# Factors contributing to sexual dissatisfaction in women with breast cancer: The specific role of conjugal relationship quality

Kristopher Lamore, Anna Maria Giardinelli, Emilie Wawrziczny

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Kristopher Lamore, Anna Maria Giardinelli, Emilie Wawrziczny. Factors contributing to sexual dissatisfaction in women with breast cancer: The specific role of conjugal relationship quality. European Journal of Oncology Nursing, 2025, European Journal of Oncology Nursing, 76, pp.102866. 10.1016/j.ejon.2025.102866. hal-05057331

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# Factors contributing to sexual dissatisfaction in women with breast cancer:
The specific role of conjugal relationship quality

Kristopher Lamore<sup>a, *, †</sup>, Anna Maria Giardinelli<sup>b</sup>, Émilie Wawrziczny<sup>a</sup>

## ARTICLE INFO

Keywords:

Breast cancer

Conjugal relationship

Model

Sexual satisfaction

Sexuality

## ABSTRACT

**Purpose:** The purpose of this study was (1) to investigate the personal, interpersonal, social, and cultural factors related to sexual dissatisfaction in women with breast cancer and (2) to explore these differences regarding surgery (lumpectomy vs. mastectomy).

**Methods:** This cross-sectional study included women diagnosed with breast cancer (n = 87). Women were invited to complete questionnaires assessing sexual satisfaction, relationship satisfaction, conjugal support, quality of life, subjective health, anxiodepressive symptomatology, body image, self-esteem, and religiosity. Partial least squares path modeling (PLS-PM) was used.

**Results:** No direct links were observed between resources (intraindividual and social) and sexual dissatisfaction (SD) or between vulnerability (physical and emotional) and SD. The quality of the conjugal relationship acted as a mediator between these different variables. Intraindividual resources are influenced directly by physical and emotional vulnerability. Age influenced only SD in women who had undergone a lumpectomy compared with those who had undergone a mastectomy. Finally, religiosity and the length of the couple relationship had no influence on SD.

**Conclusion:** The results highlight the importance of considering different levels of variables when considering SD in women with breast cancer, particularly the role of the conjugal relationship. Hence, these results encourage the need to promote conjugal relationship quality to improve sexual satisfaction.

## 1. Introduction

Sexuality is an important dimension in many romantic relationships (Foster, Shira & Campbell, 2006). In oncology, studies considering the sexual sphere have explored mainly sexual dysfunctions or problems and the factors (personal, interpersonal, social, and cultural) influencing these dysfunctions (Chang et al., 2019; Franzoi et al., 2024; Stulz et al., 2020).

Indeed, studies highlight a decrease in the frequency of sexual activity and sexual difficulties after a cancer diagnosis, including a decrease in sexual desire, arousal, and difficulties in achieving orgasm (Andrzejczak et al., 2013; Aptecar et al., 2021; Carreira et al., 2018; Chang et al., 2019; DeSimone et al., 2014; Montanés-Muro et al., 2023). Moreover, middle-aged and younger women with breast cancer (Avis et al., 2018; Chang et al., 2019; Quintard et al., 2014) who experienced fatigue, pain, anxiety and depression symptoms or body image issues

were identified as having more sexual problems (Chang et al., 2019; DeSimone et al., 2014; Hernández-Blanquisett et al., 2022; Miaja et al., 2017).

Relationship dynamics and communication with one's partner also play critical roles in sexual activity. While emotional closeness alone may not directly influence sexual activity, factors such as emotional separation, physical closeness, affectionate touch, and satisfaction with dyadic coping are linked to sexual activity and overall relationship well-being in breast cancer survivors (Bodenmann et al., 2010; Brédart et al., 2011; Debrot et al., 2020; Jakubiak and Feeney, 2017; Kleinstäuber, 2017).

Moreover, women who benefit from social support systems (groups or support provided by relatives) and strong religious beliefs tend to experience less psychological distress and fewer sexual problems with their partner (Chang et al., 2019; DeSimone et al., 2014; Kim and Jang, 2019; Rizalar et al., 2014). In two qualitative studies, women indicated

<footnote><sup>a</sup> Univ. Lille, CNRS, UMR 9193 - SCALab - Sciences Cognitives et Sciences Affectives, F 59000, Lille, France</footnote>

<footnote><sup>b</sup> Service de Psychiatrie Adulte, Hôpital Saint Vincent de Paul du Groupement Hospitalier de l'institut Catholique de Lille, Boulevard de Belfort, 59000, Lille, France</footnote>

<footnote>* Corresponding author. Université de Lille, Laboratoire SCALab UMR CNRS 9193, Rue du barreau, BP 60149, 59653, Villeneuve d'Ascq Cedex, France.
E-mail addresses: kristopher.lamore@univ-lille.fr (K. Lamore), annamaria.giardinelli@outlook.fr (A.M. Giardinelli), emilie.wawrziczny@univ-lille.fr (É. Wawrziczny).</footnote>
that their religious beliefs may motivate them to engage in sexual intercourse with their husbands, even in the absence of desire, which can lead to a lack of satisfaction in their sexual lives (Maleki et al., 2021; Zangeneh et al., 2022).

Furthermore, a recent diagnosis (Chang et al., 2019) and chemotherapy (DeSimone et al., 2014; Hernández-Blanquisett et al., 2022; Hummel et al., 2017) are also associated with increased sexual dysfunctions. Notably, breast surgeries-lumpectomy (i.e., the tumor is removed through surgery but not the breast itself) and mastectomy (i.e., removing the entire breast through surgery)-are surgical interventions with significant outcomes in terms of physical, psychological, and body image, which may influence postsurgical sexual health (Vegunta et al., 2022). Data have shown that mastectomy is sometimes identified as a risk factor for greater rates of sexual problems than a lumpectomy (Aerts et al., 2014; Hernández-Blanquisett et al., 2022; Hummel et al., 2017).

Another essential dimension to consider due to its link to relationship satisfaction and stability (Rausch and Rettenberger, 2021; Sánchez-Fuentes et al., 2014) is sexual satisfaction. It is defined as the degree to which a person is satisfied or happy with the sexual aspects of its conjugal relationship (Sprecher and Cate, 2004). In their review, Sánchez-Fuentes et al. (2014) highlighted the personal, interpersonal, social, and cultural factors influencing sexual satisfaction and highlighted the importance of considering these factors together in a general model to provide an integrative view of sexual satisfaction. Two models in the general population were developed considering all these factors. The first model was developed by Sánchez-Fuentes et al. (2014) on a Spanish heterosexual sample. This model highlights that for women, sexual satisfaction is directly predicted by relationship satisfaction and sexual life characteristics and that social support is indirectly associated with sexual satisfaction through relationship satisfaction. A second model based on this first model was developed by Wawrziczny et al. (2021b) among a French heterosexual sample. This model showed that interpersonal factors (dyadic coping and relationship satisfaction) directly contribute to sexual dissatisfaction. Sequential mediations were also highlighted through interpersonal variables (dyadic coping and relationship satisfaction) between (1) personal variables (self-esteem, body image, anxiety, depression, and self-rated health) and sexual dissatisfaction and (2) other interpersonal variables (relationship length) and sexual dissatisfaction.

In oncology, sexual satisfaction or dissatisfaction is more rarely investigated, while it is associated with physical health (Sánchez-Fuentes et al., 2014). These few studies revealed that women suffering from breast cancer, the prevailing form of cancer in women (International Agency for Research on Cancer, 2022), are dissatisfied with their sex life (Salakari et al., 2020). In fact, they reported dissatisfaction with affectionate gestures and kissing from their partner and a sense of distance in the relationship (Maleki et al., 2021). Poor sexual enjoyment was also reported in studies and increased over time between diagnosis and up to 4 years after diagnosis (Franzoi et al., 2024). Dissatisfaction is related to undesirable sexual function (e.g., decreased sexual attractiveness and decreased sexual desire) and unmet information as well as supportive care needs and emotions (i.e., feelings of loss of femininity and guilt) (Maleki et al., 2021; Zangeneh et al., 2022). These difficulties contribute to a decrease in women's physical self-esteem (Andrzejczak et al., 2013; Montañés-Muro et al., 2023). In fact, Andrzejczak et al. (2013) reported that 70 % of women covered their bodies during sexual intercourse after cancer diagnosis, whereas they did not do so before diagnosis. Additionally, Martins et al. (2022) reported that older age, a positive relationship with one's partner prior to the illness, lower levels of anxiety and depression, and a more positive body image are factors related to sexual satisfaction. These few previous studies considered sexual satisfaction either with Likert scales (Andrzejczak et al., 2013; Montañés-Muro et al., 2023; Salakari et al., 2020) or with qualitative research interviews (Maleki et al., 2021; Zangeneh et al., 2022). Most research has focused on sexual health in or with validated questionnaires assessing the existence and severity of

sexual problems or quality of life, such as the Golombok-Rust Inventory of Sexual Satisfaction (GRISS) or the EORTC QLQ-BR23 (Aptecar et al., 2021; Carreira et al., 2018; Chang et al., 2019; DeSimone et al., 2014; Franzoi et al., 2024; Hernández-Blanquisett et al., 2022; Hummel et al., 2017; Montañés-Muro et al., 2023). Therefore, in the field of senology, further research involving adapted tools to assess sexual satisfaction and identify the factors impacting sexual satisfaction is needed.

The aim of the present study was to investigate the personal, interpersonal, social, and cultural factors related to sexual dissatisfaction in women with breast cancer and the associations between them in a general model. The previous studies in the field of sexuality in breast cancer and the models described above guided the selection of the variables investigated in this study as well as the hypotheses. We retained personal variables (age, self-esteem, body image, anxiety, depression, and self-rated health); interpersonal variables (conjugal support, relationship satisfaction and relationship length); social variables (social support well-being); and cultural variables (religiosity). These variables included physical well-being and emotional well-being related to the cancer situation. We hypothesized that (1) social, interpersonal, and cultural factors directly contribute to sexual dissatisfaction and that (2) personal factors contribute to sexual dissatisfaction both directly and via interpersonal factors. We explored the differences in surgery type (lumpectomy vs. mastectomy). Identifying the factors associated with sexual satisfaction for breast cancer patients is needed to provide adapted support to women expressing sexual dissatisfaction after cancer treatment.

## 2. Materials and methods

### 2.1. Participants

The women eligible for inclusion had to be heterosexual women who were diagnosed with breast cancer and were 18 years of age or older, who had been engaged in a relationship with a partner for at least one year, who were living together at the time of questionnaire completion and who were native French speakers. No criteria regarding the length of time since diagnosis or treatment completion were formulated. Recruitment was carried out via posts on social networks (Facebook, Instagram, association websites, forums) frequented by women with breast cancer. In total, 232 women started the online questionnaire, and 111 completed it. Questionnaires completed in less than 20 min were removed from the final sample, as the short time frame suggested insufficient involvement. Ultimately, 87 participants were selected for the study. The average questionnaire completion time was 39 min.

### 2.2. Procedure and ethics approval

The present study was conducted online among the French population using LimeSurvey creation software. Invitations to participate in the study were posted across social networks. These posts invited women diagnosed with breast cancer to participate in a survey regarding their sexual activity and satisfaction; the LimeSurvey link was used to access the survey. The use of social networks in recruitment was intended to make the study accessible to a large number of people. If potential participants agreed to take part, they could click on the link taking them to the study's home page.

Ethical approval was obtained by the research ethics committee (CER) of the University of Lille (n°2018-284-S62) and adhered to the tenets of the Declaration of Helsinki (1975). Informed consent was obtained from all individual participants included in the study. After the home page, participants had access to an information note containing the following details of this study: study objectives, inclusion criteria, contact details and provisions (related to confidentiality and use of data, anonymity and the possibility of withdrawing from the study at any time without justification). The participants were then given the opportunity to confirm their wish to take part by validating their consent, which was
required for access to the questionnaires.

## 2.3. Measures

First, sociodemographic data were collected from the participants (age, level of education), their partners (age), and their partners (number of years together, marital status, monthly conjugal income). Medical data related to the year of cancer diagnosis and treatment received (chemotherapy, radiotherapy, and surgery type) were also collected.

Then, validated questionnaires were completed by the participants. In our study, the internal consistency was good, with Cronbach's alpha >0.7 for all the validated questionnaires.

Sexual satisfaction was assessed using the Index of Sexual Satisfaction (ISS) (Hudson et al., 1981; Wawrziczny et al., 2021a), the most frequently used questionnaire in studies focusing on sexual satisfaction (Sánchez-Fuentes et al., 2014). The original ISS is a 25-item scale, but in the French version, 6 items were removed. Thus, this questionnaire consists of 19 items scored on a five-point scale ranging from "rarely or never" to "most of the time or always". Higher scores correspond to higher levels of sexual dissatisfaction. In our study, $α = 0.96$.

Personal variables were investigated through measures of body image, self-esteem, anxiety, depression, and self-rated health. Body image perception was assessed with the Body Image Questionnaire (BIQ) (Bruchon-Schweitzer, 1990). This 19-item questionnaire measures body satisfaction and examines the perceptions, representations, and emotions associated with the body. This questionnaire is a five-point bipolar scale containing opposing terms. The total score ranged between 19 and 95. A higher score indicates better body satisfaction. In our study, $α = 0.93$.

Self-esteem was measured using the Rosenberg Self-Esteem Scale (RSES) (Rosenberg, 1965; Vallieres and Vallerand, 1990), a 10-item self-assessment scale. All statements are rated on a four-point scale ranging from "strongly disagree" to "strongly agree". The scale measures both positive and negative feelings about the self. A high score indicates good self-esteem. In our study, $α = 0.87$.

Anxiety and depression symptomatology were investigated with the Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983), a 14-item self-reported questionnaire with 7 items assessing anxiety and 7 items assessing depression. The four-point scale ranges from 0 to 3. The higher the score is, the greater the anxiety and depression experienced by the participants. In our study, $α = 0.78$ for the anxiety dimension, and $α = 0.77$ for the depression dimension.

Self-rated health was assessed with two measures. The Functional Assessment of Breast Cancer Therapy (FACT-B) scale (Brady et al., 1997) was implemented. This 37-item questionnaire was initially designed to assess five subdimensions specific to breast cancer: physical well-being, family/social well-being, emotional well-being, functional well-being, and other concerns. For this study, we used only the first three sub-dimensions. In addition, in the "family/social well-being" subdimension, the items related to partner support were removed to focus only on the support provided by the participants' social and family environment and avoid the problem of collinearity with the scale assessing conjugal support. This is an 18-item, five-point scale ranging from "not at all" to "very much". On this scale, a lower score indicates better well-being. In our study, $α = 0.86, 0.82$ and $0.73$ for the physical, social, and emotional well-being dimensions, respectively. In addition to measuring a personal variable (physical and emotional well-being), this questionnaire allowed us to measure a social variable (family/social well-being). Furthermore, participants also answered two questions concerning their health (based on the SF-36 items; Wawrziczny et al., 2017): "Would you say that your health is ..." for general health and "When you compare yourself with other people of your age, would you say your health is ..." for health compared with people of the same age. These questions were rated on a five-point scale ranging from "very good" to "very bad". Adding these two items together produced a total score: a higher score indicates worse

perceived health. In our study, $α = 0.96$.

Interpersonal variables were investigated through measures of conjugal support and relationship satisfaction. Conjugal support was measured with the Conjugal Support Questionnaire (CSQ) (Brassard et al., 2011). It assesses the support given and received in a conjugal relationship with 8 items rated on a five-point scale ranging from "never" to "always". The score is generated by averaging the scores for the items. In our study, we used the total score ($α = 0.94$): the higher the score was, the better the level of conjugal support.

Relationship satisfaction within the couple was assessed with the Dyadic Adjustment Scale (DAS) (Spanier, 1976; Antoine et al., 2008). The 16-item version was used to explore two dimensions: "degree of agreement between partners" and "quality of their interactions" on a six-point scale. In our study, we used the total score ($α = 0.94$): a high score indicates good satisfaction.

Cultural variables were assessed through religiosity using two subjective questions (Wawrziczny et al., 2021b): "Are you a believer?" and "Do you practice your religion?", ranging on a seven-point scale from "not at all" to "extremely". These two questions are based on the definition of the construct of religiosity by Bremer et al. (2004). Adding these two items together produced a total score: a high score indicates a high level of religiosity. The participants' and their partner's perceived level of religiosity was assessed. In our study, $α = 0.75$ for the religiosity of oneself and the perceived religiosity of one's partner.

## 2.4. Statistical analyses

Statistical analyses were carried out using SmartPLS software in several stages. First, descriptive analyses of the sociodemographic data allowed us to calculate the means and standard deviations (for the continuous variables) as well as percentages (for the categorical variables) for all participants and considered two groups: women who had undergone a lumpectomy and women who had undergone a mastectomy. These two populations were then compared using Student's t tests for continuous variables and chi-square tests for categorical variables. The significance of the results was set at $p < 0.05$.

Second, partial least squares path modeling (PLS-PM) was used to study the relationships between latent and manifest variables in a complex model. PLS-PM is more appropriate for predictive applications and theory building (exploratory analysis), does not rely on distributive assumptions and is able to address small sample sizes and non-normality (Chin et al., 2003). In comparison, structural equation modeling is used to test a strong theory (confirmatory analysis) and requires multivariate normality of the data and a minimum sample size (Diamantopoulos and Siguaw, 2000). Following the recommendations of Tenenhaus et al. (2005), the sample size for a PLS-PM model should be at least 10 times the number of manifest indicators of the latent variable (LVs) with the largest number of manifest indicators. The sample included more than 30 participants in the current study, suggesting that the PLS-PM analyses were feasible with the present sample. Two models were used to describe the PLS-PM: (1) the outer model linking the manifest (observed) variables (MV's) to the LVs associated with them, using the criteria of unidimensionality in the sense of factor analysis; and (2) the inner model connecting the LVs. As there was no a priori model, the unidimensionality of the blocks of manifest variables that form LVs obtained was then verified with indicators such as Cronbach's alpha and DG-rho (>0.70), as well as discriminant validity (heterotrait-monotrait ratio <0.80), convergent validity (AVE >0.50) and multicollinearity (VIF <5) for LVs (Henseler et al., 2015). Then, the different models examining the links between the LVs were tested until an SRMR indicator <0.08 (Henseler et al., 2015) and the highest GoF were obtained, which justified the goodness of fit of the model to the data. We used bootstrapping with 5000 resamples to estimate probability values for significance testing. PLS-PM analyses were conducted with the SmartPLS version.
<table><caption>**Table 1**
Sociodemographic characteristics of the participants.</caption><thead><tr><th rowspan="2">Variables</th><th colspan="4">All participants (N = 87)</th><th colspan="4">Partial mamectomy (N = 46)</th><th colspan="4">Total mamectomy (N = 41)</th><th rowspan="2">t-test</th><th rowspan="2">χ<sup>2</sup></th></tr><tr><th>M</th><th>SD</th><th>N</th><th>%</th><th>M</th><th>SD</th><th>N</th><th>%</th><th>M</th><th>SD</th><th>N</th><th>%</th></tr></thead><tbody><tr><td><strong>Age of participant</strong></td><td>46.63</td><td>9.19</td><td></td><td></td><td>47.02</td><td>10.13</td><td></td><td></td><td>45.75</td><td>8.34</td><td></td><td></td><td>0.42</td><td></td></tr><tr><td><strong>Age of partner</strong></td><td>48.93</td><td>9.55</td><td></td><td></td><td>48.89</td><td>10.25</td><td></td><td></td><td>48.93</td><td>8.68</td><td></td><td></td><td>-0.04</td><td></td></tr><tr><td><strong>Relationship length</strong></td><td>20.82</td><td>10.52</td><td></td><td></td><td>21.93</td><td>10.95</td><td></td><td></td><td>18.66</td><td>10.24</td><td></td><td></td><td>1.05</td><td></td></tr><tr><td><strong>Status</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>3.43</td></tr><tr><td>Married</td><td></td><td></td><td>65</td><td>74.7</td><td></td><td></td><td>36</td><td>78.2</td><td></td><td></td><td>29</td><td>70.7</td><td></td><td></td></tr><tr><td>In a civil partnership (PACS)</td><td></td><td></td><td>7</td><td>8</td><td></td><td></td><td>5</td><td>10.9</td><td></td><td></td><td>2</td><td>4.9</td><td></td><td></td></tr><tr><td>In a common-law relationship</td><td></td><td></td><td>15</td><td>17.3</td><td></td><td></td><td>5</td><td>10.9</td><td></td><td></td><td>10</td><td>24.4</td><td></td><td></td></tr><tr><td><strong>Monthly conjugal income (euros)</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>13.74*</td></tr><tr><td>&lt; 1500</td><td></td><td></td><td>1</td><td>1.1</td><td></td><td></td><td>0</td><td>0</td><td></td><td></td><td>1</td><td>2.4</td><td></td><td></td></tr><tr><td>Between 1500 and 2700</td><td></td><td></td><td>22</td><td>25.3</td><td></td><td></td><td>8</td><td>17.4</td><td></td><td></td><td>14</td><td>34.2</td><td></td><td></td></tr><tr><td>Between 2700 and 3900</td><td></td><td></td><td>36</td><td>41.4</td><td></td><td></td><td>20</td><td>43.5</td><td></td><td></td><td>16</td><td>39</td><td></td><td></td></tr><tr><td>&gt; 3900</td><td></td><td></td><td>28</td><td>32.2</td><td></td><td></td><td>18</td><td>39.1</td><td></td><td></td><td>10</td><td>24.4</td><td></td><td></td></tr><tr><td><strong>Schooling</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td><td>5.08</td></tr><tr><td>&lt; High-school level</td><td></td><td></td><td>33</td><td>37.9</td><td></td><td></td><td>14</td><td>30.4</td><td></td><td></td><td>19</td><td>46.34</td><td></td><td></td></tr><tr><td>&gt; High-school level</td><td></td><td></td><td>54</td><td>62.1</td><td></td><td></td><td>32</td><td>69.6</td><td></td><td></td><td>22</td><td>53.66</td><td></td><td></td></tr><tr><td><strong>Length since diagnosis</strong></td><td>2.82</td><td>3.62</td><td></td><td></td><td>2.96</td><td>4.28</td><td></td><td></td><td>2.68</td><td>2.86</td><td></td><td></td><td>0.36</td><td></td></tr></tbody></table>

Abbreviations: M = mean; PACS = a form of civil union between two persons in France; SD = standard deviation; N = number; % = percentage; * = p < 0.05.

<table><caption>**Table 2**
Descriptive data for MVs.</caption><thead><tr><th rowspan="3">LVs MVs</th><th rowspan="3">Questionnaires</th><th colspan="2">All participants<br>(N = 87)</th><th colspan="2">Lumpectomy<br>(N = 46)</th><th colspan="2">Mastectomy<br>(N = 41)</th></tr><tr><th>M</th><th>SD</th><th>M</th><th>SD</th><th>M</th><th>SD</th></tr></thead><tbody><tr><td><strong>Social support</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Social well being</td><td>FACT-B</td><td>15.09</td><td>3.52</td><td>14.80</td><td>3.38</td><td>15.41</td><td>3.67</td></tr><tr><td><strong>Age</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Age</td><td>Years</td><td>46.63</td><td>9.19</td><td>47.02</td><td>10.13</td><td>46.20</td><td>8.10</td></tr><tr><td><strong>Intra-individual resources</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Body image</td><td>BIQ</td><td>57.66</td><td>12.15</td><td>59.72</td><td>11.88</td><td>55.34</td><td>12.19</td></tr><tr><td>Self-esteem</td><td>RSES</td><td>31.72</td><td>5.60</td><td>32.13</td><td>5.76</td><td>31.27</td><td>5.44</td></tr><tr><td><strong>Physical vulnerability</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Self-rated health</td><td></td><td>7.06</td><td>1.69</td><td>6.98</td><td>1.67</td><td>7.15</td><td>1.74</td></tr><tr><td>Physical well being</td><td>FACT-B</td><td>10.46</td><td>5.81</td><td>9.70</td><td>5.24</td><td>11.32</td><td>6.34</td></tr><tr><td><strong>Emotional vulnerability</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Anxiety</td><td>HADS</td><td>9.34</td><td>4.10</td><td>8.46</td><td>3.82</td><td>10.34</td><td>4.23</td></tr><tr><td>Depression</td><td>HADS</td><td>6.03</td><td>3.72</td><td>5.46</td><td>3.10</td><td>6.68</td><td>4.25</td></tr><tr><td>Emotional well being</td><td>FACT-B</td><td>8.09</td><td>4.45</td><td>7.24</td><td>3.83</td><td>9.05</td><td>4.93</td></tr><tr><td><strong>Conjugal relationship quality</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Conjugal support</td><td>CSQ</td><td>7.58</td><td>1.95</td><td>7.70</td><td>1.72</td><td>7.45</td><td>2.19</td></tr><tr><td>Conjugal satisfaction</td><td>DAS-16</td><td>67.39</td><td>15.38</td><td>67.13</td><td>14.85</td><td>67.68</td><td>16.14</td></tr><tr><td><strong>Conjugal characteristics</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Relationship length</td><td>Years</td><td>20.82</td><td>10.52</td><td>21.93</td><td>10.95</td><td>19.56</td><td>10.01</td></tr><tr><td><strong>Religiosity</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Religiosity oneself</td><td></td><td>3.62</td><td>1.74</td><td>3.70</td><td>1.76</td><td>3.54</td><td>1.73</td></tr><tr><td><strong>Sexual dissatisfaction</strong></td><td></td><td></td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Sexual Dissatisfaction</td><td>ISS</td><td>28.87</td><td>19.65</td><td>30.72</td><td>18.47</td><td>26.80</td><td>20.94</td></tr></tbody></table>

Abbreviations: BIQ = Body Image Questionnaire; CSQ = Conjugal Support Questionnaire; DAS-16 = Dyadic Adjustment Scale; FACT-B = Functional Assessment of Breast Cancer Therapy; HADS = Hamilton Anxiety-Depression Scale; iSS = Index of Sexual Satisfaction; M = mean; RSES = Rosenberg Self-Esteem Scale; SD = standard deviation.

# 3. Results

## 3.1. Characteristics of participants

The participants were 46.63 years old on average (SD = 9.19), their partners were aged 48.93 years old on average (SD = 9.55), they were principally married (n = 65, 74.7 %), and their relationship length was 20.82 years on average (SD = 10.52). The participants had a monthly conjugal income higher than 2700 euros (n = 64, 73.6 %) and had a high education level (n = 54, 62.1 %).

The average length since diagnosis was 3 years (SD = 3.62). In total, 46 women underwent lumpectomy, and 41 underwent mastectomy (52.87 % vs. 47.13 %). The two groups (lumpectomy versus mastectomy) were significantly different in terms of monthly conjugal income but were comparable in terms of age, age of partner, relationship length,

marital status, education, and length since diagnosis. Table 1 shows the complete sociodemographic data.

## 3.2. Reflective measurement model with PLS-PM

The model is composed of eight reflective LVs. The reflective LVs include physical vulnerability (including health status associated with worse personal functioning), emotional vulnerability (including the emotional state associated with worse personal functioning), intra-individual resources (including self-perception associated with better personal functioning), social resources (including family and social networks), conjugal relationship quality (including the perception of the quality of conjugal adjustment), conjugal characteristics (including relationship length), age (including the age of each partner), religiosity (including the level of practice and belief of each partner) and sexual
<table><caption>**Table 3**
Outer model and unidimensionality of each latent variable.</caption><thead><tr><th>Latent Variables (LVs)</th><th>Manifest Variables (MVs)</th><th>Weights</th><th>Unidimensionality</th></tr></thead><tbody><tr><td rowspan="2">Physical vulnerability</td><td>self-rated health</td><td>0.53</td><td>α = 0.81</td></tr><tr><td>physical well-being</td><td>0.56</td><td>DG-rho = 0.81<br>Composite = 0.91<br>AVE = 0.84</td></tr><tr><td rowspan="3">Emotional vulnerability</td><td>anxiety</td><td>0.32</td><td>α = 0.79</td></tr><tr><td>depression</td><td>0.50</td><td>DG-rho = 0.82</td></tr><tr><td>emotional well-being</td><td>0.38</td><td>Composite = 0.87<br>AVE = 0.69</td></tr><tr><td>Social resources</td><td>social well-being</td><td>1.00</td><td>α = 1.00<br>DG-rho = 1.00<br>Composite = 1.00<br>AVE = 1.00</td></tr><tr><td rowspan="2">Intra-individual resources</td><td>self-esteem</td><td>0.53</td><td>α = 0.76</td></tr><tr><td>body image</td><td>0.58</td><td>DG-rho = 0.76<br>Composite = 0.89<br>AVE = 0.80</td></tr><tr><td rowspan="2">Conjugal relationship quality</td><td>conjugal satisfaction</td><td>0.58</td><td>α = 0.87</td></tr><tr><td>conjugal support</td><td>0.48</td><td>DG-rho = 0.89<br>Composite = 0.94<br>AVE = 0.88</td></tr><tr><td>Age</td><td>age</td><td>1.00</td><td>α = 1.00<br>DG-rho = 1.00<br>Composite = 1.00<br>AVE = 1.00</td></tr><tr><td rowspan="3">Conjugal characteristics</td><td>relationship length</td><td>1.00</td><td>α = 1.00<br>DG-rho = 1.00<br>Composite = 1.00<br>AVE = 1.00</td></tr><tr><td rowspan="3">Religiosity</td><td>religiosity of oneself</td><td>1.00</td><td>α = 1.00<br>DG-rho = 1.00<br>Composite = 1.00<br>AVE = 1.00</td></tr><tr><td rowspan="3">Sexual dissatisfaction</td><td>sexual dissatisfaction</td><td>1.00</td><td>α = 1.00<br>DG-rho = 1.00<br>Composite = 1.00<br>AVE = 1.00</td></tr></tbody></table>

Abbreviations: DG-rho = Dillon-Goldstein's rho; Composite = Composite reliability; AVE = Average variance extracted.

dissatisfaction (including the level of sexual dissatisfaction).

The model included 16 MVs (outer model) loaded on 9 LVs (inner model). Table 2 shows the descriptive statistics (means, SDs) of MVs for all participants and both groups.

### 3.3. Outer model

The first step consisted of selecting MVs. Two MVs were removed because of nonsignificant loading (loading <0.70): one MV for the Age LV (age of partner) and one MV for the Religiosity LV (religiosity perceived by my partner). The resulting outer model included 14 MVs loaded on 9 LVs (Table 3).

### 3.4. Inner model

The proportions of explained variance (R²) for the LVs of emotional vulnerability, intraindividual resources, social resources, conjugal relationship quality, and sexual dissatisfaction were 0.34, 0.54, 0.07, 0.39, and 0.60, respectively. The SRMR was 0.077. The direct and in-direct bootstrapped path coefficients are displayed in Tables 4 and 5. Fig. 1 shows the path coefficients (β) between LVs for the inner model.

Concerning Hypothesis (1), the most significant direct path was a negative association between conjugal relationship quality and sexual dissatisfaction (β = -0.61) and a positive association between social resources and conjugal relationship quality (β = 0.33). The most significant indirect effect observed was from social resources through conjugal relationship quality to sexual dissatisfaction (β = -0.20). Nonsignificant direct associations were observed between conjugal

characteristics and sexual dissatisfaction, between conjugal characteristics and conjugal relationship quality, between religiosity and sexual dissatisfaction and between social resources and sexual dissatisfaction.

Concerning Hypothesis (2), the most significant direct paths were as follows: a positive association between physical vulnerability and emotional vulnerability (β = 0.58); a negative association between emotional vulnerability and intraindividual resources (β = -0.57); a positive association between physical vulnerability and conjugal relationship quality (β = 0.46); a positive association between intraindividual resources and conjugal relationship quality (β = 0.32); and a negative association between emotional vulnerability and conjugal relationship quality (β = -0.27). The most significant indirect effect observed was from physical vulnerability through emotional vulnerability to intraindividual resources (β = -0.33). We emphasize that the significant indirect effect observed was from physical vulnerability through emotional vulnerability, intraindividual resources and conjugal relationship quality to sexual dissatisfaction (β = 0.07). Nonsignificant direct associations were observed between physical vulnerability and sexual dissatisfaction, between emotional vulnerability and sexual dissatisfaction, and between intraindividual resources and sexual dissatisfaction.

### 3.5. Group comparison

A resampling approach with a bootstrap t-test was used for path comparisons between the lumpectomy and mastectomy groups (Table 4). The direct path results indicated that the association between age and sexual dissatisfaction was significant only for the lumpectomy group (β = 0.35).

## 4. Discussion

The present study aims to include, in a general model, personal (age, self-esteem, body image, self-rated health, physical well-being, anxiety, depression, and emotional well-being), interpersonal (relationship length, conjugal satisfaction and support), social (social well-being) and cultural (religiosity) factors contributing to the sexual dissatisfaction of women with breast cancer.

This is one of the first studies, to our knowledge, to consider these four levels of factors and their associations together in a complex model in oncology. In fact, two other models have included these four levels of factors (Sánchez-Fuentes et al., 2014; Wawrziczny et al., 2021b), but they were conducted in the general population. While Sanchez-Fuentes' model (2016) particularly considers sexual functions, attitudes and assertiveness, our model highlights the importance of conjugal characteristics (conjugal satisfaction, conjugal support, and relationship length). Moreover, based on Wawrziczny et al. (2021b), we retained the variables evaluated in that model and added variables specific to cancer. The model described in our study accounted for 60 % of the variance in sexual dissatisfaction (compared with 44 % in the general population for Wawrziczny et al., 2021b), which is a very good data fit. Our model is both congruent with Wawrziczny et al.'s model (2021), which gives a mediator central role to the conjugal variables, and divergent because variables related to physical and emotional vulnerability, associated in this case with the cancer situation, held a different place in our model. They contributed to intraindividual resources, conjugal relationship quality and perceived social support: the more physically vulnerable women with breast cancer feel because of the disease and treatments, the more emotionally vulnerable they feel, and the less likely they are to perceive quality social support, quality relationships, and a positive self-image. This result is consistent with the fact that cancer is a life-threatening disease with significant physical and emotional consequences related to treatment and diagnosis (Carreira et al., 2018; Hashemi et al., 2020; Tao et al., 2023). These consequences have the potential to impact all areas of life, including personal, interpersonal, and social domains (Kowalczyk et al., 2019; Montañés-Muro et al.,
<caption>**Table 4**</caption>

Direct bootstrapped path coefficients for all participants and comparison regarding type of surgery.

<table><thead><tr><th rowspan="2">Variables</th><th colspan="2">All participants</th><th colspan="4">Lumpectomy Mastectomy</th><th rowspan="2">β<br>Mean<br>difference</th></tr><tr><th>β<br>Mean (SD)</th><th>95 % bootstrap<br>CI</th><th>β<br>Mean (SD)</th><th>95 % bootstrap<br>CI</th><th>β<br>Mean (SD)</th><th>95 % bootstrap<br>CI</th></tr></thead><tbody><tr><td>Physical vulnerability → Emotional vulnerability</td><td>0.58 (0.07)</td><td>[0.42; 0.71]*</td><td>0.47 (0.10)</td><td>[0.25; 0.63]*</td><td>0.67 (0.10)</td><td>[0.42; 0.81]*</td><td>-0.20</td></tr><tr><td>Physical vulnerability → Social resources</td><td>-0.02 (0.13)</td><td>[-0.23; 0.26]</td><td>0.02 (0.16)</td><td>[-0.27; 0.34]</td><td>0.09 (0.23)</td><td>[-0.38; 0.52]</td><td>-0.07</td></tr><tr><td>Physical vulnerability → Intra-individual resources</td><td>-0.24 (0.10)</td><td>[-0.42;-0.03]*</td><td>-0.27 (0.13)</td><td>[-0.49; 0.02]*</td><td>-0.22 (0.17)</td><td>[-0.52; 0.12]</td><td>-0.05</td></tr><tr><td>Physical vulnerability → Conjugal relationship quality</td><td>0.46 (0.12)</td><td>[0.23; 0.69]*</td><td>0.52 (0.14)</td><td>[0.24; 0.78]*</td><td>0.39 (0.23)</td><td>[-0.07; 0.83]</td><td>0.13</td></tr><tr><td>Physical vulnerability → Sexual dissatisfaction</td><td>-0.10 (0.11)</td><td>[-0.32; 0.13]</td><td>-0.25 (0.20)</td><td>[-0.67; 0.11]</td><td>-0.03 (0.14)</td><td>[-0.30; 0.25]</td><td>-0.22</td></tr><tr><td>Emotional vulnerability → Social resources</td><td>-0.27 (0.13)</td><td>[-0.51; 0.01]*</td><td>-0.17 (0.22)</td><td>[-0.53; 0.33]</td><td>-0.47 (0.18)</td><td>[-0.77;-0.06]*</td><td>0.30</td></tr><tr><td>Emotional vulnerability → Intra-individual resources</td><td>-0.57 (0.08)</td><td>[-0.73;-0.41]*</td><td>-0.53 (0.10)</td><td>[-0.70;-0.29]*</td><td>-0.61 (0.14)</td><td>[-0.86;-0.30]*</td><td>0.08</td></tr><tr><td>Emotional vulnerability → Conjugal relationship quality</td><td>-0.27 (0.12)</td><td>[-0.49;-0.01]*</td><td>-0.35 (0.16)</td><td>[-0.66;-0.04]*</td><td>-0.12 (0.25)</td><td>[-0.58; 0.40]</td><td>-0.23</td></tr><tr><td>Emotional vulnerability → Sexual dissatisfaction</td><td>0.14 (0.11)</td><td>[-0.08; 0.33]</td><td>0.12 (0.15)</td><td>[-0.16; 0.44]</td><td>0.38 (0.16)</td><td>[0.05; 0.68]*</td><td>-0.27</td></tr><tr><td>Social resources → Conjugal relationship quality</td><td>0.33 (0.09)</td><td>[0.16; 0.49]*</td><td>0.37 (0.13)</td><td>[0.08; 0.60]*</td><td>0.28 (0.14)</td><td>[-0.04; 0.53]*</td><td>0.09</td></tr><tr><td>Social resources → Sexual dissatisfaction</td><td>-0.13 (0.08)</td><td>[-0.28; 0.03]</td><td>-0.19 (0.13)</td><td>[-0.42; 0.09]</td><td>0.05 (0.12)</td><td>[-0.18; 0.27]</td><td>-0.24</td></tr><tr><td>Intra-individual resources → Conjugal relationship quality</td><td>0.32 (0.11)</td><td>[0.11; 0.53]*</td><td>0.28 (0.16)</td><td>[-0.02; 0.60]</td><td>0.44 (0.21)</td><td>[0.05; 0.85]*</td><td>-0.16</td></tr><tr><td>Intra-individual resources → Sexual dissatisfaction</td><td>-0.05 (0.09)</td><td>[-0.25; 0.11]</td><td>-0.21 (0.16)</td><td>[-0.54; 0.09]</td><td>0.20 (0.18)</td><td>[-0.12; 0.55]</td><td>-0.41</td></tr><tr><td>Conjugal relationship quality →Sexual dissatisfaction</td><td>-0.61 (0.09)</td><td>[-0.76;-0.41]*</td><td>-0.45 (0.17)</td><td>[-0.80;-0.11]*</td><td>-0.80 (0.12)</td><td>[-0.97;-0.48]*</td><td>0.34</td></tr><tr><td>Conjugal characteristics → Conjugal relationship quality</td><td>0.07 (0.08)</td><td>[-0.08; 0.22]</td><td>0.07 (0.10)</td><td>[-0.13; 0.25]</td><td>0.09 (0.13)</td><td>[-0.17; 0.35]</td><td>-0.02</td></tr><tr><td>Conjugal characteristics → Sexual dissatisfaction</td><td>-0.02 (0.10)</td><td>[-0.22; 0.18]</td><td>-0.12 (0.14)</td><td>[-0.41; 0.14]</td><td>0.22 (0.14)</td><td>[-0.09; 0.45]</td><td>-0.34</td></tr><tr><td>Age → Sexual dissatisfaction</td><td>0.13 (0.11)</td><td>[-0.08; 0.33]</td><td>0.35 (0.14)</td><td>[0.06; 0.64]*</td><td>-0.26 (0.16)</td><td>[-0.53; 0.09]</td><td>0.60*</td></tr><tr><td>Religiosity→ Sexual dissatisfaction</td><td>-0.08 (0.06)</td><td>[-0.21; 0.04]</td><td>-0.15 (0.10)</td><td>[-0.34; 0.07]</td><td>-0.11 (0.11)</td><td>[-0.33; 0.09]</td><td>-0.04</td></tr></tbody></table>

Note: CI = Confidence Interval; SD = standard deviation; * = p < 0.05.

2023).

## 4.1. Principal results

Concerning Hypothesis 1, only the quality of the conjugal relationship directly contributes to sexual satisfaction. Studies have reported that mutual, constructive communication between patients and partners with relationship-enhancing behaviors (e.g., responsiveness, engagement) is associated with greater relationship satisfaction and reduced psychological distress, whereas relationship-compromising behaviors (e.g., avoidance, criticism) are related to lower relationship satisfaction, as well as increased psychological distress and well-being (Chen et al., 2021; Li and Loke, 2014). Michael et al. (2021) reported that, for adult cancer survivors, greater relationship satisfaction is significantly associated with greater sexual satisfaction. Moreover, to manage stressful life events, individuals often rely on their partners for both emotional and practical support to help them cope with the situation (Falconier et al., 2019). Several studies have highlighted the importance of support provided by partners as a key correlate of women's adaptation to breast cancer (Manne et al., 2010; Ştefanuţ et al., 2021). In essence, the support provided by partners during cancer survivorship can create a supportive environment that nurtures understanding, adaptation, and emotional closeness (Ştefanuţ et al., 2021). A model developed for couples in the general population (Wawrziczny et al., 2021b) showed that dyadic coping plays a key role in sexual dissatisfaction. In our study, conjugal

relationship quality, which included conjugal satisfaction and conjugal support, was the most important variable related to sexual satisfaction. The more satisfied women with breast cancer are with their conjugal relationship and support, the more sexually satisfied they are. The conjugal relationship may thus be seen as an important variable to consider when examining sexual dissatisfaction in women with breast cancer.

While studies have shown a direct link between social support and sexual satisfaction (Kim and Jang, 2019; Rizalar et al., 2014), our study shows that when other variables (social, interpersonal, and cultural) are introduced into the model, mediating effects are observed. Sánchez-Fuentes et al. (2014) identified relationship satisfaction as a mediator of this link. Our model links it to the quality of conjugal support: high-perceived social support well-being is associated with high levels of conjugal relationships and support and, ultimately, with low levels of sexual dissatisfaction. The quality of perceived social support can therefore be seen as a protective factor for the quality of the conjugal relationship, making it an important target for the support of women with breast cancer.

Finally, while our model does not show a significant direct relationship between the level of religiosity and sexual dissatisfaction, qualitative studies have shown that religiosity has an important influence on sexual activity and satisfaction (Maleki et al., 2021; Zangeneh et al., 2022). It would thus be interesting to assess 1) religiosity using more complex measures and 2) sexual attitudes to evaluate their
<table><caption>**Table 5**
Significant specific indirect bootstrapped path coefficients for all participants.</caption><thead><tr><th rowspan="2">Variables</th><th colspan="2">All participants</th></tr><tr><th>β<br>Mean (SD)</th><th>95 %<br>bootstrap CI</th></tr></thead><tbody><tr><td>Physical vulnerability → Emotional vulnerability<br>→ Intra-individual resources</td><td>-0.33 (0.06)</td><td>[-0.47;-0.21]</td></tr><tr><td>Physical vulnerability → Emotional vulnerability<br>→ Social resources</td><td>-0.16 (0.08)</td><td>[-0.31;-0.01]</td></tr><tr><td>Physical vulnerability → Emotional vulnerability<br>→ Conjugal relationship quality</td><td>-0.16 (0.08)</td><td>[-0.31;-0.01]</td></tr><tr><td>Emotional vulnerability → Intra-individual<br>resources → Conjugal relationship quality</td><td>-0.18 (0.07)</td><td>[-0.33;-0.06]</td></tr><tr><td>Physical vulnerability → Conjugal relationship<br>quality → Sexual dissatisfaction</td><td>-0.28 (0.07)</td><td>[-0.42;-0.14]</td></tr><tr><td>Emotional vulnerability → Conjugal relationship<br>quality → Sexual dissatisfaction</td><td>0.17 (0.08)</td><td>[0.01; 0.31]</td></tr><tr><td>Intra-individual resources → Conjugal relationship<br>quality → Sexual dissatisfaction</td><td>-0.20 (0.07)</td><td>[-0.33;-0.06]</td></tr><tr><td>Social resources → Conjugal relationship quality<br>→ Sexual dissatisfaction</td><td>-0.20 (0.06)</td><td>[-0.32;-0.09]</td></tr><tr><td>Physical vulnerability → Emotional vulnerability<br>→ Intra-individual resources → Conjugal<br>relationship quality</td><td>-0.11 (0.05)</td><td>[-0.21;-0.03]</td></tr><tr><td>Physical vulnerability → Emotional vulnerability<br>→ Conjugal relationship quality → Sexual<br>dissatisfaction</td><td>0.10 (0.05)</td><td>[0.00; 0.19]</td></tr><tr><td>Emotional vulnerability → Intra-individual<br>resources → Conjugal relationship quality →<br>Sexual dissatisfaction</td><td>0.11 (0.04)</td><td>[0.04; 0.20]</td></tr><tr><td>Physical vulnerability → Emotional vulnerability<br>→ Intra-individual resources → Conjugal<br>relationship quality → Sexual dissatisfaction</td><td>0.07 (0.03)</td><td>[0.02; 0.13]</td></tr></tbody></table>

Note: CI = Confidence Interval; SD = standard deviation.

potential mediating role in this population, as in Sanchez-Fuentes et al.'s model (2016).

Hypothesis 2 is partially validated because no direct associations were observed between intraindividual resources, physical vulnerability, emotional vulnerability, or age and sexual dissatisfaction; however, only partial mediations between these variables and sexual satisfaction through conjugal relationship quality were observed. Concerning the mediation observed between intraindividual resources and sexual dissatisfaction, while previous studies have shown direct links between self-esteem or body image and sexual problems (Andrzejczak et al., 2013; Chang et al., 2019; Miaja et al., 2017; Montañés-Muro et al., 2023), our model shows once again that introducing other variables into the model leads to mediating effects (mediators: conjugal support and conjugal satisfaction): the more resources women with breast cancer have, the more satisfied they are with their conjugal relationship and support, and the more sexually satisfied they are.

Similarly, concerning the mediation observed between emotional/physical vulnerability and sexual dissatisfaction, previous studies have shown direct links between physical/psychological well-being and sexual problems (Chang et al., 2019; DeSimone et al., 2014; Miaja et al., 2017; Montañés-Muro et al., 2023). Nevertheless, in our model, mediating effects are observed (mediators: conjugal support and conjugal satisfaction): high vulnerability is associated with low conjugal satisfaction (relationship and support satisfaction) and, finally, with sexual dissatisfaction. The levels of emotional and physical vulnerability can then be considered aggravating factors in the quality of the conjugal

relationship, which should be reduced through intervention. Intra-individual resources related to self-perception can be considered protective factors in the quality of the conjugal relationship, which should be developed and strengthened in the context of support for women with breast cancer.

Similarly, Wawrziczny et al. (2021b) reported that age does not contribute to sexual dissatisfaction except when we consider surgery type. In fact, older women who underwent a lumpectomy were more at risk of being sexually dissatisfied, whereas no age-related effect was observed among women who underwent a mastectomy. Previous studies have identified mastectomy as a risk factor for sexual problems (Aerts et al., 2014; Hernández-Blanquisett et al., 2022; Hummel et al., 2017). Moreover, the impact on body image is more important after a mastectomy than after a lumpectomy (Türk and Yilmaz, 2018). Our results are consistent with these previous findings and suggest the need to adapt the support provided to women. Specific attention should be given to women who undergo mastectomy regardless of their age and older women who undergo lumpectomy.

## 4.2. Clinical implications

In oncology, data indicate that health care professionals frequently overlook sexual difficulties during routine follow-up care for cancer survivors, leaving this issue largely unaddressed (Anouk et al., 2024; Bober and Varela, 2012; Reese et al., 2017). The results obtained in our study emphasize the need to first systematically assess the quality of the marital relationship through relationship satisfaction (assessed here with two dimensions of the DAS-16: quality of interactions, agreement between both partners) and conjugal support provided (assessed here with the CSQ) as well as sexual satisfaction (with the ISS) in women with breast cancer to identify vulnerable patients.

Second, our findings suggest directly promoting conjugal relationship quality through the quality of interactions, agreement between both partners, and conjugal support provided to improve sexual satisfaction. This could be achieved by working with both partners with interventions targeting communication. According to Zhou et al.'s (2023) systematic review, interventions focused on couples' communication aim to strengthen relationship-enhancing behaviors; decrease relationship-compromising behaviors; and improve mutual communication, intimacy, and relationship satisfaction. These interventions have already proven their effectiveness concerning relationship functioning (e.g., communication, intimacy, relationship satisfaction) as well as better individual functioning (e.g., reduced anxiety, depression, and cancer-related concerns). Moreover, couple interventions based on conjugal support may help both partners identify their own needs and communicate them better so that each can better understand the other and provide appropriate support (Traa et al., 2015). Our study also highlights the possibility of increasing sexual satisfaction by indirectly improving conjugal relationship quality with interventions based on personal and social aspects. As a result, it could contribute to sexual satisfaction.

In addition, better identification of social support resources or networks and more implications for families through meetings to inform them about the disease could favor better acceptance and communication about the cancer and its treatments (Gritti, 2015).

Supporting the emotional and physical well-being of women with breast cancer, as well as enhancing their self-esteem and body image, could also be relevant, as shown in our results. However, to date, no unique intervention seems to exist that targets all these variables.

The development of a multimodular program focusing on the different variables mentioned could help enhance the effects on sexual satisfaction in women with breast cancer.

## 4.3. Study limitations

The first limitation is related to the online data collection method
<figure><img src="image_2.png" /><figcaption>Fig. 1. PLS-PM graph for all participants.</figcaption></figure>

Note: Bold lines show significant paths, the various thicknesses show low, moderate and high associations. Dotted lines show non-significant links between latent variables.

and participants' characteristics. While this method is comparable to other recruitment techniques in terms of data validity (Gosling et al., 2004), it may result in sampling a specific subset of individuals who have computer access and are comfortable with technology. Moreover, the participants may also be women with important sexuality concerns, as they answered a questionnaire about it, which may limit the generalizability of the results. With respect to the sociodemographic characteristics of the participants, the women who participated in the study were young and engaged in long-term relationships, and information related to ethnic/racial/gender/sexual orientation was not questioned; however, in previous studies, these factors often presented more challenges related to health care. In France, ethics committees do not authorize the collection of such information, except when it is the main aim of the research (which was not the case in our study) and is duly justified. Future research should test our model by including these variables and expanding the sample (age, relationship length). Second, including more variables related to the partner and couple is crucial because partners play a significant role in shaping the emotional, psychological, and sexual well-being of breast cancer survivors (Li et al., 2020; Ștefănuț et al., 2021; Traa et al., 2015). It would thus be relevant to consider the partner's characteristics (e.g., sexual problems, distress) and the quality of communication within the couple (e.g., communication on cancer-related stress) (Li and Loke, 2014; Zhou et al., 2023). Third, women were not asked whether their treatments were completed, even if most of them (95 %) seemed to be in remission as chemotherapy and radiotherapy were completed. Finally, the sole use of self-reported questionnaires may be subject to social desirability and recall biases, highlighting the importance of validating our model in another sample.

## 5. Conclusion

This study highlights the importance of taking different levels of variables (personal, interpersonal, social, and cultural variables) into account when considering sexual dissatisfaction in women with breast cancer. There is evidence that the quality of the conjugal relationship acts as a mediator between different variables (physical and emotional vulnerability, intraindividual resources, and social resources) and sexual dissatisfaction. This main result encourages the use of interventions to directly promote conjugal relationship quality to improve sexual satisfaction. These interventions, specifically those targeting conjugal support, the quality of interactions, and agreement between both partners, may be combined with interventions targeting physical and emotional well-being, self-view, and social support to potentiate their effects on sexual satisfaction in women with breast cancer.

## CRediT authorship contribution statement

**Kristopher Lamore:** Conceptualization, Writing – original draft, Writing – review & editing. **Anna Maria Giardinelli:** Formal analysis, Investigation, Methodology, Writing – review & editing. **Émilie Wawrziczny:** Conceptualization, Data curation, Formal analysis, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing.

## Funding

KL working time is funded by a grant of the French national cancer institute (grant number INCA/16136).
# Declaration of competing interest

The authors report there are no competing interests to declare.

# Acknowledgments

The authors would like to thank all the women who participated in the study. SCALab Laboratory is part of ONCOLille Institute.

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