the following domains: sexual drive, arousal, penile
erection/vaginal lubrification, ability to reach orgasm, and satisfaction
with orgasm over the past week25.
Items are rated on a 6-point scale ranging from 1(hyperfunction) through
to 6 (hypofunction), providing a total score range between 5 and 30.
A total score > 18, or a score
5 (very difficult) on any single item or any three items with
4 is indicative of clinically significant sexual dysfunction.
The sociodemographic and clinical characteristics of the sample can
be seen in table 1. The sample was comprised of 137 patients, with an
excess of males (61.3%). The mean age of the sample was 37 ±
10.3 years. Most patients were Caucasians (62.0%), with a mean of 11.6
± 4.1 years of schooling. Most patients were unemployed (78.1%).
Most patients were single (82.6% men and 78.4% women), and only few
patients (2.9%) were married (3.5% of men and 2% of women), or had a
stable partner (9.3% of men and 3.9% of women). The mean duration of
illness was 14.4 ± 9 years, with no difference between sexes.
Patients on second-generation antipsychotics (without risperidone) corresponded
to 46.7% (n = 64) of the sample and patients on first-generation antipsychotics
corresponded to 16.1% (n = 22). Risperidone was used by 14 patients
(10.2%). Combination of antipsychotics was taken by 13 patients (9.5%)
and combined antipsychotics and antidepressants were prescribed to 24
All the patients (n = 137) filled both questionnaires (ASEX and DGSFi).
The internal consistency of the ASEX was estimated by means of the Cronbach’s
and mean Pearson’s correlation for the five ASEX items was 0.47.
Table 2 displays the distribution of the ASEX scores against the DGSFi
scores. As it can be seen in Table II, sensitivity was 80.8% (95% CI
= 70-88.5), specificity was 88.1%(95% CI = 76.5-94.7), predictive positive
value (PPV) was 90% (95% CI = 79.9-95.5), and negative predictive value
(NPV) was 77.6% (95% CI = 65.5-86.5). The misclassification rate was
9.5%. As it can be seen in figure 1 the comparison between the ASEX
and the DGSFi scores resulted in an area under the curve value of 0.93
± 0.021 (95%
CI = 0.88-0.97, p = 0.0001). The ASEX cut-off point for sexual dysfunction
was found to be 14/15.
Table 3 displays the distribution of penile erection or vaginal lubrification
dysfunction according to type of treatment. The highest percentage of
dysfunction occurred for patients under the combination of antipsychotics
(61.5%), followed by combined antipsychotics and antidepressants (50%).
Patients under second-generation antipsychotics presented a higher probability
of dysfunction (28.1%) than those under first-generation antipsychotics
(13.6%), the difference being statistically significant (Fisher’s
exact test, p = 0.00108).
For the ASEX items sexual drive, arousal, and satisfaction, there were
no statistical differences across treatments.
Table 4 displays the distribution of sexual dysfunction between genders
across the pharmacological interventions. Sexual dysfunction measured
by ASEX was higher in females (79.2%) than in males (33.3%), and the
difference was statistically significant (chi-square = 27.41, d.f. =
1, p < 0,001). The mean ASEX scores for females (19.53 ± 5,69)
was higher than those found for males (13.71 ± 5.78), and this
difference was statistically significant (t = 5.77, d.f. = 1, p <
0,001). Females were more likely to have higher difficulty in sexual
drive than males when using medications, the difference being statistically
significant (Fisher’s exact test,
p = 0.0131). Moreover, females had higher probability of dysfunction
in reaching orgasm than males when under pharmacological interventions,
the difference being statistically significant (Fisher’s exact
test, p = 0.0225). The distribution of sexual dysfunction by gender
in the ASEX scores can be seen in table 5. Sexual functions as sexual
= 19.38, d.f. = 1, p < 0.001), sexual arousal (2
= 14.29, d.f. = 1, p < 0.001), orgasm (2
= 26.17, d.f. = 1, p < 0.001) and satisfaction with orgasm (2
= 12.26, d.f. = 1, p < 0.001) occurred in higher frequency in females
than in males, and these differences were all statistically significant.
The ASEX questionnaire proved to be an accurate
instrument to identify sexual dysfunction when compared to the validity
of the DGSFi questionnaire. Sensitivity and specificity were fairly
high at a c.o. p. = 14/15. It is a friendly self-administered questionnaire,
which takes a few minutes to be completed and is appropriate for individuals
with or without stable sexual partners and for heterossexual or homossexual
patients27,28. It was decided
to use the DGSFi questionnaire as a gold standard because it was the
only one adapted for a Brazilian social and cultural context. The DGSFi
was applied by Costa et al. 30 to compare the frequency of sexual dysfunction
among patients with schizophrenia between first-generation antipsychotic
treatment and olanzapine. DGDFi is a detailed and length self-report
scale with 32 questions to assess sexual functioning for males and 41
questions for females in respect to sexual activity frequency, desire,
arousal and orgasm and perceptions of medications side effects in the
prior 2 weeks. Unlike the more traditional and lengthy scales for assessing
sexual dysfunctions, the ASEX can be completed in approximately 5 minutes27,
it is a brief 5-item questionnaire designed to measure sexual functioning
in the following domains: sexual drive, arousal, penile erection/vaginal
lubrification, ability to reach orgasm, and satisfaction with orgasm
over the past week25 .
The frequency of sexual dysfunctions was very high, a finding consistent
with previous studies conducted in different countries6,11,15,32-35.
Females had a much higher rate (79.2%) than males (33.3%). Indeed, females
reported high frequencies of sexual dysfunctions in all stages of sexual
activities (sexual drive, arousal, vaginal lubrification, ability to
reach orgasm and satisfaction with orgasm). This difference between
genders can be attributed to biopsychossocial factors, in special: sexual
hormones (estrogens × androgens), sexual education (repressing
× permissive), environment (controlling × stimulant)36.
Patients under second-generation antipsychotics had a higher probability
of dysfunction (28.1%) than those under first-generation antipsychotics
(13.6%). Antipsychotic medications were associated to disturbance on
penile erection and vaginal lubrication reported in ASEX questionnaire
and had scores ranging progressively for first-generation antipsychotics
(13.6%), second-generation antipsychotics without risperidone (28.1%),
risperidone (21.4%), combination of antipsychotics (61.5%), or combination
of antipsychotics and antidepressants (50%).
Although new second-generation antipsychotics were expected to be associated
with a lower incidence of sexual dysfunction as compared with first-generation
other studies have not confirmed these findings6,15,22,30.
Increased prolactin levels are believed to play a major role in sexually
induced side effects, but the underlying mechanism of antipsychotic
agent-induced sexual dysfunction remains poorly understood45.
Contrary to the fact that the causes for sexual dysfunction of antipsychotics
were exclusively secondary to hyperprolactinemia, is that clozapine
produced little or no change on serum prolactin concentration46,
but high rates of sexual side effects in a prospective drug monitoring
program47. Because of the scarcity
of comparative studies, conflicting data and methodological issues,
the interpretation of the findings of antipsychotics leading to sexual
dysfunctions are inconclusive2.
In our study, the pharmacological interventions were different between
genders: women under long-term treatment with antipsychotics, especially
with combinations of antipsychotics or antipsychotics and antidepressants,
had significantly more sexual dysfunction in the items related to sexual
drive (p = 0.0131) and orgasm (p = 0.0225); men had no significant difference
between the items when analyzed separately. This difference may be explained
because women are clearly more sensitive than men to the effects of
antipsychotics on prolactin48-50.
In a 6-week study, 63% of haloperidol-treated men, compared with 98%
of haloperidol-treated women had a prolactin level above the upper limit
of normal48. There are few systematic data available regarding the frequency
of impaired sexual interest or function with antipsychotic treatment,
and almost all studies are cross-sectional51.
Although less research on this subject has been conducted in women than
in men with schizophrenia, there is evidence that sexual and hormonal
dysfunction is also commom in antipsychotic-treated women. In addition,
33% of women complained of change in quality of orgasm in a cross-sectional
study52. One study comparing
sexual side effects in patients treated with haloperidol and clozapine
found similar proportions treated with both antipsychotics and reported
decreased sexual desire in 28-33% of women47.
Another study examining sexual function in women treated with typical
antipsychotics found a similar proportion (22%), reporting decreased
ability to achieve orgasm with antipsychotic treatment17.
There is a need of sexual dysfunction studies including women. Many
clinical studies have tended to enlist few women or have excluded them
altogether53. Women may underreport
the frequency of sexual side effects because they are embarassed to
discuss this topic. There is a naturalistic study of galactorrhea incidence
in women treated with typical antipsychotics, 20 of 28 women who developed
galactorrhea failed to spontaneously report this side effect on general
inquiry by treating physician about medication side effects54,
so it is important to develop scales that let women confortable to discuss
This study had some limitations that should be considered when interpreting
the data. First, all patients were recruited with ages ranging from
20 to 66 years. The sexual dysfunction worsens with age since 39% of
40-year-olds have some degree of erectile dysfunction (5% are completely
impotent), but by the age of 70, two thirds have some degree of erectile
dysfunction and complete impotence triples to 15%55. Second, in this
study there were no exclusion criteria such as comorbid depressive syndrome
or diabetes, treatment with antidepressants, use of alcohol or cigarette
smoking, and thyroid problems. This is not a longitudinal study, and
there were no measurements of the effects of the illness on sexual functioning
prior to medication treatment. Since this is a croos-sectional study,
sexual dysfunction was evaluated at a single time point during the patients’
drug therapy and no baseline sexual dysfunction was determined; therefore,
there was no distinction between drug-induced or other causative factors.
Because of the small sample size it was not possible to draw conclusions
regarding cause and effects and possible relationship of antipsychotic
doses. However, it is known that the side effects of certain drugs are
Schizophrenic patients have a certain level of sexual life that cannot
be ignored by physicians. When patients are stable, they want to maintain
their sexual life. Because of the high rates of sexual dysfunction,
psychiatrists should pay more attention and ask specific questions about
their patients’ sexual life in routine clinical practice. Structured
scales can be useful to diminish the embarrassment and discomfort for
patients and physicians when this issue is raised. Controlled studies
should directly inquire about sexual side effects and investigate how
such side effects alter medication compliance and quality of life. The
development of reliable and valid detailed side effect rating scales
for use in research trials and in clinical encounters, such as the ASEX
and DGSFi, should help to further elucidate data on sexual side effects53.
A study showed that the prevalence of sexual dysfunction associated
with quetiapine or risperidone was 11.7% based on spontaneous reports,
but increased to 32% when assessed using a semi-structured interview34.
Thus, use of structured scales can yield a higher incidence of sexual
dysfunction. There is a need of studies on multifactorial etiology of
sexual dysfunction. Studies need to account for individual variation
in what constitutes normal sexual functioning and confounding factors
that can affect sexual functioning2.
These include differences between genders, alcohol and tobacco use,
relationship difficulties, co-prescribed medications and other clinical
or psychiatric symptoms. Sexual dysfunctions are different between males
and females with schizophrenia and further research on this area should
be conducted to clarify this complex subject. This study showed that
the combination of medications (two or more kinds of antipsychotics
and antipsychotics and antidepressants) leads to high rates of sexual
dysfunctions; therefore, trying to use antipsychotic in monoterapy or
lower doses, whenever possible, would be of great benefit to the patient
in terms of achieving a healthier sexual life.
Since sexual dysfunction has high prevalence in patients with schizophrenia
spectrum, psychiatrists’ awareness and sensitivity regarding this
important side effect and choosing the correct treatment would contribute
to a better quality of life for these patients.
The authors thank Anna Maria Niccolai Costa for
her assistence throughout the study. JJM is a Level I Brazilian National
Researcher (CNPq), currently on sabbatical leave funded by the Brazilian
Ministry of Education (Capes), in the Institute of Psychiatry, King’s
College, University of London.
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