Sexual intimacy is a complex and multidimensional aspect of relationships, involving emotional, physical, and psychological connections between partners during intimate moments. It requires trust, mutual understanding, and a strong bond, ultimately contributing to a more fulfilling relationship [1]. Intimacy involves exchanging personal details, emotions, and thoughts that create a sense of mutual understanding, appreciation, respect, and care for oneself and each other. In this context, the individual transforms into a collective “us”, and personal pleasure becomes a shared experience between the partners. The joy derived from personal pleasure expands to include the joy of pleasing one another [2]. Sexual intimacy is most important for sexual satisfaction [3]. On the other hand, lower satisfaction in relationships, particularly in terms of social and emotional intimacy, emotional expression, and self-disclosure, can significantly impact the quality of a sexual relationship [4]. In Iran, numerous reports indicate that many couples experience dissatisfaction with their sexual relationships [5]. Although the prevalence of sexual dysfunction is high among both men and women in Iran, precise statistics are lacking [6]. One study reported a prevalence rate of 31% among Iranian women [7]. In Turkey and Saudi Arabia, the rates of 45% and 60% have been reported, respectively [8, 9]. This issue is notably significant, as it is cited as a contributing factor in approximately 50% to 60% of divorces and around 40% of instances of sexual infidelity [10]. Sexual intimacy is influenced by a multitude of factors, including chronic diseases, such as multiple sclerosis and breast cancer, as well as psychological stressors, like anxiety, in couples. Additionally, physical disabilities, such as limb impairments, spinal cord injuries, and sensory deficits, including hearing loss, can significantly affect sexual relationships, impacting one or both partners. These factors can profoundly alter the dynamics of sexual interactions, underscoring the complex interplay among physical health, psychological well-being, and interpersonal relationships [4, 11-15]. The incidence of traumatic spinal cord injuries (TSCI) exhibits significant global variability, ranging from 3.6 to 195.4 cases per million people. In Iran, one study analyzed data from the National Trauma Registry between 1999 and 2004, revealing that traumatic spinal fractures (TSF) occurred in approximately 3.8% of trauma admissions, affecting 619 out of 16,321 cases [16, 17]. A qualitative study identified four key challenges faced by couples dealing with spinal cord injuries (SCI): difficulties in maintaining intimacy, navigating the complexities of care needs, redefining traditional masculine roles, and managing social isolation. These findings underscore the complex and multifaceted impact of SCI on interpersonal dynamics [18]. In another qualitative study on SCI patients and their partners, two major themes were identified: the changing definition of sex and emotions. Couples’ conversations about the changing definition of sex after SCI addressed the traditionally taboo topic of sexuality and highlighted the importance of open communication between partners, peers, and healthcare providers. Participants commonly expressed emotional concerns, such as fear of losing intimacy [19]. Hucker et al. reported that counseling and education through an online approach could improve sexual intimacy [20]. People with SCI and their wives are likely to experience anger, frustration, and low libido, which can affect their relationships. Creating new relationships and maintaining the existing relationships in life become more challenging for people with spinal cord injuries [21]. In Parker's study, people with SCI expressed that establishing intimate relationships with their wives has become challenging for them compared to before the injuries [22]. Rahimi et al. demonstrated that combining cognitive-behavioral therapy (CBT) with acceptance and commitment therapy (ACT) significantly improved sexual satisfaction [23]. Cognitive-behavioral therapy (CBT) is recognized as a prominent psychological intervention for enhancing sexual assertiveness and satisfaction. Rooted in the principle that thoughts and perceptions influence emotions and behaviors, CBT addresses sexual issues by targeting cognitive and behavioral patterns. This therapeutic approach assists individuals in overcoming sexual challenges by correcting misconceptions about sexuality, fostering sexual self-expression, promoting shared responsibility in intimate relationships, and enhancing problem-solving abilities [24]. This study was conducted with the aim of investigating the effect of internet-based CBT on sexual intimacy of women with spouses having SCI in accordance with the Spinal Cord Injuries Association of Yazd/Iran.

The data of 30 women in the intervention group and 30 women in the control group were subjected to statistical analysis. There was no attrition in both the groups.

The comparison of demographic characteristics between the two groups is shown in Table 2. Based on the information provided, the study demonstrated a significant improvement in sexual intimacy among women whose spouses had spinal cord injuries (SCI). The intervention group receiving internet-based cognitive behavioral therapy (CBT) exhibited a marked increase in scores immediately post-intervention and maintained better outcomes compared to the control group at follow-up. Repeated measures ANOVA revealed a statistically significant difference in sexual intimacy scores between the two groups (p=0. 01). The CBT group displayed a higher mean score post-intervention (90.9±27.2) than the control group (71.8±22.8), and this trend persisted during the follow-up period (CBT: 77.9±22.5; control: 64.6±20.4). These findings confirmed the superior efficacy of CBT in enhancing sexual intimacy compared to traditional educational methods (Table 3, Graph 1).

The primary objective of this study was to evaluate the effectiveness of online cognitive-behavioral therapy (CBT) in enhancing sexual intimacy among women with spouses experiencing spinal cord injury (SCI). The findings revealed that while sexual intimacy improved in both the intervention and control groups, the rate of improvement was significantly greater in the CBT intervention group compared to the pamphlet-based education group. There is no doubt that education can change awareness and behavior. However, the extent of this change, its persistence, and the depth of its effect on an individual's cognition and behavior can undoubtedly vary across different methods. In the present study, the level of sexual intimacy showed a marked increase in the counseling group compared to the control group, and the difference between the groups was statistically significant. Consequently, the researchers have employed various educational and counseling methods in different studies to investigate the impact of each approach on enhancing knowledge, attitudes, and behaviors. Although the pamphlet increased sexual intimacy, the magnitude of this increase was significantly smaller than that observed in the intervention group.

These results have been found to align with previous studies by Hucker and McCabe, which explored the efficacy of an online mindfulness-based cognitive-behavioral therapy (CBT) program designed to address female sexual difficulties and its effects on relationship functioning. The study found that the intervention significantly improved key aspects of sexual health, such as desire, arousal, and satisfaction, while also enhancing emotional intimacy and communication within the relationships [20]. Also, Bokaie [30] demonstrated online CBT to not only address women's sexual problems, but also enhance their sexual intimacy. Similarly, Farajkhoda's research found that online counseling was more effective than traditional face-to-face training in improving sexual health outcomes [31]. The CBT intervention employed in this study focused on restructuring irrational sexual thoughts about oneself, one’s spouse, and the relationship. Techniques, such as positive self-talk, focused attention, and self-expression, were utilized to foster cognitive and emotional changes. These strategies collectively contributed to improved sexual intimacy between the couples. Furthermore, the findings highlighted that CBT techniques enhance sexual awareness, develop sexual skills, and utilize imagination and systemic insight to address underlying causes of sexual challenges. Behavioral interventions, such as reducing performance anxiety and increasing emotional connection, were also effective in positively influencing women's sexual desire and intimacy [23].

It is noteworthy that in the control group, which received education via pamphlets, a slight increase in women's sexual intimacy was observed. It seems that the issue of sexual education is so significant for these women that even simpler methods, such as providing pamphlets, can be somewhat effective. This highlights the urgent need for these women to receive information and education related to sexual health, which can be partially addressed even through low-cost methods.

A limitation of this study was the occasional disconnection during online meetings due to weak internet infrastructure; this was mitigated as much as possible by addressing participants’ questions individually.

Moreover, while the follow-up data demonstrated sustained improvements in sexual intimacy, the slight decline in scores over time suggests the necessity of booster sessions to maintain therapeutic gains. Longitudinal studies with extended follow-up periods could provide more insights into the long-term effectiveness and scalability of such interventions.

The study's implications extend beyond the specific context of SCI, offering valuable lessons for addressing sexual health challenges in other populations with chronic health conditions. The integration of CBT into routine care practices by healthcare providers, such as midwives and psychologists, could significantly enhance the quality of life for affected couples.

This study involves several limitations that need consideration. The findings may not be generalizable due to the relatively small sample size and its recruitment from a single center in Iran. The assessment of the long-term effects has been constrained by the short one-month follow-up period. The lack of participant blinding and the use of self-reported measures for the primary outcome may have introduced bias. Furthermore, the study faced technical challenges, as weak internet infrastructure occasionally disrupted the online intervention delivery.