Letter to the Editor Reply to `The sexual health inventory for men (IIEF-5)' by JA Vroege JC Cappelleri 1 * and RC Rosen 2 1 P®zer Central Research, Department of Clinical Research, Eastern Point Road, Groton, CT 06340-8030 2 Department of Psychiatry, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, 675 Hoes Lane, Piscataway, NJ 08854-5635 We are grateful to JA Vroege for his critique of the Sexual Health Inventory for Men (IIEF-5), 1 which consists of ®ve items from the International Index of Erectile Function (IIEF). Most of his concerns appear to stem from lack of awareness or consideration of aspects underlying the development and evaluation of the IIEF-5. Several points of clari®cation are therefore in order. Firstly, summing scores and using cutoff points for diagnostic purposes is not only consistent with good science but also an essential yet simple way to permit an objective quantitative and qualitative classi®cation of erectile dysfunction. The medical literature abounds, for instance, with cutoff scores for diagnostic purposes. 2 The questions that con- stitute the IIEF-5 are transparent and, therefore, do indeed provide a clear insight into the diagnostic criteria. Merely asking a couple of relevant ques- tions with a simple yes=no dichotomy may seem suf®cient to identify the condition, but may lack the range required for accurate diagnostic discrimina- tion and hence may be susceptible to unreliable classi®cation. Such an approach can lead to extreme uncertainty when the magnitude of misclassi®cation is not evaluated or quanti®ed properly. Secondly, we disagree that items on the IIEF-5, a subset of items on the cross-culturally valid and psychometrically sound IIEF, are `a bit clumsy' or `do not excel in their transparency.' On the contrary, items on the IIEF-5 are part of a superior body of items that responders have addressed with no or little dif®culty. 3 Among a very large pool of candidate items, the ®ve items were chosen as being among the best from the perspectives of both sound science and responder comfort. Moreover, for respondents who were sexually stimulated but who never had an erection, `almost never=never' is, contrary to Vroege's claim, listed as an option to Item 2 of the IIEF-5 on how often erections were hard enough for penetration. Thirdly, the sample of men with erectile dysfunc- tion came from clinical trials, and the sample without erectile dysfunction came from an out- patient community health center. Both samples, therefore, consisted of patients who are a natural part of clinical practice. These patients may not be representative of all patients in clinical practice, a relevant point alluded to by Vroege, but they are likely to be a representative of a large number of patients in clinical practice. Fourthly, it is not true that the 15-item version of the IIEF functioned as the `gold standard' on whether or not a patient truly had erectile dysfunction. Gold standard assessments were made independently of any item on the IIEF. A gold standard diagnosis of erectile dysfunction required a medical history of at least six months duration, physician records, and objective testing where available. A gold standard diagnosis of no erectile dysfunction was made for those without a history of the condition. Fifthly, it is true that the time frame of the IIEF-5 (the past six months) is different from that in the original IIEF (the past four weeks). The time frame of the IIEF-5, as a diagnostic aid, was designed to parallel that of the recent National Institute of Health's guideline (six months). We do not expect the time-frame difference to materially affect the results, partly because recall over the last month may likely dominate a response. Nevertheless, more research would be useful in this area. Sixthly, it is quite false that all respondents would be de®ned as impotent who (1) do not have a partner; (2) do not have sexual contact with their partner; or (3) do have sexual contact but no sexual intercourse. None of these individuals would be de®ned as impotent. The IIEF-5 is not applicable in each of these three scenarios put forth by Vroege. The reason is that the IIEF-5 is primarily based on and for men who have attempted sexual activity and sexual intercourse in the past six months, as discussed in the manuscript version of the IIEF-5. 4 And that is why its lower-bound score is 5. A measure of *Correspondence: Dr Joseph C Cappelleri, P®zer Central Research, Eastern Point Road, Groton, CT 06340-8030, USA Received 5 July 1999 International Journal of Impotence Research (1999) 11, 353±354 ß 1999 Stockton Press All rights reserved 0955-9930/99 $15.00 http://www.stockton-press.co.uk/ijir