Adv Health Behav
Family is a social system that includes a group of people who live together through marriage, reproduction, and raising children . This system and social organization has played a vital role in growth, development, and socialization of people throughout the history [2,3]. It can be stated that it is undoubtedly the most important organization which provides the conditions for physical, psychological and social growth of child. It is also a factor to achieve physical, psychological and social balance . As marriage event is the initial stage of life, which is considered as the important part of the individual and social life of each person , the family, as the fundamental unit of the community and the center for human growth and excellence, is considered as a social and legal institution . Providing a certain set of rights, privileges, threats, responsibilities, and expectations, it supports a new role in sustainable marital relationships, leading to the survival and continuity of family institutions and social structure .
In this regard, what seems to be more important than marriage and family formation is marital satisfaction. It is one of the most basic human pleasures. Lack of which will be one of the greatest sufferings . Marital satisfaction is in fact an attitude that couples perceive from several aspects of marital relationships positively . Marital satisfaction is defined as adjustment between the current status and the expected status . It provides a general evaluation of the current state of affairs. It is one of the broadest concepts for determining and displaying the level of happiness and sustainability of the relationships. In fact, this phenomenon prolongs the life of the couples , and increases physical and mental health . It also causes economic progress and satisfaction within the whole life. Marital satisfaction and adjustment is caused through mutual interests, caring for each other, mutual understanding and satisfaction of needs . The satisfaction experienced by couples through marriage is a fundamental aspect of a marital system. In this regard, it can be stated that while great numbers of studies have been conducted on marital satisfaction and the relationships between its various dimensions and human life, this variable is still an important issue in relationships, treatment and factors affecting marital satisfaction in different cultures . Some researchers , believe that most people experience a high level of marital satisfaction at the beginning of life. However, their marital satisfaction declines over time gradually and they experience serious problems in the same initial weeks and months of their life. If they are not solved, they can threaten the satisfaction and stability of the marital relationships. Figures suggest that marital satisfaction is not easily achieved and high rate of divorce proves it .
The increasing rate of divorce over the recent decades suggests the reduced level of satisfaction between couples , so that the rate of divorce has increased in recent years . Since one decade ago, the rate of marriage has reduced and the rate of divorce has increased, so that the number of marriages in Iran registered in 2017 was 8 percent less than that of 2016, while the number of divorces in 2017 was more than that of 2016. In 2017, one case of divorce was registered in Civil Registration Organization every 3 minutes. In general, it can be stated that about 175000 divorces were registered in Iran in 2017 . Given the life status of Iranian people in 2018 and its worse economic status against 2017, and the change in the economic pyramid of households, the likelihood of an increase in figures compared to previous years is predictable. In this regard, we can state that in addition to economic problems, inflation, economic instability and reduced tolerance in Iranian community , depression and infertility of couples [21,22], and the lack of knowledge of couples on sexual communication skills , lack of sexual knowledge , and lack of knowledge and attitude on proper sexual relationships [25,26] are considered as the most important factors involved in increasing the rate of divorce in Iran.
Given what was stated above, one of the factors increasing the rate of divorce is the lack of sexual relationships in couples. It is important to pay attention to it, since the base of the family relies on sexual instinct . Sexual relation is an important part of marital life and the role of sexual relation is evident in the continuity and health of marital life , since sexual activity helps women and men to cope with stressors effectively and reduce its destructive effects . Sexual relationships form a part of the couples’ perceptions of each other. Moreover, sexual perceptions among couples has positive relationships with behaviors which maintain and sustain the marriage . Studies have shown that sexual intimacy is associated with emotional intimacy and that the quality of sexual relation determines many communication problems , and the lack of communication, hostile relationships, and the inability to detect and exchange emotions, are characteristics of couples who have problems in their sexual relationships . Thus, if sexual satisfaction is not achieved in any of the couples, it can be a source for the lack of adjustment and happiness , Since in this dimension of adjustment, its private aspects prevail and social embarrassment do not allow emotions and thoughts related to it to be emerged simply. Lack of satisfaction or adjustment in this regard can complicate the problem . Studies conducted on marriage show that sexual relation issue had the highest priority and the quality of marital relationships depended on level of sexual satisfaction of couples .
Thus, based on the studies conducted, the lack of proper information, lack of sexual skills, and unrealistic expectations and performance in marital relationships in couples played a significant role in the development of sexual and marital problems . However, while sexual desires are inherent and involuntary, it can be stated that sexual attitudes and behaviors are learnable, and through increasing the level of knowledge, sexual health of people would increase, as well . Marital enhancement programs increase marital satisfaction and happiness by increasing the knowledge of couples on sexual issues and correcting their unrealistic sexual expectations . Therefore, as a desirable sexual relationship, it plays a major role in the success and sustainability of the family in such a way that it can satisfy both parties , It can be stated that the sexual skills training can provide opportunities to learn sexual issues and prevent the occurrence of certain problems. Moreover, sexual health programs training is the most important way for providing the health of the community and the family, since these skills help people to improve the sexual health issues properly in their relationships .
Sexual training also helps couples acquire marital intelligence, knowledge and skills . It also provides them sexual information and knowledge necessary to achieve a common goal and meeting the needs and interaction in personal, family and social life . Comprehensive sexual training programs are effective in preventing sexual dysfunction, healthy sexual behavior, observing health, creating mental health, establishing family health and acquiring proper sexual identity . In addition, sexual skills training can lead to positive emotions, intimacy, increased marital relationships and, consequently, its continuity. Increased ability to solve couples’ conflict and increased sexual satisfaction, indicates that the training of one of the couples affects the other party .
Sexual skills training can include providing information about body growth, sexual behaviors, and healthy communication. Moreover, the content of sexual training programs should be designed in a way that be suitable and comprehensible for all participants. For example, with regard to the treatment of sexual dysfunction and the use of sexual medicine skills, sexual issues are addressed from biological, psychological, social and spiritual perspectives [40,41], or in the cognitive-behavioral approach developed by Masters and Johnson for the treatment of sexual problems , Behavioral methods are used to change the maladaptive recognitions of a person [43,44].
In general, various methods of sexual skills training help people gain information and thoughts and skills, and provide them with the knowledge required for achieving a common goal and satisfying needs and interacting in personal, family and social life . The question here is that whether sexual skills training that increase the knowledge of couple’s sexual knowledge affect their marital satisfaction? Accordingly, this paper aimed at examining the effectiveness of sexual skills training on increasing the marital satisfaction, considering the increase in marital conflicts caused by sexual problems and increased rate of divorce in Iran.
2.1 Research design
The design of current research was a quasi-experimental with pre-test and post-test design type along with a control group. This research was conducted to evaluate the effectiveness of sexual skills training on marital satisfaction. Hence, both groups were assessed twice. The first assessment was performed by a pre-test and the second assessment was performed with a post-test. To form the groups, half of the subjects were placed in the experimental group and the other half were placed in the control group. A total of 28 people (14 couples) were selected to participate in the study, from which 7 couples were assigned into experimental group and 7 couples were assigned into control group. The two groups matched to each other and dependent variable (marital satisfaction) was assessed in both of them at one time and under similar conditions.
2.2 Poulation, sample, and sampling method
The research population included all couples referring to the couple therapy clinic located at the center of Tehran in the summer of 2018. They referred to this clinic due to marital and sexual problems. The study samples were selected using convenient method among the couples referring to the mentioned clinic. Samples included 14 couples (28 people) who were willing to participate in the classes. They were randomly assigned into experimental and control groups. Accordingly, 7 couples (14 people) were placed in the experimental group and 7 couples (14 people) were placed in the control group. They were randomly assigned to the experimental and control groups. Both groups completed the marital satisfaction questionnaire before the training sessions and after the completion of the training sessions.
2.3 Research Instruments
Enrich Marital Satisfaction Questionnaire: This questionnaire was developed by Olson et al in 1989. This questionnaire was used to assess potentially problematic areas or to identify the strengths in marital relationships. The initial questionnaire of Enrich marital satisfaction included 115 closed questions answered based on 5 options .
Scoring: Due to the high number of questionnaire’s questions (115 questions) that caused excessive exhaustion of subjects, the researcher decided to prepare a short form of it. For this purpose, the correlation of each question with the whole questionnaire was first calculated by correlation coefficient. A total of 47 questions were selected. Then, the reliability coefficient of 47-question form was calculated on a group of 11 people using the alpha coefficient. The reliability coefficient was obtained 95 %. The questionnaire was scored in a five-option Likert scale, in which scores between 1 and 5 were considered for each option. The maximum score obtained by each subject was 235 and the minimum score was 47. Questions 4, 6, 11-16, 18-24, 30-33, 37-42 and 45-47 were reversely scored. In this study, 47-item Enrich marital satisfaction questionnaire was used.
Reliability and Validity: Olson et al., (1989) reported the reliability of this questionnaire 92% through alpha coefficient. The correlation coefficient of this questionnaire with family satisfaction scales ranged from 41% to 60% and correlation coefficient of this questionnaire with life satisfaction scales ranged from 32% to 41%, indicating its construct validity. All subscales of Enrich questionnaire differentiated satisfied and dissatisfied couples, indicating that this questionnaire had good criterion validity. The reliability coefficient of this questionnaire ranged from 0.68 to 0.86 in various studies .
2.4 Research procedure and structure of treatment sessions
Procedure: Before the start of the interventions, the way of completing the marital satisfaction questionnaire was explained for the subjects. After describing the questionnaire and the research objectives, the questionnaires were completed by the subjects of both groups (pre-test).
Then, participants in the experimental group received skills training during 9 sessions, weekly for 90 minutes per session. Control group‘s subjects received no intervention during this period and they were in waiting list during this time. After completing the training sessions, both groups’ subjects were asked to re-complete the marital satisfaction questionnaire (post-test). It should be noted that the written consent form was obtained from all subjects before the sessions in order to observe the ethics of research. The participants’ information was also remained confidential. Moreover, the research exclusion criteria included: physical problems (paralysis, spinal cord and limb problems), psychological problems (patient is treated under a psychiatrist), medical disease (cardiovascular disease, pulmonary disease, thyroid problems, epilepsy, and diabetes), and experiencing stressful events (a major change in the lives of people over the past three months, such as death of one of the close relatives or acute disease), and addiction (alcohol and drug use).
The structure of the treatment sessions: This intervention was designed based on the cognitive-behavioral approach of Masters and Johnson (1966), normalized by  and it was performed in 9 sessions (90 minutes per week). The structure of the sessions included: (1) examining the general status of the couples; (2) reviewing the content provided in previous sessions and responding to the existing questions and ambiguities; and (3) teaching the materials and techniques considered for each session. The most important techniques and interventions considered in training the couples’ sexual skills during 9 sessions included:
Session 1: The acquaintance of subjects of two groups with each other and directing the training sessions and reviewing the importance of healthy sexual relation, examining the common sexual beliefs and cultural and religious attitudes.
Session 2: Teaching anatomy and physiognomy of man and woman‘s sexual behavior, introducing the sexual interests, preferences and differences of men and women, examining the sexual function of the woman and man (desire, arousal, orgasm, suppression).
Session 3: Training relaxation, training imagination and regular desensitization.
Session 4: Training focus and attention techniques, training self-care assignments.
Session 5: Training the sensual focus and reviewing self-care sheets and their reconstruction.
Session 6: Training the Kegel and muscular exercises and reviewing self-care sheets.
Session 7: Training exercises to facilitate sexual satisfaction and reviewing self-care sheets.
Session 8: Introducing sexual dysfunction and its causes.
Session 9: Summing up the topics presented during the sessions and answering questions, the strengths and weaknesses of the sessions, obtaining feedback from the sessions and the level of their effectiveness.
SPSS software was used to analyze the data. Demographic characteristics and descriptive indices of the two groups are presented separately in Table 1:
Descriptive results of marital satisfaction variable (in Table 2) also indicated that the mean score of marital satisfaction in the experimental group was 128.36 in the pre-test and 151.57 in the post- test, which indicated an increase in marital satisfaction after intervention. However, the mean marital satisfaction was 126. 64 in the control group in pre-test and it was 125.21 in post-test. These means showed that there was no significant change in the score of marital satisfaction during the period when the control group received no intervention.
To evaluate the effectiveness of sexual skills training on increasing marital satisfaction, covariance analysis method (to control the error variables by this method) was used. In order to use the covariance analysis test, the assumptions of this test were first examined. The results of Levine’s test to examine the homogeneity of variances, Kolmogorov-Smirnov test to examine the normal distribution, the test to examine the linear relationships between the pre-test and post-test, and the F test to examine the homogeneity of the regression coefficients slope showed that all assumptions of this test were confirmed. Thus, covariance analysis was used. The results are presented in Table 3:
The present study was aimed at evaluating the effectiveness of sexual skills training on increasing marital satisfaction. Based on the results, experimental and control groups differed significantly in the marital satisfaction score. It means that the post-test scores of the groups were different, which was due to the effect of training in the experimental group. Thus, sexual skills training affected marital satisfaction and increased marital satisfaction. The result of this study was in line with that of studies. [10,23] In addition, the results of the present study were consistent with those of studies [24,37,49], which showed that increasing sexual knowledge, training the post-marriage skills and training of sexual skills would increase marital satisfaction, sexual satisfaction and reduce marital maladjustment.
In this regard, it can be stated that sexual skills training could have a positive effect on couples’ perceptions of each other through creating a greater intimate relationship between the husband and wife, given their personality characteristics and behaviors. It could also strengthen the relationships between men and women and created an intimate atmosphere and positive feelings, beliefs and attitudes among the couples towards the role they play in life. It could also maintain marital relationships and created a sense of love between couples and increased satisfaction among the couples by reducing conflicts and stress and enhancing the level of satisfaction with life. Accordingly, these results overlapped with theories of Gestalt and Maslow who stated that sexual need is one of the most important human needs and it is the motivation of many human behaviors and that love and sexual desires are interrelated in most people .
In addition, some studies such as [35,50], in line with results of this study, found that the sexual skills training could lead to sexual satisfaction in couples. Therefore, having a proper sexual relationship, followed by a sense of relaxation and positive emotions to this relationship, would reduce the concerns of both parties to sexual relationships [51,52] and satisfaction with sexual issues and sexual intercourse . It also provided the conditions for creating a sense of agreement between men and women . In fact, training sexual skills creates a positive attitude towards the other party, which can increase satisfaction with life by reducing the anxiety  and creating a sense of relaxation .
In explaining the results of this study, it can be stated that many couples, especially in Iran, marry without having complete and correct information, resulting in a low quality relationship. Thus, as reported in previous studies  providing correct information on the sexual response cycle, the differences between women and men in this regard and in the expression of love not only increased the likelihood of improvement in practical skills, but also modified many of the wrong beliefs of people.
In general, facility is considered as an organization, where physical, rational and emotional needs of individuals are met and one’s satisfaction with martial life is considered as his or her satisfaction with family and finally satisfaction with life , so poor marital would have negative effects on the family functioning. Accordingly, the marital relationships should be based on the various marital knowledge and skills so that intimate, romantic and full of satisfaction relationships to be created between the man and woman.
The results of this research revealed that training of sexual skills was effective in increasing marital satisfaction. Thus, increasing the knowledge of couples and the training of sexual skills and other related methods played a major role in creating healthy sexual behavior, mental health, observing the health, establishing family health, obtaining proper identity and prevention of sexual dysfunction. Since these trainings tutorials can help people gain information, thoughts and skills to achieve a common goal and to meet the needs and to have an interaction in personal, family and social life. Moreover, proper and adequate knowledge of sexual skills leads to a healthy attitude towards sexual issues, sense of intimacy, love and responsible behavior among couples, which finally leads to marital satisfaction.
The authors of this study appreciate all couple therapy clinic staffs as well as all the participants of this research.