1 INTRODUCTION

Sexual distress denotes negative feelings about one's sexuality, which can have adverse effects on the overall well-being and quality of life of individuals.¹ In recent years, the evaluation of female sexual distress has been emphasized.² A study performed in Britain has shown that approximately half of the sexually active women had experienced one or more sexual problems lasting for 3 months or more, but only about 13.4% of them described it as distressing.³ Bancroft et al. reported that although 44.3% of women had one or more sexual problems, only 24.4% found it distressing.⁴ Thus, sexual problems are not necessarily distressing and only a small percentage of these women report sexual distress.⁵

It has been shown that healthy women without sexual problems can experience sexual distress, which was corroborated by an Iranian study that showed that the prevalence of female sexual distress was 27.2% in healthy women.⁶ In another study, 34% of women had sexual dysfunction, 20% had both sexual distress and dysfunction, and 15% had sexual distress but not any dysfunctions.⁷ These population-based surveys demonstrated that sexual distress can occur in the absence of any sexual problems. Therefore, it is necessary to consider other factors like demographic, personal, and interpersonal factors in addition to sexual factors in examining the predictors of sexual distress.

Hayes et al. did not find a relationship between sexual function and sexual distress.⁸ In a community-based study of Australian women (young, midlife, and older women), advanced age and Asian ethnicity were associated with a lower likelihood of sexually related distress. On the other hand, a greater likelihood of sexual distress was observed in women who were educated beyond secondary school, current smokers, consumed alcohol, or used psychotropic medications.⁹

Although the previous research has provided abundant information on the prevalence of sexual problems and their predictors in women, there is a scarcity of data about sexual distress as a sexuality issue that occurs along with sexual problems, especially in the context of Iran. Therefore, the aim of this study is to determine the prevalence and predictive factors of sexual distress in Iranian married women of reproductive age.

2 METHODS

3 RESULTS

A total of 1055 questionnaires were sent to all centers (based on the proportion of each center), and 1000 were returned. In all, 55 were excluded due to being incomplete (35) and meeting the exclusion criteria.¹¹ The final sample consisted of 1000 women aged 16–49 years old. Based on the FSD-R cutoff score, 318 (31.8%) women were at risk for sexual distress. Univariate analysis identified demographic, personal, sexual and interpersonal factors associated with sexual distress (Tables 1–3, respectively).

Multivariate logistic regression analysis was used to predict the probability of sexual distress with independent variables known to be associated with sexual distress. Our results suggested that the odds of sexual distress are 40% lower in women with complete satisfaction with marriage (odds ratio [OR] = 0.6; 95% confidence interval [CI] = 0.4–0.8). The odds of sexual distress were 2.31 times higher in women with a history of infertility than in others (OR = 2.3; 95% CI = 1.2–4.1). Moreover, the odds of sexual distress in women who expressed fear of sexually transmitted infections due to sexual activity were 1.8 times higher compared with women without fear of sexually transmitted infections (OR = 1.8; 95% CI = 1.1–2.8). Among sexual and interpersonal factors, those with premature ejaculation disorders in their partner were at 1.4 greater risks for suffering from sexual distress (OR = 1.4; 95% CI = 1.06–1.9). Pain during sexual intercourse also increased the odds of sexual distress by 1.7 times (OR = 1.7; 95% CI = 1.2–2.3). Moderate and high levels of sexual satisfaction and satisfaction with sexual desire were associated with lower levels of sexual distress ([OR = 0.35; 95% CI = 0.2–0.6] and [OR = 0.4; 95% CI = 0.3–0.8], respectively, Table 4).

4 DISCUSSION

Our data showed that 31.8% of the participants suffered from sexual distress based on FSDS-R scores. In a community-based study of women aged 18–39 years in Australia, 50.2% of the women were found to be sexually distressed.¹² In another study, the proportion of women reporting both sexual dysfunction and distress ranged from 7% to 23% depending on the dysfunction.⁷ In an Iranian study, the prevalence of sexual distress was estimated 27.2%, 36.4%, and 36.9% for healthy women, women with hypoactive sexual desire disorder, and women with other types of female sexual dysfunction, respectively.⁶ Therefore, sexual distress may occur in the absence of a concomitant sexual dysfunction. The discrepancy in the prevalence estimates of sexual distress may be justified by the differences in the study methodologies and the context of the community.

We found that women with complete satisfaction with marriage were at a lower risk for sexual distress. Satisfaction with marriage seems to indirectly affect sexual distress through the mediating effect of partner adjustment. Moreover, compatibility with a partner through increased emotional and sexual intimacy can be an important predictor of sexual distress. Women feeling distressed or having a sexual dysfunction reported incompatibility with partners more than sexually functional women.⁷ Partners may have different values and levels of sexual desire, which may lead to sexual distress if they are too different. Therefore, different factors can affect sexual distress in a cyclical way and counselors should screen and evaluate sexual distress as a multidimensional concept.

History of infertility showed a significant association with sexual distress in the present study. Several studies have reported a decrease in sexual function in women with infertility.^{13, 14} It was shown that women with a diagnosis of infertility were found to be more likely to experience sexual dysfunction compared with those without infertility.^{15, 16} However, in a case-control study, it was shown that although lower quality of life and marital adjustment scores were noted in women of infertile couples, sexual functioning in these women was not affected by this problem.¹⁷ Based on the available evidence and since sexual function and sexual distress are closely related, it seems that the experience of infertility also affects sexual distress by affecting sexual function. However, it may lead to sexual distress without affecting sexual function as well. For instance, it was reported that the female sexual distress score was higher in women with polycystic ovary syndrome compared with those with unexplained infertility. However, the two groups were similar in terms of the total female sexual function score.¹⁸ In another study, Zheng et al.¹² reported that women who were under infertility treatment were 2.31 times more likely to develop sexual distress without any identifiable sexual dysfunctions than those who had not received infertility treatment. Differences in study populations, duration of infertility, cause of infertility, type of infertility, and type of treatment can explain this discrepancy. Therefore, asking women about their history of infertility in sexual counseling sessions is of great significance.

Fear of sexually transmitted diseases (STDs) also had a negative impact on sexual distress in this study. There is no data in the current literature as to the association between fear of STDs and sexual distress. However, a positive correlation has been shown between low sexual desire and ever having had an STD (not fear of contracting STDs).¹⁹ It seems that fear of getting STDs (e.g., due to concerns over a partner's extramarital relationships) can affect a woman's sexual desire, and subsequently, her sexual distress. Interestingly, in Ghadirian's study, a reduction in sexual dysfunction (not sexual distress) was seen with the condom contraceptive method.²⁰ This may be due to the possible role of condoms in the prevention of STDs, which reassures women of the prevention of transmission of such diseases.

Another important factor that might even be crucial is whether a woman feels sexually distressed or not his partner's sexual dysfunctions.⁷ For example, it was shown that female partners of men with premature ejaculation report significantly greater sexual problems, with reduced satisfaction, increased distress, interpersonal difficulty, and more orgasm problems than partners of men without premature ejaculation.¹¹ On the otherwise, the prevalence of female sexual dysfunction was higher than women who have a male partner without premature ejaculation (72% vs. 36%).²¹ Women with a partner suffering from premature ejaculation reported higher levels of sexual distress (from 7.12 to 9.83 times) than those with a partner not suffering from premature ejaculation.²² This finding indicates the need to obtain a sexual history from partners (women and their partners) to treat the sexual problems of the partner.

The present study also demonstrated that women with higher levels of satisfaction with sexual desire had a lower chance of developing sexual distress than women with lower levels of satisfaction. However, studies show that not all women with low sexual desire suffer from sexual distress and if low sexual desire is accompanied by sexual distress, it is known as hypoactive sexual desire disorder.²³ Therefore, the level of satisfaction with sexual desire should not be disregarded while assessing and managing sexual distress.

In this study, women suffering from pain during sexual intercourse were more likely to experience sexual distress, which was corroborated by the findings of Berg et al.²⁴ Pain during sexual intercourse is an interpersonal factor that affects both partners. Controlled studies show that vulvodynia (idiopathic pain condition) can cause decreased sexual satisfaction and increased sexual distress,^{25, 26} due to the fear of losing their partner and more emotional distance in their romantic relationship.²⁷ On the other hand, male partners of these women also report higher levels of sexual dysfunction and lower levels of sexual satisfaction than men from a control group.²⁸ In addition, pain during sex seems to affect other domains of the cycle of sexual activity such as sexual desire, hence affecting sexual distress. Therefore, screening for other sexual disorders in both partners is important while screening for sexual distress.

Our study demonstrated that higher sexual satisfaction was associated with lower sexual distress. Witting et al.⁷ pointed out that satisfaction with sexual function is an important factor along with sexual distress. In a former study of clinical and nonclinical subjects, sexual satisfaction and distress were shown to be inversely correlated. In the clinical sample, sexual distress was more tightly associated with sexual functioning variables than satisfaction, while in the nonclinical sample, satisfaction was more closely related to relational variables than distress.²⁹ Therefore, even though sexual distress is a different construct from sexual satisfaction, the correlation and overlap of these two constructs in sexual history should be addressed to promote sexual health.

5 CONCLUSION

This study provides crucial information as to the predictive factors of sexual distress among Iranian reproductive-age women. Although sexual dysfunction and sexual distress are mostly concomitant, some women may have a specific symptom causing sexual distress, but it does not necessarily cause sexual dysfunction. For some, the expressed distress may be the result of a sociodemographic condition or personal and interpersonal circumstances that were addressed in our study. Sexual well-being is a fundamental human right and it is influenced by multiple factors. Therefore, clinicians should evaluate sexual distress comprehensively and consider all the related dimensions. The high overall prevalence of sexual distress, with or without an identifiable dysfunction, signals the importance of health professionals being adequately prepared to discuss sexual health concerns.

AUTHOR CONTRIBUTIONS

Zeinab Hamzehgardeshi: Conceptualization; investigation; methodology; supervision; writing—review and editing. Shadi Sabetghadam: Data curation; writing—review and editing. Mehdi Pourasghar: Methodology; supervision; writing—original draft. Soghra Khani: Conceptualization; investigation. Mahmood Moosazadeh: Formal analysis. Mina Malary: Conceptualization; data curation; formal analysis; methodology; writing—original draft.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

TRANSPARENCY STATEMENT

The lead author Mina Malary affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.