{"paper_id":"920ef144-0149-4bad-9824-3a8c77c4a52a","body_text":"RESEARCH Open Access\n© The Author(s) 2025, corrected publication 2025. Open Access  This article is licensed under a Creative Commons Attribution 4.0 International \nLicense, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit \nto the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other \nthird party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. \nIf material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds \nthe permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit  h t t p  : / /  c r e a  t i  v e c  o m \nm  o n s .  o r  g / l i c e n s e s / b y / 4 . 0 /.\nAl-amer et al. BMC Psychology          (2025) 13:305 \nhttps://doi.org/10.1186/s40359-025-02623-1\nBMC Psychology\n*Correspondence:\nRasmieh Al-amer\nr.al-amer@outlook.com\nAhmad Ayed\nahmad.juma@aaup.edu\n1Faculty of Nursing, Yarmouk University, Irbid - Jordan, IrbidP .O.BOX (3678), \n11953, Jordan\n2Pediatric Nursing, Philadelphia University| Faculty of Nursing, Jarash \nRoad, P .O. Box 19392, Amman, Jordan\n3Faculty of Nursing, Al-Zaytoonah University of Jordan, Amman, Jordan\n4Paediatric health nursing, Arab American University, Jenin, Palestine\n5Clinical Nursing Department, Faculty of Nursing, Hashemite University, \nAmman, Jordan\n6Clinical Nursing Department, The University of Jordan, School of Nursing, \nAmman, Jordan\n7Psychiatric and mental health nursing, Arab American university, Jenin, \nRN, Palestine\n8Department of Psychiatric Nursing and Mental Health, Faculty of \nNursing, Alexandria University, Alexandria, Egypt\n9The University of Sydney, Faculty of Medicine and Health, Susan Wakil \nSchool of Nursing and Midwifery, Sydney, Australia\nAbstract\nBackground Jordan is a collectivist society where fertility is rated highly. Hysterectomy, therefore, has the potential \nto negatively impact a woman’s standing in a collectivist society leading to increased levels of anxiety and stress.\nPurpose To assess the impact of hysterectomy on the levels of anxiety, stress, body appreciation, and social support \namong women.\nMethods A cross-sectional design was utilized to recruit 251 women post-hysterectomy. The study used \nthe Depression, Anxiety, and Stress Scale (DASS), the Enriched Social Support Instrument (ESSI), and the Body \nAppreciation Scale (BAS).\nResults Sexual difficulties were experienced by the majority. Severe anxiety was reported by 39% with around 89% of \nwomen reporting stress that was moderate or higher. Overall, participants had moderate levels of body appreciation \nand a high level of perceived support. Sexual problems, body appreciation, stress, post-surgery duration, and social \nsupport predicted the levels of anxiety, with both a desire for more children and longer post-surgery durations \nheightening both anxiety and stress.\nConclusion Hysterectomy negatively impacts women’s mental health, leading to high levels of anxiety and stress. \nBody appreciation and social support are important facets in buffering the consequences of hysterectomy. A \nculturally sensitive healthcare addressing the individual needs of women in collectivist communities is paramount.\nKeywords Hysterectomy, Anxiety, Stress, Body appreciation, Social support\nPrevalence and predictors of anxiety \nand stress among Jordanian women following \nhysterectomy: an observational multicentre \nstudy\nRasmieh Al-amer1* , Maha Atout2, Malakeh. Z. Malak3, Ahmad Ayed4*, Wafa’Mousa Othman5,  \nMohammad Y.N. Saleh6, Lobna Harazne7, Amira Ali8 and Sue Randall9\n\nPage 2 of 10\nAl-amer et al. BMC Psychology          (2025) 13:305 \nIntroduction\nHysterectomy is a common gynecological procedure \ninvolving the removal of the uterus [ 1]. While often nec -\nessary for medical reasons, hysterectomy can lead to \nsignificant psychological challenges, including anxiety \nand stress; these factors are frequently overlooked. The \nincidence of hysterectomy varies from 2.13–3.62/1,000 \nin Germany to 5.4/1,000 in the United States [ 2]. In the \ndeveloping world, it ranges from 1.31/1,000 deliveries in \nEgypt [3] to 113.5/1,000 deliveries in India [ 4]. In Jordan, \nthe incidence of hysterectomy for benign conditions var -\nies significantly, with rates reported between 0.24 and \n8.7 per 1,000 deliveries in a tertiary hospital located in \na major governorate (an area controlled by a governor), \nwhich serves patients from across the country [ 5]. Simi-\nlarly, a recent study conducted in a northern governorate \nof Jordan reported that the incidence of peripartum hys -\nterectomy is 1.38 per 1,000 births, reflecting that regional \nvariations were likely influenced by differences in clinical \npractices and institutional resources [6].\nApproximately 90% of hysterectomies are for benign \nconditions such as fibroid uterus and dysfunctional uter -\nine bleeding, with malignancy being another indication \n[1, 7– 9]. Hysterectomy is linked to a mortality rate of 1 \nin 1000 [ 2] and can result in physical and psychological \ncomplications. Physical complications include bleeding, \ninfection, and sexual difficulties [ 10, 11]. Psychological \ndifficulties involve depression, anxiety, and stress [11, 12].\nHysterectomy has long been linked to psychological \nreactions, with early reports indicating a high probability \nof poor mental health, including psychosis within three \nyears [ 13]. Women often view the uterus as a core ele -\nment of their femininity symbolizing youth, vitality, and \nchildbearing [ 11, 14], leading to various psychological \nissues post-hysterectomy [11, 15, 16]. Women may expe-\nrience reduced self-confidence, poor body image, rela -\ntionship issues, and a decline in quality of life [10, 14, 17]. \nFor those wanting more children, hysterectomy can pre -\ncipitate significant psychological changes such as severe \nanxiety and stress [11].\nStudies in Low- and Middle-Income Countries \n(LMICs) with collectivist cultures, such as Egypt, Paki -\nstan, and Turkey, have reported high levels of anxiety and \ndepression before and after hysterectomy, often linked \nto feelings of lost femininity and childbearing capacity \n[14, 18, 19]. However, other studies from Egypt and India \nhave shown positive outcomes, with women reporting \nimproved quality of life except in sexual function [20, 21]. \nSome women reported that hysterectomy alleviates their \nchronic pain, and other gynecological problems, leading \nto improvement in the quality of their life [ 21– 23]. These \nconflicting results call for more studies, specifically in \ncollectivist communities.\nIn the Arab world, particularly in Jordan, data on the \npsychological outcomes of hysterectomy are scarce. \nSociocultural factors, such as mental health stigma and \nlimited resources, particularly in these communities, may \nexacerbate the impacts of anxiety and stress in women \npost-hysterectomy. Additionally, limited access to spe -\ncialized psychological care and societal taboos surround -\ning the discussion of mental health issues result in a more \ncomplicated mental health status [24]. Understanding the \nprevalence and predictors of anxiety and stress among \nwomen undergoing hysterectomy is critical to addressing \nthese mental health issues in collectivist communities.\nJordanian context\nJordanian women, who are of Arabic descent, live in a \ncollectivist society where fertility is highly valued and \ntied to identity and social status [ 24]. In this context, \nwomen unable to bear children may face social margin -\nalization and devaluation, as noted in studies exploring \nfertility and cultural perceptions in the region [25, 26].\nIn this culture, children are viewed as a vital investment \nin the future, as they are expected to care for their par -\nents as they age [ 27, 28]. Hence, in a collectivist society, \na hysterectomy, which renders complete infertility, can \nlead to extreme psychosocial repercussions, as a woman’s \nworth is deeply tied to her ability to bear children.\nIn the Jordanian community, where polygamy is \nallowed, a woman unable to bear children may fear that \nher husband might seek another wife, exacerbating their \nfeelings of loss and vulnerability [ 29– 31]. Overall, this \ncultural framework highlights the multifaceted chal -\nlenges encountered by women post-hysterectomy, in \nwhich physical and societal factors shape their mental \nwell-being [32].\nTheoretical framework\nThe Biopsychosocial Model (BPS) offers a framework \nto understand how biological, psychological, and social \nfactors collectively impact health [ 33]. This model sug -\ngests that wellness and illness stem from the intersection \nbetween these factors. Additionally, it integrates cogni -\ntive appraisal, highlighting how individuals’ perceptions \nof biological threats influence their social and emotional \nresponses. Holistic healthcare plans that address physi -\ncal, psychological, and social needs are vital [ 33, 34]. In \nhysterectomy, the removal of the uterus and its related \ncomplications, such as hormonal issues and sexual diffi -\nculties, can result in anxiety and stress [ 35]. These bio -\nlogical changes are often compounded by psychosocial \nfactors such as how women cognitively appraise their \nbodies and cope with hysterectomies [ 35, 36]. Negative \nappraisal can exacerbate their mental health, while posi -\ntive appraisal can alleviate it.\n\nPage 3 of 10\nAl-amer et al. BMC Psychology          (2025) 13:305 \nSocial factors, such as social support and cultural \nnorms, also play a crucial role in shaping mental health \noutcomes post-hysterectomy [ 33]. In collectivist soci -\neties where fertility is valued, women undergoing hys -\nterectomy may feel inadequate, leading to low body \nappreciation, and increased anxiety and stress [ 31, 32]. \nHigh social support can provide emotional comfort and \npromote adaptive health behaviors [37, 38].\nOverall, the BPS model emphasizes the value of a holis-\ntic approach, considering the intersection of biological, \nsocial, and psychological factors for individualized care \nplans [33].\nMethods\nThis study aimed to investigate the influence of hyster -\nectomy on the levels of anxiety, stress, body apprecia -\ntion, and social support among women who underwent \nhysterectomies, hence, the study addresses the following \nresearch questions:\n1. What are the levels of stress, anxiety symptoms, \nbody appreciation, and social support among \nJordanian women who underwent hysterectomy?\n2. What are the associations between the levels of \nanxiety, stress, body appreciation, and social support \nand sociodemographic data among Jordanian women \npost-hysterectomy?\n3. What are the predictors of stress and anxiety among \nJordanian women who underwent hysterectomy?\nPopulation\nThe population comprised all women who underwent \nhysterectomy for benign conditions. The inclusion cri -\nteria were (a) women who had undergone hysterectomy \nfor non-cancerous reasons; (b) no cognitive impairment \nor diagnosed mental illness, based on medical reports \nor self-reporting; (c) able to read and write in Arabic; \n(d) aged 18 to 50 years. This age range was selected as it \nencompasses many benign condition-related hysterecto -\nmies observed in Jordan [ 39]; and (e) no significant men -\ntal health event in the past six months; (f) the surgery \ntook place between two months and two years before \ndata collection (duration post-surgery). The post-surgery \nduration of two years was set as an inclusion criterion \nto minimize the confounding effects of serious long-\nterm complications of hysterectomy, which often occur \nwithin three years of the procedure. These complica -\ntions include cardiovascular events, certain cancers, early \novarian failure, menopause, and pathological depression \n[40]; j) provided informed consent. Exclusion criteria \nincluded (a) hysterectomy for cancer; (b) women on hor -\nmone replacement therapy; (c) those who had attained \nmenopause; and (d) any significant traumatic event in the \npast six months.\nDesign, setting, and sampling\nIn this cross-sectional study, data from hospitals affili -\nated with the Ministry of Health in Jordan (MOH), spe -\ncifically in Amman (Jordan’s capital) were used. Amman \nis the largest city by area and population, with around \n4,500,700 residents according to the Jordanian Statis -\ntics Department [ 41]. Thus, women recruited from this \ngovernorate are representative of Jordanian women. The \nsample size calculation was conducted using G*Power \n3.0.10. The calculation parameters were set at 0.95 power \nand 0.05 significance levels, with 12 selected predictors \nusing regression. The sample size calculation determined \nthe need for 184 participants. Three hundred question -\nnaires were distributed, yielding 275 responses, of which \n251 were fully completed and subsequently included in \nthe analysis.\nStudy measures\nWe used a structured self-reported survey to collect \ndata from participants. This survey included four com -\nponents: a demographic questionnaire and three vali -\ndated scales, the anxiety and stress subscales of the DASS \n[42– 44]; the Enriched Social Support Instrument (ESSI) \n[45, 46], and the Body Appreciation Scale (BAS) [ 47]. \nThe demographic questionnaire was developed based on \nexisting literature [12, 39, 48].\nDepression, anxiety and stress scale (DASS)\nThe current study used Depression, Anxiety, and Stress \nScale 21-item (DASS-21), a 21-item comprising three \nsubscales developed to assess emotional states: depres -\nsion, anxiety, and stress [ 42]. Each subscale includes 7 \nitems anchored in a four-point Likert scale from 0 (did \nnot apply to me at all) to 3 (applied to me very much, or \nmost of the time). The scores of each subscale were added \ntogether for the corresponding items. For more details \nabout the subscales scoring system see appendix 1. This \nstudy utilized the Arabic version of the DASS, which \nhas been extensively used among Jordanian populations. \nThe scale demonstrates strong reliability, with a Cron -\nbach’s alpha of 0.95 for the total DASS [ 43, 44]. Specifi-\ncally, among Jordanians, the scale has shown Cronbach’s \nalpha values of 0.94 for the depression subscale, 0.90 for \nthe anxiety subscale [ 49], and 0.89 for the stress subscale \n[50].\nEnriched social support instrument (ESSI)\nThe levels of social support were assessed using the Ara -\nbic translation of the Enriched Social Support Instru -\nment (ESSI); [ 51]. The ESSI scale is composed of seven \nstatements. The first six statements use a five-point Lik -\nert scale ranging from 8 to 34 with higher scores indicat -\ning higher levels of social support. This scale is scored as \nfollows, a)1 = none of the time; b) 2 = a little of the time; \n\nPage 4 of 10\nAl-amer et al. BMC Psychology          (2025) 13:305 \nc) 3 = some of the time; d) 4 = most of the time; e) 5 = all \nthe time. The seventh item is a yes/no question in which \nyes is scored as 4 and no is scored as 2 [ 45]. The Arabic \nversion of the Enriched Social Support Instrument (ESSI) \nwas validated in a previous thesis through Exploratory \nFactor Analysis (EFA), which confirmed its unidimen -\nsional structure with robust psychometric properties \n(KMO = 0.82; Bartlett’s Test: χ² = 597.577, p < 0.001). All \nseven items were loaded onto a single component, \nexplaining 59.25% of the variance, consistent with the \noriginal scale [ 45]. Furthermore, the scale has been suc -\ncessfully utilized in studies involving Jordanian popula -\ntions without changing its items or sub-dimensions [46].\nBody appreciation scale (BAS)\nThe BAS consists of six different body appreciation sub -\nscales. Example items include “How good I feel about my \nbody depends a lot on whether people consider me good-\nlooking” and “How good I feel about my body depends \na lot on what my body can do physically [ 47]. Partici -\npants were asked to complete an Arabic-translated ver -\nsion of the BAS-2. This 10-item scale assesses acceptance \nof, respect, and care for one’s body and protection from \nunrealistic beauty standards. Items are rated on a 5-point \nscale, ranging from 1 (never) to 5 (always), and an over -\nall score is computed as the mean of the 10 items with \nhigher scores on this scale being reflective of the greater \nbody appreciation. The BAS-2 has shown satisfactory \nreliability and validity in samples from diverse socio-\ncultural contexts [47]. Psychometric testing of the Arabic \nversion of the Body Appreciation Scale-2 (BAS-2) was \nconducted among Arab participants. Exploratory Factor \nAnalysis (EFA) and Confirmatory Factor Analysis (CFA) \nconfirmed its unidimensional factor structure, consistent \nwith the original English validation of the 10-item BAS-2. \nAll 10 items were loaded onto a single factor for male and \nfemale respondents [52].\nPilot testing\nThe questionnaires were pilot tested among 30 women \nwho met the study’s inclusion criteria and attended the \nsame health setting. This pilot aimed to examine feasibil -\nity, including the time required to complete the survey. \nA blank sheet was provided for the participants to offer \nfeedback, which was minimal and incorporated into the \nfinal version. Data from the pilot were excluded from the \nfinal report to prevent data contamination.\nData collection procedures\nAfter obtaining ethical approval, we recruited patients \nand collected data from hospitals affiliated with the \nMinistry of Health in Amman. The nursing manager \nreceived a detailed explanation of the purpose of the \nstudy, and permission was requested to contact potential \nparticipants.\nSubsequently, a poster was hung on the wall of the \ngynecological clinic at each participating hospital to \nadvertise the study; the poster included the first research-\ner’s detailed contact information. Patients who contacted \nthe researchers were screened for eligibility, and those \nwho were eligible received a detailed explanation of the \nstudy’s purpose and were informed about their right to \nwithdraw from the study at any point without penalties. \nThen, in the hospital setting, each participant received \nthe study questionnaires and was asked to enclose them \nin the envelope provided and return them directly to the \nprimary researcher or to leave them in the reception area, \nwhere the researcher later collected them. The women \ncompleted the questionnaires in a private and quiet room \nat the clinic while waiting for their appointments with \ntheir physicians. This arrangement was made to ensure \ncomfort and confidentiality during data collection.\nStatistical analysis\nFor data analysis, the Statistical Package for Social Sci -\nences (SPSS) version 24 was utilized. Descriptive statis -\ntics summarized participants’ demographic, clinical, and \nsocioeconomic characteristics. Continuous variables \nwere reported as means and standard deviations (SD), \nwhile categorical variables were presented as frequen -\ncies and percentages (n, %). Pearson’s correlation coef -\nficient (r) was used to assess the strength and direction \nof relationships between continuous variables, and Point-\nBiserial Correlation (p.b.r.) was employed for dichoto -\nmous categorical variables, with significance levels set at \np < 0.05.\nA regression model was performed to identify pre -\ndictors of anxiety and stress among study participants. \nResults were reported using unstandardized coefficients \n(B), standardized coefficients (β), 95% confidence inter -\nvals (CI), and P values ( p < 0.05). Model fit was evaluated \nthrough R-squared (R²) and adjusted R-squared values.\nResults\nThe study sample consisted of 251 women, with an aver -\nage age of 43.69 years (SD = 7.14), ranging from 21 to 50 \nyears. Approximately 75% were married, 45.0% had com -\npleted secondary education, 46.2% had four or more chil-\ndren, and 34.3% were employed. The primary indications \nfor surgery were uterine fibroid (54.6%) and menorrhagia \n(34.3%). More details are depicted in Table 1.\nSexual difficulties reported by the study participants \npost-hysterectomy.\nFigure 1 shows the sexual difficulties reported by the \nstudy participants post-hysterectomy. Approximately \n60% reported a decrease in libido, 16.7% experienced \nsevere dryness, 5.6% experienced vaginitis, and 3.2% \n\nPage 5 of 10\nAl-amer et al. BMC Psychology          (2025) 13:305 \nreported vaginismus. These values were calculated based \non the available data.\nTable 2 illustrates that 22.3% reported having moder -\nate anxiety, 13.5 experienced severe levels of anxiety, and \n25.1% reported extremely severe anxiety (scores ≥ 20). \nRegarding stress, 40.2% reported mild levels, while \n37.5% and 7.6% experienced moderate to severe stress \nrespectively.\nTable  3 shows that many participants had moder -\nate levels of anxiety given the spread of scores across \nthe full range of the scale. The average stress score was \n19.5 (SD = 10.3), with a range of 5–42 indicating mod -\nerate stress levels. The BAS has a mean score of 26.2 \n(SD = 6.5), ranging from 14 to 46, suggesting mild over -\nall body appreciation. However, the range of body appre -\nciation scores suggests significant variability, indicating \nthat some participants were highly likely to experience \nlow levels of body appreciation. The mean score of the \nENRICHED Social Support Instrument (ESSI) was 21.6 \n(SD = 7.3), ranging from 8 to 34, indicating a generally \nhigh level of perceived social support among participants.\nTable  4 illustrates that there was a negative correla -\ntion between age and both anxiety ( r = -0.208, p = 0.001) \nand stress ( r=-0.259; p = 0.001) indicating that older par -\nticipants tend to have lower levels of anxiety and stress. \nThere is a strong positive correlation between stress and \nanxiety levels (r = 0.634, p = 0.001), highlighting that indi-\nviduals with higher anxiety also tend to experience higher \nstress. Body appreciation was negatively correlated with \nboth anxiety ( r = -0.581, p = 0.01), suggesting that higher \nbody appreciation was associated with lower anxiety and \nstress and that social support was negatively associated \nwith anxiety ( r = -0.336, p = 0.01). The number of chil -\ndren was negatively correlated with anxiety ( r = -0.235, \np = 0.001) and stress ( r = 0.218**, p = 0.001). More details \nare presented in Table 4.\nAs illustrated in Table 5, the multiple regression model \nwas statistically significant (F change = 79.762, df = 9, p < 0 \n001). This model explains around 75% of the variance in \ntotal anxiety score (adjusted R Square = 0.750). Further-\nmore, the table shows that the desire for more children \nand sexual problems were significant predictors of the \nlevels of anxiety (β = -4.066, p < 0 0.001) and (β = -1.071, \np = 0 0.037) respectively. Additionally, body appreciation \nlevels, the levels of stress, post-surgery duration, and \nsocial support predicted the levels of anxiety (β = 1.231, \np < 0 0.001), (β = 0.394, p < 0.001), (β = -1.966, p < 0 0.002), \nand (β = 15.936, p < 0.001), respectively.\nTable  6 shows that the regression model for stress \nwas statistically significant (F change = 24.42, df = 9, \np < 0 0.001), explaining 50.8% of the variance in stress \n(adjusted R Square = 0. 508). Anxiety levels (β = 0 0.189, \np < 0 0.001) and post-surgery duration (β = -2.113, \np < 0.021) significantly predicted stress. Additionally, the \ndesire for more children is associated with higher levels \nof stress (β = 1.581, p = 0.038).\nDiscussion and conclusions.\nThis study investigated the influence of hysterectomy \non anxiety, stress, body appreciation, and social support \namong women post-hysterectomy; and identified the \nTable 1 Demographic and clinical characteristics of study \nparticipants\nVariables n (%)\nAge, Mean (SD): 43.69 (7.14); Range: 21–50 years\nMarital Status\n Married 188 (74.90)\n Widow 34 (13.54)\n Divorce 12 (4.78)\n Single 17 (6.77)\nLevels of Education\n Primary 42 (16.73)\n Secondary 113 (45.01)\n Tertiary 96 (38.24)\nNumber of Alive Children\n No Children 35 (13.94)\n One Child 12 (4.78)\n Two Children 41 (16.33)\n Three Children 47 (18.72)\n ≥Four Children 116 (46.21)\nDesire for More Children\n Yes 61 (24.30)\n No 190 (75.96)\nWork Status\n Yes 86 (34.26)\n No 150 (59.76)\nPost-Surgery Duration\n 2-Month– 6 Month 158 (62.94)\n > 6 Month– 2 Years 93 (37.05)\nIndication for Surgery\n Uterine Fibroid 137 (54.58)\n Menorrhagia 86 (34.26)\n Dysfunctional Uterine Bleeding 20 (7.96)\nSexual Problem\n Yes 147 (58.56)\n No 38 (15.13)\nBody Mass Index (kg/m²)\n > 18.5 5 (1.99)\n 18.5–24.9 65 (25.89)\n 25–29.9 84 (33.46)\n ≥ 30 97 (36.64)\nFamily Income in Jordanian Dinar, JD\n < 500 168 (66.93)\n 500–1000 59 (23.50)\n > 1000 8 (3.18)\nNumber of participants (251)\nSD: Standard deviation; Body Mass Index was classified based on the WHO \ndefinition\nFamily income: Each Jordanian Dinar (JD) equals 1.41 US Dollars\nn (sample size) in this table was calculated based on the available data\n\nPage 6 of 10\nAl-amer et al. BMC Psychology          (2025) 13:305 \ndeterminants of anxiety and stress. The sample consisted \nof Jordanian women who had undergone hysterectomy \nfor benign conditions. The findings showed that women \nexperienced high levels of anxiety and stress, and mild \nbody appreciation. Women in this study reported good \nsocial support indicating adequate post-hysterectomy \nsupport. The intersection between these factors is cru -\ncial for understanding how a biological or somatic event \ncould influence the psychosocial aspects of women fol -\nlowing hysterectomy.\nA key finding of this study is that most of the study par-\nticipants experienced sexual difficulties, with decreased \nlibido being the most frequently reported one. A pos -\nsible explanation could be related to both physical and \npsychological aspects, including possible nerve dam -\nage and reduced pelvic blood flow, impairing sexual \nTable 2 Anxiety and stress levels among Jordanian women post-hysterectomy\nAnxiety Stress\nCategory: Range n (%) Category: Range: n (%)\nNo Anxiety: 0–7 80 (31.87) No Stress: 0–14 36 (14.34)\nMild Anxiety: 8–9 18 (7.17) Mild Stress: 15–18 101 (40.23)\nModerate Anxiety: 10–14 56 (22.31) Moderate Stress: 19–25 94 (37.45)\nSevere Anxiety: 15–19 34 (13.54) Severe Stress: 26–33 19 (7.56)\nExtremely Severe Anxiety: ≥20 63 (25.09) Extremely Severe: ≥34 1 (0.39)\nNumber of participants (251)\nTable 3 Characteristics of standardized measures\nStandardized Scales; Range: Mean (SD)\nAnxiety Subscale: 0–42 13.1 (9.5)\nStress Subscale: 5–42 19.5 (10.3)\nBody Appreciation Scale: 14–46 26.2 (6.5)\nENRICH Social Support Instrument (ESSI): 8–34 21.6 (7.3)\nSD: Standard Deviation\nTable 4 Correlation between anxiety, stress, and study-related \nvariables among Jordanian women post- hysterectomy\nVariable Anxiety Stress\nr p r p\nAge −0.208 0.001 -0.259 0.001\nStress Levels 0.634 0.001 1.000 1.000\nPost-Surgery Duration 0.847 0.001 0.485 0.001\nBody Appreciation Levels -0.581 0.010 -0.246 0.010\nSocial Support Levels 0.336 0.010 -0.216 0.010\nAnxiety Levels 1.000 1.000 0.634 0.001\np.b.r p p.b.r p\nWork Status 0.095 0.123 -0.003 0.959\nMarital Status -0.146 0.010 -0.077 0.225\nDesire for More Children 0.486 0.001 -0.385 0.001\nNumber of Children -0.235 0.001 -0.218 0.001\nFamily Income -0.039 0.535 -0.057 0.365\nSexual Difficulties -0.052 0.520 -0.146 0.021\nLevels of Education 0.083 0.190 0.053 0.407\np: p-value\nr: Pearson’s correlation coefficient\np.b.r: Point-biserial correlation coefficient (used where applicable)\n* Correlation is significant at the 0.05 level (2-tailed)\n** Correlation is significant at the 0.01 level (2-tailed)\nFig. 1 Percentage of study participants experiencing sexual difficulties after hysterectomy\n \n\nPage 7 of 10\nAl-amer et al. BMC Psychology          (2025) 13:305 \nresponse [ 12]. Hysterectomy can also alter the percep -\ntion of femininity and sexual identity and image issues \naffecting sexual desire [ 12]. However, evidence regarding \nsexual dysfunction post-hysterectomy is conflicting. For \nexample, some studies reported that decreased libido \nand sexual difficulties were common among women who \nhave undergone hysterectomy [ 10, 12], while another \nstudy reported positive health outcomes aside from sex -\nual function [ 20]. Conversely, a study found no signifi -\ncant association between hysterectomy and a reduction \nin sexual function in benign conditions [ 53]. The incon-\nsistencies in the literature regarding sexual dysfunction \npost-hysterectomy may be attributed to heterogeneity \namong studies. Variations in methodology, such as dif -\nferences in sample size, participant characteristics, and \nthe timing of assessments post-hysterectomy, are likely to \ncontribute to these conflicting findings. This inconclusive \nevidence contributes to a lack of counselling on sexual \nfunction following a hysterectomy [53].\nThe psychological impact of hysterectomy extends \nbeyond physical changes, particularly concerning body \nimage. Women’s perceptions of their body appearance \nfollowing hysterectomy can negatively affect their sexual \nidentity and confidence. Additionally, cultural factors \nplay a significant role; in some collectivist societies, a \nwoman’s sense of identity and self-worth is closely tied to \nher role as a mother, which may further exacerbate the \npsychological consequences of hysterectomy [37].\nIt is worth mentioning that the psychological effects of \nhysterectomy on sexual identity are further influenced by \ngendered expectations surrounding femininity and sexual \nhealth. To illustrate, a woman’s sexual identity is linked to \nher reproductive capacity; hence, losing this may lead to \nfeelings of diminished sexual desirability, loss of feminin -\nity, and low self-worth, particularly in collectivist cultures \nwhere motherhood is highly valued [12, 14, 15].\nIn addressing the psychological status among women \nwho have undergone hysterectomy, this study indicated \nthat more than one-third of the study subjects experi -\nenced severe to extremely severe anxiety, while around \n40% had moderate stress. Our results suggest mental \nhealth complexities among this cohort. Our findings \nshould be viewed considering the distinct nature of anxi -\nety and stress. Although anxiety and stress overlap, they \nare distinct psychological constructs. Anxiety involves \nongoing concerns about future events and uncertain -\nties, while stress arises from immediate demands that \nexceed the person’s resources at the same moment [ 54, \n55]. Hence, it is plausible that the loss of the reproductive \norgans complicates the psychological status of women. \nWe hypothesized that this could be exacerbated by cul -\nture. For example, in collectivist Arabic culture, infer -\ntile women could be subjected to diminished status and \nsocial exclusion, leading to high levels of anxiety and \nstress [25].\nIn line with our study, hysterectomy as a biological \nthreat has been reported to complicate the psychosocial \naspects of women’s lives [ 10]. Depression, anxiety, and \nstress were common post-hysterectomy [ 11, 12]. Devel -\noping countries with collectivist cultures, such as Egypt, \nPakistan, and Turkey also show that women experience \nelevated anxiety and depression before and after hyster -\nectomy [12, 14, 18, 19].\nSeveral factors influenced anxiety levels among \nthe study subjects, younger women and those with \nhigher stress exhibited more anxiety. The duration of \nTable 5 Predictors of anxiety among Jordanian women Post-Hysterectomy\nVariables B β t p 95.0% CI for B\nDesire for More Children −4.066 1.081 −0.185 −3.762 < 0.001 [− 6.195, − 1.937]\nSexual Problems −1.071 0.511 −0.077 −2.095 0.037 [− 2.077, − 0.064]\nBody Appreciation 1.231 0.095 0.656 12.993 < 0.001 [1.044, 1.417]\nStress 0.394 0.090 0.215 4.388 < 0.001 [0.217, 0.571]\nSocial Support −1.966 0.635 −0.114 −3.095 0.002 [− 3.217, − 0.715]\nPost-Surgery Duration −15.936 0.695 −0.813 −22.915 < 0.001 [− 17.306, − 14.566]\nMultiple Linear Regression; Model Summary: R² = 0.87, Adjusted R² = 0.75, Standard Error of the Estimate = 4.82, F = 79.76, df for F-statistics (F (9,251)\nB: Unstandardized Coefficients; β: Standardized Coefficients; CI: Confidence Interval; t: t-value; p: p-value\nDependent Variable: Anxiety. Number of participants: 251.\nTable 6 Predictors of stress among Jordanian women who underwent hysterectomy\nVariables B β t p 95.0% CI for B\nAnxiety Total 0.189 0.043 0.347 4.394 0.000 [0.104, − 0.274]\nA desire for More Children 1.581 0.758 0.132 2.087 0.038 [0.089, − 3.073]\nPost-Surgery Duration −2.113 0.911 −0.198 −2.320 0.021 [− 3.907, − 0.319]\n* Multiple Linear Regression; Model Summary: R Square: 0.530, Adjusted R Square: 0.508, Standard Error of the Estimate: 3.61, F Change: 24.42, df for F-statistics (F \n(9,251)\nB: Unstandardized Coefficients; β: Standardized Coefficients; CI: Confidence Interval; t: t-value; p: p-value\nDependent Variable: Stress\n\nPage 8 of 10\nAl-amer et al. BMC Psychology          (2025) 13:305 \npost-surgery played a role, with shorter time after sur -\ngery associated with higher stress, this could be due to \nemotional adjustment to uterine loss. For example, the \nassociation between a shorter post-surgery duration \nand increased stress may reflect a temporary adjustment \nphase during the early recovery period, rather than a last-\ning psychological effect. Over time, it is plausible that \nstress levels decrease as individuals adapt to their new \ncircumstances [56]. Our findings support previous stud -\nies showing anxiety and stress is common post-hyster -\nectomy, particularly among younger women [ 10, 14, 19]. \nDespite this significant correlation between age and anxi-\nety and stress, age was not a predictor of these psycho -\nlogical reactions in our study.\nThose who viewed their bodies more positively after \nsurgery were highly likely to have a lower level of anxiety \n[35, 36]. Our findings are consistent with other research \nindicating negative body image post-hysterectomy can \nlead to reduced self-confidence, poor body image, rela -\ntionship issues, sexual difficulties, and a decline in quality \nof life [15, 17].\nSocial support, viewed as the social factor in the BPS, \nemerged as a significant predictor of anxiety, with higher \nlevels of support resulting in lower levels of anxiety; sug -\ngesting that social support could balance the emotional \nimpact of losing the uterus. Marital status and the num -\nber of children also were equally significant factors in \nmitigating the negative psychological status post-hyster -\nectomy. A supportive husband and children can provide \ntimely support when needed. In addition to that, women \nwith more children might feel more secure despite the \ninability to have more. On the other hand, the inability \nto bear children added another layer of emotional stress, \nexacerbating anxiety and potentially worsening their psy-\nchological status. Our findings mirror the importance of \nsocial factors in mental health outcomes following a hys -\nterectomy [21, 57], consistent with the BPS model, which \nfocuses on the intersection between biological, psycho -\nlogical, and social factors.\nBeing fertile and post-surgery duration emerged as \nsignificant influencing factors for anxiety and stress. To \nillustrate, anxiety levels predict stress levels, indicating a \ndirect correlation between these two variables; although \nthese variables are distinct, they are related and intercon-\nnected. Hence, managing anxiety is a vital component \nof managing stress and vice versa. Women who desired \nmore children experienced higher levels of anxiety and \nstress. Thus, these results could be explained by a collec -\ntivist cultural norm where fertility is highly valued. The \ngap between personal ambition and the reality of post-\nhysterectomy infertility can significantly exacerbate anxi-\nety and stress [24].\nAs with many studies, using a cross-sectional design \nposes certain limitations. This approach captures data \nat a single point in time, which precludes the ability to \nestablish causation and limits the assessment of long-\nterm psychological consequences of hysterectomy. Addi -\ntionally, the cross-sectional design does not account for \npotential variations in psychological outcomes across dif-\nferent stages of recovery, such as the acute phase imme -\ndiately post-surgery versus the long-term phase (e.g., \nmore than 1–2 years post-surgery ). Therefore, the gen -\neralizability of the study findings should be approached \nwith caution. Furthermore, the lack of baseline data on \nstress, anxiety, perception of support, body appreciation \nlevels, and sexual problems before the study, may have \ninfluenced the interpretation of the findings. However, \nwe believe the results of our study are robust because \nthey are based on a large sample size. We have only \nincluded those who can read and write in Arabic; hence \nilliterate women’s input is not presented in this study. We \nhave only assessed the views of women in the collectiv -\nist society of one country. It would be valuable to expand \nthe study methodology to other collectivist countries and \neven to countries with a more individualistic perspective \nto improve understanding of women’s reactions to under-\ngoing hysterectomy for benign conditions.\nSupplementary Information\nThe online version contains supplementary material available at  h t t p  s : /  / d o i  . o  r \ng /  1 0 .  1 1 8 6  / s  4 0 3 5 9 - 0 2 5 - 0 2 6 2 3 - 1.\nSupplementary Material 1\nAcknowledgements\nThe authors acknowledged all the women who generously contributed their \ntime to participate in this study.\nAuthor contributions\nConceptualization: RA, AR, AA1Formal analysis: MYS, MA, MZMValidation of the \nanalysis: RA, AA1, WMO, AA2Methodology: RA, AA1Validation of the methods: \nSR, LH, WMOWriting, review and editing: RA, MA, MZM, AA1, LH, WMO, AA2, \nMYS, SRSupervision: SR.\nFunding\nThe authors receive no funding grant for this research.\nData availability\nThe data that supports the findings of this study are available from the first \nauthors upon request.\nDeclarations\nEthics approval and consent to participate\nThe study received ethical approval from the Isra University Institutional \nReview Board under approval number SREC/22/12/070, and we received \napproval from the MOH ethics committee and conducted in accordance \nwith the Declaration of Helsinki. All participants provided informed consent, \nensuring they understood the purpose, procedures, and voluntary nature of \nparticipation. participants in the study.\nConsent for publication\nNot applicable.\n\nPage 9 of 10\nAl-amer et al. BMC Psychology          (2025) 13:305 \nCompeting interest\nThe authors declare no conflicts of interest exist.\nReceived: 24 October 2024 / Accepted: 17 March 2025\nReferences\n1. Chaudhary AN, et al. A clinicopathological patterns in hysterectomies in a \nmedical college in Eastern Nepal. Nepal Journal of Obstetrics & Gynaecology; \n2022.\n2. Neis KJ, et al. Hysterectomy for benign uterine disease. Deutsches Ärzteblatt \nInternational. 2016;113(14):242.\n3. Saad A, Robert M, Ahmed H. Impact of hysterectomy on uterine cancer \nincidence rates in Egypt. Obstet Gynecol Int J. 2021;12(1):34–8.\n4. Rout D, et al. Prevalence and determinants of hysterectomy in India. Sci Rep. \n2023;13(1):14569.\n5. Qatawneh A, et al. Emergency peripartum hysterectomy at Jordan university \nhospital–a teaching hospital experience. Menopause Review/Przegląd Meno-\npauzalny. 2020;19(2):66–71.\n6. Rawashdeh H, Obeidat R, Masaadeh L. Emergency peripartum hysterectomy \nin a tertiary teaching hospital in Northern Jordan: a 15-year review. Gynecol \nSurg. 2021;18(1):1.\n7. Zhang TR, et al. Pilot test of A Gender-conscious sexual health intake ques-\ntionnaire: increasing inclusivity and mitigating bias in sexual history taking. \nVolume 12. Plastic and Reconstructive Surgery–Global Open; 2024. p. e5614. \n4.\n8. Morgan DM, et al. Nationwide trends in the utilization of and payments for \nhysterectomy in the united States among commercially insured women. Am \nJ Obstet Gynecol. 2018;218(4):425. e1-425. e18.\n9. Shekhar C, Paswan B, Singh A. Prevalence, sociodemographic determinants \nand self-reported reasons for hysterectomy in India. Reproductive Health. \n2019;16:1–16.\n10. Malyam V, et al. Quality of life, sexual satisfaction and psychiatric co-morbidity \nin women posted for hysterectomy. J Evol Med Dent Sci. 2018;7(26):2989–94.\n11. Li N, et al. The real experience with women’s hysterectomy: A meta-synthesis \nof qualitative research evidence. Nurs Open. 2023;10(2):435–49.\n12. Saleh Hassan S, Abd Elhady H, Fathy N. Relation between sexual function, \nbody image and depression among women undergoing total versus partial \nhysterectomy. Egypt J Health Care. 2022;13(4):1682–96.\n13. Reich H, et al. Laparoscopic myomectomy: an alternative to laparotomy \nmyomectomy or hysterectomy? Gynaecol Endoscopy. 1997;6(1):7–12.\n14. Erdoğan E, et al. Effect of psychological care given to the women who under-\nwent hysterectomy before and after the surgery on depressive symptoms, \nanxiety and the body image levels. J Obstet Gynaecol. 2020;40(7):981–7.\n15. Malyam V, Gopalkrishna V, Tarikere S. Anxiety and psychological aspects of \nhysterectomy-A prospective study. Int J Indian Psychȯlogy, 2020. 8(2).\n16. Choi HG, et al. Association between hysterectomy and depression: a \nlongitudinal follow-up study using a National sample cohort. Menopause. \n2020;27(5):543–9.\n17. Khalifa Omar H, Barakat MM. Nabawy Abo Zeid, Relation between body image, \nSelf-esteem and quality of life among women after hysterectomy. J Nurs Sci \nBenha Univ. 2024;5(2):817–32.\n18. Khan S, et al. Depression and anxiety post total abdominal hysterectomy with \nbilateral salpingo-oophorectomy. Prof Med J. 2020;27(02):217–24.\n19. Elweley M, Sabra AI. Psychological problems, concerns and beliefs in women \nundergoing hysterectomy. IOSR J Nurs Health Sci. 2015;4(6):48–57.\n20. Elsaied HE, et al. Effect of uterine fibroid on women’s health related quality of \nlife and nursing management for patients undergoing hysterectomy. Assiut \nSci Nurs J. 2020;8(2000):12–27.\n21. Verma RK, Ansari S. Anxiety and psychological aspect of hysterectomy \npatients. NeuroQuantology. 2022;20(4):1492.\n22. Alshawish E, Qadous S, Yamani MA. Experience of Palestinian women after \nhysterectomy using a descriptive phenomenological study. Open Nurs J, \n2020. 14(1).\n23. Darwish M, Atlantis E, Mohamed-Taysir T. Psychological outcomes after \nhysterectomy for benign conditions: a systematic review and meta-analysis. \nEur J Obstet Gynecol Reproductive Biology. 2014;174:5–19.\n24. Helmy YA, et al. Psychiatric morbidity following hysterectomy in Egypt. Int J \nGynecol Obstet. 2008;102(1):60–4.\n25. Sexty RE, et al. Cross-cultural comparison of fertility specific quality of life in \nGerman, Hungarian and Jordanian couples attending a fertility center. Health \nQual Life Outcomes. 2016;14:1–8.\n26. Hamdan Z. Perceptions of Infertility among Arab Women in the US. 2016.\n27. Nydell MK. Understanding Arabs: A guide for modern times. Hachette UK; \n2018.\n28. Hussein S, Ismail M. Ageing and elderly care in the Arab region: policy chal-\nlenges and opportunities. Ageing Int. 2017;42:274–89.\n29. Al-Krenawi A. Polygamous marriages: An arab-islamic perspective. Couple \nrelationships in a global context: Understanding love and intimacy across \ncultures, 2020: pp. 193–205.\n30. Hasanpoor-Azghdy SB, Simbar M, Vedadhir A. The social consequences \nof infertility among Iranian women: a qualitative study. Int J Fertility Steril. \n2015;8(4):409.\n31. Sandelowski M. With child in Mind: studies of the personal encounter with \ninfertility. University of Pennsylvania; 2016.\n32. Kazemi F, Alimoradi Z, Tavakolian S. Effect of hysterectomy due to benign \ndiseases on female sexual function: a systematic review and meta-analysis. J \nMinim Invasive Gynecol. 2022;29(4):476–88.\n33. Taukeni SG, Mathwasa J, Ntshuntshe Z. Biopsychosocial Model, in Acceleration \nof the Biopsychosocial Model in Public Health. 2023, IGI Global. pp. 1–26.\n34. Rasmieh A-A, et al. Prevalence of depression and its influence on the \nquality of life of Jordanians living in residential care facilities. J Nurs Res. \n2019;27(6):e54.\n35. Mwangi PM. Biopsychosocial effects of cancer treatment on sexual health \namong cancer survivors at Kenyatta National hospital. University of Nairobi; \n2023.\n36. Rossi V, et al. Endometriosis and sexual functioning: how much do cogni-\ntive and psycho-emotional factors matter? Int J Environ Res Public Health. \n2022;19(9):5319.\n37. Al-Amer RM, Malak MZ, Darwish MM. Self-esteem, stress, and depressive \nsymptoms among Jordanian pregnant women: social support as a mediating \nfactor. Women Health. 2022;62(5):412–20.\n38. Yehia DBM, et al. Psychosocial factors correlate with fatigue among pregnant \nwomen in Jordan. Perspect Psychiatr Care. 2020;56(1):46–53.\n39. Saleh S, Fram K, Sumrein I. Indications for a hysterectomy at Jordan university \nhospital; a teaching hospital experience. Jordan Med J, 2013. 47(3).\n40. Madueke-Laveaux OS, Elsharoud A, Al-Hendy A. What we know about the \nlong-term risks of hysterectomy for benign indication—a systematic review. J \nClin Med. 2021;10(22):5335.\n41. The Department of Statistics of Jordan (DoS). Jordan In Fig. 2019. 2019 [cited \n2025 21 Jan]; Available from:  h t t p s :   /  / d o s w e   b .  d o  s  . g  o  v .   j o /  p r o  d  u c  t /  j o r  d a  n - i n - fi   g \nu r e 2 0 1 9 /\n42. Lovibond PF. Long-term stability of depression, anxiety, and stress syndromes. \nJ Abnorm Psychol. 1998;107(3):520.\n43. Moussa MT, et al. Psychometric properties of an Arabic version of the depres-\nsion anxiety stress scales (DASS). Res Social Work Pract. 2017;27(3):375–86.\n44. Moussa MT, Lovibond PF, Laube R. Psychometric properties of a Chinese version \nof the 21-item depression anxiety stress scales (DASS21). Sydney, NSW: Transcul-\ntural Mental Health Centre. Cumberland Hospital, 2001.\n45. Mitchell PH, et al. A short social support measure for patients recovering from \nmyocardial infarction: the ENRICHD social support inventory. J Cardiopulm \nRehabil Prev. 2003;23(6):398–403.\n46. Al-Amer R. Depression and self-care in Jordanian adults with diabetes: the \nPOISE study. University of Western Sydney (Australia); 2015.\n47. Vally Z, et al. The factor structure and psychometric properties of an Arabic-\ntranslated version of the body appreciation Scale‐2. Perspect Psychiatr Care. \n2019;55(3):373–7.\n48. Yen J-Y, et al. Risk factors for major depressive disorder and the psychologi-\ncal impact of hysterectomy: a prospective investigation. Psychosomatics. \n2008;49(2):137–42.\n49. Dwekat E, et al. Prevalence and correlates of depression and anxiety among \nJordanian adolescents: a cross-sectional study. Volume 55. Youth & Society; \n2023. pp. 103–21. 1.\n50. Al-Amer R et al. Prevalence of stress and types of coping strategies among \nadolescents (14–18 years) in collectivist communities. J Pediatr Nurs, 2024.\n51. Kocalevent R-D, et al. Social support in the general population: standardiza-\ntion of the Oslo social support scale (OSSS-3). BMC Psychol. 2018;6:1–8.\n52. Fekih-Romdhane F, et al. Psychometric properties of an Arabic translation of \nthe body appreciation scale (BAS-2) and its short forms (BAS-2SF) in a com-\nmunity sample of Lebanese adults. J Eat Disorders. 2023;11(1):160.\n\nPage 10 of 10\nAl-amer et al. BMC Psychology          (2025) 13:305 \n53. Dedden SJ, et al. Hysterectomy and sexual function: a systematic review and \nmeta-analysis. J Sex Med. 2023;20(4):447–66.\n54. Berenskoetter F. Anxiety, time, and agency. Int Theory. 2020;12(2):273–90.\n55. Kumar R. Essentials of psychiatry and mental health nursing. Elsevier India; \n2020.\n56. Goudarzi F, et al. Iranian women’s self-concept after hysterectomy: A qualita-\ntive study. Iran J Nurs Midwifery Res. 2021;26(3):230–7.\n57. Afiyah RK, et al. Recovery time period and quality of life after hysterectomy. J \nPublic Health Res. 2020;9(2):pjphr20201837.\nPublisher’s note\nSpringer Nature remains neutral with regard to jurisdictional claims in \npublished maps and institutional affiliations.","source_license":"CC0","license_restricted":false}