Health, Spirituality and Medical Ethics

Introduction
In recent years, due to cultural changes, marital life has been affected by several factors, including extramarital affairs or infidelity [1]. Marital infidelity encompasses sexual infidelity (sexual intercourse without romantic involvement), romantic infidelity (romantic involvement without any sexual intercourse), and romantic sexual involvement [2]. Attitudes toward marital infidelity can be defined as a stable set of beliefs, feelings, and behavioral tendencies regarding having a physical, emotional, or physical-emotional relationship with another person. In other words, an individual with a favorable evaluation of marital infidelity views this issue as desirable, and therefore, people who have a positive attitude toward marital infidelity are more inclined to commit it and are consequently more likely to engage in marital infidelity [3]. Attitudes are acquired through friends, relatives, and parents [4].
Over the past few decades, the psychological community has increasingly focused on the role of fathers in the psychological lives of their children. Changing patterns of marriage and divorce have raised various questions about the effects of fathers on their children’s lives. The father-child relationship plays a significant role in girls’ perspectives on relationships and marriage, as well as their attitudes toward infidelity [5]. If children feel supported by their father in the family environment, their relationship with him is positive and constructive. Moreover, if they are confident that their father will support them whenever a problem arises, they will develop positive personality traits, such as empathy, a healthy self-concept, self-control, mental health, social competence, and life skills [6]. Since each attitude has its unique thoughts, feelings, and actions, it can be inferred that the direction of children’s behavior is based on the attitudes they have toward one or both of their parents [7].
Among the factors affecting people’s attitudes toward infidelity is their religious attitude. Religion is one of the oldest and most common manifestations of the human psyche; therefore, the importance of religious attitude cannot be ignored, at least as a social and historical phenomenon [8]. People who adhere to religious beliefs experience less psychological stress, and rates of depression, divorce, and infidelity are lower among these individuals than in the general population [9]. Religion acts as a protective shield for individuals and has a wide range of positive psychological effects [10-13]. Research has shown that religiosity reduces the likelihood of marital infidelity among couples [14]. Religious attitudes may be associated with emotion regulation and the use of strategies that help bring external emotions and anxieties under control [15].
The ability to control his or her emotions is one of the most important skills that individuals must learn to communicate effectively in marriage. Emotion regulation is defined as the process of initiating, maintaining, modulating, or changing the occurrence, intensity, or recurrence of internal feelings and emotions related to socio-psychological and physical processes in accomplishing one’s goals [16]. Deficits in identifying and regulating emotions can lead to confusion and helplessness in the processes of cognitive processing, perception, and evaluation of emotions. This deficiency can disrupt the organization of emotions and cognitions, making successful adaptation difficult. As a result, couples’ relationships suffer from conflict, marital dissatisfaction, and failure in intimate relationships, ultimately leading to marital infidelity [4]. Emotional dysregulation significantly affects the way people view various issues, including infidelity [17].
Studies demonstrate that men are traditionally more likely to engage in marital infidelity than women; however, more recent studies suggest that as marital infidelity becomes more widespread, the gender gap is narrowing [18], with rates of marital infidelity among young men and women increasingly approaching each other. In one study, 25% of women reported having at least one experience of marital infidelity [19].
However, in Iran, there are no statistics available in this area, and the few studies that have been conducted have generally included both sexes. Additionally, the issue of marital infidelity and extramarital affairs has a destructive effect on the foundation of the family and the mental health of couples. Nevertheless, due to the taboo nature of the topic, limited research has been conducted in this field. Hence, this study sheds more light on the factors affecting the attitudes of married women toward infidelity. Therefore, the present study aims to predict married women’s attitudes toward infidelity based on the quality of their relationship with their father, their religious attitude, and their emotional dysregulation.
Methods
This descriptive correlational study was conducted on married women aged 20 to 60 years in Mashhad City, Iran, in 2024, with 298 participants selected through convenience sampling at the community level. The inclusion criteria included willingness to participate in the research, being Muslim, and being between 20 and 60 years old. Meanwhile, the exclusion criteria were providing incomplete information or a lack of cooperation. The samples were selected from various locations in the city, including mosques, universities, parks, and cultural centers.
In the present study, four questionnaires were used as follows: The attitude toward marital infidelity scale, the fatherhood scale (FS), the religious attitude questionnaire, and the difficulties in emotion regulation scale (DERS).
Attitude toward marital infidelity scale
The attitude toward marital infidelity scale was developed by Whatley [3] and consists of 12 questions, which are scored based on a 7-point scale ranging from (strongly agree) to (strongly disagree). The highest score (84) indicates acceptance of infidelity, while the lowest score (12) indicates rejection of infidelity [20]. To examine the validity of this scale in Iran, criterion validity (divergent type) was employed, and the reliability of the questionnaire, using the Cronbach α method, was reported to be 0.89 for the entire questionnaire [21]. Additionally, in another study, the reliability of the scale, calculated using the Cronbach α method, was found to be 0.81 [22].
FS
The FS [23] consists of 64 items in the form of descriptive sentences that the respondent must rate based on a 5-point Likert scale, ranging from (never) to (always), according to their perception of their relationship with their father during childhood. This scale measures four domains: Actual events that occurred in the relationship with the subject’s father, the subject’s perception of his father, the subject’s feelings toward their father, and the father’s emotional responsiveness [23]. The Cronbach α for the FS in the Persian version was 0.96, with this value being 0.96 for the positive emotional responsiveness and moral role subscales, 0.85 for positive father presence, 0.67 for provision, and 0.79 for negative father presence [24].
Religious attitude questionnaire
The religious attitude questionnaire was prepared by Moshirian et al. (2016) and consists of 25 questions, which are scored based on a 5-point Likert scale ranging from 0 to 4, with a total score of 100 [25]. The validity of this scale was determined through the correlation coefficient with the survey by Moshirian et al. [25], which is 0.80. This questionnaire has been re-evaluated in recent years, and its reliability, using the Spearman-Brown method, was 0.63 while its validity was 0.248 [26]. 
DERS-16
The DERS-16 was developed by Bjureberg et al. [27]. It consists of 16 questions, which are scored based on a 5-point scale ranging from “almost never” to “almost always.” The reliability of this scale was reported to be 0.94 using Cronbach α for the entire scale, and the results also indicated that this scale has good convergent and discriminant validity [27]. In the study by Fallahi et al. in 2021, the results of the internal consistency coefficient showed that this scale has adequate reliability, with Cronbach α coefficient for the entire scale being 0.91 [28].
To conduct this research, various areas of Mashhad City, Iran, such as universities, parks, and commercial centers, were visited, and questionnaires were distributed to the volunteers participating in the study. Additionally, research ethics were observed, and informed consent from the subjects was obtained. 
Data analysis
The SPSS software, version 22, was used for data analysis, employing the Pearson correlation coefficient and multiple regression analysis.
Results 
The mean age of the participants was 33.9±10.94 years. Additionally, 11.1% of the participants had a below-diploma degree, 28.9% had a diploma, 42.9% had an associate’s or bachelor’s degree, 15.9% had a master’s degree, and 1.3% had a PhD. The Mean±SD, , minimum, and maximum scores of the research variables are listed in Table 1.
The Mean±SD score of attitude toward marital infidelity was 84.73±9.32, the quality of the relationship with the father was 170.35±13.22, the religious attitude was 58.25±12.77, and emotional dysregulation was 38.63±13. Before using the correlation coefficient and stepwise regression, compliance with their assumptions was examined. One of the assumptions, the test of normality of the distribution of scores, was confirmed by the absence of significant skewness and kurtosis, as well as by the normal Q-Q plot. The assumption of linearity of the variables was also met. Additionally, the value of the Durbin-Watson statistic was between 1.5 and 2.5, which ensured that the assumption of independence of errors was satisfied.
There was a significant negative relationship between religious attitude and the quality of the relationship with the father concerning the attitude toward marital infidelity, and there was also a positive but insignificant relationship between emotional dysregulation and the attitude toward marital infidelity (Table 2). Next, multiple regression was used to predict the attitude toward marital infidelity based on the research variables (Table 3).
The regression model, which included religious attitude, quality of the relationship with the father, and emotional dysregulation, could significantly predict 0.13 of the changes in attitude toward marital infidelity. Table 4 shows the role of each variable in predicting the attitude toward marital infidelity.
Religious attitude (P<0.01, β=-0.34) could inversely predict attitudes toward marital infidelity, but the other two variables did not play a significant role in the prediction.
Discussion
The present study predicted married women’s attitudes toward infidelity based on the quality of their relationship with their fathers, religious attitudes, and emotional dysregulation. The results showed that religious attitudes had a significant negative correlation with attitudes toward marital infidelity and were also a significant predictor of attitudes toward marital infidelity. The findings of the present study are in line with those of Khosravi et al. [29] and Tuttle and Davis [14]. Belief in religious values is one of the factors influencing marital satisfaction, which also reduces individuals’ tendency toward extramarital relationships [30]. Religion connects individuals to the supramaterial and sublime dimensions of the world and, by giving meaning to life, purifies the family and the relationships within it, creating conditions for the maintenance and establishment of the family. Religious attitudes, by sanctifying marriage, increase the commitment and loyalty of couples [31]. In other words, when couples view marriage as sacred, they create a framework for themselves that they use to interpret all their actions, behaviors, and feelings. Religious attitudes give meaning to people’s lives and, by creating hope, provide psychological peace. On the other hand, religious attitudes, the spiritual relationship between an individual and God, and the meaning of life that religious attitudes create for an individual are all factors that increase people’s satisfaction and reduce their attitudes toward infidelity. Therefore, more religious people have greater life satisfaction and contentment [32].
Another result was a significant negative correlation between the quality of the relationship with the father and attitudes toward marital infidelity; however, it was not a significant predictor of attitudes toward marital infidelity, which is both consistent and inconsistent with other studies [33, 34]. Communication styles and the quality of the relationship with parents, including the father-daughter relationship, form the basis of her communication with others. Attachment in the parent-child relationship carries over into adult romantic relationships and can influence behavior, attitudes, cognition, and emotions at any stage of life. Positive parent-child relationships can also serve as a protective factor against problematic behaviors in adulthood. Individuals who have experienced positive parent-child (father-daughter) relationships are less likely to engage in extramarital affairs [34]. The lack of involvement, presence and effective communication from fathers with their children, especially their daughters, can lead to negative consequences, such as depression, poor self-esteem, violence, anxiety, separation, rejection, self-loathing, and emotional disorders, which can cause problems in adult emotional relationships [35].
In the present study, emotional dysregulation had a positive but insignificant correlation in predicting attitudes toward marital infidelity, which is both consistent and inconsistent with some studies [36-38]. Difficulty in regulating emotions is related to low levels of emotional expression and communication with others, difficulty in expressing needs, and challenges in coping with social situations. Individuals who experience greater difficulty in regulating their emotions tend to have lower expectations of others and are less inclined to satisfy and fulfill the desires of others. A good relationship with a spouse requires building close connections and understanding and recognizing each other’s feelings, emotions, and affections. People with higher levels of emotional dysregulation face difficulties due to their inability to recognize the feelings of others, as well as their inability to express their own emotions, feelings, and inner desires. This inability can prevent spouses from getting closer to each other, understanding each other’s problems, and attempting to resolve them. Additionally, not expressing feelings may make the couple’s life monotonous, leading to emotional numbness between them, which can result in marital infidelity [37]. To explain the finding that the relationship between emotional dysregulation and attitudes toward marital infidelity was not significant, we can refer to studies [39, 40] that suggest emotional dysregulation may be a consequence of marital infidelity. Therefore, in the present study, it was not a significant predictor of attitudes toward marital infidelity.
This study was conducted cross-sectionally, making it difficult to conclude causality. Although the instruments used in this study are validated in terms of psychometric indicators, the use of scales that have different cultural bases somewhat affects the internal validity of the study.
Conclusion
Based on the present study, it can be concluded that the better the level of religious attitude and the quality of the relationship with the father in married women, the lower the level of attitude towards marital infidelity. These two factors, and especially religious attitude, play an important role in preventing marital infidelity.

Study limitations
One of the limitations of the research is the use of a questionnaire; therefore, it is suggested that other methods, such as interviews, be used in future research to obtain desirable results. The present study focused on married women; hence, it is suggested that similar investigations be conducted with the male population as well. The nature of the propensity for marital infidelity questionnaire and the selection of married individuals (due to the cultural burden of the questionnaire that questions the partner) limited data collection and its generalizability. It is recommended that future research examine this study among single individuals, as well as among married individuals who have experienced infidelity.
Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the Ferdowsi University of Mashhad, Mashhad, Iran (Code: IR.UM.REC.1403.259). The authors declare that all relevant ethical principles have been observed in this study, including the confidentiality of the questionnaires, informed consent of the research participants, and the right to withdraw from the study. 
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 
Authors' contributions
Study design, statistical analysis and writing the original draft: Amir Karami and Mahla Mohammadi; Sampling: Mahla Mohammadi; Supervision, review and editing: Amir Karami.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The researchers express their gratitude to the participants in this study.