The relationship between cognitive schemas activated in sexual context and early maladaptive schemas among married women of childbearing age | BMC Psychology

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Design and participants

A cross-sectional study was carried out in ten comprehensive health centers in Qazvin with the participation of 260 married women of childbearing age. Qazvin is the largest city and capital of the Province of Qazvin in Iran. Its population is approximately 650,000 and is located 150 km northwest of Tehran. Comprehensive health centers provide community-based health services to women based on their age and health status including preconception counseling, prenatal care, postpartum care, monitoring children’s growth and development, and breast examination. They are located in different parts of the city and are therefore the best centers to recruit women from different social, economic, and cultural classes. The exclusion criteria were: currently pregnant or lactating, premenopausal or menopausal age, having other known medical or psychological illness based on participant self-report, currently experiencing a stressful event (e.g., recent loss of a loved one), and/or unwillingness to participate in the study.

Sample size estimation

No relevant study was found in this field, so it was not possible to model the present study’s sample size with a twin study. Considering the minimum correlation coefficient of 0.15, α = 0.05, and β = 0.20, the required sample size was estimated to be 260 individuals.

Sampling procedure

To recruit a research sample with maximum diversity in terms of economic, social, and cultural status, two-stage cluster sampling was used. In the first stage, two health centers were randomly selected from each of the five areas of Qazvin, with each area considered to be a cluster. Then, 26 individuals from each of the selected health centers were invited to participate in the study.


Young Schema Questionnaire-Short Form (YSQ-SF) The YSQ-SF is a 75-item scale, and is a subset of the original 205 items of the Young Schema Questionnaire-Long Form [33]. The items assess the presence of 15 early maladaptive schemas comprising emotional deprivation, abandonment, mistrust/abuse, social alienation, defectiveness, incompetence, dependency, vulnerability to harm, enmeshment, subjugation of needs, self-sacrifice, emotional inhibition, unrelenting standards, entitlement, and insufficient self-control. Each of the 75 items is rated on a six-point scale from 1 (Completely untrue of me) to 6 (Describes me perfectly) [6]. A higher score on a given subscale reflects a greater possibility of the presence of that maladaptive schema for that individual. Validity and reliability of the Persian version of the 75-item short form has been confirmed by factor analysis [34, 35].

Cognitive Schema Activated in Sexual Context Questionnaire (CSASCQ) The CSASCQ was developed by Nobre and Pinto-Gouveia and is a 28-item measure that assesses cognitive schemas in response to specific sexual episodes [18]. First, four common sexual problems are presented in the female version: hypoactive sexual desire disorder, orgasmic disorder, sexual pain, and subjective arousal difficulties. Participants rated the frequency of each sexual problem from 1 (Never occurs) to 5 (Happens often). Second, participants indicated the emotions aroused by the episode, checking all that apply from a list of ten emotions: worry, sadness, disillusion, fear, guilt, shame, anger, hurt, pleasure, and satisfaction. Finally, participants were instructed to focus on the most frequent situation and associated emotions, and respond to 28 self-statements reproducing Beck’s self-schemas [1], using a five-point Likert scale from 1 (Completely false) to 5 (Completely true). A factor analysis of the 28 schemas suggest a five-factor structure [18]: undesirability/rejection; incompetence; self-depreciation; difference/loneliness; and helplessness. Scores on the five domains and the total scale were calculated through the sum of the schema items with higher scores representing greater negative schema activation. Psychometric studies demonstrate adequate test–retest reliability with a four-week interval (r = 0.66) and excellent internal consistency with a Cronbach’s alpha of 0.94. Good psychometric properties of the Persian version have been reported [36].

Socio-demographic characteristics: These were assessed using a predefined checklist including woman’s age (years), spouse’s age (years), marriage duration (years), couple age difference (years), number of children, oldest child age (years), youngest child age (years), perception of husband’s support, strength of religious belief, and religious activities. Husband’s support, religious belief, and religious activities were assessed on a scale of 1 to 10 (e.g., for religious activities, the higher the score the more religious activities engaged in). Other demographic variables included educational status and occupation of participants and spouses, rotational working shifts for participants or spouses, long periods of husband being away from home, consanguineous marriage, having separate bedroom (from children), living with own/spouse’s family, and perceived economic status (asking about actual income tends not to be answered by Iranian participants).


After obtaining the necessary permits, the researchers contacted the selected health centers in Qazvin. With the coordination of the head of the comprehensive health centers, a private exam room was provided to the research team, in order to protect participant confidentiality. Eligible individuals were identified and invited to participate in the study. An explanation of the purpose of the study was given and willing participants then answered the self-report survey in a private space and returned it directly to the member of the research team present.


The present study was approved by the Research Council and the Ethics Committee in Biological Research of Qazvin University of Medical Sciences (code REC.1397.398). All procedures followed were in accordance with the ethical standards of the responsible committee of Qazvin University of Medical Sciences. When inviting participants, explanations were given about the importance and goals of the research, the privacy and confidentiality of collected information, the voluntary participation in the study, and the ability to leave the study at any time. Informed written consent was obtained from all participants prior to study participation.

Statistical analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS) v. 24. Quantitatively continuous variables were calculated using means and standard deviations and categorical variables were calculated using frequencies and percentages. A uni-variable and multi-variable linear regression was used to investigate the relationship between CSASCs, EMSs, and demographic characteristics. In the uni-variable regression model, the total CSASCQ score was entered as the dependent variable and the other variables (including demographic variables) were entered as the independent variables. Variables with a significance level less than 0.05 in the uni-variable model were selected to be entered in the multi-variable model. In the multi-variable model, the stepwise method of entering variables was used. Qualitative categorical variables were coded as dummy variables for entry in the regression model. The considerations of using regression methods including normal distribution of CSASCQ score, lack of discarded data, and lack of correlation between independent variables were controlled for.

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