Introduction

The genital self-image refers to women's attitudes, beliefs, and feelings about their genitalia and genital system that are involved in sexual intercourse (1, 2). These attitudes are generally based on a complex combination of factors including the sexual practice, behavior, and experience that women have during their sexual life. A positive body image may facilitate the mental experience of sexual desire and practice, while a negative body image may impede sexual experience and practice (1). The women's body image is mostly exquisite, rather than holistic. Accordingly, body organs may be evaluated individually and unequally. Studies of body image assessment dissatisfaction confirm that somebody organs are more vulnerable to negative self-assessment than other organs. For instance, fewer women (from 500 women's in a study) express dissatisfaction with their own face (11-20%) than those who complain of the middle trunk (50-57%) or lower trunk (47-50%) (2). The individual mental image and feelings about sexual behavior, organs, and gender can affect sexual functions (3).

Assertiveness is the ability to express feelings, beliefs, and thoughts and defend self-rights in a rational way, including the following three dimensions: 1) ability to express feelings, 2) ability to express openly pleasant and unpleasant thoughts and beliefs and make a clear and decisive decision even if it deprives them of advantages or is difficult to be emotionally performed, and 3) ability to sustain the self-right assertiveness and prevent others from harassing or abusing a personal weakness (4). Sexual assertiveness is a psychosocial-asocial feeling that is defined by one's personal interpretation of how to express feelings in sexual relations (5). In many societies, women have difficulty in their sexual assertiveness and have low self-esteem, and thus it is difficult for them to express their needs or maintain their independence in sex (6). Lack of attention to the importance of sexual problems in marital relationships largely damages the couples' relationship (7). In Iran, most of women suffer from inattention to their sexual demands, and 50-60% of divorces and 40% of betrayals and secret relationships are also due to this reason (8-10). Problems about sexual issues, such as the lack of sexual desire and sexual dysfunction, are hidden and unexpressed probably because of fear and anxiety, shame and embarrassment, or feeling of inadequacy and guilt. In particular, women do not express symptoms of such problems due to modesty, and thus the hidden sexual problems will be manifested in other symptoms, such as physical diseases, depression, and dissatisfaction with the marriage (11). According to research by Schick et al. (2010) on 217 female students, a higher dissatisfaction with the appearance of genitalia is along with more self-awareness of this organ during the sexual intercourse, and it thus results in lower sexual self-esteem, less sexual satisfaction, and lower motivation to avoid high-risk sexual behavior. These findings emphasize the destructive impact of negative perceptions of genitalia on the sexual health of young women (12). In another study on male and female students, Reinholtz et al. (1995) indicated that women had a more negative attitude towards their genitals than men and felt more concerned about their sexual partner's reaction to their genitals; there was a significant positive relationship between the perception of genitals and sexual activity (13). Similarly, results of research by Morrison et al. (2005) on female students in Canada indicated that a good understanding of genitals had a positive relationship with sexual self-esteem, but a reverse relationship with self-awareness of body image and sexual anxiety (14). Women, who do not have good feelings about the efficiency and appearance of their genitals, may feel more ashamed of sexual intercourse with their partners, and this can lead to less arousal and more pain during the sexual intercourse. Results of qualitative studies have also indicated that many women with dyspareunia had feelings of guilt, shame, embarrassment, failure, and loss. In addition, these women considered themselves abnormal and incomplete, had a negative attitude that led to its generalization to all their genital organs, and considered this organ a dead and useless part of the body (1).

Sexual problems often have roots in educational deprivation and false beliefs about sexual desire and intercourse (15). The lack of proper information about women's sexual rights and finally its adverse consequences on marital relationships indicates the importance and urgency of this issue (16). Sexual assertiveness training includes attitudes and behaviors associated with the initiation of sexual relationships, as well as behaviors related to sex refusal. Only a few studies have looked at sexual assertiveness (17, 18). Studies on the impact of sexual assertiveness on self-assertion, self-esteem, and interpersonal relationship satisfaction revealed substantially higher than interpersonal relationship satisfaction scores (18). According to Amini et al. (2015), sexual education using a cognitive-behavioral approach influenced both positive and negative aspects of couples' self-image (19). Despite the importance of the findings of this study, no substantial variations in sexual assertiveness training have been observed in some studies. The mean scores of participants in the workshop on sexual assertiveness training and the control group did not vary in an intervention study on female students with the aim of sexual assertiveness training.

Sabbaghan found that the training package did not affect genital self-image and sexual function (19). A group of researchers criticized the sexual assertiveness training for women, and some of them believed that sexual assertiveness training for women decreased the sexual desire in men (20).

There are only a few ideas about how sexual assertiveness impacts marital life and how it interacts with other marital issues (17). Women now have a better understanding of their rights in sexual matters; however, there is still a lack of awareness and expertise in this field.

Even though information on sexual issues is not scarce, there are issues on low sexual knowledge in relation to women, the taboo aspect of talking about sexual desires, and women's complaints in society (21). In addition to the genital self-image and women's perception of their genitalia (22), 89% of women expressed dissatisfaction with the appearance of their genitalia and considered it abnormal (12, 23, 24). Besides, there is scarce documentation about the impact of sexual assertiveness education on the genital self-image. Therefore, the present study sought to determine the impact of sexual assertiveness education on the genital self-image in women who were referred to health centers of Mashhad city in Iran.

Materials and Methods

In this study 60 married women referred to Mashhad Imam Reza Health Center in 2016, participated. This study is a randomized clinical trial assignment parallel study with a control group. The study was registered at the Iranian Clinical Trial Registration Center (IRCT2016062628650N1) and was approved by the Research Council of Mashhad University of Medical Sciences. The sample size formula was used to assign 24 subjects per category (= 0.05, Z1-2 =1.96, d = 0.6, = 0.1) using a reliability coefficient of 95% (= 0.05), a test power of 90%, and the formula for the comparison of means (= 0.05, Z1-2=1.96, d = 0.6, = 0.1). The number of subjects was projected to be 30 women per group based on a 20% drop in each group. The intervention group consisted of 32 subjects, two of whom were removed from the sample. A total of 31 subjects were included in the control sample, and one subject was omitted from the study (Fig. 1). Being married, first marriage of the spouses, not staying away from the husband or husband's bigamy, non-pregnancy, no menopause, not using hormone therapy, passing at least one year of marriage, having sexual intercourse in the previous month, not the first year after childbirth, substance non-use of the couple, not having medical or psychological disorders impairing sexual function, no experience of a traumatic occurrence in the previous 6 months, and not being treated for sexual dysfunction were the inclusion requirements. Daily education about sexual relationships by a counselor or health staff, reluctance to continue with the research, pregnancy during the research, no sexual relationship during the study, having a traumatic experience for couples during the study, and engaging in a course or class and receiving sexual education differently during the review, missing more than one training session, and failing to show up for the post-test were all the exclusion criteria in this study.

The sampling was then carried out. First, the researcher (who was not blinded) used random sampling at the health center to monitor the flow of knowledge between the experimental and control groups. The two groups were randomly assigned to the first or second half of the week, with the first and the last three days of the week chosen for the control and experimental groups, respectively (random allocation of the study subjects based on the Weekdays) (27). Women referred to the center for health services were given a rundown of the research project and instructions on how to answer the questions when they were recruited for both the control and experimental groups.

The participants were ensured that the details would be kept private and then they signed a written consent form to participate in the study. The participant-recruiting checklist was completed through an interview and consideration of the participation criteria. The Hulbert sexual assertiveness questionnaire (28) and the women's genital self-image questionnaire (29) were completed by participants (29). Due to a lack of classroom space and to improve instruction, the experimental group was split into two equal subgroups and attended the daily teaching session. The training sessions were held once a week for 2 weeks in a row. Previously, 3-h sex education was shown to have the same, if not slightly higher, impression on a girl's sexual sufficiency compare to 6-h instruction (30). The lessons were delivered via lecture and PowerPoint presentations throughout two 90-minute sessions. The intent of the training, lesson plans, and learning goals were all explained in the first teaching class. The next set of questions focused on women's understanding of general sexual and emotional problems, their sexual rights, and their effect on couple satisfaction. In  the first session an explanation about the necessity of marriage, family peace and comfort, family stability and factors affecting it, family stability from the perspective of the Holy Qur’an and the traditions of the infallible, definition of a healthy sexual relationship and its requirements, sexual relations` benefits for couples, sexual relations from the perspective of the Holy Qur'an and infallible practices, sexual function characteristics and sexual reaction cycles in men and women, how to meet sexual needs of men and women, couples' rights and consequences of neglecting it, especially women, and divorce and its sexual reasons has been explained. In the second session concepts of sexual assertiveness, couple sexual rights, Islamic views on women's sexual rights, differences between partners, the effect of women's sexual assertiveness on marital life, and application of sexual assertiveness were presented. The training package was prepared under the guidance of spiritual and religion professor, using relevant articles and tools, as well as the opinions of subject experts. After the second session the contents of the second session was given to experiment group as a booklet to review at home. One week after the completion of training both group were asked to and complete the Hulbert sexual assertiveness and genital self-image questionnaire. Finally, any concern or problem raised by either party was addressed in accordance with the study subject.

The Hulbert index of sexual assertiveness (HISA) questionnaire include 25 questions, with the options chosen using a 5-item Likert scale. The scoring ranges from "Always (0)" to "Never (4)" for each multiple-choice question. Questions 3-5, 7, 12, 15-18, 22, and 23 are scored in reverse (Always = four, Never = zero). The test has a scale of 0-100 points, with a higher score suggesting greater sexual assertiveness. Hulbert David Farley tested the sexual assertiveness questionnaire in a report (28). Bay determined the standardized content validity of the questionnaire in Iran, with an internal accuracy of 0.91 (31). Cronbach’s alpha coefficients of α = 0.86 and α = 0.92 (25) were obtained in the implementation of HISA by David Farley Hulbert and Shafiee (2006), respectively. The reliability of this scale was computed by α = 0.84 in the current study.

The genital self-image questionnaire was designed by Bremen et al. (2003) to measure women's feelings and thoughts about their genitalia. The questionnaire contains 30 questions with two sub-scales. The first sub-scale with 18 questions is about women's awareness of genitalia at a 4-point Likert scale ranging from 0 (always) to 3 (never). The second sub-scale includes 12 questions under which a number of traits about the genitalia are as "It is not true for me" (0) and "It is true for me" (1). The obtained score of this questionnaire is from 0 to 66 and higher scores reflect higher genital self-image (44). In Iran, the validity and reliability of this questionnaire were confirmed by Jafarnejad et al. (2014) (29). Marvi et al. (2017) also re-determined the validity by the content validity and finally, the reliability was confirmed by a Cronbach's alpha coefficient of 0.77 (33).

The outcome measure of this study was women’s genital self-image and confounding variables that would not be deleted or have very little effects on the study results. As a result, they were taken into account and tracked in the data collection tool, which includes the quantitative like wife's and husband's age, marriage length, infertility length, the number of abortions and dead infants, the number of children, the number of deliveries, and qualitative variables such as place of residence and accommodation, residing with people other than the spouse and children in the same place, and infertility background. The type of deliveries, the type of contraception used, viewing pornographic films and photographs, different methods of sexual intercourse, the dominant sexual intercourse process, the amount of intercourse per week, and so on were all factors considered here.

SPSS (Statistical Package for Social Sciences, Version 11.5, SPSS Inc. Chicago, IL, USA) was used to analyze the results. The characteristics of the subjects were evaluated using descriptive statistical methods, such as a frequency chart, mean, and standard deviation. The Chi-square, Mann-Whitney, and Wilcoxon tests were used for qualitative and non-parametric variables, while quantitative variables were compared using the independent t-test and paired t-test. Finally, the effects of confounding variables were regulated using one-way analysis of variance (ANOVA). Statistical significance was described as a p-value less than 0.05.

On Sunday, August 28, 2016, the sampling began after the analysis was approved by the disciplinary committee of Mashhad University under the code IR.MUMS.REC.1395.284. The study goals were explained to the participants and written approval was given after the Ethics Committee reviewed the proposal.

Results

The mean (± SD) ages of the intervention and control groups were (30.65) (7.75) and 30.40 (8.20), respectively.

  Which were not significantly different between the two groups (p > 0.05). There were no major variations in other demographic features of the two groups of participants (Table 1). To test for confounding variables, one-way ANOVA findings revealed no major differences between the two groups (p > 0.05; Table 2).

The mean score of genital self-image was 30.50 (37.82) in women. Results of the Mann-Whitney test indicated that there was no statistical difference in the genital self-image score between the intervention (26.85 ± 69.50) and control (27.15 ± 6.15) groups at the significance level of 5% (p = 0.780) before the intervention.

After the intervention, there was a statistical difference in genital self-image scores of intervention (35.93 ± 4.67) and control (31.07 ± 3.60) groups ((p ˂ 0.001). Wilcoxon's test results indicated that there was a significant difference in the intervention group before and after intervention in terms of genital self-image score (p ˂ 0.001), but no statistically significant difference was seen in the control group (p = 0.500) (Table 3).