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Effectiveness of premarital sexual counselling

program on sexual satisfaction of recently
married couples

Article in Sexual Health · September 2009

DOI: 10.1071/SH08065 · Source: PubMed

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CSIRO PUBLISHING Research Paper
www.publish.csiro.au/journals/sh Sexual Health, 2009, 6, 222–232

Effectiveness of premarital sexual counselling program

on sexual satisfaction of recently married couples

Bilgin Kıray Vural A,C and Ayla Bayık Temel B

A
Health Services Vocational School, Pamukkale University, Denizli 20020, Turkey.
B
Department of Community Health Nursing, School of Nursing, Ege University, Izmir, Turkey.
C
Corresponding author. Email: bilgin.vural@gmail.com

Abstract. Background: Through its ability to address and remove fear and misunderstanding and the resulting sexual
reluctance and related problems, pre-marital sexual education and counselling can contribute to sexual satisfaction.
Methods: This quasi-experimental research conducted in a pre-test–post-test control group design aimed to examine the
effectiveness of nursing interventions on a premarital counselling program and its impacts on the sexual satisfaction of
couples (36 couples in the experimental group and 35 couples in the control group). Results: Although no difference was
detected between the experimental and control groups in terms of the level of knowledge on pre-test point averages, the
difference between them in terms of post-test knowledge gain averages was statistically significant. Approval rates for
sexual myths in the pre-test were 27.87% in the experimental group and 37.03% in the control group; in the post-test they
were 23.51% and 36.66% respectively. In the experimental group, 80.6% of the women and 63.9% of the men, and in the
control group, 77.1% of the women and 71.4% of the men were established as having a problem-free sexual life.
Conclusions: It was also discovered that levels of sexual satisfaction were shown to be higher among women and men in
the experimental group who had attended premarital sexual counselling education than the women and men in the control
group. A recommendation to encourage engaged couples to attend premarital sexual counselling is made based on the
findings. It is thought that an intervention plan prepared within the framework of the Information, Motivation, Behavioural
Skills theoretical model will help nurses guide recently-married couples to greater sexual satisfaction.

Additional keywords: premarital counselling, sexual counselling, sexual satisfaction.

Introduction ensure a happy and satisfying married life.13 In a 15-year-

The official, emotional, attitudinal and biological aspects of
marriage are part of a social system that encompasses the
economic, social, sexual and legal aspects of relationships
between men and women.1,2 Research has established that the
fulfillment of sexual needs is the main reason for getting married
for 20% of women and 29% of men.3 Although marriage is not
merely a sexual partnership, in Turkey it is legal to cite sexual
problems as a reason for divorce.4
Research has shown that an increase in sexual satisfaction
increases marital happiness and likewise an increase in marital
happiness can cause an increase in sexual satisfaction.5 8 Trudel
et al. have also established that women who suffer from a lack of
sex drive are less happily married than those who do not.9
Donnely found that couples who did not have an active sex life
had unhappy marital relations, shared less and were more likely
to divorce.10 Because of sexual ignorance, misinformation and
misguided beliefs, sexual problems are much more widespread
in societies than the incidence of sexual dysfunction.11
It is important for couples to have recourse to counselling
initiatives before they start having serious relationship
problems.12 For this reason, couples who are about to marry
in England, Australia, Austria, Canada and the USA are
encouraged to participate in counselling programs to help
long American study of 300 married couples it was found
that the divorce rate among those who had participated in
pre-marital counseling programs was only 4.6%.14
High school and university training is available in other
developed countries for these widespread marriage counselling
programs. Although in Turkey, marriage counselling and
therapy advice and relationship building approaches have
started becoming popular; training for pre-marital counselling
is not yet widespread.15
Typically in the USA pre-marital counselling groups are led
by religious leaders, mental health experts and doctors. Doctors
can offer pre-marital advice to couples on family planning and
sexual issues.13 After they get married, couples generally
continue attending sessions for 4–6 months.11
Sexual health education helps to raise the sexual health of
individuals, couples, families and societies and to promote the
spread of information and encourage the motivation and
behaviour needed to deal with sexual health problems.16
The components of sexual health education recommended
by Health Canada’s Canadian Guidelines for Sexual Health
Education are based on the Information, Motivation,
Behavioural Skills (IMB) theoretical model of sexual health
problem prevention and sexual health enhancement.16 To

CSIRO 2009 10.1071/SH08065 1448-5028/09/030222

Premarital sexual counselling program
establish effective sexual and reproductive health education
programs the IMB model (Fisher and Fisher 1992) is used as
a guide to help reduce individual risks, prioritise sexual health
problems and improve sexual health.16 18
Sexual health education programs are based on the three
elements of the IMB model: (i) information: helping individuals
become better informed; (ii) motivation: using the information
provided to motivate individuals to change behaviours that
pose risks, and to continue consistent and healthy behaviours;
and (iii) behaviour: encouraging individuals to reduce negative
outcomes by acquiring healthy sexual behaviours.16,17
The IMB model was designed to be easy to translate
into theoretically-based, behaviourally focussed sexual and
reproductive health programs. While there are several very
good theoretical models that can be used in the development
of sexual health education curriculum and programming, the
Guidelines are based on the IMB model because there is
significant empirical evidence that demonstrates the model’s
effectiveness.16
Evidence of the IMB model’s effectiveness in the area of
sexual risk reduction has been demonstrated in several diverse
populations including young adult men,19 low income
women20,21 and minority youths in high school settings.22
Furthermore, a meta-analysis strongly supports the need to
include elements of information, motivation and behavioural
skills in interventions that target sexual risk behavioural
change.23
Moreover, studies aiming to improve sexual health have
shown that initiatives based on the IMB model are effective
in raising awareness of birth control, condom use, the need for
mammography checks, in reducing the risk of HIV and for
women undergoing gynecological cancer treatment.16–18,24,25
In terms of couples’ needs, the IMB model is considered
to be a fundamental/basic sexual health education program in
improving pre-marital knowledge of sexual behaviour and
awareness of responsibilities.
The research questions that this study aimed to test were as
follows:
Were the levels of sexual satisfaction of newly married
women and men who participated in the Pre-marital Sexual
Counseling Program subsequently improved compared with
women and men in the control group?
Does a Pre-marital Sexual Counseling Program based on the
IMB model have an effect on the sexual satisfaction levels of
newly married couples?
Methods
The sample of this pre-test–post-test design research consisted of
83 couples (41 in the experimental group and 42 in the control
group) who shared the following key characteristics: they had
agreed to participate in the pre-marital counselling program as
part of the experimental group; they had not sought professional
help for sexual dysfunction and were not observed to have any
cognitive problems; they were able to respond to the questions;
and they had decided to get married and had set a date for their
wedding. Those volunteer couples were selected according to an
improbability sample and snowball technique and thereby
assigned randomly to the control and experimental groups.26
Sexual Health 223
The random selection process took account of the couples’ ages
and levels of education; odd-numbered couples on the list were
placed in the experimental group and even-numbered ones in the
control group.27
The two part (I and II) Pre-marital Counselling Program was
developed by the researchers based on the IMB Model. In the
Pre-marital Counselling Program parts I and II, two counselling
sessions were organised for each individual couple from the
experimental group; together with this they were also provided
with two educational booklets, which provided information on
sexual education based on the literature.
The data were gathered from volunteer couples working in
various professions in the metropolitan area of Izmir and took
place in the conference rooms of the Ege University School of
Nursing between 1 September 2006 and 30 April 2007.
For the duration of the program and for 4 months afterwards,
couples in the experimental group were able to contact the
researchers by telephone when they felt the need.
Permission was sought and obtained from the Ethical
Committee of the Ege University School of Nursing in order
to carry out the research.
Instruments
(1) Identifying characteristics of the individual form
This form consists of 15 questions to ascertain information
about aspects of individuals’ sociodemographics and their
sexual history.16,28–30
(2) Sexual myths evaluation form
Zilbergeld’s ‘Sexual Myths Evaluation Form’ contains 15
items relating to various sexual myths. Those who complete the
form are asked to classify the sexual myths as true or false.11,31
This form was given to individual participants in the control
and experimental groups both before the counselling program
(pre-test) and 4 months into their marriages (post-test).
(3) Evaluation form for identifying level
of knowledge of sexual issues
The first stage of the IMB model is the provision of
information. The IMB model is based on the comparison of
individuals’ levels of knowledge before and after following the
sexual counselling program. This form contains 25 statements
based on subjects covered by the Sexual Counselling Program
and the literature.29,32–38 Participants are asked to mark each
statement true or false. Points for knowledge as evaluated by this
form vary between 0 and 100, with higher scores indicating
higher levels of knowledge. The internal validity of the form
was tested by obtaining opinions from 10 instructors/faculty
members (Kendall’s coefficient of concordance P > 0.001).39
The form was given to the experimental and control groups both
before the counselling program (pre-test) and 4 months after
getting married (post-test).
(4) Evaluation form to assess reproductive health and
sexual health of the couples during marriage – form
evaluating attitudes related to sexual health
The third stage of the IMB model focuses on the development
of behavioural skills.16,17 In this study, the Pre-marital Sexual
224 Sexual Health
Counselling Program based on the IMB model had as its aim the
development and improvement of attitudes relating to sexual and
reproductive health. To this end, 4 months into marriage,
couples in the experimental and control groups were asked if
they had experienced any sexual problems, if they had used
family planning measures, if they were pregnant, and if they had
been diagnosed with any sexually transmissible diseases during
this period.
(5) Golombok–Rust Inventory of Sexual Satisfaction
(GRISS): women’s form and men’s form
The women’s and men’s GRISS forms developed by
Rust and Golombok to measure sexual satisfaction among
married couples were used. GRISS is a means of measuring
the quality of sexual relationships and evaluating cases of
sexual dysfunction. Points scored give a general idea of the
quality of sexual relations; low scores suggest a need to explore
the relationship in more detail.5,40
This instrument consists of two forms, one each for
women and men, each containing 28 items; the forms have
five subscales out of seven in common. These five subscales
come under the headings of ‘avoidance’, ‘dissatisfaction’, ‘non-
communication’, ‘non-sensuality’ and ‘infrequency’. The non-
corresponding subscales have the headings ‘vaginismus’ and
‘anorgasmia’ on the women’s form, while on the men’s form
they are ‘premature ejaculation’ and ‘impotence’.40,41
A 5-point Likert scale is used to respond to the items with
choices as follows: ‘never – 0’; ‘rarely – 1’; ‘occasionally – 2’;
‘frequently – 3’; ‘always/every time – 4’. To maintain the
consistency of result interpretation, negative questions were
labelled in reverse. For the evaluation of results it was
possible to use both the total points measured and the points
relating to each subscale. High scores indicate sexual function
problems and poor quality of relations. After converting the total
raw scores into a standard scale from 1 to 9, with 5 as the cut-off
point, those with 5 points and higher were diagnosed as having
sexual relation or function problems and hence were assigned to
the ‘problem group’, while those who scored lower than 5 were
considered ‘problem-free’.40
The reliability coefficients for the GRISS forms were 0.87
among the women and 0.94 for the men. The internal coherence
scores of the subscales varied between 0.61 and 0.83. This
compares with the Turkey Standardisation in which men were
shown to have a score of 0.92 and women 0.91 on the Cronbach
a scale.40
(6) Sexual counselling program training booklets
Before their counselling sessions started, the experimental
group were given two booklets, ‘Sexual Counselling Program I’
and ‘Sexual Counselling Program II’. The education received by
the experimental group in their first and second sessions fell
within the framework provided by the topics covered in these
booklets.
Session 1 – Sexual Counselling Program I: This booklet
contained information on the following subjects: conceptions
of family and marriage; sexual health training; what sexuality
is; sexual health; male and female anatomy and physiology;
sexual anatomy; experiencing sexual intimacy; normal sexual
B. K. Vural and A. B. Temel
responses; sexual myths; why sexual problems occur; sexual
dysfunction; and how to contact centres where counselling and
education services are offered.
Session 2 – Sexual Counselling Program II: This booklet
contained information on these topics: infections of the sexual
organs; reproductive health and rights; sexual rights; pregnancy;
birth control measures; and ways of dealing with unwanted
pregnancy.
DISCERN was used to test intelligibility and readability of
the educational booklets.42,43 The Flesch formula was used to
ensure that the booklets had suitable sized print to be read.43,44
The readability score of the booklet was established at 82.68
points, meaning that it was within the ‘easy to read’ bracket. The
educational booklets were also tested to make sure they
conformed to content validity standards (Kendall W = 0.333,
P = 0.450). Opinions were also sought from 10 individuals who
were not among the research subjects but who had similar
characteristics.
Data collection methods
After the experimental and control groups were established
(the experimental group consisting of 41 couples, the control
group of 42 couples) written agreement was obtained from them.
Twelve couples (five from the experimental group and seven
from the control group) who had participated in the first stage of
the study withdrew for various reasons, meaning that the study
was completed by 71 couples, 36 in the experimental group and
35 in the control group.
Stage I: data collection
At the beginning of the study the pre-test forms for identifying
characteristics of the individual and level of knowledge of sexual
issues were given to the experimental and control group couples.
Because the subject of the study was of a somewhat personal
nature, names were not requested, but instead symbols were used
and all forms used were given out in closed envelopes, which
were sealed after the forms were completed for submission. To
reduce to a minimum the sharing of information and mutual
influence on answers of couples, they were asked not to discuss
answers before returning the survey forms.
Stage II: intervention – (written material
and education program)
Pre-marital sexual counselling program
for the experimental group
Each couple in the experimental group (n = 41 couples)
was given the educational booklets to read in preparation for
two 60-min counselling sessions before their wedding. Then
the couples made appointments for the 60-min pre-
marital counselling sessions. The training was based on the
IMB model. The sessions followed motivational interview
principles. In both of the sessions the couples were
encouraged to ask any questions they wanted or to share any
expectations they had regarding the program; they were also
able to contact the researchers by telephone when they felt the
need for the duration of the program. The couples’ questions
mainly concerned issues such as having or not having children
and health services that they could take advantage of; in fact,
Premarital sexual counselling program
the counselling provided them with information about health
institutions and other sources of information that they might be
able to benefit from.
Stage III: evaluation
After completing 4 months of marriage, couples in the
experimental and control groups were given in a sealed
envelope the following forms: ‘Evaluation Form for
Identifying Level of Knowledge of Sexual Issues’;
‘Evaluation Form to Assess Reproductive Health and Sexual
Health of the Couples During Marriage – Form Evaluating
Attitudes Related to Sexual Health’; ‘Sexual myths form’;
and ‘the GRISS forms’. The forms were submitted 1 week later.
Results
(1) Identificatory characteristics
No statistical difference (P > 0.05) was found to exist between
the experimental and control groups in terms of their sexes, age
groups, education and income.27 This result reflects the random
nature of the selection process.
The average age of women in the experimental group was
27.08  3.81, while for men it was 29.36  4.98; in the control
group, the average ages of women and men were 26.00  3.45
and 29.85  5.16 respectively. In terms of education, 27.8% of
the experimental group were high school graduates, while 55.6%
were graduates of university or higher education colleges. In
contrast, 35.7% of the control group members were high school
graduates, and 47.1% of them had graduated from university or
higher education college. 98.6% of the experimental group were
in employment, compared with 88.6% of the control group.
In terms of financial situation, 77.8% of the experimental
group had similar income and outgoings, whereas 19.4% earned
more than they spent. In the control group 65.7% stated that their
income and outgoings were equal and 25.7% earned more than
their outgoings.
(2) Information related to sex life
A large proportion of participants (94.4% of the experimental
group and 88.6% of the control group) stated that they had no
aversion to talking about sexually related matters with others
(P > 0.05). In terms of the people with whom they discussed
sexually related matters, in the experimental group the three
most popular were girlfriends (34.7%), fiancés (26.4%) and
boyfriends (23.6%); this differs from the control group, who
stated that they spoke most to boyfriends (42.9%), girlfriends
(27.1%) and siblings (8.7%) (P < 0.05).
A relatively low proportion of informants in both groups
stated that their parents were the source of their first information
Table 1. Distribution of pre-test and post-test knowledge scores for individuals in the experimental and control groups
Knowledge scores Experimental group
Mean Standard
deviation
Pre-test score 72.00 ±9.88
Post-test score 83.94 ±7.78
Knowledge gain 11.94 ±6.31
Sexual Health 225
about sexual matters (2.8% of informants in both groups). In
terms of a first source of sexual information, 33.4% of the
experimental group indicated the written and visual media
and 31.9% lessons at school, whereas 38.6% of the control
group reported receiving the information from a friend and
27.1% from the written and visual media (P > 0.05).
A total of 51.4% of the experimental group claimed to have
had a sexual experience, whereas in the control group the
proportion rose to 75.7% (P < 0.05). Among women in the
experimental group, the average age of first sexual relations
was 22.80  3.35 and for the men in this group it was
17.81  1.66. The control group, meanwhile, showed average
ages for women and men of 20.52  2.14 and 18.26  2.58
respectively. Among those who had had sexual relations, 35.1%
of the experimental group and 28.3% of the control group
reported having their first sexual experience between the ages
of 15 and 17, while for 40.5% of the experimental group and
45.3% of the control group this age was between 18 and 20.
For 62.2% of the experimental group and 41.5% of the
control group this experience occurred with their boyfriend
or girlfriend, but 24.3% of the experimental group and 34.0%
of the control group this happened with a sex worker in a brothel.
From the point of view of differences between the two sexes
in terms of their first sexual experience, for 55.2% of women
this was with their fiancé, and 44.8% with a boyfriend, whereas
for 52.5% of men it was with a girlfriend, for 42.6% with a
prostitute working in a brothel, and 4.9% with their fiancée
(P < 0.001).
(3) Level of knowledge about sexual issues
(pre-test–post-test)
There was not a statistically significant difference in terms of
average pre-test scores between the experimental and control
groups. However, there was a statistically significant difference
between the groups (experimental group = 11.94  6.31, control
group = 2.11  3.38) in terms of gain in knowledge in the post-
test results (Table 1). There was not a statistically significant
difference between men and women in pre-test and knowledge
gain scores, but in terms of post-test scores there was found to be
a statistical difference between them.
(4) Sexual satisfaction
The GRISS total raw averages were compared among
the women (experimental group = 24.50  10.65; control
group = 32.62  12.88) and among the men (experimental
group = 19.68  9.68; control group = 21.88  10.11).
The points scores collected were then converted into a
standard point score. Among the women, for the ‘female
avoidance’ subscale of the form, the average scores were
Control group Statistics
Mean Standard P
deviation
70.85 ±9.29 t = –0.70; P = 0.479
72.97 ±8.94 t = 7.80; P = 0.001
2.11 ±3.38 t = 11.60; P = 0.001
226 Sexual Health B. K. Vural and A. B. Temel

2.83  1.87 for the experimental group and 3.97  2.24 in the
control group. In the ‘female dissatisfaction’ subscale, the
experimental group scored on average 2.13  1.09, whereas
the control group averaged 3.28  1.79. The ‘non-
communication’ subscale saw an average score of 3.30  1.76
for the experimental group compared with 4.51  1.90 in the
control group. The experimental group scored 5.05  1.70
compared with the control group’s 5.88  1.54 in the
‘vaginismus’ subscale (P < 0.05). In terms of average overall
scores, there was a statistical difference (P < 0.05) between the
women in the experimental group (2.36  1.70) and those in the
control group (3.57  1.92; Table 2).
As for the men, their average points scores were as follows:
in the ‘non-communication’ subscale, the experimental group
averaged 3.02  1.76 and the control group 3.28  2.26; in the
subscale on premature ejaculation, the average score for the
experimental group was 3.97  1.84, whereas for the control
group it was 3.97  1.72; under ‘impotence’ the experimental
group had an average score of 3.50  1.59 and the control group
4.05  2.42 (P > 0.05). In terms of average points scored, there
was not a statistically significant difference (P > 0.05) between
men in the experimental group (3.37  2.05) and those in the
control group (3.83  2.13) (Table 3).
Examination of Fig. 1 reveals that the sexual satisfaction
scores of 80.6% of the women in the experimental group and
77.1% in the control group were below the cut-off point and
these women’s sex lives were therefore identified as problem-
free. In terms of the points under each subscale heading, the
subscale that indicated the fewest problems for women in both
the experimental and the control groups related to anorgasmia.
The subscale showing the highest number of problems in the
experimental and control groups, with a figure of 85.7% was that
relating to vaginismus (see Fig. 1).
As can be seen in Fig. 2, the sexual satisfaction scores of
63.9% of the men in the experimental group and 71.4% of
men in the control group were below the cut-off point and
these men were therefore identified as having problem-free sex
lives. In terms of the subscale, it was established that none of
the men in the experimental and control groups were completely
trouble-free. In the experimental group, the subscales that
most men indicated as being problematic were ‘infrequency’
and ‘impotence’ (33.3%), whereas in the control group
‘impotence’ (45.7%) was the most problematic area.
Moreover, 67.85% of men whose wives reported having
problems in the vaginismus subscale experienced impotence.
(5) Sexual myths
The rates of acceptance of sexual myths before counselling
(pre-test) were 27.87% for the experimental group and 37.03%
in the control group. Four months into marriage (post-test) the
rate fell to 23.51% in the experimental group, whereas the
control group saw a drop to 36.66%.
The pre-test–post-test results of individuals in the
experimental and control groups relating to sexual myths
were compared in their groups using the c2 test (McNemar) –

Table 2. Distribution of women’s average scores on the ‘Golombok–Rust Sexual Satisfaction Scale’

Golombok–Rust Sexual Experimental group Control group Statistics

Satisfaction Subscale Women Women P
Mean Standard Mean Standard
deviation deviation
Female avoidance 2.83 ±1.87 3.97 ±2.24 t = –2.32; P = 0.023
Female dissatisfaction 2.13 ±1.09 3.28 ±1.79 t = –3.24; P = 0.002
Non-communication 3.30 ±1.76 4.51 ±1.90 t = –2.77; P = 0.007
Female non-sensuality 2.63 ±1.64 2.91 ±1.91 t = –0.65; P = 0.517
Infrequency 3.58 ±1.59 4.25 ±2.03 t = –1.55; P = 0.126
Vaginismus 5.05 ±1.70 5.88 ±1.54 t = 0.91; P = 0.035
Anorgasmia 2.68 ±1.02 2.86 ±0.96 t = 0.74; P = 0.459
Overall scores 2.36 ±1.70 3.57 ±1.92 t = –2.79; P = 0.007

Table 3. Distribution of men’s average scores on the ‘Golombok–Rust Sexual Satisfaction Scale’

Golombok–Rust Sexual Experimental group Control group Statistics

Satisfaction Subscale Men Men P
Mean Standard Mean Standard
deviation deviation
Male avoidance 2.41 ±1.71 2.25 ±1.66 t = 0.39; P = 0.692
Male dissatisfaction 1.72 ±0.91 1.71 ±1.01 t = 0.03; P = 0.972
Non-communication 3.02 ±1.76 3.28 ±2.26 t = –0.53; P = 0.594
Male non-sensuality 2.00 ±1.30 2.14 ±1.80 t = –0.38; P = 0.703
Infrequency 3.69 ±2.02 3.17 ±1.50 t = 1.23; P = 0.220
Premature ejaculation 3.97 ±1.84 3.97 ±1.72 t = 0.00; P = 0.999
Impotence 3.50 ±1.59 4.05 ±2.42 t = –1.14; P = 0.259
Overall scores 3.37 ±2.05 3.83 ±2.13 t = 0.92; P = 0.356
Premarital sexual counselling program Sexual Health 227

120

94.4 97.2 97.1

100
85.7
80.6 83.3
74.3 80.0
77.1 77.8
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54.3
60
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Experimental group – problem-free Control group – problem-free

Fig. 1. Sexual dysfunction among women.

120

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88.9 88.6
85.7
82.9
77.8
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Experimental group – problem-free Control group – problem-free

Fig. 2. Sexual dysfunction among men.

two related samples. There was not a statistically significant 13 and 15 were found to be statistically significant (P < 0.05).
difference between the pre-test–post-test responses of No statistically significant differences were found for the
individuals in the experimental group for myths 1, 2, 3, 4, 6, pre-test–post-test results among members of the control group
8, 9, 10, 12 and 14, whereas the differences for myths 5, 7, 11, (P > 0.05).
228 Sexual Health
(6) Reproductive and sexual health of couples during
marriage – attitudes related to sexual health
Three women in the experimental group and five in the control
group reported having experienced immediate and lasting pain
as well as excessive bleeding at their first sexual relation. In the
period after getting married, three of the seven pregnancies in
the experimental group and four of the 10 in the control group
were planned pregnancies. A total of 69.4% of couples in the
experimental group and 74.3% of those in the control group
reported using some form of contraceptive (P > 0.05). For 40%
of couples in the experimental group and 42.3% of couples
in the control group this was an oral contraceptive; 32.2% of
couples in the experimental group and 34.6% in the control
group reported using condoms. One woman and one man in
the control group were diagnosed with a sexually transmissible
disease after getting married.
Discussion
It was found that a large proportion of participants in the
study were able to talk about sexual issues without hesitation
despite the fact that it is generally considered taboo to talk
about sexual matters in Turkish society. It is suggested that
the high socioeconomic and educational levels of the couples
in the study allowed them to overcome this social barrier. In a
study conducted among university students it was also
shown that a large majority of them (90.0%) were prepared
to talk about sexual issues.45 Members of both experimental
and control groups generally preferred to talk to friends about
matters related to sex, while the proportions of participants
who either talked to their parents about sexuality or
mentioned their parents as a first source of sexual information
were relatively low. In a study carried out by Ero
glu and
Gölbaşının, 37.6% of parents were said to be comfortable
with talking to their children about sexuality.46 According to
research carried out by the Association for Sexual Education,
Treatment and Research (CETAD-2006) among a sample of
1537 people, friends and acquaintances were the most
important source of information about sex (40% during
childhood, 51% during puberty and 34% as adults).47 Data
gathered by the World Health Organization in developed
countries revealed that young people are most likely to find
out information about sexual matters from friends and the
media; parents were not found to be a primary source of
such information.48 Ideally, children’s and adolescents’
sexual education should start in the family and continue with
formal programs in school. However, because many parents in
Turkey have not received formal education about sexuality, they
are not well enough informed. In contrast, studies carried out in
developed countries have shown that most parents are able to
discuss sexual issues with their children,49,50 which reflects
different cultural viewpoints on sexuality.
Statistically speaking, men have a first sexual experience at
an earlier age than women. While the findings on the age of first
sexual experience for men are similar to those in other studies,
those for women are higher than reported in the literature. In
Vargün’s study, first sexual experiences were shown to coincide
with the first year of entry into high school and university.45 The
Association for Sexual Education, Treatment and Research’s
B. K. Vural and A. B. Temel
study found the average age of first sexual experience for
women to be 19.5 and for men 19.0. Another finding was
that 81% of men and 68% of women had their first sexual
experience before the age of 20.47 Şen et al. found that 46.2%
of final year university students had not had any sexual
experience.51 Another study found that 34% of informants
had their first sexual experience between the ages of 16 and
20, and 87% stated that a first sexual experience should be
before marriage.52 In traditional, patriarchal societies, while
men are expected to engage in sexual relationships before
marriage, and there are open attitudes to this, for women this
is seen as something undesirable and shameful. However, it is
noticeable that attitudes to sexuality have changed in line with
changes in lifestyle related to urban life and developments in
social norms.
In common with other findings in the literature,31 this study
established that approximately half of the men paid for their first
sexual experience, whereas women had their first experience
with someone who they felt close to such as a boyfriend or
fiancé. Soylu found that the percentage of men who had their first
sexual experience in a brothel was 67.5%.53
Although the difference between the pre-test scores for the
experimental and control groups related to knowledge of sexual
issues was not found to be statistically significant, the average
post-test scores for the experimental group indicated a gain in
knowledge. It is suggested that this result may have been
affected by the higher levels of education of the respondents
who live in big cities. The fact that respondents have been made
aware of issues raised by the pre-test may result in a change in
their responses in the post-test.54 In another study of adolescents,
their average scores before sexual health education were
62.7  13.3, but afterwards their averages rose to 73.7  11.8.55
Among the women, the GRISS points averages of those in
the experimental group were lower than both average total
scores of the women in the control group and standards
established in other studies. This result could be explained by
the positive effect of the pre-marital counselling program on the
experimental group.
In terms of the GRISS subscales scores, for the women in
both the experimental and the control groups, the only subscale
that averaged above the cut-off point of 5 points was the one
relating to vaginismus. Important factors leading to these high
scores are thought to be continuous high anxiety levels,
women’s lack of trust in their spouses, and exposure to
authoritarian and oppressive attitudes in the family before
marriage.56 Because vaginismus prevents one of women’s
most important functions, having children, it can jeopardise
both women’s and the family’s place in society.
Among the women in the control group, no matter how much
below the dividing line they were in the female avoidance,
dissatisfaction, non-communication, female non-sensuality,
infrequency, vaginismus and anorgasmia subscales, their
scores were still higher in all subscales than those of the
women in the experimental group. This finding shows that
the women in the control group experienced proportionally
more difficulties in their sex lives and had more sexual
problems. It is thought that the lower scores of women in the
experimental group, especially in the female avoidance,
dissatisfaction, non-communication and vaginismus, may
Premarital sexual counselling program
reflect the positive effects of the sexual counselling program.
Based on these findings of women in the experimental group
compared with the women in the control group it is possible
to hypothesise that newly married women who receive a
pre-marital sexual counselling program show higher levels of
sexual satisfaction. However, since a pre-test was not applied in
this study, a correct scientific finding would be that the result
cannot be solely related to the effect of the nursing initiative.
Among the men, although the overall average GRISS scores
do not pass the dividing line for any subscale, there are
differences in the order of the highest scores for the two
groups: the experimental group scored highest in premature
ejaculation, infrequency, and impotence respectively, whereas
the top three subscales for the control group in terms of scores
were impotence, followed by premature ejaculation and then
infrequency. According to the literature,57 in evaluating research
results for men, premature ejaculation is the subscale that
generally scores the highest, and therefore premature
ejaculation can be evaluated as the most common problem
suffered by men. Masters and Johnson found that anxiety and
an inability to establish sexual relations played an important
role in premature ejaculation.58
This study found higher values than expected in the non-
communication subscale for both men and women. There is a
significant relationship between couples’ communication about
sexual matters and their marital happiness. Cupah and
Comstock, in a study carried out on a normal sample, found
a significant relationship between satisfactory communication
on sexual matters and marital happiness.59
In line with the findings, the hypothesis that newly married
men who follow a pre-marital sexual counselling program have
higher levels of sexual satisfaction than men in the control group
was rejected.
The GRISS findings indicated that the majority of women in
the experimental and control groups had problem-free sex lives.
The proportion of women established by the research findings as
having a problem-free sex life was higher than research results
from studies carried out both in Turkey and abroad.6,60 62
In terms of the subscale scores, the proportion of women in
both experimental and control groups who scored highly in the
vaginismus subscale was high compared with married women in
the population as a whole. It has been established that the most
common reason for consulting a sexual dysfunction clinic in
Turkey is for vaginismus.6,40,56,63,64 A possible explanation for
the high percentages in the vaginismus subscale may be by
reference to cultural values. Tu
grul and Kabakçı, in drawing
attention to the fact that the frequent incidence of vaginismus
conditions is linked to culturally specific views, emphasise that
the taboo of premarital sex and the requirement to preserve
one’s virginity until the wedding day can turn the wedding
night into a nightmare, especially for couples who come from
traditional families.56 During socialisation, looking at and
touching of sexual organs is seen as shameful or sinful, and
these parts of the body are considered different from other
organs in a negative way, which leads individuals to avoid
such behaviours as far as possible.
It was found that a quarter of the women in the experimental
group and nearly half of those in the control group experienced
difficulties in the area of sexual communication. In Kuidaki’s
Sexual Health 229
study one-third of women were shown to have experienced
problems in this area.6 Therefore it is possible to say that the
quality of sexual communication, while making sexual relations
more enjoyable, is not sufficient to affect marital happiness.
It was also established that one-quarter of the women in
the experimental group experienced difficulties in the areas of
frequency and avoidance compared with nearly half of those in
the control group in the area of frequency and one-third in
terms of avoidance. This compares with Kuidaki’s finding that
one-third of women experienced problems in terms of frequency
of relations.6 For women factors such as housework, amount
of professional work and life tempo can lead to avoidance
behaviours and reduction in frequency of sexual relations.
Most of the women in the experimental and control groups
did not report problems in the area of non-sensuality. This
contrasts with Kuidaki’s finding that a relatively significant
proportion of women (67.8%) experienced problems related
to this subject.6 It is, however, possible to say that a small
proportion of women in the study responded negatively to
questions asking about touching their own or their spouse’s
sexual organs but positively to questions relating to embracing
or caressing.
It was also established in the study that hardly any of the
women reported experiencing problems reaching orgasm and a
large majority professed themselves satisfied with their sexual
relations. Kuidaki’s study similarly found that 96.6% of women
did not have orgasm problems and 90.5% expressed themselves
satisfied with their relationships, which indicated that sexual
satisfaction improved marital relations.6 The research results are
compatible with studies carried out in other developed
societies.62 Although systematic research has not been carried
out on this topic in Muslim societies, Lavee reports that there is a
high level of orgasmic dysfunction in these societies.65 Because
participation in this study was of a voluntary nature, it seems
likely that women who had sexual problems did not participate
in the study out of concerns that these problems could be
discovered and as a result it is thought that this resulted in
the findings of a lower incidence of sexual problems among the
group compared with women in society as a whole.
Approximately two-thirds of the men in the experimental
and control groups were shown to have problem-free sex lives.
Lauman et al. in a society-based study found sexual dysfunction
to be widespread among both sexes, varying between 10% and
52% of men.61 This is in line with findings in the available
literature.
Although the most problematic areas for men in the
experimental and control groups were found to be impotence
and premature ejaculation, it is interesting to note the finding that
all of the men professed to be satisfied with their relationships.
In another study, patients suffering erectile dysfunction were
found to experience a drop in sexual satisfaction and occasional
premature ejaculation in addition to their erectile problems.66
Similarly, Gülçat found a significant relationship between
impotence, premature ejaculation, frequency of sexual
relations and sexual satisfaction, and also that the wives of
patients with erectile dysfunction had high scores in the subscale
relating to vaginismus.67 Because the male informants in this
study were younger than the population average, the incidence
of impotence was found to be lower than in the literature.
230 Sexual Health
However, it is thought that the finding that 67.85% of men
whose wives had vaginismus experienced impotence was due
to the fact that their wife’s problem, instead of motivating their
husbands, inhibited them, contributing to the duration of the
impotence.
Although according to the findings there is not a statistically
significant difference between the two groups, the fact that men
in the experimental group reported fewer problems relating to
sexual communication, avoidance, non-sensuality, premature
ejaculation and impotence is thought to reflect the positive
effect of the sexual counselling received by this group.
Although the experimental number of sexual myths accepted
by the experimental group dropped by 4.6% after the sexual
counselling program, for the control group the figure fell by only
0.37%. This result is thought to show that sexual myths are
somewhat deeply-rooted in Turkish society and therefore
resistant to challenge; it is a small change compared with
findings in the literature.31,53,68,69 It also shows the negative
effects of sexual myths on both men’s and women’s sex lives,
playing a significant role in sexual dysfunction and its duration.
Challenging and overcoming these myths can contribute to the
solution of sexual problems.31
In terms of couples experiencing problems with their first
sexual relations, the experimental group reported a lower rate of
problems than both the control group and findings in the
literature. In the study, an individual’s sexual experience was
regarded as a positive factor, helping them to overcome shyness
in discussing sexual issues and enabling them to benefit from
different sources of information. A different study found that
22% of first sexual relations were not consummated for reasons
of fear, tension, pain, and reluctance.47
A total of 69.4% of couples in the experimental group
and 74.3% of those in the control group reported using some
form of contraception. According to the Turkish Population and
Health Report the usage of some form of contraception is
71%.70 This result is consistent with the country in general.
The percentage of the experimental group who used
contraceptives was found to be lower than that of the control
group. However, the difference was not statistically significant.
In fact, the aim of the pre-marital sexual counselling program
was not to promote birth control. It is thought that this result was
due to the fact that the couples in both groups were at an age
when they were able to have children and also due to their
personal preferences for using contraceptives.
Conclusions
The research finding was that, in line with expectations, the
couples in the experimental group who followed the pre-marital
sexual counselling program had higher sexual satisfaction scores
than those in the control group. It is suggested that this result
reflects the positive effect of the premarital counselling program
as a nursing intervention. However, it was not possible to greatly
influence individuals’ in terms of sexual myths.
Taking cultural characteristics into consideration, giving
couples pre-marital sexual counselling as well as challenging
individuals’ false information and beliefs can lead to less
problematic and more satisfying sex lives and happier
married life.
B. K. Vural and A. B. Temel
It is suggested that planning studies of groups according to
different ethnic and socioeconomic make-up, and living area
(country, city) will be an effective next step. Also, from the point
of view of increasing the reliability of findings, future studies
need to be conducted with larger sample groups.
It is also proposed to evaluate the levels of sexual satisfaction
of couples who are within 6 months of their wedding day and
follow the pre-marital counselling program, both after they
receive long-term counselling and then again between 4 and
6 months into the marriage, after the first year and in the
third year of marriage through follow-up counselling.
More research is also needed into the reasons why men who
received the pre-marital sexual counselling showed lower than
expected levels of sexual satisfaction compared with women,
with the aim of identifying other means of increasing men’s
levels of sexual satisfaction.
It is further recommended that the pre-marital sexual
counselling program is given via group training.
It is thought that an intervention plan prepared within the
framework of the IMB model will guide nurses in helping
recently-married couples achieve sexual satisfaction. It may
also be beneficial to compare the effectiveness of conducting
sexual education programs with groups of different cultural
characteristics found in society through individual and/or
group training, using multi-disciplinary professionals, and
increasing the number of sessions. Moreover, increasing the
numbers of male trainers and counsellors on education and
counselling programs intended for men may increase the
effectiveness of such programs.
It is thus recommended that future studies investigate: the
effects of an increase in the number of sessions of the sexual
counselling training programs on men’s sexual satisfaction; the
effects of programs led by multi-disciplinary professionals on
men’s sexual satisfaction; and different strategies for defining
sexual satisfaction among men.
Conflicts of interest
None declared.
Acknowledgements
Thanks to the people who gave up their time to participate in the study and
thanks also to Murat Kıray and the organisers of the Newspaper Aynalı
Pazar. All funding was through internal sources only.
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Manuscript received 29 August 2008, accepted 5 March 2009