Keywords functional analytical psychotherapy (FAP) - cognitive behavioral therapy (CBT) - sexual
quality of life - married women - adolescents
Palavras-chave psicoterapia analítica funcional (FAP) - terapia cognitivo-comportamental (TCC) -
qualidade de vida sexual - mulheres casadas - adolescentes
Introduction
Sexual activity is one of the most important aspects of human life. It can be influenced
by personal characteristics, interpersonal relationships, the family, sociocultural
conditions, the environment, the sexual-activity history of the individual and their
spouse, physical and mental health, and the hormonal status of the individual. One
of the most significant components of cohabitation is a healthy and satisfying sexual
relationship between spouses, and having the necessary physical, mental, and social
readiness is undoubtedly a necessity.[1 ]
Sexual compatibility is an important factor in happiness and good quality of life.[2 ] Sexual relations can directly or indirectly affect the relationship of couples by
affecting their thoughts and feelings.[3 ] Sexual quality of life is an interactive and dynamic state that can change over
time with changes in circumstances. An optimal sex life leads to more positive sexual
feelings, which, in turn, result in happiness and satisfaction with life.[4 ]
The World Health Organization (WHO) defines the age range of 10 to 19 years as adolescence,
which is one of the most important age groups in any society; therefeore, the health
of adolescents is considered an important aspect of the health of society.[5 ]
The phenomenon of early marriage is increasing in Iranian society. Early marriage
has many negative consequences on health, development, and the rights of children,
especially of girls, and is often accompanied by the loss of educational opportunities,
social isolation, exploitation, and physical, sexual and psychological violence by
their husbands.[6 ]
Iranian cultural and religious backgrounds prevent open conversations about sexual
relationships.[7 ] Therefore, lack of sufficient knowledge about sexual issues causes these women to
feel fear and disgust regarding having sex; this sexual dissatisfaction will definitely
lead to coldness in the relationship with the husband.[8 ]
Studies[2 ]
[9 ] have shown that one-third of women do not enjoy sex with their partner, and almost
one-fourth of them do not achieve orgasm. The prevalence of sexual dysfunction among
American women ranges from 30% to 65%.[10 ] The prevalence of these disorders is also reported to be of 69% in Egypt,[11 ] and of 46.9% in Turkey.[12 ] The rate of sexual dysfunction is reported to be of 21.9% among newly-married women
in Sari, in Iran,[13 ] and it has also been reported to be of 66% in newly-married women in Zanjan, also
in Iran.[13 ]
Most couples seeking divorce in Iran were young age at the time of marriage, and this
is considered the most common cause for divorce. Over 50% of the causes for divorce
are sexual problems, which most often occur in the first 5 years of married life.[8 ]
Global studies show that around 82 million girls between the ages of 10 and 17 are
getting married before the age of 18;[4 ] globally, 36% of women between the ages of 20 and 24 are married before the age
of 18, with 14 million 15- to 19-year-olds giving birth each year.[8 ]
In recent years, the highest number of marriages registered in Iran have involved
men aged 20 to 24 and women aged 15 to 19; the number of recorded marriages of girls
under 15 has dramatically increased in the past few years.[14 ]
Cognitive behavioral interventions have been used to improve the sexual quality of
life in men and women,[15 ] and studies[16 ]
[17 ] have reported the effectiveness of functional analytical psychotherapy on self-esteem,
anxiety, depression, quality of life, and marital satisfaction.
Functional analytic psychotherapy with enhanced cognitive therapy (FECT) relies on
the skills, training, forms, procedures, and methods of cognitive therapy (CT), and,
compared with standard CT, experienced cognitive therapists are interested in using
this method.[18 ]
The two major enhancements FECT has brought to standard CT are the use of an expanded
rationale for the causes and treatment of depression, and a greater use of the therapist-client
relationship as an in-the-moment learning opportunity. In a preliminary, uncontrolled
trial,[19 ] FECT clients appreciated the expanded rationale, the incremental improvements in
depression, and the major gains in interpersonal functioning.
Despite the fact that the level of literacy in Iran is relatively high, due to gaps
in the health system, the issue of counseling in sex education has been greatly ignored.[20 ] Considering the importance of adolescence and the high population of adolescent
girls (5 million) in the country, and the fact that 17% of the country's marriages
involve girls under 18 years of age, it may be possible to prevent some sexual problems
in this age group. Therefore, the present study was conducted to determine the effect
of the FECT approach on the sexual quality of life of married adolescent women.
Methods
The present clinical trial (code: IRCT2019021707042736N1) was conducted to determine
the effect of FECT on the sexual quality of life of married adolescent women. Sampling
was conducted for 3 months, from July to the end of October 2019. The sample consisted
of 150 married adolescent women who met the inclusion criteria and were referred to
health care centers in Darab, a city in the south of Shiraz province, Iran. The study
power was of 80%, and the significance level was 0.05. The sample size was calculated
to be 80 people (40 subjects in each group), but, due to probable dropouts, we increased
it by 20%.
Those who met the inclusion criteria were Iranian girls who were Darab residents,
had a minimum level of literacy (reading and writing), were aged between 15 and 19
years, had been married for at least one year, had a monogamous husband (polygamy
is an accepted practice in Muslim communities), had no extramarital relationships,
were currently living with their husbands, had sex at least once a week, had not given
birth in the previous year, reported that their spouses did not have any sexual issues,
and had had an officially-registered marriage.[9 ]
[21 ] The exclusion criteria were having an acute illness during the study, history of
mental disorders during or before the study, experiencing a stressful incident during
the month preceding the study, unwillingness to continue participating in the study,
use of any psychiatric or psychotropic drugs, use of any psychological services, missing
at least two counseling sessions, being pregnant, history of genital surgery, and
addiction to drugs or alcohol.[9 ]
[22 ]
The eligible participants were randomly assigned to either the intervention or the
control group at all eight of the health care centers in Darab. The names of the married
teenagers were listed, and they were asked if they were willing to participate and
if they met the inclusion criteria. A total of 150 girls met the inclusion criteria,
and 75 were assigned to each group by drawing lots. Although the calculated sample
size was smaller than this number, due to the large number of sessions, which increases
the probability of dropouts, the study was conducted on all eligible individuals.
To facilitate the participants' commute due to the high number of counseling sessions,
the intervention group was invited in groups of 10 to 12 people to the nearest health
center to their residence to undergo counseling sessions. These participants completed
the Sexual Quality of Life-Female (SQOL-F) questionnaire and handed it in to the researcher
before the start of the first counseling session and during sessions 2, 4, 6, 8, 10,
12, 14, 15, and 16. Since each counseling session emphasized more on one aspect of
the sexual quality of life, we asked the participants to fill out the questionnaire
every couple of sessions to examine the differences in their answers. In the intervention
group, FECT was conducted in sixteen 90-minute sessions twice a week.
The counseling sessions were based on the FECT method. To improve the efficacy of
the sessions, cognitive techniques were applied to enhance the main domain of counselling
(functional analytical psychotherapy, FAP).[18 ]
[19 ] Homework was assigned to maintain the efficacy of the sessions during the intervention;
it included the repetition of the techniques and making the requested behavioral changes
at home, as well as concentration on the cognitive errors to replace them with correct
behaviors ([Table 1 ]). The pretest and posttest were performed for both study groups simultaneously.
When the study ended, the control group was given the choice of receiving the same
intervention as the other group. After the posttest, an educational pamphlet containing
a summary of the content of the counseling sessions was provided to the control group.
Table 1
Summary of the counseling sessions based on FECT
Session
Topic
Content
1
Introduction to the research variables
Introduction, explanation of the goals and rules of the counseling sessions focusing
on the sexual response cycle and the benefits of sex based on the FECT approach, and
homework*
2
Introduction to the method and variables
Explanation of FECT-based counseling, its benefits and limitations, types of emotions,
quality of life, and sexual self-efficacy, and homework
3
Sexual disorders and self-efficacy
Analytic interpretation of and cognitive approach to women's sexual disorders and
related psychological problems, the impact of morality and law on sexual quality and
self-efficacy, role play, and homework
4
Sexual role and confidence, clinically-relevant behavior
Analytic interpretation of and cognitive approach to sexual roles, physical sexual
attraction, sexual confidence, working on clients' clinically-relevant behavior through
role play, and homework
5
Gender identity, clinically-relevant behavior
Cognitive errors about gender identity and the factors affecting it, working on the
arousal of clinically-relevant behavior through role play, and homework
6
Sexual orientation, clinically-relevant behavior
Gender and sexual orientation, working on strengthening clinically-relevant behavior
through role play, and homework
7
Communication skills and addiction
Working on effective marital-communication skills, behaviors that lead to sexual self-efficacy,
the impact of various types of addiction on sexual relations, and homework
8
Sex life of men (husbands accompanied their wives in this session)
Cognitive focus on sexual quality of life and sexual disorders among men, and homework
9
Sexual goals
Analytic interpretation and cognitive approach to general and sexual self-efficacy
and factors affecting it (such as sexual goals, self-confidence, self-esteem), and
homework
10
Sexual satisfaction
Analytic interpretation and cognitive approach to sexual feelings, marital and sexual
satisfaction, and their influencing factors, and homework
11
Femininity
Analytic interpretation of femininity and cognitive approach to the difference between
dependence and love, how valuable women are (femininity, sexual confidence, the sense
of guilt in sex life), and homework
12
Cultural factors
Analytic interpretation and cognitive approach to the cognitive triangle, sexual repression
(feelings of pleasure, culture-related sexual errors), and homework
13
Improvement in sex life
Analytic interpretation of and cognitive approach to sexual competence, dealing with
unexpected issues in sex life, ways to create variety in sex life, and homework
14
Role play
Interpretation of variables affecting behavior through role play, and homework
15
Review
Review session, review of practical techniques, and homework
16
Review
Review session, review of practical techniques
Abbreviation: FECT, functional analytic psychotherapy with enhanced cognitive therapy.
Source: Khajeh et al.[15 ] and Kanter et al.[23 ]
Note: *Homework: practicing mindfulness-based changes in thoughts, emotions, and behaviors
related to sexual life.
To achieve the research objectives, two questionnaires were used: a demographic questionnaire
and the SQOL-F. The demographic questionnaire collected data on gender, age, duration
of marriage, spouse's age, self-employment, spouse's job, number of children, level
of schooling etc.
The SQOL-F was first evaluated by Symonds et al.[24 ] in 2005 in the United Kingdom and the United States. The internal consistency was
of 0.95, and the intragroup correlation coefficient was of 0.85. The questionnaire
consists of 18 questions graded on the Likert scale; each question is graded from
0 to 100 (0–20–40–60–80–100). The total score of the questionnaire is between 0 and
100. Questions 1, 5, 9, 13, and 18 are reverse-scored. The criterion for interpretation
is the average score of the research population, which means that a score lower than
the average of the research population indicates poor sexual quality of life, and
a score higher than the average of the research population indicates the desired sexual
quality of life.[25 ]
For the statistical analysis, we used the Statistical Package for the Social Sciences
(IBM SPSS Statistics for Windows, IBM Corp., Armonk, NY, US) software, version 24.
As we had repetitions in the measurement, we used repeated measures analysis of variance
(ANOVA) to make comparisons within the intervention group. To compare the intervention
and control groups after the intervention, we used analysis of covariance (ANCOVA).
The independent samples t -test was used to compare the study groups before the intervention due to the normality
of the data, and the Chi-squared test was used to examine the similarity between both
groups. The paired t -test was used to compare the groups before and after the intervention. To observe
ethical considerations, in addition to obtaining written informed consent from the
participants, the study was conducted under ethical code IR.KMU.REC.1398.091, issued
by the Ethics Committee at Kerman University of Medical Sciences, and clinical trial
code IRCT2019021707042736N1, issued by the Iranian Registry of Clinical Trials.
Results
In the present study, 150 married teenage women, divided into 2 groups of 75 each,
were examined, and 50 (25 women in each group) were excluded from the study. The reasons
for exclusion from the intervention group were: starting school and having preparation
classes for university entrance exams (ten participants); university admission and
moving to another city (nine participants); pregnancy (two participants); and unwillingness
to attend the meetings (one participant); in addition, three women dropped out of
the study due to concomitant use of antidepressants. In the control group, some members
were excluded due to failure to complete the posttest questionnaire (19 participants),
or because they sent an empty questionnaire (6 participants). The pretest and posttest
were competed by both study groups simultaneously. Finally, the data on 50 women in
each group were analyzed.
According to the results shown in [Table 2 ], the mean age of the participants was 17.62 ± 1.32 years (intervention group) and
17.38 ± 1.15 years (control group) (p = 0.33). The mean age of the spouse was 27.56 ± 3.43 years and 26.56 ± 3.02 years
in the intervention and control groups respectively (p = 0.12). There was a significant difference between the groups in terms of the number
of children (p = 0.04), but there was no significant difference between them regarding level of
schooling, spouse's level of schooling, or spouse's job.
Table 2
Demographics of the study groups
Variable
Intervention group: N(%)
Control group N(%)
Chi-squared test
p -value
Women education level:
0.31
0.85
First high school
7(14)
6(12)
Second high school
35(70)
34(68)
Diploma and higher education
8(16)
10(20)
Husband's level of schooling:
2.78
0.59
Illiterate
2(4)
0(0)
Elementary
6(12)
4(8)
Diploma
20(40)
20(40)
Associate degree
10(20)
11(22)
Bachelors
12(24)
15(30)
Husbandś education level:
0.60
0.89
Unemployed
5(10)
3(6)
Worker
5(10)
6(12)
Freelancer
30(60)
31(62)
Employed
10(20)
10(20)
Number of children
0.04
0
27(54)
27(54)
–
1
15(30)
15(30)
–
2
7(14)
7(14)
–
3
1(2)
1(2)
–
There was no significant difference between the mean score on sexual quality of life
before counseling in the intervention (52.33 ± 23.09) and control (59.57 ± 22.12)
groups (p = 0.11), that is, the groups were not significantly different in terms of sexual
quality of life before the intervention. There was a significant difference between
the mean score on sexual quality of life before (52.33 ± 23.09) and after (88.08 ± 10.51)
counseling in the intervention group (p < 0.0001). However, in regard to this, there was no significant difference in the
control group (p = 0.30). There was a significant difference between the mean score in the 4 dimensions
of sexual quality of life: psychosexual aspects (84.62 ± 12.68), sexual satisfaction
(93.84 ± 8.20), sexual self-humiliation (87.73 ± 12.07), and sexual repression (86.93 ± 13.46)
after counseling within the intervention group (p < 0.0001). However, there was no such difference in the control group ([Table 3 ]). According to the ANCOVA, there was a significant difference between the score
on sexual quality of life after counseling between the intervention (88.08 ± 10.51)
and control (60.32 ± 23.73) groups (p < 0.0001), with an average score of 31.91 (95% confidence interval [95%CI]: 27.89–35.92)
in the intervention group after counseling.
Table 3
Comparison of the mean score on sexual quality of life and its dimensions before and
after counseling in both groups
Variable
Group
Before counseling: mean ± standard deviation
After counseling: mean ± standard deviation
p -value
Sexual psychology
Intervention
50 ± 25.64
84.62 ± 12.68
< 0.0001
Control
58.20 ± 23.31
59.06 ± 25.10
0.414
Sexual satisfaction
Intervention
57.68 ± 24.05
93.84 ± 8.20
< 0.0001
Control
64.12 ± 21.94
64.79 ± 23.53
0.542
Sexual self- humiliation
Intervention
49.20 ± 24.86
87.73 ± 12.07
< 0.0001
Control
59.46 ± 25.97
59.33 ± 27.80
0.909
Sexual repression
Intervention
52 ± 22.77
86.93 ± 13.46
< 0.0001
Control
55.33 ± 23.26
56.80 ± 24.77
0.219
Total sexual
quality of life
Intervention
52.33 ± 23.09
88.08 ± 10.51
< 0.0001
Control
59.57 ± 22.12
60.32 ± 23.73
0.39
As can be seen from the repeated measures ANOVA, there was a significant difference
between the average sexual quality of life and its dimensions at different times (p < 0.0001) ([Table 4 ]). The mean score increased over time in the intervention group. An elevation was
observed in the mean score of different dimensions in different sessions. In the second
and twelfth sessions, the psychological dimension improved; in the eighth session,
the sexual dimension improved; sexual humiliation improved in the second and tenth
sessions; and the sexual repression subscale improved in the fourth and tenth sessions
([Fig. 1 ]).
Fig. 1 Changes in sexual quality of life and its dimensions during counseling sessions in
the intervention group.
Table 4
Trend of the average score on sexual quality of life during counseling sessions in
the intervention group
Group
Intervention
Sexual quality of life
Mean ± standard deviation
F
p -value[* ]
F-test
52.33 ± 23.09
189.27
< 0.0001
Session 2
60.02 ± 22.89
Session 4
64.97 ± 21.68
Session 6
69.02 ± 20.05
Session 8
72.04 ± 18.13
Session 10
77.64 ± 15.56
Session 12
81.88 ± 13.54
Session 14
84.57 ± 12.10
Session 16
88.08 ± 10.51
Note:* Repeated measures analysis of variance (ANOVA).
Discussion
The present study was conducted to determine the effect of FECT on the sexual quality
of life of married adolescent women. The results show a significant difference regarding
the mean score on sexual quality of life of both study groups (p < 0.0001). A significant difference in the score on sexual quality of life after
counseling was also observed for both groups through the ANCOVA (p < 0.0001). This shows that FECT was effective in improving the sexual quality of
life, which is consistent with the results found by Fatehi et al.[25 ] on the effect of psychological counseling on sexual quality of life and sexual function
among breast cancer survivors in Iran.[25 ] Similar to the present study, the meta-analysis emphasized that individual and group
psychological interventions using the cognitive approach and multidimensional therapies
with long term follow-ups are suggested for the treatment of sexual dysfunction and
for sexual life.[26 ] Another research[27 ] also showed that sexual rehabilitation programs have positive effects on the sexuality
of patients undergoing hemodialysis. These similarities could be due to the use of
psychotherapeutic interventions and counseling. Sexual rehabilitation programs, as
well as FECT, increase self-esteem and the participants' ability to resume their lives
as sexual beings, as their acceptance of their sexuality is addressed in rehabilitation.
Furthermore, the participants' ability to resume their lives as sexual beings was
affected by the their own attitudes, and those of their partners and of society. Etemadi
et al.[28 ] conducted conducted a study with the aim of determining the effect of FAP on the
rates of depression, anxiety, and marital satisfaction of women with marital issues.
The results showed that FAP was effective in reducing depression and anxiety and increasing
marital satisfaction.[28 ] The present research aimed at increasing the effectiveness of FAP by adding a cognitive
element to the counselling sessions.
The results showed that there was a significant difference between the mean score
on sexual quality of life before and after counseling in the intervention group (p < 0.0001), that is, counseling was able to improve the sexual quality of life of
the research participants. Alimohammadi et al.[29 ] conducted a clinical trial with a sample of 96 newly-married women with the aim
of investigating the effect of counseling based on Bandura's self-efficacy theory
on sexual self-efficacy and sexual quality of life. The intervention was performed
in the form of six 90-minute sessions per week, and the results showed that counseling
improved sexual self-efficacy, but did not affect the sexual quality of life. It seems
that counseling based on Bandura's self-efficacy theory cannot cover all dimensions
of sexual quality of life.
Abdelhakm et al.[30 ] reported that the permission, limited information, specific suggestions, and intensive
therapy (PLISSIT) model sexual counseling program has a significant effect on improving
the sexual quality of life of women in the postpartum period. The PLISSIT enables
participants to freely discuss sexual issues in order to solve sexual problems and
enhance sexual quality of life. With the FECT, these two aims are achieved by working
on clinically-relevant behavior (CRB) and modifying cognitive errors and behavioral
problems in sexual life to produce positive changes in those behaviors.[18 ]
According to the results of the present study, there was a significant difference
in the mean score on the four dimensions (psychosexual aspects, sexual satisfaction,
sexual self-humiliation, and sexual repression) of sexual quality of life before and
after counseling in the intervention group (p < 0.0001). In addition, the repeated measures ANOVA showed that there was a significant
difference in the average sexual quality of life and its dimensions at different times
(p < 0.0001). In the present study, FECT was able to have a positive effect on all aspects
of sexual quality of life. Also, progress was examined in each session, and clear
progress in each dimension was observed in specific sessions according to the content
of that day. Ahmadian et al.[31 ] also obtained similar results by examining the problem-solving sexual therapy process
of couples with sexual issues, demonstrating that the couples made progress in each
session. Teaching problem-solving as a component of emotional intelligence was effective
on enhancing sexual quality of life.[32 ] Both cognitive behavioral therapy (CBT) and problem-solving therapy indicated significant
improvements in satisfaction over time.[33 ]
The 2013 study by Steinke et al.[34 ] aimed to determine the effect of comprehensive sexual counseling based on social
cognitive theory on the dimensions of sexual satisfaction, sexual self-efficacy, awareness,
return to sexual activity, sexual anxiety, sexual depression, and quality of life.
The study was performed on heart attack patients aged ≥ 45 years and their spouses.
Educational videos, telephone counseling, and pamphlets were used in the intervention.
The study was conducted on 10 patients and on the sexual partners of 3 of them. Eight
weeks after the intervention, the findings showed that the participants' knowledge
and information had increased. Sexual self-efficacy before and after the intervention
was similar, and there was no significant difference in terms of sexual anxiety before
and after the intervention.[34 ]
This may be related to the fact that social cognitive theory (SCT) does not provide
a full explanation or description of how social cognition, behavior, environment,
and personality are related.[35 ]
One study[21 ] showed that four 90-minute sessions of educational intervention did not cause a
significant change in a woman's sense of guilt from coitus during pregnancy, of the
immorality of coitus during pregnancy, and of the dislike for her pregnant appearance
from the point of view of the spouse. Educational intervention, by focusing on information
about psychological and physiological changes that occur during the sexual response,
may not be as effective as FECT.[26 ]
Health is one of the basic human rights, and adolescent health is a priority in most
societies. There is little research on adolescent sexual problems, but evidence suggests
that these problems cause concern and distress among adolescents.[22 ] Young people are usually less aware of sexual issues, which increases their sexual
problems, and, as a result, their anxiety and worry; thus, this may create a wide
range of misconceptions and false beliefs. Empowering young people by increasing their
awareness regarding sexual issues can encourage them to seek professional help.[36 ] The high number of sessions was one of the limitations of the present research;
however, the results can be used in the field of clinical and counseling services
to enrich the knowledge and skills of adolescents and increase their ability to express
their issues in this field.
Conclusion
The results showed that FECT improved sexual quality of life among married adolescent
women.
