The relationship between stress, anxiety and depression with sexual function among women with premature ovarian insufficiency in the West of Iran.

The qualitative variable of the demographic characteristics of the patients are shown in Table  1 .Menstrual status showed significant disruption, with 60.83% not experiencing menstruation, likely due to infertility treatments or menopause, and 35.83% reporting irregular cycles. Table 1 Qualitative variables of the demographic characteristics of the patients Variable N Percent Education Primary 44 18.33% High school 80 33.33% Diploma 77 32.08% University education 39 16.25% Occupation House maker 202 84.17% Employee 38 15.83% Economic Situation Middle-income 177 73.75% Low-income 63 26.25% Housing Situation Mortgage/rent 171 71.25% Private home 47 19.58% Living with relatives 22 9.17% Consanguineous Marriage Yes (consanguineous) 35 14.58% No 205 85.42% Family History of Infertility Yes 50 20.83% No 190 79.17% Menstrual Status Regular 8 3.33% Irregular 86 35.83% No menstruation 146 60.83% Qualitative variables of the demographic characteristics of the patients Quantitative variables of the demographic variables and hormonal parameters of the patients are presented in Table  2 . The participants averaged 34.02 years (± 4.16) with spouses aged 37.03 (± 3.73). The mean BMI was 25.78 (± 5.00), and reproductive markers indicated diminished ovarian reserve (AMH: 0.76 ± 0.80 ng/mL; FSH: 52.93 ± 18.57 mIU/mL). Hormonal profiles showed elevated prolactin (25.96 ± 9.72 ng/mL) and LH (31.34 ± 9.40 mIU/mL), while infertility and treatment durations averaged 3.09 (± 1.34) and 2.56 (± 1.29) years, respectively. Menarche occurred at 12.26 (± 1.09) years, with broad hormonal variability (e.g., E2: 99.24 ± 87.17 pg/mL; DHEA-S: 205.51 ± 87.39 µg/dL). Table 2 Quantitative variables of the demographic variables and hormonal parameters of the patients Variable Mean ± SD* Range (Min–Max) Age (years) 34.02 ± 4.16 22–40 BMI (kg/m²) 25.78 ± 5.00 16.56–37.9 Spouse Age (years) 37.03 ± 3.73 25–46 Marriage Duration (years) 4.43 ± 1.42 2–7 Infertility Duration (years) 3.09 ± 1.34 1–6 Treatment Duration (years) 2.56 ± 1.29 1–6 Menarche Age (years) 12.26 ± 1.09 9–15 Hormonal Parameters  Estradiol (E2, pg/mL) 99.24 ± 87.17 16–345  DHEA-S (µg/dL) 205.51 ± 87.39 29–450  AMH (ng/mL) 0.76 ± 0.80 0.01–3.5  FSH (mIU/mL) 52.93 ± 18.57 20–96  Prolactin (PRL, ng/mL) 25.96 ± 9.72 5–45  TSH (µIU/mL) 2.72 ± 1.58 0.2–6.8  LH (mIU/mL) 31.34 ± 9.40 1–70 *Standard deviation Quantitative variables of the demographic variables and hormonal parameters of the patients *Standard deviation Table  3 summarizes descriptive statistics for mental health variables (depression, anxiety, and stress) and FSFI domains in a sample of 240 participants. Mental health scores cluster near mid-range (depression: 15.51 ± 2.82; anxiety: 15.18 ± 2.60; stress: 15.05 ± 2.69), suggesting moderate symptom levels, while FSFI domains (desire, arousal, lubrication, orgasm, satisfaction, pain) show low means (2.52–2.64), well below their scale midpoints, indicating impaired sexual function. Table 3 Descriptive statistics of mental health and female sexual function index (FSFI) domains Variable N Mean SD* Minimum Maximum Mental health domains Depression 240 15.51 2.82 9 21 Anxiety 240 15.18 2.60 9 21 Stress 240 15.05 2.69 8 21 Total 240 45.73 6.73 29 61 FSFI domains Desire 240 2.54 0.85 1.2 4.8 Arousal 240 2.59 0.78 1.2 4.8 Lubrication 240 2.52 0.72 1.2 4.5 Orgasm 240 2.62 0.80 1.2 4.8 Satisfaction 240 2.62 0.83 1.2 4.8 Pain 240 2.64 0.79 1.2 4.8 Total FSFI 240 15.53 3.93 10.4 26.3 *Standard deviation Descriptive statistics of mental health and female sexual function index (FSFI) domains *Standard deviation The correlation table reveals significant associations between demographic factors, mental health, and sexual function: age and spouse age show a strong positive correlation (0.74), while infertility and treatment durations are linked to reduced sexual function (negative correlations up to −0.34) and heightened depression/anxiety (positive correlations up to 0.30). Depression, anxiety, and stress exhibit strong inter-correlations (0.48–0.57) and robust inverse correlations with all sexual function domains (negative correlations up to −0.65). Components of the FSFI questionnaire (e.g., desire, arousal, satisfaction) demonstrate high correlations (0.57–0.85) (Table  4 ). Table 4 Correlation of demographic variables, mental health, and female sexual function index (FSFI) domains a Variable Age BMI Marriage_Duration Infertility_Duration Depression Anxiety Stress Desire Arousal Lubrication Orgasm Satisfaction Pain Total FSFI Age 1.00 −0.02 −0.13* −0.15* −0.03 −0.08 −0.01 0.06 0.09 0.07 0.10 0.09 0.04 0.09 BMI −0.02 1.00 0.01 −0.04 −0.12 −0.19** −0.13* 0.11 0.08 0.12 0.05 0.05 0.12 0.11 Marriage_Duration −0.13* 0.01 1.00 0.74*** 0.01 0.04 0.04 −0.03 0.04 0.08 0.07 0.09 0.05 0.06 Infertility_Duration −0.15* −0.04 0.74*** 1.00 0.28*** 0.27*** 0.30*** −0.30*** −0.28*** −0.27*** −0.30*** −0.25*** −0.29*** −0.34*** Depression −0.03 −0.12 0.01 0.28*** 1.00 0.54*** 0.57*** −0.48*** −0.55*** −0.57*** −0.56*** −0.49*** −0.56*** −0.65*** Anxiety −0.08 −0.19** 0.04 0.27*** 0.54*** 1.00 0.48*** −0.40*** −0.50*** −0.48*** −0.49*** −0.49*** −0.47*** −0.57*** Stress −0.01 −0.13* 0.04 0.30*** 0.57*** 0.48*** 1.00 −0.51*** −0.55*** −0.49*** −0.50*** −0.47*** −0.56*** −0.62*** Desire 0.06 0.11 −0.03 −0.30*** −0.48*** −0.40*** −0.51*** 1.00 0.63*** 0.59*** 0.57*** 0.57*** 0.54*** 0.79*** Arousal 0.09 0.08 0.04 −0.28*** −0.55*** −0.50*** −0.55*** 0.63*** 1.00 0.70*** 0.63*** 0.62*** 0.63*** 0.85*** Lubrication 0.07 0.12 0.08 −0.27*** −0.57*** −0.48*** −0.49*** 0.59*** 0.70*** 1.00 0.62*** 0.66*** 0.61*** 0.83*** Orgasm 0.10 0.05 0.07 −0.30*** −0.56*** −0.49*** −0.50*** 0.57*** 0.63*** 0.62*** 1.00 0.63*** 0.67*** 0.83*** Satisfaction 0.09 0.05 0.09 −0.25*** −0.49*** −0.49*** −0.47*** 0.57*** 0.62*** 0.66*** 0.63*** 1.00 0.62*** 0.83*** Pain 0.04 0.12 0.05 −0.29*** −0.56*** −0.47*** −0.56*** 0.54*** 0.63*** 0.61*** 0.67*** 0.62*** 1.00 0.82*** Total FSFI 0.09 0.11 0.06 −0.34*** −0.65*** −0.57*** −0.62*** 0.79*** 0.85*** 0.83*** 0.83*** 0.83*** 0.82*** 1.00 a Pearson’s correlation coefficient * p -value < 0.05  ** p -value < 0.01 *** p -value < 0.001 Correlation of demographic variables, mental health, and female sexual function index (FSFI) domains a a Pearson’s correlation coefficient * p -value < 0.05 ** p -value < 0.01 *** p -value < 0.001 Table  5 indicates that among the categorical variables analyzed, only economic status (mean FSFI score: 14.55 for low-incomevs. 15.87 for middle-income, p  = 0.02) and family history of infertility (mean FSFI: 14.24 with history vs. 15.86 without, p  = 0.009) show statistically significant associations with total sexual function. Other variables (education, occupation, housing, consanguineous marriage, menstrual status) demonstrated no significant differences.The analysis of total mental health scores across categorical variables revealed that family history of infertility showed a statistically significant association ( p  = 0.009), with individuals reporting a family history scoring higher (Mean = 47.94, SD = 5.68) compared to those without (Mean = 45.15, SD = 6.87)(Table  6 ). Table 5 Total female sexual function index (FSFI) score by categorical variables Variable Mean (Total FSFI) SD p -value Education Primary 15.79 3.99 0.69* High school 15.83 4.20 Diploma 15.14 3.77 University 15.36 3.66 Occupation House maker 15.45 3.94 0.48** Employee 15.94 3.89 Spouse Education Primary 15.43 3.98 0.99* High school 15.60 4.10 Diploma 15.53 3.94 University 15.42 3.47 Spouse Occupation Unemployed 15.53 4.72 0.99* Self-employed 15.48 3.87 Employee 15.77 3.95 Manual worker 15.53 3.90 Economic Situation Middle-income 15.87 4.03 0.02** Low-income 14.55 3.47 Housing Situation Mortgage/Rent 15.72 4.11 0.44* Private Home 14.91 3.24 Living with Relatives 15.30 3.84 Consanguineous Marriage Yes 14.81 3.87 0.25** No 15.65 3.94 Family History of Infertility Yes 14.24 3.05 0.009** No 15.86 4.07 Menstrual Status Regular 12.78 1.29 0.11* Irregular 15.42 3.96 No Menstruation 15.74 3.96 * One-way analysis of variance (ANOVA) **T-test Total female sexual function index (FSFI) score by categorical variables * One-way analysis of variance (ANOVA) **T-test Table 6 Total mental health score by categorical variables Variable Mean SD p -value Education Primary 44.77 6.80 0.07* High school 44.55 6.74 Diploma 47.00 6.01 University 46.74 7.57 Occupation House maker 45.76 6.52 0.89** Employee 45.61 7.83 Spouse Education Primary 45.02 6.40 0.50* High school 45.63 6.91 Diploma 45.60 7.00 University 47.30 6.10 Spouse Occupation Unemployed 44.53 6.01 0.33* Self-employed 45.85 6.71 Employee 47.48 6.41 Manual worker 44.67 7.27 Economic Situation Middle-income 45.49 6.76 0.34** Low-income 46.43 6.64 Housing Situation Mortgage/Rent 45.20 6.93 0.09* Private Home 47.60 5.25 Living with Relatives 45.86 7.45 Consanguineous Marriage Yes 47.17 6.77 0.17** No 45.49 6.70 Family History of Infertility Yes 47.94 5.68 0.009** No 45.15 6.87 Menstrual Status Regular 49.25 4.43 0.32* Irregular 45.55 6.58 No Menstruation 45.65 6.90 * One-way analysis of variance (ANOVA) ** T-test Total mental health score by categorical variables * One-way analysis of variance (ANOVA) ** T-test

This cross-sectional study was conducted on 240 women between December 2023 and April 2025. Eligible participants were women diagnosed with POI who were undergoing infertility treatment at the Fatemieh Infertility Center, a referral hospital located in Hamadan province, western Iran. Given the sensitive nature of assessing sexual function alongside psychological variables such as stress, anxiety, and depression, particularly within the cultural context of Western Iran, special attention was paid to ethical protocols throughout the study. Prior to data collection, the research protocol was reviewed and approved by the Ethical Committee of Hamadan University of Medical Sciences (approval code: IR.UMSHA.REC.1402.464), ensuring compliance with national and international ethical standards for human subject research.Informed consent was obtained from all participants after providing detailed explanations about the study’s objectives, procedures, confidentiality safeguards, and their right to withdraw at any time without any repercussions. To preserve privacy and encourage honest responses, questionnaires were self-administered in private settings, with trained female research assistant available to clarify any questions. All data were anonymized, and identifying information was securely stored separately from survey responses.Furthermore, participants were assured that their information would be treated with strict confidentiality and would be used solely for research purposes. Given potential cultural sensitivities around discussing sexual health, care was taken to use culturally appropriate language and to ensure psychological support resources were available if any participant experienced distress during or after participation. Participants were eligible for inclusion if they met the following criteria: willingness to participate in the study; residency in Hamadan; age between 20 and 40 years; currently married and living stably with their spouse; spouse not engaged in a polygamous relationship; confirmed diagnosis of POI indicated by reduced ovarian size and volume via transvaginal ultrasound, elevated follicle-stimulating hormone (FSH), and decreased anti-Müllerian hormone (AMH) levels outside the normal range based on test cut-offs; no diagnosed mental illness or history of psychiatric hospitalization based on self-report; no addiction to cigarettes or drugs; no adverse life events within the past month; and absence of underlying fertility-related conditions such as polycystic ovary syndrome (PCOS) or endometriosis, as documented in the patient’s medical records.The exclusion criterion was incomplete completion of the study questionnaires. A review of the existing literature revealed no studies with a similar focus; therefore, a pilot study was conducted involving 25 women who met the inclusion criteria. In the pilot study, the correlation between anxiety scores and sexual function was found to be 0.18. Based on this correlation, with a statistical power of 80% and a type I error rate of 0.05, the required sample size was calculated to be 240 women. The participants were selected by convenience sampling method until the sample size was reached. To recruit participants, one of the researchers (S.J.) approached women diagnosed with POI who were undergoing infertility treatment at the Fatemieh Infertility Center. The evaluation of inclusion and exclusion criteria were checked after selecting the samples. The aims of the study were explained in detail. Eligible women who provided informed consent then completed the questionnaires, and relevant laboratory data were extracted from their medical records. A researcher-developed questionnaire was used to collect maternal and demographic information, including BMI (kg/m²), the participant’s age, spouse’s age, education level of both partners, consanguineous marriage, menstrual status, family history of infertility, occupational status of both partners, and family economic status (Low-income: 300 million rials/month). Additionally, laboratory values for Estradiol, Follicle-stimulating hormone (FSH), Anti-Müllerian Hormone (AMH), Dehydroepiandrosterone sulfate (DHEA-S), Estradiol (E2), Luteinizing Hormone (LH), Thyroid Stimulating Hormone (TSH), and Prolactin were extracted from participants’ medical records. The DASS-21 questionnaire, developed by Lovibond et al. [ 15 ], consists of 21 items divided into three subscales: depression (7 items), anxiety (7 items), and stress (7 items). Responses are rated on a four-point Likert scale ranging from 0 (“does not apply to me at all”) to 3 (“applies to me very much”).The psychometric properties of the DASS-21 questionnaire in Iran were evaluated by Kakemam et al. (2022). In their study, the Cronbach’s alpha coefficients demonstrated acceptable internal consistency for anxiety (0.79), stress (0.91), and depression (0.93). The intraclass correlation coefficients (ICCs) for all subscales ranged from 0.75 to 0.86, indicating satisfactory test–retest reliability [ 16 ]. The FSFI is a self-report scale consisting of 19 items designed to assess various dimensions of sexual functioning in women over the past month. The questionnaire includes six domains: desire (2 items), subjective arousal (4 items), lubrication (4 items), orgasm (3 items), satisfaction (3 items), and pain (3 items). The total score ranges from a minimum of 2 to a maximum of 36, with higher scores indicating better sexual function, and lower scores indicating no sexual activity in the past month [ 17 , 18 ].The FSFI has been validated in Iran by Mohammadi et al. [ 19 ], who defined sexual dysfunction as a total FSFI score of less than 28. Descriptive statistics, including mean and standard deviation for quantitative variables, and frequency and percentage for qualitative variables, were used to describe the study population. The relationship between sexual function scores and stress, anxiety, and depression, across various demographic variables, was assessed using t-tests and one-way analysis of variance (ANOVA). Pearson’s correlation coefficient was used to evaluate the correlation between sexual function scores and stress, anxiety, and depression. All statistical analyses were conducted using Stata software (version 14; StataCorp LLC, College Station, TX, USA), with a significance level of 0.05 set for all p-values.

The findings of this study reveal significant positive relationship among depression, anxiety, and stress, alongside strong inverse relationships between these psychological factors and all domains of sexual function in women with POI. Among the categorical variables assessed, economic status and family history of infertility were significantly associated with overall sexual function, with lower sexual function scores observed in women with lower economic status and those reporting a family history of infertility. These results highlight the critical importance of addressing mental health and familial factors in the holistic management of sexual health in women with POI. To provide comprehensive and effective care, healthcare providers should adopt evidence-based approaches that include psychological and emotional support, sexual health management, and counseling on fertility and family-building.

The findings of this study revealed that depression, anxiety, and stress are significantly and inversely associated with all dimensions of sexual function in women with POI. This highlights the critical role of mental health in shaping sexual function in this population, suggesting that hormonal or physical treatments alone may be insufficient to address their complex needs. Furthermore, the study demonstrated strong inter-correlations among stress, anxiety, and depression, indicating that these conditions often co-occur and may function as components of a broader psychological syndrome affecting sexual experiences in women with POI. The results also showed that increases in the severity of any of these three psychological variables were associated with decreases across all subscales of sexual function. This negative association underscores the substantial impact of psychological factors not only on sexual desire but also on physical and emotional aspects of sexual experience. While POI is characterized by disrupted secretion of estrogen and other sex hormones leading to issues such as reduced libido, vaginal dryness, and difficulties with orgasm the prominent role of psychological disturbances alongside physiological factors underscores the multidimensional and complex nature of sexual function [ 20 ]. From a psychological perspective, it is important to recognize that women experiencing POI often face challenges such as a sense of failure in fulfilling the maternal role, diminished self-esteem, body shame, negative body image, feelings of premature aging, and social pressure [ 10 ]. These issues frequently go unaddressed, gradually leading to anxiety and depressive disorders, which ultimately impair the quality of sexual and marital relationships [ 21 ].A systematic review and meta-analysis revealed that women with POI are at significantly higher risk for anxiety and depression. Subgroup analyses further supported this elevated vulnerability. Consequently, early psychosocial assessment and regular mental health screening for women with POI are essential components of comprehensive care [ 8 ]. A study by de Almeida et al. (2011) demonstrated that women with POI exhibit higher levels of anxiety and depression compared to their healthy counterparts. Domain-specific analysis revealed that sexual desire was the only domain without a statistically significant difference between the two groups. However, scores for arousal, orgasm, satisfaction, and pain were significantly lower in the POI group compared to controls. Furthermore, POI increased the risk of sexual dysfunction by approximately 2.8 times [ 22 ]. Our study aligns with these findings and underscores that treatment for POI should extend beyond physiological interventions to also address psychological and social dimensions. Similarly, Javadpour et al. (2021) reported that women with POI demonstrate poorer outcomes than control groups across all domains of sexual function and quality of life [ 4 ], consistent with the present research. Within the cultural context of Iran, challenges associated with POIsuch as concerns about premature bodily aging, social pressure to conceive, and lack of mental health supportoften remain unaddressed. This environment fosters the development or exacerbation of anxiety and depression, which in turn leads to diminished sexual function. However, in a study by Ates et al. (2022) aimed at examining sleep disorders, anxiety levels, depression, and fatigue in women with POI, it was found that depression was significantly more prevalent and severe in women with POI, whereas there was no significant difference in overall anxiety scores or anxiety severity between the groups [ 21 ].Although the findings of this study align with several previous investigations highlighting the negative impact of psychological disorders on sexual function in women with POI, some other studies have reported differing or even contradictory results.One study on women with POI reported that, for most patients, POI negatively affected their sexual relationship. Due to hormonal changes, these women experienced sexual dysfunctions such as dyspareunia and decreased libido. Conversely, a subset of patients reported that POI had no effect on their sexual desire. This research suggests that the impact of POI on sexual function is not uniformly negative and, in some individuals, sexual function may remain unchanged [ 23 ]. Montazeri et al. (2024) demonstrated that sexual function in women with primary ovarian insufficiency (POI) is influenced not only by psychological factors but also by their desire for pregnancy and the type of pregnancy they have experienced. This study highlights that while psychological factors are important, they are not the sole determinants; cultural and social contexts must also be considered [ 24 ].Furthermore, these findings carry significant clinical implications. In the Iranian healthcare setting, the primary focus tends to be on pharmacological treatments or hormone replacement therapy, while the role of psychologists or sexual counselors is often overlooked [ 12 ]. This study cautions that without addressing psychological issues, full improvement in sexual function cannot be expected. Indeed, sexual function reflects mental health, the quality of marital relationships, and body image, and should not be confined solely to biological variables. The limitations of this study should be carefully considered when interpreting the results. The cross-sectional design restricts the ability to draw causal conclusions regarding the relationships between stress, anxiety, depression, and sexual function. Therefore, while associations were observed, it is not possible to determine the directionality or causality of these relationships. Additionally, the reliance on self-reported data introduces the possibility of social desirability bias, especially given the sensitive nature of sexual health topics within the cultural context of Western Iran. Participants may have underreported symptoms or distress to conform to social norms, which could lead to an underestimation of the true prevalence and severity of psychological distress and sexual dysfunction. Moreover, unmeasured factors such as marital relationship quality, partner satisfaction, religious beliefs, and sexual education, known to influence sexual function, were not controlled for and may confound the observed associations. Future longitudinal studies with more comprehensive assessments are warranted to better elucidate these complex relationships.

Premature ovarian insufficiency (POI) is characterized by impaired ovarian function occurring before the age of 40, defined by oligo/amenorrhea lasting at least four months and elevated follicle-stimulating hormone (FSH) levels greater than 25 IU/L on two separate occasions, at least four weeks apart [ 1 ]. In 2019, the global prevalence of POI was estimated at 3.7%, while in Iran, it has been reported to range from 3.2% to 5.9% [ 2 ]. POI results in a hypoestrogenic–hypergonadotropic state, leading to irregular menstruation, vasomotor symptoms, dyspareunia, infertility, osteoporosis, and increased risk of endocrine and cardiovascular disorders. These short- and long-term complications pose significant threats to women’s sexual and reproductive health. Reproductive health encompasses physical, mental, and social well-being in all aspects related to the reproductive system [ 3 ]. Studies exploring the lived experiences of women with POI have revealed feelings of depression, sadness, and resignation. Furthermore, evidence indicates that anxiety and depression can substantially contribute to sexual dysfunction by affecting mood, sexual desire, and physiological sexual responses [ 4 ]. Sexual function is a key component of women’s quality of life and is influenced by a wide range of physiological, psychological, social, and cultural factors [ 5 ]. Women with POI may experience symptoms such as decreased libido, vaginal dryness, dyspareunia, and reduced sexual satisfaction due to diminished levels of estrogen and androgens [ 6 ]. However, sexual function is not solely determined by physiological factors; psychological variables also play a crucial role in this domain [ 7 ]. Stress, anxiety, and depression are common psychological problems, particularly among women affected by chronic illnesses or fertility-related disorders [ 8 ]. Studies have shown that POI can have profound psychological consequences, including a sense of lost femininity, concerns about infertility, feelings of premature aging, and reduced self-esteem [ 9 , 10 ]. These emotional responses may contribute to the development of anxiety and depression, which in turn negatively affect sexual function. In other words, among women with POI, a vicious cycle may emerge between psychological distress and impaired sexual function, significantly diminishing overall quality of life [ 4 ]. Various studies have indicated that depression and anxiety are associated with reduced sexual desire, sexual dissatisfaction, and difficulties in achieving orgasm [ 11 , 12 ]. Chronic stress may also negatively impact physiological sexual responses by disrupting hormonal balance and elevating cortisol levels [ 13 ]. These psychological effects are particularly pronounced in conditions such as POI, where the body is already undergoing significant hormonal disturbances. In such cases, psychological and physiological factors may interact and reinforce each other, leading to intensified adverse effects [ 14 ]. Despite the importance of the topic, few studies have simultaneously examined the three psychological variables stress, anxiety, and depressionin relation to sexual function among women with POI. Most existing research has primarily focused on the physical or reproductive outcomes of the condition, with limited attention given to the role of psychological factors. However, a deeper understanding of the psychological dimensions of premature ovarian insufficiency may contribute to the development of more comprehensive interventions aimed at enhancing both the sexual and mental health of affected women.Accordingly, the present study was designed to investigate the association between stress, anxiety, and depression and sexual function in women with POI. Understanding the interrelationships among these variables may help healthcare providers adopt a more holistic approach in patient assessment and treatment, taking into account cultural sensitivities and taboos surrounding sexual issues in Iran, rather than relying solely on hormonal or physical therapies. Ultimately, the findings of this study could provide a foundation for developing treatment and counseling strategies based on a biopsychosocial model.