1. Introduction
About two-thirds of the aging population are currently living in developing countries which is estimated to be 14% in Iran and is expected to reach about 30% in 2050. One of the most important health issues related to the elderly is sexual health so that old couples have a healthy sexual relationship with desirable physical, mental and behavioral conditions, indicating a kind of love and affection in marital life. Mental health plays a key role in older women’s sexual desires, and higher levels of sexual activity have been associated with better physical health, and higher sexual satisfaction associated with better mental health and higher communication quality. Considering the increasing aging population in Iran and their life expectancy, having knowledge of the sexual satisfaction and mental health statuses of older women can help adopt health policies to develop educational, medical and recreational programs for this age group and provide the ground for more studies. Most of studies in the field of sexual satisfaction, especially in Iran, have been conducted on the age groups other than elderly groups and their results are contradictory. This study aims to determine the relationship between sexual satisfaction and mental health in older women living in Iran.

2. Materials and Methods
In this cross-sectional study, 195 married women aged ≥60 years covered by urban and rural health centers of Guilan, Iran in 2019 were selected by a cluster sampling method. The sample size was determined by performing a pilot study on 20 participants using the Cochran’s formula and considering a design effect of 1.5. Inclusion criteria were age ≥60 years and being covered by urban and rural health centers in Guilan province. Exclusion criterion was having serious cognitive or psychiatric disorders. For sampling, with the cooperation of the provincial health center, 5 urban health centers and 5 rural health centers in Guilan were first randomly selected. Then, during a Structured Clinical Interview for DSM-5 was conducted to assess the existence of any serious cognitive or psychiatric disorders in women. Then, eligible individuals willing to participate in the study signed a written informed consent form and were asked to complete a demographic form, the Persian version of the 28-item general health questionnaire. (GHQ-28), and a sexual satisfaction questionnaires. The collected data were analyzed in SPSS v. 22 software using descriptive statistics (Frequency, mean, standard deviation), and Shapiro-Wilk, Mann-Whitney U, Kruskal-Wallis and Spearman correlation tests.

3. Results
Demographic characteristics of participants are shown in Table 1.

Of 195 participants, 166 (85.1%) had active sexual intercourse in the past year. Their mean score of sexual satisfaction was 3.5 (ranging 2-6); 51.2% had low sexual satisfaction, 27.7% were with moderate sexual satisfaction, and 21.08% with high sexual satisfaction. Moreover, 79.4% had some degree of mental health problem, and the percentage of those with illness was higher than those with no illness. There was a significant relationship between mental health and educational level of older women (P=0.007) and their husbands (P=0.003). In participants with an income less than 1,500,000 Tomans (P≤0.0001), physical illness (P=0.011) and use of certain medications (P≤0.001), the mean score of GHQ-28 was significantly higher. The factor of place of residence had no significant relationship with sexual satisfaction and mental health of older women. Sexual satisfaction score had a significant relationship with age (P≤0.0001), number of children (P=0.022) and duration of marriage (P≤ 0.0001). The mental health had a significant direct relationship with age (P≤0.0001), duration of marriage (P=0.002), and number of children (P=0.012) such that with the increase of age, duration of marriage, and number of children, the score of GHQ-28 increased significantly. The age gap between spouses had no significant relationship with sexual satisfaction and mental health. The results of Spearman correlation test indicated a significant negative relationship between mental health and sexual satisfaction (r= 0.542, P≤ 0.0001).

4. Discussion and Conclusion
Based on the findings of this study, sexual satisfaction in older women living in Iran is related to their psychological, social and physical conditions. Older people need sex like other people, and it seems better to shift the focus from their sexual activity to their sexual satisfaction. Researchers involved in geriatric medicine need to be aware of the importance of sexual behavior in older women, which has been largely neglected. This study and many similar studies answer some of the questions raised in the field of sexual issues in the elderly. However, many questions remain unanswered. For example, is the sexual satisfaction of older women necessary for their sexual activity and orgasm? Are the older women really satisfied with their sex life or have just simply accepted it? Further studies can answer these questions. Health policies can be helpful by monitoring and paying attention to sexual issue of older women.

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Research Ethics committee of Guilan University of Medical Sciences (Code: IR.GUMS.REC.1395.353).

Funding
This research was supported by the Guilan University of Medical Sciences.

Authors' contributions
All authors equally contributed to preparing this article.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgements
The authors would like to thank the Vice-Chancellor for Heath of this University and Dr. Kiomars Najafi and Dr. Robabe Soleimani for their cooperation.

References

1. Sadock BJ, Sadock VA, Raiz P. Kaplan & Sadocks synopsis of psychiatry: Behavioral sciences/clinical psychiatry. 11th ed. Netherlands: Wolters Kluwer; 2015. https://books.google.com/books/about/Kaplan_Sadock_s_Synopsis_of_Psychiatry.html?id=QQmOngEACAAJ
2. Afshar PF, Asgari P, Shiri M, Bahramnezhad F. A review of the Iran's elderly status according to the census records. Galen Medical Journal. 2016; 5(1):1-6. https://www.gmj.ir/index.php/gmj/article/view/397/pdf_104
3. Mirzaei M, Zarghami H. [The aging of Iran’s population in the next four decades (Persian)]. Iranian Pattern of Progress. 2018; 3(6):73-94. http://www.ipoba.ir/article_16962.html
4. Zhou G, Wang Y, Yu X. Direct and indirect effects of family functioning on loneliness of elderly Chinese Individuals. Current Psychology. 2018; 37:295-301. [DOI:10.1007/s12144-016-9512-5]
5. Manwell LA, Barbic SP, Roberts K, Durisko Z, Lee C, Ware E, et al. What is mental health? Evidence towards a new definition from a mixed methods multidisciplinary international survey. BMJ Open. 2015; 5(6):e007079. [DOI:10.1136/bmjopen-2014-007079] [PMID] [PMCID]
6. Rashidi BH, Kiyani K, Haghollahi F, Sighaldeh SS. [Sexual health definition from the perspective of Iranian experts and description its components (Persian)]. Tehran University Medical Journal. 2015; 73(3):210-20. https://tumj.tums.ac.ir/article-1-6661-en.pdf
7. Nusbaum MR, Hamilton C, Lenahan P. Chronic illness and sexual functioning. American Family Physician. 2003; 67(2):347-54. https://www.aafp.org/afp/2003/0115/p347.html
8. Samadi F, Dalir M. [The Role of psychological and social health on sexual health of elderly women (Persian)]. Quarterly Social Psychology Research. 2021; 10(40):21-42. [doi:10.22034/SPR.2021.127712]
9. Schmiedeberg C, Schröder J. Does sexual satisfaction change with relationship duration? Archives of Sexual Behavior. 2016 45:99-107. [DOI:10.1007/s10508-015-0587-0] [PMID]
10. Ratner ES, Erekson EA, Minkin MJ, Foran-Tuller KA. Sexual satisfaction in the elderly female population: A special focus on women with gynecologic pathology. Maturitas. 2011; 70(3):210-5. [DOI:10.1016/j.maturitas.2011.07.015] [PMID] [PMCID]
11. Erens B, Mitchell KR, Gibson L, Datta J, Lewis R, Field N, et al. Health status, sexual activity and satisfaction among older people in Britain: A mixed methods study. PLoS One. 2019; 14(3):e0213835. [DOI:10.1371/journal.pone.0213835] [PMID] [PMCID]
12. Thames AD, Hammond A, Nunez RA, Mahmood Z, Jones F, Carter SL, et al. Sexual health behavior and mental health among older African American women: The sistahs, sexuality, and mental health well-being project. Journal of Women's Health. 2018; 27(9):1177-85. [DOI:10.1089/jwh.2017.6777] [PMID]
13. Maciel M, Laganà L. Older women’s sexual desire problems: biopsychosocial factors impacting them and barriers to their clinical assessment. BioMed Research International. 2014; 2014:107217. [DOI:10.1155/2014/107217] [PMID] [PMCID]
14. Rahmani A, Merghati KE, Sadeghi N, Allahgholi L. [Relationship between Sexual pleasure and Marital Satisfaction (Persian)]. Iran Journal of Nursing. 2011; 24(70):82-90. http://ijn.iums.ac.ir/article-1-988-en.pdf
15. Huang AJ, Subak LL, Thom DH, Van Den Eeden SK, Ragins AI, Kuppermann M, et al. Sexual function and aging in racially and ethnically diverse women. Journal of the American Geriatrics Society. 2009; 57(8):1362-8. [DOI:10.1111/j.1532-5415.2009.02353.x] [PMID] [PMCID]
16. Novak JR, Sandberg JG, Harper JM. Older couples with and without cardiovascular disease: testing associations between and among affective communication, marital satisfaction, physical and mental health. Families, Systems and Health. 2014; 32(2):186-97. [DOI:10.1037/fsh0000015] [PMID]
17. Malakouti SK, Salehi M, Nojomi M, Zandi T, Eftekhar M. Sexual functioning among the elderly population in Tehran, Iran. Journal of Sex & Marital Therapy. 2012; 38(4):365-77. [DOI:10.1080/0092623X.2011.628438] [PMID]
18. Woloski-Wruble AC, Oliel Y, Leefsma M, Hochner-Celnikier D. Sexual activities, sexual and life satisfaction, and successful aging in women. The Journal of Sexual Medicine. 2010; 7(7):2401-10. [DOI:10.1111/j.1743-6109.2010.01747.x] [PMID]
19. Sterling M. General Health Questionnaire - 28 (GHQ-28). Journal of Physiotherapy. 2011; 57(4):259. [DOI:10.1016/S1836-9553(11)70060-1]
20. Nazifi M, Mokarami H, Akbaritabar A, Faraji Kujerdi M, Tabrizi R, Rahi A. [Reliability, validity and factor structure of the Persian translation of General Health Questionnire (GHQ-28) in hospitals of Kerman University of Medical Sciences (Persian)]. The Journal of Fasa University of Medical Sciences. 2014; 3(4):336-42. http://jabs.fums.ac.ir/article-1-528-en.html
21. Thomas HN, Hess R, Thurston RC. Correlates of sexual activity and satisfaction in midlife and older women. Annals of Family Medicine. 2015; 13(4):336-42. [DOI:10.1370/afm.1820] [PMID] [PMCID]
22. Karraker A, DeLamater J. Past-year sexual inactivity among older married persons and their partners. Journal of Marriage and Family. 2013; 75(1):142-63. [DOI:10.1111/j.1741-3737.2012.01034.x]
23. Trompeter SE, Bettencourt R, Barrett-Connor E. Sexual activity and satisfaction in healthy community-dwelling older women. The American Journal of Medicine. 2012; 125(1):37-43.e1. [DOI:10.1016/j.amjmed.2011.07.036] [PMID] [PMCID]
24. Ghorbanian E, Mohammadlo H, Rasooli R, Khoshpoor F, Samarisafa J, Kargarbarzi H. [Psychometric properties of the marital satisfaction questionnaire of the elderly and its components prediction through sexual intimacy and mental health in the elderly in the one and six district of province Tehran (Persian)]. Journal of Gerontology (Joge). 2017; 1(3):29-38. http://joge.ir/article-1-69-en.html
25. Waterman EA. Reactions of college students to the sexuality of older people. Journal of Student Research. 2012; 1(2):46-50. [DOI:10.47611/jsr.v1i2.54]
26. Moghasemi S, Ozgoli G, Ahmadi F, Simbar M. Sexual experience of Iranian women in their middle life: A qualitative approach. International Journal of Community Based Nursing and Midwifery. 2018; 6(1):47-55. [PMCID] [PMID]
27. Mardi A, Moghadam ZB, Ghafoori F, Refahi S. Sexual activity, Interest and Satisfaction in Older Women in Iran. Journal of Biostatistics and Epidemiology. 2019; 5(1):50-7. [DOI:10.18502/jbe.v5i1.1906]
28. Chao JK, Lin YC, Ma MC, Lai CJ, Ku YC, Kuo WH, et al. Relationship among sexual desire, sexual satisfaction, and quality of life in middle-aged and older adults. Journal of Sex & Marital Therapy. 2011; 37(5):386-403. [DOI:10.1080/0092623X.2011.607051] [PMID]
29. Estill A, Mock SE, Schryer E, Eibach RP. The effects of subjective age and aging attitudes on mid- to late-life sexuality. Journal of Sex Research. 2018; 55(2):146-51. [DOI:10.1080/00224499.2017.1293603] [PMID]
30. Gewirtz-Meydan A, Hafford-Letchfield T, Ayalon L, Benyamini Y, Biermann V, Coffey A, et al. How do older people discuss their own sexuality? A systematic review of qualitative research studies. Culture, Health & Sexuality. 2019; 21(3):293-308. [DOI:10.1080/13691058.2018.1465203] [PMID]
31. Starc A, Jukić T, Poljšak B, Dahmane R. Female sexual function and dysfunction: A cross-national prevalence study in Slovenia. Acta Clinica Croatica. 2018; 57(1):52-60. [DOI:10.20471/acc.2018.57.01.06] [PMID] [PMCID]
32. Espin OM. Cultural and historical influences on sexuality in Hispanic/Latin women: Implications for psychotherapy. Latina realities: Essays on healing, migration and sexuality. 1th ed. New York: Routledge; 2018. [DOI:10.4324/9780429499319-9]
33. Zainah A, Nasir R, Hashim RS, Yusof NM. Effects of demographic variables on marital satisfaction. Asian Social Science. 2012; 8(9):46. [DOI:10.5539/ass.v8n9p46]
34. Thompson WK, Charo L, Vahia IV, Depp C, Allison M, Jeste DV. Association between higher levels of sexual function, activity, and satisfaction and self-rated successful aging in older postmenopausal women. Journal of the American Geriatrics Society. 2011; 59(8):1503-8. [DOI:10.1111/j.1532-5415.2011.03495.x] [PMID] [PMCID]
35. Merghati-Khoei E, Zargham-Boroujeni A, Salehi M, Killeen TK, Momeni G, Yousofnia Pasha YR, et al. Saturated love leading to sexual pleasure: Iranian women's narratives. Caspian Journal of Applied Sciences Research. 2015; 4(10):20-9. https://web.a.ebscohost.com/abstract?direct=
36. South SC, Krueger RF. Marital satisfaction and physical health: Evidence for an orchid effect. Psychological Science. 2013; 24(3):373-8. https://journals.sagepub.com/doi/abs/10.1177/0956797612453116
37. Bayle AT, Ayalew DW, Yimer AM. Socio-demographic determinants of marital satisfaction in Jimma Zone, Southwest Ethiopia. International Journal of Sociology and Anthropology. 2017; 9(10):131-42. https://doi.org/10.5897/IJSA2016.0689
38. Gilasi H, Hajibagheri A, Yazdani A. [Marital satisfaction and its effective factors in elderly people of Kashan city in 2015 (Persian)]. KAUMS Journal (FEYZ). 2019; 23(2):192-200. http://feyz.kaums.ac.ir/article-1-3598-en.html
39. Zarei H, Abolfathi Momtaz Y, Sahaf R, Mehdi M. [Marital satisfaction among older adults who married in old age in Sanandaj in 2016 (Persian)]. Iranian Journal of Ageing. 2019; 14(1):14-25. http://salmandj.uswr.ac.ir/article-1-1366-en.html
40. Najafi B, Arzaghi M, Fakhrzadeh H, Sharifi F, Shoaei S, Alizadeh M, et al. [Mental health status and related factors in aged population: Urban health equity assessment and response tool (Urban-HEART) study in Tehran (Persian)]. Iranian Journal of Diabetes and Metabolism. 2013; 13(1):62-73. http://ijdld.tums.ac.ir/article-1-5093-en.html
41. NeJhaddadgar N, Ziapour A, Abbas J, Mardi A, Zare M. Correlation between general health and sexual function in older women in an Iranian setting. Journal of Education and Health Promotion. 2020; 9:300. [DOI:10.4103/jehp.jehp_316_20] [PMCID] [PMID]
42. Miri M, Salehiniya H, Tiyuri A, Bahlgerdi M, Taghizadeh A. [Prevalence of mental disorders and its related factors among elderly of Birjand, 2014 (Persian)]. Journal of Gerontological Nursing. 2016; 2(2):94-103. https://jgn.medilam.ac.ir/browse.php?sid=1&a_id=153&slc_lang=en&ftxt=1
43. Shoaee F, Azkhosh M, Alizad V. [Health status of Iranian older people: A demographical analysis (Persian)]. Iranian Journal of Ageing. 2013; 8(2):60-9. http://salmandj.uswr.ac.ir/article-1-557-en.html