Investigation of the Social Determinants of Sexual Satisfaction in Iranian Women.

INTRODUCTION: A person's sexual satisfaction reflects their judgment and analysis of their own sexual behavior. Factors that affect sexual satisfaction vary in different societies and cultures. AIM: This study investigated the determinants of sexual satisfaction in women referred to health centers in Sari, north of Iran, in 2016.
METHODS: This cross-sectional study investigated 490 women who had been referred to health centers in 2016 and who were qualified for the study; the population was selected using convenient sampling method. MAIN OUTCOME MEASURE: The main outcome of this study was sexual satisfaction that assessed by the Larson's sexual satisfaction questionnaire. Other Data were 2 questionnaires: the general health questionnaire-28 and a researcher-made questionnaire developed on factors related to sexual satisfaction. Data were analyzed with IBM SPSS software using the one-way analysis of variance, Pearson correlation coefficient, and t-test. To determine the predictors of sexual satisfaction, all the significant independent variables were incorporated into a linear regression model.
RESULTS: The average age of the women in this study was 33.6 years, and average sexual satisfaction score was 99.26. The results of the linear regression model showed that the spouse's job as a laborer (P = .003), a low income (P < .002), insufficient income of the spouse (P < .001), and dissatisfaction with being a woman (P < .001) were the main social determinants of sexual satisfaction (r2 = 0.54).
CONCLUSION: It can be concluded from the findings of this study that several factors influence women's sexual satisfaction. The main social determinants of women's sexual satisfaction were dissatisfaction with their gender, the spouse's job as a laborer, low income, and insufficient income. Sexual healthcare providers can play a prominent role in increasing women's sexual satisfaction, thereby, improving the quality of their sexual life by identifying and discussing ways to control them. Afzali M, Khani S, Hamzehgardeshi Z, et al. Investigation of the Social Determinants of Sexual Satisfaction in Iranian Women. Sex Med 2020;8:290-296.

Introduction

Sexual health is an aspect of health that includes the positive physical, psychological, emotional, and social conditions that are related to the reproductive system and allow people to have a healthy and satisfying sexual life. Sexual satisfaction has been introduced as an index of sexual health. Sexual health indicates a person's level of satisfaction with their sexual relationships and their abilities to create mutual pleasure; however, there are many factors that affect sexual satisfaction. Lack of sexual satisfaction is considered to be a physical and mental health disorder that can affect a person's self-esteem, capability, and creativity; it is also a factor that contributes to interpersonal problems, and negatively affects the longevity of marital life.

Various factors affect sexual satisfaction, including sociodemographic variables, such as race, age,, gender, education, personality, self-confidence, sexual orientation, acceptance of sexual role, pregnancy and childbirth, psychological diseases, chronic diseases, abuse of drug, alcohol, or tobacco, and sexual abuse, sexual injury, or bad sexual experiences. These factors are socioculture-dependent. There have been numerous studies on factors related to sexual health in different societies in different periods of a woman's life. However, a systematic review found that there were contradictions in the predictors of sexual satisfaction.

In Iran, in accordance with the dominant cultural-religious context, sexual relationships are available to women only within the framework of marriage and monogamy. Considering the fact that sexual relationships outside of marriage are condemned in religious communities, a woman obtains sexual satisfaction with her spouse, primarily. Therefore, women's sexual satisfaction needs to be investigated within the framework of marriage. Studies on sexual health that have been conducted in various provinces of Iran, which have distinctive cultures, have reported different levels of sexual satisfaction in women. For instance, a study carried out in Gachsaran city by Shahvary et al reported that about 58% of women had low and moderate sexual satisfaction. A study in Iran showed that 36% of women had low or moderate sexual satisfaction.

A review of qualitative studies indicates that sexual satisfaction has a different meaning for Iranian women (compared the Iranian women with similar studies); for instance, sexual satisfaction is related to “values.” These “values” comprise the sexual or emotional feelings of affection in a married couple. It is also important to investigate the effect of variables on women's sexual satisfaction, including cultural and religious factors, the increase in divorce, the change in people's perspectives due to an increase in women's level of education, the employment and financial independence of women, the gap between sexual puberty and marriage, and women's empowerment and change in their attitudes toward sexual life. This study aimed to determine the social determinants of sexual satisfaction in Ianian women who were referred to health centers in Sari in 2016.

Methods

This descriptive cross-sectional study was approved by the Research Council and the Ethics Committee of Mazandaran University of Medical Sciences (Code Number: 1670). The study was conducted on 490 married women who were referred to health centers in Sari, Iran in 2016. 12 health centers selected from the list of 23 health centers of Sari by the method of simple random using the random generator. 12 health centers were selected using a table of random digits from the existing list in the city health center. Participants in each center were chosen using convenient sampling method.

A justification session was held for the assistants (midwives in the health centers holding at least an undergraduate degree in midwifery). The women who met the inclusion criteria referred in the health centers were asked by the researcher (Master degree in Midwifery Counseling), and the midwives, to participate in the questionnaire survey by clarifying the purpose of the study and obtaining consent.

Inclusion criteria proposed for this study included marital status, literacy, and free of any known physical and mental diseases as well as conflict in marriage. The participants were informed that their admission was non-compulsory.

3 questionnaires were used to collect the data. The first questionnaire was developed by the researcher and consisted of 3 parts about demographic information and sexual satisfaction determinants. The first part investigated sociodemographic factors, such as age, education, spouse's occupation, income and its sufficiency, height, weight, satisfaction with body shape, spouse's satisfaction with body shape, gender satisfaction, type of marriage (permanent or temporary), record of acquaintance with spouse before marriage, record and extent of relationship with people other than the spouse before marriage, record type of infertility, number of pregnancies and types of deliveries, and the number of children. The second part of the questionnaire considered factors related to physical and mental health, such as physical and mental illnesses and addictions to smoking, alcohol or drugs. The third part investigated communicative factors related to the interactions between the couple, such as the state of peace within the marriage and the stability of family life, acts and type of domestic violence, the level of intimacy and affection toward the spouse, the method of contraception used and the agreement with the spouse over its type, the average number of times the couple had sexual intercourse per month, and the average duration of intercourse.

A content validation method was used for the questionnaire. 10 reproductive health specialists and counselors were, thus, subjected to the questionnaire, and some required corrections were made by them. With 2 weeks of teaching the qualified women, we focused on the reliability and tested the reliability using intraclass correlation coefficient. The result was 0.9 for intraclass correlation coefficient.

The Larson's sexual satisfaction questionnaire was used as a valid tool to determine sexual satisfaction in the participants. Validity and reliability of this questionnaire have been verified and approved in Farsi language.To assess the reliability of the tools, a retest was used. The in-line correlation coefficient was 0.9 for the questionnaire about sexual satisfaction determinants and 0.78 for the Larson's standard questionnaire of sexual satisfaction.

This questionnaire contained 25 questions, which were measured on a 5-point Likert scale according to the choices of never, hardly ever, sometimes, often, and always; scores ranged from 1–125. To determine the levels of sexual satisfaction, the scores were categorized. A high score was associated with high sexual satisfaction. A score <50 indicated low sexual satisfaction, a score of 51–100 indicated moderate sexual satisfaction, and <100 indicated high satisfaction.

The general health questionnaire was used to identify people with mental disorders. The questionnaire contained 28 questions divided into 4 subscales: questions 1 to 7 took physical symptoms into account; questions 8 to 14 investigated symptoms of anxiety and sleeping disorders; questions 15 to 21 assessed social function symptoms; and questions 22 to 28 assessed symptoms of severe depression. Filling in this questionnaire required about 10–12 minutes, and the scores range from 0 to 85. A low score indicated better mental health.

The data from the questionnaires were entered into IBM SPSS Statistics for Windows software (version 21) (SPSS Inc, Chicago, IL) and analyzed after encoding the variables. Considering the goals of the study and the nature of the variables, the descriptive statistics were given in terms of frequency, means, and standard deviation. For the inferential statistics, the one-way analysis of variance, t-test, Pearson correlation coefficient, and paired t-test were used.

Results

The sociodemographic characteristics and the average sexual satisfaction of the women are presented in Table 1. The average age of the women in this study was 33.63 ± 9.15 years, and the average sexual satisfaction score was 99.26 ± 13.56. The education levels for the women and their spouses were similar. More than half of the participating women (51.2%) had non-academic education, and most spouses (51.6%) had university education. Most (60.4%) of the participants were housewives. Almost half of spouses (45.9%) were government employees. The income of most participants (42.7%) was 300–600 US dollars. A high percentage of participants (48.1%) expressed satisfaction with their incomes.

Table 1

The sociodemographic characteristics and average sexual satisfaction of the women in the study

Variables	Frequency (percentage) or mean (standard deviation)	Sexual satisfaction mean (standard deviation)	P value	ANOVA (F)/t/correlation coefficient (r)
Age (year)	33/63 (9/1)		.001	r = −0.189
Age of spouse (year)	37/22 (9/1)		.001	r = −0.182
Mental health score	59.90 (11.4)	99 (13)	.002	r = −0.143
Education
Non-university	251 (51.2)	96.64 (14.07)	.001	t = −3.86
University	239 (48.8)	102.02 (12.43)
Education of spouse
Non-university	237 (48.4)	96.94 (14.15)	.001	t = −3.71
University	253 (51.6)	101.45 (12.61)
Occupation of spouse
Unemployed	14 (2.8)	98.57 (16.61)	.003	F = 4.65 df = 3
Laborer	130 (26.5)	95.91 (14.9)
Government employee	225 (45.9)	101/41 (11.91)
Self-employed	121 (24.6)	98.95 (13.94)
Income
Less than $300	150 (30.6)	98.92 (14.96)	.023	F = 3.20 df = 3
$300–600	209 (42.7)	98.64 (13.24)
$600–900	71 (14.5)	97.6 (13.42)
$900 and more	60 (12.2)	104.18 (9.8)
Income sufficiency
Yes	86 (17.6)	102.65 (15.7)	.001	F = 6.64 df = 5
No	91 (18.6)	95.2(13.98)
To some extent	41 (8/4)	101.41 (11.56)

ANOVA = analysis of variance; df = degree of freedom.

Among the participants, 38.6% had a normal body mass index, and 36.1% were overweight. In terms of satisfaction with their weight and body shape, 48.1% were rather satisfied with their weight and 59.9% were rather satisfied with their shape. Regarding the spouse's satisfaction with the wife's body shape, most participants (59.9%) stated that their spouses were happy with their body shapes. Furthermore, most participants (71.1%) were satisfied with being a woman. Most participants (96.1%) were in their first marriage, and most (96.5%) were in a monogamous marriage. For husbands in their second marriage, there were more permanent marriages (2.7%) than temporary marriages (0.8%); a high number of women (69.5%) were first wives. (Temporary marriage in Islam means having a marital relationship within the frame of the laws of the country. In this type of marriage, the woman has fewer rights than a woman in a permanent marriage) (Table 1).

Most participants had a high sexual satisfaction score, and only a few women were not sexually satisfied; the average score for sexual satisfaction was 99 with a standard deviation of 13 (Table 2).The results of the linear regression model showed that the spouse's job as a laborer (P = .003), a low income (P = .002), insufficient income of the spouse (P = .001), and dissatisfaction with being a woman (P = .001) were the main social predictors of sexual satisfaction (r2 = 0.54) in women (Table 3).

Table 2

Average sexual satisfaction of the women in the study

Sexual satisfaction classification	Number (percentage)	Mean (standard deviation)
Low	27 (5.5)	68.11 (14.82)
Medium	207 (42.2)	90.89 (6.9)
High	254 (52.2)	1.9/38 (5.36)

Table 3

Regression results

Variables	Number	Coefficient of regression effect (B)	P-value
Occupation of spouse
Employee	225	−0.942
Laborer	130	−5.35	.417
Self-employed	131	Reference	.001
Income more than 3,000,000	60	6.037	.001
Income sufficiency
Yes	86	Reference
No	168	−2.56	.012
Pride of femininity
Somewhat	41	Reference
Yes	358	−0.619	.716
No	91	−6.1	.002
The method of contraception
One-month injection and tubing and other	43	−10.42	.001
Quarterly injection, no method, pill, condom	447	−1.54	.131

Discussion

The results showed more than half the participants (52.2%) had high levels of sexual satisfaction, whereas less than half (42.2%) had moderate levels of sexual satisfaction, consistent with other studies.,,21, 22, 23 Comparatively, an Iranian study conducted in Urmia city in 2015 found that the average sexual satisfaction score was low.

The results of this study showed that high income was an independent predictor of an increase in sexual satisfaction. Other independent predictors of decreasing sexual satisfaction included insufficient income, the spouse's job as a laborer, and dissatisfaction with being a woman. In determining the relationship between sexual satisfaction and the spouse's occupation, the findings of this study showed that the highest and lowest sexual satisfaction were observed in women whose spouses were governmental employees and laborers, respectively. Similar results were reported by a study conducted in Babol city, which found that the highest level of sexual disorder was in women whose spouses were laborers; this relationship was statistically significant.

Contrary to this study, Safarinejad conducted a study to investigate the prevalence and risk factors of sexual dysfunction in women; the results showed that there was a significant relationship between unemployment and sexual dissatisfaction. However, the present study found that sexual satisfaction was higher in women with unemployed spouses than in women with employed spouses. These contradictory results may be related to the length of unemployment, the support received from families, and the amount of people's savings, which can alleviate concerns about unemployment. In addition, because unemployed spouses spend more time with their wives, they will have more satisfaction with their sexual relationships. On one hand, Azari et al did not find a relationship between sexual satisfaction and employment of the spouse; similar results were reported in other studies,, Results can be affected by differences in the types of studies, the sample size, the population under study, and the number of participants from any job category. In this study, there was a relationship between a spouse's job and sexual satisfaction. Women whose spouses were governmental employees had a higher sexual satisfaction than women whose spouses were laborers, which can indicate sexual satisfaction is influenced by other relevant factors, such as education and income; Regarding the relationship between the economic situation and sexual satisfaction, the results showed that there was less sexual satisfaction in women with low incomes. Furthermore, the results of the linear regression showed that there was a significant positive relationship between the economic situation and sexual satisfaction, which mean that women with a better economic situation had higher sexual satisfaction. Consistent with this finding, Bahrami et al reported that more than half of the participants in their study had an average economic situation.On the other hand, another study reported that only 4.7% of their participants were in poor economic situations and found that there was a direct relationship between sexual satisfaction and the economic situation.

A similar study in 2004 investigated the relationships between 19 independent variables and sexual satisfaction and found there was a direct relationship between the level of sexual satisfaction and the economic situation. A study in 2006 reported that a good economic situation was a factor that increased sexual satisfaction. Another study in 2006 showed that there was sexual dissatisfaction in women who had spouses with a low income or had high levels of household and financial stress.Obviously, poor economic situations and financial problems can lead to a decrease in self-confidence and an increase in mental problems, which can play a role in the decrease of sexual function and satisfaction.

This study investigated income sufficiency, which is another factor that is relevant to a person's economic situation. To distinguish between income sufficiency and economic situation, it should be mentioned that satisfaction with the amount of income does not necessarily increase with a high income; people with low incomes may sometimes be more satisfied than those with high incomes because of their expectations, lifestyles, and facilities that they need. Income sufficiency is the amount of income necessary for a person to meet their basic living needs.

The findings of a studyindicated that there was a significant relationship between income sufficiency and sexual satisfaction; based on the linear regression analysis, sexual satisfaction significantly decreased in people who were not satisfied with their incomes. Similar results were reported by Satoh et al in Japan and confirmed in a meta-analysis conducted by von Sydow.

Conclusion

In this study, we focused on the social factors determining sexual satisfaction among women referred to the health centers located in Sari, the north of Iran. The results primarily showed an average level of sexual satisfaction among the participants primarily. Among all social factors, 4 factors were predictors of sexual satisfaction in women, including job, family economic status, income satisfaction, and self-satisfaction.

The results of this study and other investigations showed that there was a direct relationship between income sufficiency and sexual satisfaction. It should be mentioned that the results also showed a relationship between sexual satisfaction and the amount of income. From these findings, we can conclude that income sufficiency and amount of income affect each other and they are related. The direct role that these 2 factors have on sexual satisfaction emphasizes the importance of the economic situation to the quality of life and the stability of the family. Thus, the economic supply and sufficiency are considered to be major determinants in marital satisfaction and divorce.

We can infer that the women who participated in the study were satisfied with their gender; otherwise, they would have shown low marital compatibility. Owing to cultural and religious considerations in Iranian society, some women may be dissatisfied with their gender because they face more limitations than the men in their families. Overall, we found that satisfaction with one's gender, apart from being instinctive, is influenced by the conditions and culture of society.

The results of this study may serve as a basis for future research. Considering the strengths and weaknesses as well as the limitations of this study, future investigations may result in a comprehensive approach.

Statement of authorship

Conception and Design

Mansoureh Afzali; Soghra Khani; Reza-Ali Mohammadpour

Acquisition of Data

Mansoureh Afzali

Analysis and Interpretation of Data

Soghra Khani; Reza-Ali Mohammadpour

Drafting the Article

Mansoureh Afzali

Revising It for Intellectual Content

Soghra Khani

Final Approval of the Completed Article

Mansoureh Afzali; Soghra Khani; Zeinab Hamzehgardeshi; Reza-Ali Mohammadpour; Foruzan Elyasi