Mediators of Sexual Distress in Women with Dyspareunia: A Population-based Cross-sectional Study

Background: Dyspareunia (recently been named as GPPPD), is considered as one of the negative factors affecting couple’s sexual health. The present paper explores the characteristics of pain in dyspareunia cases and also determine protective factors cause fewer sexual distress among sufferers. Methods: A population-based cross-sectional study conducted in 2017, on 590 married women aging 18 -70 years, in 30 health center via cluster-quota sampling method. Demographic data, sexual distress and Binik’s GPPPD Questionnaire were utilized as study tools. Results: Although 33% of the women report dyspareunia, based on standard criteria the prevalence of severe and moderate dyspareunia were dropped to 10.5% and 25.8%, respectively that among them the most common location, time and type of pain were in vaginal entrance, at the beginning of intercourse and with burning nature, respectively. Dyspareunia had a signicant negative impact not only on women’s ability to have intercourse (P=.004) but also on their sexual desire (P=.038). Interestingly, 5.4% of the women did not report any distress despite having severe dyspareunia. In comparison with those patients with distress, the latter group had higher sexual satisfaction, more positive body image and self-condence, as well as more intimacy in relationship (P=.000). Notably, 19% of the participants experienced signicant sexual distress, although in 8.5% of them dyspareunia was not conrmed. Conclusion: Promote positive and image and factors like can be effective in the dyspareunia via decrease of and fewer These ndings can be applicable in the patients and clinicians to cope with the pain problem. In addition, attention to women’s concerns about is crucial. In our sample, 19% of participants reported signicant sexual distress, 10.5% of women with conrmed dyspareunia and 8.5% of unconrmed dyspareunia cases. It shows that the sexual can be and obtaining comprehensive is necessary nding the behind and


Introduction
In DSM-5, the formerly separate dyspareunia and vaginismus merged and called genito-pelvic pain/penetration disorder (GPPPD) (1). Because the majority of the existing studies have used the term "sexual pain" or "dyspareunia" instead of GPPPD, in the present study also, these terms has been used interchangeably.
Sexual pain is a common problem that has signi cant effects on the couple relationships. According to a study conducted on women of 40 to 80 years of age from 29 countries, the distribution of sexual pain in middle-eastern women was reported as 21% (2). Other studies report that 12% of premenopausal women suffer from sexual pain (3). Although cultural and religious factors can effect on dyspareunia experience and also sexual distress, few standard studies conducted in the sexual pain prevalence and associated factors in the Middle east and Muslim Countries (4). In the systematic review carried out in Iran in 2017, due to many methodological problems in existing studies such as lack of standard questionnaires, inappropriate sample size, and lack of population-based survey; a wide range of dyspareunia (between 9% and 95.9%) has been reported. The authors stated that more precise surveys are needed to estimating of dyspareunia prevalence and its characteristics (5).
In addition to diagnostic criteria and a minimum duration of 6 months, the presence of marked sexual distress are crucial for diagnosis GPPPD (1). Sexual distress means all negative emotions, such as worry, frustration, or feelings of inadequacy, that people experience in their sexual relationship that effect negatively on overall well-being and quality of life (6). It should be mentioned that some sexual dysfunctions are not distressing for women and it is crucial to understand why and when sexual problems are distressing. In other words, is there any factors that moderate the relationship between sexual functioning and sexual distress? (7).
With regard to need of survey based on the new concept of GPPPD and importance of standard study in society with different culture from western countries, our research team designed a population-based study in 2017-2018. The results related to the prevalence of GPPPD, risk factors and protective factors of GPPPD explicitly discussed in other article (8). In the present paper, we explained about the characteristics of sexual pain such as the pain location, time and nature of pain. In addition, we tried to determine the factors that may effects on sexual distress of women with dyspareunia. In other word, we want to understand which contextual factors mediate between sexual distress and dyspareunia. These characteristics assist the therapists to make more effective interventions for controlling patients' pain.

Methods
The present research was a population-based, cross-sectional study which conducted after obtaining the necessary scienti c and Ethic permissions from Tehran University of Medical Sciences; IR.TUMS.FNM.REC.1396.2087. dated: 2017.04.17.

Sampling
A two-stage cluster sampling was conducted. To achievement maximum heterogeneity, 30 main health centers were included in the study. Then married women were randomly selected from the existence list in each center. The sample in each center was determined with consideration of the probability of selection in proportion to population size (or estimated population size). As a complete listing of all inhabitant women was available, a systematic sampling was employed. For random selecting of participants, random starting point and xed sampling interval (by dividing the population size by the desired sample size) was used. Then the individuals were contacted and invited to the study. The sampling process conducted on the study area of 65 km 2, by 4 trained midwives and during 20 weeks Participants 615 women randomly selected from a list of 344,243 families who lived in 2017 in these region. 590 person completed our questionnaire and entered in the analysis. The study population was apprised of the nature of the survey and their verbal and written informed was obtained. The participants completed the questionnaires at the health centers, and each participant was attended by a trained researcher. The inclusion criteria were: married, aged 18-70 years, cohabiting with spouse for at least one year and the exclusion criterion was a report of drug abuse on the demographic questionnaire Research tools One demographic checklist (11 self-reported questions); self-reporting of pain or fear during intercourse (one question); presence of sexual distress by 2 questions of Female Sexual Distress Scale-Revised (FSDS-R) (9) and Binik questionnaire (10) for assessment of GPPPD (19 questions include 8 diagnostics and 11 complementary questions) served as the research tools. The nal diagnosis of GPPPD con rmed only when 8 diagnostic questions in Binik scale and 2 questions of sexual distress showed signi cant pain and distress. In addition, those who reported pain or fear in single self-report question were asked to answer the 11 complementary questions to assess the characteristics of pain. participants and with more than 80% agreement between participants, all questions remained without changes. It was the same for the content validity of GPPPD that was con rmed by eight faculty members of Tehran University of Medical scineces. To con rm the reliability of the questionnaire, the questionnaire was administered in two iterations with an interval of 2 weeks to 35 women quali ed for participation in the study, which yielded a Cronbach's alpha of 0.90 and an internal consistency of 80%.

Statistical methods
A review of the previous studies on dyspareunia indicated that considering a 26% prevalence (11) could lead to an appropriate estimation of the sample size. Considering a two-sided 95% con dence interval with a width equal to 0.08 (margin of error = .04), design effect of 1.2, and a non-responding rate of 10%, a sample size of 615 women was obtained. For the purpose of data analysis, distribution, mean, and standard deviation values were initially obtained using description statistics. Chi-square and independent t-test were used for homogeneity of the two groups. The linear logistic regression analysis was conducted to estimate the strength of associations between sexual distress and associated factors. The collected data was then captured in a Statistical Package for Social Sciences-22 software (SPSS Inc., Chicago, IL, USA) for further analysis.

Results
The analysis of demographic characteristics of 590 individual showed that the mean of women's age and duration of marriage were 35.5 and 13.8 year, respectively. The majority of women had, two children (43.5%), proper nancial status (66.8%), high school diploma level education (75%). Approximately 90% of women were housewife and 32% reported that they were nervous during sexual activities due to lack of privacy. Only 4.2% had vulvar pain during vestibular touch. About 70% had su cient intimacy with their husband and mostly (86%) reported moderately to high sexual satisfaction. Moderate and high Marital satisfaction reported in 27% and 61% of participant, respectively.
As it has mentioned in our previous paper, based on the Binik criteria nal prevalence of severe and moderate dyspareunia was 10.5% and 25.8%, respectively. However, 33% of participants reported experience of sexual pain in the single self-report question. Table 1 explains the sexual distress among participants. It was worth to note among 84% of participants who were either healthy or those with self-reported dyspareunia (the pain did not con rm based on Binik criteria), 8.5% reported considerable level of sexual distress. In contrast, between 16% of women that their dyspareunia con rmed based on the strict Binik criteria, 5.4% did not report any sexual distress despite severe pain (Table 1) Table 2 shows the status of eight diagnostic questions for all participants. Even though the level of pain was severe in all 62 participants suffering from GPPPD, 100% of them stated that they had experienced more than 10 intercourses within the past six months (versus 82% in healthy women). Severe, or considerable levels of, pain and fear of pain during intercourse was reported in 3.6% and 1.3% of healthy women, and in 53.2% and 37.1% of the women suffering from the GPPPD disorder, respectively. Severe, or considerable levels of, distress during intercourse and stiffness of vagina muscles was observed in 2.8% and 3.8% of healthy women, and in 25.8% and 33.9% of the women suffering from the GPPPD disorder, respectively ( Table 2). * without pain or self-report pain that did not con rm based on both Binik criteria and sexual distress Table 3 shows sexual pain characteristics in response to 11 complementary questions of GPPPD questionnaire which was answered by only 196 participants (33% of the sample) with self-report of dyspareunia. It is worth to note that these questions were quite personal and not of any diagnostic nature, thus there was not any insistence on answering the questions and therefore the number of the individuals who had answered this question was not equal for each question in Table 3.  ¥ tested between the last two columns (con rmed and not con rmed dyspareunia) *P < .05, **P < .01, ***P < .001  ¥ tested between the last two columns (con rmed and not con rmed dyspareunia) *P < .05, **P < .01, ***P < .001 Sexual pain characteristics self-report of dyspareunia ¥ tested between the last two columns (con rmed and not con rmed dyspareunia) *P < .05, **P < .01, ***P < .001 Sexual pain characteristics self-report of dyspareunia ¥ tested between the last two columns (con rmed and not con rmed dyspareunia) *P < .05, **P < .01, ***P < .001 In the majority of participants' (53.1%), main reason for sexual intercourse was better marital relationship.
The time of pain in the majority of women (36.2%) were at the beginning of intercourse and the site of pain in the majority of women (49.7%) were in vagina entrance. Most of the women (44.1%) described the pain as a sense of burning or heat. The negative impact of sexual pain on desire for sexual intercourse, and especially on the ability to have a sexual intercourse, was signi cantly different in the two groups (P = .038 and P = .004, respectively).
In those individuals whose sexual pain was con rmed by the standard criteria, in comparison with those who had sexual pain but their pain was not con rmed by the standard criteria, sexual pain had a more signi cant effect on abstinence from sexual intercourse. Also, the negative impact of a fear of sexual intercourse on the ability to have a sexual intercourse was signi cantly different in the two groups (P = .036). It is worth to note that 67.3% of the population who had a feeling of pain never discussed their problem with the treatment team (Table 3).

Discussion
This paper discussed about the characteristics of sexual pain and also determined the protective factors cause fewer sexual distress among sufferers. In the other word, this study showed why some women with sever dyspareunia did not complain of any sexual distress while some women without even any sexual pain diagnosis experience signi cant sexual distress.
In this survey 19% of the population reported signi cant distress during sexual intercourse, although in 8.5% of them sexual pain did not con rm that should be interpreted carefully. This group either were without pain or reported pain that did not con rm based on standard pain criteria. Existence of sexual distress despite meaningful sexual pain can be due to several reasons: rstly, considering various criteria may lead to an underestimation of sexual pain. This research has been conducted in accordance with the new DSM-5 standards and the criteria recommended by BINIK questionnaire and only the presence of considerable and sever pain (options 3 and 4) was deemed as a diagnostic criterion. Therefore, those individuals who experienced medium or mild pain were exclude from dyspareunia diagnosis. It should be considered that pain bears a considerable effect on the quality of life. In addition, people's interpretation of pain is completely different. Even those women who are suffering from slight pain might experience signi cant distress in their sexual life due to the nature of pain or pain catastrophizing. Various studies have suggested that one of the in uential factors on sexual pain, or fear of intercourse, might be pain catastrophizing (4). The second interpretation of sexual distress in healthy individuals in this paper can relate to the presence of other sexual problems in these individuals which is not dealt with in this study.
The third, and probably the most important interpretation, is that sexual issues are broadly related with other aspects of life. This nding is applicable to clinician and shows assessment of sexual disorders is not enough for evaluating of sexual health and sexual distress cannot happened merely due to sexual dysfunction. In fact, comprehensive medical history is necessary for appropriate interventions and nding the reason behind sexual concerns and distress. Sexual distress may stem from various reasons including not trusting or not loving one's spouse, concerns about pregnancy, and the presence of children (12).
In this survey 5.4% out of 16% of participants that their dyspareunia con rmed by strict Binik criteria, did not complain of any sexual distress and consequently this participant excludes from nal diagnosis of GPPPD. However, this 5.4% (32 women) are very important group because some variables protect them from experience of distress or con ict in their sexual relations. On other word, their coping strategies could be useful solutions for others sufferer. Our analyses showed that self-con dence (P = .000), sexual satisfaction (P = .000), a positive body image (P = .000) and proper intimacy relationship (P = .000) were signi cantly higher in this subgroup compared to those suffering from distress in addition to pain. The protective effect of sexual satisfaction in this women can be interpreted by replacing and enjoying other sexual activities instead of penetration and consequently less attention and anxious about dyspareunia. More intimacy also can help to better communication and selection of alternative sexual activities. Selfcon dence and positive body image direct and indirectly effect on increasing sexual satisfaction and declining distress. Even though the previous studies have shown that sexual pain may in uence selfcon dence and body image (13), the present study took one step further and showed that these factors might even be of some protective in uence against sexual distress. To this end, the studies conducted by Liner et al. and Stephenson et. Al. and show that increased emotional intimacy decreases both sexual pain and anxiety in the a icted individuals; they also emphasized that it is necessary for the spouses to participate in the sexual pain treatment process (14,7). Benoit-Piau et al. also reported that partner support has moderating effect on pain catastrophizing in women with vulvodynia (15). In fact, the present study states strategies for overcoming severe pain, and these strategies can bene t the patients as well as therapists. Still other surveys need to determine the other factors that may cause a better toleration of dyspareunia.
The present research showed some characteristics of sexual pain among Iranian women who suffer from dyspareunia. The ndings contained in Table 2 show that all individuals whose nal diagnosis had been con rmed had more than 10 sexual intercourses during the past 6 months. A review of Table 3 and the reasons for having sexual intercourse simply shows that 81% of the suffering individuals counted spouse's satisfaction and betterment of marital relations as the main reasons behind having sexual intercourse. Intercourse despite severe pain can be devastating and, in case therapists fail to alleviate patients' pain, they must assist the couples with enjoying sexual activities other than penetration. Painful intercourse disgust people not only of the penetration, but also of any other sexual activity. To this end, spouse's accompaniment during the treatment process is bene cial not only in the resolution of the pain issue but also in easing these types of concerns (16). In response to location and timing of the pain, most participants experienced pain in vaginal opening and at the beginning of intercourse. These ndings help the therapists to pay more attention to speci c reasons for this type of sexual pain such as infections and decreased lubricity of vagina due to insu cient stimulations.
Three out of eleven items related to Table 3 showed a signi cant difference between individuals with and without dyspareunia con rmation. The two groups showed a signi cant difference regarding the effect of pain on intercourse ability, the effect of pain on sexual desire, and the effect of fear on intercourse ability. These ndings are in itself a con rmation of diagnostic criteria, and shows that a diagnosis of sexual disorder is valid only when pain and fear bear a signi cant effect on intercourse ability and sexual desire.
Various studies show that pain disorder decreases sexual desire by creating fear and a vicious circle (17), and ultimately leads to abstinence from sexual intercourse (18). It is noteworthy that around 70% of those who were experiencing pain in their own view and those whose GPPPD was con rmed had never shared their problem with the treatment team. Similarly, the previous studies reporting that a considerable percentage of women suffering from various types of sexual disorder had never sought medical examinations and counseling, and as a result inquiry about women's sexual health should form part of each gynecology appointment (19,20).
It is worth to note that the current research employed a single question and participants' self-reporting for studying factors related to sexual pain. As a limitation of this study, these factors were not assessed by the standard questionnaire. The large population of the study, their randomized selection, the populationbased nature of the study, making use of a standard questionnaire for diagnosis, and conduction based upon the new DSM-5 de nitions count as the strengths of this research study.

Conclusion
Even though pain concurs with decreased quality of life and various side-effects, sexual pain bears signi cant negative effects not only on the individual, but also on the couple and their interpersonal relations through decreasing sexual desire and the number of sexual intercourses and consequently sexual satisfaction. Nevertheless, the majority of the women do not inform health providers of their sexual pain or fear, and continue to have intercourse due to fear of losing their spouse. Our results showed that in addition to routine managements for sexual pain or fear of intercourse, promote positive self-con dence and body image, sexual satisfaction, and intimacy in marriage were protective factors that cause better toleration of pain and fewer sexual distress. These ndings can be applicable in the patients and clinicians to cope with the sexual pain problem. In addition, attention to women's concerns about sexuality is crucial. In our sample, 19% of participants reported signi cant sexual distress, 10.5% of women with con rmed dyspareunia and 8.5% of uncon rmed dyspareunia cases. It shows that the cause of sexual distress can be reasons other than sexual dysfunctions and obtaining comprehensive medical history is necessary for nding the reasons behind sexual concerns and distress.