Sexual Cognition Among Iranian Women With Genital Pelvic Pain Disorder: A Short Communication

Background: Genital misconceptions can lead to sex avoidance in women with genital pelvic pain and penetration disorder (GPPPD). Therefore, this study was conducted to examine the sexual cognition of Iranian women with GPPPD. Methods: This comparative analytical descriptive study was performed on 200 GPPPD and non-GPPPD Iranian women who referred to women’s clinics in Hormozgan province in 2021. In this study, availability samples were used, and data were collected using a demographic questionnaire and a localized vaginal penetration cognitive questionnaire. Statistical analysis was performed using SPSS version 25

without GPPPD (100 per group) who referred to 6 women's clinics in Hormozgan province from May to August 2021 (One clinic in the center and 5 clinics in the west and east of the province). Using the statistical formula of n ( ) (α = 0.05, β = 0.2, S 1 = 1.9, S 2 = 0.6, d = 0.5, and effect size d = 0.354) and the study of Klaassen and Ter Kuile (11), the sample size of the study was estimated to be 200 women with GPPPD and without GPPPD. Availability sampling was used in this study. The inclusion criteria were women within the age range of 20-49 years old, having adequate literacy) literacy for reading and writing), involved in monogamous relationships, and experiencing sexual activity for at least 6 months, while the exclusion criteria were non-Iranian women and unwillingness to participate in the study. Women with GPPPD have experienced pain, spasm, and contraction during sexual intercourse or were unable to have intercourse, and demonstrated pain and spasm/contraction and avoidance behaviors as a response to the examination based on Disorders Diagnostic and Statistical Manual (Fourth Edition) criteria (10). The final diagnosis of GPPPD was by a midwife or gynecologist. The purpose of this study was explained to the participants, and they were assured of data confidentiality. For this purpose, questionnaires were provided to participants in an anonymous and encrypted format. In addition, they signed a written consent form without any force, threats, or seduction.
Data collection consisted of questionnaires measuring socio-demographic (age, education, economic situation, and the like) and sexual (number of sexual intercourses per month and awareness about female and male genitals) information and a standard localized vaginal penetration cognition questionnaire (VPCQ). In this study, to measure awareness about female and male genitals, two questions were employed that evaluated the level of awareness of women about the anatomy of male and female reproductive systems based on a scoring scale of 1-4 (low to high). The original version had 40 questions, which was shortened to a 22-item version when its initial validity and reliability were confirmed by Klaassen and Ter Kuile, and the questions of the tool are answered using a Likert-type scale from 0 (never) to 6 (always) (11,12). The validity (face, content, and structure) and reliability of this questionnaire were approved by Banaei et al. Cronbach's alpha and maximum reliability of all factors were acceptable. The absolute reliability of the tool was confirmed with a standard error of measurement of 2.67 and a minimal detectable change of 28% (13). The VPCQ has 20 items and three areas of catastrophic and control, positive, and self-image cognition.
The extracted data were statistically analyzed using the SPSS software, version 25 (SPSS Inc., Chicago, IL). Descriptive (Frequency, percentage, mean, and standard deviation [SD]) and inferential (Student's t-test and chisquare test) statistics were used for data analysis. The significance level was assumed to be 0.05 in this study.

Results
The mean age of participants was 29.14 ± 5.44. Most women in the GPPPD and non-GPPPD groups had a university education (84% and 83%, respectively), and 14% of the GPPPD groups had a poor economic situation. The majority of participants in both groups had no family relationship with their spouse (80% vs. 75% of controls). Mean scores for negative self-images, and catastrophic and control cognition were higher in the GPPPD group, while the mean scores of positive cognitions in the GPPPD group were lower compared to the non-GPPPD group (P < 0.001, Table 1). The mean scores of awareness about females and genitals in the GPPPD group were lower (P < 0.001).

Discussion
In this study, the results revealed that women with GPPPD had less sexual cognition and higher negative sexual beliefs than the comparison group, and their awareness score was lower than the comparison group. In fact, catastrophic domain is truly multidimensional and is a combination of activation, evaluation, and attention towards the harmful event experience, as well as coping with that experience (14). Catastrophic beliefs about vaginal penetration due to its direct relation to panic disorder experience in women with vaginismus and dyspareunia lead to fear response and avoidant behavior. This relationship demonstrates the perceived importance of control components (15). Increased fear of losing control during vaginal penetration in women with GPPPD (16) can reduce perceived penetration control and increase catastrophic pain recognition (17). A study on Iranian women with lifelong vaginismus showed that these women have similar experiences to women with sexual pain disorders (18). The effect of pain and pain prediction on the exacerbation of catastrophic thoughts and vaginal penetration fear are similar in women with sexual pain disorders (19). Reissing et al showed that women with vaginismus experience increased catastrophic pain when having intercourse or vaginal penetration, as well as increased frequency of avoidant-defensive distressing behaviors when examining the pelvis and higher levels. They also demonstrated emotional distress (20). The fear-avoidance model of vaginismus indicated that fear of penetration can be originated from inconsistent and catastrophic thoughts about vaginal penetration. This fear may lead to avoidance of sexual intercourse (19). Positive cognition was the second domain. Several studies reported lower positive cognitive domain scores in women with GPPPD (21). Moreover, the finding of another study in Iran represented that women with GPPPD had reduced positive cognition and increased disturbed thoughts and feelings. In fact, high intimacy and increased marital satisfaction, and positive treatment attitudes reduce the intensity of stress (22). In the current study, it was found that women with GPPPD do not have a good image of their bodies. Image is a complex mental structure that can influence personality via physiological, emotional, and behavioral concepts (23). Genital body image refers to the feelings and beliefs of an individual about his/her body and genitals, which are all involved in sexual activity (22). Klaassen and Ter Kuile reported that women with vaginismus had increased negative body image recognition and genital incompatibility (11). Based on the results of current research, for improving the sexual health of women with GPPPD and correcting their beliefs and knowledge, interventions should be designed to resolve their needs to improve sexual relationships and prevent sexual tension. Therefore, we recommend including cognitive dimensions of vaginal penetration in designing interventions to treat and provide sexual counseling to women with GPPPD (3). Considering that a self-reported questionnaire was used in the current study, there is a possibility of recall bias, which was the limitation of this study. The self-reported method was the weak point of this study. On the other hand, one of the strengths of this study was using standard questionnaires and a comparative design. Collecting data from 6 centers was another strength of this study.

Conclusion
The findings demonstrated that the beliefs and knowledge of women with GPPD should be corrected to promote their sexual health. Interventions should be designed to meet the needs of this group to improve sexual relationships and avoid sexual tension.