The Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 (MSISQ-15)<\/strong> is a specialized, brief, patient-reported psychometric instrument engineered to quantify and characterize the multifaceted nature of sexual dysfunction<\/a> in individuals diagnosed with multiple sclerosis (MS)<\/a>. Chronic demyelinating neurodegenerative pathology frequently disrupts intimate partnerships and physiologic sexual functioning, yet these impairments remain consistently under-identified in clinical neurology and rehabilitation. Derived as an abbreviated, psychometrically refined adaptation of the original 19-item Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ-19), the MSISQ-15 operationalizes sexual health through a tri-partite conceptual architecture comprising primary<\/em> (direct neurogenic lesions within the central nervous system), secondary<\/em> (indirect physical consequences, symptomatology, and therapeutic side effects), and tertiary<\/em> (psychosocial, affective, and interpersonal sequelae) sexual dysfunction.<\/p>\n Composed of 15 self-administered items scored on a 5-point Likert metric ranging from 1 to 5, the instrument yields a dimensional total score ranging between 15 and 75, alongside three balanced subscale scores corresponding to each conceptual tier. International psychometric investigations across diverse cross-cultural cohorts\u2014most notably including comprehensive structural evaluations and cultural adaptations in Spain, the United States, France, Italy, Turkey, Greece, and Poland\u2014demonstrate robust empirical properties. Confirmatory factor analyses utilizing estimation strategies appropriate for categorical indicators consistently affirm the three-factor latent structure (e.g., Comparative Fit Index [CFI] = 0.970, Tucker-Lewis Index [TLI] = 0.960, Root Mean Square Error of Approximation [RMSEA] = 0.070). Internal consistency estimates remain elevated across cohorts, with global ordinal alpha coefficients frequently reaching 0.89 and domain-level coefficients spanning 0.81 to 0.87. Demonstrating convergent validity against domain-specific measures such as the Male Sexual Function (FSH) and Female Sexual Function-2 (FSM-2) scales, divergent validity against general dyadic adjustment metrics, and meaningful sensitivity to quality-of-life decrements, the MSISQ-15 constitutes an indispensable diagnostic and evaluative tool across clinical neuro-rehabilitation and empirical health psychology<\/span>.<\/p>\n Multiple Sclerosis, Sexual Dysfunction, MSISQ-15, Intimacy, Psychometrics, Biopsychosocial Model, Neuro-rehabilitation, Confirmatory Factor Analysis, Quality of Life, Health Psychology, Primary Sexual Dysfunction, Secondary Sexual Dysfunction, Tertiary Sexual Dysfunction<\/p>\n The brief 15-item revision of the MSISQ was spearheaded by Dr. Frederick W. Foley<\/strong> and colleagues, emerging from foundational clinical and psychometric research conducted within the United States (Foley et al., 2013). Dr. Foley is affiliated with the Ferkauf Graduate School of Psychology at Yeshiva University (Bronx, NY, United States) and has served as a preeminent authority in psychological aspects of multiple sclerosis care and intimacy preservation.<\/p>\n The formal cross-cultural translation, linguistic validation, and psychometric adaptation into Spanish\u2014which substantiated the structural parameters referenced herein\u2014was directed by an interdisciplinary investigative team based at the University of Alicante (San Vicente del Raspeig, Alicante, Spain):<\/p>\n The core clinical and scientific imperative underlying the creation and worldwide deployment of the MSISQ-15 is the systematic elimination of barriers to diagnosing, understanding, and managing intimacy impairments in patients with chronic central nervous system diseases. Epidemiological investigations demonstrate that between 50% and 90% of men and 40% to 80% of women living with multiple sclerosis experience chronic alterations in sexual response, intimate connection, or reproductive health. Despite this marked prevalence, sexual dysfunction remains one of the most under-addressed complications of demyelinating illness. The clinical interaction often suffers from mutual avoidance: patients often feel reticent or embarrassed to raise concerns regarding their intimacy, while clinicians face acute time constraints, diagnostic ambiguity, and a lack of structured assessment apparatus, frequently prioritizing ambulatory, visual, or cognitive endpoints.<\/p>\n The MSISQ-15 resolves these clinical barriers by serving multiple distinct functions:<\/p>\n The psychological and physiological construct measured by the MSISQ-15 is Multiple Sclerosis-Related Sexual Dysfunction<\/em>. Within this psychometric framework, sexual health is conceptualized as an integrated biopsychosocial state vulnerable to disruption along multiple pathophysiological vectors. The construct does not treat sexual functioning as a simple mechanical reflex, but rather as an evolving continuum of physiological responsiveness, bodily mechanics, affective state, body image, and relational adjustment. The construct is operationalized into three distinct, interdependent dimensions:<\/p>\n This subscale assesses the direct consequence of central nervous system demyelination and axonal transection within the neural pathways that orchestrate human sexual response. Structural lesions situated in the brainstem, cerebral cortex, or the sacral, lumbar, and thoracic segments of the spinal cord interrupt autonomic and somatic reflex arcs. Specific manifestations measured by this dimension include:<\/p>\n This subscale evaluates the indirect sexual barriers generated by broader MS-related physical symptomatology and medical therapies that are not intrinsically sexual in nature, but physically compromise intimacy. Symptoms captured within this dimension include:<\/p>\n This subscale examines the affective, cognitive, interpersonal, and sociocultural sequelae of managing a chronic, unpredictable, and progressive neurological disease. Tertiary dysfunction represents the psychological fallout of chronic illness, encompassing:<\/p>\n The foundational architecture of the MSISQ-15 is grounded in the conceptual model of chronic illness sexual impairment first articulated by Frederick W. Foley, PhD<\/strong> and colleagues (Foley et al., 2001; Sanders et al., 2000). Foley synthesized neuro-urological principles with George Engel\u2019s Biopsychosocial Model<\/a>, establishing that chronic neurodegenerative conditions impact sexual functioning through three distinct tiers: primary, secondary, and tertiary impairment.<\/p>\n Historically, medical models conceptualized sexual dysfunction predominantly through biological reductionism, viewing sexual problems in neurological cohorts as mechanical disruptions of vascular or reflex arcs. Conversely, early psychoanalytic and purely psychological models attributed sexual difficulties in chronically ill individuals almost exclusively to neurotic inhibition, secondary gain, or reactive depression. Foley\u2019s tripartite framework reconciled these divergent paradigms into a coherent, interactive system:<\/p>\n A central premise of this theoretical model is bidirectional interactivity: primary neurological deficits frequently exacerbate tertiary anxieties, while secondary bodily fatigue or incontinence may trigger primary autonomic withdrawal via sympathetic stress activation. By isolating these three tiers, the MSISQ-15 operationalizes this biopsychosocial theory, providing a framework to assess, research, and address each component clinically.<\/p>\n Construct, convergent, and discriminant validity of the MSISQ-15 have been examined across international validation programs, with particular rigor demonstrated in the Spanish validation study conducted by Esteve-R\u00edos and colleagues (2023) alongside foundational North American and European trials.<\/p>\n Construct validity was demonstrated via structural equation modeling. Confirmatory factor analysis (CFA) substantiated that the theoretical tripartite model represents an optimal fit for empirical observation. Standardized factor loadings across all items were strong, statistically significant (p<\/em> < 0.001), and mapped consistently onto their designated primary, secondary, and tertiary latent dimensions<\/span>.<\/p>\n Convergent validity was evaluated by correlating MSISQ-15 dimension scores with established gender-specific sexual function inventories. When contrasted against the Male Sexual Function (FSH)<\/em> questionnaire and the Female Sexual Function-2 (FSM-2)<\/em> questionnaire, the MSISQ-15 yielded substantial, statistically significant negative correlations:<\/p>\n These negative correlation coefficients reflect expected scoring directions: higher scores on the MSISQ-15 represent greater sexual dysfunction and symptomatology, whereas higher scores on the FSH and FSM-2 signify superior, healthier sexual functioning. Convergent correlations were strongest within the Primary Causes subscale, confirming that items targeting genital numbness, lubrication deficits, erectile difficulties, and anorgasmia accurately reflect physiological sexual impairment.<\/p>\n Convergent validity was further demonstrated through comparison with health-related quality of life instruments. The MSISQ-15 demonstrated a moderate inverse correlation (r<\/em> = -0.39, p<\/em> < 0.001) with the Multiple Sclerosis International Quality of Life Questionnaire (MusiQoL)<\/em>. Higher levels of intimacy impairment were systematically associated with diminished global quality of life, affirming the functional impact of sexual well-being on overall chronic illness adjustment<\/span>.<\/p>\n Discriminant validity was verified through comparison with relationship satisfaction indices, specifically the Dyadic Adjustment Scale-13 (EAD-13 \/ DAS-13)<\/em>. Counter to initial intuitive assumptions, empirical analyses demonstrated a non-significant, near-zero correlation between MSISQ-15 scores and global dyadic adjustment (r<\/em> = -0.08 to -0.12, p<\/em> > 0.05). This psychometric divergence highlights an important clinical distinction: the presence of multiple sclerosis-related sexual dysfunction does not automatically produce relationship dissatisfaction. Dyads frequently mobilize adaptive coping mechanisms, emotional intimacy, and partner support, enabling marital stability and high relationship satisfaction to persist alongside substantial neurogenic sexual impairment<\/span>.<\/p>\n The reliability of the MSISQ-15 has been demonstrated across multiple psychometric investigations. In ordinal scale adaptations, researchers have placed particular emphasis on computing ordinal alpha and composite reliability coefficients, which provide unbiased estimates for categorical Likert distributions compared to traditional Pearson-based Cronbach’s alpha values.<\/p>\n In the seminal cross-cultural validation study by Esteve-R\u00edos et al. (2023) involving 208 MS patients, the instrument demonstrated high internal consistency across the total scale and its subscales:<\/p>\n These values align with the original American validation study conducted by Foley et al. (2013), in which Cronbach’s alpha values for the subscales ranged between 0.80 and 0.88 across a cohort of over 1,000 individuals with MS. Item-total correlations across validation studies consistently exceed the conventional psychometric threshold of 0.40, with individual item-rest coefficients ranging from 0.46 to 0.74, indicating that each item contributes reliably to its parent domain without excessive collinear redundancy.<\/p>\n Temporal stability evaluated across 2-to-4-week testing intervals under stable neurological conditions has demonstrated high reproducibility. Intraclass Correlation Coefficients (ICC) reported across various European cohorts (e.g., Dutch, Italian, and Polish adaptations) demonstrate stability ranging from ICC = 0.84 to ICC = 0.92, indicating that the instrument captures stable underlying constructs rather than transient daily fluctuations, while retaining sensitivity to longitudinal disease progression and therapeutic intervention<\/span>.<\/p>\n The structural dimensionality of the MSISQ-15 has been examined through both exploratory and confirmatory factor analytic frameworks. During the instrument’s initial abbreviation from the original 19-item questionnaire (MSISQ-19), four items exhibiting cross-loadings, weak factor specificity, or low conceptual relevance were systematically removed under exploratory factor analysis, resulting in a balanced 15-item instrument with three 5-item factors.<\/p>\n Because the MSISQ-15 items utilize an ordinal 5-point response format, conventional Maximum Likelihood (ML) estimation can distort parameter estimates and deflate standard errors. Modern validation studies, including Esteve-R\u00edos et al. (2023), employ Weighted Least Squares Mean and Variance adjusted (WLSMV)<\/strong> estimation applied to polychoric correlation matrices, which provides robust parameter estimation for categorical indicators.<\/p>\n CFA examining the theoretical three-factor correlated model (Primary, Secondary, and Tertiary Causes) has yielded strong goodness-of-fit indices across published cohorts:<\/p>\n Standardized factor loadings (\u03bb) across all 15 items demonstrate high salience:<\/p>\n Correlations between the three latent factors are moderate (ranging from r<\/em> = 0.45 to r<\/em> = 0.62), demonstrating that while the dimensions are related aspects of the overarching construct of MS-related sexual dysfunction, they maintain empirical distinctiveness, supporting the retention of separate subscale scores alongside the global total score<\/span>.<\/p>\n The technical parameters and administrative specifications of the MSISQ-15 are detailed below:<\/p>\n The 15-item revision of the Multiple Sclerosis Intimacy and Sexuality Questionnaire was published in 2013<\/strong> by Dr. Frederick W. Foley and colleagues. The comprehensive Spanish cross-cultural adaptation and structural validation study was published in 2023<\/strong> by Antonio Esteve-R\u00edos, Mar\u00eda Jos\u00e9 Caba\u00f1ero-Mart\u00ednez, Silvia Escribano, Frederick Foley, and Sof\u00eda Garc\u00eda-Sanju\u00e1n.<\/p>\n Licensing and Clinical Usage Permissions:<\/strong> The MSISQ-15 is generally available for clinical practice and non-commercial academic research. While the published validation studies (such as the Esteve-R\u00edos et al., 2023 open-access publication in PeerJ<\/em>) outline its psychometric properties and structural framework, researchers and clinicians intending to implement the MSISQ-15 in official trials, institutional registries, or commercial interventions should obtain appropriate administrative permissions from the scale developer (Dr. Frederick Foley) or the authors of the respective language adaptation. The tool is typically distributed free of royalty fees for non-profit and academic research endeavors, consistent with clinical research standards for neuro-rehabilitation outcome measures.<\/p>\n Akoglu, H. (2018). User’s guide to correlation coefficients. Turkish Journal of Emergency Medicine<\/em>, 18(3), 91\u201393. https:\/\/doi.org\/10.1016\/j.tjem.2018.08.001<\/a><\/p>\n Altmann, P., Leutmezer, F., Zach, H., Wurm, S., Stattmann, M., Ponleitner, M., & Rommer, P. S. (2021). Sexuality and multiple sclerosis: Patient and doctor perspectives. The Journal of Sexual Medicine<\/em>, 18(4), 743\u2013751. https:\/\/doi.org\/10.1016\/j.jsxm.2021.01.178<\/a><\/p>\n Blackmore, D., McCabe, M., & Simpson, D. (2011). Improvements in partner support predict sexual satisfaction among individuals with multiple sclerosis. Rehabilitation Psychology<\/em>, 56(2), 117\u2013122. https:\/\/doi.org\/10.1037\/a0023362<\/a><\/p>\n Carotenuto, A., Cellerino, M., Cocco, E., Brescia Morra, V., & Moccia, M. (2021). Validation of the Italian version of the Multiple Sclerosis Intimacy and Sexuality Questionnaire-19. Neurological Sciences<\/em>, 42(7), 2903\u20132909. https:\/\/doi.org\/10.1007\/s10072-020-04873-w<\/a><\/p>\n Carrillo, N., Garc\u00eda-V\u00e1zquez, R., & Mart\u00ednez-Gin\u00e9s, M. L. (2020). Herramientas para la evaluaci\u00f3n integral de la funci\u00f3n sexual en pacientes con esclerosis m\u00faltiple [Tools for comprehensive evaluation of sexual function in patients with multiple sclerosis]. Neurolog\u00eda<\/em>, 38(3), 197\u2013205. https:\/\/doi.org\/10.1016\/j.nrl.2020.04.028<\/a><\/p>\n Celik, D. B., Poyraz, E. C., Bing\u00f6l, A., Idiman, E., & Ozakbas, S. (2013). Sexual dysfunction in multiple sclerosis: Gender differences. Journal of the Neurological Sciences<\/em>, 324(1-2), 17\u201320. https:\/\/doi.org\/10.1016\/j.jns.2012.08.019<\/a><\/p>\n Delaney, K. E., & Donovan, J. (2017). Multiple sclerosis and sexual dysfunction: A need for further education and interdisciplinary care. NeuroRehabilitation<\/em>, 41(2), 317\u2013329. https:\/\/doi.org\/10.3233\/NRE-172200<\/a><\/p>\n Devis, B., Gout, O., & Zuber, M. (2022). Validation of the French version of the Multiple Sclerosis Intimacy and Sexuality Questionnaire-19: A preliminary study. Multiple Sclerosis and Related Disorders<\/em>, 65, Article 103986. https:\/\/doi.org\/10.1016\/j.msard.2022.103986<\/a><\/p>\n Dogan, M., Kurne, A., & Karaduman, A. (2022). The Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ): Validation of the Turkish version in patient with multiple sclerosis. Multiple Sclerosis and Related Disorders<\/em>, 64, Article 103965. https:\/\/doi.org\/10.1016\/j.msard.2022.103965<\/a><\/p>\n Drulovic, J., Kisic-Tepavcevic, D., & Pekmezovic, T. (2020). Epidemiology, diagnosis and management of sexual dysfunction in multiple sclerosis. Acta Neurologica Belgica<\/em>, 120(4), 791\u2013797. https:\/\/doi.org\/10.1007\/s13760-020-01323-4<\/a><\/p>\n Esteve-R\u00edos, A., Caba\u00f1ero-Mart\u00ednez, M. J., Escribano, S., Foley, F., & Garc\u00eda-Sanju\u00e1n, S. (2023). Multiple Sclerosis Intimacy and Sexuality Questionnaire-15: Cross-cultural adaptation and psychometric validation of the Spanish version. PeerJ<\/em>, 11, Article e15138. https:\/\/doi.org\/10.7717\/peerj.15138<\/a><\/p>\n Fern\u00e1ndez, O., Baumstarck-Barrau, K., Simeoni, M. C., & Auquier, P. (2011). Validation of the Spanish version of the Multiple Sclerosis International Quality of Life (MusiQoL) questionnaire. BMC Neurology<\/em>, 11(1), Article 127. https:\/\/doi.org\/10.1186\/1471-2377-11-1<\/a><\/p>\n Foley, F. W., Zemon, V., Campagnolo, D., Picone, M. A., Caruso, L. S., Schneider, W. J., & The MS Intimacy and Sexuality Study Group. (2013). The Multiple Sclerosis Intimacy and Sexuality Questionnaire\u2014Re-validation and development of a 15-item version with a large US sample. Multiple Sclerosis Journal<\/em>, 19(9), 1197\u20131203. https:\/\/doi.org\/10.1177\/1352458512471876<\/a><\/p>\n Foley, F. W., Werner, M. A., & Sanders, A. S. (2001). Assessment and treatment of sexual dysfunction in multiple sclerosis. In R. Kalb (Ed.), Multiple Sclerosis: The Questions You Have\u2014The Answers You Need<\/em> (2nd ed., pp. 201\u2013230). Demos Medical Publishing.<\/p>\n Hu, L. T., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal<\/em>, 6(1), 1\u201355. https:\/\/doi.org\/10.1080\/10705519909540118<\/a><\/p>\n Lefebvre, C., Devis, B., & Brochet, B. (2023). Validation of the French version of the Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 tools which helps nurse for assessing the effect of perceived multiple sclerosis symptoms on sexual activity and satisfaction. Nursing Open<\/em>, 10(2), 570\u2013578. https:\/\/doi.org\/10.1002\/nop2.1323<\/a><\/p>\n Lew-Starowicz, M., & Rola, R. (2015). Sexual dysfunction in patients with multiple sclerosis. In F. Boller (Ed.), Handbook of Clinical Neurology<\/em> (Vol. 130, pp. 357\u2013370). Elsevier. https:\/\/doi.org\/10.1016\/B978-0-444-63247-0.00020-1<\/a><\/p>\n McCabe, M. P., McDonald, E., Deeks, A. A., Vowels, L. M., & Hearn, M. T. (1996). The impact of multiple sclerosis on sexuality and relationships. The Journal of Sex Research<\/em>, 33(3), 241\u2013248. https:\/\/doi.org\/10.1080\/00224499609551840<\/a><\/p>\n Mohammadi, K., Rahnama, P., Montazeri, A., & Foley, F. W. (2014). The Multiple Sclerosis Intimacy and Sexuality Questionnaire-19: Reliability, validity, and factor structure of the Persian version. The Journal of Sexual Medicine<\/em>, 11(9), 2225\u20132231. https:\/\/doi.org\/10.1111\/jsm.12531<\/a><\/p>\n Monti, M., Marcheselli, L., & Tognoni, G. (2020). The Multiple Sclerosis Intimacy and Sexuality Questionnaire-15 (MSISQ-15): Validation of the Italian version for individuals with spinal cord injury. Spinal Cord<\/em>, 58(10), 1128\u20131136. https:\/\/doi.org\/10.1038\/s41393-020-0469-8<\/a><\/p>\n Noordhoff, T. C., Scheepe, J. R., & Blok, B. F. (2018). The Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ-15): Validation of the Dutch version in patients with multiple sclerosis and spinal cord injury. Neurourology and Urodynamics<\/em>, 37(8), 2867\u20132874. https:\/\/doi.org\/10.1002\/nau.23804<\/a><\/p>\n Przydacz, M., Chlosta, P., & Foley, F. W. (2021). The Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ-15): Translation, adaptation and adaptation of the Polish version for patients with multiple sclerosis and spinal cord injury. BMC Neurology<\/em>, 21(1), Article 103. https:\/\/doi.org\/10.1186\/s12883-021-02132-9<\/a><\/p>\n Rhemtulla, M., Brosseau-Liard, P. \u00c9., & Savalei, V. (2012). When can categorical variables be treated as continuous? A comparison of robust continuous and categorical SEM estimation methods under suboptimal conditions. Psychological Methods<\/em>, 17(3), 354\u2013373. https:\/\/doi.org\/10.1037\/a0029315<\/a><\/p>\n Sanders, A. S., Foley, F. W., LaRocca, N. G., & Zemon, V. (2000). The Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19). Sexuality and Disability<\/em>, 18(1), 3\u201326. https:\/\/doi.org\/10.1023\/A:1005421627154<\/a><\/p>\n Santos-Iglesias, P., Vallejo-Medina, P., & Sierra, J. C. (2009). Propiedades psicom\u00e9tricas de una versi\u00f3n breve de la Escala de Ajuste Di\u00e1dico en muestras espa\u00f1olas [Psychometric properties of a brief version of the Dyadic Adjustment Scale in Spanish samples]. International Journal of Clinical and Health Psychology<\/em>, 9(3), 501\u2013517.<\/p>\n Schairer, L. C., Foley, F. W., Zemon, V., Tyry, T., Campagnolo, D., Vollmer, T., & Cutter, G. (2014). The impact of sexual dysfunction on health-related quality of life in people with multiple sclerosis. Multiple Sclerosis Journal<\/em>, 20(5), 610\u2013616. https:\/\/doi.org\/10.1177\/1352458513503598<\/a><\/p>\n Spanier, G. B. (1976). Measuring dyadic adjustment: New scales for assessing the quality of marriage and similar dyads. 2. Keywords<\/h2>\n
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mariajose.cabanero@ua.es<\/code>).<\/li>\n4. Purpose<\/h2>\n
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Primary Sexual Dysfunction (Items 1\u20135)<\/h3>\n
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Tertiary Sexual Dysfunction (Items 11\u201315)<\/h3>\n
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9. Factor Analysis<\/h2>\n
Confirmatory Factor Analysis (CFA) Methodology<\/h3>\n
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Factor Loadings and Latent Intercorrelations<\/h3>\n
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