The study presented a novel and significant findings. The study showed that implementing the psychosexual GES-based Counseling on Reproductive and Sexual Concerns of Female Breast Cancer Survivors has resulted in significant reduction in means score of stress, anxiety and depression using the DASS-21, reproductive concern was using the RCAC, and improvement of female sexual function using the FSFI-BC. Assessment of intervention was done twice; two and three months after intervention.
The two groups were homogeneous in terms of disease features, personal characteristics, and socioeconomic status (P ˃ 0.05), which can affect sexual outcomes of breast cancer survivors. Accordingly, duration of disease, type of surgery, and type of adjuvant therapy have been found to affect psychological outcomes and reproductive and sexual concerns of female breast cancer survivors (27, 28).
Cancer is a life threatening disease and breast cancer is the most common, deadly, and emotionally challenging disease in women (29). The results showed that the psychosocial approach of GES-based, couple-centered group counseling significantly reduces depression, anxiety and stress levels in female breast cancer survivors.
The result of a systematic meta-analysis (2018) showed that continuous supportive-cognitive therapy is the most effective psychological intervention in improving anxiety, depression, quality of life, and sexual function of female breast cancer survivors who have undergone mastectomy (30). The GES model emphasizes that physiological, psychological, and interpersonal relaxation is the basis of proper sexual functioning and high marital satisfaction. Physiological and psychological relaxation is lost when one tries too much to be perfect; this in turn causes functional stress and anxiety and results in a vicious cycle. Therefore, the development of cognitive, emotional, and behavioral skills is a prerequisite to sexual therapy (31). This is consistent with the results of the present study, as well as with the findings of Shandiz et al. (32). In the present study, we may attribute the participants’ good psychological outcomes to improvements in their sexual indicators.
Khatibian et al. (2014) found that psychosocial interventions are helpful to cancer patients, because these interventions help patients cope with their negative automatic thoughts and replace them with positive thoughts; thus, they can reduce negative psychological outcomes in cancer survivors (33). This is consistent with the present results.
In line with the present findings, Nabipour et al. (2019) concluded that mindfulness-based cognitive therapy reduces depression, stress, and anxiety levels in female breast cancer survivors (34). Considering the effect of psychosocial approach of GES-based group therapy on psychological status of breast cancer survivors, as well as the interaction between mental health of these people and quality of their sexual lives, sex therapy programs must focus on psychological status of these individuals.
The GES-based counseling also significantly reduced productivity concerns of the participants. Breast cancer is a dreadful malignancy that affects the reproductive ability of women through cytotoxic effects of radiotherapy and chemotherapy treatments (35).
In a multifaceted prospective cohort study entitled “Cancer and Fertility”, Vu et al. (2017) investigated the effect of training and counseling intervention on breast cancer survivors in the United States (36). The researchers provided women with face-to-face, telephone, and online training through group discussions and Q&A sessions in cooperation with an oncologist and a fertility specialist. Vu et al. found that counseling and training programs provided along with routine cancer treatments encourage women with breast cancer to talk about their fertility concerns. These sessions also significantly increase the number of visits and telephone calls after face-to-face meetings, as well as the number of requests for assisted reproductive treatment, and reduce fertility concerns of these women (37). Accordingly, the present results confirmed the positive effect of counseling and training fertility sessions on breast cancer survivors. Kufel-Grabowska et al. (2020) investigated the effect of cancer and fertility counseling strategies on young women (under 45 years of age) with breast cancer. They concluded that the most appropriate time to provide fertility counseling is after diagnosis and before starting the treatment process. They also highlighted the need to reduce reproductive concerns of these women at any stage of life even after full recovery (38). This is consistent with the results of the present study, as well as with the findings of Macklon et al. (2019) (39).
In the review study of Deshpande et al. (2015), receiving fertility preservation counseling and obtaining information about the benefits and harms of assisted reproductive treatment was associated with improvements in the quality of life and psychological outcomes of female breast cancer survivors. They also argued that these women demand accurate, attainable, and standardized information to meet their reproductive and sexual health needs (40). These findings are in line with the results of aforementioned studies (41, 42).
The findings also showed that the GES-based group counseling significantly improves sexual function of female breast cancer survivors. The GES-based group counseling was designed creatively as a set of principles and rules in the form of a sexual cognitive-behavioral therapy to reflect the meaning and value of sex, accentuate sexual intimacy and psychological relaxation, and promote sexual function of the participants at the end of the intervention, as well as 2, and 3 months after the intervention. This is in line with the results of Fatehi et al. (2019) (43).
Hamel et al. (2019) investigated the effect of sexual counseling (with cognitive-behavioral therapy approach) on participants’ quality of sexual life, and observed that counseling can be adopted as a dynamic problem-solving process to improve the quality of sexual life (44). This is also consistent with the present results.
In another study conducted by Lampic et al. (2011) in Sweden, the researchers found that Fex-Can intervention (a web-based self-help training program) significantly improves sexual satisfaction and function of participants. Based on their findings, psychological interventions provide a wide range of psychosocial support to reduce feelings of sexual and reproductive inability, fear of the unknown and psychological distress. Lampic et al. predicted significant improvement in sexual function and satisfaction of young women with breast cancer (45). These findings are consistent with the present results, as well as with the findings of Farah et al. (2014) (46), León-Pizarro (47), Reese et al. (48), and Fatehi et al. (43) who investigated the effectiveness of “group training on sexual skills”, “group counseling on sexual function and sexual quality of life in breast cancer survivors”, “in-person training and telephone interviews on management of sexual concerns”, and “psycho-sexual counseling on quality of life and sexual function”, respectively. In line with the present results, some studies have highlighted the role of distance counseling and training (e.g. telephone interviews (49), Internet-based interventions (44)) on sexual function and sexual quality of life of female breast cancer survivors who have undergone mastectomy.
Despite its limitations, this is the first study conducted in Iran to determine effectiveness of psychosexual GES based counseling on reproductive and sexual concern. Due to cultural contexts, Iranians feel embarrassed to talk about sexual issues; therefore, the researcher provided a private environment and established an intimate relationship with the participants to encourage them to participate in the study.