Factors associated with satisfaction with genital self-image in Brazilian university womenABSTRACT
Female Genital Self-Image (GSI) refers to how women feel about their genitals and can be influenced by psychological and behavioral aspects of sexual well-being. In Brazil, a recent study investigated the factors associated with satisfaction with male GSI, but there are no studies investigating this issue in females. This study aimed to analyze the factors associated with satisfaction with GSI among Brazilian university women. This is a cross-sectional, online study conducted among Brazilian women (>18 years old) who are university students, and nulliparous. The Female Genital Self-Image Scale (FGSIS) and a sociodemographic characterization questionnaire were used. Data were analyzed using binary logistic regression and multiple linear regression based on the FGSIS cutoff point for female GSI satisfaction and FGSIS total score, respectively. 915 (24.30±5.48 years) women participated. The mean total FGSIS score was 21.51 ± 4.59 points. 55.52% of the women were classified as satisfied with their GSI. Women who were satisfied with GSI were more likely to report more frequent sexual activity, more gynecological appointments, and older age. Black and Mixed-race women were less likely to be satisfied with GSI than White women. Satisfaction with GSI among Brazilian university women is associated with sexual behavior, gynecological consultations, and sociodemographic factors such as older age and skin color.
Keywords:
Women; Genitalia; Sexuality; Risk factors
RESUMO
A autoimagem genital (AIG) feminina refere-se à forma como as mulheres se sentem em relação aos seus genitais e pode ser influenciada por aspectos psicológicos e comportamentais do bem-estar sexual. No Brasil, recentemente um estudo investigou os fatores associados à satisfação com a AIG masculina, porém não há estudos que tenham investigado na população feminina. O objetivo deste estudo foi analisar os fatores associados à satisfação com a AIG de mulheres universitárias brasileiras. Este é um estudo transversal e online realizado com mulheres brasileiras (>18 anos), universitárias e nulíparas. Foram utilizados o Female Genital Self-Image Scale (FGSIS) e um questionário de caracterização sociodemográfica. Os dados foram analisados por meio de regressão logística binária e regressão linear múltipla, de acordo com o ponto de corte do FGSIS para satisfação com a AIG feminina e a pontuação total do FGSIS, respectivamente. Participaram 915 (24,30±5,48 anos) mulheres. A média da pontuação total da FGSIS foi de 21,51±4,59 pontos. Das participantes, 55,52% foram classificadas como satisfeitas com a AIG. Mulheres satisfeitas com a AIG tinham maior probabilidade de relatar maior frequência de atividade sexual, maior frequência de consulta ginecológica e idade mais velha. Mulheres pretas-pardas tiveram menor probabilidade de estar satisfeitas com a AIG, em comparação com as mulheres brancas. A satisfação com a AIG entre brasileiras universitárias está associada ao comportamento sexual, consultas ginecológicas e a fatores sociodemográficos, como idade mais velha e cor da pele.
Descritores:
Mulheres; Genitália; Sexualidade; Fatores de risco
RESUMEN
La autoimagen genital (AIG) femenina se refiere a cómo se sienten las mujeres respecto a sus genitales y puede verse influida por aspectos psicológicos y conductuales del bienestar sexual. Un estudio reciente en Brasil analizó los factores asociados a la satisfacción con la AIG en la población masculina; sin embargo, no hay estudios que hayan examinado este tema en la población femenina. El objetivo de este estudio fue analizar los factores asociados a la satisfacción con la AIG de las universitarias brasileñas. Este es un estudio transversal y en línea realizado con mujeres brasileñas (>18 años), universitarias y nulíparas. Se utilizaron la Female Genital Self-Image Scale (FGSIS) y un cuestionario de caracterización sociodemográfica. Los datos se analizaron mediante regresión logística binaria y regresión lineal múltiple de acuerdo al valor límite del FGSIS para la satisfacción con la AIG femenina y la puntuación total del FGSIS, respectivamente. Participaron 915 mujeres (24,30 ± 5,48 años). La media total de la puntuación de la FGSIS fue de 21,51 ± 4,59 puntos. El 55,52% de las participantes se mostraron satisfechas con la AIG. Las mujeres satisfechas con la AIG estaban más propensas a declarar mayor frecuencia de actividad sexual, mayor frecuencia de consultas al ginecólogo y una edad más avanzada. Las mujeres de color pardo-negro tuvieron menos probabilidades de estar satisfechas con la AIG en comparación con las mujeres blancas. La satisfacción con la AIG entre las estudiantes universitarias brasileñas se asocia con el comportamiento sexual, las consultas ginecológicas y los factores sociodemográficos, como la edad avanzada y el color de la piel.
Palabras clave:
Mujeres; Genitalia; Sexualidad; Factores de riesgo
INTRODUCTION
Genital Self-Image (GSI) refers to the feelings that arise from interactions and experiences with the genitals1 and can influence sexual interactions2,3. GSI is considered a subset of body image, and women who are satisfied with their appearance report a higher frequency of sexual activity, orgasms and confidence in their sex life4. A positive GSI is also associated with sexual satisfaction4, sexual health, better sexual behaviors5 and high frequency of gynecological exams, as the shame of exposing one’s genitals may prevent a woman from going to the gynecologist6,7.
Several psychological and behavioral aspects of sexual well-being have been linked to GSI7. Age, lower body mass index (BMI), better sexual function, and desire for cosmetic procedures are associated with better female GSI5,8-10. Advertisements for cosmetic surgery of the female genitalia that create a desire for different genitalia may also influence GSI11,12. In this regard, the ease with which pornography and sexually explicit media images are consumed presents an unrealistic pattern of genital appearance and disregards variations in the shape, size, and color of the vulva in the general population7,11-13. For Bedford and Johnson14, social pressure and the media may influence younger women’s body satisfaction. Thus, because of the relationship between body image and genital image, body dissatisfaction may extend to the genital region and affect genital self-image8.
In Brazil, a recent survey investigated aspects of male GSI and its associated factors15, but research carried out with Brazilian women is scarce. Among the existing studies, 30.29% (n=186) of the participants in the Brazilian Portuguese validation study of the Female Genital Self-Image Scale (FGSIS) were classified as dissatisfied2. Furthermore, studies evaluating female GSI observed a mean change in FGSIS total score from 20.95±3.81 to 23.80 ± 3.40 points in young primiparous women8, multiparous16 and with specific pathologies, such as fibromyalgia17, urinary incontinence18, and Mayer-Rokitansky-Küster-Hauser syndrome19.
Although existing studies demonstrate the importance of GSI for overall health, well-being, and its relationship to various factors5,9,15, research on this topic remains limited-especially regarding factors associated with satisfaction with female genitalia. This issue is particularly relevant in Brazil, where no research has been conducted on aspects of female genitalia and related factors. Notably, Brazil has the second highest rate of cosmetic genital surgery. According to the latest data published by the International Society of Aesthetic Plastic Surgery in 2020, referring to procedures performed in 2020, Brazil is the second country in the ranking of surgical aesthetic procedures, reaching a total of 1,306,962 procedures20. Considering this the impact GSI has on women’s self-esteem, self-confidence, quality of life, and emotional and sexual well-being21,22, it is important that health professionals be aware of the factors that influence women’s perceptions of their genitals. This may help to better understand female GSI and its relationship to other variables, such as sociodemographic, clinical, and behavioral characteristics, and guide the assessment and treatment of genital dissatisfaction in clinical practice. Therefore, this study analyzed the number of women satisfied with GSI and the factors associated with satisfaction with GSI among Brazilian university women. Based on the literature, we hypothesize that satisfaction with female GSI is associated with factors such as age8 and BMI9,10.
METHODOLOGY
Study design and ethical aspects
This cross-sectional and online study was conducted from April 2021 to July 2022 and followed the STROBE guidelines, which establish a 22-item checklist for observational studies23. There was no financial benefit to the participants, and consent to participate in the study was obtained voluntarily after explanation of the research and the risks and benefits of participation. Participants were also informed of their right to discontinue their participation in the study at any time without consequence. In addition, no data were collected in a way that could identify any individual. All information collected was kept confidential and used only for statistical analysis.
Population
Brazilian women over 18 years old who were university students and nulliparous were included in the study. Primiparous or multiparous women were excluded because of the effects of changes in pelvic floor anatomy and function during pregnancy, childbirth, and postpartum. Factors such as breastfeeding, perineal trauma from vaginal delivery, vaginal laceration, and episiotomy may be associated with the decline in sexual function in the postpartum period16. Thus, childbirth can affect the image and perception of a woman’s genitalia and sexuality, especially because of its impact on her sexual life and intercourse24.
Transgender individuals were excluded from the study. In addition, participants who reported psychiatric disorders such as schizophrenia and psychosis were also excluded. We decided not to include participants with self-reported psychiatric disorders because these conditions can cause frequent changes in personality or mood that could influence their responses.
Procedure
In this study, we used Google Forms, which contained the questionnaires and the consent form. The research link was sent to the email addresses of public and private Brazilian universities with a request to disseminate the study. Furthermore, the invitation to participate was made available on social networks and instant messaging applications, such as Instagram, Facebook, X (former Twitter), and WhatsApp. The invitation clearly explained the research objectives related to GSI and sexual function assessment.
Measures
The characterization of the sample was analyzed by a questionnaire developed by the authors, including sociodemographic questions (age, skin-color, education, relationship status, and BMI in kg/m2); behavioral (smoking, alcoholism, and physical activity); clinical (associated diseases) and sexual behaviors (sexual orientation, frequency of genital hair removal, cosmetic procedures on the genitals, frequency of pornography consumption, and frequency of sexual acts). The physical activity variable was categorized as “never,” ““once per week,” and “once per week or more”; frequency of gynecological visits was categorized as “never,” “less than once per year,” and “once per year or more”; frequency of genital hair removal was categorized as “never,” “once per week,” and “twice per week or more”; frequency of sexual activity was categorized as “no sexual activity (including virgins),” “once per week or less,” and “twice per week or more.”
To assess female GSI, the FGSIS validated for Brazilian Portuguese was used2. This instrument has 7 items with responses on a 4-point Likert-type scale ranging from 1 (strongly disagree) to 4 (strongly agree). The total score ranges from 7 to 28 points, with higher scores indicating greater satisfaction with the GSI25. To classify women as satisfied or dissatisfied with the GSI, we used the cutoff point ≥22 from the Brazilian version to identify women who were satisfied with the GSI. This cutoff was developed based on item response theory analysis using responses from 614 women2. Therefore, they were divided into two groups: satisfied with GSI (SG) and dissatisfied with GSI (DG).
Statistical analysis
First, the data were assumed to have a non-normal distribution using the Kolmogorov-Smirnov test. Therefore, Mann-Whitney U and Fisher’s Chi-squared or exact tests were used to compare sample characteristics and sexual function between groups of women who were satisfied and dissatisfied with GSI. For the variables that showed a significant difference between the groups in the bivariate analysis, multiple linear regression was conducted with forward insertion and with the total FGSIS score and binary logistic regression with backward insertion method with the cutoff point for satisfaction with the GSI of the study by Arruda et al.2. Multiple linear regression values were presented as F values (degrees of freedom), p value, and adjusted R2. Binary logistic regression results were presented as odds ratios (OR) and 95% confidence intervals (95%CI). A p-value <0.05 was adopted in all tests.
RESULTS
A total of 1,207 women participated in the survey. However, 256 (21.21%) were excluded because they were not nulliparous and 36 (2.98%) because they were not university students. After analyzing the eligibility criteria, 915 (24.30±5.48 years) university students and nulliparous women were included in this study. Of these, 508 (55.52%) were classified as satisfied with the GSI.
Table 1 shows the comparison between groups and sociodemographic, clinical and behavioral characteristics. Compared to the women dissatisfied with GSI, the women satisfied with GSI had a higher mean age (25.32 ± 6.22 years), were White (64.17%), had a partner (66.53%), performed physical activity once a week or more (50.39%), and had gynecological consultations once a year or more (69.88%). Significant differences (p<0.05) were observed between the groups for these characteristics.
Table 2 shows the comparison of sexual behavior between DG and SG. Only the frequency of sexual activity in the last 4 weeks showed a statistical difference between the groups (p<0.001), with a higher proportion reporting sexual activity once per week or less in the SG (50.98%).
Associated factors
In the multiple linear regression analysis (Table 3), the frequency of gynecological consultation, the frequency of sexual activity, age, and skin color significantly influenced the GSI score [F(4, 867) = 34.955, p < 0.001]. For each 1-point increase in the GSI score, the frequency of sexual activity increased by 1.23 points, the frequency of gynecological visits increased by 1.09 points, and age increased by 0.12 points. Conversely, being Black or Mixed-race was associated with a decrease of 0.71 points. Skin color explained the most variation in GSI (13.5%).
Table 4 shows the logistic regression of the variables of characterization and sexual behavior of university women satisfied and dissatisfied with GSI. The variables identified as factors associated with GSI were older age [OR=1.063 (95%CI 1.030-1.096)], one or more gynecological consultations per year [OR=1.867 (95%CI 1.217-2.865)], and sexual activity in the last four weeks once per week or less [OR=1.763 (95%CI 1.128-2.754)] and twice per week or more [OR = 2.681 (95%CI 1.661-4.328)]. Black and Mixed-race women were less likely to be satisfied with GSI than White women [OR=0.693 (95%CI 0.519-0.924)].
DISCUSSION
This study aimed to analyze the factors associated with female GSI among university women. In it, 55.52% of women were satisfied with GSI. However, this finding is worrying, especially in the Brazilian population. This percentage reveals a significant proportion of women dissatisfied with their GSI, which may have a negative impact on their sexual activity and behavior. In the regression analyses, frequency of sexual activity, frequency of gynecological visits, older age, and skin color were factors associated with satisfaction with GSI. In the comparisons between groups, women satisfied with GSI had a higher mean age, were White, had a partner, engaged in physical activity once per week or more, had gynecological consultations once per year or more, and had sexual activity once per week or less.
Considering sexual function and sexual behavior, satisfied women reported higher frequency of sexual activity in the 4 weeks prior to our study. For Rowen et al.5, sexual activity and frequency are negatively associated with genital dissatisfaction, so sexually active women are more likely to report greater satisfaction. In addition, dissatisfaction with GSI is associated with lower levels of sexual satisfaction26. Therefore, satisfaction with GSI is associated with sexual satisfaction9. Concerns about physical appearance and the embarrassment of exposing body parts during sex can lead to a decrease in self-esteem, desire, and pleasure, resulting in low sexual pleasure and poor sexual function27.
According to our results, women satisfied with GSI reported a higher frequency of gynecological visits compared to dissatisfied women. This confirms previous studies6,7 that indicated GSI may be associated with health-seeking behaviors in women, such as routine gynecological examinations. This may be due to several factors. First, better GSI is associated with greater self-esteem and body confidence2,7, which may encourage women to be more aware of their gynecological health and to seek regular medical care. In addition, a positive GSI is associated with greater awareness and knowledge of the importance of routine gynecological examinations6,7,28, which may motivate women to schedule and attend appointments. For example, in the FGSIS development study, the authors also found a significant correlation between recent gynecological visits and higher FGSIS scores25. Another important factor is that a positive GSI is correlated with better sexual health and psychological well-being5,7, which may contribute to greater motivation to seek preventive gynecological care. These results highlight the importance of satisfaction with GSI, not only in emotional and sexual aspects, but also in the adoption of gynecological health care practices25.
Another sociodemographic factor observed was being older, which is also consistent with previous studies. Rowen et al.5 found that in a representative American sample, older women were less likely to be dissatisfied with their GSI. This may be due to the fact that younger women are more susceptible to social and media pressures8 and trends in cosmetic surgery7. The spread of access to pornographic images sometimes reflects a narrow and unrealistic range of genital appearances11-13.
Although the relationship between skin color and satisfaction with the GSI is not well established in the literature, in our study, Black and Mixed-race women were less likely to be satisfied with GSI than White women. This contrasts with findings by Rowen et al.5 and Herbenick et al.28, who found that Black women were less likely to report dissatisfaction with their genitalia than White women. The authors of those studies attributed their findings to cultural differences in intimate aesthetics across communities. The divergence in our results highlights the diversity of the cultural environment in which Brazilian women find themselves.
In this study, women who practiced physical activity once per week or more showed significant differences between the groups of women who were satisfied and dissatisfied with GSI, but associated factors were not considered by adjusted logistic regression. Nevertheless, there was a higher prevalence in those satisfied with GSI. This relationship may be indirectly explained by the acute and chronic effects of exercise on women’s sexual function and body image. For Stanton et al.29, the increased sympathetic nervous system activity and endocrine changes resulting from the acute effects of exercise significantly increased the desire domain of sexual function. The chronic effects of exercise were associated with increased sexual satisfaction, cardiovascular health, improved body image, and increased sexual well-being. Similarly, Silva, Arruda, and Braz15 observed that in Brazilian men, the group satisfied with GSI practiced more physical activities and this may help explain our findings because GSI is an important component of body image.
The relationship status “with a partner” also had a higher prevalence in the women satisfied with their GSI, confirming the literature. For Rowen et al.5, relationship status was associated with GSI satisfaction and was more common among married women. Having a partner who positively stimulates a woman’s body image seems to influence her own genital self-perception. Furthermore, women who receive positive messages from their partners show greater self-confidence and self-acceptance, in addition to empowerment and sexual fulfillment30, which may increase satisfaction with GSI.
This is a cross-sectional convenience study with a sample of female university students recruited online. The recruitment method used may have biased the study toward homogeneous characteristics, with most women being young, White, and without comorbidities. This can also be considered a selection bias, as women with internet access and interest in the study topic participated. However, women may have felt more comfortable responding online, anonymously and confidentially. In addition, the cross-sectional design of this study does not enable causal relationships, although statistical associations are shown. This is because cross-sectional studies collect both exposure and outcome at a single point in time, which prevents analysis of the temporal sequence of events and a more robust understanding of the existence of a causal relationship.
CONCLUSION
A high proportion of university women were dissatisfied with GSI. Satisfaction with the GSI was associated with higher frequency of sexual activity, higher frequency of gynecological consultations, older age, and skin color. It is important for health professionals working in the field of body image and sexuality to be aware of this issue, as satisfaction with GSI may be an indicator of women’s health and sexual well-being. Further studies are needed to examine these factors and their variations in different populations.
ACKNOWLEDGMENTS
We thank the participants for their contribution to the study.
DATA AVAILABILITY
The data underlying this study are available in the published article.
REFERENCES
-
1 Waltner R. Genital identity: a core component of sexual-and self-identity. J Sex Res. 1986;22(3):399-402. doi: 10.1080/00224498609551319
» https://doi.org/10.1080/00224498609551319 -
2 Arruda GT, Silva EV, Somavilla P, Oliveira MCR, Braz MM. Female Genital Self-image Scale (FGSIS): cut-off point, reliability, and validation of measurement properties in Brazilian women. Fisioter Pesqui. 2023;30:e22015823en. doi: 10.1590/1809-2950/e22015823en
» https://doi.org/10.1590/1809-2950/e22015823en -
3 Rouzi AA, Berg RC, Alamoudi R, Alzaban F, Sehlo M. Female genital self-image in women with and without female genital mutilation/cutting in Jeddah, Saudi Arabia. Sex Med. 2020;8(4):752-6. doi: 10.1016/j.esxm.2020.06.010
» https://doi.org/10.1016/j.esxm.2020.06.010 -
4 Ellibes Kaya A, Yassa M, Dogan O, Basbug A, Pulatoglu C, et al. The Female Genital Self-Image Scale (FGSIS): cross-cultural adaptation and validation of psychometric properties within a Turkish population. Int Urogynecol J. 2019;30(1):89-99. doi: 10.1007/s00192-018-3688-1
» https://doi.org/10.1007/s00192-018-3688-1 -
5 Rowen TS, Gaither TW, Shindel AW, Breyer BN. Characteristics of genital dissatisfaction among a nationally representative sample of U.S. Women. J Sex Med. 2018;15(5):698-704. doi: 10.1016/j.jsxm.2018.03.004
» https://doi.org/10.1016/j.jsxm.2018.03.004 -
6 DeMaria AL, Hollub AV, Herbenick D. The Female Genital Self-Image Scale (FGSIS): validation among a sample of female college students. J Sex Med. 2012;9(3):708-18. doi: 10.1111/j.1743-6109.2011.02620.x
» https://doi.org/10.1111/j.1743-6109.2011.02620.x -
7 Schick VR, Calabrese SK, Rima BN, Zucker AN. Genital appearance dissatisfaction: Implications for women's genital image self-consciousness, sexual esteem, sexual satisfaction, and sexual risk. Psychol Women Q. 2010;34(3):394-404. doi: 10.1111/j.1471-6402.2010.01584.x
» https://doi.org/10.1111/j.1471-6402.2010.01584.x -
8 Gomes TBS, Brasil CA, Barreto APP, Ferreira RS, Berghmans B, et al. Female genital image: Is there a relationship with body image? Turk J Obstet Gynecol. 2019;16(2):84-90. doi: 10.4274/tjod.galenos.2019.49799
» https://doi.org/10.4274/tjod.galenos.2019.49799 -
9 Komarnicky T, Skakoon-Sparling S, Milhausen RR, Breuer R. Genital Self-Image: Associations with Other Domains of Body Image and Sexual Response. J Sex Marital Ther. 2019;45(6):524-37. doi: 1080/0092623X.2019.1586018
» https://doi.org/1080/0092623X.2019.1586018 -
10 Amos N, McCabe M. Positive perceptions of genital appearance and feeling sexually attractive: is it a matter of sexual esteem? Arch Sex Behav. 2016;45:1249-58. doi: 10.1007/s10508-015-0680-4
» https://doi.org/10.1007/s10508-015-0680-4 -
11 Davis SW. Loose Lips Sink Ships. Feminist Studies. 2002;28(1):7-35. doi: 10.2307/3178492
» https://doi.org/10.2307/3178492 - 12 Braun V, Tiefer L. The "designer vagina" and the pathologisation of female genital diversity: interventions for change. Radical Psychol. 2010;8(1).
-
13 Green FJ. From clitoridectomies to "designer vaginas": the medical construction of heteronormative female bodies and sexuality through female genital cutting. Sexual Evolut Gender. 2005;7(2):153-87. doi: 10.1080/14616660500200223
» https://doi.org/10.1080/14616660500200223 -
14 Bedford JL, Johnson CS. Societal influences on body image dissatisfaction in younger and older women. J Women Aging. 2006;18(1):41-55. doi: 10.1300/J074v18n01_04
» https://doi.org/10.1300/J074v18n01_04 -
15 Silva EV, Arruda GT, Braz MM. Factors Associated with Satisfaction with Male Genital Self-Image in Brazil. Arch Sex Behav. 2023;52(7):1-10. doi: 10.1007/s10508-023-02656-w
» https://doi.org/10.1007/s10508-023-02656-w -
16 Silva TB, Bulhões TRB, Cirqueira RP, Ferreira JB. Análise da função sexual e imagem genital em primíparas e multíparas pós-parto vaginal. Rev Psicol. 2018;12(39):97-111. doi: 10.14295/idonline.v12i39.982
» https://doi.org/10.14295/idonline.v12i39.982 - 17 Schlemmer GBV, Pereira MB, Braz MM. Autoimagem genital e função sexual de idosas com e sem fibromialgia. Rev Kairós-Gerontol. 2020;23(1):295-307.
-
18 Tavares DI, Souza CG, Pivetta HMF, Braz MM. Existe diferença entre imagem corporal e autoimagem genital de idosas com e sem incontinência urinária? Rev Kairós-Gerontol. 2020;23(1):223-37. doi: 10.23925/2176-901X.2020v23i1p223-237
» https://doi.org/10.23925/2176-901X.2020v23i1p223-237 -
19 Weijenborg PTM, Kluivers KB, Dessens AB, Kate-Booij MJ, Both S. Sexual functioning, sexual esteem, genital self-image and psychological and relational functioning in women with Mayer-Rokitansky-Küster-Hauser syndrome: A case-control study. Hum Reprod. 2019;34(9):1661-73. doi: 10.1093/humrep/dez130
» https://doi.org/10.1093/humrep/dez130 -
20 International Society of Aesthetic Plastic Surgery. ISAPS international survey on aesthetic/cosmetic procedures performed in 2020 [Internet]. 2020 [cited 2024 May 29]. Available from: https://www.isaps.org/it/discover/about-isaps/global-statistics/reports-and-press-releases/global-survey-2020-full-report-and-press-releases-english/
» https://www.isaps.org/it/discover/about-isaps/global-statistics/reports-and-press-releases/global-survey-2020-full-report-and-press-releases-english/ -
21 Zielinski R, Miller J, Low LK, Sampselle C, DeLancey JOL. The relationship between pelvic organ prolapse, genital body image, and sexual health. Neurourol Urodyn. 2012;31(7):1145-8. doi: 10.1002/nau.22205
» https://doi.org/10.1002/nau.22205 -
22 Coelho CG, Giatti L, Molina MDCB, Nunes MAA, Barreto SM. Body image and nutritional status are associated with physical inactivity in men and women: The ELSA-Brasil study. Int J Environ Res Public Health. 2015;12(6):6179-96. doi: 10.3390/ijerph120606179
» https://doi.org/10.3390/ijerph120606179 -
23 Vandenbroucke JP, von Elm E, Altman DG, Gøtzsche PC, Mulrow CD, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): Explanation and elaboration. Epidemiology. 2007;18(6):805-35. doi: 10.1097/EDE.0b013e3181577511
» https://doi.org/10.1097/EDE.0b013e3181577511 -
24 Dominoni M, Gritti A, Bergante C, Pasquali MF, Scatigno AL, et al. Genital perception and vulvar appearance after childbirth: a cohort analysis of genital body image and sexuality. Arch Gynecol Obstet. 2023;307(3):813-9. doi: 10.1007/s00404-022-06826-4
» https://doi.org/10.1007/s00404-022-06826-4 -
25 Herbenick D, Reece M. Development and validation of the Female Genital self-image scale. J Sex Med. 2010;7(5):1822-30. doi: 10.1111/j.1743-6109.2010.01728.x
» https://doi.org/10.1111/j.1743-6109.2010.01728.x -
26 Loewinski T, Östling F, Alehagen S, Grundström H. Translation, cross-cultural adaptation, and validation of the Swedish version of the female genital self-image scale. Sex Reprod Healthc. 2022;33:100758. doi: 10.1016/j.srhc.2022.100758
» https://doi.org/10.1016/j.srhc.2022.100758 -
27 Komon W, Kijmanawat A, Chattrakulchai K, Sarit-Apirak S, Silpakit C, et al. Validation of the Thai version of the Female Genital Self-Image Scale (FGSIS). BMC Womens Health. 2022;22(1):254. doi: 10.1186/s12905-022-01841-8
» https://doi.org/10.1186/s12905-022-01841-8 -
28 Herbenick D, Schick V, Reece M, Sanders S, Dodge B, et al. The Female Genital Self-Image Scale (FGSIS): Results from a Nationally Representative Probability Sample of Women in the United States. J Sex Med. 2011;8(1):158-66. doi: 10.1111/j.1743-6109.2010.02071.x
» https://doi.org/10.1111/j.1743-6109.2010.02071.x -
29 Stanton AM, Handy AB, Meston CM. The Effects of Exercise on Sexual Function in Women. Sex Med Rev. 2018;6(4):548-57. doi: 10.1016/j.sxmr.2018.02.004
» https://doi.org/10.1016/j.sxmr.2018.02.004 -
30 Goldsmith KM, Byers ES. Perceived impact of body feedback from romantic partners on young adults' body image and sexual well-being. Body Image. 2016;17:161-70. doi: 10.1016/j.bodyim.2016.03.008
» https://doi.org/10.1016/j.bodyim.2016.03.008
