Effect of Attachment Styles to Parents on Sexual Dysfunction Domains of Married Women.

INTRODUCTION: According to Bowbly attachment theory, attachment of a baby and its main care provider, influences on social growth and the baby's feelings throughout its life. The present study was performed aim to determine the effect of attachment style to parents on domains of sexual dysfunction in married women.
METHODS: This cross-sectional study was carried out on two hundred married women who were fertile, and referred private and governmental gynecology clinics in Mashhad, Iran, in 2014. Data collection tools were three questionnaires; Demographic and marital questionnaire, Female sexual function index questionnaire, and Adult attachment style questionnaire. Data were analyzed by SPSS version 20 (IBM© SPSS© Statistics version 20 using independent-samples t-test and logistic regression. The statistical tests were performed at the 95% confidence interval. RESULT: Mean of safe attachment style to parents in all aspect of sexual dysfunction was significantly lower (p≤0.01), however, mean of distant attachment style to parents in all aspects of sexual dysfunction was significantly higher (p≤0.05).
CONCLUSION: Secure and distance attachment style to the mother showed maximum power of prediction for sexual dysfunction, which indicates the importance of attachment to parents and its impact on adult relationships.

1. Introduction

Sexual dysfunction is referred to as sexual desire disorder, and changes the physical and psychological sexual response cycle, which arises, creating severe anxiety and severe problems in interpersonal relations (1). These disorders are the main source of communication conflicts, which could create room for hesitancy in love interests, a couple’s anxiety for a long lasting relationship, create a tendency to have many partners (2, 3) and may lead to divorce (4). Several factors are involved in determining sexual desire and behavior such as environment, hormonal, anatomical, physiological, cultural and psychological factors, relationships with others and growth experience through life periods (5, 6). Attachment style is one psychological factor. Attachment is defined as a deep and lasting relationship between the baby and its care provider during the first year of its life, which deeply influences all aspects of life, such as mind, body, excitement, communication and personal values (7). Attachment theory explains how individuals cope with conflict and assume various interpretations from the behavior of others (8). Bowbly believed that attachment in parent–baby relationships will transfer to adulthood as amorous relationship, it can influence behavior, excitement and recognition, in every period of life. Studies have shown that attachment is associated with factors such as mental health (9, 10) and quality of interpersonal relationships. Dampster found a positive relationship between dependent, fearful and distant attachment to the father, and unwanted sexual relations, while a negative relationship was found between people with safe attachment to parents and unwanted sexual relationships (11). Birnbaum also found a significant relationship between ambivalent attachment style and decreased satisfaction, intimacy, pleasure and sexual excitement. They showed relationship between avoidant attachment style and decreased sexual intimacy (12). The body of evidence indicated to not only separation of attachment and sexual affairs independently, but also internal conflict between them, because attachment is established based on security of communication, but sexual relationship is rooted in seeking diversity (13). Cooper conducted a longitudinal study and discovered that safe attachment in the adolescence period could not be applied as a predictor for sexual motivation. For avoidant and ambivalent styles, they could predict just for sexual dissatisfaction (14). The aim of the present study was to determine the effect of attachment style to parents on domains of sexual dysfunction in married women in Mashhad, Iran.

2. Material and Methods

2.1. Participants and design

This cross-sectional study was sample by convenient method. Participants were two hundred married women who were in their fertility period and referred gynecology clinics of Ghaem hospital and offices of private gynecologists in Mashhad, Iran in 2014. Among the427 women who were going to participate in the study, 236 women met inclusion criteria and 36 women were excluded from the study due to questionnaires being incomplete. Therefore, the study was conducted on two hundred women. According to the pilot study which represents the correlation coefficient between adult attachment and female sexual dysfunction is 0.212, at least 172 participants will be provided 80.1 potency in Pearson’s test with a confidence level of 95%.

2.2. Inclusion criteria

The following were set as the inclusion criteria of the study: being Iranian, being fertile, being literate, being married for at least six months, absence of mental health problems or drug use, absence of underlying medical conditions, absence of experiencing severe stressful events for the past 12 months, absence of experience of sexual assault, not currently experiencing menopause, pregnancy, postpartum or breastfeeding.

2.3. Measurement tools

2.3.1. Demographic and marital questionnaire

This questionnaire includes 22 questions in different sections of demographic and marital data, midwifery and marriage, sexual relationship and feminine roles. Content validity was used for confirming to validity in which ten MUMS faculty members in various fields of midwifery, gynecology, psychology and physiology read and commented on it. Test–re test confirmed its reliability (r=0.9).

2.3.2. Female sexual function index questionnaire

This scale was developed by Rosen et al. It includes nineteen questions, which tests six independent domains of desire, psychological arousal, wet, orgasm, satisfaction and sexual pain. In order to calculate the score of sexual dysfunction, initially scores of each domain were determined; as the questions of different domains were unequal, based on instruction, the scores of domain were multiplied in factor number and then they were summed to calculate total scores (15). Cut off point of each domain was detected according to a Mohammadi et al. study. In each domain, women were divided to two groups: with sexual dysfunction and without sexual dysfunction. Validity and reliability of this questionnaire has been approved in Iran by Mohammadi et al. (16).

2.3.3. Adult attachment style questionnaire

This scale was developed by Snow et al. and includes 84 questions, which are arranged in two sections for the mother and father. This scale determines five attachment styles of safe, fearful, dependent, parented and distant in adults. It was designed and applied by Snow et al. for the first time and they also confirmed its validity. The permission letter was received for applying it in study. Then it was translated and its validity was confirmed using content validity in which ten gynecologist, clinical psychologist and psychiatrist of Mashhdad University of Medical Science read and commented on it. The Cronbach’s alpha method was used for reliability of each subscale (r≥ 0.70). Score of each attachment style was calculated by summing the related scores. As the number of questions was not equal, a mean score of each style was calculated. It varied between 0–5. General explanations were given to participants for answering the questions. For the attachment style questionnaire, research emphasized participants should ignore their present feelings when answering questions. In order to assure, two important questions of “I put my mother’s needs before my own “ and “I enjoyed taking care of my mother” should be explained by subjects orally, if they understood, a questionnaire was given to them to complete. For sexual function index, at first instructions attached to questionnaire were given to participants to read definitions of some terms of sexual activity, such as sexual excitement etc. She was asked to read it carefully and then answer the question. In order to assure, they were asked to read two following questions of one domain and explaine the differences between them: “how often have you had a sexual desire in the past four weeks?” And “how was your sexual desire in the past four weeks?” For better understanding of the questions, they were explained as required.

2.4. Statistical analysis

Data were analyzed by SPSS version 20 (IBM© SPSS© Statistics version 20 (IBM© Corp., Armonk, NY, USA) using independent-samples t-test and logistic regression. Significance level was considered as 0.05.

2.5. Research Ethics

Ethical consideration was followed by approving MUMS Ethics committee. Participants were assured that their answers would be kept confidential and presented as general information. They signed informed consent and were free to exit the study at any time during the study.

3. Results

Mean of participants’ age was 28.85 years and mean of their spouse was 33.45 years, also the mean of marriage period was 101.94 months. Level of education in 79.5% was at high school and 71.5% of them were housewives. Independent-samples t-test was applied for comparing mean scores of attachment styles in sexual function domains in two groups, with sexual dysfunction and without sexual dysfunction. It showed mean scores of safe attachment style to the mother (desire: t= −5.84, arousal: t= −3.82, lubrication: t=−3.32, orgasm: t= −5.30, satisfaction: t=−4.59, pain: t= −4.87) and the father (desire: t= −2.91, arousal: t=−2.68, lubrication: t=−1.94, orgasm: t= −3.30, satisfaction: t= −2.47, pain: t=−3.71) in all domains of sexual dysfunction are significantly lower and mean score of distant attachment style to the mother (desire: t= 6.06, arousal: t= 5.33, lubrication: t= 4.00, orgasm: t= 6.02, satisfaction: t= 5.43, pain: t=5.52) and the father (desire: t= 4.78, arousal: t= 4.78, lubrication: t= 2.25, orgasm: t= 6.58, satisfaction: t= 5.76, pain: t= 4.34) in all domains of sexual dysfunction are significantly higher. Scores of dependent attachment style to the mother in all domains except lubrication were significantly lower (desire: t= −3.53, arousal: t= −2.27, orgasm: t= −2.89, satisfaction: t=−2.61, pain: t= −2.55) and score of dependent attachment style to the father in the group with sexual dysfunction in domains of orgasm (t=−3.22) and sexual satisfaction (t=−2.01) were significantly lower. Score of fearful attachment style to the mother in the group with sexual dysfunction in domains of orgasm (t=3.75), desire (t=2.95) and sexual pain (t=3.21) were significantly higher and score of fearful attachment style to the father in the group with sexual dysfunction in domain of orgasm (t=2.88) were significantly higher as well (Table 1).

Table 1

Comparison of average scores of attachment styles to parents in sexual function domains in two groups (with and without sexual dysfunction)

Attachment styles	Sexual Function (sig)
	Desire	Arousal	Lubrication	Orgasm	Satisfaction	Pain
Safe mother	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001
Safe father	0.004	0.008	0.053	0.001	0.014	<0.001
Dependent (mother)	0.001	0.024	0.530	0.004	0.010	0.011
Dependent (father)	0.135	0.743	0.987	0.002	0.060	0.098
Parental mother	0.596	0.291	0.776	0.812	0.496	0.475
Parental father	0.830	0.395	0.711	0.477	0.247	0.740
Fearful mother	0.004	0.066	0.573	<0.001	0.288	0.002
Fearful father	0.164	0.094	0.340	0.004	0.260	0.189
Distant mother	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001
Distant father	<0.001	<0.001	0.025	<0.001	<0.001	<0.001

Results of logistic regression for comparing the effect of attachment style to parents in domains of sexual dysfunction showed negative significant effect of safe attachment style to the mother on all sexual dysfunction (desire: B= −1.09, arousal: B= −0.71, lubrication: B= −0.77, orgasm: B= −0.91, satisfaction: B= −0.92, pain: B= −0.93). It also showed positive significant effect of distant attachment style to the mother on all domains of sexual dysfunction (desire: B= 1.19, arousal: B= 0.58, lubrication: B= 1.03, orgasm: B= 0.92, satisfaction: B= 0.75, pain: B= 1.07). Positive significant effect of distant attachment style to the father was shown on sexual dysfunction in domains of desire (B= 0.45), arousal (B= 0.86) and sexual satisfaction (B= 0.86). Negative significant effect of dependent attachment style to the mother was also shown on sexual dysfunction in domains of desire (B= −0.62), arousal (B= −0.58) and sexual pain (B= −0.41). Positive significant effect of fearful attachment style to the mother was also shown on sexual dysfunction in domains of orgasm (B= 0.60), desire (B= 0.59) and sexual pain (B=−0.75) (Table 2).

Table 2

Effect of attachment styles to parents in various domains of sexual dysfunction

Attachment styles		Sexual dysfunction (sig.)
		Pain	Satisfaction	Orgasm	Lubrication	Arousal	Desire
Safe	Mother	>0.001	>0.001	>0.001	0.002	0.002	>0.001
	Father	0.102	0.628	0.210	0.687	0.292	0.528
Dependent	Mother	0.050	0.060	0.120	0.469	0.006	0.002
	Father	0.654	0.498	0.063	0.723	0.86	0.771
Parental	Mother	0.525	0.858	0.526	0.609	0.447	0.626
	Father	0.995	0.339	0.357	0.573	0.672	0.976
Fearful	Mother	0.004	0.597	0.012	0.197	0.266	0.012
	Father	0.628	0.508	0.289	0.133	0.410	0.826
Distant	Mother	>0.001	0.004	0.001	>0.001	0.021	>0.001
	Father	0.066	0.001	0.78	0.918	0.001	0.048

4. Discussion

Mean scores of attachment style to parents in all domains of sexual dysfunction in the group with sexual dysfunction were significantly lower than the group without sexual dysfunction. Dempster, in the US showed that people with safe attachment, experienced significantly lower unwanted sexual activity. They also had less functional attitude toward sexual activity such as masturbation or use of artificial devices (11). A Tracy et al. study which was conducted on adolescents of New York showed that people with safe attachment reported less negative experience and more unrestricted and positive excitement during sexual activity, however, it was not statistically significant (17). According to the Cooper longitudinal study, which was conducted on adolescents, girls with safe attachment style most likely use sexual activity for showing intimacy to a partner and increased sexual pleasure however, it also was not statistically significant. It was determined that safe attachment style could not predict any of the elements of sexual motivation (14). Results of the Tracy and Cooper studies were in agreement with the present study because of applying a threefold instrument of attachment style, however, as the results showed no significant difference, it is not similar to the present study. It could be due to different methodology, sampling, instrument and community. Dempster found positive significant relationship between fearful and distant attachment style to parents and unwanted sexual activity (11). Butzer et al. in London found significant relationship between unsafe avoidant and ambivalent attachment style and decreased sexual satisfaction and marital satisfaction as well (18). Birnbaum et al. conducted their study on ninety six females of whom thirty percent had no official spouse. They reported lower sexual satisfaction, excitement, sexual pleasure and intimacy during sexual activity in females with ambivalent attachment style. They also found reverse relationship between avoidant attachment style and all domains of sexual function (satisfaction, excitement, orgasm, and intimacy during sexual activity). Significant correlation was found only between intimacy domain and attachment style (12). Findings of the present study about distant attachment style and some domains of fearful attachment style are in agreement with the Dempster study, which applied five classifications of attachment style, the Butzer study and some parts of the Birnbaum study, which applied three classifications of attachment style. The group with sexual dysfunction got significantly lower mean scores of dependent attachment style to the mother in all domains of sexual function except wet and dependent attachment style to the father in all domains except orgasm and sexual satisfaction. Dempster found negative significant relationship between dependent attachment style to parents and negligent attitude, although the agreements of the present study with the Dempster study has regarded dependent attachment style as one type of safe attachment style (11). According to logistic regression, in order to compare attachment style to the mother and the father in predicting all domains of sexual dysfunction, significant negative role of secure attachment style to the mother was clarified: It could predict sexual dysfunction in domains of desire, excitement and sexual pain. Positive significant effect was found for distance attachment style to the mother in all domains and fearful attachment style to the mother in domains of desire, orgasm and sexual pain. Negative significant effect was found for predicting sexual dysfunction in sexual excitement by dependent attachment style to the father. Positive significant effect was shown for predicting domains of desire, satisfaction and pain by distance attachment style to the father. Secure and distance attachment styles to the mother could predict sexual dysfunction in all domains while fearful attachment style could predict it just in three domains. Of attachment style to the father, distance attachment style could predict sexual dysfunction in four domains. Bowbly believed that although a child could attach to several people, there is a hierarchical for this attachment. It is not true to think of a child on his attached person, or no strong attachment is formed between a child and special person, while most often, there is a deep attachment between a child and the main person, and he may feel heavy-hearted when he is absent. According to the results, the mother as a main attached person plays a much more important role than the father, for predicting sexual dysfunction. Therefore, results of the present study focuses on importance of interaction in childhood, especially with main attached person in secure and distance attachment style and its effect on sexual activity in adulthood. It could depict different clear fields for future research. Regarding the limitations of the study, they were accessible sampling, retrospective answering to questions, using cutoff points for sexual dysfunction based on a Mohammadi’s study in Iran, which may not be accurate for two groups with sexual dysfunction, and without sexual dysfunction.

5. Conclusions

This result show, secure and distance attachment style to the mother showed maximum power of prediction for sexual dysfunction. Distance attachment style to the father had a more important effect on sexual dysfunction which indicates the importance of attachment to parents and its impact on adult relationships. Further extensive research should be conducted for comparing threefold and fivefold attachment style in different communication by prospective approaches.