The Relationship between Sexual Satisfaction and Genital Self-image in Infertile Women

Introduction

Lack of sexual satisfaction is considered as one of the most important problems, which impacts individuals’ personal and social lives and plays an important role in their personality development (1). Sexual satisfaction refers to pleasant feelings about one’s sexual relationships. In other words, sexual satisfaction denotes a person’s judgment and analysis of one’s sexual behaviors that are assumed pleasurable (2). During infertility treatments, 50-60% of couples reported a drastic decrease in their sexual satisfaction (1). Most couples assume that sexual relationship is solely for pregnancy purposes; therefore, sexual relationship is considered futile if pregnancy is not achieved (3). In most cases, infertility can profoundly affect sexual relationships (4). Another study defined infertility as the inability to conceive after one year of continuous sexual activity without using contraceptive methods (5).

According to the related literature, about 50-80 million individuals suffer from infertility worldwide (6). Based on the statistics released by the World Health Organization (WHO) in January 2013, 10-15% of American couples suffer from infertility (7). In Iran, the overall mean rate of infertility was reported to be 10.2% (8). Moreover, infertility stress can give rise to psychological problems such as low self-esteem and sexual satisfaction, as well as increased anxiety, depression, anger, sense of inferiority, sense of inefficiency, and marital problems (9). Due to infertility, individual and social competencies, that is, motherhood and spousal values are impaired; this sense of self-blame can exacerbate problems such as reduced sexual self-efficacy and self-confidence, as well as sexual functioning disorders (10). Body image can predict some sexual behaviors in individuals (11), that is to say, a positive body image can improve sexual desire and activity, while a negative one may hinder sexual functioning (12).

Researchers introduced genital sself-image as an issue affecting women’s sexual behaviors (13). The concept of genital self-image was put forth by Waltner (1986) as a component of sexual identity that can be influenced by sociocultural and external norms associated with genitals, as well as sexual and social experiences. These factors can strongly influence women’s feelings towards their gender (14).

Genital self-image refers to attitudes, feelings, and beliefs about one’s sex organs that can influence sexual relationships (12, 15). Positive genital self-image has been deemed associated with sexual self-esteem (16). On the other hand, dissatisfaction with genital self-image can negatively influence sexual health in women; consequently, it can cause sexual dysfunction (17).

In a study on male and female university students, Reinholtz et al. (1995) showed that women’s attitudes towards their genitals were more negative compared to men's, and they had concerns over their partners’ reaction to their sex organs. There was also a significant positive relationship between perception of female genitalia and quality of sexual relationship. Moreover, a significant correlation was found between genital self-image and sexual satisfaction (18).

Pazmany et al. (2013) reported that women with dyspareunia had less positive beliefs regarding their bodies compared to women without this disorder (12). Additionally, Morrison et al. (2005) demonstrated that positive perceptions of genital appearance were correlated with high sexual self-esteem, while it was inversely correlated with sexual anxiety (19). Pakpour et al. (2014) also suggested a significant relationship between genital self-image score and all the dimensions of sexual functioning, especially sexual satisfaction (20). According to the results of a study by Schick et al. (2010), dissatisfaction with genitals and high bodily self-consciousness could lead to lower sexual self-esteem and sexual satisfaction (21). As reported by the American College of Obstetrics and Gynecologists (ACOG) (2013), cosmetic surgery on genitals could act as an effective strategy to boost pleasure and satisfaction with appearance and sexuality; however, its effectiveness has not been established yet (22).

The factors raising women’s concern over their genitals include low self-confidence, dissatisfaction with physical appearance, physical and emotional factors, and sexual abuse (23). Women may undergo aesthetic genital surgery due to age or childbirth (22). Genital self-image and the way women perceive their reproductive organs vary in different cultures and societies (24). Based on former studies, almost 89% of women show their dissatisfaction with their genitals and consider them abnormal (21, 25).

Since infertility affects women’s self-confidence and sexuality, women with this problem find sexual relationship frustrating and mentally distressing. Therefore, they develop negative feelings about their bodies, lose their self-confidence and sexual desire, and become depressed and disappointed (26). Considering the scarcity of studies on the relationship between genital self-image and sexual satisfaction among Iranian infertile women,
we attempted to investigate the relationship between genital self-image and sexual satisfaction among infertile women visiting Milad Infertility Center, Mashhad, Iran, to take the necessary steps in improving sexual health among women and their families.

Materials and Methods

This descriptive cross-sectional study was conducted on 102 women visiting Milad Infertility Center in Mashhad, Iran, during 2016. The inclusion criteria consisted of being Iranian and Muslim, formally married, literate, and aged 18-40 years, living with the spouse, not becoming pregnant after one year of regular unprotected sexual intercourse, and having a diagnosis of primary infertility as confirmed by a gynecologist. The exclusion criteria entailed addiction to illicit drugs or alcohol, post-traumatic stress over the past six months, any specific diseases, psychological disorders, use of medications influencing sexual functioning, disabilities affecting sexual functioning, history of pelvic surgery, radiation therapy for vaginal or cervical cancer, pregnancy during the study, and having an adopted child.

Prior to the study, we obtained the approval of the Ethics Committee of Mashhad University of Medical Sciences. The participants were selected using the convenience sampling method to ensure its comprehensiveness (sampling was performed across all income levels from different cultural backgrounds). After selecting the eligible individuals and obtaining written informed consent from the participants, we provided the necessary information to the participants on how to respond to the questionnaire items.

Research instruments

Genital Self-image Scale

This questionnaire, which was first designed by Berman et al., is comprised of 30 items and 2 subscales. The first subscale contains 18 items on women’s awareness of their genital system and is rated using a 4-point Likert-type scale (i.e., 0: always to 3: never). The second subscale includes 12 items pertaining to genital traits and is rated using a 2-point scale (i.e., 0: it is true for me and 1: it is not true for me). The minimum and maximum possible scores of this scale are respectively 0 and 66, with higher scores indicating a more favorable genital self-image (14). The validity and reliability (α= 0.86) of this questionnaire were confirmed by Berman et al. (2003) (14). Jafarnejad et al. (2015) also confirmed the validity and reliability of this questionnaire in Iran. In this study, we re-established its content validity and reliability (α= 0.77).

Golombok-Rust Inventory of Sexual Satisfaction (GRISS)

This 28-item questionnaire rated on a 5-point Likert-type scale (range: 0 to 4) examines the types and severity of sexual problems in seven domains. The minimum and maximum possible scores of this scale are 0 and 112, respectively, with lower scores reflecting higher sexual satisfaction. This inventory includes seven subscales, namely Infrequency subscale (items 3 and 15; evaluating the frequency
of sexual relationship), Non-communication subscale (items 2 and 16; examining to the extent to which the individual talks about sexual issues), Female Dissatisfaction (items 5, 10, 18, and 22; evaluating the duration of courtship, time of intercourse, as well as love and interest), Female Avoidance (items 20, 13, 7, and 23; investigating avoiding and refusing sex), Female Non-sexuality (items 19, 12, 9, and 25; surveying rejection to be touched and cuddled), Vaginismus (items 6, 17, 11, and 24; examining the dimensions of vaginismus), and Anorgasmia (items 8, 14, 21, and 28; checking lack of orgasm). This questionnaire was designed by Golombok-Rust, and its validity and reliability for women were confirmed by the known-groups method and Cronbach’s alpha of 0.94 (27). The validity and reliability
of this inventory were also established by Besharat and Hosseinzadeh (2004), who reported a Cronbach’s alpha coefficient of 0.89 (9). In the present study, its reliability was also confirmed through Cronbach’s alpha coefficient in infertile women (α=0.88).

Data analysis

To analyze the data, descriptive statistics, Mann-Whitney U test, Chi-square test, Kruskal-Wallis test, Pearson product-moment correlation, and multiple regression were used in SPSS, version 16. P-values less than 0.01 were considered statistically significant.

Results

The mean age of the infertile women was 30.63±5.485 years and the mean age of their husbands was 34.48±5.791 years. The mean age of marriage was 8.65±4.688 years. Furthermore, 35.3% of the infertile women had academic education, 49% of them had high school diploma, and 15.7% had basic literacy. Moreover, 39.2% of the husbands had academic education, 54.9% of them had high school education, and 5.9% had basic literacy. Other demographic characteristics are presented in Table 1. The mean scores of duration of

Table 1. Frequency distribution of demographic characteristics of the participants

infertility and treatment were 6.56±4.248 and 5.07±3.241 years, respectively. The mean body mass index (BMI) of the participants was 25.76±5 kg/m² (Table 2).

The mean scores of sexual satisfaction and genital self-image are presented in Table 3.

Spearman correlation coefficient was also used to determine the correlation of genital
self-image with sexual satisfaction and its dimensions (Table 4). We found a significant positive correlation between genital self-image and sexual satisfaction (P˂0.001). Moreover, there was a significant correlation between genital self-image score and sexual satisfaction dimensions including infrequency, non-communication, female avoidance, female non-sexuality, and anorgasmia. However, no significant correlation was observed between genital self-image and vaginismus

Multiple regression analysis was run to determine the dimension of sexual satisfaction that better predicts genital self-image.
Multiple correlation coefficient, coefficient of determination, and adjusted coefficient of determination were found to be 0.655, 0.442, and 0.401, respectively. The statistics of the predictor variables in the regression model are illustrated in Table 5. According to Table 5, female non-sexuality and anorgasmia were better predictors of genital self-image.

Table 2. Distribution frequency of patient charac-teristics

Table 3. Mean and standard deviation scores for sexual satisfaction and genital self-image

Table 4. Correlation coefficient between sexual satisfaction, its dimensions, and genital self-image

a: It was significant at 5% error level.

Table 5. Statistics of the predictor variables within the multiple regression model

a: It was significant at 5% error level.

Discussion