{'fraction_non_alphanumeric': 0.02522935779816514, 'fraction_numerical': 0.013433813892529489, 'mean_word_length': 5.0825029892387406, 'pattern_counts': {'":': 0, '<': 7, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 0, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
The earthquake's effect on the men's sexual function; 1 year after the earthquake's occurrence: A cross‐sectional study

Abstract Background and Aims Sexual dysfunctions are one of the health problems after natural disasters that are usually less attention. The purpose of this study was to evaluate the effect of the earthquake on men's sexual functions 1 year after the earthquake. Methods This study was a descriptive‐analytical cross‐section study that took place a year after the Kermanshah earthquake. The population studied was all men living in the Kermanshah earthquake. Demographic, socioeconomic, psychological, health situations, facilities availability, and environmental situations after the earthquake and International Index of Erectile Function (IIEF) were randomly distributed among men affected by the earthquake. Participants returned the questionnaires through the mail. Based on the IIEF cut‐point score, men were divided into two groups: those with sexual dysfunction (Group A) and without sexual dysfunction (Group B). Results In this study, 225 married men participated. The prevalence of sexual dysfunction in earthquake‐affected men was 44.9%. The mean total IIEF scores in the A and B groups were 43.47 ± 7.82 and 62.11 ± 6.39, respectively. There was a significant difference between the total and all subcategories IIEF scores in the two groups (p < 0.001). There was a statistically significant difference between the age (p < 0.001), child numbers (p < 0.017), current live location (p < 0.001), social support after the earthquake (p = 0.033), underlying disease (p < 0.001), availability of sanitary toilets (p < 0.001) and bathrooms (p = 0.002), and total IIEF scores between the two groups (p < 0.001). Conclusions Approximately half of the earthquake‐affected men had sexual dysfunctions. The men's age, child numbers, current live location, social support, underlying disease, and availability of sanitary toilets and bathrooms were influential in the severity of men's sexual dysfunctions after the earthquake. Therefore, crisis managers, policymakers, psychiatrists, and psychologists should pay enough attention to men's sexual dysfunction after earthquakes.


| Study design and participants
This descriptive-analytical cross-sectional study collected information about the sexual health of the earthquake-affected men in the year ending November 13, 2018. The study population was all men living in Sar-e-Pol-e-Zahab and Kermanshah cities when the Kermanshah earthquake occurred and had the inclusion criteria.
Inclusion criteria: 1. Reside in the earthquake area from the time of the earthquake until the completion of the questionnaire.
2. The participant has expressed willingness to participate in the research and completed the informed consent form.
3. Be alert and fully able to answer the questionnaire's questions. 4. There should be no pain or acute problems when completing the questionnaire. 5. The participants be married and should not have any restrictions on the sexual activity before and after the earthquake. 6. No history of previously known physical and mental illnesses.
Exclusion criteria: 1. Unwillingness to continue participating in the study.
2. Failure to complete and send the questionnaire.

| Sample size
The sample size was estimated based on a preliminary study conducted on 20 earthquake-affected men with a mean and standard deviation International Index of Erectile Function score of 52.80 ± 13.53.
The sample size was computed using the G * power software with a confidence interval of 95%, a test power of 99%, and an effect size of 0.150. The minimal sample size was obtained as 212 patients per group.

| Measures
Data collection tools were demographic, socioeconomic, psychological, health situations, facilities availability, and environmental situa- The IIEF-15 questionnaire was used to determine the past year's quality of the sexual function in the participants. This present study utilized the 15-question format of this questionnaire. This questionnaire is a brief, reliable, validated, multidimensional, self-administered investigation that has helped assess erectile dysfunction. IIEF-15 evaluates the presentation of male sexual dysfunction. The minimum score of this questionnaire was 5, which was interpreted as a lack of sexual quality functions and the maximum score was 75, demonstrating the highest amount of sexual quality functions (Table 1). 17 This study evaluated the five components of sexual function: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction from sexual activity.
Erectile function was evaluated based on six questions, yielding a maximum score of 30 points.
Results below 25 points were considered abnormal. The orgasmic function was evaluated using two questions, yielding a maximum score of 10 points. Results below 9 points were considered abnormal. Sexual desire was also evaluated using two questions, yielding a maximum score of 10 points, and results below 9 points were considered abnormal. Intercourse satisfaction was evaluated based on three questions, yielding a maximum score of 15 points, and the threshold value was 13 points. Overall satisfaction from sexual activity was evaluated using two questions, yielding a maximum score of 10 points, and results below 9 points were considered abnormal (Table 1). 18 In the present study, a score of 53 was considered the cut point for total IIEF scores. 19 This questionnaire has validity for erictical dysfunction and has been used in some studies. 20

| Procedures
Participants were randomly selected from the displaced and nondisplaced population following the 2017 Kermanshah earthquake. The researcher divided the earthquake-stricken area of Sarpol-e Zahab from the map into four parts. Then, he randomly went to the participants' houses, Conex, and Tents.
After explaining the objectives and methodology of the study, written informed consent was obtained from participants. All participants were given a stamped envelope containing questionnaires with an address to send back the questionnaire through the national post service. In each region, 75 questionnaires and, in total, 300 questionnaires were distributed. Of these, 263 questionnaires were filled and sent back. Thirty-eight questionnaires were incomplete and were excluded from the study, and analyzed the data related to 225 questionnaires. After sampling, the data were entered into SPSS-16 software, and the data were analyzed. The samples were divided into two groups with sexual dysfunction (Group A) and without sexual dysfunction (Group B) based on the cut-point score of 53 on the IIEF questionnaire. Then, the relationship between demographic, socioeconomic, psychological, health situations, facilities availability, and environmental situations after the earthquake variables in people with and without sexual dysfunction were analyzed.

| Statistical methods
All analyses were performed using SPSS-16 software (SPSS Inc  There was a statistically significant difference between the mean scores of IIEF and the participants' age between the A and B groups.
Sexual dysfunction was more severe in older men than in younger men. Moreira et al. 25 showed in a study that increasing age was a significant predictor of a lack of sexual interest and erectile difficulties in men. Geerkens et al. 26  seek help from healthcare professionals or use medication for SD. 26 There was a statistically significant difference between the mean scores of IIEF and the participants' child's numbers and current live location between the A and B groups. Sexual dysfunction was more severe in the participants with more child's number and people who lived in Connex containers after the earthquake. In a study, Abrams et al. 27 showed that one factor affecting sexual dysfunction is the number of children under 18-year-old. Living with children in a small environment, such as a Tent or a Connex container, prevents couples from performing proper sexual activity. Therefore, it is recommended to consider at least two Tents or Connex containers for married people who have children in disasters.
In the current study, there was no statistically significant relationship between the body mass index, education level, and type of occupation of earthquake-affected men with the mean of their total IIEF scores between groups A and B. Mykoniatis et al. 28 and Dursun et al. 29 showed in a study that body mass index is effective on sexual dysfunctions, and the severity of sexual dysfunction is higher in men who have a higher body mass index. In the present study, the reason for the nonsignificance of the difference between BMI in the two groups is that the participants in the two groups were almost equal in terms of BMI.
Bonde 30 showed in his study that occupational hazards could affect men's sexual activity and fertility. Yafi et al. 31 showed in a study that occupation can affect men's sexual dysfunction. However, Omar et al. 32 showed in a study that being employed has no effect on sexual dysfunction in men with diabetes. The result of the study by Omar and his colleagues confirms the result of the present study and shows that if men suffer from an illness or a crisis such as an earthquake, being T A B L E 3 The male sexual functions after the earthquake in with and without sexual dysfunction groups based on IIEF subscales T A B L E 4 Comparison of socioeconomic, psychological, and health situations in the with and without sexual dysfunction groups and the effect of these variables on IIEF scores There was a statistically significant difference between the mean scores of IIEF and the level of social support from men affected by the earthquake. Sexual dysfunctions were more severe in men their families and friends did not support. Social support seems to reduce the severity of sexual dysfunction in earthquake-affected people by lowering posttraumatic stress disorders. Warner et al. 35 reported that receiving social support from relatives shortly after an earthquake was an important coping resource, as it alleviated the association between resource loss and the severity of posttraumatic stress response. Alipour and Ahmadi, 36 In a systematic review, showed the positive effect of social support on the prevention of PTSD. Eray et al. 37 showed that perceived family support has a protective role on PTSD symptoms of adolescents after the earthquake. In the current study, participants who received less social support were people who were unable to communicate with others and express their problems. Therefore, in disasters, people who are less likely to seek services should be given more attention in terms of mental disorders and especially sexual dysfunctions.
There was a statistically significant difference between the mean scores of IIEF and the presence or absence of underlying disease between the with and without sexual dysfunction groups. Venggadasamy et al. 38 in a study showed that in men with diabetes, several issues might occur in sexual dysfunction, such as erectile dysfunction, orgasmic disorders, ejaculatory disorders, and reduced libido, and men with diabetes-induced SDs experienced a poor quality of life due to the distress caused by SD. Terentes-Printzios et al. 39 a study showed an interaction between erectile dysfunction, cardiovascular disease, and cardiovascular drugs, and ED could be used as a predictor of vascular disorders. Therefore, since there was a positive relationship between ED and underlying diseases in the with and without sexual dysfunction groups, men with underlying diseases must be examined for sexual dysfunctions after the earthquake.
Sexual disorders were more severe in men not supported by their families and those not using psychological counseling services. There was no significant relationship between the use of psychological counseling after the earthquake between the groups with and without sexual disorders, and only 4% in the group with sexual disorders and 2.4% in the without sexual disorders group had used these services. Many studies have shown that the prevalence of psychosexual disorders increases after disasters. Also, the findings showed that people who had used psychological services had very low IIEF scores and were probably forced to use psychological services due to severe mental disorders. Men who used psychological services seemed exposed to postearthquake stress, anxiety, and depression. Sexual dysfunctions of these individuals may have been due to their mental disorders and using antidepressant and anxiety drugs. Yang et al. 40 reported a significant association between anxiety and depression with sexual disorders. Only a minority of older adults seek help from healthcare professionals or use medication for SD. 26 85.2% of the participants in both groups faced financial damages due to the earthquake. However, there was no significant association between financial damages and sexual dysfunctions. It seems that the reason for the insignificancy of this association is the high percentage of people affected by the earthquake. In contrast, Dadomo et al. 41 reported a significant association between financial damages and erectile dysfunction.
Men injured due to the earthquake and those with at least one underlying disease (e.g., diabetes, asthma, heart problems, etc.) had more severe sexual dysfunction. In line with the current study's findings, Bahar et al. 42 reported a significant association between diabetes and sexual dysfunction. Soto et al. 43 also reported a significant association between asthma and the quality of sexual activity.
There was no significant association between having an adequate sleep in earthquake-affected men and the severity of sexual dysfunction in both groups. Since most participants had a good or relatively good sleep, this finding was not significant in the present study. Consistent with the current study's findings, Pastuszak et al. 44 reported a significant association between sleep quality and sexual disorders. There was no significant association between adequate food intake and consumption of sufficient fruits and sexual dysfunction in both groups. Mykoniatis et al. 28 showed in a study that greater consumption of vegetables and fruits, a lower intake of dairy and alcoholic beverages, and a less intense smoking habit increase sexual disorders in men.
There was a significant association between the availability of life facilities such as sanitary toilets and bathrooms between the groups with and without sexual dysfunctions. The authors did not find a study on the association between life facilities of earthquake victims and sexual disorders. However, it seems that the higher the living facilities of earthquake-affected victims, the higher their physician and mental health would be, and they will have more desire for sexual activities.
In this study, a self-report questionnaire was used to investigate sexual dysfunctions, and the researchers were not present when the T A B L E 5 Comparison of facilities availability and environmental situations after the earthquake in the with and without sexual dysfunction groups and the effect of these variables on IIEF scores