Impact of group assertiveness-based sexual training on the quality of marital relationships among female university students.

BACKGROUND: Sexual assertiveness plays a crucial role in the quality of sex, as well as in investigating and treating sexual problems. The purpose of this study was to determine the impact of assertiveness-based sexual training on the quality of marital relationships of married female students.
METHODS: This quasi-experimental study was done in southeastern Iran in the academic year of 2017. A total of 80 married women were chosen from university students through convenience sampling, and they were assigned to the intervention (n = 40) and control (n = 40) groups. Data were collected using the Perceived Relationship Quality Components Inventory. For the intervention group, assertiveness-based sexual counseling was provided in four sessions (90-120 min each session). The posttest was performed 12 weeks after the last counseling session. Independent t-test and covariance analysis were employed to analyze data using SPSS version 21 software.
RESULTS: After the intervention, the two groups revealed a significant difference in their respective mean total score of the quality of various dimensions of marital relationships (P = 0.0001). This indicates that assertiveness-based sexual counseling has improved this mean total score in the intervention group compared to the control group.
CONCLUSION: Given the positive impact of assertiveness-based sexual training on the quality of students' marital relationships, the integration of sexual training with focus on assertiveness in usual sexual counseling will help therapists to improve the quality of marital relationship from the perspective of women.

RCT Entities:   Population Interventions Outcomes

Introduction

The most important expectation of any couple from marriage is to enjoy high-quality marital relationships.[1] Such marital relationships enhance the level of health, vitality, and happiness of the family, whereas low-quality marital relationships adversely influence the psychosocial interactions of couples and the growth of children, leading to separation and divorce.[2] One of the most prominent factors affecting marital quality is the sexual performance of couples.[345]

Having healthy sexual relationships is indispensable for achieving a successful marital life. Desirable sexual function and sexual satisfaction are associated with high-quality marital relationships.[6] Women with high sexual satisfaction adore their husbands, and their marital relationships are of higher quality.[7] Sexual assertiveness or the ability to express one's sexual inclinations can have a decisive role in identifying and treating sexual problems. Ultimately, it affects the quality of marital relationships.[8] Lee showed that sexual assertiveness could be a positive predictor of the quality of marital relationships among students, especially in a culture, where this assertiveness is not encouraged.[9] Recently, some sexual counseling programs and educational interventions have begun to pay attention to sexual assertiveness. For instance, some authors have addressed the impact of assertiveness-based sexual counseling on sexual function and the effect of group sexual counseling on marital satisfaction.[1011]

One of the important items of social relations and social skills is assertiveness. Social skills are a collection of learned abilities that enable an individual to communicate with a proper capability and form, in a social aspect. Some most common known social skills are self-expression (assertiveness), coming to an agreement, communicative skills, finding friends, solving interpersonal problem, and ability of regulating knowledge, emotions, and behaviors of a person (Safarzadeh et al., 2018; Dastyar et al., 2018). Sexual assertiveness is a social skill which refers to exhibiting confident and decisive behaviors in sexual situations. Sexual assertiveness consists of three interdependent aspects, including the ability to start a sexually desirable relationship, refuse unwanted sexual contact, and discuss the use of contraceptive methods to avoid unintended pregnancies.[12] Some of the benefits of sexual assertiveness are better sexual performance, reduced sexual victimization, and decreased high-risk sexual behaviors. Sexual assertiveness, therefore, facilitates achieving sexual goals such as sexual autonomy and satisfaction and protects individuals from unsafe sexual behaviors.[13] Women usually do not refuse to have a sexual experience that is proposed by the spouse, even if they are not willing to do so, because they are afraid of wounding their husband's emotions or their marital relationship. Compared with men, women feel more responsible for maintaining their marital relationship and wish to provide whatever their husbands demand. Consequently, women are more likely to become involved in forced sexual relationships.[9] It has been established that many women refrain from giving their true responses lest they should be regarded unrestrained, shameless, or indecent. For example, saying “no” for some women could mean “yes” or “maybe.” Sexual assertiveness is generally downplayed in sexual counseling programs. This is especially the case in Iran, where sexual assertiveness is generally low in women due to different stereotypes and strict gender norms.[14] Gender norms intensify when combined with cultural norms. In Asia, gender norms are much more restrictive than other continents.[9] Thus, some Asian countries, including Iran, demonstrate particularly low ranks in terms of gender transparency. One of the problems that gender and cultural norms impose on women is that religious, cultural, traditional, and regional expectations make it difficult for them to refuse unwanted sexual behaviors and lead them to be engaged in forced and inappropriate sexual relations. As a result, the quality of marital relationship diminishes.

Despite the fact that many cultural and ethnic communities, including Iran, pay special attention to sexual issues, most of their individuals do not have access to accurate and timely information. On the other hand, most couples do not go to counseling centers for resolving their sexual problems. Meanwhile, complying with gender stereotypes and expectations, women decline even to talk about them with others. The persistence of women's sexual passivity, even in educated individuals, leads to sexual problems and ultimately reduces the quality of marital life.

Given that students are in the process of forming their marital relationship, the present study was carried out to determine the impact of assertiveness-based sexual counseling on the quality of this relationship.

Methods

This is a two-group quasi-experimental study comprising a pretest–posttest design. The research was conducted on 80 married female students in southeastern Iran in the academic year of 2017. The participants were divided into the intervention and control groups, each consisting of 40 members. The inclusion criteria were a 1 year minimum of married life, an age of 18–40 years, not studying psychology or counseling majors, no history of psychiatric disorders, not taking drugs affecting sexual function, lack of physical illness or surgeries influencing sexual function, and absence of severe marital conflicts such as threats to divorce and separation. Students who were absent from more than one counseling session were excluded from the study. First, a list of married female students was prepared through a public announcement in the University for holding a program on student sexual counseling. The qualified students were chosen and randomly allocated to the intervention or control group.

The data collection tool was a two-part questionnaire. The first part included demographic information, and the second part consisted of the Perceived Relationship Quality Components Inventory (PRQC). PRQC was designed and developed by Fletcher et al. in 2009[15] and includes 18 questions in six dimensions as follows: satisfaction, commitment, intimacy, trust, passion, and love. It should be noted that each dimension is measured by three questions. The answers were scored in a 7-point Likert scale from 1 (not at all) to 7 (completely). The minimum and maximum scores of PRQC are, respectively, 18 and 126, which are obtained from the sum of scores. Lower scores represent poorer quality, and higher scores indicate better quality of marital relationship in various dimensions. In Iran, Nilforoshan et al. established the validity of the questionnaire through convergent and divergent validity tests as well as confirmatory factor analysis and its reliability through determining its internal consistency and stability.[16] In the present study, the reliability of the whole questionnaire was 0.78 as calculated through Cronbach's alpha internal consistency test.

At first, a public announcement was made by the University Deputy for Student and Cultural Affairs regarding the implementation of student sexual counseling sessions. Then, a list of married female students was prepared. Subsequently, the eligible individuals were divided into the intervention (n = 40) and control (n = 40) groups through simple random sampling.

The envelopes were randomly distributed, and an enclosed envelope indicating the respective group of each individual (A for intervention and B for control) was provided to all participants. The envelopes were given to the participants in order.

To prevent the disclosure of educational content between the intervention and control groups, data were first collected for those in the control group, who were then placed on the waiting list. Women in the intervention group were divided into subgroups of 6–8 members. Initially, the intervention group took the pretest by completing the marital satisfaction questionnaire. The group assertiveness-based sexual counseling was provided in four sessions (2 h each session) during 2 weeks and according to the content and structure prepared at the counseling center. As neither formal nor informal education on sexual issues is provided for the Iranian couples before marriage, generally they have little sexual knowledge;[1514] therefore, identifying the level of basic sexual knowledge through sexual education studies in Iran, including the present study, seems to be unnecessary. Determining the level of general sexual knowledge was not the objective of this study.

Group counseling sessions were presented by a trained midwifery assistant and supervised by an expert with PhD in family counseling. The content of workshops was also given to couples in compact discs for subsequent usage or for those who had been absent in a session. Besides, a telephone number was announced for answering their possible questions. Twelve weeks after the end of the intervention, the participants were invited to the University Counseling Center to gather posttest data. Due to the attractiveness of the subject of the study and availability of the classes in the campus of married students, so many participants eagerly participated in the study that no dropout was observed.

The intervention conducted in this study revolves around assertiveness-based sexual counseling. It was designed based on a review of similar studies and surveying a number of clinical psychologists, family counselors, and psychiatrists with experience in the treatment of sexual dysfunctions. Sex education was focused on the concept of behavioral assertiveness in general and sexual assertiveness in particular. Some parts of the program were presented using lectures, discussions, workgroups, and PowerPoint. To access the content of the sessions, educational CDs were given to all participants at the end of the intervention sessions. Furthermore, a specific telephone line was used solely for answering emergency questions and resolving any possible marital problems caused by the educational intervention. However, due to the short interval between the sessions, no phone call related to the educational content was received. The outlines and content of each of the four sessions are given in Table 1.

Table 1

Structure and concept of sexual group counseling based on sexual assertiveness

Session	Content
1st	Meeting and greeting, primary communication, and introduction to the principles and goals of the meeting, anatomy of the internal and external genitals, physiology of genitals, sexual performance, and sexual response cycle
2nd	Distinguishing daring from nondaring behaviors (aggressive and neutral), skill of saying no, assertiveness in social relations, necessity of self-express and its benefits in life, having or lacking the right to self-express, and right to freedom of choice
3rd	Marital satisfaction and its influential factors, role of sexual assertiveness in marital satisfaction, lack of sexual assertiveness and unwanted pregnancy, lack of sexual assertiveness and sexual misbehaviors of sex partner, wrong beliefs about sexual roles and expectations, and dual sexual norms
4th	Review of previous session teachings, sexual assertiveness and sexual performance, expressing the benefits of sexual assertiveness and factors affecting this issue, methods to increase sexual assertiveness, question and answer, and conclusion

Having collected and codified the data, the researchers analyzed it using SPSS-21 software (Version 21.0, SPSS Inc., Chicago, Illinois, USA). First, the frequency, percentage, mean, standard deviation, minimum, and maximum were determined using descriptive statistics. Then, paired t-test was used for comparing the mean of each single group before and after; to compare the means of the two groups, independent t-test was employed; and to compare the frequency of qualitative variables of the two groups, Chi-square test was used. Finally, while controlling the impact of the pretest, covariance analysis was carried out to determine the effectiveness of assertiveness-based sexual counseling on the quality of marital relationships. The significance level was considered at 0.05.

The main hypothesis of this study was “The effect of group assertiveness-based sexual training on increasing quality of marital relationships in female university students is different from that of control group.”

This study was approved at the Ethics Committee of Zahedan University of Medical Sciences and registered under the code of REC.1395.244 IR.ZAUMS. The ethical considerations were related to providing information on the implementation of the research, duration, and type of intervention; obtaining the written informed consent form from women and their spouses; ensuring confidentiality of information; and autonomy of the participant to attend or quit at any stage of the study.

Results

The results of the Shapiro–Wilk test on the quality of marital scores showed that the data had a normal distribution. Therefore, parametric tests were employed.

The results of the individual characteristics of the study subjects indicate that the mean and standard deviation of women's age in the intervention and control groups was 22.30 ± 2.81 and 22.47 ± 3.10, respectively, and mean and standard deviation of husbands' age in the intervention and control groups was 26.58 ± 3.37 and 26.67 ± 3.69, respectively. The results of independent t-test demonstrated that there was no significant difference between the two groups in terms of the mean age of women and their spouses (P > 0.05). As Table 2 shows, the two groups do not have a significant difference with regard to their demographic characteristics (P > 0.05).

Table 2

Demographic characteristics of the intervention and control groups

Variable	Intervention, n (%)	Control, n (%)	P
Husband’s job
Student	12 (30)	8 (20)	0.58*
Self-employed	18 (45)	21 (52.5)
Others	10 (25)	11 (27.5)
Total	49 (100)	40 (100)
Husband’s education
Diploma and lower	12 (30)	13 (32.5)	0.9*
Associate diploma	6 (15)	8 (20)
Bachelor	15 (37.5)	13 (32.5)
Higher than bachelor	7 (17.5)	6 (15)
Total	40 (100)	40 (100)
Female’s education
Bachelor	33 (82.5)	34 (85)	0.99*
Higher than bachelor	7 (17.5)	6 (15)
Total	40 (100)	40 (100)
Couple’s relative relationship
Yes	27 (67.5)	28 (70)	0.99*
No	13 (32.5)	12 (30)
Total	40 (100)	40 (100)
Type of marriage
Modern (selective)	30 (75)	35 (87.5)	0.99*
Traditional (forced)	10 (25)	5 (12.5)
Total	40 (100)	40 (100)
Age of female, mean±SD	22.30±2.81	22.47±3.10	0.79**
Age of husband, mean±SD	26.58±3.37	26.67±3.69	0.89**
Marriage duration (year), mean±SD	3.00±2.21	3.55±2.23	0.61**

*Chi-squared test, **Independent t-test. SD=Standard deviation

Findings related to the main purpose of the study reveal that the mean total score of quality of marital relationship in the intervention group increased from 96.02 ± 21.89 before sexual counseling to 103.07 ± 16.09 after sexual counseling. In the control group, however, this score decreased from 115.17 ± 16.95 before training to 104.62 ± 10.85 after training [Table 3]. Considering that in the pretest, the two groups differed in terms of the mean score of the quality dimensions of marital relationship; the result of the covariance test controlling the effect of pretest [Table 4] illustrated that the mean total score of the quality of marital relationship in the two groups has a statistically significant difference after the training sessions (P = 0.0001). Thus, it can be inferred that sexual counseling has improved the mean total score of marital satisfaction among students in the intervention group.

Table 3

Quality of marital relationships scores in the intervention and control groups before and after the sexual counseling based on assertiveness

Group	Time, mean±SD			Paired t-test (before-after)
	Before	After	Changes
Intervention	89.21±20.96	103.07±16.09	7.05±12.40	P=0.0001
Control	115.17±16.95	104.62±10.85	−10.55±12.41	P=0.0001
Independent t-test, P	0.0001	0.61	0.0001

SD=Standard deviation

Table 4

The results of covariance analysis on the score of quality of marital relationships in women after sexual counseling by adjusting the pretest effect

Source of change	SS	df	MS	F	Significant	η	Power
Pretest	8886.92	1	8886.92	117.59	0.0001	0.6	1
Group	1268.48	1	1268.48	16.78	0.0001	0.17	0.98
Error	5819.22	77	75.57
Total	877,540	80

SS=Sum of square, MS=Mean of square

Discussion

The results exhibited that this type of counseling significantly enhances marital relationships of these individuals. Sayyadi et al. have observed that there is a significant correlation between sexual assertiveness and having positive emotions toward the spouse, and the growth of sexual assertiveness is associated with an increase in positive emotions toward the spouse.[17] Therefore, it may be concluded that the assertiveness-based sexual education in the present research has been able to improve the quality of marital relationship from the point of view of women. Increasing positive emotions toward the spouse can lead to the improvement of the relationship between the couples and enable them to share their needs, desires, and interests; it helps them express their love, care, and affection or anything that causes discomfort; moreover, this rise of positive feelings assists them to successfully solve their inevitable family problems. The combination of these benefits will entail the improvement of the quality of marital relationship between couples.

Consistent with these results, Assadi et al. affirmed that among the variables associated with sexual activities, decreased sexual assertiveness leads to the rise of marital disappointment, and the growth of this assertiveness mitigates marital disappointment.[18] This is mainly due to the fact that women, who share their sexual desires, needs, and feelings with their spouses and have a high sexual intimacy, have greater sexual relations, which in turn improve marital satisfaction.[19] Regarding the effectiveness of assertiveness-based sexual training on marital adjustment and sexual relationship, Safarzadeh et al. showed that the assertiveness-based sexual counseling method significantly influenced sexual function and expression of sexual rights and reduced the shame and contempt.[10] The study of Dastyar et al. also showed that group sexual assertiveness counseling had a positive effect on the marital satisfaction of female students.[11] The positive impact of sexual counseling with focus on assertiveness shows that first, the women studied have low sexual assertiveness and second, assertiveness is one of the missing contents in such educational programs.

By teaching women the proper pattern of sexual relationship based on assertiveness, this research enabled them to express their desires, interests, sexual needs, love, and affection for their partner. This capability leads to a more healthy marital life, boosts marital satisfaction, and consequently increases the quality of marital relationship. In addition, training sexual issues, reforming the belief in sexual dignity, and increasing women's awareness of their sexual rights lead to increased marital satisfaction. In fact, enhanced sexual satisfaction is one of the most important factors affecting the quality of marital relationships.[20]

The results of this research concerning the effectiveness of sex education on the improvement of the quality of marital relationship are compatible with the findings of the following researchers: Navidian et al. who explored the effect of sexual education on the quality of marital relationships in pregnant women; Karimi et al. who focused on the role of sexual health in improving the quality of marital satisfaction and the quality of married life; Khanjani Veshki et al. who investigated the impact of sex education on the enhancement of quality components of married life; and Shakarami et al. who aimed at determining the effect of sex education on the intimacy of married women.[21222324] The studies also show that sex education, irrespective of the approach adopted, can improve the relationship between couples in different ways. This leads one to infer that couples do not have an effective access to sexual information and education in less developed countries such as Iran. The difference between this research and the studies mentioned above is that here, in addition to conventional sexual and communicative education of couples, the axial issue of sexual assertiveness has been accentuated. This is the topic which most women seem to be afraid of expressing and applying its techniques in their sexual life. On the other hand, in this study, all aspects of sexual intercourse including sexual pleasure, commitment, love, intimacy, trust, and satisfaction have been investigated.

Based on the main findings of the present study and similar studies, it can be concluded that group sex education is conductive to the promotion of women's awareness and access to adequate information about sexuality. These trainings help women get acquainted with the anatomy and physiology of genitalia, misconceptions about sexual problems, and having healthy and enjoyable marital relationships. Thereby, the psychological, emotional, and sexual distance between couples will decrease, and their sexual satisfaction will grow. Eventually, the quality of marital relationship is raised.

Most studies in Iran have concentrated on providing a general sex education to couples who have sexual problems. Indeed, few studies have dealt with training couples about sexual assertiveness and its role in developing and maintaining healthy marital relationships. Given the cultural, religious, social, and regional characteristics of Iranians and the general absence of sexual assertiveness, especially in women, one can view providing sexual counseling focused on enhancing sexual assertiveness as one of the positive aspects of the current study. Due to the ethical and regional restrictions of the Iranian society, the sexual counseling carried out in this research was limited to a group of women. Hence, if future studies present these trainings for both genders or for each couple individually, the results might be more effective and generalizable. Another limitation of this research is that it did not measure the sustainability of the positive results in the long run.

Conclusion

Regarding the positive impact of group assertiveness-based sexual training on raising the quality of marital relationships among educated women, it is recommended that such instructions be developed and implemented further. The results of the current study will help clinicians in their marital counseling, sexual health promotion, and couples' enrichment programs to increase the effectiveness of their interventions in this way. These findings will be very helpful and useful in countries, where for social, cultural, and religious backgrounds, women have lower sexual assertiveness. Given the low level of female sexuality in Iran, the sexual education based on assertiveness can improve the quality of women's marital relationship.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.