Hypothesis / aims of study
Many initiatives and advances have existed in the world in the attempt to demystify the theme of sexuality, however, it continues to be surrounded by a series of paradigms and taboos that end up influencing the sexual health of all people, especially women because of historical issues , which involves the development of sexuality in this genre. Cognitive-behavioral psychotherapy (CBT) is a psychotherapeutic approach that favors the restructuring of dysfunctional thoughts and beliefs and, although it is indicated as effective in the treatment of female sexual dysfunctions, no research has been found to prove its efficacy when compared to sexual education. Thus, this study raises the hypothesis that CBT can have a positive impact on the treatment of sexual dysfunctions with repercussions on the perception of improvement in the quality of life of the women served in this protocol.
Study design, materials and methods
Randomized Clinical Trial that made an evaluation of the results using two methods: qualitative (Content Analysis) and quantitative. Women between the ages of 18 and 59 years old were referred by a gynecologist with a diagnosis of Psychogenic Sexual Dysfunction and with a FSFI score of less than or equal to 26. Those with BECK (BDI, BAI and BHS) scores were excluded from moderate to moderate and severe, patients with other diseases of the pelvic floor and with diagnostic suspicion of other psychiatric pathologies.
Protocol of Intervention:
The Control Group protocol consisted of an Initial Individual Evaluation, 8 individual sessions of sex education in which the patients were informed about: physiology of the male and female genital organs, the relevance of positions in sexual relations, the importance of body self-focus, genital self-focusing, masturbation, cultural aspects that interfere with sexuality and sexual function, the difference between sexual function and sexuality, and a Final Individual Evaluation. These encounters occurred weekly and had an average duration of 30 minutes.
The Intervention Group consisted of an Initial Individual Evaluation, 08 sessions of Cognitive-Behavioral Psychotherapy, based on the principles and techniques of CBT
(Psychoeducation, Identification and Restructuring of Automatic Thoughts, Identification and Restructuring of Intermediate and Central Beliefs, Prevention of Relapse) and a Final Individual Evaluation. The sex education procedure was included in the protocol of this group and occurred at the beginning of the CBT sessions. These encounters occurred on a weekly basis and averaged 50 minutes in duration.
In the Qualitative Study (content analysis), the semi-structured interview was used as data collection technique, since each session of both groups had pre-established guiding topics to guide the researcher throughout the service.
The Quantitative Study used the FSFI numerical scores and their domains, as well as the numerical scores of the Beck scales (BDI, BAI and BHS) applied before and after the test.
In the Qualitative Study, six main categories were selected to be analyzed, since they were considered of greater relevance for the establishment of the quality of life of the studied population. They are: Sexual Education, Affective / Conjugal Area, Family Context, Social Area / Recreation, Body Image / Self Care and Sexual Function.
In the Quantitative Study the Mann-Whitney Test was used for the statistical analysis of numerical scores of the FSFI and its Domains, as well as the numerical scores of the Beck Scales (BDI, BAI and BHS) before and after intervention.
From the Qualitative Methodology (content analysis), it was observed that: All the patients (n = 21) reported not having sexual education, they presented impairment of the category Sexual Function, as well as in the Social / Leisure area.
Intervention Group (n = 11): Regarding the social / leisure area, it was observed that throughout the visits all patients (n = 11) started to include this type of activities in their daily lives. In the category Body image & self care, nine patients (n = 09) demonstrated an increase in the relation of care and satisfaction with regard to their body. Throughout the CBT process, it was found that all patients (n = 11) in the intervention group started to develop the activities of genital self-focusing with regularity in their life dynamics. Nine women (n = 09) underwent masturbation and / or improvement in FS. Regarding the affective / marital area, two women (n = 02) developed strategies and sought self-protection measures to cope with their partner's aggressive behavior, five (n = 05) began to identify affinities with their partners, favoring the development of recreational activities between the couple. Six women (n = 06) reported that they began to plan for the future together with their partner. With regard to the Family Context it was possible to
perceive that the patients developed a greater assertiveness in the interpersonal relations with close relatives (parents, brothers, children, husbands).
Control Group (n = 10): No relevant changes were observed in the patients' discourse regarding thoughts, emotions and behavior in relation to the Social / Leisure Areas; affective / conjugal; Family context. Regarding Body Image & self-care, only one (n = 01) reported having initiated genital self-focusing activities. When the patient was questioned about the Sexual Function, none of the patients reported improvement.
Considering the quantitative methodology, statistical significance was not revealed for FSFI (general score) and its FSFI domains (Desire, excitation, lubrication, orgasm, satisfaction, Pain), as well as, there was no statistically relevant difference in the scales analysis BECK (BDI, BAI, BHS). Mann-Whitney test was used to perform the data analysis.
Interpretation of results
The results of the qualitative analysis point to a great influence of CBT in the rehabilitation of aspects of the life of women in the intervention group, represented in this study by the categories: Sexual Education, Affective / Conjugal Area, Family Context, Social Area / Leisure, Body Image / Self Care and Sexual Function. Based on the discourse analysis of the study participants, it was possible to perceive that this change is directly related to the cognitive restructuring that starts to generate more functional thoughts and emotions and, therefore, physiological reactions and behaviors more coherent with these and with the personal goals of the patient.
The fact that the quantitative analysis did not reveal statistical significance between the FSFI scores (general and domains), as well as the Beck scales (BDI, BAI and BHS), is directly related to the power of this sample, since it is a study preliminary, the N established in the sample calculation of the project has not yet been reached.
However, the data of this research point to the need to use qualitative and quantitative methods for psychological and subjective issues, since they have historical, social, cultural, economic and political determinations, and the use of a quantitative methodology would make aspects of extreme relevance to the quality of life and sexual function not be perceived, studied and considered.
Using the qualitative method (content analysis), the Positive Influence of CBT in the rehabilitation of the categories analyzed in this study (Sexual Education, Affective / Conjugal Area, Family Context, Social Area / Leisure, Body Image / Self Care and Sexual Function), due to the cognitive restructuring of dysfunctional beliefs.
However, from the quantitative analysis it is evident the necessity of a sample with more power for more precise conclusions.