The effectiveness of sexual health group counseling based on cognitive behavioral therapy on sexual satisfaction of newly married women.

BACKGROUND: The beginning of a marital relationship is very important as a part of a family relationship, and it satisfies many mental and physical necessities in a safe environment and has a great impact on people's health. The aims of this study were to investigate the effectiveness of sexual health counseling based on cognitive behavioral approach on satisfaction and excitability of newly married women.
MATERIALS AND METHODS: A randomized clinical trial study was conducted in 50 newly married women who referred to the health center of Jiroft City. They randomly divided into the intervention and the control groups. All of the participants completed Linda Berg's Sexual Satisfaction Scale before intervention, 8 weeks after intervention and 4 weeks later (follow-up). The interventional group participated in CBT (8 sessions, 90 min), but the control group received routine counseling. In all tests, a significance level of 0.05 was considered. Data were analyzed by SPSS version 20. Descriptive test, t-test, and repeated measure test used to analyze data.
RESULTS: In intervention group, sexual satisfaction was obtained 51.88 ± 12.27, 57.2 ± 12.88 and 62.76 ± 11.35 (P < 0.05) and in the control group was gotten 47.12 ± 9.6, 45.8 ± 8.07 and 43.48 ± 7.39 (P > 0.05) before intervention, 8 weeks after intervention and 4 weeks later (follow-up), respectively. In intervention group, sexual excitability was obtained 82.80 ± 17.24, 91.72 ± 13.07, and 99.28 ± 11.2 (P < 0.05) and in the control group was gotten 87.04 ± 12.99, 87.48 ± 11.64, and 81.96 ± 12.83 (P > 0.05).
CONCLUSION: It can be concluded that cognitive-behavioral counseling can help to improve the sexual satisfaction and excitability of the newly married and can be used to improve and promote women's sexual health. Copyright:

Introduction

The successful marriage and the beginning of a marital relationship is very important as a part of a family relationship, and it satisfies many mental and physical necessities in a safe environment and has a great impact on people's health.[1] Achieving the goals of marriage after the marital relationship leads to make the satisfaction feeling and luckiness, and lack of this situation leads to make the disputes and discontent of marriage.[2] Nowadays, the family structure has endured many changes due to various factors such as rapid social, economic, and cultural changes, and two marriages of three ones conduce to divorce. Sexual and marital behaviors are the factors affecting the divorce prevalence and troubles of the couples relationships.[3] The Marital satisfaction is a positive and enjoyable view of the couple from different aspects of the matrimony relationships such as relation, personality issues, conflict resolution, sexual relations, and childbearing.[4] Sexual satisfaction is an important part of marital satisfaction, that is a personal satisfying feeling that the individual meets his own and spouse’ sexual needs and expectations, and has a positive and pleasant assessment of his sexuality.[5] The agreement about the quality and style of sexual relationships and the resulting tendency are very effective in marital satisfaction and promote the mental health in couples.[6] The investigations show that sexual dissatisfaction leads to the instability of couple's relationship and adultery, and increases the probability of divorce.[5] According to the latest reports from the civil registration organization, the ratio of marriage to divorce was 3.9 during the first 9 months of 2016 in Iran. This means one divorce from 3.9 marriages has been registered in Iran.[7] It is estimated that 80% of marital disputes, 50%–60% of divorces, and 40% of infidelities are caused by couple's sexual dissatisfaction.[8] Gheshlaghi et al. confirmed sexual satisfaction was an important part in marital stability of Iranian women.[9]

The necessary grounds for training the correct sexual relationship is not prepared before the marriage and also for the young couples in Iran.[8] Bostani Khalesi and Simber showed in their study that the young couple need some knowledge and skills which are not prepared in the current pre-marriage training program.[10] There are some significant gaps in sexual counseling, despite the efficient primary health-care system.[11] lack of knowledge may be lead to vaginismus.[12] In Khaki Rostami et al., 21% of the women had sexual dysfunction, of which 41% did not seek help[13] and sexual counseling could reduce marital stress.

Nowadays, the cognitive-behavioral counseling approach is commonly used in treatment or sexual functional enhancement and includes a combination of behavioral strategies and cognitive styles that try to change the behavior through the change of thought, explanations and interpretations, and ways of answering.[6] We can pay attention to some cases such as sexual knowledge, expressing emotions and excitements and couples relationships in the cognitive therapy approach, and their role in increasing sexual satisfaction and treating sexual problems has been confirmed in the studies[5] and sexual counseling could reduce marital stress.

The correct learning of sexual issues prevents sexual dysfunction and helps to deal with sexual issues more properly.[714] In the meantime, sexual counseling plays an important role in preventing sexually transmitted diseases, reducing sexual violence, making positive attitude toward sexual encounters and sexual harassment, and reducing incompatibility in the family.[8] According to Rabiepoor and Sadeghi study, attention to education and family counseling programs, especially in the field of sexuality, is effective in increasing sexual satisfaction.[3]

Although premarital counseling is currently practiced in Iran, couples do not receive adequate sexual counseling after marriage. Due to midwives, sexual health cost-effectiveness services, the aim of this study was to evaluate the effectiveness of sexual health group counseling based on cognitive-behavioral therapy (CBT) on sexual satisfaction of newly married women.

Materials and Methods

Study design and setting

This randomized, controlled, clinical trial study was conducted from June to July 2019 with the pretest, posttest (8th week), and follow-up (12th week) period.

Study participants and sampling

First, 110 newly married women who referred to Jiroft Health Center were invited to joint to this study by phone. According to inclusion and exclusion criteria, 50 new married women were engaged to study.

Inclusion criteria

A 18–35 years old, first marriage, duration of marriage between 3 months and 1 year, Iranian nationality, able to read and write, permanent marriage, experience sexual intercourse.

Exclusion criteria

Compulsory marriage, suffering from diabetes, high blood pressure, addiction, Cigar smoking, being under the treatment of a psychiatrist, being pregnant, great stress in the last months.

They randomly divided into the intervention (n = 25) and the control (n = 25) groups.

The intervention group received eight sessions (90 min) weekly. All participants completed the questionnaires before the intervention, after 8 weeks and 12 weeks (follow-up) later. For ethical consideration after follow-up period, intensive sexual health counseling sessions were performed for the control group.

Ethical consideration

The ethical code (IR.SSU.REC.1397.117) was obtained from the Ethics Committee of Shahid Sadoughi University of Medical Sciences and IRCT20200214046486N1code was obtained from Iranian clinical trial. All participants signed informed consent.

Questionnaires

Demographic questionnaires

Demographic characteristics were including age, spouse age, education level, duration of marriage, employment status and income.

Linda Berg's Sexual Satisfaction Scale

Linda Berg's Sexual Satisfaction Scale[15] (1997) was translated to Persian by Salehi Fadardi.[16] This questionnaire is composed sexual satisfaction (17 questions) and sexual excitability (26 questions). The questions designed by Likert's 5 items (5 for “always,” 4 for “often,” 3 for “sometimes,” 2 for “seldom,” and 1 for “never”). The minimum score of sexual satisfaction score is 17 and its maximum score is 85. The minimum and maximum scores of sexual excitability score are 26 and 130. The reliability of this questionnaire was confirmed in many Iranian study.[1718]

The content of the counseling sessions was performed based on similar study[10] and the opinion of the research team [Table 1].

Table 1

Content of the sexual counseling based on CBT

Meeting content	Homework
Introducing each other	Familiarity with the genital area
Distributing the questionnaires
Talking about importance of the sexual relationship
Explaining about genital anatomy and sexual cycle
Answering the questions
Checking the assignments of the previous session	Paying attention to sexual needs
Talking about sexuality in men and women	Write about how to respond spouse’s sexual desire
Talking about physiology and sexual performance
Answering the questions
Checking the assignments of the previous session	writing about sexual concerns and sexual expectations and sexual schemas
Talking about how we can solve our sexual problems
Talking about sexual schemas and concerns
Talking about sexual expectations
Checking the assignments of the previous session	Performing non sensate focus massage two days a week
Training the sexual skills
Explaining about non-sensate focus massage	Doing relaxation exercises
Improving communication skills	Doing verbal and nonverbal exercises to improve communication skills
Talking about how manage negative emotion
Checking the assignments of the previous session	Doing Kegel exercises daily
Training kegel exercise and other factors affecting sexual performance (nutrition, focusing on the moments, enjoying)	Getting proper diet
	Writing negative thoughts
Checking the assignments of the previous session	Writing irrational beliefs (your and your spouse’s)
Talking about cognitive errors and irrational beliefs in matrimony life and teaching how to deal with them and resolve conflicts	Writing the thoughts daily
Training how to use daily table of thoughts
Checking the assignments of the previous session Talking about the effect of emotions on matrimony life and sexual issues	Identifying positive and negative emotions, especially in sexual matters
Talking about the role of skills in effective sexual relationship
Summarizing and reviewing the content distributing the questionnaires

CBT=Cognitive Behavioral Therapy

Data analysis

Descriptive (Independent t-test and Chi-squared test), and analytical statistics (ANOVA) were used for the data analysis. We used a statistical software package IBM SPSS version 16 (IBM, USA, 2007). The significance level is considered P < 0.05.

Results

An average age of the intervention and the control group were obtained 27 ± 6.08 25 ± 5.09 and their husbands’ age was achieved 31 ± 6.4 in the intervention and 29.7 ± 7.6 in the control group. The duration of marriage was 7.5 ± 1.2 months in the intervention and 7.8 ± 2.4 in the control group. Other demographic characteristics including education, occupation, and income were not significant difference in both the groups (P > 0.05). There was no significant statistical difference between two groups in terms of sexual satisfaction and sexual excitability variables at the beginning of the study, but there were significant statistical differences between the two groups after the intervention and 1 month later [Tables 2 and 3].

Table 2

Mean sexual satisfaction score in three measurement stages in the intervention and the control group

Sexual satisfaction	Mean±SD		P*
	Intervention group (n=25)	Control group (n=25)
Before intervention	51.88±12.27	47.12±9.6	0.134
Immediately after the intervention	57.2±12.88	45.8±8.07	0.024
One month after the intervention	62.76±11.35	43.48±7.39	0.001

t-test. SD=Standard deviation. *P<0.05

Table 3

Mean sexual excitability score in three measurement stages in the intervention and the control group

Sexual excitability	Mean±SD		P*
	Intervention group (n=25)	Control group (n=25)
Before intervention	82.80±17.24	87.04±12.99	0.130
Immediately after the intervention	91.72±13.07	87.48±11.64	0.001
One month after the intervention	99.28±11.2	81.96±12.83	0.001

t-test. SD=Standard deviation. *P<0.05

The results of the variance analysis test with the repeated measure showed that the effect of the “time” and “time *group” is significant in sexual satisfaction (P < 0.004) and (P < 0.001) and sexual excitability (P = 0.005) and (P < 0.001) [Table 4].

Table 4

Results of the analysis of variance with the repeated measures of sexual satisfaction and sexual excitability intra-group and inter-group

Change resource sexual satisfaction	Sum of squares	Degrees of freedom	Mean of squares	Statistics F	P*	Effect size
Intra-group (satisfaction)
Time	361.333	1.298	278.325	7.590	0.004	0.137
Time × group	1254.773	1.298	966.517	26.356	0.001	0.354
Error	2285.227	62.316	36.672
Inter-group
Group	5127.527	1	5127.527	18.788	0.001	0.968
Error	13,099.973	48	272.916
Intra-group (excitability)
Time	637.213	1.624	392.352	6.404	0.005	0.118
Time × group	6669.293	1.624	4106.486	67.026	0.001	0.583
Error	4776.160	77.956	61.267
Inter-group
Group	3109.927	1	3109.927	7.185	0.002	0.130
Error	20,776.080	48	432.835

ANOVA and repeated measures. *P<0.05

The mean score of sexual satisfaction in the intervention groups before intervention (Base line) and after intervention (8th week) was significant (P < 0.009), and before intervention and follow-up (12th week) was significant (P < 0.001), but after intervention (8th week) and follow-up (12th week) was not significant (P < 0.001). In the control group sexual satisfaction was not significant in any time (P > 0.05). The mean score of sexual excitability in the intervention groups before intervention (base line) and after intervention (8th week) (P < 0.002), before intervention and follow-up (12th week) (P < 0.001) and after intervention (8th week) and follow-up (12th week) (P < 0.002). The results showed in the control group this variation was not significant in any time (P > 0.05) [Table 5].

Table 5

Mean difference of sexual satisfaction and sexual excitability in two groups before intervention (base line), after intervention (8th week) and follow-up (12th week)

Groups	Sexual Satisfaction
	Time 1	Time 2	Mean difference (2-1)	SE	P*
The intervention group	Before intervention (base line)	After intervention (8th week)	−5.320	1.615	0.009
	Before intervention (base line)	Follow-up (12th week)	−10.880	2.297	0.001
	After intervention (8th week)	Follow-up (12th week)	−5.560	1.203	0.001
The control group	Before intervention (base line)	After intervention (8th week)	1.320	0.637	0.184
	Before intervention (base line)	Follow-up (12th week)	3.328	1.114	0.021
	After intervention (8th week)	Follow-up (12th week)	1.960	0.631	0.014
The intervention group	Before intervention (base line)	After intervention (8th week)	−4.680	1.314	0.002
	Before intervention (base line)	Follow-up (12th week)	−0.700	2.821	1.000
	After intervention (8th week)	Follow-up (12th week)	3.980	1.283	0.002
The control group	Before intervention (base line)	After intervention (8th week)	5.320	2.081	0.200
	Before intervention (base line)	Follow-up (12th week)	10.880	0.637	0.800
	After intervention (8th week)	Follow-up (12th week)	5.560	0.631	0.550

Bonferroni post hoc test. SE=Standard error. *P<0.05

Discussion

Findings of this study showed that the scores of women's sexual satisfaction and excitability increased after 8 sessions of cognitive-behavioral approach and one month after the intervention. The results of the present study are consistent with the studies by Lotfi Kashani et al.[19] Omidi et al.[20] Ramesh et al.,[4] Engman et al.[21] Lotfi Kashani et al. in their study stated that sexual skills training has an important role in increasing personal desire to express emotions and ease sense in discussion and sexual intercourse.[19] The study was performed on 71 couples in Turkey and they showed the improvement of the average sexual performance of women, four months after teaching the information-motivation-behavior model.[22] In Farjkhoda et al.[23], and Trudle et al.'s[24] study they showed sexual consultation could improve sexual intimacy and satisfaction. In the present study, we notice women's ability to express sexual feelings improve their sexual satisfaction in the intervention group.

The results of Tahan et al.'s showed psycho-educational group consulting helps to increase sexual functioning and marital satisfaction of married couples[25] and the study of Bostani et al. also showed Information about sexual health is one of the essential needs of young couples.[26] The results of this study are consistent with the present study. We found how the participant could change their negative thought by CBT.

Pachano Pesantez et al.[27] also investigated the effectiveness of CBT on women's sexual desire disorder. They showed the positive effect of CBT on reducing sexual desire disorder in women and their results are consistent with the present study.

Contrary to the results of the present study, Turkestani et al.[28] compared the effect of conventional premarital counseling and the acceptance and commitment-based approach on sexual performance of couples, and showed that there was no significant difference between the effect of premarital counseling and the acceptance and commitment-based approach on sexual performance of couples. One of the reasons for the difference in their study with the results of the present study is the selection of a very short period of time before or immediately after cohabitation and the statistical population of the couple before marriage. The couples have not yet dealt with the problems required to be addressed to receive counseling.

Bruto et al.[29] did not show any effect on improving women's sexual performance after mindfulness-based behavioral cognitive intervention in their study aimed at investigating the effect of mindfulness-based behavioral cognitive intervention on improving the sexual performance of women aged 31–64 years old with endometrial and cervical cancer. The difference between their study and the present study is the statistical sample that the present study is about the newly married women and their study in women of a waiting list for the treatment of endometrial and cervical cancer.

In a longitudinal study by James et al.,[30] which followed 207 newly married couples aged 18–35 years who had been married for <6 months, followed for 4–5 years, the results showed that over time, all three variables of sexual satisfaction, marital satisfaction, and the frequency of sexual intercourse decreases. The present study which investigated the newly married women aged 18–35, like James’ study, did not receive any intervention in the control group and we saw a decrease in sexual satisfaction and excitability scores in follow-up period, which could indicate the necessity of interventions in terms of improving sexual relationships over the marriage time. As the duration of marriage increases, the level of sexual satisfaction and sexual excitability of women decreases, which requires useful interventions to maintain sexual satisfaction and naturally, marital satisfaction and family survive. It is suggested that the effect of cognitive-behavioral counseling approach in enhancing sexual satisfaction and excitability in other age groups of men and women be investigated in future research.

Limitation and suggestion

Limitations of this study were dissatisfaction of some women's husbands to participate in this study, and some people are unwilling to participate in this study due to the length of counseling sessions.

The authors suggest that sexual health counseling sessions be held for newly married couples. In addition, we recommend couple therapy for young couples who have sexual problem.

Conclusion

The findings of the present study showed that cognitive-behavioral counseling can be helpful in improving couples’ sexual satisfaction and excitability. The level of sexual satisfaction and excitability of women decreases with the increase in the duration of marriage, and it needs useful interventions to maintain sexual satisfaction and of course, matrimony satisfaction, and family survival.

Financial support and sponsorship

This study was financially supported by Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

Conflicts of interest

There are no conflicts of interest.