Supportive Care in Cancer

, Volume 23, Issue 9, pp 2633–2641 | Cite as

The Female Sexual Functioning Index (FSFI): evaluation of acceptability, reliability, and validity in women with breast cancer

  • Iris Bartula
  • Kerry A. Sherman
Original Article



Sexual dysfunction commonly arises for women following diagnosis and treatment of breast cancer. The aim of this study was to systematically evaluate the acceptability, reliability, and validity of the Female Sexual Functioning Index (FSFI) when used with these women.


Sexually active women previously diagnosed with breast cancer (N = 399) completed an online questionnaire including the FSFI and measures of acceptability (ease of use, relevance), sexual functioning, body image, fatigue, impact of cancer, physical and mental health, and relationship adjustment. Reliability and validity were evaluated using standard scale validation techniques.


Participants indicated a high degree of acceptability. Excellent internal consistency (α = 0.83–0.96) and test–retest reliability (r = 0.74–0.86) of the FSFI were evident. According to the confirmatory factor analysis, the best fit was achieved with removal of item 14 (regarding the extent of emotional closeness with the partner) and six subscales (desire, arousal, lubrication, orgasm, satisfaction, pain), without a total score (TLI = 0.96, CFI = 0.97, RMSEA = 0.07). Correlations with measures of sexual functioning and related constructs provided evidence for convergent and divergent validities, respectively. All but one subscale (orgasm) discriminated between women who are, and are not, currently receiving treatment for breast cancer (discriminant validity).


These findings indicate that not only is the FSFI psychometrically sound when used with women with breast cancer, but it is perceived as being easy to use and relevant. It is recommended that the FSFI subscale scores can be used in both clinical and research settings as a screening tool to identify women experiencing sexual dysfunction following breast cancer.


Breast neoplasms Sexual dysfunctions (psychological) Sexual dysfunctions (physiological) Psychosexual dysfunctions Questionnaires DSM-V 



We would like to acknowledge the women from the Breast Cancer Network Australia for giving their time to complete the surveys and Dr. Alan Taylor for his statistical insights. This study was undertaken with funding support from National Breast Cancer Foundation and Cancer Australia (ID: 543400).

Conflict of interest

The authors report no conflicts of interest.


  1. 1.
    Ma J, Jemal A (2013) Breast cancer statistics. In: Ahmad A (ed) Breast Cancer Metastasis and Drug Resistance: Progress and Prospects. Springer pp 1-18. doi: 10.1007/978-1-4614-5647-6_1
  2. 2.
    Den Oudsten BL, Van Heck GL, Van der Steeg AFW, Roukema JA, De Vries J (2009) The WHOQOL-100 has good psychometric properties in breast cancer patients. J Clin Epidemiol 62(2):195–205. doi: 10.1016/j.jclinepi.2008.03.006 CrossRefGoogle Scholar
  3. 3.
    Klaeson K, Berterö CM (2008) Sexual identity following breast cancer treatments in premenopausal women. Int J Qual Stud Heal 3(3):185–192. doi: 10.1080/17482620802130399 CrossRefGoogle Scholar
  4. 4.
    Wilmoth MC (2001) The aftermath of breast cancer: An altered sexual self. Cancer Nurs 24(4):278–286PubMedCrossRefGoogle Scholar
  5. 5.
    Mok K, Juraskova I, Friedlander M (2008) The impact of aromatase inhibitors on sexual functioning: current knowledge and future research directions. Breast 17(5):436–440. doi: 10.1016/j.breast.2008.04.001 PubMedCrossRefGoogle Scholar
  6. 6.
    Panjari M, Bell RJ, Davis SR (2011) Sexual function after breast cancer. J Sex Med 8(1):294–302. doi: 10.1111/j.1743-6109.2010.02034.x PubMedCrossRefGoogle Scholar
  7. 7.
    Ussher JM, Perz J, Gilbert E, Wong WK, Mason C, Hobbs K, Kirsten L (2013) Talking about sex after cancer: a discourse analytic study of health care professional accounts of sexual communication with patients. Psychol Health 28(12):1370–1390. doi: 10.1080/08870446.2013.811242 PubMedCrossRefGoogle Scholar
  8. 8.
    Ussher JM, Perz J, Gilbert E (2012) Changes to sexual well-being and intimacy after breast cancer. Cancer Nurs 35(6):456–465PubMedCrossRefGoogle Scholar
  9. 9.
    Bartula I, Sherman KA (2013) Screening for sexual dysfunction in women diagnosed with breast cancer: systematic review and recommendations. Breast Cancer Res Treat 141(2):173–185. doi: 10.1007/s10549-013-2685-9 PubMedCentralPubMedCrossRefGoogle Scholar
  10. 10.
    Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, Ferguson D, D'Agostino R Jr (2000) The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 26(2):191–208. doi: 10.1080/009262300278597 PubMedCrossRefGoogle Scholar
  11. 11.
    American Psychiatric Association (2013) Diagnostic and Statistical Manual of Psychiatric Disorders, 5th edn. American Psychiatric Association, WashingtonGoogle Scholar
  12. 12.
    World Health Organization (2004) International Statistical Classification of Diseases and Health Related Problems. World Health Organization, GenevaGoogle Scholar
  13. 13.
    Meston CA (2003) Validation of the Female Sexual Funcion Index (FSFI) in women with Female Orgasmic Disorder and women with Hypoactive Sexual Desire Disorder. J Sex Marital Ther 29(1):39–46PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Wiegel M, Meston C, Rosen R (2005) The Female Sexual Function Index (FSFI): Cross-validation and development of clinical cutoff scores. J Sex Marital Ther 31(1):1–20. doi: 10.1080/00926230590475206 PubMedCrossRefGoogle Scholar
  15. 15.
    Baser RE, Li Y, Carter J (2012) Psychometric validation of the Female Sexual Function Index (FSFI) in cancer survivors. Cancer 118(18):4606–4618. doi: 10.1002/cncr.26739 PubMedCrossRefGoogle Scholar
  16. 16.
    Likes WM, Stegbauer C, Hathaway D, Brown C, Tillmanns T (2006) Use of the Female Sexual Function Index in women with vulvar intraepithelial neoplasia. J Sex Marital Ther 32(3):255–266. doi: 10.1080/00926230600575348 PubMedCrossRefGoogle Scholar
  17. 17.
    Masheb RM, Lozano-Blanco C, Kohorn EI, Minkin MJ, Kerns RD (2004) Assessing sexual function and dyspareunia with the Female Sexual Function Index (FSFI) in women with vulvodynia. J Sex Marital Ther 30(5):315–324. doi: 10.1080/00926230490463264 PubMedCrossRefGoogle Scholar
  18. 18.
    Verit FF, Verit A (2007) Validation of the female sexual function index in women with chronic pelvic pain. J Sex Marital Ther 4(6):1635–1641. doi: 10.1111/j.1743-6109.2007.00604.x Google Scholar
  19. 19.
    Opperman EA, Benson LE, Milhausen RR (2013) Confirmatory factor analysis of the female sexual function index. J Sex Res 50(1):29–36. doi: 10.1080/00224499.2011.628423 PubMedCrossRefGoogle Scholar
  20. 20.
    Coscarelli A, Heinrich RL (1988) Cancer Rehabilitation Evaluation System (CARES): Manual. CARES ConsultantsGoogle Scholar
  21. 21.
    The WHOQOL Group (1998) The World Health Organization Quality of Life Assessment: Development and general psychometric properties. Soc Sci Med 46(12):1569–1585CrossRefGoogle Scholar
  22. 22.
    Hopwood P (1993) The assessment of body image in cancer patients. Eur J Cancer 29(2):276–281CrossRefGoogle Scholar
  23. 23.
    Michielsen HJ, De Vries J, Van Heck GL (2003) Psychometric qualities of a brief self-rated fatigue measure: The Fatigue Assessment Scale. J Psychosom Res 54:345–355. doi: 10.1016/S0022-3999(02)00392-6 PubMedCrossRefGoogle Scholar
  24. 24.
    Horowitz M, Wilner N, Alvarez W (1979) Impact of Event Scale: A measure of subjective stress. Psychosom Med 41(3):209–218PubMedCrossRefGoogle Scholar
  25. 25.
    Lovibond SH, Lovibond PF (1995) Manual for the Depression Anxiety Stress Scales Psychology Foundation of Australia, SydneyGoogle Scholar
  26. 26.
    Stewart AL, Hays RD, Ware JE (1988) The MOS Short-Form General Health Survey: Reliability and validity in patient population. Med Care 26(7):724–735PubMedCrossRefGoogle Scholar
  27. 27.
    Graham JM, Liu YJ, Jeziorski JL (2006) The Dyadic Adjustment Scale: A reliability generalisation meta-analysis. J Marriage Fam 68:701–717. doi: 10.1111/j.1741-3737.2006.00284.x CrossRefGoogle Scholar
  28. 28.
    De Vries J, Van der Steeg AF, Roukema JA (2010) Psychometric properties of the Fatigue Assessment Scale in women with breast problems. Int J Clin Hlth Psyc 10(1):125–139Google Scholar
  29. 29.
    Hopwood P, Fletcher I, Lee A, Ghazal SA (2001) A body image scale for use with cancer patients. Eur J Cancer 37:189–197PubMedCrossRefGoogle Scholar
  30. 30.
    Thewes B, Meiser B, Hickie IB (2001) Psychometric properties of the Impact of Event Scale amongst women at increased risk for hereditary breast cancer. Psycho-Oncology 10(6):459–468PubMedCrossRefGoogle Scholar
  31. 31.
    Dozois DJA, Dobson KS (2010) Depression. In: Antony MM, Barlow DH (eds) Handbook of Assessment and Treatment Planning for Psychological Disorders, 2nd edn. The Guildford Press, New YorkGoogle Scholar
  32. 32.
    Schafer JL, Graham JW (2002) Missing data: Our view of the state of the art. Psychol Methods 7(2):147–177. doi: 10.1037//1082-989x.7.2.147 PubMedCrossRefGoogle Scholar
  33. 33.
    Jackson DL, Gillaspy JA, Purc-Stephenson R (2009) Reporting practices in confirmatory factor analysis: an overview and some recommendations. Psychol Methods 14(1):6–23. doi: 10.1037/a0014694 PubMedCrossRefGoogle Scholar
  34. 34.
    Streiner DL, Norman GR (1995) Health Measurement Scales: A practical Guide to their Development and Use. Oxford University Press, OxfordGoogle Scholar
  35. 35.
    Aday LA, Cornelius LJ (2006) Designing and Conducting Health Surveys, 3rd edn. Josey-Bass: A Wiley Imprint, San FranciscoGoogle Scholar
  36. 36.
    West SG, Finch JF, Curran PJ (1995) Structural equation models with nonnormal variables: Problems and remedies. In: Hoyle RH (ed) Structural Equation Modelling: Concepts. Issues and Applications Sage Publications, LondonGoogle Scholar
  37. 37.
    Chen CH, Lin YC, Chiu LH, Chu YH, Ruan FF, Liu WM, Wang PH (2013) Female sexual dysfunction: definition, classification, and debates. Taiwan J Obstet Gynecol 52(1):3–7. doi: 10.1016/j.tjog.2013.01.002 PubMedCrossRefGoogle Scholar
  38. 38.
    Schreiber JB, Nora A, Stage FK, Balrow EA, King J (2006) Reporting Structural Equation Modeling and Confirmatory Factor Analysis Results: A review. J Educ Res 99:6. doi: 10.3200/JOER.99.6.323-338 CrossRefGoogle Scholar
  39. 39.
    Vrieze SI (2012) Model selection and psychological theory: a discussion of the differences between the Akaike information criterion (AIC) and the Bayesian information criterion (BIC). Psychol Methods 17(2):228–243. doi: 10.1037/a0027127 PubMedCentralPubMedCrossRefGoogle Scholar
  40. 40.
    Carver CS (1989) How should multifaceted personality constructs be tested? Issues illustrated by Self-Monitoring, Attributional Style and Hardiness. J Pers Soc Psychol 56(4):577–585PubMedCrossRefGoogle Scholar
  41. 41.
    Basson R (2005) Women's sexual dysfunction: revised and expanded definitions. Can Med Assoc J 172(10):1327–1333. doi: 10.1503/cmaj.1020174 CrossRefGoogle Scholar
  42. 42.
    Thirlaway K, Fallowfield L, Cuzick J (1996) The Sexual Activity Questionnaire: a measure of women's sexual functioning. Qual Life Res 5(1):81–90PubMedCrossRefGoogle Scholar
  43. 43.
    Rouquette A, Falissard B (2011) Sample size requirements for the internal validation of psychiatric scales. Int J Methods Psychiatr Res 20(4):235–249. doi: 10.1002/mpr.352 PubMedCrossRefGoogle Scholar
  44. 44.
    Addis IB, Van Den Eeden SK, Wassel-Fyr CL, Vittinghoff E, Brown JS, Thom DH, Reproductive Risk Factors for Incontinence Study at Kaiser (PRISK) Study Group (2006) Sexual activity and function in miggle-aged and older women. Obstet Gynecol 107(4):755–764. doi: 10.1097/01.AOG.0000202398.27428.e2 PubMedCentralPubMedCrossRefGoogle Scholar
  45. 45.
    Tierney KD (2008) Sexuality: A quality of life issue for cancer survivors. Semin Oncol Nurs 24(2):71–79. doi: 10.1016/j.soncn.2008.02.001 PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  1. 1.Centre for Emotional Health, Department of PsychologyMacquarie UniversitySydneyAustralia
  2. 2.Westmead Breast Cancer InstituteWestmead HospitalSydneyAustralia

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