Effect of Expressive Writing on Sexual and Marital Satisfaction in Women with Multiple Sclerosis

¹ Master of Counseling in Midwifery, Faculty of Nursing and Midwifery, Iran University of Medical Sciences, Tehran, Iran

² Nursing and Midwifery Care Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran

³ Department of Brain and Cognitive Sciences, Royan Institute of Stem Cell Biology and Technology, Jahad, Tehran, Iran

*Corresponding author: Leila Amini, Nursing and Midwifery Care Research Center, Health Management Research Institute, Iran University of Medical Sciences, Tehran, Iran. Email: amini.l@iums.ac.ir

EXTENDED ABSTRACT

Background

Multiple sclerosis (MS) is a chronic autoimmune neurological disorder of the central nervous system that affects approximately 2.8 million people worldwide [1]. In Iran, reported prevalence ranges from 14.7 to 101.4 per 100,000 population, and the disease disproportionately affects women, particularly during young adulthood and the reproductive years [2-4]. MS can impair reproductive and sexual health through neurological, hormonal, psychological, and functional pathways. Sexual dysfunction has been reported in more than 60% of women with MS and may include reduced sexual activity and desire, diminished genital sensation and lubrication, and orgasmic difficulties [9, 10]. These problems may occur early in the course of the disease and can adversely affect sexual satisfaction, intimacy, marital relationships, and overall quality of life [11-14]. Psychological approaches have therefore been explored alongside routine medical care. Expressive writing, which encourages individuals to translate emotionally meaningful experiences into written language, has shown beneficial effects on body image, sexual dysfunction, anxiety, stress, and broader health-related outcomes in different populations, including people with MS [8, 15-19]. Because few studies have directly examined sexual and marital satisfaction as outcomes of expressive writing in women with MS, the present randomized clinical trial evaluated whether a brief home-based expressive-writing intervention could improve sexual satisfaction and marital satisfaction in married women with MS.

Methods

This randomized clinical trial with a control group was conducted among married women with MS attending a selected specialized neurology and MS clinic in Tehran, Iran. A total of 104 women aged 18-45 years were enrolled and randomly allocated, using a random-number table, to intervention and control groups of 52 participants each. Eligibility required at least basic literacy, at least six months since MS diagnosis, at least one sexual intercourse episode during the preceding month, no pregnancy or breastfeeding, no other chronic disease apart from MS, and no use of psychotropic drugs, alcohol, narcotics, hallucinogens, or medications affecting sexual desire or function in either partner. Women also had to report no major stressful event during the previous three months and needed access to virtual communication platforms for follow-up. Participants were free to withdraw at any stage.

Data were collected using a demographic questionnaire, the Larson Sexual Satisfaction Questionnaire, and the ENRICH Marital Satisfaction Questionnaire. The Larson instrument contains 25 items covering desire for sexual relations, sexual attitude, sexual quality of life, and sexual compatibility; total scores range from 25 to 125, with higher scores indicating greater sexual satisfaction. Its Persian version had previously demonstrated acceptable reliability [21]. The 35-item ENRICH instrument evaluates marital satisfaction, communication, conflict resolution, and idealistic distortion, with higher scores indicating greater marital satisfaction; the Persian version has also demonstrated acceptable reliability [22, 23].

After baseline assessment and individual explanation of the intervention, women in the intervention group performed self-directed expressive writing at home for four consecutive weeks, at least one day each week. They were instructed to use a “morning pages” approach, writing freely for at least 30 minutes about feelings, thoughts, and emotions without concern for spelling or composition, preferably in a quiet setting soon after awakening. The researcher used scheduled telephone contacts to remind participants about the writing process. At the end of the four-week period, both groups completed the sexual and marital satisfaction questionnaires again. Data were analyzed using SPSS version 20 with independent and paired t tests, chi-square tests, and nonparametric equivalents as appropriate. Statistical significance was defined as P<0.05. The study was approved by the Iran University of Medical Sciences ethics committee (IR.IUMS.REC.1399.716), registered in the Iranian Registry of Clinical Trials (IRCT20110629006917N5), and conducted after written informed consent was obtained.

Results

The intervention and control groups were homogeneous for all assessed baseline characteristics, including participant age, spouse age, age at marriage, age at disease onset, number of children, educational level, spouse education, employment, spouse occupation, economic status, and previous sexual education. Mean participant age was 32.35±6.33 years in the control group and 34.00±6.30 years in the intervention group; mean spouse age was 37.75±6.84 and 38.63±7.09 years, respectively. Most participants and their spouses had university education, and most reported relatively favorable economic status.

Before the intervention, sexual satisfaction did not differ significantly between the groups (control 70.25±2.98 versus intervention 69.76±2.33; t=-1.162, df=102, P=0.248). After four weeks, sexual satisfaction was significantly higher in the intervention group (78.97±6.71) than in the control group (72.18±11.88; t=3.358, df=88, P=0.001). Within-group analysis showed a significant increase in sexual satisfaction in the intervention group (t=-8.435, df=45, P<0.0001), whereas the change in the control group was not significant (t=-1.272, df=45, P=0.210). Marital satisfaction was comparable at baseline (control 112.55±6.90 versus intervention 113.07±6.02; t=0.408, df=101, P=0.684). At follow-up, the intervention group had a significantly higher marital satisfaction score than the control group (115.79±7.31 versus 110.52±4.26; t=4.130, df=86, P<0.0001).

Table 2. Comparison of sexual and marital satisfaction scores before and after the intervention.

The mean change in sexual satisfaction was 9.21±7.41 in the intervention group compared with 2.39±12.44 in the control group (t=-3.81, df=88, P=0.002). Marital satisfaction increased significantly from baseline in the intervention group (t=-2.242, df=43, P=0.030), while the control group showed a significant decrease (t=5.696, df=43, P<0.0001). The mean change in marital satisfaction was +2.43±7.20 in the intervention group and -3.16±3.68 in the control group (t=-4.589, df=64.03, P<0.0001). These findings consistently favored expressive writing for both study outcomes.

Table 3. Comparison of mean changes in sexual and marital satisfaction scores after versus before the intervention.

Conclusion

A four-week, home-based expressive-writing intervention performed at least once weekly improved both sexual satisfaction and marital satisfaction in married women with MS. These findings support expressive writing as a complementary supportive intervention for women with MS. The study was conducted during the COVID-19 pandemic, and the psychological effects of the pandemic could not be controlled; this limitation should be considered when interpreting the findings. Larger studies are warranted to confirm the observed improvements in sexual and marital satisfaction.

Keywords: Multiple Sclerosis, Sexual satisfaction, Written expression

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