1. Background
Sexual issues are among the first issues of married life. Adequacy in sexual relations, the proportion, the balance and amount of sexual desire in men and women are crucial proponents for happiness and success in married life (1). In other words, satisfaction from sexual activity is one of the most important dimensions of adult life and attention to this is an essential component of health care standards (2, 3). Sexual satisfaction is the judgment of each person with respect to his/her sexual behavior and how enjoyable it is. It is also as one of the physiological needs that leads to human health and in the case of sexual dissatisfaction, the physical and psychological pressures owing to it can be problematic for the individual and may disrupt his/her health and reduces his/her abilities and creativity (1, 4). In fact, sexual satisfaction not only should bring warmth and passion for couples but also protects them from many diseases (5). About 60% - 80% of women were found to have different forms of sexual dysfunction (6). Some researchers believe that the main cause of 80% of marital conflicts is due to sexual dissatisfaction of one of the partners (7). Researchers have reported that about 20% - 30% of males and 15% - 20% of females in the United States engage in sexual relationships with someone other than their spouses because of the lack of sexual satisfaction with their own spouses. Also, 40% of known betrayals and secret relationships of Iranian spouses are due to the same reason. Recent studies showed that sexual dysfunction is closely related to social problems, such as sexual crimes, including sexual intercourse without consent, mental illness, and divorce (8). In this regard, Bentwood quoting master and Johnson stated that the cause of failure of 50% of marriages is due to sexual dissatisfaction (9).
There are several factors involved in the progression and development of female sexual disorders (8). Some people have organic diseases that affect their activity and sexual satisfaction. Depression, mental stress, chronic disease, medication, infertility, pregnancy, childbirth, and social characteristics are also factors that contribute to sexual dissatisfaction. Methods of contraception also have different effects on females’ sexual satisfaction (10, 11). In this regard, a major problem facing today’s society is the lack of adequate information on sexual issues and the existence of inappropriate beliefs about this, which has resulted in the destruction of many families. A misconception that is most common in this area, especially among women, is that the sexual act is a sin. This mode of thinking is so powerfully engraved in some minds that some women protest against legitimate demands of their husbands; therefore, neither partners are able to fulfill their natural and emotional demands so neither partners achieve sexual satisfaction (12).
2. Objectives
Considering the importance of sexual satisfaction to be a legitimate factor of married life, and the lack of attention to sexual health in Iran through the midwives’ awareness of sexual issues due to their regular contact within the community acting as professional family advisers, this study was conducted to determine the levels of sexual dissatisfaction and to understand some of its related factors in Ahvaz city.
3. Methods
In order to determine the sample size, due to the lack of a similar article, this study was conducted as a pilot with a size of 15 people per occupation group, in a total volume of 75 people. According to the following formula, the sample size per occupational group was determined to be 137, in total, the total sample size was 685. Considering r = 0.35, z2 = 2.58 for power of 99% and z1 = 1.65 for 95% power and placement in the formula is obtained as follows:
The sampling method was that from 32 health centers in Ahvaz, 6 centers (3 centers from the west and 3 centers from the east) and from 7 hospitals affiliated to Ahvaz University of Medical Sciences, 4 hospitals (2 large hospitals, 1 medium hospital and 1 small hospital) were randomly selected. Sampling during the week with 2 days of referral to large hospitals, 1 day of moderate hospital, 1 day of a small hospital, and 2 days of referral to health centers was random. Sampling method was available to both employed and housewives. Sampling with this method continued until the samples were completed. Women working in the fields of education in a group, health care (nurse and midwife), the second group, third grade, and administrative services in the fourth group. For sampling, employed and housewives were referred to health centers and hospitals affiliated to Ahvaz University of Medical Sciences in selected centers. The data collection tool was a two-part questionnaire consisting of section A: personal details including age, length of the marriage, number of offspring, age of the youngest child, age of the spouse, and methods of contraception used; and section B: sexual satisfaction questionnaire.
The validity of the demographic content of the questionnaire came from the study of the newest books and articles. The questionnaire and a checklist were then prepared and presented to 10 faculty members of the Nursing and Midwifery College of Ahvaz. After providing necessary amendments according to their opinion, the final version of the questionnaire was developed. This sexual satisfaction questionnaire contained 25 questions. For each question 5 answer options based on the Likert scale were used: always, often, sometimes, rarely, and never. Each question was scored from 1 to 5.
In questions 1, 2, 3, 10, 12, 13, 16, 17, 19, 21, 22, and 23 the ‘never’ option equaled 1, ‘rarely’ 2, ‘sometimes’ 3, ‘often’ 4, and ‘always’ 5. For each of the remaining questions, ‘always’ was scored 1, ‘often’ 2, ‘sometimes’ 3, ‘rarely’4, and ‘never’ 5. This scale was used to analyze the data between a score of 25 to 125. With the obtained score, the variable classification depended on the levels of sexual dissatisfaction (score less than 50), low satisfaction (50 - 75), somewhat satisfied (75 - 100), and high satisfaction (scores greater than 100).
The questionnaire and its contents were validated formally in Iran by Shams Mofraha of the Midwifery Department of Qom University of Medical Sciences in 2010. The reliability of the questionnaire was conducted using the ‘test/re-test method’. This gained a 98% confidence rating (13, 14). The questionnaire was filled by each participant after coordinating with the relevant authorities and obtaining written and verbal consent from the participants. In order to protect confidentiality, the names of the individuals were not included in the questionnaire. The participants were allowed to be excluded from the research study at any time that a participant was reluctant to participate. The researcher who was responsible for the study came to the research unit to respond to any questions from the participants about the study. The data were analyzed by the SPSS software (version 22), descriptive statistics, and chi-square test.
4. Results
The results showed that education has a significant and prominent effect on sexual satisfaction. Women with university education have a satisfactory sexual satisfaction rate of 9.34 times more than illiterate women (P = 0.002, CI = 0.026 - 0.422, OR = 0.107) and 6.13 times more than women that their education was at the level of the diploma (P = 0.000, CI = 0.069 -0.384, OR = 0.163) (Table 1).
Table 1.Logistic Regression Test to Examine the Effect of Demographic Variables on Sexual Satisfaction
| The Studied Variable | B | P Value | OR | Confidence Interval 95% | |
|---|---|---|---|---|---|
| Lowest Value | Highest Value | ||||
| Age | -0.103 | 0.412 | 1.154 | 0.705 | 1.154 |
| Marriage age | 0.071 | 0.557 | 1.363 | 0.846 | 1.363 |
| Duration of marriage | 0.084 | 0.501 | 1.390 | 0.851 | 1.390 |
| Number of children | 0.086 | 0.671 | 1.622 | 0.732 | 1.622 |
| Age of youngest child | 0.023 | 0.648 | 1.132 | 0.926 | 1.132 |
| Age of husband | -0.051 | 0.151 | 1.019 | 0.887 | 1.019 |
| Income | 0.000 | 0.95 | 1.002 | 0.998 | 1.002 |
| Education (academic base) | |||||
| Illiterate | -2.23 | 0.002 | 0.442 | 0.026 | 0.442 |
| Under diploma | -1.81 | 0.000 | 0.384 | 0.069 | 0.384 |
| Diploma | -0.307 | 0.455 | 1.645 | 0.329 | 1.645 |
| Contraceptive method (base of tube closure) | |||||
| Tablet | 0.668 | 0.139 | 4.722 | 0.806 | 4.722 |
| Ampoules | 0.284 | 0.750 | 7.662 | 0.231 | 7.662 |
| IUD | -0.192 | 0.674 | 2.022 | 0.337 | 2.022 |
| Condom | 0.825 | 0.073 | 5.619 | 0.927 | 5.619 |
| No prevention | 0.344 | 0.584 | 4.823 | 0.412 | 4.823 |
Abbreviation: IUD, intrauterine device.
Table 2 shows that sexual satisfaction has a significant relationship with all the demographic characteristics and contraceptive methods (P < 0.05). There was a negative relationship between age and sexual satisfaction, and it appeared sexual satisfaction was decreased with increasing the age. It should be noted that due to the low number of the cases of total sexual dissatisfaction, these figures were merged with the low satisfaction ones. There was also a negative relationship between marriage duration and sexual satisfaction that sexual satisfaction was decreased with the increase in the length of the marriage. The results also showed that there was a negative relationship between the number of offspring in the marriage and sexual satisfaction, and the study also showed that those without children recorded the most sexual satisfaction. There was also a negative relationship between the age of the youngest child and the age of the spouse. Sexual satisfaction was the lowest among those who used tube closure, but the highest among those who used condoms for contraception (Table 2).
Table 2.Investigating the Association Between Sexual Satisfaction and Individual Characteristics of the Participantsa
| Demographic Characteristics | Sexual Satisfaction | P Value | ||
|---|---|---|---|---|
| Weak and Dissatisfaction | Average | High | ||
| Age of participant | < 0.001 | |||
| 19 - 29 | 106 (61.6) | 57 (33.1) | 9 (5.3) | |
| 30 - 39 | 137 (36.5) | 196 (52.3) | 42 (11.2) | |
| 40 - 49 | 37 (26.8) | 77 (55.8) | 24 (17.4) | |
| Years of marriage | < 0.001 | |||
| 1 - 10 | 194 (50.7) | 163 (42.6) | 26 (6.8) | |
| 11 - 20 | 76 (30.9) | 136 (55.3) | 34 (13.8) | |
| 21 - 30 | 10 (17.9) | 31 (55.4) | 15 (26.8) | |
| Children | < 0.001 | |||
| No child | 63 (62.4) | 30 (29.7) | 8 (7.9) | |
| One child | 119 (50.6) | 99 (42.1) | 17 (7.2) | |
| Two children | 77 (35) | 119 (54.1) | 24 (10.9) | |
| Three children | 21 (20.8) | 63 (62.4) | 17 (16.8) | |
| Four children | 0 (0) | 9 (67.9) | 9 (32.1) | |
| Age of youngest child | < 0.001 | |||
| 1 - 8 | 173 (42.5) | 201 (49.4) | 33 (8.1) | |
| 9 - 16 | 38 (24.5) | 88 (56.8) | 29 (18.7) | |
| 17 - 24 | 6 (27.3) | 11 (50) | 5 (22.7) | |
| Age of spouse | < 0.001 | |||
| 20 - 30 | 53 (65.4) | 23 (28.4) | 5 (6.2) | |
| 31 - 40 | 153 (46.8) | 150 (45.9) | 24 (7.3) | |
| 41 - 50 | 69 (27.8) | 140 (56.5) | 39 (15.7) | |
| 51 - 60 | 5 (17.2) | 17 (58.6) | 7 (24.1) | |
| Contraception method | < 0.001 | |||
| The pill | 79 (42.5) | 89 (47.8) | 18 (9.7) | |
| Ampoules | 2 (16.7) | 8 (66.7) | 2 (16.7) | |
| IUD | 20 (24.4) | 47 (57.3) | 15 (18.3) | |
| Condom | 131 (48.3) | 122 (45) | 18 (6.6) | |
| Without any contraception | 35 (50) | 29 (41.4) | 6 (8.6) | |
| TL | 13 (3.20) | 35 (54.7) | 16 (25) | |
Abbreviations: IUD, intrauterine device; TL, tubal ligation.
aValues are expressed as No. (%).
5. Discussion
The results of this study showed that the effect of demographic variables on sexual satisfaction has been investigated using the odds ratio derived from logistic regression. As the findings show, the chance of having sexual satisfaction in women with university education is higher than illiterate women (P = 0.002, CI = 0.026 - 0.422, OR = 0.107) and 6.13 times more than women Their education at the level of the diploma is higher (P = 0.000, CI = 0.069 - 0.384, OR = 0.163). Because different job groups require different education, it was up to the researcher to unify groups in terms of their level of education. Also, the results showed that sexual satisfaction was higher in individuals aged 19 - 29 years of age and was lower in the age group 40 - 49 years. Addis et al. concluded in their study that younger women were more sexually active and gave sexual consent more frequently (15). In a case study, Cohen et al. also found that sexual satisfaction was decreased with age increment (16). Berek also reported that sexual desire and the frequency of intercourse gradually decreases with age (17). The results of this study showed that the length of the marriage is also related to sexual satisfaction. This case study shows that sexual satisfaction is decreased with the increase of age.
Perhaps, the problems of life and the mental problems that result from it become more evident by increasing the length of the marriage and provoke a feeling of false dissatisfaction in couples. The researcher finds that in the early stages of marriage regarding sexual satisfaction, the feelings of men and women are at their strongest state, but gradually with the passage of time linked to the increasing age of men and women, sexual desire diminishes and, as a result, sexual interest becomes less intense. Of course, this does not mean that sexual satisfaction should reduce over time, but sexual satisfaction should remain throughout the life if it is not affected by other factors such as lack of marital understanding, illness or poor mental health. However, Halford found that sexual satisfaction was not reduced over time in most couples (18). Liu et al. and Jose et al. also reported similar results (19, 20). According to the results of this study, sexual satisfaction was shown to be related to the number of children in the marriage that with the increase in the number of children sexual satisfaction is decreased. In fact, it can be deduced that the frequency of sexual activity is a key factor in the prediction of sexual satisfaction in couples (21). Over time, the frequency of sexual activity is decreased (22). In addition, pregnancy may reduce the wife's sexual attractiveness to her husband; likewise, child-care and mental health are other negative factors. Sexual satisfaction appears to reduce through decreased sexual activity due to the longevity of marriage. Witting et al. found that nulliparous women had less sexual satisfaction due to painful intercourse compared to women who had children, regardless of the number of children, which was not consistent with the present study (23). In this study, the age of the smallest child is related to the sexual satisfaction of the parents. It was shown that sexual satisfaction of the parent was decreased with the increase of the age of the child within the family. In fact, it can be deduced that as the child's age increases and related responsibilities increase alongside the increasing age of the parent; meanwhile, sexual satisfaction within marriage is decreased. In the present study, the age of the spouse has a significant effect on female sexual satisfaction, as it was shown that female sexual satisfaction was decreased when the husband’s age was increased. Therefore, the absence of age differences between couples could be considered an effective factor for sexual satisfaction. Men and women with a low age difference are more aware of each other and have the same interests and needs, and therefore, have a more mutual understanding of all aspects of life, including sexual matters. Research has shown that the family is threatened by increasing age gaps between spouses. The optimum range is between 0 to 10 years. A 20-year age gap shows that 50% of couples divorce (24). Pothen et al. concluded that women who married men 5 - 6 years older than themselves derived the most sexual satisfaction (25). Therefore, it appears that age differences can be an important factor in our understanding of different issues, including sexual issues. In this study, female sexual satisfaction was shown to vary according to the types and methods of contraception used. Condom users recorded the highest levels of sexual satisfaction. In Auslander’s research, the condom was the only contraceptive method that had an impact of increased sexual satisfaction. In his study, the sexual satisfaction of women who were sterile due to tube closure was less than by use of other methods. In the study of Costello et al., the sexual satisfaction of women with closed tubes was higher, which is not consistent with the results of the present study (26). Also, in Cooper et al.’s study, a majority reported increased pleasure and frequency after tube closure (27). The study also found that users of the pill recorded higher sexual satisfaction scores than those who used injectable ampules and intrauterine devices (IUDs). In the Carco’s study, women recorded an increased activity and libido whilst taking the pill. Merghati Khuei and Jafarpoor concluded that there was no significant relationship between any contraceptive method and sexual satisfaction (28). Davis and Castano also showed that in general, some women experienced positive effects and others had negative effects, and there were also individuals who did not record any changes while used oral contraceptive methods (29).
5.1. Conclusions
Given the relationship between demographic characteristics and contraceptive methods regarding sexual satisfaction, attention needs to be paid to contraceptive methods during marriage counseling, family planning, and sexual counseling. It is essential to establish marital counseling classes in health centers to enable women to improve all types of sexual health issues and benefit from group- or individual-treatment methods.
