Sexual and marital satisfaction is the most important factor for the sustainability and durability of a mutual life. Marital satisfaction exists when marital status conforms to the expected situation. If couples can improve the level of satisfaction in marital life, they will protect the family [1]. Several studies have shown significant relationships between sexual satisfaction and gratification with marital interactions and relationships [2]. Iranian experts believe that 50 to 60 percent of divorces are caused by sexual problems and disorders [3]. Sexual dysfunctions occur in all societies that affect the quality of sexual relationships of married people [4]. Sexually disordered people often hide this problem, and the lack of proper treatment results in chronic symptoms, anxiety, individualism, and guilt feeling [5].
The way an individual observes one’s sexual characteristics depends on self-esteem, which is defined as a series of feedbacks and beliefs that individuals express in their relationships with the external world. To put it simply, self-esteem is the value that a person considers for oneself [6] as one of the important and influential variables on marital quality [7]. A low self-esteem leads to a relationship in which there is no trust and intimacy with significant reduction in the relationship quality [6]. People with low self-esteem suppress their ability to express sexual desires [8], but a high self-esteem will lead to a healthy sexual behaviour [9]. A study by Ramezani M et al., indicated that self-esteem was correlated with sexual satisfaction and people with low self-esteem levels noted higher sexual dysfunctions [10]. Low self-esteem in individuals gives rise to a variety of psychological disorders such as anxiety and stress.
Stress is another variable affecting marital satisfaction, the impact of which is very evident on marital satisfaction. Stress is perhaps the most common issue of man’s everyday life. Stress is so universal and widespread that it is considered as a hallmark of human life, such that all humans are exposed to and affected by high stress levels in their everyday lives. Studies suggest negative significant relationships between depression, anxiety, and stress with marital satisfaction. In fact, married people who suffer from greater depression, anxiety, and stress are therefore less satisfied with their marital life [7,11,12].
Considering the high prevalence of sexual disorders in women of Iran, and the lack of relevant studies in Iran, this study was conducted with an aim to examine sexual satisfaction and its relationship with self-esteem and stress in reproductive age women.
Materials and Methods
This cross-sectional study was conducted using convenience sampling method on 300 women of reproductive age group who attended Women’s Healthcare Clinic of Jahrom, Iran from June to December 2017. The formula was utilized for calculation of the sample size, in which the power of study considered was 90% and α=0.05% [13]. According to the formula, the sample size was 255, and, by adding 20% for drop-outs, the sample size was increased to 306. Out of the 306 cases, 300 completed the questionnaire, and 6 filled the questionnaire incompletely and were excluded.
The research was approved by the ethics committee of Jahrom University of Medical Sciences (IR.JUMS.REC.1394.036). The samples were enrolled in the study according to the inclusion criteria: age of women between 15-45 years, non-pregnant and literate with Iranian nationality, no chronic conditions like Mental illness, hypertention, diabetes, Cardiovascular problems, Chronic vaginal infection, Renal disorders, no history of smoking, alcohol, and antidepressants, and no history of stressful events like death of relatives and divorce in the past six months. The women were explained the study and informed consent was obtained from them.
Sexual Satisfaction Scale
The sexual satisfaction of the samples was measured by the Larsson sexual satisfaction questionnaire, which has been proven to be of scientific validity and reliability. The questionnaire contains 25 questions with quintuple-choice answers based on a Likert scale of 1-5 scores. Scores of 25-50, 51-75, 76-100, and 101-125 denote zero, low, intermediate, and high sexual satisfaction levels, respectively [14]. In the study of Bahrami N et al., and Azari S et al., (in Iran, the reliability of the Larsson sexual satisfaction questionnaire was calculated by Cronbach’s alpha method and reported to be 93% and 82% respectively [15,16]. Also, in the study of Rahmani A et al., reliability of the questionnaire was 0.89 using test-retest methods [17].
Perceived Stress Scale
This test was designed by Cohen et al. for the perceived stress section. The test has 14 phrases scored 0-4 based on a 5-point Likert-type scale ranging from 0 (never) to 4 (mostly). Scores ranged from 0 to 56. A 5-point scale ranging from 0 (mostly) and 4 (never) was used for seven questions. Alsunni A et al., calculated the internal consistency of this test by Cronbach’s alpha (0.74) [18]. The validity and reliability of the Perceived Stress Scale in Iran were confirmed in a study by Ezati A et al., and Asghari F et al., [19,20].
Self-Esteem Questionnaire
The Rosenberg self-esteem questionnaire contains 10 questions with agree/disagree choices. A 10-item scale that measures global self-worth by measuring both positive and negative feelings about the self. The scale is believed to be uni-dimensional. All items are answered using a 4-point Likert scale format ranging from strongly agree to strongly disagree. Items 2, 5, 6, 8, 9 are reverse scored. Give “Strongly Disagree” 1 point, “Disagree” 2 points, “Agree” 3 points, and “Strongly Agree” 4 points. Sum scores for all ten items. Keep scores on a continuous scale. Higher scores indicate higher self-esteem [21].
Statistical Analysis
Data were analysed by SPSS18 using ANOVA, and Pearson and Spearman correlation coefficients. ANOVA test utilised to compare level of sexual satisfaction score with stress and Self-esteem score of the participants. Spearman correlation test was used in order to correlate between characteristics of the participants with Sexual Satisfaction and Self-Esteem and Perceived stress. Besides, p-value <0.05 was considered as statistically significant.
Results
The results showed that the subject’s average age was 29.55±6.68 years and husband’s age was 34.59±7.84 The majority (50.7%) of women aged in the range of 20-30 years. Most of the subjects’ education level was diploma 136 (45.5%) and the majority 241(80.3%) were housewives. Most of the subjects’ spouses 121 (40.3%) had diploma educations with the majority being self-employed 224 (74.7%) [Table/Fig-1].
Demographic characteristics of the participants (n=300).
| Variable | Mean±SD |
|---|
| Age | 29.55±6.68 |
| Duration of marriage | 9.22±6.73 |
| Age different between couples | 5.59±3.77 |
| Husband age | 34.59±7.84 |
| Family income (tuman)1 | 1,413500±0.07 |
| Number of deliveries | 1.41±1.22 |
| Number of children | 1.39±1.18 |
| N (%) |
| Educational level (degree) | Primary school | 17 (5.7) |
| Secondary school | 43 (14.4) |
| Diploma | 136 (45.5) |
| College or University | 104 (34.4) |
| Husband Educational level (degree) | Primary school | 32 (10.7) |
| Secondary school | 60 (20) |
| Diploma | 121 (40.3) |
| College or University | 87 (29) |
| Employment status | Housewife | 241 (80.3) |
| Employed | 59 (19.7) |
| Husband Employment status | Employed | 224 (74.7) |
| Unemployed | 76 (25.3) |
Numbers are presented as Mean±SD and N(%)
1At the time of data collection, US$1=8,200 Tuman
The results in [Table/Fig-2] indicate that there is a relationship between stress and self-esteem with women’s sexual satisfaction (p<0.05). Women with high sexual satisfaction scores have high self-esteem scores. Moreover, an increase in mean perceived stress score is observed with a decrease in women’s sexual satisfaction.
The comparison between level of sexual satisfaction and self-esteem and stress in study participants.
| Level of satisfactionVariable | High sexual satisfaction n=132 | Medium sexual satisfaction n=138 | Low sexual satisfaction n=27 | Lack of sexual satisfaction n=3 |
|---|
| Self-esteem | 6.59±3.54 | 5.20±4.11 | 1.18±6.61 | 1.33±8.32 |
| Perceived stress | 24.62±5.70 | 27.20±5.87 | 29.51±4.53 | 37.66±3.21 |
p-value ANOVA test
It was also found that there were relationships between sexual satisfaction with the women’s education, spouses’ education, Husband Employment status and family income levels. Self-esteem also represented positive significant correlations with the women’s education levels, occupation, spouses’ education, Husband Employment status and family income levels [Table/Fig-3].
Correlation coefficient between characteristics of the participants with Sexual Satisfaction and Self-Esteem and Perceived stress in Women.
| Variable characteristics | | Sexual satisfaction | Perceived stress | Self-esteem |
|---|
| Age | Pearson Correlation | 0.02- | 0.04 | 0.02 |
| Sig | 0.7 | 0.4 | 0.6 |
| Educational level | Pearson Correlation | 0.22 | -0.02 | 0.22 |
| Sig | 0.000 | 0.88 | 0.001 |
| Educational of spouse | Pearson Correlation | 0.17 | -0.04 | 0.16 |
| Sig | 0.003 | 0.44 | 0.01 |
| Employment status | Pearson Correlation | 0.05 | -0.008 | 0.21 |
| Sig | 0.3 | 0.8 | p<0.05 |
| Employment of spouse | Pearson Correlation | 0.11 | 0.01 | 0.12 |
| Sig | 0.04 | 0.73 | 0.03 |
| Family income | Pearson Correlation | 0.12 | 0.008 | 0.12 |
| Sig | 0.03 | 0.87 | 0.03 |
Discussion
This study aimed to investigate the relationship between sexual satisfaction with stress and self-esteem among women of reproductive age. Fortunately, a small percentage of subjects had disturbed satisfaction in this study, which is consistent with Bakhshi H et al., [22] but differs from studies by Abedi P et al., and Amidu N [13,23]. The taboos of sexual issues in Iran as well as cultural, social, and educational differences prevent women from easily raising their sexual dissatisfaction issues, which explain the discrepancy between statistics on disturbed sexual satisfaction in Iran and other countries.
The results of the ANOVA test between sexual satisfaction levels and self-esteem showed that sexual dissatisfaction was higher in people with lower self-esteem than those with greater self-esteem. Shackelford TK also demonstrated significant relationships between sexual satisfaction with all aspects of self-esteem [24]. Muehrer RJ et al., have achieved the same results as well [25]. A study by Taghizadeh M showed that marital dissatisfaction in individual with low self-esteem is 9 times higher than normal people [26]. All of the above studies are in line with present findings. Sexual abnormalities lead to decreased self-esteem and a sense of inefficiency in an individual.
Stress as a variable can also affect women’s sexual satisfaction. As seen in this study, women with lower sexual satisfaction levels had higher stress scores, which agrees with Abedi P et al., and Bodenman G et al., [13,27]. Similarly, Lee HH et al., conducted a study on nurses and concluded that occupational stresses could affect marital satisfaction [28]. High levels of occupational stress and the resultant negative effects can lead to conflicts, tension, and distress in family and marital relationships, thereby, increasing the probability of marital problems such as divorce [29,30].
The results showed significant relationships between sexual satisfaction and self-esteem with couples’ education levels. The relationship between sexual dysfunction and low educational level was highlighted in various studies [31,32] and it is considered as one of the risk factors for increased sexual dysfunction. This finding is similar to that of the Nobre PJ et al., [33]. It seems that educated people are more engaged in studying and thinking, hence, they can easily look for solutions to their problems resulting in enhanced self-esteem and consequently improved sexual satisfaction.
The results of this study signifies the relationship between sexual satisfaction and income, as was pointed out by Zincir H et al., [34]. In this research, 56.8% of the participants reported to have problems in sexual relation as well. Ramezani M et al., also reported a high chance of dissatisfaction event in low-income spouses suggesting the impact of the economic situation on sexual satisfaction [10]. Apparently, job security and consequently improvements in the family’s welfare and economic security can reduce economic-psychosocial stresses on the person and raise the satisfaction of marital relationship between couples.
Conclusion
Considering the importance of marital satisfaction in the family and the impacts of self-esteem and stress on sexual relations and satisfaction of couples, health policy makers and family counselors should provide women with ways to achieve self-esteem along with training strategies to deal with stress, so that they can take a step forward towards safe fertility.
Strength and Limitation
One of the strengths of this study is that women of reproductive ages that were not pregnant, in menopause or lactating period were examined, because these situations could have different effects on sexual function. Therefore, it is suggested that effects of stress on sexual function in the mentioned groups can be studied.
This study was conducted only on women referred to public health clinics in Jahrom, so the results may not represent the entire population. Besides, because of the cultural and religious limitations in our society, people may not be able to speak easily about their sexual issues, so the potential insecurity of some people in expressing explicitly their issues was a limitation.
Numbers are presented as Mean±SD and N(%)1At the time of data collection, US$1=8,200 Tumanp-value ANOVA test