Effect of Counseling based on Sexual Self-Concept on the Sexual Health of Women in Reproductive Age

Sexual health is fundamental to the physical and emotional health and the basis of well-being of individuals, couples and families. Sexual health is considered as a measure to determine the level of social and economic development in countries. The World Health Organization states that, having sexual health, pleasurable sexual life and sexual awareness are among human rights, and considers counseling as an important method to enter into discussion on sexuality of people. Individuals’ sexual self-concept is an important factor that affects sexual health. It refers to understanding and conception of individuals from their sexuality. Therefore, counseling based on sexual self-concept can be effective in maintaining and improving sexual health. The aim of this study was to determine the effect of counseling based on sexual self-concept on Women’s sexual health.


Introduction
The World Health Organization [1] has defined sexual health as a status of physical, mental, emotional, psychological and social health in sexuality, and stated that, having and maintaining sexual health must be considered as human's sexual right. Sexual health is an important component of well-being and health [2]. Lack of sexual health in addition to affecting interpersonal relationship, leads to undesired consequences such as inability to make a healthy and satisfactory sexual relation with sexual partner, which itself leads to undesired physical, mental and social consequences in couples. Thus, sexual health plays a crucial role in the quality of marital life [3][4][5]. Lack of sexual health in women leads to psychological disorders such as; depression, anxiety, mood swings, sexual fear and sexual dysfunction [6]. One of the key components of people's sexual health is sexual function, which unfortunately, is the most common sexual health problem in people. Studies have shown that, sexual function at any level is able to affects women's sexual satisfaction, and causes degrees of stress in them [7]. On the other hand, women's sexual function is influenced by physical and psychological factors. Among the common factors that can threaten sexual function is the understanding or conception of individuals from their sexuality. For instance, women who think they are not attractive for their husbands are at the risk of developing sexual disorder twice the time than women who think the opposite [8,9]. Understanding and conception of people from their sexuality is called sexual self-concept, and this psychological factor consists of positive and negative dimensions [10] Positive sexual self-concept regulates behaviors and excitements in such way that, women with positive self-concept experience positive sexual behaviors and excitements.
On the other hand, women with negative self-concept have less successful interpersonal relationships and fewer sexual experiences and sexual satisfaction, and usually have a negative and conservative attitude towards sexual issues. These women (with negative sexual self-concept) when asked to predict their future sexual plan, they show a great deal of uncertainty and pessimism [11,12]. Accordingly, assessing sexual selfconcept as a tool to determine the status of sexual interaction with others (interpersonal) and intra-personal status can have a crucial role in people's sexual health, so in people, who need sexual intervention, the counselor or therapist can use their sexual self-concept as a tool to examine their sexual health [13]. Furthermore, whereas sexual self-concept, due to the past personal experiences, is different from person to person and because of the need to preserve the principle of confidentiality [14], self-concept as a method of sexual counseling, is effective in maintaining or improving the sexual health in individuals.

Materials and Methods
This interventional study was conducted on 59 married 15 to 44 years old women attending health centers of Gorgan city, Iran to receive healthcare services. Conventional sampling method was used to select the women who were later randomly divided into two groups (intervention and control groups). The inclusion criteria of the study were; willingness to participate in the study, having at least primary school education and higher, having passed over 6 month since last birth delivery, having no history of adverse event (such as death of loved ones or accidents causing disability) in the last three months, having no chronic mental/ physical disease such as vaginal infection, having no severe marital conflicts, not being pregnant or plan to get pregnant during the study, not taking anti-anxiety and antidepressants medication, not being drug addict(husband and wife), and not being pregnant for more than 5 times. The exclusion criteria were; immigration of samples during the study, couples' decision to separate from each other, occurrence of adverse event (death of loved ones or accident leading to disabilities, etc.), and diagnosis of acute or chronic sexual problems due to physical or mental reasons during the study.
Data collection tools included a form and two questionnaires, the demographic form and, the Persian Female Sexual Function Index questionnaire, consisted of 19 questions with 5 options. The validity and reliability of the questionnaire was confirmed in the study of Mohammadi et al. with Cronbach's Alpha of 0.70 and above in which, the sexual function in six dimensions including sexual desire (first and second question with scores of 1 to 5), sexual excitement (3 to 6 questions), vaginal lubricant (7 to 10 questions), orgasm (11 to 13 questions), sexual satisfaction ( 14 to 16 questions with the scores 1-5) and sexual pain (17 to 19 questions with the scores 1-5) were assessed (14) and the Persian multidimensional questionnaire on self-concept with 18 domains and 78 items. The validity and reliability of the Persian multidimensional questionnaire on self-concept with Cronbach's Alpha of 0.88 and reliability index greater than 0.70 was also confirmed in the study of Ziaei et al. [15]. In this study, from Global Journal of Reproductive Medicine the 23 questions asked, five dimensions of sexual self-concept including sexual fear (Q: 5-9-13-18-23), sexual anxiety (Q: 1-6-10-14-19), sexual self-efficacy (Q: 2-7-15-20), sexual satisfaction (Q: 4-8-12-17-22) and sexual self-esteem (Q: 3-11-16-21) a) were used [15].
All participants completed the demographic questionnaire form. Women who were in the intervention group underwent individual counseling based on sexual self-concept. Short-term counseling session with eclectic approach was conducted for 45 minutes by a midwifery consultant under the supervision of a clinical psychologist with MSc degree. The consultation process with sexual self-concept approach, based on scores in each area of sexual function was started and continued with non-verbal observation (behavioral and emotional) and verbal review during the interview process. The progress was assessed and sexual function based on scores obtained from the questionnaire was evaluated. Positive and negative points were identified through sexual self-concept questionnaire, which put forward two conditions: a.
The existing condition was approved, and b. Problems and concerns were identified so they could be responded to, and if the problems were too many, they were prioritized [16]. If further session was required or the participant asked for further session, a time for the next meeting was set up. One month after the consultation, women in both groups were called again to complete the questionnaire once more. All subjects signed consent from to participate in the study. The participants had right to withdraw from the study if their wished to do so.

Ethical considerations
i.
Written consent was obtained from the entire participant before taking part in this study. ii.
All participants had right to withdraw from the study at any time if they wished to do so.
iii. The confidentiality principal was preserved by; keeping all the participants' information confidential, using anonymous questionnaire and a code was given to each questionnaire instead of name, and conducting the counseling individually and giving the researchers' telephone number to the participants to ask any question any time.
iv. This study had benefits for the sample as it was included the consultation on sexual functioning in order to improve it. v.
The results of the project were effective in promoting sexual health of the participants.
vi. An informed consent was obtained from the spouses of the participants in intervention group before the taking part in counseling sessions'.
vii. The counselors and the participants belonged to same gender. Statistical analysis was carried out on the data collected from 59 participants. Demographic data was analyzed using parametric test and non-parametric test (Wilkekson, Spearman and Mann-Whitney) according to the research objectives through SPSS software version 16.

Results
The results of Chi-square test and t-test showed no statistically significant differences between the intervention and control groups in terms of demographic variables such as age, occupation and education of the spouses, mode of birth delivery, contraception way, breastfeeding condition, and parental style. Mann-Whitney test showed no statistically significant difference between the two groups in terms of average female sexual function scores before the intervention in various fields. The result of Wilkerson showed a statistically significant increase in the overall score of sexual function in the intervention group (P<0.0001) compared to before the intervention, and also a significant increase was observed in the dimensions of; sexual desire (P<0.02), sexual excitement (P<0.01), orgasm (P<0.000) in the intervention group after the intervention. But, in the control group, no significant increase was seen in any of these dimensions ( Table 1). Results of the same test also showed in the intervention group, the mean score of dimensions of sexual selfconcept after the consulting showed a significant decrease in the dimension of sexual anxiety (P<0.01), and a significant increase in the dimensions of sexual self-esteem (P<0.04) and sexual satisfaction (P<0.03). But, no significant difference was observed in any of these dimensions in the control group (Table 2).

Discussion
The present study showed that, counseling based on sexual self-concept has a positive effect on maintaining and improving sexual function, which is consistent with the findings of Markus study (1987) which concluded that, dimensions of sexual selfconcept as an important component of individuals' cognitive system, have active and dynamic nature and are able to change, and can influence the function of individuals and also can be influenced with it [17]. Also in this study, the mean score of dimensions of sexual self-concept after consulting showed a statistically significant decrease in the dimension of sexual anxiety and an increase in the dimensions of sexual self-esteem and sexual satisfaction. The findings of Hensel [18] which showed, the more we reduce sexual anxiety, the more sexual health improves, is also in line with the results of this study. These results are consistent with the findings of Reissing et al. [19] study which indicated that, improving and changing sexual self-concept is immensely effective in improving natural sexual function and preventing sexual dysfunction. Hucker et al. [20] observed that, sexual self-concept potentially increases women's sexual function. Chen et al. [21] showed that, strengthen sexual self-concept in women improves their sexual health. The results of Andersen et al. [22] suggested that, women with improved sexual self-concept have a better and are more successful sexual function [23,24].

Conclusion
The present study aimed to determine the effect of counseling based on sexual self-concept on sexual health of women in reproductive age who attended health centers in Gorgan a city in Iran. This study showed that, counseling based on sexual selfconcept can affect the sexual function of women in reproductive age. It maintains and improves the women's sexual function by changes the dimensions of sexual self-concept. On other words, the results showed the importance of counseling based on sexual self-concept on improving sexual function in people particular women in childbearing age. Since all dimensions of sexual function in this study were not significantly affected by sexual self-concept counseling, it is suggested that, it would be better to conduct such counseling on each of the dimensions of sexual function separately in order to better determine the effects of such counseling on sexual health.