Prediction of Sexual Function in Married Women Based on Sexual Attitudes: The Mediating Role of Sexual Self-Esteem

Introduction

exual health is an integral component of psychological well-being, marital adjustment, quality of life, and the broader functioning of intimate relationships. Within marital relationships, sexual function is not limited to physiological responsiveness but is shaped by an interconnected set of cognitive, emotional, interpersonal, cultural, and self-evaluative processes. For women in particular, sexual functioning may be influenced by the way sexuality is perceived, interpreted, valued, and integrated into the broader self-concept. Accordingly, contemporary psychological approaches increasingly conceptualize female sexual function as a multidimensional phenomenon involving sexual desire, arousal, lubrication, orgasm, satisfaction, and pain, while also recognizing the influence of personal beliefs, relational experiences, emotional regulation, body-related evaluations, and social norms. Evidence from clinical and community samples indicates that female sexual dysfunction remains a relatively common concern and may be associated with age, reproductive status, psychological distress, relationship conditions, and sociocultural influences (Ahmadi & Saadati, 2025; Silva et al., 2020). These findings underscore the importance of examining psychological mechanisms that may explain individual differences in women’s sexual functioning rather than treating sexual difficulties exclusively as biomedical problems.

Female sexual function is particularly sensitive to the broader relational context in which sexuality is experienced. Marital intimacy, perceived relationship quality, emotional connectedness, and the ability to regulate distress have all been linked to women’s interpersonal and psychological adjustment (Abdi & Sadeghi, 2024; Ganjian et al., 2025). Sexual functioning therefore emerges within a dynamic system in which cognitive evaluations, emotional experiences, partner interactions, and self-perceptions mutually influence one another. Studies of women facing medical or psychological stressors likewise show that sexual well-being is closely tied to quality of life, emotional regulation, and intimacy (Abdi & Sadeghi, 2024; Fischer et al., 2022). This multidimensional perspective is especially relevant in societies where sexual beliefs are shaped not only by individual preferences but also by family expectations, cultural scripts, gender roles, moral norms, and attitudes toward marital sexuality.

One of the psychological variables that may play a particularly important role in women’s sexual function is sexual attitude. Sexual attitudes refer to relatively enduring beliefs, evaluations, values, and affective orientations regarding sexuality, sexual expression, sexual relationships, and sexual behavior. These attitudes influence how sexual experiences are interpreted and how individuals respond to sexual thoughts, emotions, and interpersonal situations. Sexual attitudes can range from accepting, flexible, and positive orientations to restrictive, guilt-laden, avoidant, or negatively evaluative patterns. In marital relationships, such attitudes may shape sexual communication, willingness to express needs, expectations regarding intimacy, interpretations of sexual behavior, and the degree of comfort experienced in sexual encounters. Research has shown that sexual attitudes are related to marital outcomes and may contribute to variations in relationship satisfaction and sexual functioning (Mirzaei Jahed & Saberi, 2019). Moreover, sexual education interventions that address knowledge and attitudes have been shown to improve sexual health-related outcomes, suggesting that attitudes are modifiable psychological constructs rather than static dispositions (Khani et al., 2025; Rezaei et al., 2021).

Sexual attitudes are also influenced by broader sociocultural environments. Sexual beliefs develop through family socialization, religious and cultural narratives, gender-role expectations, educational experiences, peer norms, and exposure to media. In contemporary environments, attitudes toward sexuality may additionally be affected by social media, changing body ideals, and the increasing visibility of diverse sexual narratives. Although research on social media has often focused on body image and general self-esteem, there is growing recognition that digitally mediated comparisons and normative pressures can influence personal evaluations and sexual self-perceptions as well (Merino et al., 2024; Nguyen et al., 2025). Cultural and gender-related differences in body perception and self-evaluation may therefore indirectly influence sexuality by shaping beliefs about attractiveness, desirability, and acceptable sexual behavior (Özbay, 2025). These processes suggest that sexual attitudes should be understood within a broader psychological and cultural system rather than as isolated opinions about sexuality.

Empirical research has also indicated that sexual attitudes may be related to sexual self-efficacy, sexual schemas, and other cognitive-affective components of sexual self-concept. For example, sexual attitudes have been shown to predict sexual self-efficacy through sexual schemas among married women, indicating that beliefs about sexuality may influence confidence and perceived competence in sexual situations (Behravan & Behrad, 2024). Similarly, sexual schemas and gender-role beliefs may shape sexual assertiveness through their influence on sexual desire and self-perception (Arab Khazaei, 2020). Sexual attitudes can therefore exert effects through multiple cognitive pathways, including expectations, internalized standards, perceived competence, and self-evaluative processes. This suggests that the relationship between sexual attitudes and sexual function may not be exclusively direct; rather, important mediating psychological constructs may explain how attitudes are translated into sexual experiences and behavioral responses.

Among these potential mediators, sexual self-esteem is particularly relevant. Sexual self-esteem refers to the evaluative dimension of sexual self-concept and reflects the degree to which individuals perceive themselves as worthy, competent, attractive, acceptable, and effective within the sexual domain. It encompasses judgments concerning sexual attractiveness, sexual competence, control, moral acceptability, relational adequacy, and confidence in sexual experiences. Unlike global self-esteem, sexual self-esteem is domain-specific and may therefore have a more proximal relationship with sexual behavior and functioning. A woman may report generally adequate global self-worth while simultaneously experiencing insecurity, shame, perceived inadequacy, or low confidence regarding sexuality. For this reason, sexual self-esteem provides a theoretically meaningful bridge between general psychological processes and concrete sexual outcomes.

Research supports the relevance of sexual self-esteem to women’s sexual health. Sexual self-esteem has been identified as an important correlate of female sexual function, alongside sexual desire and sexual assertiveness (Chesli, Bostani Khalesi, & Chenari, 2024; Chesli, Bostani Khalesi, & Shirzad Chenari, 2024). Women with higher sexual self-esteem may be more capable of communicating needs, expressing preferences, engaging confidently in intimate situations, and interpreting sexual experiences in less threatening ways. In contrast, low sexual self-esteem may contribute to self-monitoring, fear of negative evaluation, avoidance of sexual interaction, reduced desire, and difficulty experiencing satisfaction. Findings also indicate that sexual self-esteem can function as an intermediary variable linking other psychological constructs to sexual or marital outcomes. For example, it has been examined as a mediator between sexual mindfulness and marital adjustment, suggesting that awareness and acceptance in sexual experiences may influence relationship functioning partly through enhanced sexual self-evaluation (Rabiei, 2025).

The importance of sexual self-esteem is further supported by studies examining body image and sexual functioning. Body image satisfaction and sexual desire have been linked to women’s sexual function, with sexual self-esteem playing a mediating role in these associations (Aslami & Malekzadeh, 2025). Similarly, sexual interest and arousal difficulties have been associated with body-image concerns, sexual guilt, marital satisfaction, and self-esteem (Alikhani, 2024). Research among women has also shown that sexual esteem and sexual communication may explain part of the association between body image and sexual function (Wu & Zheng, 2021). These findings suggest that women’s sexual functioning is partly dependent on how they perceive and evaluate themselves as sexual individuals, rather than solely on objective physical characteristics or relationship status.

The broader literature on body image, cognitive appraisal, and self-evaluation also provides theoretical support for this framework. Concerns about body image can be understood through cognitive and experiential mechanisms involving cognitive fusion, reappraisal, and experiential avoidance (Ahmadi et al., 2026). These processes may be highly relevant to sexual situations, where attention to perceived bodily flaws, fear of judgment, and internalized negative beliefs can interfere with arousal and satisfaction. Moreover, sexual self-esteem has been implicated in psychological phenomena involving body dysmorphic concerns and appearance-related behavior among married women (Ghaffari et al., 2023). The relationship between self-esteem, body perceptions, and sexual attitudes has also been observed across different populations, including older adults living with chronic diseases (Özbay, 2025). Taken together, this literature suggests that self-evaluative mechanisms may substantially influence sexual functioning by shaping both emotional responses and behavioral engagement.

Psychological regulation processes represent another relevant dimension. A scoping review of the literature has demonstrated associations between emotion regulation, sexual function, and sexual satisfaction, highlighting the importance of how individuals manage emotional responses during intimate experiences (Fischer et al., 2022). Difficulties identifying and expressing emotions, such as alexithymia, have also been linked to sexual dysfunction and related clinical conditions (Ledermann et al., 2024; Mohammadbeigi & Ganji, 2024). Such findings indicate that sexual function may deteriorate when emotional experiences cannot be effectively processed, communicated, or integrated into intimate interaction. Conversely, psychological skills that facilitate emotional awareness, cognitive flexibility, and adaptive self-evaluation may enhance sexual well-being. This is consistent with evidence that cognitive-behavioral interventions can improve sexual self-concept among married women (Khanmohammadi Otaghsara, 2022).

Sexual health interventions provide additional evidence that both cognition and self-perception are modifiable. Educational programs have demonstrated beneficial effects on sexual function and attitudes among women of reproductive age (Rezaei et al., 2021), while multidimensional sexual education and counseling have improved sexual knowledge and attitudes among couples preparing for marriage (Khani et al., 2025). Similarly, structured sexual health training has been developed to improve sexual quality of life, sexual knowledge, attitudes, and functioning among engaged and newly married couples (Izadi, 2023). Stress-management interventions have also been associated with improved sexual functioning in perimenopausal women, further indicating that psychological intervention may positively affect sexual outcomes through mechanisms extending beyond direct sexual stimulation (Nisani Samani et al., 2024). These findings are important because they suggest that sexual difficulties may be responsive to interventions targeting cognitive, emotional, and relational factors.

At the same time, sexual functioning should be interpreted within the larger context of women’s marital and reproductive lives. Decisions concerning childbearing, marital intimacy, relationship quality, and sexual well-being are often interrelated. Research among Iranian women suggests that reproductive intentions are shaped by psychological, demographic, and socioeconomic determinants (Rahbar-Zeraati et al., 2026). Qualitative work on low motivation for childbearing among young couples has likewise emphasized the complexity of personal, relational, and contextual influences on intimate and reproductive decision-making (Fakhar et al., 2024). These findings illustrate that sexual and reproductive experiences occur within a broad psychosocial framework in which beliefs, self-perceptions, relational quality, and contextual pressures interact.

The significance of self-esteem within this broader framework is also supported by research on psychological well-being. Self-esteem has been associated with women’s psychological functioning and may operate together with personal belief systems and broader orientations to influence well-being (Rezaeian Bilondi et al., 2023). Although global self-esteem and sexual self-esteem are distinct constructs, the broader literature reinforces the importance of self-evaluative processes in adjustment. Contemporary studies of younger populations similarly demonstrate that self-esteem is linked to life satisfaction and psychological functioning in conjunction with personality and behavioral factors (Nguyen et al., 2025). These findings strengthen the rationale for focusing specifically on sexual self-esteem when examining sexual function, because domain-specific self-evaluations may influence behavior more directly than general perceptions of self-worth.

The importance of considering sexual self-concept is further demonstrated by studies showing that sexual self-image may mediate the relationship between adverse developmental experiences and female sexual function (Saberi et al., 2022). This suggests that distal experiences may affect current sexual functioning through the meanings women assign to themselves as sexual individuals. Such pathways are theoretically consistent with the proposition that sexual attitudes may influence sexual function through sexual self-esteem. If a woman holds restrictive, negative, or conflicted sexual attitudes, these beliefs may gradually shape her perception of her sexual worth, competence, attractiveness, and legitimacy of sexual needs. In turn, diminished sexual self-esteem may impair desire, arousal, communication, orgasmic capacity, satisfaction, or comfort during sexual activity.

Conversely, positive sexual attitudes may foster a more accepting and confident sexual self-concept. When sexuality is perceived as a legitimate, meaningful, and mutually responsive component of marital life, women may be more likely to experience lower shame, greater emotional safety, stronger sexual agency, and greater confidence in expressing preferences. This interpretation is compatible with findings that sexual self-esteem, sexual desire, and sexual assertiveness are closely related to female sexual function (Chesli, Bostani Khalesi, & Chenari, 2024; Chesli, Bostani Khalesi, & Shirzad Chenari, 2024). It is also consistent with research emphasizing sexual self-efficacy, sexual schemas, and self-concept as important psychological mechanisms in married women’s sexual experiences (Behravan & Behrad, 2024; Khanmohammadi Otaghsara, 2022).

Recent research on sexuality also underscores the need to examine changing cultural and behavioral patterns rather than assuming that sexual attitudes remain stable over time. Population-level studies have documented shifts in sexual behaviors and associated factors across successive survey periods, reflecting broader changes in social norms, lifestyles, and attitudes toward sexuality (Fischer et al., 2025). Although such findings arise from different cultural settings, they demonstrate that sexual attitudes and behaviors are responsive to historical and social change. In societies experiencing rapid transformations in media exposure, gender-role expectations, marriage patterns, and access to sexual-health information, investigating psychological determinants of sexual function becomes particularly important.

Despite the growing literature, several gaps remain. Many studies have examined sexual function in relation to body image, sexual desire, sexual assertiveness, childhood trauma, emotion regulation, marital intimacy, or clinical symptoms, but fewer have simultaneously modeled sexual attitudes and sexual self-esteem within a single structural framework. Existing evidence suggests that sexual attitudes are associated with sexual outcomes (Mirzaei Jahed & Saberi, 2019; Rezaei et al., 2021), that sexual self-esteem is closely related to female sexual function (Aslami & Malekzadeh, 2025; Chesli, Bostani Khalesi, & Shirzad Chenari, 2024), and that self-evaluative mechanisms can mediate relationships between psychological antecedents and sexual or marital outcomes (Rabiei, 2025; Saberi et al., 2022). However, the specific pathway through which sexual attitudes may influence sexual function via sexual self-esteem remains insufficiently clarified, particularly among married Iranian women.

Clarifying this pathway has both theoretical and practical implications. Theoretically, a mediation model can determine whether sexual attitudes operate directly on sexual function or whether part of their influence occurs through women’s evaluations of themselves as sexual individuals. Practically, identifying sexual self-esteem as a mediator could support the development of more targeted psychological and couple-based interventions. Rather than focusing only on sexual technique or general psychoeducation, interventions could address maladaptive sexual beliefs, cognitive distortions, body-related concerns, sexual guilt, self-criticism, and low perceived sexual competence. Such an approach would be consistent with evidence supporting cognitive-behavioral, educational, and stress-management interventions for improving sexual outcomes (Khanmohammadi Otaghsara, 2022; Nisani Samani et al., 2024). It would also complement broader models of women’s psychosocial adjustment that emphasize the interaction of cognitive appraisal, emotional regulation, self-esteem, and relationship quality (Ahmadi et al., 2026; Ganjian et al., 2025).

Therefore, the present study aimed to develop and test a structural model predicting sexual function among married women based on sexual attitudes, with sexual self-esteem examined as a mediating variable.

Methods and Materials

Study Design and Participants

This study employed a descriptive-correlational, applied research design and was conducted within a structural equation modeling framework. Because the study sought to formulate and empirically test a structural model explaining sexual function among married women on the basis of sexual attitudes and the mediating role of sexual self-esteem, it also incorporated an explanatory predictive approach. Structural equation modeling (SEM) was selected because it permits the simultaneous examination of direct and indirect relationships among latent and observed variables and provides an appropriate analytical framework for testing mediation effects within a theoretically specified model. The statistical population consisted of married women residing in Kermanshah, Iran, who attended counseling, psychology, or psychiatric clinics in the city during the winter of 2025–2026 and spring of 2026. Participants were recruited through convenience sampling from counseling, psychological, and psychiatric centers in Kermanshah. The required sample size was estimated using G*Power software, and a total of 251 eligible women were ultimately recruited and completed the study questionnaires. Participants were selected according to the predefined eligibility criteria after receiving information about the objectives and procedures of the study and providing informed consent to participate. Participation was voluntary, and respondents were informed that the information obtained through the questionnaires would be treated confidentially and used solely for research purposes. Following recruitment and confirmation of eligibility, the Female Sexual Function Index, Sexual Attitudes Questionnaire, and Sexual Self-Esteem Inventory for Women–Short Form were administered to the participants. The resulting data were subsequently used to test the hypothesized structural relationships among sexual attitudes, sexual self-esteem, and sexual function.

Data Collection Tools

The Female Sexual Function Index (FSFI) was used to assess sexual functioning among the participants. The FSFI was originally developed and validated by Rosen et al. (1997) as a multidimensional self-report measure of female sexual function. The instrument consists of 19 closed-ended items assessing six domains of female sexual functioning, including sexual desire, arousal, lubrication, orgasm, sexual satisfaction, and pain. Items are rated using Likert-type response options, and the domain scores are combined to provide an overall indicator of sexual functioning, with higher scores generally representing better sexual function. The instrument has been widely used to identify difficulties across different dimensions of female sexual functioning. According to the scoring criteria reported in the Persian validation literature, different score ranges have been used to distinguish varying levels of sexual dysfunction, including severe, moderate, and mild dysfunction, while scores above the proposed threshold are interpreted as indicating the absence of clinically meaningful dysfunction. In addition, a score below approximately 65% of the maximum obtainable score in an individual domain has been proposed as indicative of dysfunction within that specific domain (Safarinejad, 2006). The psychometric properties of the FSFI have been supported in both the original and Persian-language studies. Rosen et al. (1997) reported satisfactory internal consistency across the different domains, with reliability coefficients ranging approximately from .79 to .86 and an overall Cronbach’s alpha coefficient of approximately .82. Construct validity of the original scale was supported through factor-analytic procedures. In the Persian validation study conducted by Barghi Irani (2013), the internal consistency of the instrument was also found to be satisfactory, with a Cronbach’s alpha coefficient of .86. Content validity of the Persian version was evaluated through expert review, in which academic and clinical specialists assessed the relevance, clarity, comprehensibility, and appropriateness of the questionnaire items for measuring female sexual function.

The Sexual Attitudes Questionnaire developed by Ozgoli, Tork Zahrani, and Khoshabi (2000) was used to assess participants’ attitudes toward sexuality. This questionnaire consists of 16 items designed to measure cognitive and evaluative orientations toward sexual issues. Responses are scored on a four-point Likert-type scale ranging from 0 (completely disagree) to 3 (completely agree), with item scores combined to generate an overall sexual-attitude score. The instrument is intended to capture the extent to which respondents endorse favorable or unfavorable beliefs, evaluations, and attitudes concerning sexuality and sexual relationships. Evidence for the validity of the questionnaire was reported in the original study by Ozgoli et al. (2000), in which significant associations were observed between sexual attitudes and orgasmic functioning as well as demographic characteristics such as age and socioeconomic status, providing evidence supporting its concurrent validity. The questionnaire has subsequently been used in studies involving Iranian women. In the study by Mirzaei Jahed and Saberi (2014), the questionnaire demonstrated satisfactory internal consistency, with a Cronbach’s alpha coefficient of .89, indicating adequate reliability for the assessment of sexual attitudes in female populations. Accordingly, the instrument was considered suitable for assessing sexual attitudes as the principal predictor variable in the present structural model.

The Sexual Self-Esteem Inventory for Women–Short Form (SSEI-W-SF) was used to evaluate sexual self-esteem. The short-form instrument contains 32 items and is designed to assess women’s affective and evaluative responses toward themselves as sexual individuals across several dimensions. These dimensions include moral judgment, adaptiveness, experience and skill, control, and attractiveness. The items are scored using a four-point Likert-type response format. Scores for each dimension are calculated by summing the responses to the items corresponding to that subscale, while an overall sexual self-esteem score is obtained by combining the relevant item scores across the scale. Higher total scores indicate higher levels of sexual self-esteem, whereas lower scores represent less positive sexual self-evaluations. The Persian version of the instrument has demonstrated strong psychometric properties. Farrokhi and Shareh (2014) reported a test–retest reliability coefficient of .91 for the total scale, while reliability coefficients for the five subscales ranged from .82 to .94. Evidence supporting convergent validity was obtained through statistically significant positive associations between scores on the sexual self-esteem measure and both the Coopersmith Self-Esteem Inventory (r = .31) and the Female Sexual Function Index (r = .31). Divergent validity was also supported through examination of the relationship between sexual self-esteem scores and the depression subscale of the Depression Anxiety Stress Scales–21 (DASS-21). Collectively, these findings indicate that the SSEI-W-SF possesses adequate reliability and construct validity for evaluating sexual self-esteem among women and was therefore used as the mediating variable in the present study.

Data Analysis

Data analysis was conducted using partial least squares structural equation modeling (PLS-SEM) in SmartPLS software. PLS-SEM was selected because the primary objective of the study was to develop and test a predictive structural model involving both direct and indirect relationships among sexual attitudes, sexual self-esteem, and sexual function. Prior to evaluation of the structural model, the data were screened for completeness and suitability for analysis, and descriptive statistics were used to summarize the characteristics of the study variables and participants. The measurement model was then evaluated to determine the adequacy of the psychometric properties of the constructs. Internal consistency reliability was assessed using Cronbach’s alpha and composite reliability, with coefficients of .70 or greater considered acceptable. Convergent validity was evaluated using factor loadings and average variance extracted (AVE), with an AVE value of at least .50 indicating that the latent construct explained an adequate proportion of the variance in its indicators. Discriminant validity was assessed to determine whether the constructs represented empirically distinct dimensions, including evaluation of the heterotrait–monotrait ratio of correlations where appropriate. Collinearity among predictor constructs was also examined using variance inflation factor indices to ensure that excessive multicollinearity did not distort the estimated structural relationships.

Following confirmation of the adequacy of the measurement model, the structural model was evaluated by examining standardized path coefficients, coefficients of determination (R²), predictive relevance indices, and the statistical significance of hypothesized relationships. The direct effects of sexual attitudes and sexual self-esteem on sexual function were estimated using standardized beta coefficients. The mediating role of sexual self-esteem in the relationship between sexual attitudes and sexual function was evaluated by examining the indirect effect within the PLS-SEM framework. The statistical significance of both direct and indirect effects was assessed using the bootstrapping procedure implemented in SmartPLS, which generates empirical standard errors, confidence intervals, and significance levels without imposing strict distributional assumptions on indirect effects. A p value below .05 was regarded as statistically significant, while effects with p values below .01 were interpreted as providing stronger statistical evidence. This analytical strategy made it possible to estimate simultaneously the direct association between sexual attitudes and sexual function, the association between sexual attitudes and sexual self-esteem, the effect of sexual self-esteem on sexual function, and the indirect pathway through which sexual attitudes were hypothesized to influence sexual function via sexual self-esteem.

Findings and Results

The distributional characteristics of the principal study variables were first examined before evaluating the measurement and structural models. The one-sample Kolmogorov–Smirnov test was used to determine whether the observed distributions significantly deviated from normality. According to the conventional decision rule, a significance value greater than .05 supports the null hypothesis of normality, whereas a value below .05 indicates a statistically significant departure from a normal distribution. As shown in Table 1, the Kolmogorov–Smirnov statistics were .069 for sexual attitudes, .073 for sexual self-esteem, and .153 for sexual function. The corresponding significance levels were .006, .003, and < .001, respectively. Thus, the null hypothesis of normality was rejected for all three principal variables. The standard deviations were 6.47 for sexual attitudes, 19.05 for sexual self-esteem, and 19.39 for sexual function. The observed non-normality further supported the suitability of partial least squares structural equation modeling (PLS-SEM), which does not require strict multivariate normality assumptions.

Bivariate associations among the study variables were subsequently examined using Pearson correlation coefficients. The supplied correlation results indicated statistically significant positive relationships among the principal psychological and sexual variables at the 99% confidence level. Sexual self-esteem was positively correlated with sexual attitudes, r = .539, p < .01. Sexual function was also positively associated with sexual attitudes, r = .494, p < .01, and with sexual self-esteem, r = .425, p < .01. Additional coefficients reported in the initial correlation matrix included r = −.097, r = .042, r = −.010, r = .213, r = .495, r = .229, and r = .349; however, the source matrix did not provide identifiable labels for the additional variables corresponding to these coefficients. The source results also referred to a correlation coefficient of r = .567 for sexual attitudes. Because the matrix supplied for the present analysis identified only sexual attitudes, sexual self-esteem, and sexual function by name, the interpretation was restricted to the clearly identifiable associations. Collectively, the interpretable coefficients demonstrated that more favorable sexual attitudes and higher sexual self-esteem were associated with better sexual function, while sexual attitudes and sexual self-esteem themselves were also moderately and positively related. These findings indicated substantial interrelationships among the psychological and sexual constructs included in the proposed model.

The adequacy of the measurement model was assessed using composite reliability and average variance extracted (AVE). Table 2 presents the reliability and convergent validity coefficients for both first-order and higher-order constructs. Composite reliability coefficients for the dimensions of sexual self-esteem ranged from .87 to .92, including moral judgment (.87), adaptiveness (.89), experience and skill (.91), control (.92), and attractiveness (.88). The second-order composite reliability coefficient for sexual self-esteem was .94. For sexual function, composite reliability coefficients ranged from .89 to .93 across sexual desire (.91), arousal (.89), lubrication (.93), pain (.91), orgasm (.92), and sexual satisfaction (.89), while the overall second-order composite reliability coefficient was .92. The overall composite reliability coefficient reported for sexual attitudes was .94. Because all coefficients exceeded the recommended threshold of .70, the constructs demonstrated satisfactory internal consistency reliability.

Convergent validity was assessed using AVE, for which values of at least .50 are generally considered acceptable (Davari & Rezazadeh, 2014). The AVE for sexual attitudes was .72. For the first-order dimensions of sexual self-esteem, AVE values were .74 for moral judgment, .75 for adaptiveness, .70 for experience and skill, .74 for control, and .79 for attractiveness, while the second-order AVE was .74. For sexual function, AVE values were .58 for sexual desire, .62 for arousal, .60 for lubrication, .61 for pain, .57 for orgasm, and .62 for sexual satisfaction. The second-order AVE for sexual function was .60. All AVE coefficients therefore exceeded the minimum recommended value of .50, confirming adequate convergent validity for all first- and second-order constructs. For the higher-order variables, the corresponding validity coefficients were calculated manually, as required for the hierarchical measurement specification.

After confirmation of the measurement model, the explanatory and predictive adequacy of the structural model was examined through the coefficients of determination (R²), predictive relevance coefficients (Q²), effect sizes (f²), and variance inflation factors (VIFs). As presented in Table 3, the R² coefficient for sexual self-esteem was .337, indicating that approximately 33.7%, or about 34%, of its variance was explained by its predictor(s) in the model. The R² value for sexual function was .374, indicating that approximately 37.4%, or about 37%, of the variance in sexual function was explained by the predictors included in the structural model. These coefficients indicated satisfactory explanatory power for the endogenous constructs.

Predictive relevance was examined using Q². The Q² coefficient was .38 for sexual self-esteem and .54 for sexual function. Because both coefficients were positive, the structural model demonstrated predictive relevance for both endogenous constructs, with particularly strong predictive performance for sexual function. The effect-size analysis further indicated substantial effects of the independent variables on sexual function. The f² coefficient for the effect of sexual attitudes on sexual function was .398, whereas the effect of sexual self-esteem on sexual function produced an f² of .408. Both values indicated practically meaningful contributions of these variables to the explanation of sexual function.

Collinearity diagnostics also supported the adequacy of the structural model. The VIF value for sexual attitudes in predicting sexual function was 1.325, whereas the corresponding VIF for sexual self-esteem was 1.021. Both coefficients were substantially below the conventional threshold of 5.00, demonstrating that problematic multicollinearity was absent among the predictor constructs. Accordingly, the structural coefficients could be interpreted without substantial concern regarding inflation caused by linear dependence among predictors. Taken together, the R², Q², f², and VIF results supported the explanatory adequacy, predictive relevance, effect magnitude, and absence of problematic collinearity in the proposed structural model.

The importance–performance map analysis (IPMA) was subsequently used to determine the relative strategic importance of sexual attitudes and sexual self-esteem in relation to sexual function. As shown in Table 4, sexual self-esteem had a total effect, representing importance for sexual function, of .425 and a performance score of 65.239. Sexual attitudes demonstrated a larger total effect of .532 and a higher performance score of 77.695. Thus, among the predictors considered in the importance–performance analysis, sexual attitudes showed both the greatest relative importance and the highest performance. This pattern indicates that sexual attitudes occupy a particularly influential position in explaining sexual function within the proposed model. Consequently, interventions intended to improve sexual functioning among married women may benefit particularly from targeting maladaptive or unfavorable sexual attitudes, while sexual self-esteem remains another important intervention target.

Finally, the overall goodness of fit of the PLS-SEM model was examined using the goodness-of-fit (GoF) criterion based on the geometric mean of average communality and average R². The reported average communality was .706 and the R² component used in the reported calculation was .374, producing a GoF coefficient of .361. Wetzels et al. (2009) proposed approximate GoF benchmarks of .10, .25, and .36 for small, medium, and large overall fit, respectively. The obtained GoF value of .361 therefore reached the criterion for a strong overall model fit. Accordingly, the combined assessment of the measurement and structural components indicated that the proposed model provided an adequate representation of the observed relationships among sexual attitudes, sexual self-esteem, and sexual function.

Overall, the findings supported the psychometric adequacy of the measurement model and the explanatory and predictive quality of the structural model. Composite reliability and AVE coefficients exceeded their recommended thresholds across the first- and second-order constructs, the endogenous variables demonstrated satisfactory explained variance and predictive relevance, and no problematic collinearity was detected. The importance–performance analysis further identified sexual attitudes as the comparatively more important predictor of sexual function, followed by sexual self-esteem. Finally, the overall GoF coefficient of .361 indicated a strong fit of the proposed model, supporting progression to the evaluation of the direct and indirect structural paths and the formal testing of the study hypotheses.

Discussion

The present study aimed to develop and test a structural model of sexual function among married women based on sexual attitudes, with sexual self-esteem examined as a mediating variable. Overall, the findings supported the proposed conceptual model and demonstrated that sexual attitudes and sexual self-esteem were meaningfully associated with women’s sexual function. The measurement model showed satisfactory composite reliability and convergent validity, and the structural model demonstrated acceptable explanatory and predictive power. Sexual attitudes and sexual self-esteem both contributed substantially to the prediction of sexual function, while the importance–performance analysis indicated that sexual attitudes had the highest relative importance and performance among the examined predictors. The obtained R² values further showed that the model accounted for a meaningful proportion of variance in both sexual self-esteem and sexual function, and the positive Q² coefficients confirmed satisfactory predictive relevance. In addition, the absence of problematic multicollinearity and the acceptable overall goodness-of-fit index supported the adequacy of the proposed structural model.

One of the principal findings was that sexual attitudes were significantly associated with sexual function. This result suggests that women’s cognitive and evaluative orientations toward sexuality may influence how they experience, interpret, and respond to sexual situations within marriage. Sexual attitudes encompass beliefs regarding the acceptability, desirability, meaning, and relational role of sexuality, and these beliefs may shape sexual desire, communication, comfort, arousal, and satisfaction. The present finding is consistent with previous research indicating that sexual attitudes are related to women’s sexual and marital outcomes. Mirzaei Jahed and Saberi reported that women’s sexual attitudes were associated with marital burnout, demonstrating that sexual beliefs and evaluations can influence the broader quality of marital functioning (Mirzaei Jahed & Saberi, 2019). Similarly, educational interventions that modify sexual knowledge and attitudes have been associated with improvements in women’s sexual function, supporting the proposition that sexual attitudes are not merely passive beliefs but potentially modifiable psychological factors with behavioral and relational consequences (Khani et al., 2025; Rezaei et al., 2021).

The significant association between sexual attitudes and sexual function may be explained through several psychological mechanisms. Women with more adaptive and accepting sexual attitudes may experience less guilt, shame, anxiety, or cognitive inhibition during sexual interactions, allowing greater attention to sensory and emotional aspects of intimacy. In contrast, restrictive, negative, or conflict-laden sexual beliefs may increase self-monitoring and psychological tension, thereby interfering with desire, arousal, and satisfaction. The role of cognitive interpretations in women’s sexual experiences is consistent with findings indicating that sexual schemas, gender-role expectations, and sexual beliefs are related to sexual assertiveness and sexual self-efficacy (Arab Khazaei, 2020; Behravan & Behrad, 2024). Therefore, sexual attitudes may influence sexual functioning partly by shaping how women interpret their own sexual needs, perceive their legitimacy in intimate relationships, and evaluate their competence in sexual interactions.

The present results also showed that sexual self-esteem was significantly associated with sexual function. This finding indicates that women who evaluate themselves more positively as sexual individuals are more likely to report better sexual functioning. Sexual self-esteem is a domain-specific component of self-concept that includes perceptions of attractiveness, competence, control, experience, moral acceptability, and adequacy in sexual contexts. The present result is strongly aligned with previous studies demonstrating that sexual self-esteem is closely related to female sexual functioning. Chesli and colleagues found that sexual self-esteem, together with sexual desire and sexual assertiveness, played an important role in female sexual function (Chesli, Bostani Khalesi, & Chenari, 2024; Chesli, Bostani Khalesi, & Shirzad Chenari, 2024). Similarly, Aslami and Malekzadeh showed that sexual self-esteem was involved in the relationship between body image satisfaction, sexual desire, and women’s sexual function (Aslami & Malekzadeh, 2025). These findings support the view that sexual function is influenced not only by physiological responsiveness but also by the meanings women assign to themselves in the sexual domain.

The association between sexual self-esteem and sexual function can also be understood in terms of cognitive-affective processing. A woman with higher sexual self-esteem may feel more confident expressing preferences, initiating or responding to intimacy, communicating boundaries, and remaining psychologically engaged during sexual activity. By contrast, lower sexual self-esteem may increase concern about attractiveness, perceived inadequacy, fear of negative evaluation, avoidance of sexual communication, and excessive self-focused attention. These processes may undermine arousal and satisfaction while increasing distress during intimate encounters. Previous research showing relationships among body image, sexual self-esteem, and sexual functioning provides empirical support for this interpretation (Alikhani, 2024; Wu & Zheng, 2021). The finding is also consistent with evidence linking appearance-related concerns and sexual self-esteem to maladaptive psychological outcomes among married women (Ghaffari et al., 2023). Together, these studies suggest that women’s sexual self-evaluations can serve as a proximal psychological mechanism through which broader concerns about body image, attractiveness, and relational acceptance affect sexual functioning.

A particularly important finding was the mediating role of sexual self-esteem in the association between sexual attitudes and sexual function. This result indicates that sexual attitudes may influence sexual functioning not only directly but also indirectly by shaping women’s evaluations of themselves as sexual individuals. In other words, the way a woman thinks about sexuality may contribute to how she perceives her own sexual worth, competence, attractiveness, and acceptability, which in turn may influence sexual functioning. This mediating pathway is theoretically plausible because attitudes provide cognitive frameworks for interpreting experience, whereas self-esteem reflects the internalized evaluative consequences of these frameworks. When sexual attitudes are positive, flexible, and nonjudgmental, women may be more likely to develop greater confidence and acceptance of themselves in sexual relationships. Conversely, negative or restrictive attitudes may foster guilt, inhibition, or self-criticism, reducing sexual self-esteem and ultimately impairing sexual functioning.

This mediating pattern is consistent with studies emphasizing the intermediary role of sexual self-concept variables in marital and sexual outcomes. Rabiei reported that sexual self-esteem mediated the relationship between sexual mindfulness and marital adjustment, indicating that psychologically adaptive engagement with sexuality may enhance relational outcomes partly through improved sexual self-evaluation (Rabiei, 2025). Likewise, Saberi and colleagues showed that sexual self-image mediated the association between childhood trauma and women’s sexual function, suggesting that distal psychological influences may affect current sexual functioning through internalized sexual self-perceptions (Saberi et al., 2022). The present findings extend this literature by showing that sexual attitudes may similarly exert part of their effect through sexual self-esteem. This reinforces the importance of examining internal self-evaluative processes when attempting to understand how sexual beliefs become translated into sexual outcomes.

The mediating role of sexual self-esteem is also compatible with research on sexual self-concept and cognitive-behavioral processes. Cognitive-behavioral interventions have been found to improve sexual self-concept among married women, suggesting that beliefs and evaluative processes related to sexuality are amenable to psychological modification (Khanmohammadi Otaghsara, 2022). In addition, sexual self-efficacy has been predicted by sexual attitudes through sexual schemas, indicating that cognitive structures may form pathways between general sexual beliefs and specific perceptions of sexual competence (Behravan & Behrad, 2024). From this perspective, sexual self-esteem can be understood as one of the mechanisms through which culturally and personally acquired sexual beliefs become internalized into self-evaluative judgments.

The present findings may also be explained in light of body image and broader self-esteem processes. Research indicates that body perceptions are closely related to psychological well-being and self-esteem and are shaped by cultural and gender-based standards (Merino et al., 2024). In sexual contexts, body-related concerns may become especially salient because intimate interactions involve perceived exposure and vulnerability. Studies have shown that body image, sexual esteem, and sexual communication are interrelated in predicting women’s sexual function (Wu & Zheng, 2021), while body image concern, sexual guilt, and self-esteem have also been associated with sexual interest and arousal disorders (Alikhani, 2024). Therefore, women with negative sexual attitudes may be more likely to interpret bodily or relational experiences through a critical evaluative lens, whereas higher sexual self-esteem may protect against such negative cognitive processing.

The results can further be interpreted through the broader literature on emotional regulation and psychological adjustment. Sexual function is influenced by the ability to identify, regulate, and communicate emotions during intimate experiences. Fischer and colleagues emphasized the relationship between emotion regulation and sexual function and satisfaction, indicating that emotional processes play a significant role in sexual well-being (Fischer et al., 2022). Similarly, alexithymia has been linked to female sexual dysfunction and to sexual difficulties in other clinical contexts (Ledermann et al., 2024; Mohammadbeigi & Ganji, 2024). If individuals have difficulty processing emotional states or experience persistent negative self-evaluation, sexual interactions may become associated with tension, avoidance, or reduced psychological presence. Sexual self-esteem may therefore facilitate better sexual functioning partly because it supports a more secure and less defensive emotional orientation toward intimacy.

The importance–performance analysis showed that sexual attitudes were more important than sexual self-esteem in relation to sexual function. This finding suggests that sexual attitudes may be a particularly influential intervention target. Although sexual self-esteem emerged as an important mechanism, sexual attitudes may represent a broader cognitive foundation from which self-evaluations, expectations, and behavior develop. This interpretation is consistent with evidence that interventions targeting sexual knowledge and attitudes can improve sexual function and related outcomes (Izadi, 2023; Rezaei et al., 2021). Multidimensional sexual education programs have also been shown to improve sexual knowledge and attitudes among couples, emphasizing that cognitive and educational interventions can meaningfully affect intimate functioning (Khani et al., 2025). Accordingly, interventions aimed at improving women’s sexual functioning may benefit from identifying restrictive sexual beliefs and replacing them with more adaptive, realistic, and relationally constructive attitudes.

The predictive adequacy of the model also indicates that the combination of sexual attitudes and sexual self-esteem captures a meaningful proportion of variance in sexual function, although a considerable proportion remains unexplained. This is expected because female sexual function is multidetermined. Previous studies have highlighted the contributions of marital intimacy, distress tolerance, relationship quality, body image, sexual desire, emotional regulation, reproductive concerns, and health-related factors (Abdi & Sadeghi, 2024; Ganjian et al., 2025; Rahbar-Zeraati et al., 2026). Sexual functioning is therefore best conceptualized as the product of multiple interacting systems rather than as the outcome of a single psychological trait. The present model contributes to this broader understanding by identifying sexual attitudes and sexual self-esteem as important cognitive and self-evaluative components within a more comprehensive biopsychosocial framework.

The findings may also be considered in relation to changing sexual norms and sociocultural patterns. Population-level research demonstrates that sexual behaviors and associated factors change across time and social contexts, indicating that sexual attitudes are responsive to broader cultural transformations (Fischer et al., 2025). In Iranian society, sexual attitudes may be influenced by family norms, religious beliefs, expectations regarding modesty, gender roles, and limited access to formal sexual education. Broader studies of reproductive and marital decision-making among Iranian women also indicate that psychological, demographic, socioeconomic, and relational factors interact in shaping intimate life choices (Fakhar et al., 2024; Rahbar-Zeraati et al., 2026). This sociocultural context may make sexual attitudes particularly important because attitudes can serve as the psychological interface between external norms and personal sexual experience.

The relationship between self-esteem and psychological well-being provides additional support for the present results. Studies of women have shown that self-esteem is associated with psychological well-being and interacts with broader belief systems and personal orientations (Rezaeian Bilondi et al., 2023). More generally, self-esteem has been associated with life satisfaction and psychological functioning across contemporary populations (Nguyen et al., 2025). Although global self-esteem differs from sexual self-esteem, both involve evaluative judgments about the self. The present findings suggest that domain-specific sexual self-esteem may be especially relevant when predicting sexual outcomes because it directly concerns sexual competence, desirability, and worth.

Conclusion

Finally, the findings support the broader view that sexual health interventions should integrate cognitive, self-evaluative, emotional, and relational components rather than focusing exclusively on physiological aspects of sexual response. Evidence indicates that stress-management training can improve sexual function (Nisani Samani et al., 2024), while cognitive-behavioral approaches can enhance sexual self-concept (Khanmohammadi Otaghsara, 2022). Similarly, research on cognitive reappraisal, experiential avoidance, and body image concern suggests that maladaptive cognitive processes can influence self-evaluation and psychological functioning (Ahmadi et al., 2026). These findings collectively support intervention models in which maladaptive sexual attitudes are identified, sexual self-esteem is strengthened, emotional responses are regulated, and couple communication is improved.

Several limitations should be considered when interpreting the findings. First, the cross-sectional and correlational design limits causal inference, and the observed structural paths should therefore be interpreted as theoretically consistent predictive relationships rather than definitive causal effects. Second, participants were recruited through convenience sampling from counseling, psychology, and psychiatric centers in Kermanshah, which may restrict the generalizability of the findings to married women who do not seek psychological or clinical services or to women living in other regions. Third, all major variables were measured using self-report questionnaires, which may be influenced by social desirability, recall bias, response styles, and the sensitivity of reporting sexual experiences. Fourth, because sexuality is strongly shaped by cultural norms and interpersonal context, participants may have underreported or selectively reported certain experiences. Finally, the model included only sexual attitudes and sexual self-esteem as primary psychological predictors, whereas other potentially influential variables such as marital satisfaction, partner communication, body image, attachment style, depression, anxiety, medication use, reproductive status, and physical health were not simultaneously controlled.

Future studies should examine the proposed model using longitudinal and prospective designs to clarify temporal ordering among sexual attitudes, sexual self-esteem, and sexual function. Replication with probability-based samples and participants from different geographic, cultural, socioeconomic, and clinical backgrounds would improve external validity. Researchers should also consider dyadic designs involving both partners to examine how each partner’s sexual attitudes, self-esteem, communication patterns, and relationship satisfaction jointly influence sexual functioning. Future models could integrate additional psychological variables such as body image, sexual guilt, emotional regulation, attachment, sexual assertiveness, mindfulness, marital intimacy, and perceived partner responsiveness. Experimental and intervention studies are also needed to determine whether modifying maladaptive sexual attitudes or increasing sexual self-esteem leads to measurable improvements in sexual function. Qualitative and mixed-methods studies could further clarify how women interpret sexual self-worth and how cultural norms shape sexual attitudes in marital relationships.

The findings suggest that psychologists, counselors, sex therapists, and professionals working with couples should assess sexual attitudes and sexual self-esteem when evaluating sexual difficulties in married women. Intervention programs may be strengthened by incorporating cognitive restructuring of restrictive or dysfunctional sexual beliefs, psychoeducation about normal sexual responses, enhancement of sexual self-acceptance, and exercises designed to improve confidence and perceived competence in intimate relationships. Couple-based interventions should also emphasize emotionally safe communication, expression of sexual needs and preferences, mutual validation, and reduction of judgment or shame around sexuality. Where low sexual self-esteem is prominent, therapeutic work may focus on body acceptance, reduction of self-criticism, strengthening of sexual agency, and development of more adaptive sexual self-schemas. Integrating these components into counseling and sexual-health education programs may provide a more comprehensive approach to improving sexual function among married women.

Authors’ Contributions

Authors equally contributed to this article.

Declaration

In order to correct and improve the academic writing of our paper, we have used the language model ChatGPT.

Transparency Statement

Data are available for research purposes upon reasonable request to the corresponding author.

Acknowledgments

We would like to express our gratitude to all individuals helped us to do the project.

Declaration of Interest

The authors report no conflict of interest.

Funding

According to the authors, this article has no financial support.

Ethical Considerations

The study protocol adhered to the principles outlined in the Helsinki Declaration, which provides guidelines for ethical research involving human participants.