Introduction

   Sexual beliefs, including the rules which a person sets for himself or herself about sexual events, play a decisive role in a person's sexual dysfunction (1). Sexual beliefs and attitudes are related to various aspects of sexual behavior, function, satisfaction and health (2). Carvalho and Nobre (2010) examined the cognitive dimensions of female sexual desire and concluded that unconscious thoughts and dysfunctional sexual beliefs have a significant effect on female sexual desire (3). Silva et al. (2016) also showed the role of body image beliefs and cognitive disorders in predicting sexual function (4). Nobre et al. (2006) & (2008) showed that women with sexual dysfunction had higher scores of dysfunctional sexual beliefs, especially “age and body image beliefs”, “conservative beliefs”, “sexual desire”, and “pleasure as a sin” are associated with low libido. However, the age and body image beliefs, in addition to sexual desire, are associated with orgasmic disorders and sexual pain (5-6).

The rate of sexual dysfunction in Iran is approximately the same as worldwide except orgasmic disorder, which is two times higher than the worldwide average (7). The higher sexual dysfunction in Iranian women can be due to insufficient information and misconceptions about sexual issues and sexual life (7). In many cultures, parents feel uncomfortable to discuss about sexual issues with their children, so lack of effective education causes children to rely on invalid sources of knowledge and misconceptions and misinformation (8-9). Counseling and psychotherapy are the core interventions in sexual medicine and clinical sexology (10).

Sexual disorders can negatively affect sexual satisfaction (10). Sexual counseling is effective on achieving optimal sexual health and promoting sexual function and satisfaction (10-11). PLISSIT model, Permission, Limited Information, Specific Suggestions, and Intensive Therapy, is one of the common methods in sex therapy which has been used to treat sexual problems for more than thirty years; it helps the counselor identify any beliefs and attitudes of the patient which are effective in the treatment (12). Studies have shown that the PLISSIT model compared to the sexual health model is more effective in reducing sexual stress and problems (13) and has the same effectiveness as the cognitive-behavioral model (14). PLISSIT model has four levels, including; Permission: the patients are given the opportunity to express their thoughts, beliefs and attitudes toward sexual issues; Limited information: attempts are made to correct the patient's misinformation by providing general information to address false information and beliefs, myths and inadequate sexual skills; Specific suggestion: may include patients' training or retraining on specific attitudes and practices; and Intensive therapy: clients are referred (12, 15-16).

According to the literature review, previous studies were performed to treat sexual dysfunction through counseling and have not focused on dysfunctional sexual beliefs. Accordingly, the present study was performed to evaluate the effect of counseling based on PLISSIT Model focused on dysfunctional sexual beliefs among women with sexual dysfunction.

Materials and Methods

This randomized Clinical trial was performed on married women with sexual dysfunction who referred to the Comprehensive Health Centers of Mashhad, Iran during 2019, and was registered in the Iranian registry of Clinical Trials (IRCT20180710040407N1).

The study had a parallel design. The sample size was estimated as 18 women in each group according to the study by Rostamkhani et al. (2012) (17) and using the formula of comparing means and considering to the mean score of sexual function in intervention group (29.4±4.28) and control group (23.74±4.40) with 95% confidence interval and 80% test power. Considering the possibility of 10% sample attrition and in order to increase the accuracy of the study, the sample size was considered as 33 women in each group.

The inclusion criteria were: Being Iranian and living in Mashhad, age of fertility (above 18 years), having usual sexual intercourse during the last month, living with husband, being in first marriage, having sexual dysfunction based on the Female Sexual Function Index (FSFI), and having at least three dysfunctional sexual beliefsbased on the Sexual Dysfunctional Beliefs Questionnaire (SDBQ) (Nobre & Pinto-Gouveia).

Exclusion criteria were: depression, stress, or anxiety based on the DASS-21 scale, a medical or mental illness affecting sexual function, consumption of a drug affecting sexual function, participation in an educational or counseling course yet, experiencing burdensome or severe incidents in the last 6 months, being in pregnancy or lactation period (having child younger than two years old), having mental or physical disability in the woman or spouse, and infertility.

Sampling was performed using a convenience sampling method. The two comprehensive Health Centers of Mashhad, Iran (Fadaeian Eslam and Kargaran centers) were selected due to the large number of clients, moderate socio-economic level of population, geographical and cultural similarity of the two centers, and cooperation between personnel and authorities. To prevent the dissemination of information, one center was randomly assigned to the control group and another to the intervention group using a simple lottery method. In this way, the names of the two comprehensive health centers were written on a small sheet of paper, folded and placed in a container. The first sheet was assigned to the intervention group and the second sheet to the control group. Due to the nature of the intervention, blinding of the participants and the researcher was not possible.

Data collection tools were the questionnaires of demographic characteristics, FSFI and SDBQ. The FSFI included 19 five-point questions that its validity and reliability have been confirmed in several national and international studies (3). SDBQ has 40 questions in six domains, each of which is scored on a Likert scale from 1 to 5 (strongly disagree to strongly agree), and a higher score indicates more dysfunctional sexual beliefs. Due to cultural issues, one question (No. 27) was deleted in accordance with the opinion of the supervisors and advisors. Abdolmanafi et al. (2015) confirmed the validity and reliability of the Persian version of this questionnaire (18). Five counselors and psychologists presented to determine the content and face validity of the questionnaire. The items disproportionate to the culture of the society were corrected or removed. Cronbach's alpha coefficient of 0.96 was reported to determine homogeneity and validity.

The consistency of this questionnaire was also assessed through a retest. IRCT20180710040407N1).

 To collect data, a written letter of introduction was presented to the authorities of the selected healthcare centers, then the researcher started sampling. Thus, the researcher presented in the comprehensive health centers every other day, and after introducing herself, asked the participants about their sexual status. In case of existence of any sexual dissatisfaction, the study objectives and methods were explained. Written informed consent was obtained from the participants, assuring them that their information would remain confidential and the overall results would be published. The subjects willing to participate in the study were directed to a calm and quiet room to complete the questionnaires in the presence of the researcher. Then, the researcher reviewed and scored the questionnaires, and if the subjects met the inclusion criteria, they were selected as the study subjects, and then informed consent was signed, and the telephone number of the researcher was given to them.

After selecting the research subjects in the intervention group, the necessary coordination was performed for the consultation sessions. Four counseling sessions were held at intervals of one week based on PLISSIT model (Table 1).

The first, third and fourth sessions were held individually for 60 minutes and the second session was held in groups of five to eight women for 90 minutes. The informed consent was obtained from the spouses of the research subjects to observe the ethical considerations before holding group meetings. Counseling sessions were held in a quiet and safe room. The first session was based on the first level of the PLISSIT model (permission), so that the researcher, by asking open-ended questions and using the counseling techniques, especially active listening, allowed clients to freely discuss about their sexual function, beliefs and attitudes without being judged by the counselor. During counseling, the dysfunctional sexual beliefs of clients were noted by the counselor. At the end of the session, the researcher adjusted the content of subsequent sessions based on the questionnaires completed by the research subjects and notes.

The second session as group meetings was held based on the second level of the PLISSIT model (limited information). General information was given including sexual anatomy and physiology, sexual cycle, normal and abnormal sexual behaviors, myths and dysfunctional sexual beliefs in the form of educational slides and posters.

The third session was held based on the third level of the PLISSIT model (specific suggestions). The person was advised in accordance with dysfunctional sexual beliefs and then practical suggestions were provided. For example, in the case of the dysfunctional belief such as "sex should happen only if a man initiates", the woman was taught to start sex. The fourth session was based on the third and fourth levels of the PLISSIT model. At the beginning of the session, the clients were asked to talk about their experiences in the last week and to express their feelings and feedback from their spouses. Then, the women’s' sexual beliefs were re-examined, and further advice was provided to modify the dysfunctional sexual beliefs. None of the research subjects required the implementation of the fourth level of the PLISSIT model (intensive therapy). The research subjects again completed the questionnaires immediately after the counseling sessions, which lasted one month, and one month after the sessions. The control group received only routine care of the Comprehensive Health Center, including training by the healthcare provider and if necessary, referral to the physician and psychologist. The research subjects were invited to complete the questionnaires before intervention, immediately after and one month after the intervention. Upon completion of the study, the booklet containing general information about sexual function and beliefs was delivered to the control group.

Data were analyzed by SPSS software (version 24). The Shapiro-Wilk test was used to examine the normality of data. Independent t-test and Mann-Whitney U test were used to compare the groups in terms of quantitative variables. Chi-square and Fisher’s exact tests were used for nominal variables. Paired t-test and Wilcoxon tests were applied for intergroup comparison. P <0.05 was considered statistically significant.

Results

The initial research subjects consisted of 72 people, in which 6 of whom were excluded from the study due to exclusion criteria and 66 participants were allocated to the intervention (n=33) and control group (n=33); finally with 5 lost from the trial (3 people due to absence in counselling sessions in the intervention group and 2 people due to unwillingness to continue study in the control group), data from 61 individuals were analyzed (Figure 1).

The mean age of women was 35.5±5.6 years in the intervention group and 36.7±6.7 years in the control group; the two groups were homogeneous in this regard (P=0.436). Most women in the intervention (73.3%) and the control (80.6%) groups were housekeepers; there was no significant difference between thetwo groups in this regard (P=0.497). There were no significant differences between the two groups regarding other demographic characteristics and the two groups were homogeneous (Table 2).

The mean of overall sexual function score before the intervention was 24.0±2.7 in the intervention group and 23.5±3.5 in the control group. The independent t-test indicated no significant difference between the two groups regarding total score of sexual function before the intervention (P =0.552). The mean of the total score of sexual function immediately after the intervention and one month after the intervention were 30.5±2.2 and 30.5±2.4, respectively in the intervention group and 23.4±3.6 and 23.4±3.2,

respectively in the control group. The Mann-Whitney U test indicated significant differences between the two groups regarding total score of sexual function immediately after the intervention and one month after the intervention (P<0.001 in both) and these scores were higher in the intervention group. The difference in total score of sexual function after the intervention compared to before the intervention was 6.5 ± 2.8 increase in the intervention group and 0.1 ± 0.6 decreases in the control group. The Mann-Whitney U test found this difference to be significant (P<0.001). In the intragroup comparison, the paired t-test in the intervention group indicated significant difference in the total score of sexual function immediately and one month after the intervention compared to before the intervention (P<0.001). The Wilcoxon test results in the control group indicated that the difference in the total score of sexual function did not significantly differ immediately and one month after the intervention compared to before the intervention (P = 0.219) (Table 3).

The mean scores of sexual desire, sexual arousal, lubrication, orgasm, sexual satisfaction and dyspareunia before the intervention did not significantly differ between the two groups, but after the intervention, there was a statistically significant difference in all domains between the two groups (P<0.001), so that all sexual function scores after the intervention were significantly increased in the intervention group compared to the control group (P<0.001) (Table 4).

Two groups were homogeneous regarding mean total score of dysfunctional sexual beliefs before the intervention (P =0.284). After the intervention, the score of dysfunctional sexual beliefs significantly decreased in the intervention group compared to the control group (P<0.001).

Discussion

The complex nature of female sexual function requires a comprehensive therapeutic approach. A wide range of methods such as psychological counseling, behavioral therapy, sexual counseling and education can be useful in this regard (19). The aim of the current study was to evaluate the impact of improving dysfunctional sexual beliefs through counseling on female sexual function. The findings of the current study indicated that the PLISSIT-based counseling focused on dysfunctional sexual beliefs significantly reduced the dysfunctional sexual beliefs in women with sexual dysfunction and improved female sexual function in all six domains of sexual desire, sexual arousal, lubrication, orgasm, sexual satisfaction and dyspareunia as well as total score of sexual function.

The positive effect of PLISSIT-based counseling on female sexual function has also been shown in some previous studies, so that PLISSIT-based counseling improved the female sexual function in different groups of women (14,17,20). However, these studies didn't specifically consider sexual beliefs and modification of clients' dysfunctional sexual beliefs, but the present studyused the PLISSIT counseling focused on modifying the clients' dysfunctional sexual beliefs among the target group of married women with sexual dysfunction based on FSFI. In the studies of Khakbazan et al. (2007) (14) and Ayaz & Kubilay (2009) (20), the samples were people with multiple sclerosis and stoma, while in the present study, the samples were women who had sexual dysfunction based on the FSFI with no specific disease.

Prior studies indicated that people have a set of misconceptions about sexual relationships, behavior, and sexual intimacy that led to unrealistic expectations, and the modification of those misconceptions leads to greater sexual intimacy between couples and an increase in overall sexual satisfaction (21). The results of the current research indicated that the modification of dysfunctional sexual beliefs improved six domains of sexual conservatism, sexual desire and pleasure as a sin, age-related beliefs, body image beliefs, affection and motherhood primacy, female sexual function in the domains of sexual desire, sexual arousal, lubrication, orgasm and sexual satisfaction.

In line with these results, the study of Nobre & Pinto-Gouveia (2006) showed that dysfunctional sexual beliefs negatively affect sexual dysfunction and women with sexual dysfunction scored higher on dysfunctional sexual beliefs, especially in the field of age and body image beliefs (6). Also, the study of Silva et al. (2016) showed that body image beliefs played an important role in the female sexual function (4).

Moreover, Amanelahi et al. (2017) showed that dysfunctional sexual beliefs can predict sexual dysfunction (1). These studies indicate a close link between a person's beliefs and sexual dysfunctions and incorrect information and beliefs are more likely to be associated with sexual dysfunction, while the present study actually showed that modifying dysfunctional sexual beliefs could lead to improved sexual function in women with sexual dysfunction.

The limitations of the present study include lack of consulting with the spouses of the research subjects due to cultural issues and time constraints and project facilities. Accuracy of the answers given by the research subjects due to the sensitivity and privacy of the study topic was another limitation of the study, which tried to ensure participants about maintaining confidentiality. Finally, this study was carried on Iranian women and generalizability of the results should be cautioned for using in other countries. Future studies are suggested to examine the impact of modifying male dysfunctional sexual beliefs on couples' sexual function and the impact of counseling on female dysfunctional sexual beliefs with long-term follow-up (3-6 months).

counseling, behavioral therapy, sexual counseling and education can be useful in this regard (19). The aim of the current study was to evaluate the impact of improving dysfunctional sexual beliefs through counseling on female sexual function. The findings of the current study indicated that the PLISSIT-based counseling focused on dysfunctional sexual beliefs significantly reduced the dysfunctional sexual beliefs in women with sexual dysfunction and improved female sexual function in all six domains of sexual desire, sexual arousal, lubrication, orgasm, sexual satisfaction and dyspareunia as well as total score of sexual function.

The positive effect of PLISSIT-based counseling on female sexual function has also been shown in some previous studies, so that PLISSIT-based counseling improved the female sexual function in different groups of women (14,17,20). However, these studies didn't specifically considered sexual beliefs and modification of clients' dysfunctional sexual beliefs, but the present study used the PLISSIT counseling focused on modifying the clients' dysfunctional sexual beliefs among the target group of married women with sexual dysfunction based on FSFI. In the studies of Khakbazan (14) and Ayaz &Kubilay (20), the samples were people with multiple sclerosis and stoma, while in the present study, the samples were women who had sexual dysfunction based on the FSFI with no specific disease.

Prior studies indicated that people have a set of misconceptions about sexual relationships, behavior, and sexual intimacy that lead to unrealistic expectations, and the modification of those misconceptions leads to greater sexual intimacy between couples and an increase in overall sexual satisfaction (21). The results of the current research indicated that the modification of dysfunctional sexual beliefs improved six domains of sexual conservatism, sexual desire and pleasure as a sin, age-related beliefs, body image beliefs, affection and motherhood primacy, female sexual function in the domains of sexual desire, sexual arousal, lubrication, orgasm and sexual satisfaction. In line with these results, the study of Nobre & Pinto-Gouveia (2006) showed that dysfunctional sexual beliefs negatively affect sexual dysfunction and women with sexual dysfunction scored higher on dysfunctional sexual beliefs, especially in the field of age and body image beliefs (6). Also, the study of Silva and colleague (2016) showed that body image beliefs played an important role in the female sexual function (4). Moreover, Amanelahi and colleague (2017) showed that dysfunctional sexual beliefs can predict sexual dysfunction (1). These studies indicate a close link between a person's beliefs and sexual dysfunctions and incorrect information and beliefs are more likely to be associated with sexual dysfunction, while the present study actually showed that modifying dysfunctional sexual beliefs can lead to improved sexual function in women with sexual dysfunction.

The limitations of the present study include lack of consulting with the spouses of the research units due to cultural issues and time constraints and project facilities. Accuracy of the answers given by the research units due to the sensitivity and privacy of the study topic was another limitation of the study, which tried to ensure participants about maintaining confidentiality. Finally, this study was carried on Iranian women and generalizability of the results should be cautioned for using in other countries. Future studies are suggested to examine the impact of modifying male dysfunctional sexual beliefs on couples' sexual function and the impact of counseling on female dysfunctional sexual beliefs with long-term follow-up (3-6 months).

Conclusion

The results of this study showed that counseling based on PLISSIT Model focused on dysfunctional sexual beliefs improved the sexual dysfunction. Therefore, it is recommended that this intervention be included in the agenda of sexual counseling clinics to improve sexual function in the women with sexual dysfunction.

Acknowledgements

The authors would like to thank the participants in this research, the staff of the Comprehensive Health Centers and others who helped us in this research. The current article has been derived from the master's thesis of Counselling in Midwifery. The authors appreciate the Deputy of Research, Mashhad University of Medical Sciences for financial support (with grant of 970386).

Conflicts of interest

The authors declared no conflicts of interest.

Ethical considerations

Participation was voluntary. The confidentiality of research subjects’ information was guaranteed.

The informed consent was obtained from the research subjects and their spouses.

Ethical approval

The study was approved by the Ethics Committee of the University (IR.MUMS.NURSE.REC.1397.052).

Funding

The present paper is result of a research project that it was ratified by the vice-Chancellor for Research of Mashhad University of Medical Sciences.

Authors’ contribution

M. M. was a MSc student, supervised by M.M. M. M. M., M.M., K. M. N, and M. A. R. contributed substantially in the study design. M. M. M. and M.M. carried out the data collection. M. M. M., and M.M., and M. T. S. conducted data analysis and interpretation. M. M. M. and M.M. provided the first draft of the work. All authors have reviewed the manuscript critically. All authors have read and approved the final version of the manuscript.