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Quality of Life Research 9: 739±745, 2000.

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Ó 2001 Kluwer Academic Publishers. Printed in the Netherlands.

The McCoy Female Sexuality Questionnaire

Norma L. McCoy
Department of Psychology, San Francisco State University, San Francisco, USA

Accepted in revised form 15 March 2000

Abstract

The McCoy Female Sexuality Questionnaire (MFSQ) was developed from the questionnaire used in a
longitudinal study of the menopausal transition and designed to measure aspects of female sexuality likely
to be a€ected by changing sex hormone levels. The original questionnaire was revised to insure that
questions were easy to understand and that labels for the Likert scales described a continuum. The revised
MFSQ contains 19 questions, 18 items using 7-point Likert scales with labels at the center and endpoints
and one item requesting a frequency of activity. Seven studies involving both clinical and convenience
samples and two with double blind randomized controlled trials used 7, 9, 10 or 17 MFSQ items and
demonstrated acceptable reliability, internal consistency, apparent face and content validity as well as
considerable evidence of construct validity. Results showed selected MFSQ item ratings decreased as
women progressed through the menopausal transition, varied positively with endogenous estradiol and
androgen levels, were higher in postmenopausal women receiving hormone replacement therapy (HRT),
and di€erentiated between di€erent types of oral contraceptives and the presence or absence of ovaries.
Convergent validity was demonstrated for change in 9-item MFSQ score with change in psychological
general well-being (PGWB) score and the Women's Health Questionnaire (WHQ) sex life subscale.

Key words: McCoy Female Sexuality Questionnaire (MFSQ), Questionnaire, Sexuality, Women

Introduction presents problems for assessment of reliability and


validity, and has the e€ect of increasing the
It is virtually indisputable that the quality of a reporting of results for individual items with less
woman's sexual life plays a signi®cant role in her reporting and focus on total scores.
general or overall quality of life. The problem has
been valid measurement of the quality of a wom-
an's sexual life. Sexuality is inherently a sensitive Description
area wherein many relevant questions may be
viewed as an invasion of privacy. This problem of The MFSQ contains 19 questions, 18 answered
sensitivity is compounded because the acceptabil- using 7-point Likert scales that are labeled in the
ity of a particular question concerning sexuality middle and at the ends [1] and ask about the
varies from culture to culture, and no researcher subject's sexual experience during the last 4 weeks.
can a€ord to su€er signi®cant subject attrition due One question asks for a frequency of heterosexual
to asking a question concerning sexuality that is coitus during the last 4 weeks and answers to this
viewed as improper. The McCoy Female Sexuality question can also be converted to a 7-point Likert
Questionnaire (MFSQ) was developed with these scale for the purpose of conducting statistical
considerations in mind, but typically, researchers analysis or obtaining a total MFSQ score. In ad-
have eliminated questions from the scale with dition, if a total score is obtained, item 16, addi-
which they were not comfortable. This practice tional stimulation needed to reach orgasm, must be
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reverse scored. The 19 questions that currently available to woman who does not meet those
comprise the scale are listed in abbreviated form in requirements.
Table 1 with the middle descriptor omitted. Items Depending on respondents' reading skills and
7 and 8 are items that were added to the 17-item comfort level with sexuality, the MFSQ typically
MFSQ to measure attractivity that subsequently takes no more than 10 min for women to com-
increased the number of items in the questionnaire plete. The 19-item MFSQ is available in French
to 19. and English, and a 9-item MFSQ (items 1±4, 10,
Questions 1±12 can be answered by lesbian as 11, 14, 17, 18) has been translated into French,
well as heterosexual women as long as they have Swedish, Norwegian, and Danish [2].
engaged in sexual activity during the last 4 weeks.
Questions 13±19 assume heterosexual intercourse
and a woman who has not had coitus during the Development
last 4 weeks is instructed to stop after question 12.
The issue of whether a woman has a sex partner or The MFSQ was developed from the questionnaire
not is one confronted by everyone who studies used in the longitudinal study of the menopausal
sexuality; it cannot be avoided. One can solve it by transition period conducted in the Physiology
studying only women with or only women without Department at Stanford University from 1979
partners. One may, of course, study both groups until 1986 [3±6]. The questionnaire was designed to
by prorating scores, or by analyzing data sepa- measure major aspects of female sexuality and
rately for each group, or by conducting some of particularly those aspects of female sexuality likely
the analyses on those questions that both groups to be a€ected by changes in sex hormone levels.
can answer. For all questions on the MFSQ that Common variables that may a€ect sexuality as
presume a partner or sexual activity during the last measured by the MFSQ include menopause, age,
4 weeks, `not applicable' (NA) is a response choice the use of exogenous sex hormones and various

Table 1. McCoy Female Sexuality Questionnaire content

Questionnaire items 7-point Likert scales labels for 1 and 7

General sexuality/sexual interest


(1) Enjoyment of sexual activity Not at all enjoyable ± extremely enjoyable
(2) Satisfaction with frequency of sexual activity Too infrequent ± too frequent
(3) Frequency of sexual thoughts and fantasies Never ± more than ten times a day
(4) Excitement/arousal during sexual activity Not at all excited ± extremely excited
(5) Level of sexual interest Extremely low ± extremely high
(6) Vaginal lubrication Absent ± excessive
(7) Sexually attractive, generally Not at all sexually attractive ± extremely
sexually attractive
(8) Sexually attractive, to partner Not at all sexually attractive ± extremely
sexually attractive
(9) Decreased satisfaction due to Every time ± never
partner's disinterest
(10) Satisfaction with partner as lover Not at all satis®ed ± extremely satis®ed
(11) Satisfaction with partner as friend Not at all satis®ed ± extremely satis®ed
Sexual intercourse
(12) Frequency (past 4 weeks) (Reported frequency)
(13) Enjoyment of sexual intercourse Not at all enjoyable ± extremely enjoyable
(14) Frequency of orgasm Never ± every time
(15) Pleasure of orgasm Slightly pleasurable ± extremely pleasurable
(16) Additional stimulation needed Never ± every time
to reach orgasm
(17) Insucient lubrication Every time ± never
(18) Painful sexual intercourse Every time ± never
(19) Erectile problems, partner Every time ± never
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drugs, as well as reproductive surgery, and chronic Table 2. Factors extracted from 17-item MFSQ using principal
disease. Whereas items 10, 11 and 19 (see Table 1) components analysis with oblique rotation [7]
concern the sexual partner, a woman whose ca- Factor labels and items Factor
pacity to respond sexually has been diminished (% variance explained) loadings
may well believe her partner to be the source of her
I. Sexual interest (23.1)
decreased sexual responsiveness. Thus, such ques- (1) Enjoyment of sexual activity 0.79
tions are appropriately included in the MFSQ. (5) Level of sexual interest 0.76
Following the longitudinal study [3] of the (3) Frequency of sexual thoughts and fantasies 0.56
menopausal transition, the questionnaire was (4) Excitement/arousal during sexual activity 0.51
modi®ed as a result of the experience using it II. Satisfaction frequency sexual activity (11.1)
during that study. Revisions involved making sure (2) Satisfaction with frequency of sexual activity 0.82
(12) Frequency of sexual intercourse )0.67
the questions were simple and easy to understand
(reported past 4 weeks)
as well as making sure that the labels at the ends (9) Decreased satisfaction due to partner's )0.50
and middle of the 7-point Likert scales described a disinterest
continuum rather than discrete categories. The III. Vaginal lubrication (8.3)
revised 17-item MFSQ was then used in a study of (6) Vaginal lubrication 0.82
the e€ects of birth control pills on the sexuality of (17) Insucient lubrication 0.79
354 university women ranging in age from 18 to 26 (18) Painful sexual intercourse 0.34
[7]. Using these data from the 17-item MFSQ, a IV. Orgasm (7.7)
(16) Additional stimulation needed to reach 0.79
factor analysis was conducted and the ®ve factors
orgasm
that resulted are presented in Table 2. (14) Frequency of orgasm )0.77
The latest revision of the MFSQ addressed the (15) Pleasure of orgasm )0.58
lack of questions measuring sexual attractiveness. (13) Enjoyment of sexual intercourse )0.57
In 1976, Beach [8] described the three components V. Sex partner (7.3)
of the sexuality of female mammals. These com- (19) Erectile problems, partner 0.68
ponents were (1) proceptivity or sexual interest (11) Satisfaction with partner as friend 0.68
(10) Satisfaction with partner as lover 0.61
and behavior indicating sexual interest, (2) re-
sponsivity or sexual response and (3) attractivity
or sexual attractiveness. The original sex ques- dardized item a of 0.80. These unpublished data
tionnaire had many questions concerning sexual were derived from a convenience sample of 318
interest and response but only one question that women ranging in age from 17 to 70 with an
appeared to deal with attractivity (item 9). Thus, average age of 28.9 years.
when the questionnaire was revised, two new
questions dealing with sexual attractiveness (items
7 and 8) were added. Validity

The MFSQ has been successfully employed to


Reliability assess change in general sexual functioning with
clinical and non-clinical samples of perimeno-
Employing a convenience subsample of university pausal women. The MFSQ appears to have face
women, test±retest correlations for individual and content validity in that the sexual topics cov-
items following a 2-week interval ranged from ered are viewed as important by consensus of
0.69 to 0.95 with an average test±retest correlation researchers in the ®eld. This becomes clear if one
of 0.83. In the study of birth control pills and examines the results of studies reporting on aspects
sexuality [7], the 17-item MFSQ had an internal of sexuality shown to change as a function of the
consistency a of 0.74 and a standardized item a of menopausal transition [9]. It also appears that
0.77. Using an unpublished data set from the 19- research ®ndings support the construct validity of
item MFSQ, correlations between the 19 single the scale in that they are consistent with other
items and the total score ranged from 0.12 to 0.74. ®ndings and predictions based on prior knowl-
The internal consistency a was 0.76 with a stan- edge.
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In the longitudinal study using a non-clinical Table 3. Correlations of change in PGWB score with change in
convenience sample, for which the original ques- 9-item MFSQ item ratings for women treated with a placebo or
estradiol [10]
tionnaire was developed, women were followed for
varying lengths of time from before to a year or MFSQ items Placebo Estradiol
more after their last menstrual cycle [3]. Analyses
(1) Enjoyment of sexual activity 0.29** 0.49***
of the longitudinal data for 16 women collected (2) Satisfaction with frequency 0.20* 0.45***
every 3 months revealed that (item 3) frequency of of sexual activity
sexual thoughts and fantasies, (item 10) satisfaction (3) Frequency of sexual thoughts 0.08 0.11
with partner as lover showed signi®cant reduction, and fantasies
and (item 17) insucient vaginal lubrication had (4) Excitement/arousal during 0.18 0.46***
sexual activity
signi®cantly increased as a problem from pre- to (14) Frequency of orgasm )0.06 0.47***
post-menopause. (17) Insucient lubrication )0.25* 0.18**
In further work [4] using data from the above (18) Painful sexual intercourse 0.01 0.23*
longitudinal study, all women were selected who (10) Satisfaction with partner as 0.08 0.16
had experienced both very low as well as normal lover
(11) Satisfaction with partner 0.20 0.24*
levels of estradiol during the study. Their average as friend
responses to MFSQ items when estradiol levels
were low (<30 pg/ml) were compared with their * p < 0.05; ** p < 0.01; *** p < 0.0001.
average responses when estradiol levels were
within the normal range. When estradiol was low, for (item 1) enjoyment of sexual activity, (item 2)
women reported signi®cantly fewer (item 3) sexual satisfaction with frequency of sexual activity, (item
thoughts and fantasies, a signi®cant increase in the 4) excitement/arousal during sexual activity and
occurrence of (item 9) decreased satisfaction with (item 14) frequency of orgasm. Table 4 shows the
sex because of their partner's level of sexual interest correlations between change in several quality of
in them, signi®cantly decreased (item 10) satisfac- life (QOL) measures and change in (item 14) fre-
tion with partner as lover, and a signi®cant increase quency of orgasm . In contrast to subjects receiving
in (item 17) insucient vaginal lubrication, as well placebo, data from women receiving estradiol
as (item 18) painful sexual intercourse (dyspareu- revealed signi®cant correlations for increases in
nia). frequency of orgasm with positive change on all
Using a 9-item MFSQ (items 1±4, 10, 11, 14, 17, ®ve QOL instruments.
18) derived from the original questionnaire, two The second study [11], described as a centrally
studies [10, 11] were conducted comparing placebo randomized open trial was conducted in France
with the use of an estrogen patch (Estraderm, with 442 postmenopausal subjects having an
50 mcg/24 hour). In a double blind randomized average age of 50.8 years. This study utilized
and placebo controlled study conducted in Sweden the same 9 MFSQ items with the original 7-point
[10], the subjects were 242 postmenopausal women Likert scales collapsed into 5-point scales and
aged 45±65. After 12 weeks of treatment, women found convergent validity for the MFSQ items
receiving estrogen showed signi®cant improvement with the Women's Health Questionnaire(WHQ)
in (item 1) enjoyment of sexual activity, (item 2)
satisfaction with frequency of sexual activity, (item
Table 4. Correlations of change in MFSQ item 14 (frequency of
3) frequency of sexual thoughts and fantasies, (item orgasm) with change in the kupperman index (KI), psycholo-
17) insucient vaginal lubrication, and (item 18) gical general well-being (PGWB) index, Women's Health
painful sexual intercourse. As shown in Table 3, Questionnaire (WHQ), and the Nottingham Health Pro®le-I
this study also reported correlations between and -II (NHP-I, NHP-II) for women treated with placebo and
with estradiol for 12 weeks [10]
change in psychological general well-being [12]
(PGWB) scores with change in each of the 9 KI PGWB WHQ NHP-I NHP-II
MFSQ items. Change in 7 of 9 MFSQ items was
Placebo )0.14* )0.06 0.01 )0.09 )0.06
signi®cantly correlated with change in PGWB
Estradiol )0.37** 0.47*** )0.31* )0.41*** )0.36**
score for subjects receiving estradiol; signi®cant
correlations in the mid to high 0.40 s were found * p < 0.05; ** p < 0.001; *** p < 0.0001.
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[13, 14] sex life subscale, reproducing the same signi®cantly from non-users describing less (item
direction and magnitude of signi®cance. These 6) vaginal lubrication (p < 0.05), more (item 3)
authors also found a signi®cant positive di€erence frequency of sexual thoughts and fantasies, and a
in total score for the 9-item MFSQ (p < 0.005) higher (item 5) level of sexual interest. They also
after 6 months of treatment with the same estra- were signi®cantly higher (p < 0.05) on Factor II,
diol patch compared to women receiving symp- satisfaction frequency sexual activity (see Table 2).
tomatic treatment only. This ®nding needs to be A comparison between monophasic and triphasic
viewed in the context of an initial signi®cant OC users revealed that triphasic pill users had
di€erence in MFSQ scores after randomization higher ratings for (item 1) enjoyment of sexual
favoring those selected to receive estradiol activity (p < 0.03), (item 4) excitement/arousal
(p < 0.05). during sexual activity (p < 0.02), and had higher
Wiklund [15] used a standardized measure of the Factor I, sexual interest scores (p < 0.02) than
responsiveness to change, an e€ect size index, for monophasic users.
several QOL measures from a study [10] of post- FloÈter and his colleagues [17] examined andro-
menopausal women comparing estrogen with gen status and sexual life in a convenience sample
placebo. For the 9-item MFSQ, she reported an of 83 female nurses (aged 40±53) ± 45 premeno-
e€ect size of 0.36 for estrogen and 0.01 for place- pausal, 23 postmenopausal using hormone re-
bo. She pointed out that for all QOL measures placement therapy (HRT) and 15 not using HRT.
examined, the subscales pertaining to the more Employing a 10-item MFSQ (items 1±4, 10±12, 14,
disease speci®c dimensions were the most respon- 17, 18), the data revealed a signi®cant positive
sive to change. For the MFSQ, sex problems (items correlation between plasma androstenedione (A-4)
17, 18) had an e€ect size of 0.50 with estrogen and and the total 10-item MFSQ score as well as for
0.01 with placebo. (item 4) excitement/arousal during sexual activity
Nathorst-BoÈoÈs et al. [16], examined a clinical and subscores for desire (items 3 and 4) and sat-
convenience sample of 66 ovariectomized, hyster- isfaction (items 1±4, 14). For premenopausal
ectomized women, 33 receiving estrogen replace- women, the total 10-item MFSQ score was posi-
ment therapy (ERT) and 33 without such tively correlated with A-4, testosterone/sex hor-
replacement and compared them to 35 women mone-binding globulin ratio (T/SHBG), T and
who had experienced a hysterectomy only. The dehydroepiandrosterone sulfate; (item 4) excite-
total score on the 9 MFSQ items in Swedish were ment/arousal during sexual activity correlated
correlated 0.32 (p < 0.01) with insulin-like growth positively with T and T/SHBG but negatively with
factor-1 (IGF-1), as were the individual items age. For postmenopausal women not using HRT,
(item 1) enjoyment of sexual activity, (item 2) sat- there were signi®cant correlations for the desire
isfaction with frequency of sexual activity, and subscore (items 3 and 4) with A-4 and T/SHBG. A
(item 4) excitement/arousal during sexual activity. multiple regression analysis with sexual assessment
The ovariectomized, hysterectomized women with as the criterion variable and A-4, age, and T as
ERT reported signi®cantly more (item 3) frequency predictor variables found that A-4 was the most
of sexual thoughts and fantasies (p < 0.05) than important variable, independent of age and T. The
women with the same surgery but without ERT. correlation previously found [16] between IGF-1
Women who had experienced only hysterectomy and the MFSQ items was not replicated.
reported signi®cantly less problem with (item 17) In a randomized double blind study [2] of two
insucient vaginal lubrication than either the types of hormone replacement, 315 of 437 women
ovariectomized women with (p < 0.01) or those completed 48 weeks of treatment with either
without (p < 0.05) ERT and signi®cantly (item 1) tibolone or 17-b estradiol plus norethisterone
more enjoyment of sexual activity (p < 0.05) than acetate (E2/NETA). Using an abbreviated 7-item
the ovariectomized women with ERT. MFSQ (items 1±4, 10, 11, 14), all 7 items were
The revised 17-item MFSQ was used in a study signi®cantly improved over baseline in the tibolone
[7] of oral contraceptives (OC) and sexuality in a group while 5 items (1, 2, 4, 10, 11) were signi®-
non-clinical convenience sample of university cantly improved for the group using E2/NETA.
women. Findings revealed that OC users di€ered After 48 weeks of treatment, women using tibo-
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lone had signi®cantly higher scores on (item 1) porated into an existing questionnaire (Personal
enjoyment of sexual activity, (item 2) satisfaction Experiences Questionnaire) being used in an on-
with frequency of sexual activity, and on the sub- going longitudinal study [18] of the menopausal
score satisfaction (items 1, 3, 4, 14). There were transition period. However, these items as used are
strong signi®cant correlations between baseline not standard MFSQ items in that they vary in
and change for all 7 MFSQ items indicating that wording, utilize 5-point Likert scales, and the
lower the score at baseline, greater the propor- 3-part descriptors tailored to each MFSQ item to
tionate positive change in areas assessed by MFSQ express a continuum have been removed and
items at both 24 and 48 weeks of treatment. replaced by two discrete descriptors ± `not at all'
No published research has reported the rela- and `a great deal' for all items.
tionship between the 9-item and the 19-item
MFSQ. Using the unpublished data set described
in the section on reliability, the correlation be- Conclusion
tween the total score on all 19 MFSQ items with
the total score on the items of the 9-item MFSQ Given the intimate nature of female sexuality
was 0.88, r(318), p < 0.01. While this is reassur- and the fact that sexuality is often only one of
ing, clearly the amount of important information many variables studied, it is not surprising that
concerning sexuality from 9 vs. 19 items di€ers published research has used 7, 9 or 10 items
considerably. from the 19-item MFSQ and that no published
research has used all 19 items. Seven di€erent
published studies ± some small and some large ±
Current use of the MFSQ and problems have utilized the MFSQ; two of these studies
were double blind randomized control trials,
The MFSQ is currently being used in several four used clinical samples and three used non-
ongoing projects. As already discussed, it is not clinical convenience samples. The MFSQ as used
unusual for some of the items to be omitted due to has demonstrated acceptable reliability, internal
cultural sensitivity or the belief on the part of the consistency, obvious face and content validity,
investigators that certain items will not be and the results from published research provide
acceptable to their subjects. In addition, when considerable evidence of construct validity. Re-
sexuality is only one of many dependent variables search ®ndings suggest that item ratings decrease
being studied, the tendency has been to use fewer as women progress through the menopausal
items as a means of reducing the total number of transition and vary positively with endogenous
items to which subjects must respond. Reliability estradiol levels. Postmenopausal women receiving
and validity become more dicult to establish with various forms of HRT have shown higher item
the omission of items. To some extent, this results ratings than those without HRT. Monophasic as
in a commensurate focus on individual items as compared with triphasic OCs a€ect MFSQ-
well as on the total score. Some of the current use assessed female sexuality di€erentially. Women
of the MFSQ is in research projects on sublingual with intact ovaries have scored higher on se-
hormone replacement therapy in postmenopausal lected MFSQ items than women who have had
women, hormonal replacement therapy in female their ovaries removed. Higher levels of sex hor-
dialysis patients, health during the menopausal mones, particularly androgens have been associ-
transition period in Caucasian and African- ated with higher ratings on selected MFSQ
American women, surgical removal of the uterus items. Convergent validity has been demonstrat-
in women in which the cervix was either removed ed for change in total 9-item MFSQ score with
or retained and treatment (radiotherapy and sur- change in PGWB scores and also for change in
gery) for rectal carcinoma in women. Countries the WHQ sex life subscale.
involved in these projects include Spain, France, In the interests of improved knowledge con-
Sweden and the United States. cerning female sexuality and the factors that a€ect
In Australia, the subject matter of 9 items from it, it is hoped that future research will utilize more
the MFSQ (items 1±4, 10±12, 17, 18) were incor- fully the 19 items that constitute the complete
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MFSQ and barring this, that abbreviated versions therapy? A double blind placebo controlled study in post-
will respect the integrity of the scale. menopausal women. Acta Obstet Gynecol Scand 1993; 72:
656±660.
11. Limouzin-Lamothe M, Mairon N, Joyce CRB, Le Gal M.
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