The relationship of sexual health and marital satisfaction with spiritual health among women seeking mental health services

Zahra khorrami ¹, Nadereh Memaryan ², Mitra Borji ^3*, Elahe Farshadnia⁴, Shahrbanoo Ghahari ⁵

¹Faculty of Mental Health & Behavioral Sciences Branch, Iran University of Medical Sciences, Tehran, Iran

² Spiritual Health Research Center, Mental Health Department, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran

³Mental Health Department, School of Behavioral Sciences and Mental Health (Tehran Institute of Psychiatry), Iran University of Medical Sciences, Tehran, Iran

⁴Mental Health at School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran

⁵Department of Mental Health, School of Behavioral Sciences and Mental Health (Tehran institute of psychiatry), Iran University of Medical Sciences (IUMS),Tehran, Iran

^*Corresponding Author: Mitra Borji

* Email: Mitra.borji@yahoo.com

Abstract

Introduction: Marital satisfaction is a multidimensional concept including various aspects. Sexual satisfaction is not only a factor affecting marital satisfaction but also a common cause of sexual dysfunction, disagreements, and communicational problems of couples. There is a relationship between these two interconnected variables and other variables, such as spirituality that is the most substantial one. This study was conducted to examine the relationship between sexual health and marital satisfaction with spiritual health.

Materials and Methods: Statistical population of this descriptive-correlational study included women who seek mental health services provided in the psychology and psychiatry clinic of the Faculty of Behavioral and Health Sciences. Of these women, 183 subjects were chosen using a convenient sampling method. The data obtained from Spiritual Health Questionnaire, Sexual Health Questionnaire, and Enrich Couple Scale (ECS) were analyzed using mean, standard deviation, and Pearson correlation coefficient through SPSS19 software.

Results: There was a positive and significant correlation between spiritual health and marital satisfaction (P-value=0.001, r=0.31) while there was not any significant association between spiritual health and sexual health.

Conclusion: Mental health issues can affect the relationships between many variables, including spiritual health, marital satisfaction, and sexual health. As an ambiguous relationship, the correlation between spiritual health and sexual health should be addressed.

Keywords: Mental Health, Sexual Health, Marital Satisfaction

Introduction

Family is an integrated and efficient unit as a factor affecting the growth, behavior, and wellbeing of a person; hence, many social sciences study the significant role of the family in this case (1). The stability of family structure depends on the quality of the relationship between couples. Dysfunctional marital relationships or unsuccessful marriages not only threaten mental health but also endangers the survival of the family (2).

As a popular concept, marital satisfaction is used to evaluate the happiness and stability level of marriage. Hawkins defines marital satisfaction as feelings of happiness, satisfaction, and pleasure experienced by spouses when considering all aspects of their marriage (3). Marital satisfaction is a multidimensional concept, which consists of different aspects of marital relationships such as adaptation, happiness, integration, and commitment (2). Various factors affect marital satisfaction (3, 4). Sexual performance of couples and satisfaction with sexual relationships are factors affecting marital satisfaction (5).

According to WHO definition, sexual health is a state of mental, emotional, and social well-being, and not merely the absence of dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence (6). Disagreements and communicational problems are reasons causing sexual dysfunction among couples. Sexual problems lead to other marital issues in relationships between couples. Marital satisfaction is associated with more sexual pleasure and satisfaction, which in turn leads to higher marital satisfaction (7). These two interconnected variables are influenced by many other variables, such as spirituality and spiritual health that are the most important ones (8, 9).

Spiritual health is defined as a state of being where an individual can deal with day-to-day life in a manner that leads to the realization of one's full potential, meaning and purpose of life, and excellence (10). An individual with higher spirituality has a higher quality of life and a more optimistic attitude towards life (11, 12). Religion and spirituality are overlapped. Religiosity includes behavioral manifestations of spirituality which are along with different actions associated with a specific religious group (13). Since religion is strongly linked to a wide range of relevant values and norms (14), some studied have shown that religious couples are more satisfied with their marriages compared to non-religious couples (15), while others have not experienced such relationships (16). Although many studies have proved the positive relationship between spiritual health and marital satisfaction (17, 18), many of these studies have been conducted on those who have mental health. Accordingly, mental health level affects all three variables studied in this paper (19-21). Hence, this study aimed at examining the relationship between spiritual health and marital satisfaction among applicants for mental health services.

According to Nelson (1990), if one believes in sexual desires as a symbol of relationship and intimacy then the close association between sexuality and spirituality will be revealed. The secret behind sexual desires is the human need for the spiritual and physical embrace of others (22). In this lieu, results of several studies have shown the positive relationship between religion and sexual satisfaction (9, 23, and 24). However, a relevant paper found a negative association between frequency of sexual relationship and spirituality or religiosity (25). Despite the presence of a close connection between religion and spirituality, these are two separate concepts so that that spirituality can be inside or outside of a religious framework (26). The positive relationship between religion and sexual satisfaction implies the positive association between spiritual health and sexual health, which may be stronger since spirituality is more personal, not a social concept rather than religion (26). Due to the research gap of this relationship, this study was conducted to investigate the relationship between spiritual health and sexual health.

Materials and Methods

This was a cross-sectional study with descriptive-correlational research type that was carried out after the ethics code of IR.IUMS.REC1396.30715 received from Iran University of Medical Sciences and Health Services. The statistical population comprised of all female applicants for health services who had referred to specialty and subspecialty clinics of psychology and psychiatry associated with faculty of behavioral science and mental health, 2017. Of them, 226 subjects were chosen using the convenient sampling method of which 43 subjects were excluded regarding the exclusion criteria, including being single, having acute psychiatric symptoms such as illusion and delusion in the current situation. Finally, the information of 183 subjects was analyzed. After the selected subjects announced their informed consent, therapists asked them to fill out the following questionnaires:

Spiritual Health Questionnaire: this 48-item questionnaire was designed by Amiri et al. (2014) to assess spiritual health within three conceptual structures of insight, tendency, and behavior. These structures measure three sub-scales of relationship with self, god, and surroundings. Each item is scored on the Likert Scale from 1 (strongly agree) to 5 (strongly disagree). In the next step, scores are converted to 0-100 format (1-100, 2-75, 3-50, 4-25, 5-0) that the higher scores indicate a higher level of spiritual health. Internal consistency (Cronbach's alpha= 0.98) and retest reliability of this questionnaire obtained at an optimal level. Moreover, the content validity of this questionnaire was confirmed by experts (27).

Sexual Health Questionnaire: this questionnaire was developed by Rouhani et al. (28) to examine sexual health. This tool includes 33 items scored on a 3-point Likert scale, including I agree, I do not know, I disagree. This questionnaire explains more than 92% of sexual health variance with a reliability coefficient of 0.82. Exploratory and Confirmatory Factor Analyses indicated suitable and adequate validity and reliability indicators to measure sexual health.

ENRICH Couple Scales (ECS): this scale was designed by Olson in 1985 and was updated in 2010 (29). This questionnaire includes 35 items and four subscales. Alpha coefficients of marital satisfaction, communication, conflict resolution, and ideal distortion subscales equaled 0.86, 0.80, 0.84, and 0.83, respectively; retest reliability of these subscales equaled 0.86, 0.81, 0.90, and 0.92, respectively. Daneshpour et al. (2011) translated this scale into Persian and measured alpha coefficients of marital satisfaction (0.78), communication (0.78), conflict resolution (0.62), and ideal distortion (0.78) (30).

The collected data were analyzed through descriptive analysis of data, including mean and standard deviation, as well as inferential analysis including Pearson correlation coefficient through SPSS19 software. After the normality of data was examined, the Kolmogorov-Smirnov test was used for inferential analysis.

Results

Table 1 reports descriptive indicators of variables. According to Table 1, subjects were in the age range of 23-69 with an age average of 38.8. Mean (SD) of marital satisfaction, mental health, and sexual health equaled 94.03(12.84), 81.83(21.36), and 53.54 (7.90), respectively.

Table 2 reports correlation coefficients between spiritual health, marital satisfaction, and sexual health.

Discussion

The positive side of this study is the investigation of spiritual wellness and sexual health by using a native questionnaire although there was not any significant relationship between these two variables in this paper. This finding has been discussed herein.

According to the results of the extant study, there was a positive relationship between spiritual health and marital satisfaction, which means that an increase in spiritual health leads to enhancement of marital satisfaction and vice versa. This finding was consistent with results obtained from studies conducted by Salehi et al. (2017), Tajvidi et al. (2017), and Mousavi et al. (2015) who found a positive significant relationship between spiritual health and marital satisfaction among students, married women who had referred to health centers, and nurses (8, 17, 31).

Zarei and Ahmadi (2016) found a positive and significant relationship between spiritual intelligence, which can be a subset of spiritual health, and marital satisfaction (32). Zaheri et al. (2016) conducted a systematic study and found positive effect of religious, spiritual, sexual, interpersonal, and mental health factors on marital satisfaction (33); such relationship not only seen in Iranian culture that is affected by the religious viewpoint but also can be observed in other communities (34). Farshadnia et al. concluded that married women and men have higher spiritual health (35), which provides a consistent association between internal forces. Spiritual health is associated with some characteristics, including life stability, calmness, and a sense of close relationship with God and the environment. In general, it can be stated that mental health affects the health and stability in life, in particular marital life (17). Mental health affects marital satisfaction through various mechanisms. For example, Hosseini and colleagues (2019) indicated that spirituality could strengthen the morale of social acceptance and cohesion by increasing social participation and prosperity. Moreover, spirituality provided individuals with intra-group social supports and interactions by making an empathic attitude. Accordingly, spirituality leads to higher social wellbeing with a positive and direct effect on marital intimacy (36). Another study indicated that religious attitude could predict marital satisfaction through resilience (37).

In the abovementioned studies (8, 17, 31), the correlation between spiritual health and marital satisfaction was higher than 0.60, which was greater than the equivalent correlation obtained in the present study (r=0.31). As the surveyed sample of this study comprised female applicants for mental health services and there was a significant relationship between spiritual and mental health (19), as well as between mental health and marital satisfaction (21), the relationship between spiritual health and marital satisfaction is affected by mental health. Spiritual health influences the behavior of individuals when dealing with life-related issues, and can contribute to the improvement and promotion of psychological wellbeing (38).

According to the results of the present study, there was not any significant relationship between spiritual wellness and sexual health. Several studies have found the positive impact of religion on satisfaction with sexual life (9, 24), while some other studies have found a negative relationship between religion and sexual health (39). Such opposite results may stem from the different relationship between religion and sexual satisfaction in various groups; on the other hand, they might be associated with the use of different tools for evaluation of the multidimensional concept of religion (9). It worth noting that assessment of spiritual health was done based on the questionnaire designed by Amiri et al. who assume spirituality and religion as interconnected concepts regarding religious beliefs in Iranian society. Different religions from a specific attitude toward a sexual relationship in minds of individuals (40). Although religion and spirituality are overlapped, they are distinct concepts, which may leave different effects. Since spiritual and religious beliefs are crucial issues in the life of Iranian people, it is possible to expand the positive attitude of people towards life through spirituality (41). Rahmati and Mohebbi (2018) studied the relationship between spiritual intelligence and sexual satisfaction and found a significant association between them. They defined spiritual intelligence as a facilitator to solve daily problems and to achieve goals (42). Accordingly, problem-solving is a substantial factor associating with mental health (43). The extant paper studied the relationship between the spiritual and sexual health of applicants for mental health services. Mental health plays a mediating role in the relationship between these two variables and justifies the lack of correlation between them.

Conclusion

Sexual health and marital satisfaction contribute to the stability of the family and the health of the community. To this end, variables affecting sexual health and marital satisfaction should be addressed and required measures should be taken to improve positive effective variables. On the other hand, it is difficult to achieve this goal since it is related to mental health issues, which influence the relationship between other psychological factors. As mentioned in this study, spiritual health affected the marital satisfaction of applicants for mental health services, while spiritual health could not explain the sexual health of the studied group. Due to the research gap in the relationship between spirituality and sexual health, it is recommended to examine this relationship by consideration of other effective factors, such as mental health. The most important constraint of this study was the limited number of the studied population and the convenient sampling method that selected only married women referring to specialized and subspecialized psychology and psychiatry clinic of faculty of behavioral sciences and mental health. Hence, caution should be taken when generalizing the results of this study.

Author contribution

ZKh, NM, EF and ShGh wrote and compiled this article. MB wrote and edited the manuscript comprehensively. All authors confirmed the final version of the paper.

Acknowledgments

This paper was adopted from the research project of the student research committee approved and funded by the Iran University of Medical Sciences under the ethics code of IR.IUMS.REC1396.30715. We appreciate the Research Deputy of Iran University of Medical Sciences and Executive Board of specialized and subspecialized psychology and psychiatry clinic of faculty of behavioral sciences and mental health (Tehran Psychiatric Institute), clients, and all individuals who participated in this research.

Conflict of interest

The authors declare that they have no conflicts of interest.

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		R	P-values
Spiritual health	Marital satisfaction	0.31*	0.001
	Sexual health	0.11	0.22

	Age	Marital satisfaction	Spiritual health	Sexual health
Mean	38.88	94.03	81.83	53.54
SD	8.56	12.84	21.36	7.9
Min	23	53	48	33
Max	69	149	141	70