Pregnancy and Sexual Relationships Study Involving Women and Men (PASSION Study)

ORIGINAL RESEARCH

Pregnancy and Sexual Relationships Study Involving wOmen and meN (PASSION Study)

Denicia S. Dwarica, MD,1 Gretchen G. Collins, MD,2 Colleen M. Fitzgerald, MD,3 Cara Joyce, PhD,4 Cynthia Brincat, MD, PhD,5 and Mary Lynn, DO3

ABSTRACT

Introduction: Sexual satisfaction is believed to decrease during pregnancy; however, the effect of pregnancy on the sexual relationship in a couple is not well studied. Aim: To assess for sexual dysfunction in heterosexual couples during pregnancy. Methods: We performed a cross-sectional study of heterosexual pregnant women in the third trimester and their cohabitating partners. Main Outcome Measures: Sexual satisfaction in heterosexual couples during pregnancy was assessed with a self-reported questionnaire, the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) questionnaire. Results: A total of 53 couples met eligibility criteria, and nearly all of those approached participated (52 of 53 couples). All couples were enrolled at or after 35 weeks’ gestation. The mean age was 29.0 ± 6.4 and 31.3 ± 6.9 years for women and men, respectively. 60% of couples were married, and the remainder were cohabitating and in a committed relationship. When analyzing the results of the GRISS questionnaire for both partners, a significant difference was seen in mean avoidance of sex between women and men (3.31 vs 2.63; P ¼ .047) and non-sensuality (3.54 vs 2.75; P ¼ .040). Women reported more of a decrease in communication about sex when compared with their partners (3.79 vs 3.23; P ¼ .047). Vaginismus was more problematic during pregnancy than before (mean ¼ 4.17), and frequency of intercourse was decreased (mean ¼ 4.93) based on calculated GRISS scores. Clinical Implications: Pregnant couples reported decreased frequency of intercourse and more pain with in- tercourse in women. Women were more likely to avoid intercourse and reported more problems with communication regarding sexual needs. Strength & Limitations: This study is the first to assess both partners in pregnancy. Due to the nature of the study, we were unable to assess other factors affecting the relationship that may result in sexual dysfunction, there was no control group, and the results are limited to heterosexual couples. Conclusion: Overall sexual satisfaction and function were not problematic for these couples during pregnancy based on the GRISS scale. Dwarica DS, Garbe Collins G, Fitzgerald C, et al. Pregnancy and Sexual Re- lationships Study Involving WOmen and MeN (PASSION Study). J Sex Med 2019;XX:XXXeXXX. Copyright 2019, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved. Key Words: Sexual Satisfaction; Sexual Dysfunction; Pregnancy; Couple

INTRODUCTION patient discomfort with sexual topics, a lack of provider training Female sexual dysfunction affects 10%e40% of women but is in the area of sexual medicine, and a perceived lack of time to e often overlooked by patients and providers.1 4 Barriers, which address these concerns during a typical prenatal visit. One study contribute to a lack of screening for sexual dysfunction, include that evaluated the prevalence of self-reported sexual problems in

Received October 19, 2018. Accepted April 18, 2019. 5Department of Obstetrics and Gynecology, Rush University Medical Cen- 1Department of Obstetrics and Gynecology, University of Oklahoma Health ter, Chicago, IL, USA Sciences Center, Oklahoma City, OK, USA; Abstract was presented as an oral presentation at the 21st Annual Scientific 2Wisconsin Fertility Institute, Middleton, WI, USA; Meeting of the Sexual Medicine Society of North America, November 2015. ª 3Department of Obstetrics and Gynecology, Loyola University Medical Copyright 2019, International Society for Sexual Medicine. Published by Center, Maywood, IL, USA; Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jsxm.2019.04.014 4Department of Public Health Science and Health Promotion, Loyola Uni- versity Chicago Heath Sciences Division, Maywood, IL, USA;

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United States women found that sexually-related personal approximately 15 minutes to complete, evaluates 12 domains distress occurred in 10.8% of women aged 18e44 years.4 (5 female-specific, 5 male-specific, and 2 non-gender-specific). Quality of life is significantly impacted by sexual satisfaction.5 The female version produces a “Total GRISS Female Score,” Sexual satisfaction can fluctuate throughout a relationship and as well as the following subcategories: anorgasmia, vaginismus, with significant life events. non-communication, infrequency, avoidance, non-sensuality, “ Prior studies have demonstrated a decline in sexual activity and dissatisfaction. The male version produces a Total GRISS e ” during pregnancy and the postpartum period.6 10 Factors Male Score, as well as the following subcategories: impotence, contributing to the decrease in sexual activity during pregnancy premature ejaculation, avoidance, non-sensuality, and dissatis- fi include physical discomfort, fear of injury to the fetus, loss of faction. The non-gender-speci c domains were non- interest, physical awkwardness, painful coitus, and perceived lack communication and infrequency, and the scores reported are of attractiveness.11,12 Unfortunately, return to pre-pregnancy calculated from the average of the scores for women and men. sexual function may take up to 2 years.13 Aslan et al14 evalu- Total GRISS scores are calculated based on a survey-provided e ated intercourse frequency and satisfaction in couples before and scoring sheet and resulted in a 1 9 score, with non- e after pregnancy and found that the physical effects of pregnancy problematic relationships scoring between 1 4. The higher the > and the stress of a new infant had long-lasting effects. The third transformed score, the greater the sexual dysfunction. A score 4 16,17 trimester has been found to be an independent variable for indicates a problem of that couple. The GRISS was chosen decreased sexual activity frequency and sexual function.15 because it is validated to capture the sexual relationship of both partners in a heterosexual relationship. There is a paucity of data regarding the sexual satisfaction of partners during pregnancy. Given the importance of intimate The Research Electronic Data Capture web application was relationships for emotional well-being and overall health, this used to manage data. All data were compiled into the Research topic warrants further investigation. The aim of our study is to Electronic Data Capture web application and prepared for sta- assess for sexual dysfunction in heterosexual couples during tistical analysis using SAS 9.4 (SAS Institute, Cary, NC, USA) by pregnancy. a statistician. Descriptive values were reported with percentages. Means and SDs were used where applicable. Significance was defined as MATERIALS AND METHODS P .05 and was calculated using a paired sample t-test. Impact The Loyola University Medical Center Institutional Review of previous pregnancy or body mass index (BMI) on GRISS Board approved this study. We performed a cross-sectional study scores were compared using separate sample t-tests. The corre- of a convenience sample of married or cohabitating couples who lation between years in the relationship and overall GRISS score presented at or after 35 weeks’ gestation to an outpatient was assessed using Spearman’s r. obstetrics clinic or the labor and delivery unit. To be eligible for A previous study examining relationships in couples under- the study, each participant needed to be 18 years old, married going in vitro fertilization found a mean female GRISS score in or cohabitating, planning to deliver at Loyola University Medical the non-sensuality domain of 3.52 (±1.86) and a mean GRISS Center or Gottlieb Memorial Hospital, able to provide informed score in their male partners of 2.59 (±1.47). Given that there is consent, and able to complete a written questionnaire. Partici- no current data in pregnancy regarding the GRISS score, using pants were excluded if they were <18 years old, non-English this previously published work in couples, for 80% power with speaking, or if the male partner was not present at the time of an a of 0.05, we needed a total of 52 couples based on a 2-group recruitment. comparison via a 2-sample t-test (STATA 11.0, College Station, Participants were recruited and consented at our academic TX, USA).18 medical center and its affiliated community hospital by the in- vestigators if they met eligibility criteria from July 1, 2015eFebruary 1, 2016. No patient identifiers were included. RESULTS Participants completed a demographic questionnaire and the Our sample included 52 matched pairs (n ¼ 52 women and Golombok-Rust Inventory of Sexual Satisfaction (GRISS) sur- n ¼ 52 men). 53 couples met eligibility criteria, and 52 of the 53 16,17 vey. We asked participants to answer survey questions based couples approached agreed to participate in this study. All par- on their experience for the entire pregnancy. Consenting male ticipants approached, except for 1 couple, agreed to participate in partners completed similar demographic variables and the GRISS the study. Table 1 describes the participant’s demographics by survey. Each individual was asked to complete their respective sex. The mean age of participants was 29.0 ± 6.4 years in women questionnaires in a separate space to avoid discussion with their and 31.3 ± 6.9 years in men. The mean BMI was 34.4 ± 6.6 kg/ partner. m2 and 31.9 ± 6.9 kg/m2 for women and men, respectively. The GRISS survey is a 28-item, self-administered question- When comparing women and men, 35% vs 48% identified as naire that was developed by therapists to assess for sexual Hispanic, respectively. Most participants were white (56% vs dysfunction in a heterosexual couple. The survey, which takes 52%, women vs men). In our cohort, 60% of the couples were

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Table 1. Demographics >4 signifies a problem in that category. A significant difference Female Male in non-communication scores was seen between women Demographic (n ¼ 52) (n ¼ 52) (mean ¼ 3.79 ±1.75) and men (mean ¼ 3.23 ± 1.73), P ¼ .047. A significant difference was also seen in avoidance ± ± Mean age 29.0 6.4 31.3 6.9 scores between women (mean ¼ 3.31 ± 1.90) and men Mean BMI 34.4 ± 6.6 31.9 ± 6.9 (mean ¼ 2.63 ±1.62), P ¼ .047. Women reported higher non- Ethnicity sensuality scores (mean ¼ 3.54 ± 2.16) compared with men Non-Hispanic 34 (65%) 27 (52%) (mean ¼ 2.75 ± 1.80), P ¼ 0.04. Last, there was a significant Hispanic 18 (35%) 25 (48%) ¼ Race difference in overall scores between women (mean 2.21 ± ¼ ± ¼ Asian 3 (6%) 1 (2%) 1.36) and men (mean 3.04 1.61), P .002 (Table 2). Black or African American 9 (17%) 9 (17%) Female vaginismus was more problematic during pregnancy Alaskan Native or 1 (2%) 1 (2%) than before (mean ¼ 4.17) based on the GRISS scale. In addi- American Indian tion, the frequency of intercourse was decreased (couple White 29 (56%) 27 (52%) mean ¼ 4.93 [5.06 in women, 4.79 in men]) overall as described Prefer not to answer 10 (19%) 14 (27%) collectively by women and men participating in this study Marital status (Table 2). Married 31 (60%) 32 (62%) Living together 21 (40%) 20 (38%) Separate 2-sample t-tests were used to assess whether differ- Education ences in overall sexual activity scores for men and women were College 26 (50%) 20 (38%) associated with the presence of a previous pregnancy. There was Graduate 8 (15%) 7 (13%) no significant difference in history of a previous pregnancy on High 16 (31%) 21 (40%) overall sexual function in women or men. Most couples Technical 2 (4%) 4 (8%) continued having sex at the time of survey, because only 65% of Years with current partner 6.8 ± 5.4 6.8 ± 5.4 women and 79% of men reported there were, at most, occasional Number of pregnancies weeks without sex. The association of years of relationship with 1e2 34 (65%) — overall GRISS was not strong, and the direction of the associa- 3e4 11 (21%) — tion was opposite in men vs women. Women with longer 5e7 7 (13%) — relationships had slightly lower overall GRISS scores Descriptive values are reported with percentage within group in parenthe- (r ¼0.10, 95% CI ¼0.36e0.18, P ¼ .49), and men with ses, as well as means and standard deviations where applicable. longer relationships had higher overall GRISS scores (r ¼ 0.24, 95% CI ¼0.04e0.48, P ¼ .09). married and the mean length of relationships was 6.8 ± 5.4 A 2-sample t-test was used to assess differences in avoidance years, with a range of 1e26 years (Table 1). scores by obesity. The was no significant difference in female Table 2 describes the results for each sexual activity parameter avoidance of intercourse based on obesity (Table 3). measured by the GRISS and compares the results where possible A combined GRISS profile for the couple was created based using a paired sample t-test. All of the individual GRISS sub- on the mean scores of the 52 couples (Figure 1). As previously category scores are reported on a scale from 1e9, where a result stated, a score 4 indicated a problem of that sexual relation- ship.16,17 Based on this criteria, pregnant couples were most affected by infrequency of intercourse (mean ¼ 4.93). Overall, Table 2. GRISS scores most values in the GRISS profile categories were <4, indicating Female Male normal, non-problematic sexual relationships (Figure 1). Survey measure (n ¼ 52) (n ¼ 52) P Infrequency 5.06 ± 1.81 4.79 ± 2.14 .26 DISCUSSION Non-communication 3.79 ± 1.75 3.23 ± 1.73 .047 Avoidance 3.31 ± 1.90 2.63 ± 1.62 .047 Sexual activity and function have been shown to decrease 8e10 Non-sensuality 3.54 ± 2.16 2.75 ± 1.80 .040 during pregnancy. Both women and men have been found Female vaginismus 4.17 ± 2.25 ——to engage in sexual activity for motives such as love, Female anorgasmia 2.63 ± 1.17 —— — ± — Male Impotence 2.71 1.56 Ta b l e 3 . Impact of BMI on female avoidance Male premature — 3.96 ± 1.61 — e P ejaculation GRISS Avoidance Dissatisfaction 2.56 ± 1.47 2.83 ± 1.73 .35 Female obesity .59 Overall 2.21 ± 1.36 3.04 ± 1.61 .002 Ye s ( n ¼ 37) 3.22 ± 1.83 ¼ ± Mean and standard deviation are reported. No (n 15) 3.53 2.13

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Figure 1. Passion Griss Profile. ANORG ¼ female anorgasmia; AVF ¼ female avoidance; AVM ¼ male avoidance; DISF ¼ female dissatisfaction; DISM ¼ male dissatisfaction; IMP ¼ male impotence; INF ¼ average infrequency; NCO ¼ average non-communication; NSF ¼ female non-sensuality; NSM ¼ male non-sensuality; Overall-female ¼ GRISS female overall score; Overall-male ¼ GRISS male overall score; PE ¼ male premature ejaculation; VAG ¼ female vaginismus. Figure 1 is available in color online at www.jsm.jsexmed.org. commitment, and self-esteem.19 In spite of this decrease, our sexual dysfunction and sexual dissatisfaction.26 The couples study demonstrates that the sexual relationship in pregnant identified a decrease in frequency of intercourse as most prob- couples is unaffected by pregnancy. lematic to their sexual relationship during pregnancy. In this study, we used the GRISS questionnaire, a valid and A study conducted in Brazil evaluated women at each safe measurement of sexual function in women, men, and het- trimester using the Female Sexual Function Index survey, which erosexual couples. The survey provides a total score for both men is a similar survey to the GRISS but only focuses on women. and women, as well as subscales for each sex.17 The GRISS This study found that there was a decrease in sexual desire and an received a Grade A recommendation from the International increase in pain during pregnancy, and sexual dysfunction was Continence Society for its appropriateness as a tool for evaluating noted in 73.3% of adult women in the third trimester.27,28 We sexual function as a dimension of overall health-related quality of found that women avoid intercourse more during pregnancy and life among patients with pelvic floor disorders.20 We decided to are more likely to report issues with communication when capture couples in the third trimester, because sexual dysfunction compared with men. Women also identified a greater decrease in has been previously shown to increase throughout pregnancy and sensuality than men. This decrease in sensuality for women was e peaking in the third trimester.14,15,21 24 To our knowledge, this consistent with a prior meta-analysis of 59 studies that showed is the first study that assessed the changes in sexual function that female sexuality significantly decreased in the third during pregnancy for not just women, but also for their male trimester.29 Both partners noted that the greatest issue during partner, as well as the couple. pregnancy was the decrease in frequency of intercourse. A comfortable and satisfactory sexual life during and after Women reported an increase in vaginismus based on the pregnancy is an important aspect of a relationship. This study GRISS definition during pregnancy, which may have also investigated the hypothesis that pregnancy negatively affects contributed to women avoiding intercourse. Our data are sexual function and satisfaction in a heterosexual relationship. consistent with prior studies that demonstrated a significant in- Although there are prior studies that specifically address the fe- crease in dyspareunia and vaginismus during pregnancy.14 male changes in sexual function during pregnancy, there is a Moreover, problems with communication about sexual needs paucity of data regarding the effects of pregnancy on the male was identified during this study, which may make it more partner and the couple together.8 Additionally, the perspective of difficult for the woman to express her discomfort during inter- the male partner will greatly aid in treatment of sexual course. The combination of vaginismus (or dyspareunia) and a dysfunction aimed at the couple as a unit. 25 decrease in communication between partners is very likely to In our study, during pregnancy, women avoided sex more contribute to the decrease in sexual function and frequency that than men. These women also reported less pleasure from was found to be prevalent and distressing to the couples in this touching and caressing while they were pregnant. Our study is study. Interestingly, a prior pregnancy or BMI was not found to consistent with prior studies that assessed sexual dysfunction in affect the sexual relationship in the current pregnancy. women during pregnancy.8 Women described less communica- The male version of the GRISS focuses on specific issues for tion about sex than men and more pain with intercourse. A lack men: impotence (erectile dysfunction) and premature ejacula- of communication about sexual problems is associated with tion.16,17 In our cohort, neither of these sexual dysfunction issues

J Sex Med 2019;-:1e6 Sexual Dysfunction in Pregnant Couples 5 was problematic. This finding is not surprising when considering evidence on factors that affect women and men separately, while that erectile dysfunction increases with age and is found to be offering reassurance that satisfaction and overall quality of the most severe after age 60.30 The mean age of men was 31.29 relationship during pregnancy is unchanged. ± 6.91 years, which supports why this finding was not significant > in our study. The mean BMI in men was 30 for our population CONCLUSIONS and cannot be generalized. There was no association with increased BMI in men and problems in the sexual relationship The third trimester of pregnancy affects certain aspects of a fi with their pregnant partners. The overall GRISS score for men sexual relationship, speci cally sexual frequency and vaginal pain/ was significantly higher than the overall GRISS for women. discomfort. Overall, sexual satisfaction and function in hetero- However, the only subscale that scored higher for men was sexual couples appear relatively normal. dissatisfaction with the sexual relationship, a non-significant Corresponding Author: Denicia Shane Dwarica, MD, Uni- finding as well. versity of Oklahoma Health Sciences Center, 800 Stanton L. This study provides an important basis for which other studies Young Blvd, Suite 2000, Oklahoma City, OK 73104, USA. Tel: can follow. It evaluates the heterosexual couple during the third 405-271-8787 x 48774; Fax: 405-271-8547; E-mail: deni- trimester of pregnancy. It looks at the overall sexual relationship [email protected] in this partnership and addresses issues that present to the couple fl fl as a unit. It also dispels the ideas that prior pregnancies and Con icts of Interest: The authors report no con icts of interest. obesity may play a role in pregnancy-related sexual dysfunction. Funding: Supported by a research grant from the Sexual Medi- We showed that 65% of couples were sexually active on a cine Society of North America and by the Loyola Clinical more-than-weekly basis. This finding seems to support that Research Office (CRO) at Loyola University Chicago, Health illustrated by Paulet et al,9 who describe that, during pregnancy, Sciences Division. 59% of couples were having intercourse 1e3 times a week, whereas 6% were having intercourse >4 times weekly. STATEMENT OF AUTHORSHIP Our study is limited because it only assesses the couples during Category 1 pregnancy, and, although it is a convenience sample, it is (a) Conception and Design representative of our study population. A future study should Denicia Shane Dwarica; Gretchen Garbe Collins; Colleen Fitz- evaluate the same couples before pregnancy and then while gerald; Cynthia Brincat; Mary Lynn pregnant; however, this is difficult, because one would need to (b) Acquisition of Data capture couples actively trying to conceive. Additionally, couples Denicia Shane Dwarica; Gretchen Garbe Collins; Colleen Fitz- were approached in the third trimester only, which limits the gerald; Cynthia Brincat; Mary Lynn ability to compare sexual function at different stages in the (c) Analysis and Interpretation of Data Denicia Shane Dwarica; Cara Joyce pregnancy. Although the GRISS provides a multitude of data, it also has limitations in scoring. The non-communication and Category 2 infrequency subcategories provide an individual score for each (a) Drafting the Article partner; however, the GRISS scoring requires that the scores for Denicia Shane Dwarica; Gretchen Garbe Collins; Colleen Fitz- men and women be reported as an average for the couple. gerald; Cynthia Brincat; Mary Lynn Another limitation with the GRISS and our study was that we (b) Revising It for Intellectual Content evaluated mean scores for the 52 couples in our analysis to create Denicia Shane Dwarica; Gretchen Garbe Collins; Colleen Fitz- a profile for the cohort. This may not capture clinically signifi- gerald; Cara Joyce; Cynthia Brincat; Mary Lynn cant differences in each couple pair. The GRISS was validated Category 3 > “ ” 30 years ago; hence, there are terms such as vaginismus, (a) Final Approval of the Completed Article ”female,” and “male,” which are antiquated. Terms that are more Denicia Shane Dwarica; Gretchen Garbe Collins; Colleen Fitz- common include dyspareunia, pelvic floor muscle spam, or pelvic gerald; Cara Joyce; Cynthia Brincat; Mary Lynn pain. Additionally, our study only evaluated heterosexual cou- ples. A future study should be performed to assess the changes in sexual function during pregnancy among couples using the REFERENCES 1. Basson R, Berman J, Burnett A, et al. Report of the interna- PROMIS Sexual Function and Satisfaction.31 The PROMIS tional consensus development conference on female sexual Sexual Function and Satisfaction was validated in 2014 to assess dysfunction: Definitions and classifications. J Urol 2000; for sexual function and satisfaction among women and men and 163:888-893. thus uses more accurate terms to describe aspects of sexual 31 2. Derogatis LR, Burnett AL. The epidemiology of sexual dys- dysfunction that affect couples at present. functions. J Sex Med 2008;5:289-300. 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