Background
Sexual addiction is usually defined as any sexually-related, compulsive behavior which interferes with normal living and causes severe stress on family, friends, and one’s work environment [
1,
2].
Sex addiction symptoms consist of looking for new sexual partners, having compulsive masturbation and sexual intercourse, frequent pornography consumption, repeated unsuccessful efforts to stop excessive sexual behaviors, having risky sexual experiences, obsessive thoughts of sex, feeling guilt or shame about their sexual behaviors, and a strong desire for anonymous sex [
1,
3‐
5]. Sex addiction is associated with increased risk-taking behaviors such as drug use, alcohol consumption and having multiple sexual partners, anxiety, depression, impulsivity, loneliness, low self-confidence, and insecure attachment styles [
1,
3,
6‐
8].
Although the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) did not accept sex addiction as a mental disorder, excessive sexual behavior conceptualized as a “Sexual Disorder Not Otherwise Specified” is in the DSM-III.
In the general population, 15–61% of people assessed by various questionnaires [
9‐
11], were estimated as sex-addicted [
8]. The prevalence of this disorder among Iranian population is unknown.
Regarding the traditional and religious culture of Iranian society, some sexual activity (erotic behavior, masturbation) and cross-gender interactions such as premarital dating and friendship of girls and boys are legally banned and culturally unacceptable [
12]. Hence, these issues make many problems for these patients. On the other hand, due to the lack of a valid and reliable instrument to diagnose this disease, many research about them are limited. Therefore, we need a valid and reliable tool in line with Iranian contexts.
The Bergen–Yale Sex Addiction Scale (BYSAS) is a short self-report instrument that specifically measures sexual addiction and it is available in English and Norwegian languages. Andreassen and colleagues developed and validated this scale in 2018 [
9]. To expand the utility of the BYSAS for diverse populations, the aim of the current study was to translate and investigate the psychometric properties of the BYSAS in a sample of Iranian adults.
Methods
Participants
This cross-sectional study was conducted in Zanjan University of Medical Sciences, Zanjan, Iran, from February to November 2019. The ethics committee approved the study (1397.328IR.ZUMS.REC.). The inclusion criteria for participant selection included: 1) age between 18 and 60 years; 2) necessary communication skills; 3) the absence of intellectual disability; and 4) not using drugs, and medications affecting sexual functioning. Participants were 756 Iranian men and women, aged up to 60 years who were selected based on convenience sampling method. Sampling was performed at 8 to 11 am and 5 to 9 pm in summer and winter to avoid the influence of seasonal and temporal conditions on the sexual behavior. Before completing the questionnaire, verbal information was provided to inform participants about the purpose of the study and adherence to ethical principles and informed consent form was obtained. According to application of exploratory and confirmatory analyses, the study sample was divided into 376 and 380 individuals. Sample information is shown in Table
1.
Table 1
Participants’ characteristics (N = 756)
Age g | 34.31(8.22) | 33.95(8.67) |
Gender m |
Male | 128(34%) | 144(38%) |
Female | 248(66%) | 236(62%) |
Marital status |
Single | 90(23.9%) 271 | 100(26%) 271 |
Married | 273(72.9%) | 266(70%) |
Others | 12(3.2%) | 14(4%) |
Job |
Employment | 162(43.1) | 164(43.2) |
Worker | 12(3.2) | 10(2.6%) |
Self-employment | 56(14.9) | 58(15%) |
Jobless | 27(7.2) | 28(7.3) |
House wife | 119(31.6) | 120(31.5) |
Education |
University | 240(63.8) | 252(66.3%) |
Non university | 136(36.2) | 128(44.7%) |
Measures
The Bergen–Yale sex addiction scale
The Bergen–Yale Sex Addiction Scale (BYSAS) consists of 6 statements. The BYSAS is scored by adding the score of each single item (0 = very rarely, 1 = rarely, 2 = sometimes, 3 = often, and 4 = very often). The BYSAS yields a composite/continuous score ranging from 0 to 24. Hence, the BYSAS can be used as a continuous score of sex addiction. To classify a respondent as a “sex addict”, at least 4 symptoms have to be present at a specific level/magnitude [defined as scoring at least 3 (often) or 4 (very often)]. Hence, the BYSAS can also provide a dichotomized score/categorization. Indeed, a specific number of criteria (often more than half) had to be approved (here “often” or “very often”) to be classed as having sex addiction. Also, participants that answered “never” to all the six items were classified as having “no sex addiction”. A summed score between 1 and 6 (two of the six items) was considered as “low sex addiction risk”. Those with a composite score of 7 or above but did not fulfill the criteria for sex addiction were defined as having “moderate sex addiction risk”. This label seems suitable as this equals a mean score above one on all six items [
9].
Translation
The ‘forward-backward’ procedure was applied to translate the questionnaire from English into Persian (Iranian language). Two health professionals translated the questionnaires into Persian and these were backward translated into English by a psychologist and a professional translator. Then, a provisional version of the Iranian questionnaire was provided. In general, there were no difficulties in translating items.
Statistical analysis
The data were analyzed using SPSS version 16 for windows (SPSS, Inc., Chicago, IL, USA) and Lisrel 8.8 software was used for confirmatory factor analysis. The weighted least squares method with data from the correlation coefficient and asymptotic covariance matrix was used for data analysis. The indices used for the confirmatory model are as follows: X2 Exponential Ratio (X2), X2 Liberty Ratio (X2 / df), Goodness of fit index (GFI), Adjusted Goodness of fit Index (AGFI), Root Mean Square Error of Estimation (RMSEA), CFI and NFI and Tucker-Lewis Index (TLI). In addition, Cronbach’s alpha was used to assess the internal consistency coefficient of the scale.
Face validity, content validity, exploratory factor analysis (in the first sample), and confirmatory factor analysis (in the second sample) were used to assess the validity and Cronbach’s alpha coefficient and test-retest reliability.
Structural validity
A confirmatory factor analysis was conducted to confirm the factor structure reported in the first sample. If the structure obtained from the first sample to the second sample is confirmed, a certificate is provided for its validity. Lisrel8.8 software was used for confirmatory factor analysis. Weighted Least Squares estimation method was used in data analysis with data from polychoric correlation and asymptotic covariance matrix. The Weighted Least Squares method was preferred because the query options were four-class and Polyureic correlation was calculated instead of Pearson correlation [
13]. There are two types of evaluations to consider in confirmatory models. Partial evaluation and overall fit of the model. The Partial evaluation relates to paths drawn from current agents to the markers (in measurement model). The overall fit of the measurement models was judged using several goodness of fit indices (which measure the amount of data support for the conceptual model). The indices used are: Chi-square exponential ratio (X2), Chi-square to degrees of freedom (X2 / df), goodness of fit (GFI), modified goodness of fit (AGFI), root mean square error of estimation (RMSEA), CFI and NFI and the Tucker-Lewis Index (TLI).
Discussion
To our knowledge, this study is the first assessment of a sex addiction measure ensuing from translating, conducting reliability and testing validity of the BYSAS in a non-clinical sample in an Iranian population. Generally, participants found the BYSAS to be fast and clear to complete, and reflective of their experiences. The scale also demonstrated excellent psychometric properties (high internal consistency, test-retest reliability, and evidence of construct validity).
As noted by others, translating an existing tool into another language is not a simple translation of words and requires extensive research to produce a cultural version comparable to the tool plus psychometric testing to ensure equivalence [
14,
15]. In this study, cultural and conceptual equality were obtained; furthermore, we used guidelines to examine the psychometric properties of the instrument. The Persian version of the BYSAS was culturally functional and transferred the main purpose of the original English BYSAS.
In this study, we found acceptable validity (face and content) and reliability. In terms of face validity, experts and other interviewees (males and females) read the BYSAS items using similar interpretations. Respondents said that the questionnaire covers all aspects of sexual addiction. We also found that the impact score of all items was above 1.5 that indicates the proper face validity of the translated tool (especially Persian). However, the instruments used in previous studies were inappropriate with regard to defining sex addiction [
16]. The shortcomings of the previous instruments were offset by the construction of this questionnaire by Anderson et al., and its validity was confirmed by our study. Specifically, we found that a single factor accounted for 62.31% of the total variance. Also, the instrument yielded high content validity that was consistent with previous studies, despite different sample sizes, race or cultures, and different translations (such as the study of Paz et al., (Hebrew), and Anderson et al., (original English version)) [
9,
17]. However, in comparision with other countries, Iranians might have the same experience of sexual addiction.
According to the psychometric properties of this study, the BYSAS was highly test-retest reliable (a 2-week period) for screening of sexual addiction and Cronbach’s alpha was for internal consistency coefficient of 0.88 and for the intra-class correlation coefficient of 0.89 that was higher than the values obtained in previous reliable studies [
9,
17]. In addition, the positive and significant correlations found in the Christon et al. study indicated the high reliability of the BYSAS. Also, Paz et al. showed high test-retest reliability of the instrument, but covariances emerged in the model of his study could ensue from the smaller sample size or interpretation features in Hebrew.
Moreover, the results concerning the one-factor structure analysis model with six subscales are consistent with the previous studies funding from Norway [
9] and Italy [
18] that investigated the psychometric properties of the instrument. Also, our study indicated that the favorable relationship of all markers of the model with their substrates and strong association between its subscales, and appears suitable for the evaluating of the partial and general indices and specifically known for sexual addiction. In studies, there are slight differences due to different age groups (variety in cognitive abilities between adolescents and adults, (different countries (different habits or accessibility to the social media) and cultural variation.
The current study presents a number of limitations. First, the study is limited by the common limitations in the psychological literature, including using voluntary partisipation (e.g. the self-selected samples) and self-report data. Second, despite the adequacy of the sample size, it was not nationally representative. Third, for the validity assessment of this scale, we used face, content, and construct (only confirmatory factor analysis) validity. We also did not assess other types of construct validity such as concurrent, discriminant, predictive, convergent, and criterion-related validity. Forth, the use of convenience sampling method is other limitation of this study. Future research is needed to examine the clinical utility of the BYSAS among clinical populations in Iran.
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