The Effect of Group Sexual Assertiveness Training on Sexual Assertiveness of Female Students: A QuasiExperimental Study View PDF

Society regards marriage as an important event and sexual relation is an inseparable part of romantic relationships [1,2]. A healthy sexual relationship requires a positive and respectful view on sex, and sexual relation equally requires safe and enjoyable sexual experience away from force, discrimination, and violence in the marital relationship. Sexual relation is a vital part of life and plays a significant role in the general health of people [3-5]. It has been shown that appropriate sexual function and sexual satisfaction lead to increased intimacy of couples and protect them against many diseases and mental/physical disorders. For example, there is a relationship between sexual satisfaction and reduced heart attack in men, and reduced incidence of migraine, signs of premenstrual syndrome and chronic arthritis in women [6]. In contrast, those who have problematic sexual relations, usually have low self-confidence, anxiety and depression [7]. Most people who work in the field of sexual disorder therapy have found that sexual assertiveness as an intervening variable plays an important role in assessing sexual problems and identifying the nature of such problems as well as sexual growth and development [8]. According to studies, one of the most important factors affecting sexual satisfaction and function as well as marital satisfaction is sexual assertiveness or the ability to express sexual existence [9]. The assertiveness or ability to express existence is a behavior that empowers people to hold their beliefs without any fear and anxiety, express their true feelings, and take their rights while considering the rights of others [10,11]. Sexual assertiveness is the ability to recognize prioritization and express limitations, needs, and sexual orientation in a sexual situation [12]. Sexuality assertiveness is a social skill that involves displaying assertive behaviors in sexual situations. The structure of sexual assertiveness includes three parts; the ability to start desired sexual relation, refuse unwanted sexual contact, and discuss the use of contraceptive methods to prevent unwanted pregnancies [13]. Sexual assertiveness can be a positive and unique predictor of women’s marital satisfaction, especially in cultures that do not encourage sexual assertiveness [14]. Sexual assertiveness is one's perception of sexual behaviors and is associated with the better sexual function, reduced experience of sexual abuse, and reduced high-risk sexual behaviors. Therefore, sexual assertiveness facilitates the achievement of sexual goals such as sexual autonomy and sexual satisfaction and protects individuals from insecure sexual activities [12]. Theorists argue that sexual assertiveness is a vital human need and has many advantages such as; increasing sense of vitality and strength, and improving sexual and cognitive function [16]. Furthermore, it has been shown that women with a higher sexual assertiveness have a higher score in the frequency of sex, the number of orgasms, sexual desire, sexual satisfaction and marital satisfaction [17]. and fall victim sexually far less [18]. Women are afraid of harming their husbands’ emotions and damaging their marital relationship, so they usually do not stop the sexual behavior that has been started by their husbands. Women are more likely to become involved in unwanted sexual relations than men since they take more responsibility for maintaining the relationship and try to provide whatever their husbands want [12]. In addition, women's sexual assertiveness is in contradiction with the traditional views on gender [19,20]. When sexual norms are mixed with cultural norms, they become more intense. In Asia, sexual norms are stricter than other parts of the world [14]. Iranian women fallow cultural/sexual norms too [21]. One of the problems that gender, and cultural norms create for women is that the religious, cultural, traditional, and regional expectations make it difficult for women to refuse unwanted sexual behaviors [22]. Past studies have examined the relationship between sexual assertiveness and fear of lacking sexual power and emotional-cognitive problems [16], sexual desire, stimulation, attitude [18], attachment style [23], falling victim to sexual assault [24] and dignity of women’s body [25]. However, very few interventional studies have been conducted in this field. Although in many cultural and ethnic groups such as Iran, sexual issues are of great importance and Iranian women are changing their strategy of silent sexto begin to learn about sexual issues and start claiming their sexual rights [23], but they do not have access to right and timely information. On the other hand, most couples do not go to counseling centers to resolve their sexual problems. Meanwhile, women refuse to even talk about such problems with others as they have accepted gender stereotypes and expectations. The prolonged sexual passivity of women in marital relationships, even in educated individuals, leads to sexual problems and ultimately reduced the quality of life. On the other hand, students are at the stage, where they shape their romantic marital relationship; therefore, it is necessary to examine the effectiveness of psychological interventions on their sexual assertiveness. Thus, the present study was conducted to determine the impact of group sexual assertiveness training on the sexual assertiveness of married female students.

Design and participants

This quasi-experimental pre and posttest studywas conducted on 80 married female students of Sistan and Baluchestan University (southeast of Iran), from 1 July 2018 to 30 March 2019. Sample size was calculated based on a previous study [26]. The sample was divided into two groups of intervention (N=40) and control (N=40) using simple random allocation. Living as a couple for at least one year, being 18 to 40 years old, not having previous education in psychology or counseling, having no history of psychiatric disorders, not using medications that affect sexual function, not having physical illness or surgery affecting sexual function, having no significant marital conflict, such as threats of divorce or separation, and not being pregnant were the criteria for entering the study. Not taking part in more than one training session and not willing to continue with the study were the exclusion criteria. Initially, with the help of University's Counseling Center, the announcement of the assertiveness workshop for married female students was displayed on the announcement board and then, a list of eligible students who were interested in taking part in the workshop was prepared and randomly divided into two groups of intervention and control. No students were excluded from participation in the study.

Data collection

At first, general information about the research was given to the students. Written informed consent was obtained from the participants and their spouses. The data gathering tool in this study was a questionnaire with two parts. The first part was dedicated to the personal information such as the age of the sample and their spouses, occupation of samples and their spouses, the education of samples and their spouses, duration of the marriage, and the family relation with their spouses. The second part contained the Hurlbert Index of Sexual Desire (HISD). This questionnaire was developed by Hurlbert in 1991. Internal consistency reliability was 0.86 and test retest reliability after 4-wk was 0.85. Hurlbert also a correlation of 0.82 found with the Gambrill-Richey Assertion Inventory [27,28] and has been used in many international studies. It contains 25 questions and is based on a 5-option Likert scale (always=score 0, most=score 1, sometimes=score 2, rarely=score 3, never=score 4). Questions 3, 4, 5, 7, 12, 15, 16, 17, 18, 21, 22, and 23 are scored reversely. The score ranges from 0 to 100, with a higher score indicating a high degree of sexual assertiveness and a lower score expressing lower level of sexual assertiveness. This tool has been evaluated by Yousefiet al in Iran. The validity of the questionnaire has been confirmed through convergent validity with the sexual self-reporting questionnaire, the Arizona sexual experiences questionnaire, the Spector's sexual inventory and the confirmatory factor analysis. The reliability of the questionnaire was calculated by Cronbach's alpha (0.92) and doubling reliability coefficient (0.78) [29]. In the present study, the reliability of this questionnaire was 0.78 for the whole questionnaire using internal consistency (Cronbach's alpha). To prevent the exchange of training material between the intervention and control groups, the pre-test data, and after 12 weeks, the post-test data were collected from the samples in control group and they were placed on the waiting list to receive the training. The data were collected in the intervention group after the end of the semester and the women in the intervention group were divided into 8 groups of 5. At first, pre-test was carried out in the samples of intervention group in the form of completing HISD and personal information questionnaire. The sessions of assertiveness workshop with emphasis on sexual assertiveness were presented as 4 two-hourly sessions for two weeks, based on the content and structure provided by the University's Counseling Center (Table 1).

Table 1: Demographic characteristics of intervention (N=40) and control group (N=40).

Workshop sessions were conducted by a postgraduate midwifery counseling expert under the supervision of an expert with a PhD in family counseling. The content of workshops was provided as CDs and booklets for the use of both couples and in case of not attending one of the sessions, it was given to them. The participants were invited to the university’s counseling center 12 weeks after the intervention and were asked to once again complete the sexual assertiveness questionnaire. The intervention in this study was based on the behavioral assertiveness in general and sexual assertiveness, which was designed according to the review of similar studies and survey of psychologists, family counselors and experienced psychiatrists in the treatment of sexual dysfunction. The training was carried out in the form of lecture, slideshows, group discussions, and role play (Figure 1).

Statistical analysis

The data were analyzed by SPSS software version 20. First, the minimum and maximum frequency, percentage, mean, and standard deviation were determined using descriptive statistics. To compare the mean scores before and after the intervention in each group, the paired t-test was used. To compare the mean score of the two groups, independent t-test was used, and the chi-square test was used to compare the frequency of qualitative variables in the two groups. Also, to determine the effectiveness of group sexual assertiveness training with the effect control of pre-test, analysis of covariance was used. The significance level of 0.05 was considered in this study.

Ethical considerations

The present study was approved by the Ethics Committee of Zahedan University of Medical Sciences and was registered with the number: REC.1395.244 IR.ZAUMS. Information about the implementation of the study, the duration of the study and the type of intervention were given to the participants in full. Written informed consent was obtained from the women and their spouses. All individuals were ensured about the confidentiality of their information and they were told that their participation in the study in voluntarily and they can withdraw from the study at any stage. Also, coordination was made in the event of any family conflict caused by the participation of women in the study, so that the couples can go to the university’s counseling center to receive counseling services free of charge.

The results of the Shapiro-Wilk test on the scores of sexual assertiveness training showed that, the data had normal distribution. Therefore, the use of parametric tests in this study was possible.The characteristics of research units in terms of demographic characteristics and the intervention and control groups are presented in Table 2. The mean of participants age was 22.47±3.10, 22.30±2.81, the mean age of participants husbands was 26.67±3.69, 26.58±3.37 and the mean of marriage duration was 3.55±2.23, 3.00±2.21 years in intervention and control group respectively. The results of independent t-test showed that, the two groups of intervention and control in terms of the age of samples and their spouses, the occupation of samples and their spouses, the education of samples and their spouses, and the duration of marriage and family relation with their spouses were similar and their difference was statistically significant (P =0.01), (Table 1).

The findings of the present study showed that the mean score of sexual assertiveness changed from 45.85±14.43 to 65.90±15.44 in the intervention group and from 46.32±15.12 to 47.82±13.85 in the control group. The results of t-test showed that, the score of sexual assertiveness significantly increased in the intervention group (P =0.01).

Also, the mean score of sexual assertiveness in post-test was significantly higher in the intervention group than in the control group (P<0.0001), and the mean overall score of sexual assertiveness in the intervention group (20.35±14.33), was significantly higher in comparison with the control group ((P=0.01), 1.11±14.66), (Table 2). With the control of confounding the effect of pre-test, analysis of covariance showed that in the post-test, the mean score of sexual assertiveness of women in the intervention group was significantly higher than the control group (F=104.36, (P=0.01)). Considering the impact size of the test, 58% difference was caused by the group-sexual assertiveness training (Table 3).

Table 2: Sexual assertiveness score in the intervention and control group before and after the group sexual assertiveness training.

Table 3: Results of analysis of covariance on the score of sexual assertiveness in the intervention and control group after the group sexual assertiveness training with control of pre-test effect.

Where: Adjusted R² = 0.85.

This quasi-experimental study was conducted to determine the effect of group sexual assertiveness training on sexual assertiveness of 80 female married students in the south-east of Iran. It was statistically determined that, there was a significant difference between the mean score of sexual assertiveness before and after the group sexual training and the content of assertiveness, meaning that sexual assertiveness of female married student improved with the training.

A study conducted on women in two major cities in Iran revealed that most of the participants were inactive in sexual relations and considered any request for sex to be initiated by men. In Iran, the patriarchal system has caused the superiority of men and authority of them in all cases of decision-making in the families. Therefore, men are often the initiators, managers, and terminator of all sexual relations, and pay little attention to the conditions, needs, rights, and satisfaction of women [22]. In Iran, despite the very effective primary health care system, the subject of sexual education is not fully considered and there are gaps in this regard [9]. These gaps have been mentioned in the quantitative and qualitative studies conducted on women's health. In Iran, studies that have been conducted on women's health have focused on the role of fertility and reproductively of women, and very few studies have been carried out on the sexual health in which, sexual education is one of its components [30]. It seems that, in cultures that women are sexually disregarded and less attention is paid to women's sexual issues than men’s [31], and only in some cases women are allowed to talk about their issues and problems [32], and also in cultures in which, talking about sexual issues, especially women’s sexual issues is a taboo and even married women and men are reluctant to talk about it, sexual education with any content may be able to increase marital satisfaction by increasing women's sexual knowledge. That is why, most studies on sexual education with any approach have been found to be significantly effective [33,34]. According to the present study the group sexual assertiveness training has increased the sexual assertiveness of married women. A study in Iran (2010) entitled: Feminist group sex therapy, was conducted on 20-35 years old educated women and the result showed that sexual education improved sexual assertiveness of women [35].A study on African American female 18-24 showed that assertiveness communication skills training was boosted assertive behaviors with their partners [36]. Another study(2018) was conducted to examine the effectiveness of sexuality enriching counseling on sexual assertiveness of 60 married women aged 18 to 45 years in Iran, and the result showed that educational and counseling courses on sexual issues in Iranian culture were effective in increasing the ability of married women to express their sexual opinions, which are consistent with the results of present study [20]. Studies have shown that sexual assertiveness reduces unwanted pregnancy and sexually transmitted diseases and increases marital satisfaction [37,38]. It has also been determined that there is a significant correlation between the degree of assertiveness, sexual self-consciousness and, sexual function, and sexual assertiveness has a positive relationship with the sexual function indexes, such as desire, arousal, satisfaction, and orgasm [39,40]. Therefore, it is necessary to take measures to promote the sexual assertiveness of women.

Due to the ethical limitations of Iranian society, in this study, education was only provided for women in a group sexual training workshop, which could be considered as a limitation. Therefore, it is suggested that future studies should investigate the sexual assertiveness training in couples. Not examining the long-term effects of the results was another limitation in this study.

Considering the positive impact of group sexual assertiveness training on educated women, further research on this subject is recommended. Taking into account the impact of healthy sexual relation and excitement on marital relationship, mental health, and the formation of healthy family, the necessity of sexual assertiveness education is more evident, especially in cultures where women have a lower sexual assertiveness than men, and male-dominated stereotypes are more prevalent (like many countries in the Asian region, including Iran). It is recommended to have these training integrated into the pre-marriage education programs already available in these countries.

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