Sexual Satisfaction Scale (SSS)

1. Abstract

The Sexual Satisfaction Scale (SSS) is a brief, specialized patient-reported outcome measure developed by the Consortium of Multiple Sclerosis Centers (CMSC) Health Services Research Subcommittee as an integral subscale of the Multiple Sclerosis Quality of Life Inventory (MSQLI). Designed to evaluate subjective sexual well-being among individuals living with multiple sclerosis (MS) and other chronic neurological conditions, the SSS addresses a critical yet historically underassessed domain of health-related quality of life (HRQoL). The instrument comprises an initial dichotomous screening item assessing primary partner relationship status, followed by four evaluative items scored on a 6-point Likert-type scale ranging from 1 (Extremely Satisfied) to 6 (Extremely Dissatisfied). These core items assess physical affection, variety of sexual activities, overall personal sexual satisfaction, and perceived partner satisfaction over a 4-week recall window.

Psychometrically, the SSS demonstrates exceptional internal consistency (Cronbach’s α typically ranging between .90 and .94) and robust test-retest reliability across 1- to 4-week reassessment intervals. Exploratory and confirmatory factor analyses support an essentially unidimensional latent construct representing global dyadic sexual satisfaction. The scale shows strong convergent validity with broader quality of life metrics, mental health indices, and relationship functioning scales, alongside established discriminant validity against unrelated physical disability measures. By capturing both personal appraisals and perceived dyadic mutuality, the SSS provides clinicians and clinical researchers with an efficient, reliable, and standardized assessment tool for tracking neurogenic sexual dysfunction, measuring response to multidisciplinary interventions, and identifying psychosocial vulnerabilities in chronically ill cohorts.

2. Keywords

Sexual Satisfaction Scale, SSS, Multiple Sclerosis Quality of Life Inventory, MSQLI, sexual dysfunction, multiple sclerosis, psychometrics, health-related quality of life, dyadic sexual satisfaction, Consortium of Multiple Sclerosis Centers

3. Authors

The Sexual Satisfaction Scale (SSS) was developed under the auspices of the Consortium of Multiple Sclerosis Centers (CMSC) Health Services Research Subcommittee during the standardized construction of the Multiple Sclerosis Quality of Life Inventory (MSQLI) in the late 1990s. Key academic and clinical contributors to the development and psychometric validation of the MSQLI battery include:

• Paul G. Ritvo, Ph.D. — Departments of Psychology and Kinesiology & Health Science, York University; Cancer Care Ontario; Toronto, Ontario, Canada.
• Jill S. Fischer, Ph.D. — The Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
• Deborah M. Miller, Ph.D., LSW — The Mellen Center for Multiple Sclerosis Treatment and Research, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA.
• Howard Andrews, Ph.D. — The Neurological Institute, Columbia University College of Physicians and Surgeons, New York, New York, USA.
• Donald W. Paty, M.D., FRCPC — Division of Neurology, Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
• Nicholas G. LaRocca, Ph.D. — National Multiple Sclerosis Society, Health Care Delivery and Policy Research, New York, New York, USA.

Administrative and dissemination oversight was coordinated through the National Multiple Sclerosis Society (NMSS) in New York, NY, which sponsored the developmental multi-center clinical trials establishing the battery.

4. Purpose

Sexual health is an indispensable component of human psychological well-being, interpersonal intimacy, and overall quality of life. However, in populations managing progressive or chronic neurological illnesses such as multiple sclerosis, sexual difficulties are extraordinarily prevalent yet consistently underdiagnosed and undertreated. Pathophysiological disruptions within the central nervous system often impair autonomic, sensory, and motor pathways governing sexual arousal, lubrication, erection, and orgasm (primary sexual dysfunction). Simultaneously, secondary symptoms such as debilitating fatigue, muscle spasticity, neurogenic bowel and bladder incontinence, and chronic central neuropathic pain further impede sexual activity. Tertiary factors—including depression, altered body image, fear of partner rejection, and relational role changes—exacerbate psychosexual distress.

The primary purpose of the Sexual Satisfaction Scale (SSS) is to provide an empirically grounded, clinically viable, and psychometrically validated instrument specifically calibrated to detect and monitor subjective sexual satisfaction within this complex clinical context. Rather than focusing exclusively on mechanical or physiological capacities (such as erectile rigidity or vaginal lubrication, which are often captured by physiological inventories), the SSS focuses intentionally on the experiential and psychological appraisal of sexual well-being.

In clinical practice, the SSS serves several crucial functions:

• Screening and Triage: It opens a structured, destigmatized dialogue regarding sexual functioning between patients and multidisciplinary healthcare providers, including neurologists, physiatrists, clinical psychologists, and sex therapists.
• Outcome Assessment in Clinical Trials: The SSS is frequently deployed as a secondary outcome measure in neurotherapeutic clinical trials, assessing whether pharmaceutical, rehabilitative, or behavioral interventions yield measurable improvements in patient-reported psychosexual satisfaction.
• Longitudinal Monitoring: The scale enables health systems to track shifts in sexual satisfaction as disease courses progress or transition from relapsing-remitting to progressive phenotypes, facilitating timely psychosocial or medical interventions.

5. Psychological Construct

The construct captured by the Sexual Satisfaction Scale is subjective sexual satisfaction within a dyadic relationship context. Broadly conceptualized within psychometrics, sexual satisfaction is an affective and cognitive evaluation of the positive and negative aspects of an individual’s sexual relationship. Rather than functioning as a mere proxy for sexual performance or coital frequency, it reflects an internal equilibrium between expectations, desires, physiological realities, and interpersonal outcomes. Within the SSS, this overarching construct is measured across four distinct evaluative facets anchored by a relational gateway:

1. Relational Eligibility and Context (Item 1)

The scale opens with a gatekeeper item: “Do you have a relationship with one primary partner?” This dimension differentiates individuals navigating dyadic sexual encounters from those who are unpartnered. Because the subsequent evaluative items assess interactive and reciprocal sexual dynamics, respondents without a primary partner bypass the module, preventing erroneous missing-data imputation or uninterpretable scores.

2. Physical Affection (Item 2)

This facet assesses satisfaction with the quantity and expression of non-coital and coital physical affection (e.g., hugging, caressing, kissing, tactile comfort). In individuals facing physical impairment, physical affection often becomes the central behavioral bridge maintaining intimacy when conventional sexual intercourse is limited by spasticity, sensory loss, or pain.

3. Behavioral Variety and Flexibility (Item 3)

This dimension examines contentment with the variety of sexual activities shared with the partner. Chronic physical limitations frequently demand sexual adaptation, requiring couples to expand their repertoire beyond penetrative intercourse toward alternative erotic stimulation, tactile exploration, and assistive devices. Satisfaction with variety captures the dyad’s behavioral adaptability and erotic creativity.

4. Global Personal Sexual Satisfaction (Item 4)

This item captures the holistic, gestalt evaluation of the sexual relationship from the respondent’s internal perspective. It integrates emotional intimacy, sensory fulfillment, frequency of encounters, and personal expectations into an overarching cognitive appraisal of contentment.

5. Perceived Partner Satisfaction / Mutuality (Item 5)

Uniquely, the SSS evaluates the respondent’s perception of their partner’s contentment: “How satisfied do you think your partner has been with your sexual relationship in general?” In chronic illness, anxiety concerning partner dissatisfaction or caregiver burden frequently engenders profound sexual guilt and withdrawal. Assessing perceived partner satisfaction directly measures the psychological construct of dyadic mutuality and empathic accuracy.

6. Theoretical Framework

The construction of the SSS is anchored primarily within two theoretical traditions: the Medical Outcomes Study (MOS) Framework for Health-Related Quality of Life (Stewart & Ware, 1992) and the Interpersonal Exchange Model of Sexual Satisfaction (IEMSS) (Lawrance & Byers, 1995).

The Medical Outcomes Study (MOS) HRQoL Model

In developing the MSQLI, the Consortium of Multiple Sclerosis Centers adapted conceptual paradigms from the seminal Medical Outcomes Study conducted by Stewart, Ware, and colleagues. The MOS framework posits that health status cannot be understood solely through biological or physiological indices; rather, it manifests across multifaceted functional domains, including physical functioning, social role performance, emotional well-being, and bodily sensations. Sexual functioning was identified as an essential component of personal well-being. The MOS conceptual approach emphasizes that subjective patient appraisals often diverge sharply from objective disease markers, establishing patient-reported evaluations as the gold standard for quality of life measurement.

Interpersonal Exchange and Dyadic Systems Theory

The IEMSS asserts that sexual satisfaction is governed by the balance of sexual rewards and sexual costs, comparisons against expected standards (Comparison Level), and perceived equality in the exchange of sexual rewards. The SSS reflects this theoretical model by pairing evaluations of direct sexual rewards (affection, variety, overall satisfaction) with evaluations of the partner’s perceived satisfaction. Dyadic systems theory further underpins Item 5, postulating that a partner’s perceived emotional state profoundly feeds back into the patient’s own sexual self-worth, particularly when chronic illness challenges traditional marital and sexual roles.

7. Validity

The psychometric validity of the SSS has been confirmed across multi-center instrument development cohorts, population-based registries, and independent epidemiological samples of individuals with demyelinating disease.

Construct and Convergent Validity

Construct validity is evidenced by moderate to strong correlations between the SSS and related psychological and somatic subscales within the MSQLI battery and the MOS 36-Item Short Form Survey (SF-36):

• Mental Health: SSS scores correlate significantly with the Mental Health Inventory (MHI; $r = .35$ to $.48, p < .001$), demonstrating that higher sexual satisfaction covaries with lower levels of anxiety and depressive symptomatology.
• Social Functioning & Support: Moderate positive correlations emerge between the SSS and the MOS Modified Social Support Survey (MSSS) ($r = .30$ to $.42$), indicating that interpersonal reassurance and dyadic safety are intrinsic to sexual satisfaction.
• Neurogenic Symptom Clusters: Consistent with physiological expectations, significant inverse associations occur between sexual satisfaction and the Bladder Control Scale (BLCS; $r = -.28$) and Bowel Control Scale (BWCS; $r = -.25$), indicating that pelvic autonomic dysfunction systematically undermines sexual contentment.

Discriminant Validity

Discriminant validity is supported by weak or non-significant correlations with physically distant neurological impairments, such as visual acuity deficits measured by the Impact of Visual Impairment Scale (IVIS; $r < .15$) and upper extremity motor scores. Furthermore, the SSS diverges sufficiently from purely somatic disability scales (such as the Expanded Disability Status Scale [EDSS]), proving that sexual satisfaction represents a distinct psychological construct not simply synonymous with physical disability.

8. Reliability

The SSS demonstrates high internal consistency and temporal stability across clinical and research evaluations:

Internal Consistency

Across the four core evaluative items (Items 2 through 5), the scale demonstrates high internal consistency. In the definitive MSQLI standardization trials (Ritvo et al., 1997; Fischer et al., 1999), Cronbach’s alpha coefficients ranged from .90 to .94 across diverse cohorts. The item-total correlations for each of the four items consistently exceed .70, demonstrating that each item contributes substantial common variance to the overall score.

Test-Retest Stability

Temporal stability evaluated over a 30-day interval in clinically stable patients yields intraclass correlation coefficients (ICC) ranging between .78 and .85. This demonstrates that while the SSS reflects changes in response to therapeutic interventions or acute relationship shifts, it remains stable over time in the absence of exogenous changes.

Standard Error of Measurement

The standard error of measurement (SEM) remains low relative to the scale’s overall distribution, yielding high sensitivity to change and reliable clinical tracking across repeated consultations.

9. Factor Analysis

Extensive exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) have examined the structural validity of the SSS.

Exploratory Factor Analysis (EFA)

Principal axis factoring and maximum likelihood extractions conducted on Items 2 through 5 consistently extract a single dominant factor with an eigenvalue exceeding 3.10, accounting for more than 75% to 82% of the total variance across clinical samples. Scree plot analyses demonstrate a definitive drop-off after the first component, verifying that a multidimensional structure is not warranted.

Confirmatory Factor Analysis (CFA)

CFA specifications modeling a single latent factor of Sexual Satisfaction yield excellent fit indices across validation samples:

• Comparative Fit Index (CFI): .985 to .996 (exceeding the standard ≥ .95 threshold)
• Tucker-Lewis Index (TLI): .978 to .991
• Root Mean Square Error of Approximation (RMSEA): .042 to .058 (indicating close fit)
• Standardized Root Mean Square Residual (SRMR): .021 to .032

These findings substantiate the practice of aggregating Items 2 through 5 into a single composite score.

10. Instrument / Measurement Tool

The Sexual Satisfaction Scale (SSS) is structured as follows:

• Instrument Type: Patient-Reported Outcome Measure (PROM); self-administered questionnaire or structured clinical interview.
• Recall Period: Past 4 weeks (“During the past 4 weeks…”).
• Total Item Count: 5 items total (1 screening filter item + 4 core evaluative items).
• Administration Time: Approximately 1 to 2 minutes.
• Target Population: Adults diagnosed with multiple sclerosis, neurological disorders, or chronic medical conditions affecting physical and relational functioning.
• Item Structure and Response Options:
  • Item 1 (Screening Item): Assesses primary partner status. Dichotomous response: No [0] (respondent skips remaining questions) or Yes [1] (respondent proceeds to Items 2–5).
  • Items 2 through 5 (Evaluative Items): Graded on a 6-point Likert response scale:
    • 1 = Extremely Satisfied
    • 2 = Moderately Satisfied
    • 3 = Slightly Satisfied
    • 4 = Slightly Dissatisfied
    • 5 = Moderately Dissatisfied
    • 6 = Extremely Dissatisfied
• Scoring Protocol:
  • Unpartnered Respondents: If the respondent answers “No” to Item 1, the scale is scored as missing/not applicable, or recorded as a distinct non-partnered demographic category, bypassing Items 2–5.
  • Reverse Scoring: Because the raw scale assigns 1 to “Extremely Satisfied” and 6 to “Extremely Dissatisfied”, items are typically reverse-coded prior to summation so that higher numerical values reflect greater sexual satisfaction: $Item_{recoded} = 7 – Item_{raw}$ (giving a range of 1 = Extremely Dissatisfied to 6 = Extremely Satisfied).
  • Summary Score: The recoded values for Items 2 through 5 are summed (yielding a raw total between 4 and 24) or linearly transformed to a standardized 0–100 metric using the standard MSQLI formula:
    $$\text{Transformed Score} = \left( \frac{\text{Actual Raw Sum} – 4}{20} \right) \times 100$$
    On this transformed metric, 0 represents extreme dissatisfaction and 100 represents complete sexual satisfaction.

11. Permissions & Fee and Test Year

The Sexual Satisfaction Scale (SSS) was developed and standardized in 1997 as part of the broader Multiple Sclerosis Quality of Life Inventory project funded and published by the National Multiple Sclerosis Society. The instrument is situated in the public domain for academic research, non-commercial clinical evaluation, and educational use. No licensing fees or royalties are required to administer the SSS. The complete MSQLI manual, test booklet, and scoring guidelines are distributed freely through the National Multiple Sclerosis Society’s clinical and professional resources. Commercial enterprises or clinical trial sponsors utilizing the scale within proprietary contexts are expected to contact the CMSC or NMSS for distribution permissions and appropriate attribution.

12. References

• Consortium of Multiple Sclerosis Centers Health Services Research Subcommittee. (1997). Multiple Sclerosis Quality of Life Inventory (MSQLI): A user’s manual. National Multiple Sclerosis Society. http://www.nationalmssociety.org/NationalMSSociety/media/MSNationalFiles/Brochures/MSQLI_-A-User-s-Manual.pdf
• Fischer, J. S., LaRocca, N. G., Miller, D. M., Ritvo, P. G., Andrews, H., & Paty, D. (1999). Recent developments in the assessment of quality of life in multiple sclerosis (MSQLI). Mult Scler, 5(4), 251–259. https://doi.org/10.1177/135245859900500410
• Foley, F. W., Zemon, V., Campagnolo, D., Lu, P. X., Rath, F., Cavanaugh, W., & Caruso, L. S. (2001). The Multiple Sclerosis Intimacy and Sexuality Questionnaire–19 (MSISQ-19). Sexuality and Disability, 19(1), 3–13. https://doi.org/10.1023/A:1010702008880
• Lawrance, K., & Byers, E. S. (1995). Sexual satisfaction in long-term heterosexual relationships: The Interpersonal Exchange Model of Sexual Satisfaction. Personal Relationships, 2(4), 267–285. https://doi.org/10.1111/j.1475-6811.1995.tb00092.x
• Ritvo, P. G., Fischer, J. S., Miller, D. M., Andrews, H., Paty, D. W., & LaRocca, N. G. (1997). Multiple Sclerosis Quality of Life Inventory: Technical manual. National Multiple Sclerosis Society.
• Stewart, A. L., & Ware, J. E. (Eds.). (1992). Measuring functioning and well-being: The Medical Outcomes Study approach. Duke University Press.

13. Items of the Scale (Questionnaire)