# Endometriosis and Sexual Functioning: How Much Do Cognitive and Psycho-Emotional Factors Matter?
## 4 Discussion
In line with this, in our study, women with endometriosis showed a higher score on SDS, highlighting that these women were more sexually distressed than control women. This result could also explain the greater percentage of EG women who self-declared to suffer from a sexual problem. Data are in accordance with our first hypothesis and with previous studies [11; 21; 23; 35; 37], underling the disease's influence on patients' sexual health. Concerning the presence of psychopathological symptoms, the group of women with endometriosis scored worse than the control group in several domains of the SCL-90-R. These findings confirm that mental health may be severely impaired in women who have this disease [11; 28; 29]. Anxiety and depression are widely reported in the literature [14; 17; 19; 28; 29; 30; 31; 32; 33], as well as phobic anxiety, obsessive compulsive and somatization; CPP may lead women to focus more to signals from their body or the situation they are experiencing. This could result in a persistent anxious state, often phobic, especially towards pain (catastrophizing) or obsessive compulsive behaviors to feel control [102]. Samatization was another expected outcome [28; 29; 33; 34]. The Psychocticism domain could denote the presence of a tendency for detachment and retirement, which the pathology could cause. As reported in other studies, women might avoid social situations due to the symptomatology and the feeling of distrust [11; 13]. In addition, the burden of the pathology might elicit detachment as a reaction, a splitting mechanism to manage emotions. Emotional difficulties, such as recognizing feelings (TAS-20), were more present in the endometriosis group than in the control one. However, our hypothesis was only partially confirmed as there were no significant differences in the total score and the other domains of TAS-20. The presence of alexithymia in endometriosis patients has been widely reported in the literature [28; 29; 30; 33], emphasizing that it is a crucial aspect clinicians should take into account when treating these patients. These findings appear to have a link to those obtained in SCL-90-R. On the one hand, difficulties in recognizing feelings may be associated with a tendency to somatization [103; 104]; in fact, suppression of emotions seems to correlate with a high level of perceived pain [59]. On the other hand, alexithymia traits could represent a defense mechanism against mental and physical pain (e.g., expression of emotional numbing in post-traumatic stress disorder) [105; 106]. Psychopathological traits and alexithymia play a role in female sexual dysfunctions in general [107] and endometriosis-related sexual dysfunctions [28; 29; 48; 108]. Therefore, these data emphasize the importance of assessing them. The two groups also differed significantly in the presence of negative emotions about sexuality, with higher scores reported by women with endometriosis. These data confirmed studies on GP [12] and other sexual dysfunctions [64; 65; 68; 69; 72; 73; 74; 75; 109; 110; 111] in which negative thoughts and feelings (anger, sadness, disappointment, etc.) may distract from the erotic and pleasurable situation, increasing the possibilities of incurring in an unpleasant experience, characterized by a sense of guilt and detachment [69; 73; 76; 109]. Finally, women with and without endometriosis also showed significant differences concerning cognitive factors. Sexual dysfunctional beliefs (SDBQ) were more prevalent in women with endometriosis. These women scored higher only in the \"Affection Primacy\" domain. These findings were not surprising since women with endometriosis seem to give much importance to the relationship: the presence of a partner has a significant and protective role for women affected by the pathology, acting as an emotional support [24; 112]. Although having a partner has a protective role, being focused only on the partner and on the affection can lead women to shift their attention away from their wellbeing and pleasure.