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International Journal of Sexual Health logoLink to International Journal of Sexual Health
. 2024 Jun 3;36(3):287–301. doi: 10.1080/19317611.2024.2360731

Impact of Cognitive Behavior Therapy on Sexual Dysfunction of Women in Reproductive Age: A Systematic Review

Foruzan Sharifipour a, Kowsar Qaderi b, Razieh Peighambardoost c, Maryam Zahedian d, Faeze Azizi e, Shahla Faal Siahkal f,✉
PMCID: PMC11323872  PMID: 39148917

Abstract

Background

A large number of women suffer from sexual dysfunction. Cognitive behavior therapy (CBT) is a psycho-educational therapy the main purpose of which is to help the individual alter their dysfunctional beliefs and behaviors. We investigated the impact of CBT on reproductive-aged women’s sexual function.

Methods

The present study is a systematic review and meta-analysis in which a number of databases (Web of Science, PubMed, Scopus, Cochrane Library, and Embase) were searched from inception to November 2023. Clinical trials examining the impact of CBT on female sexual dysfunction were included. This study evaluated female sexual function and its components, including satisfaction, discomfort, lubrication, arousal, climax, desire, and assertiveness. We used Review Manager version 5.3 for performing the meta-analysis. P values less than 0.05 were considered statistically significant.

Results

Seven articles including a total of 448 women with sexual dysfunction were reviewed. The participants’ mean age in the CBT groups was 33.43 ± 6.04 years and that of the control group was 33.24 ± 5.97, which were not significantly different. Our results indicated that CBT is efficient in improving the total score of women’s sexual function (SMD = 1.34, 95% CI = (1.02, 1.65), I2 = 86%), sexual satisfaction, lubrication, desire, orgasm, and assertiveness compared with the control group. However, CBT had no positive effect on reducing sexual pain.

Conclusion

Based on the result of the current study, CBT can be suggested as an effective treatment method along with other treatments for women with sexual problems.

Keywords: Cognitive behavioral therapy, sexual dysfunction, physiological, women, systematic review

Introduction

Based on the definition of the World Health Organization, an individual is sexually healthy when they do not suffer from any disease, disability or dysfunction in relation to sexuality, and when they are physically, emotionally, psychologically, and socially healthy as far as sexuality is concerned. In fact, sexually healthy individuals have not only a positive and respectful view of sexual relations but also enjoyable and safe sexual experiences, without force, prejudice or violence. Of course, sexual health could be said to be achieved and maintained on the condition that the sexual rights of the parties involved are respected and protected (WHO, 2021).

Sexual health is a multifaceted phenomenon including the health of the nervous, vascular and endocrine systems along with psychosocial health, family and religious beliefs, etc. Disruption in these can result in sexual dysfunction (Avasthi et al., 2017). This condition is commonplace among women and is rarely evaluated and treated during routine examinations. Stress, anxiety and relationship problems between couples are among the problems that these women face (Adam & Grimm, 2023). When an individual has problem in experiencing one or all stages of sexual activity including desire, arousal, vaginal moisture (in women), erection/ejaculation (in men), and orgasm, they suffer from sexual dysfunction (Graziottin et al., 2023). Studies investigating sexual dysfunction in the general population have found that about 43% of women suffer from at least one type of sexual disorder while this rate is 31% for men (Avasthi et al., 2017).

Sexual satisfaction, as an essential component of sexual health, is effective in building a healthy and intimate couple relationship (Pascoal et al., 2014). Evaluation of sexual satisfaction is a type of cognitive analysis of the overall quality of a person’s sexual life based on the personal standards of every person (Neto, 2012). Sexual satisfaction refers to “a subjective feeling of happiness with one’s sexual experiences”. There is a wealth of research investigating the factors which facilitate and inhibit sexual satisfaction. We can define the variables that affect sexual satisfaction as intrapersonal or interpersonal, though the factors on both these levels often interact and affect one another. Factors positively correlated with sexual satisfaction on an intrapersonal level for men and women include education, physical health, mental health, sexual function and health, sexual confidence, reaching orgasm, and mindfulness (Sears et al., 2023). On the other hand, interpersonal factors affecting sexual satisfaction include relationship satisfaction, positive communication, and sexual compatibility (Freihart et al., 2020; Newcomb et al., 2021). Another important factor in sexual satisfaction is sexual assertiveness which is the ability to talk about one’s sexual needs, including self-disclosure, commencing or refusing sexual intercourse with a partner, etc. (Sayyadi et al., 2019). Sexual assertiveness is related to an individual’s information, knowledge, feelings, values, attitudes, communication, and decision-making skills in relation to sexuality (Sayyadi et al., 2019).

Various studies have been designed and implemented to treat sexual problems and reduce sexual conflicts using many educational and psychological interventions such as PLISSIT and EX-PLISSIT model, sexual training, couple-based consultations, assertiveness-based sexual training, and psychoeducational therapy (Ahmadnia et al., 2017; Azari-Barzandig et al., 2020; Bafrani et al., 2023; Dastyar et al., 2019; Xu et al., 2023). Cognitive-behavioral therapy (CBT) is a kind of psychological intervention aimed at changing the way a person thinks and behaves in relation to a certain problem.

According to this therapy, people’s thoughts and perceptions and their influence on their emotions and behavior are of particular importance (Beck, 2020). In this treatment method, the focus is on sorting out conflicting thoughts related to emotional distress, increasing engagement with activities in form of gradual contact with anxiety-causing factors, and finally, finding a solution to the problem (Mestre-Bach et al., 2022). This method is used to treat various mental disorders such as substance use disorder, schizophrenia, depression, stress and anxiety, bulimia and anorexia nervosa, insomnia, personality disorders, criminal behaviors, pain, mental disorders in pregnancy, female hormonal disorders, and sexual disorders (Hofmann et al., 2012). In terms of sexual disorders, CBT assesses the frequency of sexual behavior, sexual fantasies and beliefs, symptoms of anxiety and depression, as well as environmental and interpersonal factors (Mestre-Bach et al., 2022). CBT helps clients to correct their misconceptions about sexuality, practice expressing themselves in relation to sexual matters, assume shared responsibility in sexuality, solve sex-related problems, eliminate anxiety in sexual relations, acquire communication skills, adopt sexual techniques, make changes in sexual behavior, and perform cognitive reconstruction (Rezaian et al., 2022). According to Chizary et al., the type of CBT which focuses on assertiveness leads to improvement of adult sexual function (Chizary et al., 2023). Besides, the type of CBT stressing how cognition and thoughts affect behavior can have an effective contribution to the improvement of assertiveness among individuals (Tavakoli & Mirghaemi, 2023). Since few, if any, empirical studies have thus far examined the role of CBT in the treatment of female sexual dysfunction, the present systematic review and meta-analysis evaluated how treatment based on CBT affects sexual function and its dimensions such as sexual satisfaction, desire, arousal, lubrication, orgasm, pain, and sexual assertiveness in reproductive-aged women.

Methods

The present systematic review and meta-analysis which included controlled trials was conducted following the PRISMA checklist (Page et al., 2021). This project was registered in PROSPERO with code: CRD42024498113.

Search strategies

The following databases were searched from inception to November 2023: PubMed, Web of Science, Scopus, Embase, and Cochrane Library. The keywords used were: “Cognitive Behavioral Therapy” along with “Sexual Dysfunctions” and “Women.” The search strategies of some databases are shown in supplementary data.

Inclusion and exclusion criteria

Full-text clinical trials examining the impact of CBT on female sexual dysfunction which were written in English were eligible for inclusion in the study. Quasi-experimental papers, review articles, studies written in local languages, books, articles with descriptive, qualitative, and cross-sectional designs, congress presentations, case reports, and study protocols were excluded.

Types of participants

Participants included non-pregnant women of reproductive-aged (between 15 and 49 years) having sexual dysfunction. Women with any medical or surgical issue that can impact sexual function were excluded from the study. This included cancer, urinary incontinence, infertility, etc. Any medical or surgical problem can impact sexual function by affecting sexual anatomy, vascular, nervous, and endocrine systems, each requiring different management (Avasthi et al., 2017).

Types of interventions and comparisons

This review included clinical trials involving sessions of counseling or treatment based on individual, group, in person, or online CBT for managing sexual dysfunction in women. No restriction was imposed on the form or length of treatment. Also, trials in which the control groups received routine counseling and care, waiting lists, or no therapy were included in this review. Trials relying on complementary or alternative medicine were excluded.

Types of outcome measures

The outcomes of this study were to investigate female sexual function based on the Female Sexual Function Index (FSFI) or Female Sexual Quotient Questionnaire (FSQQ) and its dimensions such as sexual satisfaction, desire, arousal, lubrication, orgasm, pain, and assertiveness.

Selection of studies and data extraction

MZ conducted the search. FSH and SHF performed independent screenings of titles and abstracts of all retrieved studies based on the inclusion criteria. The same two authors analyzed the full texts of the relevant articles and extracted the data from them independently. In case of conflicts, the authors discussed the topic with or sought assistance from a third research team member (KGH). All screenings were done using Endnote X9. In order to extract the data, a table was prepared including information about the study authors, study location, study type, participant type, sample size, participants’ age, participants’ duration of marriage, questionnaire, intervention, control, and outcomes.

Assessing the risk of bias in the retrieved articles

Assessment of the risk of bias in the included studies was done independently by FSH and SHF based on the seven criteria of Cochrane guidelines for quality assessment of randomized clinical trials: (a) concealing allocation (selection bias), (b) generating random sequences (selection bias), (c) blinding of outcome assessment (detection bias), (d) blinding of the subjects and the personnel (performance bias), (e) inadequate outcome data (attrition bias), (f) selective reporting (reporting bias), and (g) other risks of bias (e.g., calculating sample size, power of study, receiving consent from participants, and ethical approval (Matthew et al., 2018).

Statistical analysis

Meta-analysis was performed by Review Manager version 5.3. Mean differences (MD) and 95% confidence intervals (CI) were used in order to compare variables between groups. If outcomes were measured with different scales, standard mean differences (SMD) and 95% CI were used. Significance level was determined by z-test. Evaluation of the heterogeneity of included articles was done using I2. In order to demonstrate effect sizes and 95% CI, forest plots were used. We used the fixed effects model for the meta-analysis of all pooled studies. According to the initial heterogeneity assessment, the random effects model was used when I2 > 35%. Furthermore, sensitivity analyses were performed by removing individual articles for evaluation of the role of the moderating paper. P values less than 0.05 were considered statistically significant.

Results

Our database search yielded 6551 articles. After removing duplicates (n = 1302), 5249 articles were screened. Screening culminated in fourteen articles that were evaluated for eligibility. At this point, we excluded seven papers due to inadequate outcomes (Erfanifar et al., 2022; Gholami et al., 2021; Hosseini et al., 2020; Khoshbooii et al., 2021; Stephenson et al., 2013), irrelevant population (Taravati et al., 2018), and problematic study design (Omidi et al., 2016). Ultimately, seven articles were selected for the quantitative and qualitative analysis. Figure 1 shows the flow diagram of the search and selection process.

Figure 1.

Figure 1.

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The flow diagram of the systematic review for selection of the studies.

Characteristics of the studies

All reviewed studies were clinical trials published between 2014 and 2023. The total number of participants in these studies was 448 women with sexual dysfunction, of whom 194 received cognitive behavior therapy, and 204 were controls. The number of participants in the included studies ranged between 24-106. Four out of seven studies were done in Iran (Chizary et al., 2023; Farajkhoda et al., 2019; Jangi et al., 2023; Mirzaee et al., 2020), two in Australia (Hucker & McCabe, 2014; 2015), and one in Brazil (Lerner et al., 2022). Table 1 provides information about the details of the participants. The participants’ mean age in the CBT groups was 33.43 ± 6.04 years and 33.24 ± 5.97 in the control groups. The counseling sessions included eight 90-minute sessions, held once or twice a week (except for the two articles by Hucker et al. which included six sessions).

Table 1.

The characteristics of the included studies.

Study Location Study type Age (y) Duration of marriage Participant Intervention
 Control
 Outcome
Size Care/questionnaire Size Care
Variable Intervention Control
1. Chizary et al. (2023) Iran Randomized controlled clinical trial Intervention: 39.92 ± 7.79 17.58 ± 9.05 years women with secondary anorgasmia 12 eight 90-minute sessions of CBGT (Cognitive-Behavioral Group Therapy) that were administered once a week

  • FSFI

 12 No intervention Assertiveness 65.75 ± 8.91 43.67 ± 11.30
Desire 5.20 ± 0.64 3.65 ± 0.80
Arousal 4.72 ± 0.69 2.52 ± 0.75
Lubrication 4.64 ± 0.55 3.51 ± 0.65
Orgasm 5.33 ± 0.62 2.47 ± 0.76
Control: 39.17 ± 6.71 17.09 ± 8.21 years Sexual satisfaction 5.53 ± 0.58 3.20 ± 1.16
pain 5.63 ± 0.49 4.95 ± 1.13
FSFI 31.0 ± 2.14 20.39 ± 3.37
2. Farajkhoda et al. (2019) Iran RCT Intervention: 33.75 ± 4.33 – women in reproductive age with sexual satisfaction < 75 20 8 counseling sessions with a mindfulness-based cognitive therapy approach

  • Larson Sexual Satisfaction Questionnaire

 20 routine sexual consultation sexual satisfaction 69.55 ± 4.70
 60.80 ± 8.91
Control: 35.70 ± 6.9 –
3. Hucker and McCabe (2015) Australia Randomized clinical trial Intervention: 33.31 ± 7.4 7.94 ± 5.52 years Mixed Female Sexual Problems 26 Six sessions CBT based on Mindfulness training and online chat groups

  • FSFI

  • Female Sexual Distress Scale-Revised (FSDS-R)

 31 wait-list Desire 3.55 ± 0.64 2.74 ± 1.11
Arousal 4.70 ± 0.79 3.37 ± 1.18
Control: 31.94 ± 5.17 8.84 ± 5.29 years Lubrication 5.31 ± 0.8 4.51 ± 1.27
Orgasm 4.70 ± 1.39 3.08 ± 1.62
pain 5.00 ± 1.21 4.70 ± 1.17
satisfaction 4.72 ± 0.59 3.35 ± 0.98
Distress 19.13 ± 10.54 29.61 ± 8.99
4. Hucker and McCabe (2014) Australia   Intervention: 33.31 ± 7.4 7.94 ± 5.52
years		 female sexual difficulties 26 Six sessions online, mindfulness-based, cognitive behavioral therapy

  • Sexual Function Scale

  • The Personal Assessment of Intimacy in Relationships Scale

  • FSFI

  • Female Sexual Distress Scale–Revised

 31 Wait-list Sexual intimacy 23.12 ± 2.71
 20.34 ± 3.6
8.84 ± 5.29 years
Control: 31.94 ± 5.17
Emotional intimacy 24.32 ± 3.34 23.00 ± 3.34
Communication 25.04 ± 3.02 23.99 ± 3.43
Relationship satisfaction 34.12 ± 3.93 32.55 ± 4.99
5. Jangi et al. (2023) Iran RCT Intervention: 26.18 ± 2.93 2.59 ± 0.59 newly married women and scoring less than 50 in the Hulbert Sexual Assertiveness Index 22 Eight group sessions of CBT

  • Hulbert sexual assertiveness index,

  • Larson sexual satisfaction questionnaires

 22 No intervention sexual assertiveness 69.37 ± 7.28 22.31 ± 2.47
Control: 27.13 ± 3.07 2.54 ± 0.5 sexual satisfaction 86.57 ± 7.5 66.44 ± 10.11
6. Lerner et al. (2022) Brazil Clinical trial randomized Intervention: 40.6 ± 6.36 13.63 ± 10.88
years		 women with hypoactive sexual desire 53 CBT for 8-weeks

  • Female Sexual Quotient (FSQQ)

 53 waiting list Desire and interest 19.83 ± 6.78 11.38 ± .86
Foreplay 8.62 ± 2.96 4.87 ± 3.05
Excitement and attunement 14.70 ± 5.47 9.64 ± 5.79
Comfort 14.40 ± 5.05 10.98 ± 6.56
Control: 38.5 ± 10.36 12.43 ± 9.31
years		 Orgasm satisfaction 12.77 ± 5.91 5.77 ± 4.90
FSQQ Total 68.57 ± 19.20 41.51 ± 17.54
7. Mirzaee et al. (2020) Iran clinical trial Intervention:
≤ 31
(54.5%)
>31
(45.5%)		 ≤5
(42.4%)
>5
(57.6%)		 women who obtained score 28 in the FSFI 35 Eight counseling sessions CBT counseling sessions (two/week/ 1.5 hour) 35 No intervention Desire 7.61 ± 1.32 6.00 ± 2.1
Arousal 16.24 ± 1.94 12.97 ± 2.87
Lubrication 11.09 ± 1.18 11.4 ± 1.29
Control:
≤ 31
(60%)
>31
(40%)		 ≤5
(51.4%)
>5
(48.6%)		 Orgasm 10.18 ± 1.01 9.4 ± 1.22
Sexual satisfaction 12.76 ± 1.06 9.94 ± 2.25
pain 5.7 ± 1.29 9.14 ± 2.7
FSFI 24.22 ± 1.72 68.57 ± 19.20
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Quality assessment of included papers

Article quality assessment, as shown in Figure 2, was performed by two reviewers (SHF and FSH) based on the Cochran risk-of-bias tool using RevMan software. No attrition bias or reporting bias was found in the articles. Selection bias was found in twenty-five percent of the studies. Twenty-five percent of them did allocation concealment. Due to the type of study design, no study performed blinding of participants or personnel. Only one study did not have detection bias. In general, the quality of most studies was assessed to be low.

Figure 2.

Figure 2.

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Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.

Outcome measures

Total sexual function

Three studies (Chizary et al., 2023; Lerner et al., 2022; Mirzaee et al., 2020), which assessed the total sexual function, were subjected to meta-analysis. According to the results, compared with the control group, CBT could increase the overall sexual function score (SMD = 1.34, 95% CI = (1.02, 1.65), I2 = 86%) (Figure 3). Because of the high heterogeneity, we did the sensitivity analysis, but it was not reduced.

Figure 3.

Figure 3.

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Forest plot showing total sexual function score between the two intervention and control group.

Sexual satisfaction

Seven papers (Chizary et al., 2023; Farajkhoda et al., 2019; Hucker & McCabe, 2014, 2015; Jangi et al., 2023; Lerner et al., 2022; Mirzaee et al., 2020) including 448 participants were involved in the meta-analysis. The two groups were significantly different with high heterogeneity regarding sexual satisfaction score (SMD = 1.33, 95% CI = (1.11, 1.55), I2 = 76%). After sensitivity analyses and removing two papers (Hucker & McCabe, 2014; Jangi et al., 2023), the heterogeneity was reduced to 24%, and compared with the control group, CBT could still increase the satisfaction rate (SMD = 1.49, 95% CI = (1.19, 1.78), I2 = 18%) (Figure 4).

Figure 4.

Figure 4.

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Forest plot of sensitivity analysis showing sexual satisfaction score between the two intervention and control group.

Sexual desire

To assess this outcome, four papers (Chizary et al., 2023; Hucker & McCabe, 2015; Lerner et al., 2022; Mirzaee et al., 2020) were subjected to meta-analysis. In comparison with the control group, CBT had a positive effect on the sexual desire score (SMD = 1.45, 95% CI = (1.13, 1.78), I2 = 73%). To reduce heterogeneity, we applied the sensitivity analysis, and after removing one paper (Hucker & McCabe, 2015), heterogeneity was reduced to zero, and the intervention and control groups were still significantly different (SMD = 1.79, 95% CI = (1.38, 2.20), I2 = 0%) (Figure 5).

Figure 5.

Figure 5.

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Forest plot of sensitivity analysis showing sexual desire score between the two intervention and control group.

Sexual arousal

Sexual arousal was assessed in three papers (Chizary et al., 2023; Hucker & McCabe, 2015; Mirzaee et al., 2020). According to the results of meta-analysis, the intervention and control groups were significantly different with high heterogeneity regarding sexual arousal score (MD = 1.87, 95% CI = (1.51, 2.24), I2 = 82%) (Figure 6). However, the sensitivity analysis could not reduce the heterogeneity rate.

Figure 6.

Figure 6.

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Forest plot showing sexual arousal score between the two intervention and control group.

Sexual lubrication

Meta-analysis of three papers (Chizary et al., 2023; Hucker & McCabe, 2015; Mirzaee et al., 2020) showed that compared with the control group, CBT could increase the total score of sexual lubrication (MD = 0.62, 95% CI = (0.32, 0.93, I2 = 86%). The sensitivity analysis decreased the heterogeneity rate to zero, and the control and intervention groups were still significantly different (MD = 0.98, 95% CI = (0.62, 1.34), I2 = 0%) (Figure 7).

Figure 7.

Figure 7.

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Forest plot of sensitivity analysis showing sexual lubrication score between the two intervention and control.

Orgasm

Meta-analysis of three papers (Chizary et al., 2023; Hucker & McCabe, 2015; Mirzaee et al., 2020) showed that compared with the control group, CBT could increase the rate of orgasm (MD = 1.75, 95% CI = (0.42, 3.08), I2 = 93%) (Figure 8). Because of the high heterogeneity, we did the sensitivity analysis, but it was not reduced.

Figure 8.

Figure 8.

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Forest plot showing orgasm score between the two intervention and control.

Sexual pain

Sexual pain was assessed in three papers (Chizary et al., 2023; Hucker & McCabe, 2015; Mirzaee et al., 2020), and the intervention and control groups were not significantly different with high heterogeneity regarding pain score (MD = −0.23, 95% CI = (-0.65, 0.19), I2 = 96%). The sensitivity analysis decreased the heterogeneity rate to zero, and the groups remained significantly different (MD = 0.47, 95% CI = (0.00, 1.93), I2 = 0%) (Figure 9).

Figure 9.

Figure 9.

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Forest plot of sensitivity analysis showing sexual pain score between the two intervention and control.

Sexual assertiveness

Two papers (Chizary et al., 2023; Jangi et al., 2023) were involved in the meta-analysis, and the groups were found to be significantly different regarding sexual assertiveness (MD = 0.78, 95% CI = (0.26, 1.29), I2 = 88%) (Figure 10).

Figure 10.

Figure 10.

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Forest plot showing sexual assertiveness score between the two intervention and control.

Discussion

According to our results, CBT programs are effective in improving the overall score of women’s sexual function, satisfaction, and desire compared with the control group.

Female sexual dysfunction disorders have a negative effect on women’s quality of life. These include female sexual interest/arousal disorder, Genito-pelvic pain/penetration disorder, and female orgasmic disorder (Mestre-Bach et al., 2022). As a psychotherapy which focuses on symptoms, CBT is based on the assumption that individuals’ malfunctioning thoughts and actions should be regarded as treatment targets, and it is important that the chains of maladaptive thoughts, emotions, and behaviors be broken. As far as women’s sexual dysfunctions are concerned, CBT relies on non-pharmacological strategies (Mestre-Bach et al., 2022).

A recent review, addressing the role of behavioral therapies in treating women’s sexual dysfunction, recommended further research for the promotion of treatment in these women and improvement of their sexual health (Mestre-Bach et al., 2022).

An RCT conducted in 2018 examined the effect of four CBT sessions (each lasting 2 hours) on sexual function (FSFI). The participants included 198 married women in the age range of 15-45 who were sexually active. A significant increase in the overall FSFI score and the scores of all dimensions of FSFI was observed in the intervention group as opposed to the control group (Babakhani et al., 2018). Similarly, according to the findings of Halvaiepour et al., (2021), women suffering from sexual interest arousal disorder (SIAD) based on FSFI could benefit from cognitive bias modification of interpretation (CBM-I) by replacing their positive interpretations of cognitive bias with negative ones (Halvaiepour et al., 2021). In line with our results, in another study, virtual cognitive-behavioral counseling significantly increased expectant mothers’ sexual function and intimacy (Fathalian et al., 2022).

An RCT investigated the effect of sixteen sessions of group culturally adapted Cognitive Behavioral Therapy (CA-CBT) versus eight sessions of individual CA-CBT on promotion of sexual satisfaction among 64 Iranian perimenopausal women suffering from depression. According to the results, participants receiving both treatments, as opposed to those in the control group, experienced an increase in their sexual satisfaction, which was sustained after six months of follow-ups with large effect sizes of significant differences (p < 0.001) (Khoshbooii et al., 2021). In another RCT on 86 women suffering from arousal and orgasm dysfunction, the intervention involved both 50 mg of oral sildenafil one hour before intercourse and weekly sessions of CBT for eight weeks. The intervention led to higher mean scores of enrich sexual scale, sexual satisfaction, and FSFI. Of course, CBT appeared to have a more significant role in increasing relationship and sexual satisfaction (Omidi et al., 2016). According to Bokaie et al. who studied sexual satisfaction among Iranian primigravida women, although CBT-informed sexual health counseling could increase these women’s sexual satisfaction and reduce their inefficient sexual beliefs during pregnancy, there was a preference among most of the participants for a smaller number of sessions (Bokaie et al., 2022). The results of all above-mentioned studies are consistent with ours.

Our study also showed that compared to the control group, CBT had a positive effect on the sexual desire score. Contrary to our results, a previous review evaluated the efficacy of CBT and mindfulness meditation training (MMT) in treatment of hypoactive sexual desire disorder (HSDD) in females. The results suggested there is still inadequate clinical trials supporting HSDD treatments that are psychologically oriented. The authors also recommended that psychological treatment trials should be subjected to the same current scientific standards that regulate drug treatment trials (Pyke & Clayton, 2015). The discrepancy between the results of the our study and that of the mentioned study may result from differences in the time of study, number of studies included, number and type of study population. Their review was conducted in 2015 and only three CBT trials were included, while our study was conducted in 2024 and on 7 trials. However, a recent qualitative paper investigated the experience of online interventions using CBT and mindfulness techniques among women whose sexual desire was low. According to the results, CBT techniques (e.g., cognitive restructuring) had a positive role in eliminating challenging maladaptive thinking patterns among most of the participants (44 out of 51, 86.3%). Formal mindfulness techniques, on the other hand, led to the women’s disengagement from negative thoughts related to sexuality (Meyers et al., 2022).

The efficacy of CBT in the treatment of secondary orgasmic dysfunction was investigated by Libman et al. whose results indicated that after CBT intervention, the participants experienced inner satisfaction based on a variety of behavioral scales (Hofmann et al., 2012). Similarly, Meston et al. reported that CBT is the best treatment option for this dysfunction among women (Stephenson et al., 2013).

According to our findings, CBT did not have a positive effect on reducing sexual pain. A nonsystematic review investigated Genito-pelvic pain/penetration disorder (GPPPD) treatments, addressing the cognitive dimensions of GPPPD and the CBT treatment options. After providing a summary of the available treatment options and the strategies aimed at the psychological trigger and the factors persisting in the couple, this review advised that the couple should be guided out of the fear-avoidance circle of this disorder by receiving beneficial suggestions from professionals (Dias-Amaral & Marques-Pinto, 2018).

Our results showed a significant positive effect of CBT on sexual assertiveness. Alizadeh et al. (2019) investigated the communication skills of women suffering from low sexual function and how these skills are affected by film therapy including eight sessions based on CBT. They suggested that film therapy based on CBT can contribute to improved communication skills in these women (Alizadeh et al., 2019). Consistent with our results, they recommended CBT for the improvement of the relationship of couples having low sexual function. On the contrary, in another study, sexual assertiveness among breast cancer survivors was not promoted by four-factor psychotherapy (behavior regulation, therapeutic relationship, increasing awareness, and expectancy to therapy) (Akbari & Lotfi Kashani, 2017).

Strengths and limitations

This was the first scholarly attempt to systematically review and meta-analyze the impact of CBT on all aspects of sexual function in reproductive-aged women. All outcomes included were patient-reported, which reflects the actual inconvenience due to sexual dysfunction. Our meta-analysis showed a high level of heterogeneity, which could be attributed to the different populations studied and the different interventions used (e.g. design, length, etc.). The length of intervention was eight sessions except the two studies by Hucker et al. (six sessions). The observed heterogeneity level was not seriously problematic since the current study was aimed to provide an answer to the broader question concerning the impact of stress reducing psychological interventions such as CBT on female sexual function, since all these therapies share the assumption that female sexual dysfunction could be improved regardless of what causes it.

We found no protocols for the included studies. Protocols of large-scale well designed RCTs are often registered and/or published, and the authors are obliged to report any protocol deviations. This could decrease the potential for bias caused by reporting outcomes selectively and deviating from intended interventions (Saldanha et al., 2022).

Given the limitations of the study, the certainty of the evidence was downgraded by one level since the reviewed studies’ risk of bias was substantially high regarding the incomplete outcome data, random sequence generation, and absence of blinding procedures. Certainty of evidence was also downgraded by two levels because of imprecision. This was because all the studies reviewed were RCTs, and the findings related to any outcome were extracted from RCTs in which the number of participants ranged between 24-70 (except for Lerner et al., 2022 which included 106 participants) (Lerner et al., 2022). Formal assessment of statistical heterogeneity or the probability of publication bias was not possible since the number of the reviewed studies was small for this purpose. More precise appraisal and interpretation of results will be possible if future RCTs are rigorous in design and delivery, include a larger sample size, and report results more efficiently. It should also be mentioned that the number of participants in some of the reviewed studies was small (i.e. n < 60 in five out of the seven articles), and there was the likelihood of publication bias. Lack of long-term outcomes was another limitation of findings. Long-term (≥52 weeks) outcomes were not reported in any reviewed study. The impact of a booster CBT session on the maintenance of intervention effect needs further analysis, which was not possible to be done properly in our meta-analysis since none of the included articles involved a booster session, and they were conducted in a short-term period. In addition, the majority of the studies were conducted in the Iran, and due to the influence of race, ethnicity and culture on female sexual function, the results may not be generalizable to all communities.

Conclusion

The findings of our meta-analysis showed that CBT could significantly improve the total score of FSFI, sexual satisfaction, desire, lubrication, orgasm, and assertiveness in women. Therefore, it could be regarded as an effective, cheap, and noninvasive method from improvement of sexual function and satisfaction among reproductive-aged women suffering from sexual dysfunction.

Acknowledgments

This study was extracted from a research project (4020765) approved by Student Research Committee, Motazedi hospital, Kermanshah University of Medical Sciences (KUMS), Kermanshah, Iran. Authors would like to express their gratitude to the officials of the Clinical Research Development Center of KUMS, Kermanshah, Iran.

Conflict of interest statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

Ethics approval

Approval for conduction of this research was obtained from the Ethics Committee of Kermanshah University of Medical Sciences (Ref. No IR.KUMS.REC.1402.364).

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