ORIGINAL RESEARCH–COUPLES' SEXUAL DYSFUNCTIONS: Does Mode of Delivery Affect Sexual Functioning of the Man Partner?
Sadettin Gungor, MD, GATA Kadin Hst. ve Dogum Anabilim Dali, Etlik, Ankara 06010, Turkey. Tel: (+90) 312 304 5815; Fax: (+90) 312 304 5800; E-mail: firstname.lastname@example.org
Introduction. Recent surveys showed that the major reasons for avoiding vaginal delivery were the fear of childbirth and the concern for postpartum sexual health. Although sexual dysfunction is a disorder that affects a couple rather than an individual, all studies investigating the relationship between the mode of delivery and sexual problems have been conducted only in cohorts of women.
Aim. To determine the effect of mode of delivery on quality of sexual relations and sexual functioning of men by using the Golombock–Rust Inventory of Sexual Satisfaction (GRISS).
Main Outcome Measure. Mean score of sexual function and prevalence of sexual dysfunction in overall and specific areas of the GRISS were compared among the three groups.
Methods. A total of 107 men accompanying their wives in outpatient clinics of obstetrics and gynecology met inclusion/exclusion criteria. Three groups of men were defined; men whose partners had: (i) “elective cesarean delivery” (N = 21; mean age 32.2 ± 3.8 years); (ii) “vaginal delivery with mediolateral episiotomy” (N = 36; mean age 31.4 ± 4.5 years); and (iii) “not given birth” (N = 50; mean age 28.8 ± 4.0 years).
Results. Mean overall sexual function score (normal value < 25 points) was 20.5 ± 8.2 in the elective caesarean group, 19.3 ± 6.5 in the vaginal delivery group, and 18.8 ± 9.3 in the nulliparae group (P = 0.731). Prevalence of sexual dysfunction in men was 28.6% in the elective caesarean group, 19.4% in the vaginal delivery group, and 30.0% in the nulliparae group (P = 0.526).
Conclusion. Overall sexual function of men was not affected by their partner's parity and mode of delivery. An elective cesarean section simply because of concerns about sexual function would not provide additional benefit to men, and could deny women a possible vaginal delivery, which is generally assumed to be safer than cesarean section. Gungor S, Baser I, Ceyhan T, Karasahin E, and Kilic S. Does mode of delivery affect sexual functioning of the man partner? J Sex Med 2008;5:155–163.
Normal sexual functioning comprises sexual activity with transition through the phases from arousal to relaxation with no problems, and with a feeling of pleasure, fulfillment, and satisfaction. In addition to supporting the abdominal and pelvic organs, and maintaining urine and fecal continence, the pelvic floor muscles, in particular the levator ani and perineal membrane, participate in female sexual function and responsiveness . These muscles are responsible for the involuntary rhythmic contractions during orgasm. The levator ani muscles also modulate motor responses during orgasm as well as receptivity. When voluntarily contracted, pelvic floor muscles can intensify orgasm for both women and men . It was suggested that hypotonic muscles could cause vaginal hypoesthesia and coital anorgasmia .
Although the relationship between the type of delivery and sexual problems remains yet to be substantiated, vaginal delivery is accepted as themajor cause of pelvic floor damage by some authors [1,3,4]. Recent surveys from the United Kingdom and Australia examining obstetricians' personal preferences toward delivery both showed that approximately one-third of respondents would choose cesarean section for delivery [5,6]. The major reasons for avoiding vaginal delivery were the fear of childbirth and the concern for postpartum sexual health. Such evidence might cause high preference rate of elective caesarean section due to the perceived benefits of this mode of birth [7–12].
Sexual dysfunction is a disorder that affects a couple rather than an individual. Sexual dysfunction of any etiology may negatively impact the woman's sexual partner . Therefore, investigating the effects of delivery mode on the man partner's sexual function is necessary to characterize the true impact of birth on sexual quality of both couples. It is interesting that all relevant studies have been conducted in cohorts of women. To our knowledge, no studies have documented the effect of mode of delivery on sexual function of men.
In this study, we aimed to determine the effect of mode of delivery on sexual function of men by using a validated instrument.
Subjects and Procedures
The present study was approved by our Institutional Ethics Committee, and was conducted at Gulhane Military Medical Academy, School of Medicine, between December 2005 and March 2006 as part of a larger study designed to determine the contributing factors to sexual functions of women, men, and couples.
Accompanying partners of nulliparous or primiparous women attending the outpatient clinics of obstetrics and gynecology department for gynecologic care, family planning issues, and routine prenatal care were consecutively identified upon their presentation at the outpatient desk, and were asked to complete a demographic survey and an inventory of sexual function. Accompanying partners of multiparous women, apparently pregnant women, and those with a stillbirth were excluded from the study to avoid possible confounding factors. In order to obtain a better comparison for sexual dysfunction, accompanying partners of women who had undergone caesarean delivery after the onset of labor, and who had delivered vaginally without an episiotomy or with the assistance of vacuum extraction or forceps application, were also excluded.
The study protocol was explained, complete privacy was assured, and voluntariness of participation was emphasized. A written informed consent statement was obtained from all volunteers prior to taking part in the study. Then the man partner self-completed the questionnaire in a separate room allowing for sufficient privacy. One of the authors was available if additional information about the questions would be requested. All the questionnaires were coded and recorded daily and have been kept in computerized files by the first author.
Details of the Questionnaire
The self-administered questionnaire had two parts. Part I was designed to collect data about sociodemographic characteristics of men, such as age, weight, height, educational level, employment status, and medical background. Other questions included couples' duration of marriage, type of marriage, presence of a relative in the same home, having a separate parent bedroom, sleeping together with the partner or, if any, with the child, and use of contraception. Women partners' obstetric history and details of delivery were also recorded. The questions of Part I were tested on a pilot group of patients prior to onset of the study, to ensure that patients would understand exactly what was required from each question.
Part II of the questionnaire included the Golombock–Rust Inventory of Sexual Satisfaction (GRISS), which is a short paper-and-pencil questionnaire that provides an objective assessment of the quality of sexual relationships and sexual functioning [14–16]. The questionnaire has separate forms for men and women. Each form consists of 28 items and covers the most frequently occurring sexual dysfunctions of heterosexual persons with a steady partner. The male form of the GRISS comprises 28 questions, each with five possible answers, ranging from “never” to “always.” Each of these 28 items are scored, and 24 of them converted to provide eight discrete scores, one for overall sexual function and seven for each specific area of sexual function—i.e., frequency of intercourse, communication, degree of satisfaction, avoidance, sensuality, premature ejaculatory function, and erectile function. This allows investigation of specific areas of sexual dysfunction in men. The final scores on each of the GRISS subscales range from 1 to 9: scores of 1–4 indicate normal sexual functioning, and scores of 5–9 indicate increasing degrees of sexual dysfunction. The GRISS can be applied as a screening instrument and for the measurement of therapy outcome [15–17].
The factor structure, internal consistency, and stability of the Turkish adaptation have been examined in our population . On the basis of the findings, it was justified to maintain the original subscale structure. The results of the standardization study indicated that the GRISS could be used in the Turkish population, both in practice and in research, as a valid and reliable scale. In the present study, one more question was asked among participants in order to identify the role of pelvic floor integrity on sexual satisfaction of men. The question was as follows: “Do you ever happen to think your spouse's vagina is so loose that it affects your sexual pleasure?” A Likert-type scale similar to that of the GRISS was used (i.e., never, hardly ever, occasionally, mostly, or always). Participants were also asked for ignorance of periods of temporary illness and ongoing pregnancy while answering the questions.
Our initial assessment in the first 20 men with nulliparous partners demonstrated a mean overall sexual function score of 17.1, with a standard deviation of 9.0. As it is the discriminatory point between normal and dysfunction in overall sexual function scale of the GRISS, we presumed that a 25-point score in the vaginal delivery group was clinically significant. PS Power and Sample Size Calculations Version 2.1.30 (available at http://biostat.mc.vanderbilt.edu/twiki/bin/view/Main/PowerSampleSize) statistical package revealed that a minimum of 21 participants were required for each group to demonstrate the 8-point difference at alpha = 0.05 and beta = 0.20. Recruitment for the study groups was started at the same time and conducted until the smallest group reached the required number of participants.
For the primary analysis, internal consistency of the GRISS questionnaire was assessed by using Cronbach's alpha and found to be 0.74 in our study population. The sample was divided into three groups according to mode of delivery. One-sample Kolmogorov-Smirnov test was used to analyze the normality of distribution of variables. Levene's test was used to test the homogeneity of variance for the continuous variables. Comparisons between proportions were made using chi-square test. Continuous variables were compared by using student's t-test and analysis of variance (anova), where appropriate. Data are expressed as mean ± standard deviation, number, and percentage, according to the variables. Differences were considered significant when P < 0.05 for the two tails. Data analysis was carried out using SPSS for Windows version 10.0.1 (SPSS, Inc., Chicago, IL). All mathematical processing of the GRISS were carried out electronically using appropriate formulas.
Primary Outcome Measures
The primary outcome of this study was the difference in overall sexual function score among the men whose partners had vaginal delivery with an episiotomy, whose partners had elective caesarean delivery, and whose partners had not given birth. Although the study end point was overall sexual function, we also included the specific areas of sexual function as end points. This was to enable us to assess men's sexual function in a fuller picture.
Of the 282 women attending the outpatient clinics, 108 (38.3%) were being accompanied by their spouse. All the men accepted to participate in study, and complete data were available for 107 (99.1%) of them. One participant was excluded from the study due to inadequate data in the GRISS.
All of the subjects for this study were heterosexual couples, legally bound by the state of marriage as husband and wife. At recruitment, median time since delivery was 4 years (range 7 months to 13 years) in 57 women who gave birth. Four (7%) of these women delivered within the past 12 months. The shortest period after delivery was 7 months in the vaginal delivery group and 8 months in the cesarean group. In the nulliparae group, median time since the marriage was 2 years (range 6 months to 10 years). In the vaginal delivery group, all of the episiotomies were mediolateral in type.
The median age of the participants was 32 years (range 26–40 years) in the cesarean delivery group, 30 years (range 25–44 years) in the vaginal delivery group, and 28 years (range 22–41 years) in the nulliparae group. Sociodemographic and reproductive characteristics of the three groups are demonstrated in Table 1. The three groups exhibited similar sociodemographic characteristics except for age of men, and age and body mass index of their spouses, duration of marriage, last method of contraception, and pleasure for the contraceptive method. Multiple comparisons of these variables between each pair of group (i.e., nulliparous vs. elective caesarean, nulliparous vs. mediolateral episiotomy, and caesarean vs. mediolateral episiotomy) indicated that the men whose wives had not given birth were, naturally, younger and their duration of marriage was shorter than the men whose wives had given birth. In accordance with these findings, women who had not given birth were younger and leaner than the women who had given birth. As expected, use of any method of contraception in couples without a child was less frequent than in the couples with a child. The rate of pleasure for the contraceptive method was significantly lower in couples with a child compared with those couples who had not a child. Considering the above-mentioned variables, there was no difference between men in the elective caesarean group and mediolateral episiotomy group.
Table 1. Sociodemographic and reproductive characteristics of study groups
|Men's age (year)||28.8 ± 4.0†||32.2 ± 3.8||31.4 ± 4.5||0.002‡|
|Men's BMI||23.8 ± 2.0||25.0 ± 2.4||25.0 ± 2.6||0.035‡|
|Women's age (year)||23.9 ± 3.9†||29.4 ± 3.3||27.3 ± 4.2||<0.001‡|
|Women's BMI||21.4 ± 2.5†||24.2 ± 3.9||24.7 ± 4.5||<0.001‡|
|Educational level|| || || ||0.101|
| Primary/secondary||2 (4.0)||—||2 (5.6)|| |
| High school||30 (60.0)||11 (52.4)||21 (58.3)|| |
| Some college/college||18 (36.0)||10 (47.6)||13 (36.1)|| |
|Holding a regular job|| || || ||0.561|
| Yes||48 (96.0)||21 (100.0)||34 (94.4)|| |
|Family income|| || || ||0.343|
| Low||4 (8.0)||2 (9.5)||—|| |
| Middle||45 (90.0)||19 (90.5)||36 (100.0)|| |
| High||1 (2.0)||—||—|| |
|Marriage duration (year)||2.4 ± 2.2†||7.0 ± 3.5||6.3 ± 3.0||<0.001‡|
| 1–5||46 (92.0)||8 (38.1)||18 (50.0)||<0.001|
| 6–10||4 (8.0)||9 (42.9)||15 (41.7)|| |
| >10||—||4 (19.0)||3 (8.3)|| |
|Marriage type|| || || ||0.972|
| Love marriage||42 (84.0)||18 (85.7)||30 (83.3)|| |
| Arranged marriage||8 (16.0)||3 (14.3)||6 (16.7)|| |
|Presence of a relative in the same house|| || || ||0.334|
| Yes||5 (10.0)||—||3 (8.3)|| |
|Having a child with sleeping habit with parents|| || || ||0.707|
| Yes||NA||10 (47.6)||19 (52.8)|| |
|Degree of satisfaction for relationship with the spouse|| || || ||0.104|
| Very good||37 (74.0)||9 (42.9)||26 (72.2)|| |
| Good||10 (20.0)||10 (47.6)||9 (25.0)|| |
| Neither good nor bad||3 (6.0)||2 (9.5)||1 (2.8)|| |
| Bad/very bad||—||—||—|| |
|Last method of contraception|| || || ||<0.001|
| Withdrawal||13 (26.0)||8 (38.1)||16 (44.4)|| |
| Condom||7 (14.0)||6 (28.6)||6 (16.7)|| |
| IUD||—||3 (14.3)||7 (19.4)|| |
| Combined oral contraceptive||6 (12.0)||—||3 (8.3)|| |
| Other||1 (2.0)||2 (9.5)||3 (8.4)|| |
| None||23 (46.0)||2 (9.5)||1 (2.8)|| |
|Satisfaction for the last contraceptive method|| || || ||<0.001|
| Both spouses satisfied||24 (88.9)||11 (57.9)||21 (60.0)|| |
| Either spouse not satisfied||3 (11.1)||8 (42.1)||14 (40.0)|| |
| Time since delivery (=child's age)||NA||5.5 ± 3.3||5.3 ± 3.3||0.764§|
| Child's birth weight (g)||NA||3315 ± 384||3206 ± 506||0.361§|
| Ongoing pregnancy||24 (48.0)||4 (19.0)||11 (30.6)||0.744|
| Chronic medical illness||1 (2.0)||—||1 (2.8)||0.753|
Mean scores of men in overall sexual function and specific areas of sexual function are demonstrated in Table 2. All of the mean scores of three groups were in the range of normal except for premature ejaculation.
Table 2. Mean scores of the study groups in overall and specific areas of sexual function
|Overall sexual function||≤24||18.8 ± 9.3||20.5 ± 8.2||19.3 ± 6.5||0.731|
|Specific areas of sexual function|
| Frequency of intercourse||≤3||1.6 ± 1.5†||2.7 ± 1.4||2.4 ± 1.4||0.005|
| Communication||≤3||2.0 ± 1.7||2.7 ± 1.9||2.0 ± 1.4||0.200|
| Degree of satisfaction||≤7||2.3 ± 2.4‡||4.1 ± 2.6‡||3.1 ± 2.2||0.016|
| Avoidance||≤3||1.8 ± 1.9||1.6 ± 1.7||2.1 ± 1.7||0.618|
| Sensuality||≤11||3.2 ± 2.6||2.8 ± 2.3||3.3 ± 2.5||0.715|
| Premature ejaculation||≤4||5.1 ± 2.7||4.7 ± 2.6||4.5 ± 1.8||0.481|
| Erectile dysfunction||≤3||2.7 ± 2.2||1.9 ± 1.6||1.9 ± 1.8||0.099|
There were significant differences among the three groups in the mean score of frequency of intercourse and degree of satisfaction. Multiple comparisons of these variables between each pair of group indicated that the mean score of frequency of intercourse was significantly better in men whose wives had not given birth than the mean scores of both elective caesarean and mediolateral episiotomy groups (P < 0.05). It was also demonstrated that the score of degree of satisfaction among men whose wives had not given birth was significantly better than that among men whose wives had elective caesarean deliveries.
Comparisons of all subscales of sexual function did not demonstrate any statistically significant difference between the elective caesarean delivery group and mediolateral episiotomy group.
Prevalence of sexual dysfunction in men is demonstrated in Table 3, according to study groups. In total, 28 men (26.2%) demonstrated overall sexual dysfunction. Premature ejaculation was the most common dysfunction, with a prevalence of 49.5% (N = 53). When the mean score of this subscale was taken into account, this was an expected finding. None of the men demonstrated nonsensuality. Prevalence of sexual dysfunction was 23.4% (N = 25) in erectile function, 19.6% (N = 21) in communication, 15.9% (N = 17) in avoidance, 13.1% (N = 14) in frequency of intercourse, and 4.7% (N = 5) in degree of satisfaction.
Table 3. Prevalence of dysfunction in overall and specific areas by mode of delivery
|Overall sexual dysfunction||15 (30.0)||6 (28.6)||7 (19.4)||0.526|
|Specific areas of sexual dysfunction|
| Infrequent intercourse||3 (6.0)||5 (23.8)||6 (16.7)||0.094|
| Noncommunication||7 (14.0)||8 (38.1)||6 (16.7)||0.057|
| Dissatisfaction||2 (4.0)||2 (9.5)||1 (2.8)||0.484|
| Avoidance||8 (16.0)||3 (14.3)||6 (16.7)||0.972|
| Nonsensuality||0 (0.0)||0 (0.0)||0 (0.0)||1.000|
| Premature ejaculation||28 (56.0)||8 (38.1)||17 (47.2)||0.366|
| Erectile dysfunction||15 (30.0)||2 (9.5)||8 (22.2)||0.174|
Prevalence of sexual dysfunction in overall and specific areas of the GRISS did not demonstrate any statistically significant difference among the three groups. Similar results were obtained, when the nulliparous and the elective caesarean groups were merged together as an intact perineum group, and then compared with the mediolateral episiotomy group.
The responses to the question about vaginal function of the spouse with respect to the sexual pleasure of the man partner were converted to dichotomous variables by merging “never” and “hardly ever” as normal pleasure and merging the others together as unpleasure. This was due to obtain functional assessment of the situation similar to the context of the GRISS. Ninety-six of 107 men (89.7%) self-reported pleasure about this issue. The dichotomous responses demonstrated that there was no statistically significant difference among the three groups (P = 0.852) (Table 4).
Table 4. Men's assessment of their spouse's vaginal function by mode of delivery
|Never/hardly ever||44 (88.0%)||19 (90.5%)||33 (91.7%)||0.852|
|Occasionally/mostly/always||6 (12.0%)||2 (9.5%)||3 (8.3%)|| |
Sexuality is a complex entity with physical, emotional, psychological, cultural, and religious dimensions that differ from person to person; assessment of sexuality is never simple, particularly when one considers sensitivity of this area and how changes in the sexuality of an individual may affect his or her partner's sexuality. Several instruments, including interviews, diaries, and postal questionnaires, have been developed and used widespread for sexual function assessment in both men and women. The GRISS is one of those few questionnaires, which has been cross-validated in multiple samples of sexually functional and dysfunctional women. The advantage of the present study was that we were able to examine the sexual function by using the above-mentioned questionnaire rather than relying on general questions about sexual problems, or focusing on only certain types of sexual dysfunction. This provided a fuller picture of overall sexual function in the study groups.
The present study, the first of its type, demonstrated that overall sexual dysfunction of men does not seem to be affected by their partner's parity and mode of delivery. Any advantage of nulliparity of the spouse, in terms of sexual function, was limited to the frequency of intercourse and was probably due to the shorter duration of marriage in these couples. Interestingly, men whose wife had delivered by elective caesarean section demonstrated worst score in degree of satisfaction, and the difference was statistical significant compared with those whose wife had not given birth. However, prevalence of sexual dissatisfaction was similar among the three groups. These findings suggest that an elective cesarean section simply because of concerns about sexual function would not provide additional benefit to men, and could deny women a possible vaginal delivery, which is generally assumed to be safer than cesarean section. Moreover, sexual dysfunction should not be assumed simply a product of the parity or delivery mode. It certainly warrants further research, including the effects of sociodemographic, cultural, and psychosocial factors, health behavior, mental health, and physical symptoms, to better understand self-rated sexual function in the context of childbirth.
Unusually high prevalence of overall sexual dysfunction (26.2%) in our study group was an unexpected finding for us, because none of these men had sought help for their own sexual dysfunction prior to this study. They were merely accompanying their partner during her visit to the hospital. Although social characteristics of the three groups were similar, we did not specifically ask men whether there were any cultural issues pertinent to them being involved in the study or being with their wives.
We could not fully investigate the validity of the GRISS in our study population. The construct validity of the GRISS has been investigated in both male and female sexological patients and in gynecologic patients and their men partners in the Netherlands . The least-satisfactory prediction was revealed in men partners of gynecologic patients. Although overall correct prediction in this group appeared to be sufficient (89.7%), this finding was entirely accounted for by specificity (99.2%), whereas sensitivity was very low (17.7%). Using both partners' GRISS scores, it was not possible to raise sensitivity to an acceptable level (41.7%), which suggested that this low validity was attributable to the fact that the data were collected within a gynecologic outpatient clinic . The presence of men partners in the gynecology outpatient clinic was hypothesized to reflect a shared view of both partners that the female sexual problem had priority.
Premature ejaculation and erectile dysfunction are probably the most prevalent sexual complaint seen in clinical practice and has been reported as affecting from 5% to 40% of sexually active men, depending on age [21–23]. Prevalence estimates of premature ejaculation vary widely, probably because there is no universally accepted definition of premature ejaculation . This absence allows a patient-dependent definition and a patient-decided diagnosis. The American Urological Association stated that premature ejaculation is ejaculation occurring sooner than desired, either before or shortly after penetration, causing distress to either one or both partners . The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) defines premature ejaculation as “the persistent or recurrent ejaculation with minimal sexual stimulation before, or shortly after penetration, and before the person wishes”.
Of all the specific areas of sexual dysfunctions, in the present study, premature ejaculation was the only one with a mean score above the normal range. Moreover, it was the most common problem in accordance with the previous studies. Considering the age range, the 49.5% of premature ejaculation in our study population was higher than the reported rates. Our findings corroborate earlier contentions that the clinician should actively ask for the existence of sexual dysfunctions, because patients tend not to forward their sexual dysfunctions all by themselves despite their apparent need for professional assistance [20,22–24]. Moreover, although more research is needed, men should be informed about that the new treatment guidelines and algorithms, based on systematic grading of the medical literature, cultural, and ethical considerations, have been developed for assessment and treatment of their sexual dysfunction [27–29].
Our data did not include what the women were saying; therefore, this important factor could not be assessed. Although there are plausible mechanisms that could argue for the improved sexual functioning among women with cesarean, major gaps in information about sexual functioning remain . Hicks et al. , in a systematic review of the literature, concluded that the greatest risk for increased perineal pain occurred among women with assisted vaginal delivery. Spontaneous vaginal delivery was associated with decreased sexual problems compared with assisted vaginal delivery or cesarean delivery. However, reported associations between cesarean delivery and perineal pain, dyspareunia, and delay in resumption of sexual intercourse postpartum were inconsistent. Recently, Baytur et al.  investigated the respective roles of the mode of delivery and strength of pelvic floor muscles in the long-term (more than 2 years after delivery) sexual function of 32 women who were delivered vaginally (all had a right mediolateral episiotomy) and 21 women who underwent cesarean delivery. Fifteen nulliparae were also recruited as controls. Desire, arousal, lubrication, orgasm, satisfaction, and pain were measured separately by a validated questionnaire, and pelvic floor muscle strength was assessed by a perineometer. There was no difference among the groups regarding sexual function, and there was also no correlation between sexual function and pelvic muscle strength. In theory, the women can have several sexual problems related to type of delivery, but it may not affect the man partner. In our study, the similarity of the three groups in responses to the question designed to capture the perception of vaginal looseness of the man partner may provide a continuum to their findings. Considering that the postpartum sexual health may be an important factor for not only women, but also men in driving the current high cesarean section rates, this information needs to be delivered to both prospective parents and their health care professionals. More information on the partner and partner's role may be elicited in future studies on this subject.
In conclusion, our study demonstrated that the mode of delivery did not affect sexual functioning of the man partner. In addition, this study did not detect any significant differences in the reporting of sexual pleasure with regard to vaginal functioning of the partner between men whose wife had an intact perineum and those with an episiotomy. Finally, our data confirmed that sexual dysfunction was common in men. Because sexual satisfaction is frequently linked to quality of life, and discussion of sexual concerns appears to be a neglected area in primary health care, screening for sexual dysfunction is important.
Nonexistence of studies to compare our findings directly with regard to time period after delivery, use of measures, and gender of the studysample shows that this is clearly a promoting area for future researchers, worthy of designing larger-scale studies in which basic principles of comparability have been met.
We would like to thank Zuhal Baltaci, PhD, for the assistance in recruiting men to participate in this study. We would also like to thank Serap Gungor, PhD, for her valuable advice and assistance in preparing the questionnaires. We are especially grateful to the participants of the study, who so generously gave their time and support to complete this study.
Conflict of Interest: None declared.