A cross-sectional analysis in order to validate the translation of FSFI-6 to Bahasa Indonesia

Introduction

Sexual dysfunction is a health problem that could potentially degrade quality of life. However, this problem is less discussed and treated, especially in women in Indonesia. This is because of the culture in Indonesia, which considers the topic of sexuality taboo. Therefore, anything that is related to sexuality is rarely discussed. There are only a few pieces of research about sexual dysfunction. Female sexual dysfunction (FSD) is a complex issue in the classification, diagnosis, or treatment. Studies related to the prevalence and incidence of sexual dysfunction in women are scarce. Lack of data and limited research methods make it difficult to interpret the data.

In recent decades, reproductive health has been a crucial component of quality of life, and it is now a program initiated by the World Health Organization (WHO). WHO defines FSD as the inability of a woman to participate in sexual intercourse. Sexual dysfunction can be grouped into four major groups, they are sexual arousal disorder, sexual desire disorder, pain disorder, and disorders on orgasm.¹ Without proper management, sexual dysfunction can potentially influence interpersonal relationships with a spouse, reduce confidence, cause emotional disturbances, and finally affect quality of life.

The prevalence of FSD in western countries is known to be relatively high. Research has indicated that the numbers are between 43–88% in the US and 22% in Europe.^2,3 Based on previous epidemiological research conducted by the Department of Urology of Rumah Sakit Cipto Mangunkusumo (RSCM or Mangunkusumo National Central General Hospital) in 2001, about 15.2% of the 560 female respondents had experienced sexual dysfunction, and its prevalence increased with age.⁴ Another study in Indonesia stated that the prevalence of FSD is 9.2%.⁵ The prevalence is relatively high; however, public and health professionals’ awareness is still deficient regarding this issue, especially in Indonesia, which embraces Eastern culture, so sexual problems are taboo topics to talk about. Sexual dysfunction in women is often not explored in high-risk groups.

There are many instruments designed to evaluate sexual dysfunction in women. Some of them also have tested validity. They are the Brief Index of Sexual Functioning for Women,⁶ Changes in Sexual Functioning Questionaire,⁷ Female Sexual Function Index (FSFI),⁸ and Golombok Rust Inventory of Sexual Satisfaction.⁹ The FSFI-6 questionnaire is a self-report questionnaire used as an instrument for assessing FSD. It is a short version of the FSFI-19, which has 19 items instead of six. FSFI-19 may took too much time for clinical studies, especially in Indonesian women, who do not talk openly about their sexual problems and get embarrassed quickly when talking about sexuality. It was also considered not suitable to be used in a crowded clinical settings in Indonesia. This questionnaire consists of six questions covering six domains: desire, arousal, lubrication, orgasm, satisfaction, and pain. The FSFI was developed and validated for the first time in 2000.^7,10 This questionnaire has been successfully translated into many different languages, ranging from Mandarin, Arabic, Persian, Malay, Turkish, Korean, and Japanese.^11–16 Based on a previous study, the FSFI questionnaire is easily understood and can measure all aspects of women’s sexual function.¹⁷ A previous study about translation and validation of the FSFI-6 questionnaire into Bahasa Indonesia was conducted on the original version of the FSFI-6, which consisted of many questions. Hence, this study was conducted to validate and translate the simpler version of the initial questionnaire to make it more understandable.

Methods

Results

The subjects filling out the questionnaire were categorised based on demographic status. This study’s subject demography data included age, latest education status, occupation, and geographical region. Subject demography data are listed in Table 2.¹⁹

Table 2 shows the percentage of each demographic status. Women under 43 years old (70.8%) were the majority subjects in this study. Most of the women who filled this questionnaire graduated with a bachelor’s degree (70.8%). Most of the subjects who filled out this questionnaire worked as employees (61.1%). For geographical region, 79.2% of the subjects lived in an urban area, 5.6% lived in a rural area, and 15.3% did not answer.

The results of the Pearson’s correlation test in this study, along with the mean and standard deviation, can be seen in Table 3.

Table 3 shows that there were 69 valid data from 72 respondents. The first question had r value 0.837, second 0.676, third 0.808, fourth 0.813, fifth 0.623, and sixth 0.846.

The FSFI-6 questionnaire translated into Bahasa Indonesia had a value of Cronbach’s Alpha of 0.831. The results of the reliability test on each question if it was deleted can be seen on Table 4.

Table 4 shows reliability test result of FSFI-6 questionnaire translated into Bahasa Indonesia.

Discussion

FSD is a widespread health problem with complex pathogenesis (organic, relational, sociocultural, and psychogenic). In Indonesia, it is often not reported by patients. This problem exists because the topic of sexuality is often avoided. It is embarrassing for people in Indonesia to talk openly about their sexuality because sexuality is a social taboo. This social taboo also means that sexual health education in Indonesia is rarely given. The lack of sexual health education also means that people do not understand FSD and rarely complain about it.^20,21 Another reason is that the psychosocial aspect of FSD is overlooked in Indonesia. Public knowledge about mental health in Indonesia is still low, and there are not many schools that implement education about mental health. There is a stigma in Indonesia about going to a psychologist, and because of that, there are not many people who go to a psychologist, even for a consultation. Four factors affect someone’s sexual function according to the biopsychosocial model. The biopsychosocial model states that biology, psychology, sociocultural, and interpersonal factors affect an individual’s sexual function. Any distress in one or more of these factors can cause sexual dysfunction.²² Therefore, the lack of knowledge in mental health and the social taboo about sexuality make FSD undertreated and under-recognized. Because of this, doctors play a big part in discovering and diagnosing FSD with diagnostic tools such as the FSFI.²³

The FSFI-19 has a 19-item self-reported measurement for FSD. Because of this, FSFI-19 is considered to take too much time for routine use in outpatient clinics. Long questionnaires do not work well with overcrowded clinical settings. For this reason, FSFI-6 was made to create a more straightforward diagnostic tool that may help with physical examination and taking a patient’s history in a clinical setting. Isidori et al., validated the English FSFI-6 and concluded that the FSFI-6 is a highly accurate, easy-to-administer, and quick questionnaire to detect FSD.²³

The primary purpose of this study was the translation and validation of the FSFI-6 to Bahasa Indonesia so it may be used in overcrowded clinical practices in Indonesia. The FSFI-6 Bahasa Indonesia was developed through a series of stages, including translation (both forward and back translation), a validation test, and a reliability test.

This study showed a high reliability of 0.831 using Cronbach’s Alpha coefficient with the six questions of FSFI-6. This means that the sexual function defined by the six domains of FSFI-6 is comprehensible to Indonesian women. The procedure that includes backward and forward translation is aimed to make the questionnaire easily understood by Indonesian women. Issues of anonymity and confidentiality were clarified at the beginning of this study to ensure that women would feel free to express themselves.

Table 1 shows that there were 69 valid data from 72 respondents. On the first validity test, the first question had r value 0.837, second 0.676, third 0.808, fourth 0.813, fifth 0.623, and sixth 0.846. All the questions of the questionnaire had r value higher than 0.3 and the Cronbach’s Alpha higher than 0.7, hence it can be concluded that the six FSFI-6 questions that have been translated into Bahasa Indonesia are valid and reliable. Therefore, this questionnaire can be used for the assessment of FSD.

Compared to other studies that have validated and translated FSFI to other languages, this study shows a significant correlation in each question (P<0.05) and high reliability (Cronbach’s Alpha >0.7). Validation and translation of FSFI-6 in Japanese, Korean, Philippine, and Malaysian languages shows high reliability with Cronbach Alpha >0.7 in each study.^15,17,24,25 The validity and significance values in Malaysian and Korean languages show significant correlation indicated by P<0.05 in each question of the translated questionnaire.^15,24 However, the validity in both Japanese and Filipino populations were not significant (P>0.05).^17,24 The study conducted by Nuring et al., about the validation and translation of the original version of the FSFI-6 to Bahasa Indonesia, which consists of 19 aspects, show high reliability (Cronbach’s Alpha 0.844) and was valid.²⁶ These findings indicate that the translation of FSFI-6 into Bahasa Indonesia is valid and reliable enough compared to other studies.

The limitation of this study was that it didn’t analyse the questionnaire’s responsiveness on the subjects. The subjects of this study were also mainly healthcare workers who were already well-educated. Hence these subjects are less likely to represent Indonesian women in general. This questionnaire may need to be further evaluated in a group of Indonesian women with other social backgrounds.

Conclusions

Based on the data analysis that has been performed, it can be concluded that the translated FSFI-6 questionnaire is valid and reliable. Researchers suggest further questionnaire evaluation in a group of Indonesian women with other social backgrounds.

Data availability