Introduction
Sexual health is one of the main aspects of personal health, affecting people at any age [1, 2]. Sexual health refers to a state where both men and women enjoy healthy, appropriate, and normal sexual relationships, such that their physical, mental, and behavioral conditions are favorable and reflects a kind of harmony and affection in married life [3 ]. Healthy sexual relationship can help strengthen emotional bonds between couples and prevent the development and exacerbation of mental disorders and the disintegration of family foundation and society [4]. Sexual activity can be affected by individual traits, interpersonal relations, family/social/cultural conditions, environment, sexual activity history of couples, physical and mental health of couples, and hormonal status [5]. Promoting women’s sexual health has become interesting research topic, which primarily focuses on identifying safe and cost-effective interventions than can improve the quality of sexual relationships and treat sexual disorders [6, 7]. 
Sexual satisfaction refers to an individual’s perception of the level of pleasure during sexual activities and reaching the peak of sexual pleasure [8]. Sexual satisfaction is important because the strength of marital relations depends on having satisfactory sexual relations, which can make life’s hardships and problems bearable for couples [9, 10]. Sexual satisfaction and sexual health are crucial in preventing sexual dysfunction [5]. According to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, sexual dysfunction is characterized by feeling extreme distress and interpersonal strain for at least six months, excluding substance abuse or medication related sexual dysfunction. It is categorized into three diagnostic categories: Disorders of desire, arousal, and pain. Disorders of desire include reduced desire (in men), low interest; arousal disorders include erectile disorder, premature ejaculation, delayed ejaculation, orgasmic disorder (in women); pain disorders include genito-pelvic pain/penetration disorder, substance-related disorder, or other disorders [11, 12]. 
Mindfulness is characterized by paying attention to the present moment intentionally and non-judgmentally [13]. Mindfulness-based sex therapy emphasizes the focused attention on both internal and external experiences as they occur, helping the individual become more aware of the present, increasing nonjudgmental observation, and subsequently reducing automatic reactions [14]. Mindfulness plays an important role in treating women’s sexual health problems by facilitating her experience in the present moment. This, even in a short period, can provide a way to free an person from intrusive thoughts, anxiety, and stress [15]. Considering the potential of mindfulness-based therapy, it can be integrated with other therapeutic methods such as art therapy, cognitive-behavioral therapy (CBT), and improve the efficacy of treatment [14]. 
Numerous studies have been conducted on mindfulness, sexual satisfaction and sexual disorders, and have reported different results [16-18]. Systematic reviews in this field are needed for assessing the impact of health interventions and making informed decisions. A systematic review can help address discrepancies by finding related studies and allowing the readers to see the outcomes of different studies, and make a more informed decision [19]. Despite the importance of sexual health in women and the high effectiveness of mindfulness-based interventions in addressing sexual problems, no systematic review has been conducted in this field. Therefore, this systematic review study aims to investigate the efficacy of mindfulness-based interventions on women’s sexual health. 

Materials and Methods
This is a systematic review study of all interventional studies related to mindfulness, women’s sexual satisfaction, and sexual performance, indexed in various databases. The search for these articles was conducted by the first and second authors in international databases (Web of Science, Scopus, PubMed, PsycINFO, Embase, and Cochrane Library), and national databases including MagIran, Scientific Information Database (SID), IranDoc, IranMedex, and the Iranian Registry of Clinical Trials (IRCT) website. The used MeSh-based keywords in English included “Psychological interventions”, “women”, and “sexual satisfaction”, using Boolean operators “OR” and “AND”. The keywords in Persian included “mindfulness interventions”, “women”, “sexual satisfaction”, “dysfunction”, “vaginismus”, “arousal”, “stimulation”, and “sexual desire”. A time limitation was set for all relevant articles such that on those published from 2015 to 2023 were included. To achieve maximum comprehensiveness in the search, all articles were also manually searched to find additional potential studies.
The inclusion criteria were being an interventional study (quasi-experimental, experimental, and clinical trials) focusing on mindfulness-based interventions for increasing women’s sexual satisfaction and performance, clear sample sizes and outcomes, and being published in Farsi or English within the time period. The studies that did not meet the determined criteria, the abstracts for conference papers, and those without available full texts were excluded.
The quality of articles was assessed using the Cochrane risk-of-bias checklist [20] to evaluate potential biases, including selection bias (random sequence generation and allocation concealment), performance bias (blinding of participants and personnel), detection bias (blinding of outcome assessment), attrition bias (incomplete outcome data), reporting bias (selective reporting), and other biases. Articles were categorized into three quality levels: “High”, “Low”, and “Unclear”. The quality assessment results are provided in Table 1. 


The initial search yielded 1001 articles. An additional 3 articles were found by manual search. After removing duplicates and irrelevant studies, 31 articles remained. After reading their abstracts, 12 articles were excluded, and 5 were removed after reading the full-texts. Finally, 14 studies were selected for the review (Figure 1). After reading the abstracts and full texts of the eligible articles, the relevant data were extracted from them. The extracted information included the author’s name, the publication year, the study area, title, sample size, instruments, study design, study variables, study population, interventions, and outcomes. The data are presented in Table 2.







Results 
Characteristics of studies
The findings extracted from 14 articles, were categorized into two groups: Sexual performance and sexual satisfaction. Eleven studies used mindfulness-based interventions for improving sexual performance and addressing sexual disorders in women [21, 22, 25-32, 34], while five studies examined the effect of mindfulness-based interventions on women’s sexual satisfaction [22-24, 33, 34]. Participants in these studies were women aged 17-56 years, with a total sample size of 557. The interventions in these studies were individual or group therapies, and none of them had used couple therapy. The participants included healthy women, women with sexual dysfunction, overweight women, pregnant women, women with multiple sclerosis [21-34].

Mindfulness-based interventions and women’s sexual performance
Eleven studies investigated the effect of mindfulness-based interventions on the sexual performance of women [21, 22, 25-32, 34]. The participants in these studies included women with substance abuse, sexual dysfunction, and obesity. The number of intervention sessions ranged from 6 to 8, each session for 50-90 minutes. The contents of these interventions included focus on the present moment, physical mindfulness training, emotional mindfulness training, and body mindfulness training, thinking and feelings, and mindfulness regimen, which are often used in combination with other treatments [21, 22, 25-32, 34]. One study on women with substance abuse, used eight 90-minute sessions of mindfulness-based cognitive therapy. This intervention successfully improved the sexual performance of women [21]. In the study by Soleimani et al., 30 obese women underwent eight weekly mindfulness-based intervention, which resulted in improved sexual performance [28]. Two studies in Iran and Canada assessed women with sexual dysfunction. These studies employed mindfulness-based sex therapy and cognitive therapy, achieving significant reductions in sexual dysfunction [25, 27]. Additionally, a study in Iran assessed the effect of mindfulness-based therapy on pregnant women, and reported that those who received the therapy had lower sexual dysfunction, suggesting the treatment’s effectiveness during pregnancy [34]. Other studies conducted in Vancouver and Australia examined the influence of mindfulness-based therapy and CBT on sexual interest/arousal in healthy women. Their findings indicated that mindfulness-based therapy can be used to effectively improve sexual performance [29, 30].

Mindfulness-based interventions and women’s sexual satisfaction
Five studies assessed the effect of mindfulness-based interventions on women’s sexual satisfaction [22-24, 33, 34], two of which was conducted on pregnant women by providing weekly sessions, once per week lasting 2 hours, for 6-8 weeks. The sessions included mindfulness training, body scan mediation, breathing exercises, music and biofeedback support, group counseling, and psycho-education (psychological challenges, grief processes, emotions associated with adapting to chronic pain, stress and pain, healthy habits including food and exercise, and mind-body interaction) [33, 34]. In another study, the effect of a mindfulness-based psychological intervention on the sexual satisfaction of women with substance abuse was examined. The women received eight 90-minute sessions twice a week, which finally resulted in increased sexual satisfaction in women [24]. Furthermore, a study conducted in Iran assessed the comparative effects of CBT alone versus CBT plus mindfulness-based intervention. This study revealed that the group receiving the combined treatment reported a lower sexual dysfunction score, indicating the superior effect of the integrated approach compared to the CBT alone [23].

Discussion
This study reviewed 14 interventional studies (quasi-experimental, experimental, and clinical trials), that assessed the effect of mindfulness-based interventions (alone or combined with other treatments) on improving women’s sexual satisfaction and sexual performance [21-34]. Among these studies, 11 studies were found to assess the effects of mindfulness-based interventions combined with CBT or sex therapy on different groups of women such as healthy women, women with sexual dysfunction, women with substance abuse, and women with obesity [21, 22, 25-32, 34]. Five studies assessed the role of mindfulness-based interventions in increasing women’s sexual satisfaction [22-24, 33, 34]. All studies reported that mindfulness-based therapy significantly improved women’s sexual health, and suggested its application alone or with other therapeutic approaches. Norouzi et al. used 8 sessions of mindfulness-based cognitive therapy for 28 women with substance abuse which resulted in increased sexual satisfaction and sexual performance [21, 24]. Similarly, Hocaloski et al. used 6 mindfulness training sessions for Canadian women with multiple sclerosis and reported improvements in sexual performance [32]. A study in Iran on women with obesity experiencing sexual problems, found that 8 sessions of 90 minutes significantly improved women’ sexual performance [28]. In 2022, Naji Abhari et al. applied mindfulness-based therapy and could improve sexual function of pregnant women with sexual disorders [32].These studies, despite having different study populations, have consistently reported the positive effects of mindfulness-based interventions. These studies varied in the number (from 6 to 8) and duration (50-90 minutes) of sessions. All studies used an expert to confirm the intervention content and provided the intervention by a trained person [21-34]. Thus, the correct implementation of the treatment protocol is crucial for the effectiveness of mindfulness-based interventions. 
Mindfulness training includes the practice of attention to the present thoughts, feelings and emotions in a non-judgmental manner [35], which not only can reduce self-criticism and negative evaluation of sexual responses, but also can reduce disturbing thoughts during the sexual relationship [36]. This approach encourages women to consider the distracting factors such as disturbing thoughts as mental events that are not necessarily correct and there is no need to believe in them or follow them [37]. Furthermore, it helps the person not to be spectator (a concept introduced by Masters and Johnson in 1966) during sexual activity and focus on herself from a third person perspective [37]. Therefore, distractions from non-sexual thoughts can be reduced and non-judgmental self-acceptance can be increased which can directly affect various aspects of women’s sexual responses [38].
Mindfulness techniques not only can improve moment-to-moment awareness of sexual stimuli and physical changes (e.g. vaginal contractions or pulsing) and maintain sexual arousal and desire, but also can encourage women to perceive other stimuli in a sexual and non-judgmental manner [39]. Moreover, mindfulness has been shown to alter the neural structure of brain regions involved in regulating attention, emotions, and self-awareness [38]. Increased awareness is related to the activity in the anterior cingulate cortex and reduced activity in various frontal brain areas and the limbic region [39]. Increased self-awareness through mindfulness training is marked by the activity of the insula, the midsection of the prefrontal cortex, the posterior cingulate cortex, the prefrontal cortex, and the striatum. Moreover, there is evidence that the ability to express feelings non-judgmentally which is improved by mindfulness training, is positively correlated to the gray matter volume in the right anterior insula and the right amygdala, suggesting that an increase in insula volume may indicate a elevated awareness of stressful situations and improved ability in cognitive management of feelings [40]. In some diseases, individuals’ sexual function may be impaired which can have various consequences. According to studies on women with sexual dysfunction [21, 23, 24, 28, 32], psychological interventions such as mindfulness-based therapy can be effective in these cases.

Conclusion
Mindfulness-based psychological interventions are effective in improving sexual satisfaction and sexual performance of women in a short period. However, due to the limited number of studies in this field, more research with less bias is needed to obtain stronger evidence.

Limitations
Some limitations of this study were the unavailability of full texts for some studies, not reviewing the studies in languages other than Persian and English and the lack of a meta-analysis due to the heterogeneity of findings and measurement tools in studies

Ethical Considerations
Compliance with ethical guidelines
All publication ethics including the avoidance of scientific misconducts (data fabrication, plagiarism, and re-submitting work for duplicate publication) were observed.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Data collection and data analysis: Maryam Najiabhary and Seyedeh Zeynab Hoseinnezhad; Manuscript writing and Revising the manuscript: All authors.

Conflict of interest
The authors declared no conflict of interest.

Acknowledgments
The authors would like to thank to the student research committee of Mashhad University of Medical Sciences for supporting this study.


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