Volume 11, Issue 1 (Winter 2023)                   PCP 2023, 11(1): 45-56 | Back to browse issues page


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Shirkhani M, Sadeghi A, Naeemi Nezam Abad A, Sabbagh K. Investigating the Relationship Between Childhood Sexual Abuse, Marital Satisfaction and Sexual Performance in Iranian Married Women. PCP 2023; 11 (1) :45-56
URL: http://jpcp.uswr.ac.ir/article-1-846-en.html
1- Department of Clinical Psychology, Faculty of Psychology and Education Science, Ferdowsi University of Mashhad, Mashhad, Iran.
2- Department of Clinical Psychology, Faculty of Behavioral Science and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran. , sadeghiamirhosein.ahs@gmail.com
3- Department of General Psychology, Faculty of Psychology and Education Science, University of Zahedan, Zahedan, Iran.
4- Department of Psychology, Faculty of Psychology and Education Science, Ferdowsi University of Mashhad, Mashhad, Iran.
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1. Introduction
Child abuse is a recurring phenomenon that can be observed worldwide. Various studies define child abuse as any behavior that involves intentional physical, emotional, or sexual abuse, and carelessness or neglect toward a child (Afifi et al., 2014; Higgins & McCabe, 2001). One type of child abuse is child sexual abuse (CSA). The World Health Organization (WHO) defines CSA as the “involvement of a child in sexual activities that they do not fully understand, cannot give informed consent, are not developmentally ready, or violate social rules or social taboos” (Choudhry et al., 2018). CSA is a serious public health problem that affects many boys and girls. Being a victim of CSA increases the risk of developing numerous physical, psychological, and health problems, as well as the risk of sexual and nonsexual offenses later in life (Assini-Meytin et al., 2020).
Global estimates show that the experience of CSA varies widely by country and gender. For example, one study estimated the prevalence of 7.6% to 7.9% among boys and 18% to 19.7% among girls (Stoltenborgh et al., 2015). In another study, the prevalence of CSA was estimated to range from 20% to 25% in women and about 10% in men (Moody et al., 2018). In Iran, the prevalence was reported to range from 2.3% in Tabriz to 32.5% in Khorramabad (Khoori et al., 2020).
Nevertheless, all figures on the prevalence of CSA appear to underestimate the actual rate of sexual violence experienced by children (McTavish et al., 2019). CSA has serious long-term consequences for its victims. Survivors often suffer from various symptoms, such as cognitive problems, including denial and withdrawal; unwanted thoughts or flashbacks; lack of control toward reality; self-loathing and self-criticism (Shirkhani et al., 2022; Barrera et al., 2013; Sanjeevi et al., 2018); feelings of fear, guilt, and extreme avoidance (Paivio & Pascual-Leone, 2010); emotional disorders such as anxiety, depression, substance abuse, post-traumatic stress disorder; obsessive-compulsive disorder; borderline personality disorder; dissociative disorders (Dorri Mashhadi et al., 2022; Cashmore & Shackel, 2013; Olafson, 2011); and sexual problems, such as confusion about sexual preferences, shame in sexual relationships, deficiencies in sexual quality and performance, and dissatisfaction with marital relationships (Blais, 2020; Russell et al., 2020).
One of the signs and long-term effects of CSA is dissatisfaction in marital relationships. Marital satisfaction is one of the common concepts used to assess happiness and stability in marriage. Meanwhile, what is more important than marriage is marital success and satisfaction (Tavakol et al., 2017). Marital satisfaction is the most important indicator of the quality and stability of married life and is defined as a person’s general attitudes or feelings toward their spouse and their relationship (Bachem et al., 2018). Marital satisfaction is a multidimensional concept that is influenced by several factors, such as the age of marriage, length of the marriage, ethnicity, personal characteristics, mental maturity, mindset, understanding of self and others, life expectations, emotional intelligence of the husband and the wife, communication and problem-solving skills, religious beliefs, understanding and mutual respect, affection and love, attachment to one another, intimacy, trust, commitment, loyalty, educational level, family financial status, economic factors, cognitive and emotional factors, physiological factors, behavioral patterns, social support, violence, sexual behavior, physical attractiveness, the presence of children, parenting style, relationships with relatives and friends, type of leisure time, marital conflicts, stress, and many other factors at the individual and social levels (Tavakol et al., 2017). In this context, the results of a study by Walker et al. (2009) showed that CSA experiences lead to a decline in the quality of marital emotional relationships and satisfaction with married life (Walker et al., 2009). Similarly, in a study by Miller et al. (2013) the results showed that CSA experiences decrease marital satisfaction in people (Miller et al., 2013). In addition, the results of Goodman et al. (2020) study in Kenya showed that a history of CSA can lead to violent behavior in marriage and reduce the quality and satisfaction of marital life (Goodman et al., 2020). In their 2020 study, Francis Laughlin and Rusca (2020) reported that couples in which one or both partners have had a history of CSA often have problems with social adjustment, stability, and satisfaction with married life, as well as sexual dysfunction (Francis Laughlin & Rusca, 2020).
According to recent research, couples’ sexual performance is one of the important and crucial dimensions of marital satisfaction and the quality of life can be affected by CSA (Van de Grift et al., 2020). Sexual performance is defined as the ability to participate in sexual intercourse and includes several aspects (Esmaeili et al., 2020). Sexual performance is influenced by a person’s physiological and hormonal status, health behaviors especially during puberty, early relationships, family, social, and cultural factors, environmental complexity, a person’s and their spouse’s sexual history, sexual self-disclosure, previous relationships, mental health status, urinary tract infections, and previous illnesses (Chizari et al., 2019). In addition, disruptions in women’s sexual performance can harm mental health and the quality of life (Khajehei & Doherty, 2018). CSA experiences may impact women’s sexual performance. For example, the results of a study by DiMauro et al. (2018) showed that women’s experiences of sexual abuse can affect their satisfaction and sexual performance (DiMauro et al., 2018). The results of Blais’s (2020) study also show that women’s history of sexual abuse is significantly related to satisfaction with married life, sexual performance, and sexual satisfaction (Blais, 2020). The results of Pulverman and Meston’s (2020) study showed that women who were sexually abused in childhood have unfavorable sexual performance because of a deep sense of shame (Pulverman & Meston, 2020).
However, in Iran, because of the sensitive and taboo situation of this issue, a considerable number of participants in various studies refuse to answer questions about CSA, which makes research on this topic very difficult (Ramezani et al., 2015). Iranian families are often silent or indifferent to their children’s sexual issues. One reason for this problem is the concern about their children’s sexual deviance and promiscuity (Merghati-Khoei et al., 2014). Nevertheless, it is clear that concern about CSA is increasing in Iran and many parents seek education in the area of proper parenting principles to prevent CSA (Badrfam et al., 2020).
Considering the prevalence of CSA, especially in girls, and the impact of such experiences on women’s satisfaction with married life and sexual performance, this study aims to examine the relationship between CSA experiences and satisfaction with married life and sexual performance among Iranian married women.

2. Participants and Methods 
Since the current study aims to investigate the relationship between CSA experiences with satisfaction with married life and sexual performance among Iranian married women, the research design is descriptive and correlational. The statistical population of this study includes all married women in the age range of 18-50 years who live in Tehran Province, Iran, in 2021. Based on the type of statistical method used, a 25% sample fall, and an effect size of 0.12 by the G*power software, the minimum sample size was set at 200 subjects. This population was selected as the sample via the available method. The criteria for participation in the study were being married, having no history of divorce, having a minimum level of literacy to read and answer the questionnaires, and being in the age range of 18-50 years. 
The exclusion criteria were being diagnosed with physical and mental illness (according to the demographic checklist), a history of addiction (according to the demographic checklist), and not answering more than 5% of the questionnaires. Since adherence to ethical considerations is one of the research principles, participants were informed about the aims of the study before data collection, were assured about their voluntary participation in the study, and that the study is subject to their full consent to participate in the study. In addition, the current study did not collect any information that would indicate the identity of the subjects; accordingly, the confidentiality of the subjects’ information was fully maintained. After data collection, descriptive indices, such as frequency distribution, mean, and standard deviation (SD), and inferential indices, such as the Cronbach α coefficient, the Pearson correlation test, and the multivariate regression test were used to analyze the research data. Data analysis was performed using the SPSS software, version 25.
Study instruments
Demographic checklist
In this section, demographic information such as age, education level, history of physical and psychological problems, and ways to reestablish contact to send the study results was obtained.
Unwanted Childhood Sexual Experiences Questionnaire
The Unwanted Childhood Sexual Experiences Questionnaire (UCSEQ - 1998) includes 13 items and is developed by Stevenson in 1998. The instructions in this questionnaire refer to unwanted sexual experiences in childhood and the respondents indicate the age and extent of these experiences. Each of the 13 items in this questionnaire refers to different behavioral categories that can be classified as minimum contact (items 1 to 3), moderate contact (items 4 to 8), or maximum contact (items 9 to 13) (Stevenson & Gajarsky, 1998). The items of this questionnaire are adapted from Finkelhor’s questionnaire and have been investigated in other studies (Finkelhor, 2010; Stevenson, 2010). To confirm the reliability of this questionnaire, Stevenson and Gajarsky (1998) enquired university students to indicate the unwanted sexual experiences they had reported in previous reports using this questionnaire. Although the percentage of men who reported unwanted sexual experiences was relatively higher than some previous estimates, the overall results showed high agreement (Poppen & Segal, 1988; Stevenson, 2010). In the present study, the face validity of this questionnaire was confirmed by the distinguished members of the academic faculty of the university. The reliability of the questionnaire was tested via the Cronbach α method. The Cronbach α coefficient for the “minimum contact”, “medium contact”, and “maximum contact” was obtained at 0.72, 0.83, and 0.75, respectively. Meanwhile, the coefficient for the whole questionnaire was 0.89, indicating the good reliability of this questionnaire.
Enrich Marital Satisfaction Scale
The Enrich Marital Satisfaction Scale (EMSS--1989) was developed by Fowers and Olson in 1989 and is designed to assess the potential problem areas and to identify areas of strength and enrichment in marital relationships. This questionnaire has been used as an important and valid research instrument in many surveys measuring marital life satisfaction. This test consists of two forms with 115 questions and 125 questions and includes 12 subtests. Fowers and Olson reported the Cronbach α coefficient of this questionnaire at 0.95 (Fowers & Olson, 1989). In 1997, Soleimanian developed the short form of this questionnaire in Iran with 47 items (Saeidi et al., 2019). The short form with 47 items examines 9 components of personality, marital relationship, conflict resolution, financial management, leisure activities, sexual relationships, the marriage of children, relationships with relatives and friends, and religious orientations. This questionnaire is scored on a 5-point Likert scale from 1 to 5 (from “strongly disagree” to “strongly agree”). Scores between 47 and 84 indicate extreme dissatisfaction, scores between 85 and 122 indicate relative dissatisfaction, scores between 123 and 160 indicate moderate satisfaction, scores between 161 and 198 indicate high satisfaction and scores between 199 and 235 indicate very high satisfaction (Soleimanian, 1997). The concurrent validity of this questionnaire with the original form was obtained at 0.95, and its Cronbach α coefficient was 0.65, indicating the reliability and validity of this questionnaire. The 47-item short form of the scale is currently the most widely used tool in Iranian research (Seraj et al., 2014). In the present study, the Cronbach α coefficient for the short form with 47 items was obtained at 0.92.
The Female Sexual Function Index
The Female Sexual Function Index (FSFI- 2000) was developed and validated by Rosen et al. in 2000. This questionnaire contains 19 items and is scored on a 6-point Likert scale (from 0 to 5). FSFI- 2000 examines 6 components of sexual desire (questions 1 and 2), sexual arousal (questions 3 to 6), vaginal lubrication (questions 7 to 10), orgasm (questions 11 to 13), sexual satisfaction (questions 14 to 16), and sexual pain (questions 17 to 19). By summing the scores of the questions for each component, the total score of the respective component is obtained. Higher scores indicate more favorable sexual function (Rosen, 2000). In their research, Rosen et al. reported a test-retest reliability coefficient of 0.79 to 0.86 and a Cronbach α coefficient greater than 0.82 for all components. In Iran, Mohammadi et al. investigated the validity and reliability of this questionnaire, and the results showed that the test-retest reliability coefficient for the components ranged from 0.75 to 0.81. Meanwhile, the coefficient for the entire questionnaire was 0.75. Also, the Cronbach α coefficient ranged from 0.73 to 0.85 for the components and 0.85 for the whole questionnaire (Mohammadi et al., 2008). In the present study, the Cronbach α coefficient for this questionnaire was 0.82.

3. Results
The mean and SD of the participants’ age was 26.07±6.98 years. Of the participants, 18.4% had a diploma, 43.2% had an associate degree, 27.7% had a bachelor’s degree, and 10.7% had a master’s degree or higher. The descriptive indices of the variables mentioned in the study were examined and the results are provided in Table 1.



Before examining the results concerning the research hypotheses, the following section demonstrates the normality distribution assumption for the variables. For this purpose, the skewness and elongation indices were used. These results are provided in Table 2. The results of the skewness and elongation indices presented in Table 2 show that, except for “maximum contact”, the remaining cases have favorable skewness and elongation indices (-1 to +1). Thus, the assumption of normal distribution of the variables is met. Then, the research hypotheses were tested.



In the first step, the Pearson correlation test was used and the results are listed in Table 3.
The results of Table 3 show that the experience of sexual abuse at minimum contact, moderate contact, maximum contact, and the total score has a negative and significant relationship with marital life satisfaction (P<0.01). The results also show that the experience of sexual abuse at minimum contact, moderate contact, maximum contact, and the total score has a negative and significant relationship (P<0.01) with the sexual pain and sexual desire component of women’s sexual performance.



In addition to the results of the correlation test, the multiple regression test with the method of simultaneous entry (inter) was used to obtain the regression equations.
The results of Table 4 show that the values of the tolerance statistic for the predictor variables of the study are above 0.40; therefore, the degree of collinearity between the predictor variables of the study is not an issue. Also, considering that the values of the Durbin-Watson test are between 1.5 and 2.5, the assumption of error independence (the difference between the actual values and the values predicted by the regression equation) is met. Table 4 also shows that the minimum contact with a standard β coefficient of -0.13 (P>0.01), moderate contact with a standard β coefficient of -0.17 (P>0.01), and maximum contact with a standard β coefficient of -0.17 (P>0.01) predict satisfaction with married life among women. The multiple correlation coefficient between the predictor variables and the criterion variable is 0.41 and the coefficient of determination is 0.16.



Considering that the correlation values for the relationship between CSA experiences and the two components of sexual desire and sexual pain from the variable of women’s sexual performance were significant. The regression equation for these two components was also examined and the results are reported in Table 5 and Table 6.






The results of Table 5 show that only “maximum contact” in sexual abuse experiences predicts sexual desire in women with a standardized β coefficient of -0.23 (P<0.01). Moreover, the multiple correlation coefficient between the predictor variables and the criterion variable was 0.28 and the coefficient of determination was 0.07.
The results of Table 6 show that only “maximum contact” in sexual abuse experiences predicts sexual pain in women with a standardized β coefficient of -0.13 (P<0.01). In addition, the multiple correlation coefficient between the predictor variables and the criterion variable was 0.19 and the coefficient of determination was 0.03.

4. Discussion
This study was conducted to investigate the relationship between CSA experiences with satisfaction with married life and sexual performance among Iranian married women. As the results in Table 3 show, CSA experiences are negatively and significantly related to satisfaction with married life along with the two components of sexual pain and sexual desire in the variable of sexual performance. Also, the results in Table 4, Table 5, and Table 6 show that CSA experiences predict marital life satisfaction. However, only the “maximum contact” component in the CSA variable predicts the “sexual pain” and “sexual desire” components in the “sexual performance variable”.
The results of the Pearson correlation test and multivariate regression showed that CSA experiences at the three levels of minimal contact, medium contact, and maximum contact were negatively related to satisfaction with married life and had a significant predictive role in this regard. This result is consistent with the research findings of Walker et al. (Walker et al., 2009), Miller et al. (Miller et al., 2013), Goodman et al. (Goodman et al., 2020), and Francis Laughlin and Rusca (Francis Laughlin & Rusca, 2020)
Experiences of CSA mainly occur in a relationship that can influence later interpersonal relationships. In other words, in sexual abuse, the child is usually sexually abused by their family members, acquaintances, and caregivers; thus, considering that the experience of CSA is a form of trauma, it also has certain psychological consequences for the individual (Goodman et al., 2020; Paivio & Pascual-Leone, 2010). Especially in Iranian society, most of these abuses remain hidden because of cultural inhibitions, such as fear of dishonor. This issue either consciously or unconsciously affects the person’s performance and relationships (Dolisgan & Razisni, 2020). Therefore, one of the explanations for the correlation between CSA experiences and satisfaction with married life is that both occur in an interpersonal relationship where there are similarities, such as intimacy, closeness, and proximity. This correlation and similarity can form the basis for predicting the current relationship based on past experiences. In other words, a person’s early experiences in a relationship in which they have suffered harm because of sexual abuse, whether in the form of trauma or unconscious effects, may have an impact on the person’s marital relationship, which is the focus of their sexual relationship. Therefore, the experience of CSA, with its negative effects on sexual performance (sexual desire, orgasm, and vaginal lubrication), may lead to dissatisfaction with the marital relationship, such as conflict and discomfort, feelings of inability able to give pleasure to oneself, and inability to satisfy one’s spouse in a marital relationship. 
Another fundamental aspect of the damaging effects of CSA is attachment. This is because attachment is the main reason for the formation of emotional and intimate relationships. In other words, people enter marital relationships with attachment motives to experience intimacy, support, closeness, and belonging, which is a normal and natural process. However, findings suggest that the experience of CSA may prevent the formation of pleasurable marital relationships through negative effects on secure attachment and the promotion of anxious and avoidant attachment (Rumstein-McKean & Hunsley, 2001). In other words, the experience of CSA violates and impairs a person’s sense of security in an intimate relationship. Based on this sense of insecurity, a person tends to develop avoidant attachment and anxiety in interpersonal relationships (Dalton, Greenman, et al., 2013; Timulak, 2015). Consequently, in interpersonal relationships, a person who shows fear of intimacy because they have been violated in the past cannot practically express their emotional and attachment needs in a marital relationship. Additionally, the fear of being abused again prevents them from responding and being available to their partner. Therefore, in such a relationship, the experience of intimacy, the satisfaction of attachment-oriented needs, and emotional experiences such as support and responsiveness do not occur, and satisfaction is not generated because of disruptive fears and avoidances.
The results of the Pearson correlation test and multivariate regression also showed that the experience of sexual abuse at minimum, medium, and maximum contact levels, as well as the total score, had a negative and significant relationship with the sexual pain and sexual desire components of women’s sexual performance, and at the maximum contact level, it predicted sexual desire and sexual pain. This result is consistent with the research findings of DeMaioro et al. (DiMauro et al., 2018), Blasis (Blais, 2020), and Polverman and Maston (Pulverman & Meston, 2020). CSA is an important risk factor for a wide range of interpersonal disorders in female survivors, including problems related to intimate partner relationships and impaired sexual functioning (Pulverman & Meston, 2020). To some extent, this negative effect can be said to be related to negative cognitive and emotional schemas that a person forms about sex and sexual performance as a result of the unpleasant experience (Pilkington et al., 2020). In this context, women with experiences of CSA have been shown to have less romantic sexual schemas compared to women without these experiences, and the experience of sexual abuse may harm a person’s sexual schemas, independent of the impact on depression and anxiety symptoms (Meston et al., 2006). Therefore, it can be said that experiences of childhood sexual abuse may decrease sexual desire because of the negative effects on sexual schemas. In other words, sexual abuse experiences hinder sexual desire by forming negative schemas related to intimate relationships (at the highest level, the marital relationship), reducing positive attitudes toward romantic relationships and sexual relationships, or depriving a person of the necessary context and opportunity for sexual desire (Impett et al., 2008). 
For women who have experienced sexual abuse and have been the victims of this event, the unpleasant mental images of the incident can be a major obstacle to experiencing sexual desire. Since recalling the mental images of the incident has unpleasant content related to sex, fear, and aversion to sex may reduce sexual desire in these individuals (Felitti et al., 2019). Women who had been sexually abused in childhood were also found to have a greater number of painful body sites, more diffuse pain, fibromyalgia diagnoses, surgeries, hospitalizations, and primary care physician visits. In other words, the occurrence of chronic pain is a result of experiencing CSA for women (Finestone et al., 2000). Another finding in this context is that victims of sexual abuse are more affected by psychological pain than victims of physical abuse (Kremer et al., 2017). Therefore, experiencing pain and discomfort in the body is one of the future consequences of childhood sexual abuse. In addition, recent evidence shows that unwanted sexual experiences in childhood are an important predisposing factor for the lack of self-care and involvement in mortality risk factors (Felitti et al., 2019).
The experience of sexual abuse or, in other words, unwanted sexual experiences in childhood is considered a major vulnerability for the child’s future life. Considering that most of these events occur in the relationships of acquaintances, neighbors, and the main caregivers of the child, the interpersonal relationship that provides security and intimacy suffer the most damage from these events. In this context, the results of the present study showed that the experience of CSA is negatively related to marital satisfaction, and the predictive role of the experience of CSA is significant in this context. Furthermore, the results of this study have shown that a significant relationship exists between the experience of CSA and sexual desire and pain in women and the experience of CSA plays a significant role in predicting this relationship. The results of the present study indicate that the experience of CSA among Iranian married women may affect their marital relationship and sexual behavior; therefore, efforts should be made to identify these people and consider appropriate psychological measures for their recovery.
However, it should be noted that the study of sexual behavior is much more complicated than what has been discussed in this article because in many cases, CSA may provide the ground for excessive sexual activity as well as the early initiation of such behaviors, which require much research in the future. On the other hand, most of these people in Iranian culture hide the incident because of social shame and fear of being dishonored. It is necessary to take appropriate psychological measures to reduce the suffering of this population affected by unjust and inhumane events and to put these measures on the agenda of social service organizations and centers with greater seriousness.

5. Conclusion 
The experience of CSA in married Iranian women can affect their marital relationship and their sexual performance in the marital relationship. Therefore, efforts should be made to identify these people and consider appropriate psychological measures for their recovery because, in Iranian culture, most people hide the incident out of social shame and fear of being dishonored.
Future research suggestions
Concerning future research, it is suggested that similar studies be conducted for men so that the results can be generalized to other populations. In addition, given that the experience of CSA seems to exert part of its effect on intimate relationships through attachment style, it is proposed to investigate the mediating role of attachment style in the relationship of the research variables through structural equation analysis. Since the questionnaire on the experience of CSA was used for the first time in the Iranian population in the present study, investigating the validity and reliability of this instrument can be another suggestion for future studies. The final recommendation is that since the experience of childhood sexual abuse has dynamic effects on couple relationships and women’s sexual performance, future studies can examine other relevant variables that may play a mediating role.
Study limitations
Regarding the limitations of the current study, the method of the current research was correlative, therefore, the obtained results cannot show causal relationships and there are limitations in this regard. Since there is a cultural barrier in Iranian culture and people avoid expressing their experiences of sexual abuse, unwillingness to participate in the research and answer the relevant questionnaire was another limitation of the present study. Also, the sampling method of the present study was the available method because it was not possible to identify an affected population related to the subject of the study; therefore, the lack of random sampling is another limitation of the present study. On the other hand, it should be noted that the sample of the present study included educated and literate women of society from a relatively favorable social class. This limits the generalizability of the results. Additionally, since the present study sample included married women, the results are limited to this gender and cannot be generalized to men.

Ethical Considerations

Compliance with ethical guidelines

All of the methods used to collect the data for the questionnaires follow the ethical standards of the Helsinki Declaration (1964) and subsequent amendments or ethical standards. All data were collected anonymously and there was no relationship between the questionnaires and the participants. All participants were informed about the goals, methods, potential benefits, and risks of this research before participating.

Funding
This study did not receive any funding from public, private, or non-profit organizations.

Authors' contributions
All authors equally contributed to preparing this article.

Conflict of interest
The authors declare no conflict of interest.


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Type of Study: Research | Subject: Psychiatry
Received: 2022/08/25 | Accepted: 2022/10/4 | Published: 2023/01/14

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