Introduction
Given the relatively high prevalence of sexual dysfunctions in the general population and the lack of reliable and valid questionnaires in this area in Iran, a screening scale is necessary [1]. Sociocultural changes require health-related sectors to take this group of disorders more seriously than before [2, 3]. Based on current knowledge, there is a positive correlation between decreased quality of life and increased levels of sexual dysfunction in the general population [4]. According to comprehensive epidemiological studies, 20–30% of men experience at least one type of sexual dysfunction, and the prevalence of sexual dysfunction among men increases with age [5]. Although researchers in different parts of the world have focused on sexual dysfunctions, this category of disorders, especially erectile dysfunction, has not been systematically studied in Asian countries [5]. Studies conducted on the prevalence of sexual disorders indicate that these disorders are considered one of the serious mental health problems in our country [6].
 In summary, although there are questionnaires for assessing sexual disorders in our country, the study conducted by the authors indicates that there is currently no questionnaire available for screening sexual problems in the general population. Given the brevity of the Arizona sexual experience scale (ASEX) and its focus on the main areas of sexual disorders, this questionnaire would be an appropriate tool for identifying potential sexual problems in the general population. 
Therefore, this study aimed to evaluate the validity, reliability, and cutoff point of the ASEX among the Iranian male population.

Methods
The statistical population of the present analytical and descriptive study consisted of married men (aged 18-60 years) who were referred to Imam Khomeini and Roozbeh hospitals, as well as the urology clinic of Shariati Hospital, selected using a convenience sampling method. Initially, the five-item ASEX was translated into Persian by the researchers. For this purpose, the method recommended by the World Health Organization (WHO) was utilized [11].
To examine content validity, Lawshe’s criterion was used quantitatively, utilizing the content validity ratio (CVR) and content validity index (CVI). To assess the CVI, three criteria—simplicity, specificity (relevance), and clarity—were evaluated separately for each item on a 4-point Likert scale by a panel of experts. Finally, the CVI score was calculated by summing the agreement scores for each item that received ranks of 3 and 4 (the highest scores) and dividing by the total number of experts. According to Lawshe’s coefficient table, the minimum acceptable level for the CVR was set at 0.75, while for the CVI, it was set at 0.7. After summing the results and calculating the CVR and CVI, it was observed that the scores obtained for all items exceeded the acceptable criteria.
The indices were calculated using SPSS software, version 19. A paired t-test was employed to assess the reliability of the questionnaire. Cronbach’s α coefficient was also utilized to examine the internal consistency of the items. To determine the cut-off point of the Persian version of the questionnaire, a clinical psychiatric interview was conducted by a psychiatrist with all participants and sexual dysfunction was assessed based on DSM-V criteria. The sensitivity and cut-off point were estimated using the ROC curve.

Results
Eighty-four participants, including 40 male patients and 44 non-patients as controls, completed the demographic questionnaire and the Persian version of the ASEX. After one week, 67 participants answered the same questionnaire again. The minimum age was 26 years, and the maximum age was 60 years, with a Mean±SD of 41.36±9.630 years. The mean age in the patient group was 40.8 years, while in the healthy group, it was 38 years. The maximum frequency of sexual intercourse was 7 times a week and 30 times a month, with a minimum frequency of zero. Additionally, 35% of patients and 9% of healthy participants reported no comorbidities. Furthermore, 52.5% of patients and 15.9% of healthy participants were not using any medication.
The CVR and CVI for all items were higher than the standard level. Additionally, the values for the entire questionnaire were 4.87 and 2.85, respectively. The Cronbach’s α coefficient for the entire questionnaire was 0.831, indicating the appropriateness of the internal reliability of the questionnaire. In other words, the items of the Persian version of the ASEX effectively and accurately measure sexual dysfunctions. A high correlation was observed between the test and re-test scores of the questionnaire (Spearman’s rank correlation coefficient=0.993, P<0.0001). The paired t-test showed that the difference between the test and re-test scores was not statistically significant (P=0.766).
In the clinical interview using DSM-V criteria, the most common diagnosis among sexual dysfunctions was erectile dysfunction. There was no significant difference between the mean age, education level, and socioeconomic status of the control and patient groups (P=0.092, P=0.639, and P=0.230, respectively); however, there was a significant difference in the frequency of sexual intercourse between the two groups (control and patient) (P<0.05). The mean score of the questionnaire in the control group was 9.9±4.6, while in the patient group, it was 12.6±5.3, which was statistically significant (P=0.01). Sensitivity, specificity and cut-off point were estimated using the ROC curve. The area under the curve in the ROC graph was 99.8%, and the cut-off point was calculated as 11 (out of 20), with 100% specificity and 95% sensitivity. In other words, a score of 11 or more indicates the presence of a disorder. A cut-off point equal to or greater than 3 for questions 1 to 4 and a cut-off point equal to or greater than 2 for question 5 were determined to indicate sexual dysfunction.

Conclusion
The revised Persian version of the ASEX demonstrates validity, reliability, and an appropriate cut-off point for diagnosing sexual dysfunctions among men. Overall, the Persian version of the ASEX can be a useful and effective tool for screening and assessing sexual dysfunctions. Although it contains a limited number of questions, it is comprehensive enough for diagnosing sexual dysfunctions. Finally, it can be asserted that, within the context of Iranian culture and for a better understanding of sexual problems in Iranian male society, this questionnaire is more effective than the original version.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the Vice Chancellor for Research at Tehran University of Medical Sciences, Tehran, Iran (Code: 3984).

Funding
This study did not receive any financial support from funding organizations in the public, commercial, or non-profit sectors.

Authors' contributions
Conceptualization: Firoozeh Raisi and Abbasali Nasehi; Methodology: Firoozeh Raisi; Study analysis: Seyed Taha Yahyavi and Mohammad Ali Seddiqi Gilani; Research, review and sourcing: Hamideh Sadat Sadr-Amely; Drafting: Azin Ahmadzadeh and Hamideh Sadat Sadr-Amely; Editing and finalization: Firoozeh Raisi and Azin Ahmadzadeh; Visualization: Azin Ahmadzadeh; Project supervision and management: Firoozeh Raisi.

Conflicts of interest
The authors declare no conflicts of interest.

Acknowledgements
The authors would like to express their gratitude to the late Sokrat Faghihzadeh, who made significant contributions to all stages of this research and extend their thanks to Robabeh Soleimani,  Mani Monjemi, Reyhaneh Firoozi,  Zahra Salmanian and  Fataneh Abdi.


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