The Determinants of Housewives’ Sexual Health: A Qualitative Study: Qualitative Study

Background & Aims of the Study: Women’s health including, the sexual dimension is the basis of family’s and community’s health. Due to the lack of research on women’s sexual health, investigations seem necessary in this area. The present research aimed to study factors affecting women’s sexual health. Materials and Methods: This was qualitative research. The required data were collected using in-depth individual interviews. The statistical population consisted of married women under the age of 50 years residing in Qom City, Iran. Twenty married women were selected by the purposive sampling method and data were obtained until reaching saturation. Results: Our findings indicated that sexual disorders, anal intercourse, neglecting sexual foreplay, environmental conditions, body image, pudency, and feeling guilty during intercourse degraded sexual health according to the interviewed women. According to this qualitative research data, the most common dysfunction reported by the interviewed women was anorgasmia. Conclusion: In the present qualitative study, the factors affecting the sexual health of housewives were identified. Paying attention to these characteristics in designing appropriate interventions is suggested by health authorities in the country.


Introduction
exual satisfaction is among the main components of a marital relationship and an indicator of a successful marriage, survival, and family health [1]. Any conflict, incompatibility, and sexual dissatisfaction can lead to marital issues. Besides, if left untreated, such conditions can lead to failed marriages, divorce, and devastating mental health consequences in the spouses, children, and society [2]. Sexual problems disrupt the process of fulfilling the needs and desires of couples [3]. Couples who experience these conflicts are more prone to generate the signs of depression [4], anxiety disorders, social anxiety, bipolar disorder, and biological conditions, such as malnutrition, sleep problems, smoking, alcohol, and self-medication [5,6]. Sexual dissatisfaction can lead to the hatred of spouse, resentment, jealousy, competition, revenge, feelings of humiliation, feelings of lack of self-confidence, and so on [7]. The cause of numerous psychological disorders, moral perversion, betrayals, marital conflicts, incompatibility, unpleasant temper, delinquency, and even crime are the lack of attention to sexual issues or are to some extent related to it [8].
Sexual instinct is among the inherent needs of man; Maslow has classified this need in the category of physical needs or basic vital needs [9]. Sexual orientation is a dynamic change in life, i.e., influenced by biopsychosocial and cultural issues [10]. The World Health Organization has also defined the 3 dimensions of biopsychosocial health. By definition, sexual health is the integration and harmony between the mind, feelings, and body; the social and intellectual aspects of man fall in the direction of improving their personality and leads to communication and love. Therefore, any condition that leads to incoherence and consequently dissatisfaction with sexual intercourse can lead to sexual dysfunction [11]. Murtagh determined sexual problems in women and found that 42% of women encounter at least one sexual problem [12]. The largest international study by the World Institute for the Study of Sexual Behavior reported that 38% of women present sexual disorders [13]. Bassoon believed that sexual performance and desire must be accompanied by a positive motivation for a woman to desire sexual acceptance to emerge. These positive motivations include the desire to express love, to receive and share physical pleasure, the feeling of intimacy, the desire of the sexual partner, and to increase one's wellbeing [14]. Hossein Rashidi et al., in a qualitative study, concluded that sexual health is the satisfactory and correct satisfaction of sexual needs. Such health is achieved through the establishment of a healthy and defined social relationship with a subject of the opposite sex. Besides, the factors affecting sexual health are the level of awareness and education, health and biopsychological development, economic needs, as well as socio-cultural and religious values [15]. Asadi et al. also argued that wrong sexual beliefs, conservatism in marital life, and marital distress were related to female sexual dysfunction [16]. Ghazaii et al. also stated that guilt, marital satisfaction, and body image-concerned anxiety were effective in orgasmic disorders in women [17].
In Iran, the prevalence of female sexual dysfunction in different age groups ranged from 31% to 72%, i.e., was higher respecting orgasmic disorders, sexual arousal, and a decreased libido [18]. Healthy sexual function is an essential component to creating a happy and successful life. Numerous international studies identified sexual health and methods to improve sexual function or the treatment of its related disorders; however, studies conducted to improve sexual function and health in Iran are scarce. Due to the importance of the subject, the prevalence of sexual disorders in Iranian women, data heterogeneity on sexual health, and the need for further studies, the present study aimed to explain the factors affecting the sexual health of housewives in Qom City, Iran.

Materials and Methods
The present qualitative study investigated the factors affecting sexual health among married housewives under the age of 50 years, in Qom City, Iran from January 2017 to April 2018. To collected the necessary data, in-depth structured interviews were employed. The study participants were selected by the purposive sampling method. The interview location was chosen based on the agreement between the researcher and the participants, i.e., the most convenient place for the research participants. The main research questions were "How do you evaluate your sexual relationship with your spouse and what problems have you encountered so far in terms of your sexual needs?" and "Have you ever benefited from sex education?" First, the general questions of the interview were asked and the next items were probed based on the initial answers. Moreover, as needed, in interviews, questions, such as "What do you mean?" were used. At the end of each interview, the study participant was asked to comment on the missing aspects. The average interview time equaled 45 minutes. All interviews were recorded with the permission of the research participants. In this study, after interviewing 20 participants, the data were saturated due to the repetition of the cases and the lack of a new class and subclass at the time of analysis. After each interview, their text was transcribed verbatim, then analyzed by the content analysis method.
According to Table 1, most interviewees were aged 26-35 years. Most explored women had a marriage history of more than 16 years. Additionally, 3 of the interviewees had no children, 5 had one child, 7 had two children, and 5 had three or more children. The educational status of the interviewees was as follows: 3 undergraduates, 4 with diplomas, 10 with diplomas, and 3 with MA.

Results
In this qualitative study, sexual health components of female sexual disorders; spouse sexual disorders; anal intercourse; spouse not paying attention to foreplay; the lack of management of environmental conditions' issues related to body image' feelings of shame towards the spouse, and feelings of guilt in sexual intercourse with the spouse were discussed by the interviewees, i.e., extracted and described.

Female-related sexual dysfunctions
Sexual dysfunctions related to women, like male-concerned ones, are highly prevalent among couples; however, in this particular study, orgasmic disorder, sexual arousal disorder, and the loss of libido were more frequently reported in women. In this study, 6 subjects reported arousal disorder (the lack of vaginal discharge), 5 individuals referred to orgasmic disorder, 3 respondents reported the loss of libido (sexual reluctance), and one subject reported painful intercourse. Some of the explored women addressed their sexual dysfunction as a result of their physical conditions and most of them considered their disorders as a result of their husband's bad temper and violence as well as serious disagreements with their husbands. For example, Razia, a 37-year-old, with middle school education, stated that: "My husband's harsh morals and anger have made our relationship distant and I have become emotionally and sexually reluctant towards him. I was not sexually undesired at the beginning of the marriage; however, over time, my husband's serious differences of opinion and immorality made me cold towards my husband and our marital life. I do not even experience vaginal discharge with my husband and I no longer feel attractive".

Spouse-concerned sexual dysfunctions
Five of the respondents mentioned the problem of the distant spouse as the main reason for their dissatisfaction and lack of sexual health. These respondents considered the lack of intimacy of the spouses to be biological and due to temperament problems, stress and hard work, as well as financial issues. Zeinab, a 30-year-old with an associate's degree commented that: "I think the truth is that material issues are causing problems in the marital relationship. My husband and I are no exception. My husband's intense work pressure is a major cause of his lack of sexual desire. This is because he is always tired and unable to meet my sexual needs. Of course, every time I talk to my husband or complain about it, my husband talks about the problems and I am somewhat convinced; however, I like to have sex with my husband at least once a week because when the interval between our sexes increases, I get emotionally disturbed and it affects my whole life".
In addition to the lack of desire or sexual reluctance, 4 respondents highlighted other conditions in their spouse. The reported dysfunctions included erectile dysfunction, premature ejaculation, and excessive sexual desire. The explored women addressed these conditions as the main cause of sexual dissatisfaction, dissatisfaction with sexual needs, and sometimes, developing anxiety before sexual intercourse and depression. For example, Maeda, a 44-year old with an elementary school education stated the following about sex with her husband: "My husband loses his erection during intercourse and is unable to satisfy my and his sexual needs. This has always made me anxious and not even well aroused before sexual intercourse. Although he has a lot of sexual desire, "when he fails to satisfy me, I have problems, like back pain and mental health issues".

Anal intercourse
Four of the examined women addressed anal intercourse as a major problem in sexual relationships with their partners. A study subject believed that this particular form of relationship causes pain, reluctance, and dissatisfaction. Respondents also mentioned complications associated with anal intercourse. For example, Nasrin, a 27-year-old, with an MA degree mentioned the following points: "My husband's constant demand for anal intercourse is very annoying to me. I suffer a lot in such a practice and it makes me hate my husband. Unfortunately, I have physical problems caused by anal intercourse, such as fecal incontinence and anal abnormalities, and this causes me further reluctant to my husband. Besides, another problem that has arisen me is that my sexual desire is not satisfied and that is why I have masturbated, which hurts me psychologically. I know that it is physically harmful to me, too. Despite all these problems, my husband is unwilling to give up his request, and I am accompanying him for fear that he will seek this need outside the home. I can no longer bear this situation and I am thinking of divorce".

Spouse's failure to paying attention to foreplay before intercourse
Two of the respondents reported the reason for their lack of sexual health was their spouse not paying attention to foreplay. The women also reported problems with their husbands. For example, Fatemeh, a 45-year-old, with a BA degree stated the following in this regard: "My husband always attempts sexual intercourse without foreplay and only thinks about his pleasure. Therefore, I am not ready for sex and our sexual relationship is always cold, hard, and unwanted. We do not have a good emotional relationship with each other either. Insults and humiliations are common between us, and my husband's anger often bothers me".

The lack of environmental management
Some respondents attributed environmental conditions and their inability to manage these conditions to their sexual dissatisfaction. Some environmental factors included the presence of a child or children, the presence of a parent, or other relatives in the family. For example, Negar, a 26-year-old, with a BA degree, believed that: "With the birth of our child, the quality of our marital relationship decreased. This is because before initiating the relationship, foreplay must occur and our child's sleep plan has not been set yet. We cannot have a regular and acceptable plan for the relationship".

Issues related to body image
Having an inappropriate body image in women can lead to impaired sexual health and dissatisfaction with sexual relationships. The 28-year-old Haditha, with elementary education, mentioned that: "I do not like my appearance and I do not feel attractive to my husband and we cannot have a good relationship. I think if I can make changes in myself with surgery, these problems will be solved and we can experience a good and enjoyable relationship".

Feeling ashamed of the spouse
Feelings of shame towards one's spouse have been assessed as one of the most essential examples of irrational sexual destructive shame by the respondents. Four of the respondents considered shame as an obstacle to establishing a healthy and desirable relationship with their spouse. For example, Zohreh, a 50-year-old illiterate subject stated that: "In sex with my husband, shame does not allow me to express my needs and wants, and I think he does not know exactly what I need to be able to meet it. Sometimes I felt the need to have sex with my husband, but due to my shame I was never able to express my desires".

Feeling guilty about having sex with the spouse
In this study, 4 respondents stated that they feel guilty about having sex with their spouses. A 28-year-old Samira, with a fifth-grade education, believed that: "I feel guilty when I am close to my husband and I think this is why I cannot enjoy sex and I have depression and anxiety before intercourse. I am generally not satisfied with my relationship with my husband and I do not feel comfortable in life. I will not succeed in the rest of my life".

Discussion
Sexual health is a situation in which couples enjoy a healthy, appropriate, and normal sexual relationship. Accordingly, biopsychological and behavioral conditions are desirable and indicate a kind of harmony, love, and affection in married life. Proper sexual intercourse serves as a prerequisite for strengthening the emotions and feelings between couples and can promote family ties and prevent the emergence and aggravation of mental health disorders and the disintegration of the family and society.  The obtained results on sexual health suggested that the explored women had reasons, such as female sexual disorders, male sexual disorders, anal intercourse, the lack of attention to foreplay, the lack of environmental management, mental image issues, feelings of shame towards the spouse, and guilt in sexual intercourse with the spouse for their lack of sexual health. By scientifically and accurately analyzing the statements of the interviewees, numerous psychosocial causes related to sexual health can be found; sexual health can be explained according to them.
The most common condition reported by the examined subjects was anorgasmia. Individuals with anorgasmia reported feeling ashamed of their partner and guilty of sexual intercourse, or both. Theories about anorgasmia in women consider the psychosocial roots of anorgasmia as belonging to a strict and fanatical family and culture that addresses sex as sinful and the male reproductive organ as dirty.
Male unilateral demand for anal intercourse was another common complaint of the studied women; however, it is increasing over time. In such a situation, the woman feels that she has been abused by her husband because she feels like a victim physically and painfully during intercourse; also because of the consequences of this intercourse, such as incontinence and flatulence, the malformations of the anus, etc. Moreover, she is unsatisfied with her sexual needs; thus, she distances herself emotionally from her husband. Naturally, reducing the emotions and feelings between couples in other areas of the couple's relationship will also be effective. For example, one of the interviewees considered her husband's constant request for anal intercourse as the cause of emotional divorce with her husband, her masturbation addiction, and her tendency to have extramarital affairs.
Men's inattention to foreplay was raised as an issue by some interviewed women. The lack of sex education, including the gender-wise differences in sexual relations, and the importance of observing the preconditions that lead to the sexual pleasure of couples was among the main factors in the lack of this adjustment among couples. The lack of management of environmental conditions and body image concerns can also be examined from a psychosocial perspective. Regarding environmental conditions, sociocultural issues, such as respect for privacy, independence, the freedom of human beings, and paying attention to teaching skills to adapt to the environment and social contexts, the development of these skills is critical. Appearance satisfaction is also directly related to issues, such as identity, self-confidence, and self-esteem that can be further analyzed. According to the research findings, a very small percentage of women received sex education, while sexual health requires awareness and the knowledge of sexual rights and sexual needs and the correct methods to respond to sexual needs.
Regarding the disorders that are the most common complaints of women concerning sexual health, the analyzed statements distinguished 2 disorders; non-acquired and acquired. In the acquired disorders, psychosocial factors explained the disorder. For example, numerous psychosocial characteristics, such as anxiety, guilt, and fear were associated with sexual arousal disorder in women. Furthermore, erectile dysfunction and male sexual dysfunction in young and middle-aged men, the disorders mainly had psychosocial roots. Factors, such as strong, strict, and punitive transcendence, inability to trust, feeling of inadequacy as a sexual partner, fear, anxiety, anger, and the lack of constructive management of needs in a couple's relationship can be considered. The obtained results revealed that the frequency of acquired disorders was higher than non-acquired ones. Therefore, to eliminate the dysfunction, the relevant psychosocial factors must be studied and resolved.
The present study data supported the results of previous studies, including those of Bassoon [12], Hossein Rashidi [15], Asadi [16], and Ghazaii et al. [17]. This qualitative study also signified a relatively high rate of dissatisfaction and sexual disorders in women, i.e., in line with the findings of Murtagh [12] and Jahani [13].
The present study had some limitations. One of the limitations was that due to the taboo nature of sexual issues in our society, it was very difficult to find articles related to the research variables (almost all related sites were filtered). It was also difficult to obtain the consent of the study sample for the interview, given that the subject of the research was related to the most private area of life and relationships of couples.

Conclusion
The present study data revealed that reasons, such as female sexual disorders, male sexual disorders, anal intercourse, male inattention to intimacy, the lack of management of environmental conditions, body image concerns, feelings of shame towards the husband, and feelings of guilt in sexual intercourse with the spouse have been cited as the reason for the lack of sexual health in the study subjects. According to the present qualitative study findings, the most common disorder reported by interviewed women was anorgasmia; in the studied cases, they felt ashamed of their sex partner and expressed feelings of guilt in sex. Moreover, out of the 20 interviewees, only one received primary sex education and was not satisfied with the quality of education. The current study results could be beneficial for health policymakers in the country to provide practical solutions for education, promotion, and improvement of sexual health in the society.
It is suggested that in future studies, the experiences of pregnant or postmenopausal women, due to special contextual considerations of this period on sexual life, psychosocial factors affecting sexual disorders, and sexual health of men be explored.

Compliance with ethical guidelines
All ethical principles are considered in this article. The participants were informed about the purpose of the research and its implementation stages. They were also assured about the confidentiality of their information and were free to leave the study whenever they wished, and if desired, the research results would be available to them. Any opinions, findings, and conclusions expressed in this publication are those of the author and necessarily reflect the current views and policies.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.