Journal of Sex & Marital Therapy

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The Arizona Sexual Experience Scale (ASEX):

Reliability and Validity
Cynthia A. McGahuey, Alan J. Gelenberg, Cindi A. Laukes, Francisco A.
Moreno, Pedro L. Delgado, Kathy M. McKnight, Rachel Manber
To cite this article: Cynthia A. McGahuey, Alan J. Gelenberg, Cindi A. Laukes, Francisco A.
Moreno, Pedro L. Delgado, Kathy M. McKnight, Rachel Manber (2000) The Arizona Sexual
Experience Scale (ASEX): Reliability and Validity, Journal of Sex & Marital Therapy, 26:1, 25-40,
DOI: 10.1080/009262300278623
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Published online: 02 Feb 2011.

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Journal of Sex & Marital Therapy, 26:2540, 2000

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Th e Arizon a Sex ual Ex perien ce Scale (ASEX):

Reliability an d Validity
CYNTHIA A. MCGAHUEY, ALAN J. GELENBERG, CINDI A. LAUKES,
FRANCISCO A. MORENO, and PEDRO L. DELGADO
Department of Psychiatry, College of Medicine, The University of Arizona,
Tucson, Arizona, USA

KATHY M. MCKNIGHT
Department of Psychology, University of Arizona, Tucson, Arizona, USA

RACHEL MANBER
Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA

Although sexual dysfunction is common in psychiatric patients,

quantification of sexual dysfunction is limited by the paucity of
validated, user-friendly scales. In order to address this problem, the
authors have developed the Arizona Sexual Experiences Scale
(ASEX), a five-item rating scale that quantifies sex drive, arousal,
vaginal lubrication/penile erection, ability to reach orgasm, and
satisfaction from orgasm. Possible total scores range from 5 to 30,
with the higher scores indicating more sexual dysfunction. This
study assesses the internal consistency, testretest reliability, and
convergent and discriminant validity of the ASEX.

Many studies have revealed high prevalence rates of sexual dysfunction in

individuals suffering from major depression (Mathew & Weinman, 1982;
Howell, Reynolds, Thase, Frank, Jennings, Houck, Berman, Jacobs, & Kupfe,
We thank Les Lesman, M.D., John Misiaszek, M.D., and the staff at the front desk in the
University Medical Center psychiatric outpatient clinic for their help in distributing ASEX
packets. We would further like to thank Mark Borgstrom, Ph.D., for his assistance in the
ASEX analyses; Renee Collins, Marcy Watchman, Donna Dewitt, Judy Stewart, M.S.N., and
Pat Joyce-Collins, R.N., B.S.N., for their clinical expertise; Linda Richardson for her accounting skills; Laurie Deurloo, Char Powell, and Roberta Lippse for their administrative support;
and Lynda Zentner, R.N., for her assistance with legal issues.
Address correspondence to Cynthia A. McGahuey, Department of Psychiatry, College
of Medicine, The University of Arizona, 1501 N. Campbell Ave., Rm. 7303, Tucson, AZ
85724, USA. E-mail: [email protected] u
25

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26

C. A. McGahuey et al.

1987; Reynolds, Frank, Thase, Houck, Jennings, Howell, Lilienfeld, & Kupfer,
1988; Herman, Brotman, Pollack, Falk, Biederman, & Rosenbaum, 1990;
Segraves, 1992; Wise, 1992). Mathew and Weinman (1982) reported a 47%
rate of sexual dysfunction among a sample of depressed subjects. More recent studies involving pharmacological treatment of depression suggest that
selective serotonin reuptake inhibitors (SSRIs) lead to a significant degree of
treatment-emergent sexual dysfunction (e.g., delayed orgasm or anorgasma,
decreased libido and interest), with rates ranging from 8% (Herman, Brotman,
Pollack, Falk, Biederman, & Rosenbaum, 1990) to as high as 73% (Piazza,
Markowitz, Kocsis, Leon, Portera, Miller, & Adler, 1997) compromising treatment compliance (Jacobsen, 1992) and quality of life. These observations
have generated considerable interest in improving methods of evaluating
and alleviating SSRI-induced sexual dysfunction.
There are several unidimensional self-report measures available for assessing sexual dysfunction, all with some advantages and limitations. The
Sexual Evaluation Scale (SES) (Othmer & Othmer, 1987) is a 16-item scale
that addresses the global factors of sexual interest, arousal, and performance
but does not address the factors of sexual drive and satisfaction. The Brief
Index of Sexual Functioning (BISF) (Taylor, Rosen, & Leiblum, 1994) adapted
from the Brief Sexual Function Questionnaire (BSFQ) (Reynolds, Frank, Thase,
Houck, Jennings, Howell, Lilienfeld, & Kupfer, 1988), which is a revision of
the Sexual Function Questionnaire (SFQ) (Howell, Reynolds, Thase, Frank,
Jennings, Houck, Berman, Jacobs, & Kupfe, 1987), is more lengthy (2223
questions). All of these scales may be used during initial assessment and/or
other major timepoints in the course of a study (i.e., exit from study). However, they are time-consuming and include clinically irrelevant information
for the weekly assessment of sexual dysfunction. These scales also contain
sexually explicit questions that could contribute to patient noncompliance
(Herman, Brotman, Pollack, Falk, Biederman, & Rosenbaum, 1990).
The Sexual Symptoms Distress Index (SSDI) (Croog, Levine, Testa, Brown,
Bulpitt, Jenkins, Klerman, & Williams, 1986), adapted from a questionnaire
initially designed by Hogan, Wallin, & Baer (1980) is more brief and less
intrusive in its design than the SES, BISF, or the DSFI, yet it does not contain
specific measures for sexual drive and sexual satisfaction.
In response to the need for developing a more pertinent, expedient,
and less intrusive method for evaluating psychotropic druginduced sexual
dysfunction and changes in sexual dysfunction, the authors have designed a
brief five-question scale called the Arizona Sexual Experiences Scale (ASEX)
(see Appendix ) (McGahuey, Gelenberg, Laukes, Manber, McKnight, Moreno,
& Delgado, 1997). The ASEX is designed to assess five major global aspects
of sexual dysfunction: drive, arousal, penile erection/vaginal lubrication, ability
to reach orgasm, and satisfaction from orgasm. All of these are domains most
commonly impaired by psychotropic dugs (Mathew & Weinman, 1982; Howell,
Reynolds, Thase, Frank, Jennings, Houck, Berman, Jacobs, & Kupfe, 1987;

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Reliability and Validity of the ASEX

27

Segraves, 1992; Wise, 1992; Othmer & Othmer, 1987; Derogatis & Melisaratos,
1979).
The purpose of this study is to test the internal consistency, testretest
reliability, and convergent and discriminant validities of the ASEX in assessing sexual dysfunction among SSRI-treated subjects. Preliminary validity and
reliability data were presented at the 150th annual meeting of the American
Psychiatric Association (McGahuey, Gelenberg, Laukes, Manber, McKnight,
Morena, & Delgado, 1997) and at the 38th annual meeting of the New Clinical Drug Evaluation Unit Program (McGahuey, Gelenberg, Laukes, Manber,
McKnight, Morena, & Delgado, 1998).

METHOD
Development of the Measure
The ASEX scale is designed to measure five specific items identified in a
comprehensive literature review as the core elements of sexual function:
sexual drive, arousal, penile erection/vaginal lubrication, ability to reach
orgasm, and satisfaction from orgasm (Mathew & Weinman, 1982; Howell,
Reynolds, Thase, Frank, Jennings, Houck, Berman, Jacobs, & Kupfe, 1987;
Segraves, 1992; Wise, 1992; Piazza, Markowitz, Kocsis, Leon, Portera, Miller,
& Adler, 1997; Othmer & Othmer, 1987; Derogatis & Melisaratos, 1979). It
measures them in a relatively nonintrusive bimodal fashion, using a 6-point
Likert scale ranging from hyperfunction (1) to hypofunction (6). An openended comment line is included for individual concerns and feedback. The
male and female versions differ on the third question, which corresponds to
penile erection/vaginal lubrication. Three ASEX questions related to arousal,
erection/lubrication, and ability to reach orgasm were adapted from previous work (Prisant, Carr, Bottini, Solursh, & Solursh, 1994).
The ASEX was designed to be self- or clinician-administered, and it is
for use in heterosexual or homosexual populations, regardless of availability
of a sexual partner. Questions addressing frequency/preference of sexual
activity were considered unrelated to sexual dysfunction.
The ASEX was designed to be simple in order to enhance the overall
accuracy in measuring sexual dysfunction by (a) minimizing patient noncompliance with rating (Prisant, Carr, Bottini, Solursh, & Solursh, 1994), and
(b) allowing for rapid quantification and detection of the presence of sexual
dysfunction.

Survey Packet
Male and female judges selected from the psychiatry research program at the
University of Arizona Health Sciences Center evaluated face validity of all
scales to be used in the current study. This led to the selection of the final

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28

C. A. McGahuey et al.

instruments. The final survey packet included the ASEX, the modified version of the Brief Index of Sexual Functioning (BISF) (Reynolds, Frank, Thase,
Houck, Jennings, Howell, Lilienfeld, Kupfer, 1988; Taylor, Rosen, & Leiblum,
1994), the Beck Depression Inventory (BDI) (Hamilton, 1960), or the Hamilton
Depression Rating Scale (HDRS) (Beck, Steer, Ball, & Ranieri, 1996), and a
brief eight-item demographic and health questionnaire assessing subjects
age, ethnicity, educational level, health status, use of medications (available
on request from authors), and global perception of sexual dysfunction. Patients were administered the HDRS by trained research clinicians who had
established reliability on the HDRS. Anonymity of healthy subjects was maintained by replacing the clinician-rated HDRS with the self-rated BDI.
The modified female and male versions of the BISF included all items
originally used in factor analyses of the BISF, revealing three major constructs: Factor 1 Sexual Performance/Activity, Factor 2 Satisfaction from Sex
Life, and Factor 3 Sexual Interest/Desire (Reynolds, Frank, Thase, Houck,
Jennings, Howell, Lilienfeld, & Kupfer, 1988; Taylor, Rosen, & Leiblum, 1994).
The accuracy of patient self-ratings of sexual dysfunction was verified
with a four-item Gold Standard Clinician Rating scale (GSR, available on
request from authors), which was developed by the authors and administered at each time interval. The GSR was administered during a semistructured
brief interview by a research clinician. The interview focused on specific
elements of sexual activity and satisfaction, including sexual interest, frequency of arousal, sexual performance and global satisfaction. The clinician
was asked to categorically rate the presence of sexual dysfunction and make
a determination as to whether, if present, it was due to antidepressants,
secondary to depression, or due to other factors.

Subjects
ASEX packets were given to 107 control subjects (hospital employees, staff,
residents, and faculty of the University of Arizona) and 58 psychiatric patients
participating in one of several ongoing research projects. All subjects were aged
18 years and older. Demographic characteristics for healthy and psychiatric
subjects are presented in Table 1.

Procedures
All subjects were provided with a written description of the study and its
objectives. Subjects gave informed consent to participate, and the study was
approved by the University of Arizona Human Subjects Committee.
Healthy subjects received a set of two survey packets of numbered
rating scales corresponding to each time interval. Anonymity was maintained
through a random labeling process to ensure that the investigators would
not know which specific person received a particular study number.

29

Reliability and Validity of the ASEX

TABLE 1. Subject Demographic Characteristics

PATIENTS

Female 45
N = 35 (14.01)
Male
50
N = 23 (13.03)

49%

66%

80%

20%

94%

69%

65%

70%

86%

13%

96%

74%

CONTROLS

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%
%
%
% Receiving
% with
College
%
Diagnosed Diagnosed Antidepressant Sexual
Age Educated Caucasian with MDE with Anxiety
Therapy
Difficulty

Female 38
N = 22 (10.88)
Male
38
N = 16 (10.81)

68%

91%

18%

0%

4%

18%

88%

63%

6%

0%

6%

0%

Note. Values in parentheses represent standard deviations from the mean. MDE = Major Depressive
Episode.

Psychiatric patients were asked to fill out rating packets at initial entry
into the research program and again 1 to 2 weeks later.

Statistical Methods
Internal consistency of the ASEX scale, a measure of scale reliability, was
assessed using Cronbachs alpha analysis. Cronbachs alpha is an index of
correlation among items on a scale. To determine the testretest reliability of
the ASEX, bivariate correlations were performed of total ASEX scores obtained at an initial administration and again 1 to 2 weeks later. In order to
assess the convergent validity of the ASEX, bivariate correlations were performed between ASEX item scores and the BISF factor scores as well as
selected BISF items having similar face value with the ASEX items. Discriminant validity of the ASEX was assessed by performing bivariate correlations
between ASEX scores and ratings of depression on the HDRS or BDI.
The literature suggests that psychiatric patients report more sexual dysfunction than healthy controls (Mathew & Weinman, 1982; Howell, Reynolds,
Thase, Frank, Jennings, Houck, Berman, Jacobs, & Kupfe, 1987; Reynolds,
Frank, Thase, Houck, Jennings, Howell, Lilienfeld, & Kupfer, 1988; Herman,
Brotman, Pollack, Falk, Biederman, & Rosenbaum, 1990; Segraves, 1992;
Wise, 1992), and that there could be gender differences in the responses to
individual ASEX items (Piazza, Markowitz, Kocsis, Leon, Portera, Miller, &
Adler, 1997). If the ASEX has strong concurrent validity, then significant
differences in ASEX scores between these groups would be expected. To
determine the concurrent validity of the ASEX, analyses of variance (ANOVAs)
were performed to compare patients to controls on total ASEX score and
females to males on individual ASEX item scores.
Based on preliminary experience with the ASEX, as well as on predictions based on the actual design of the scale, we hypothesized that a subject

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30

C. A. McGahuey et al.

with a total ASEX score of > 19, any one item with a score of > 5, or any three
items with a score of > 4 would have sexual dysfunction. These criteria were
used in subsequent analyses to define whether subjects met ASEX criteria for
sexual dysfunction.
In order to determine whether the ASEX criteria accurately reflect sexual
dysfunction (determined by GSR rating or self-report), positive and negative
predictive value (PPV and NPV), and sensitivity and specificity were measured (Hennekens & Buring, 1987). PPV reflects the percentage of individuals who meet ASEX criteria for sexual dysfunction and actually self-report
sexual dysfunction. NPV reflects the percentage of individuals who do not
meet ASEX criteria for sexual dysfunction and do not self-report sexual dysfunction.
In order to determine how well the total ASEX score would separate
individuals with sexual dysfunction from those without, a Receiver Operating Characteristic (ROC) analysis was performed. This involved a plot of the
true-positive and false-positive values resulting from the use of various ASEX
total score categories (e.g., ASEX total score 5, 7, 9, 11, and so forth) to
define presence of sexual dysfunction. In all cases, the subjects self-report
of sexual dysfunction or GSR was used to define the true rate of sexual
dysfunction. The area under the curve (AUC) of this plot was calculated. A
ROC analysis of the BISF also was performed (for this analysis the BISF
factors were used) (Reynolds, Frank, Thase, Houck, Jennings, Howell,
Lilienfeld, & Kupfer, 1988; Taylor, Rosen, & Leiblum, 1994), and AUC values
for both scales then were compared. All statistical tests were two-tailed, and
results were considered significant when p < .05. The cutoff categories for
both ASEX and BISF ROC analyses were arbitrarily determined.

RESULTS
Demographic Characteristics
For the controls, 107 packets were distributed and 38 were returned. All
patients filled out the ASEX and were administered the Hamilton Depression
Rating Scale (HDRS). Of the healthy subjects, four women self-reported a
current major depressive episode (MDE), however, their depression ratings
did not reflect this (BDI < 11). One male control self-reported a substanceabuse disorder. One female and one male control currently were using antidepressants. Of the psychiatric subjects, 86% of men and 80% of women had
been currently diagnosed with an MDE. Thirteen percent of men and 20% of
women were currently diagnosed with Panic Disorder. One male patient
(measures were taken anonymously) did not disclose his type of psychiatric
disorder.

Reliability and Validity of the ASEX

31

Reliability
Results from Cronbachs alpha analysis indicated that the ASEX demonstrated
excellent internal consistency and scale reliability (alpha = .9055). The ASEX
also demonstrated strong testretest reliability (for patients, r = .801, p < .01,
for controls, r = .892, p < .01).

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Validity
The items on the ASEX correlated with BISF factors and related items on the
BISF as reported in Tables 2 and 3, but not with depression score.
ANOVAs revealed significant differences on total ASEX scores between
patients and controls (for males F = 18.1, p < .000; for females F = 31.71, p <
.000) and between females and males (for patients F = 5.22, p = .026; for
controls F = 5.05, p = .031). ANOVAs further revealed significant gender
differences for patients on ASEX items drive and arousal (F = 4.69, p = .035
and F = 5.88, p = .019, respectively) and a trend on ASEX item ability to reach
orgasm (F = 3.72, p = .059). For controls, there were trends for gender differences on ASEX items drive, arousal, and ability to reach orgasm (F = 3.57, p
= .067; F = 3.51, p = .069; and F = 3.83, p = .058, respectively). In all cases,
women scored higher than men (Figure 1).

FIGURE 1. Comparison of ASEX item scores between subjects (ASEX = Arizona Sexual
Experiences Scale). Possible scores for each item range from 1 (hyperfunction) to 6
(hypofunction). Each of the four variably shaded bars represents one of the four subject
groups (female patients, male patients, female controls, male controls). Values shown at the
ends of the bars represent mean ASEX item scores for each subject group.

.457**, N=34
.213, N=22

.041, N=34
.472*, N=22

.044, N=34
.335, N=22

Vagin al
Lubr ication

Or gas m

Satis factio n
fr o m Or gas m

.381*, N=34
.179, N=22

.021, N=34
.057, N=22

.064, N=34
.102, N=22

.254, N=34
.252, N=22

.031, N=34
.123, N=22

.032, N=34
.082, N=22

.381*, N=34
.279, N=22

.049, N=34
.238, N=22

.270, N=34
.073, N=22

.079, N=34
.046, N=22

.297, N=34
.039, N=22

.251, N=34
.082, N=22

Satisfaction Interest/
From Sex Life Desire

BISF FACTORS

.213, N=33
.448*, N=22

.119, N=33
.503*, N=22

.359*, N=33
.219, N=22

.507**, N=33
.520*, N=22

.663**, N=33
.365, N=22

Thoughts

Arousal

.026, N=34
.349, N=22

.082, N=34
.442*, N=22

.508**, N=34
.298, N=22

.577**, N=34
.525*, N=22

.047, N=34
.289, N=22

.013, N=34
.452*, N=22

.411*, N=34
.099, N=22

.448**, N=34
.519*, N=22

.697**, N=34 .562**, N=34

.388, N=22
.428*,N=22

Desire

.094, N=34
.147, N=22

.179, N=34
.084, N=22

.265, N=34
.117, N=22

.179, N=34
.077, N=22

.084, N=34
.026, N=22

Vaginal
Lubrication

.218, N=34
.396, N=22

.024, N=34
.521*, N=22

.358*, N=34
.226, N=22

.318, N=34
.501*, N=22

342*, N=34
.377, N=22

Frequency
of Orgasm

RELATED BISF ITEMS

.138, N=34
.464*, N=21

.032, N=34
.612**, N=21

.307, N=34
.236, N=21

.253, N=34
.318, N=21

.254, N=34
.164, N=21

Sexual
Pleasure

.952, N=30
.071, N=22

.034, N=30
.038, N=22

.076, N=30
.073, N=22

.250, N=30
.287, N=22

.099, N=30
.031, N=22

.075, N=30
.001, N=22

HDRS/BDI

Note. Values in bold print correspond to patients. Values in normal print correspond to controls. ASEX = Arizona Sexual Experiences Scale; BISF = Brief Index of
Sexual Functioning Scale; HDRS = Hamilton Depression Rating Scale; BDI = Beck Depression Inventory.
** = Correlation is significant at the 0.01 level (2-tailed).
* = Correlation is significant at the 0.05 level (2-tailed).
1 = For BISF item Thoughts, N = 33, for HDRS with BISF Factor Activity, N = 29, and for HDRS with ASEX items and total, N = 30.
2 = For BISF item Sexual Pleasure, N = 21.

HDRS / BDI

.085, N=29
.162, N=22

.485**, N=34
.504*, N=22

Ar o us al

ASEX Total

.561**, N=34
.376, N=22

Activity/
Frequency

Driv e

ASEX Items

Patie n ts / Controls
(N=34) 1 / (N=22)2

FEMALES

TABLE 2. Correlations Between ASEX Items, BISF Items, and Depression Scores for Females

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.528*, N=20
.083, N=16

.594**, N=20
.252, N=16

.347, N=20
.465, N=16

Pe n ile
Er e ction

Or gas m

Satis factio n

.023, N=16
.215, N=16

.435, N=20
.239, N=16

.512*, N=20
.195, N=16

.378, N=20
.094, N=16

.299, N=16
.141, N=16

.306, N=20
.104, N=16

.406, N=20
.327, N=16

.465*, N=20
.777**, N=16

.385, N=20 .604**, N=20

.017, N=16
.602*, N=16

.621**, N=20 .495*, N=20

.134, N=16 .608*, N=16

.310, N=20
.069, N=16

.310, N=20
.265, N=16

.453*, N=20
.707**, N=16

.553*, N=20
.512*, N=16

.431, N=20
.481, N=16

Thoughts

.359, N=20
.285, N=16

.484*, N=20
.367, N=16

.444*, N=20
.784**, N=16

.615**, N=20
.647**, N=16

.531*, N=20
.694**, N=16

Desire

.120, N=20.
.260, N=14

.063, N=20
.547*, N=14

.011, N=20
405, N=14

Ability to
Maintain
Erection

.344, N=20
.476, N=16

.085, N=20
.226, N=14

.514*, N=20 .115, N=20 .

.185, N=16
.344, N=14

.498*, N=20
.059, N=16

.422, N=20
.014, N=16

.476*, N=20
.227, N=16

Degree of
Penile
Erection

.138, N=20
.384, N=16

.282, N=20
.021, N=16

.377, N=20
.101, N=16

.448*, N=20
.124, N=16

.413, N=20
.034, N=16

Frequency
of Orgasm

RELATED BISF ITEMS

.568**, N=20
.344, N=16

.647**, N=20
.202, N=16

.490*, N=20
.160, N=16

.563**, N=20
.179, N=16

.564**, N=20
.245, N=16

Sexual
Pleasure

.097, N=19
.278, N=16

.337, N=19
.049, N=16

.069, N=19
.402, N=16

.146, N=19
.345, N=16

.054, N=19
.200, N=16

.050, N=19
.090, N=16

HDRS/BDI

Note. Values in bold print correspond to patients. Values in normal print correspond to controls. ASEX = Arizona Sexual Experiences Scale; BISF = Brief Index of
Sexual Functioning Scale; HDRS = Hamilton Depression Rating Scale; BDI = Beck Depression Inventory.
** = Correlation is significant at the 0.01 level (2-tailed).
* = Correlation is significant at the 0.05 level (2-tailed).
1 = For HDRS with BISF factors, N = 16, and for HDRS with ASEX items and total, N = 19.
2 = For BISF item Ability to Maintain Erection, N = 14.

HDRS / BDI

.268, N=16
.133, N=16

.518*, N=20
.048, N=16

Ar o us al

ASEX TOTAL

.532*, N=20
.218, N=16

Dr iv e

ASEX Items

BISF FACTORS

Performance Satisfaction Interest/

/Activity
From Sex Life Desire

Patie n ts / Controls
(N=20) 1 / (N=16)2

MALES

TABLE 3. Correlations Between ASEX Items, BISF Items, and Depression Scores for Males

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34

C. A. McGahuey et al.

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Sensitivity, Specificity, Positive and Negative Predictive Values

Female and male patients demonstrated higher scores on the ASEX (mean =
20.3 4.8 and 17.2 5.4, respectively) than did the controls (mean = 13.5
3.9 and 10.9 2.6, respectively). GSR scores correlated 100% with the patients
belief of the presence of sexual dysfunction. The sensitivity and specificity of
the ASEX at identification of sexual dysfunction were 82% and 90%, respectively, PPV was 88%, and NPV was 85%.
ROC analysis revealed an AUC value of .929 .029 (Figure 2). The
plotted true-positive and false-positive values for the scoring criteria (total
ASEX score > 19, any one item with and individual score > 5, or any three
items with individual scores > 4) fell near the ideal point on the ROC curve
(Figure 2). ROC analysis of the BISF revealed an AUC value of .786 .050
(Figure 3). The independent area test revealed a significant difference between the two ROC curves (F = 2.4752, p = .0133).

FIGURE 2. ASEX ROC analysis (ROC = Receiver Operator Characteristics). Area under the
curve (AUC) = .929 .029; two 4s = at least two ASEX items with scores > 4; 16 with one 4
= a total ASEX score of > 16, with at least one ASEX item with a score > 4; 18 = a total ASEX
score of > 18; 19, one 5, or three 4s = a total ASEX score > 19, any one item with an
individual score > 5, or any three items with individual scores > 4. = The point corresponding
to the paired true and false positive values for the ASEX target scoring criteria determined to
be most discriminative. The higher the ROC fitted curve (smooth line), the closer the AUC
value is to 1. Higher AUC values predict greater discrimination capacity of the scale.

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Reliability and Validity of the ASEX

35

FIGURE 3. BISF ROC analysis (ROC = Receiver Operator Characteristics). Area under the
curve (AUC) = .786 .050. The higher the ROC fitted curve (smooth line), the closer the AUC
value is to 1. Higher AUC values predict greater discrimination capacity of the scale. Target
scoring criteria for the BISF were not determined in this analysis.

DISCUSSION
The current study demonstrates that the ASEX has internal consistency and is
a reliable, valid, and sensitive tool for measuring sexual dysfunction. In addition, the ASEX has certain advantages over other, more lengthy, scales.
The questions are short, easy to understand, and less intrusive than questions typically found in more traditional tools (Reynolds, Frank, Thase, Houck,
Jennings, Howell, Lilienfeld, Kupfer, 1988; Taylor, Rosen, Leiblum, 1994;
Derogatis & Melisartos, 1979; Clayton, Owens, & McGarvey, 1995). The 6point Likert design makes the ASEX extremely easy to score and interpret.
Although the ASEX does not establish the etiology of sexual dysfunction, it
does accurately measure sexual dysfunction when it is present. The ASEX is
simple because only basic core elements of sexual dysfunction are addressed
rather than every level of every aspect of sexual activity (Mathew & Weinman,
1982; Howell, Reynolds, Thase, Frank, Jennings, Houck, Berman, Jacobs, &
Kupfe, 1987; Segraves, 1992; Wise, 1992; Othmer & Othmer, 1987; Derogatis
& Melisaratos, 1979; Clayton, Owens, & McGarvey, 1995). Once the core

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36

C. A. McGahuey et al.

elements have been identified, measurement of sexual dysfunction is simplified. In summary, the high positive and negative predictive values of the
ASEXalong with its internal consistency, reliability, and validitysupport
the theory that measurement of only the core aspects may be sufficient for
clinical detection of sexual dysfunction.
Traditional sexual dysfunction rating scales, such as the BISF (Reynolds,
Frank, Thase, Houck, Jennings, Howell, Lilienfeld, & Kupfer, 1988; Taylor,
Rosen, & Leiblum, 1994) contain many additional items relevant to the measurement of overall sexual function; however, they may not be as effective
as the ASEX in determining sexual dysfunction (see Figures 2 and 3). Furthermore, the scoring of scales with a large number of items is complicated
and can be difficult to interpret, making it harder to quantify the degree of
sexual dysfunction. It should be noted that since the cutoff categories for
both the ASEX and BISF ROC analyses were arbitrarily determined, it is
reasonable to assume that modification of the categories could result in ROC
curves differing from the ones presented in Figures 2 and 3. However, given
the high correlation between total ASEX score and the presence of sexual
dysfunction, the ASEX seems to quantify the core elements of sexual dysfunction quite well, suggesting that any additional items may not be required.
Recent studies involving mirtazapine substitution show that the ASEX
can also effectively measure change in sexual function over time (Gelenberg,
Laukes, McGahuey, Okayli, Moreno, Bologna, & Delgado, 1998; Delgado,
1998). The brief (it takes less than 5 minutes for patients to complete) and
nonintrusive qualities of the ASEX allow for repeated and frequent measurement of sexual dysfunction, causing minimal discomfort and embarrassment
for the patient. The ASEX allows the clinician to quickly identify which core
elements of sexual dysfunction are affected and treat those symptoms accordingly. In addition, the ASEX is a bimodal scale that is capable of measuring reduced or enhanced sexual function.
There were important limitations of this study that should be considered
when interpreting the results. First, the sample size was relatively small and
may not be representative of the general population. For example, we did
not test subjects younger than 18 years, and there were few elders in the
study. Although we included subjects with a history of MDE or Anxiety, all
were on antidepressants. Although we would expect the ASEX to show comparable reliability and validity in unmedicated depressed patients and other
groups, future studies should be conducted in other populations, including
people from other cultures and those with other concurrent problems (e.g.,
drug abuse or medical illness).
Only high ASEX scores initially were considered to reflect sexual dysfunction. However, we subsequently realized that subjects suffering from
premature ejaculation or spontaneous orgasm (reflected in extremely low
ASEX scores) could also be considered to have sexual dysfunction. In the
future, analyses should focus both on extremely low and extremely high

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Reliability and Validity of the ASEX

37

ASEX scores, given that sexual dysfunction can involve both hyperfunction
and hypofunction.
Another limitation of the study design was in the choice of scales with
which to compare the ASEX. At the time of the study, the BISF was the best
choice of the available validated scales, but correlating the BISF to the ASEX
was less than ideal. This is due in part to the fact that the BISF is more
inclusive of the construct of sexual dysfunction, requiring numerous computations to derive the factor scores.
Another inherent limitation in studies of sexual dysfunction is that the
definition of sexual dysfunction can be subjective. A lack of sexual activity,
for example, is not always perceived as sexual dysfunction. Personal views
(i.e., religious or other) often bias interpretation. Who or what ultimately
decides when sexual dysfunction is present? Is the patients self-report the
deciding factor, or should it be left up to the clinician or a score on a questionnaire? Clearer guidelines defining the boundaries of sexual dysfunction
for use in clinical and research studies should be developed.

REFERENCES
Beck, A. T., Steer, R. A., Ball, R., Ranieri, W. F. (1996). Comparison of Beck Depression InventoriesIA and II in psychiatric outpatients. Journal of Personality
Assessment, 67, 588597.
Clayton, A. H., Owens, J. E., & McGarvey, E. L. (1995). Assessment of paroxetineinduced sexual dysfunction using the Changes in Sexual Functioning Questionnaire. Psychopharmacology Bulletin 3, 397413.
Croog, S. H., Levine, S., Testa, M. A., Brown, Byron, Bulpitt, C. J., Jenkins, C. D.,
Klerman, G. L., & Williams, G. H. (1986). The effects of antihypertensive therapy
on the quality of life. New England Journal of Medicine, 314, 16571664.
Delgado, P. L. (1998). Treatment strategies of depression and sexual dysfunction,
Clinical Conference on Antidepressant Therapy and Sexual Dysfunction, New
York, May 21, 1998.
Derogatis, L. R., & Melisaratos, N. (1979). The DSFI: A multidimensional measure of
sexual functioning. Journal of Sex and Marital Therapy, 5, 244281.
Gelenberg, A. J., Laukes, C., McGahuey, C. A., Okayli, G., Moreno, F. A., Bologna,
L., & Delgado, P. L. (1998). Mirtazapine substitution in SSRI-induced sexual
dysfunction, 38th Annual Meeting of the New Clinical Drug Evaluation Unit
Program, Boca Raton, FL, Poster No. 174, June 12, 1998.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurological Neurosurgical Psychiatry, 23, 5662.
Hennekens, C. H., & Buring, J. E. (1987). Epidemiology in medicine. Boston: Little
Brown.
Herman, J. B., Brotman, A. W., Pollack, M. H., Falk, W. E., Biederman, J., & Rosenbaum,
J. F. (1990). Fluoxetine-induced sexual dysfunction. Journal of Clinical Psychiatry, 51(1), 2527.
Hogan, M. J., Wallin, J. D., & Baer, R. M. (1980). Antihypertensive therapy and male
sexual dysfunction. Psychosomatics, 21, 234237.

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Howell, J. R., Reynolds, C. F., Thase, M. E., Frank, E., Jennings, J. R., Houck, P. R.
Berman, S., Jacobs, E., & Kupfe, D. J. (1987). Assessment of sexual function,
interest and activity in depressed men. Journal of Affective Disorders, 13, 6166.
Jacobsen, F. M. (1992). Fluoxetine-induced sexual dysfunction and an open trial of
Yohimbine. Journal of Clinical Psychiatry, 53, 119122.
Mathew, R. J., & Weinman, M. L. (1982). Sexual dysfunction in depression. Archives
of Sexual Behavior, 11, 323328.
McGahuey, C. A., Gelenberg, A. J., Laukes, C., Manber, R., McKnight, K., Moreno, F.
A., & Delgado, P. L. (1997). The Arizona Sexual Experiences Scale (ASEX):
Validity and reliability, 150th Annual Meeting of the American Psychiatric Association, San Diego, CA, NR # 184, May 19, 1997.
McGahuey, C. A., Gelenberg, A. J., Laukes, C., Manber, R., McKnight, K., Moreno, F.
A., Delgado, P.L. (1998). The Arizona Sexual Experiences Scale (ASEX), 38th
Annual Meeting of the New Clinical Drug Evaluation Unit Program; Boca Raton,
FL, Poster No. 62, June 11, 1998.
Othmer, E., & Othmer, S. C. (1987). Evaluation of sexual dysfunction. Journal of
Clinical Psychiatry, 48, 191193.
Piazza, L. A., Markowitz, J. C., Kocsis, J. H., Leon, A. C., Portera, L., Miller, N. L., &
Adler, D. (1997). Sexual functioning in chronically depressed patients treated
with SSRI antidepressants: A pilot study. American Journal of Psychiatry, 154,
17571758.
Prisant, L. M., Carr, A. A., Bottini, P. B., Solursh, D. S., & Solursh, L. P. (1994). Sexual
dysfunction with antihypertensive drugs. Archives of Internal Medicine, 154,
730736.
Reynolds, C. F., Frank, E., Thase, M. E., Houck, P. R., Jennings, J. R., Howell, J. R.,
Lilienfeld, S. O., & Kupfer, D. J. (1988). Assessment of sexual function in depressed, impotent, and healthy men: Factor analysis of a brief sexual function
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Segraves, R. T. (1992). Overview of sexual dysfunction complicating the treatment
of depression. Journal of Clinical Psychiatry Monograph Series, 10(2), 49.
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39

Reliability and Validity of the ASEX

ARIZONA SEXUAL EXPERIENCES SCALE (ASEX)-MALE

For each item, please indicate your OVERALL level during the PAST WEEK, including
TODAY .
1. How strong is your sex drive?

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1
extremely
strong

2
very strong

3
somewhat
strong

4
somewhat
weak

5
very weak

6
no sex drive

5
very
difficult

6
never aroused

4
somewhat
difficult

5
very
difficult

6
never

4
somewhat
difficult

5
very
difficult

6
never reach
orgasm

4
somewhat
unsatisfying

5
very
unsatisfying

6
cant reach orgasm

2. How easily are you sexually aroused (turned on)?

1
extremely
easily

2
very easily

3
somewhat
easily

4
somewhat
difficult

3. Can you easily get and keep an erection?

1
extremely
easily

2
very easily

3
somewhat
easily

4. How easily can you reach an orgasm?

1
extremely
easily

2
very easily

3
somewhat
easily

5. Are your orgasms satisfying?

1
extremely
satisfying

2
very
satisfying

3
somewhat
satisfying

COMMENTS:

Copyright 1997, Arizona Board of Regents, University of Arizona, All rights reserved
APPENDIX A: The Arizona Sexual Experiences Scale (ASEX), Male and Female versions

40

C. A. McGahuey et al.
ARIZONA SEXUAL EXPERIENCES SCALE (ASEX)-FEMALE

For each item, please indicate your OVERALL level during the PAST WEEK, including
TODAY .
1. How strong is your sex drive?

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1
extremely
strong

2
very strong

3
somewhat
strong

4
somewhat
weak

5
very weak

6
no sex drive

5
very
difficult

6
never aroused

2. How easily are you sexually aroused (turned on)?

1
extremely
easily

2
very easily

3
somewhat
easily

4
somewhat
difficult

3. How easily does your vagina become moist or wet during sex?
1
extremely
easily

2
very easily

3
somewhat
easily

4
somewhat
difficult

5
very
difficult

6
never

4
somewhat
difficult

5
very
difficult

6
never reach
orgasm

4
somewhat
unsatisfying

5
very
unsatisfying

6
cant reach orgasm

4. How easily can you reach an orgasm?

1
extremely
easily

2
very easily

3
somewhat
easily

5. Are your orgasms satisfying?

1
extremely
satisfying

2
very
satisfying

3
somewhat
satisfying

COMMENTS:

Copyright 1997, Arizona Board of Regents, University of Arizona, All rights reserved
APPENDIX A: (Continued)