Introduction
The first concept for every person at any age is recognizing his physical dimension the physical appearance of the human being creates his first impression. Thompson depicts that body has three dimensions: perception of the physical appearance including the assessment of the weight, size, and body shape; subjective dimension (cognitive-affective) related to satisfaction or concerns over her appearance (1, 2), and the behavioral aspect that points to avoid some of the circumstances that put a person in sight anxiety and discomfort.
The important issue of human physical appearance is the image of her reproductive system (3). Attitude along with the feelings and thoughts on genital appearance could change the woman’s behavior in a variety of conditions in positive or negative ways. This image can be affected by factors such as physical growth, the interaction of the individual with the social environment, accidents, physical injuries, and damage to the reproductive system which causes the concern of the image toward the reproductive system (4). The body image toward the reproductive system is also affected by the family, the media, and friends (5, 6).
Many women, since adolescence, have a sense of self-loathing in their mind towards their body, and by considering the appropriate models of body figures in their mind dissatisfaction occurs. The unhappiness of women could be a result of the gap between subjective perception of oneself in the process of socialization and different characteristics of the ideal woman of culture and society in every historical period.  Sometimes this situation could lead women to be a risk of mental and spiritual conflict, anxiety, lack of confidence, and depression. Given that human learning can be a decisive factor in the development of women's body image, reviewing procedures of socialization, and other social factors can help to understand the tendency of women to the body (7).
  On the other hand, in societies shaped by gender the attention to body among people is different and there are specific social expectations, from men and women, which are more serious in women. In such a situation women compared to men had more attention to their body, resulting in women going under more pressure to the body, physical appearance, and conformity to ideals of beauty (8).
Today,  due to the pretty up and beautifying the body of women, this problem has been the most complex discourse of the last decade in societies, so the need to address this issue will be when to understand the preoccupation, mental and spiritual concern, a distorted image of the body,  dissatisfaction of physical appearance which might involve women to waste up all energy, cost and time to make a priority of achieving and even not considering the other issues that are critical to life; it can also be very effective on the confidence of women and their mental and social health (7).
Cash & Sarwer (2004) in their study mentioned that deep concern of negative evaluation by others, led to dissatisfaction in women's body image (9). The intense concern of negative evaluation by others has resulted in dissatisfaction with the genital image of women (10, 11).  Poor body image of the reproductive system is associated with serious consequences. This increases the harmful surgeries including cosmetic surgery of the labia and use of harmful makeup material to reduce the bad feeling towards their body image and its performance-out (12). In a study by the British Association of Cosmetic and Plastic Surgery in 2007, there was reported 31% increase in cosmetic surgery in the UK and 92% of this increase was accounted for women (13).  The study by Sarwer et.al (2012) with the aim of image disorder of the reproductive tract, in people who have undergone cosmetic treatment, reported that 5 to 15% of people who were looking for beauty treatments suffered from image disorder of the reproductive system. They rarely had experienced improvement with surgery (14). As health care providers play a crucial role in education about the health of the reproductive system, so midwives could take an important step to educate females about the reproductive system function, its natural appearance, and hygiene to encourage patients to obtain accurate information about their body. Sometimes there is a need to reduce the fear and anxiety that can lead to negative perceptions of people about their reproductive tract abnormalities by using booklet or pamphlet containing normal and abnormal reproductive system to eliminate negative perceptions. In some cases, people with negative perceptions need to be referred to consultants to provide sexual health (12).
The results of the cross-sectional study by Marvi et al (2018) showed a significant correlation between genital self-image and sexual satisfaction in infertile women.  They emphasized identifying and treating sexual problems of infertile women in healthcare and infertility centers to promote their sexual satisfaction (15). The results of the study by Veale et al (2014) showed increased dissatisfaction of women towards the appearance of their genitalia, with lower sexual satisfaction and poor quality of life in terms of body image (16). The results of a descriptive-analytic study by Dehghani et al (2012) showed a high satisfaction rate from their body image in high school female adolescents except for the domain of “orientation to the appearance”. It also indicated that the subjects’ satisfaction from their body image was under the influence of BMI index, general patterns of society, and athletes (17). The results of a case-control study by Ekrami et al (2018) showed the poor sexual function of women with less body image satisfaction and their demand for various types of Female Genital Cosmetic Surgery (FGCS) (18).
 According to samples’ questions about negative self-body image towards their genitalia which could express an individual’s attitudes towards her feelings-thoughts and her behavior in positive or negative ways, as well as its importance on the quality of marital life, in addition to the lack of study in this field, this study aimed to determine the relationship between socio-demographic characteristics with the genital self-image in women referred to Qazvin health care centers.
 
MethodsThis cross-sectional study was performed on women between 18-40 years in 5 health care centers of Qazvin, Iran in 2016. From 15 health centers in Qazvin, 5 centers with the largest number of clients with different cultural and socioeconomic status were selected by purposeful sampling. The present study was approved by the Ethics Committee of Tabriz University of Medical Sciences, the ethic code: TBZMED.REC.1394.253, (IRCT code: IRCT201506148170N8). The researcher checked the files in health centers based on inclusion criteria and the phone number of women was extracted; then, they were invited to attend health centers. They completed an informed consent form by assuring them to keep their information confidential. The inclusion criteria were as follows: age between 18-40 years old, Iranian nationality, elementary and higher educational levels, nuli gravida women or with parity of 1-2, both vaginal delivery and cesarean section, with no mental illness according to self-report, lack of reproductive tract diseases, the couple's first marriage, and monogamy, living with her husband permanently (during the past four weeks) and being non-pregnant and non-lactation. The exclusion criteria included women with multiple sexual partners, history of divorce, history of pelvic or any genital surgery, and chemotherapy.
 Data collection tools were questionnaire included socio-demographic characteristics (included age of participants and their spouses, marriage age, educational level and employment status of women, husband's education and occupation, sufficiencyadequacy of monthly income for living costs) and a researcher-made genital self-image questionnaire which developed based on a review of the literature with 20 questions regarding color & size of the genital set, size of labia major and minus, colors of groin & genital area, and pattern of the growth of pubic hair, vaginal canal tight or loose, vaginal canal prolapses and function of the reproductive system. All items of the questionnaire were based on the Likert scale from 1 to 5: 1 (very bad) to 5 (very good) with the score range from 0-100. A score lower than 50 was considered to be inappropriate and higher than 50 was considered to be appropriate genital self-image.
Validity of the genital self-image questionnaire has been approved by content and face validity so that 10 members of the faculty of Midwifery and Psychiatry participated in assessing content validity. After gathering their viewpoints, necessary corrections were made based on obtained feedback. The reliability of the questionnaire was determined by using the test-retest method (ICC= Intra Correlation Coefficient) and internal consistency (Cronbach's alpha coefficient that both were higher than 0.9.
Data were analyzed using SPSS Statistics for Windows, version 16 (SPSS Inc., Chicago, Ill., USA). Descriptive statistics were used to describe the socio-demographic characteristics and the status of genital self-image. Bivariate statistical tests such as independent t-test and one-way ANOVA were used to assess the relationship between socio-demographic characteristics and genital self-image. To control the confounding variables and to estimate the effect of each independent variable (socio-demographic characteristics) on the dependent variable (genital self-image), those independent variables with P-value<0.05 in the bivariate analysis were entered in the general linear model. The P<0.05 was considered significant.

According to bivariate tests, there was a significant statistical relationship between the variables of occupation, women & their husband's educational level, and body mass index with the genital self-image of women (P<0.05) (Table 2).
Based on the adjusted general linear model, there was no statistically significant association between any of the socio-demographic characteristics and genital self-image (Table 3).
In this study, there was no significant relationship between the age of man and woman, age and duration of the marriage, the number of sexual activities over a month, and genital self-image. This result contrasts with the research results of Haghighatian et al (2012), since there was a negative correlation between age and body image, with a significant relationship between marital status and body image, in other words, singles were better than married females in terms of their body image (7). This discrepancy could be due to differences in the population studied in the research. In this study, the results are related to research that has been done in Iran and has its pros and cons. The reason for these differences in this study might be due to the target groups and their different characteristics. Girl students, many of whom were single and satisfied with a different mental image had differed from older females with ethnic groups and different characteristics. Research studies on adolescents show that adolescents were satisfied with their body image, which changed with age.

 

The results of the present study showed that the majority of women had moderate genital self-image, but there was no significant correlation between socio-demographic characteristics and genital self-image. Because there was no study regarding this field in the literature review, so the researcher was focused to use women's studies relating to body image towards the whole body.
The study by Momoni et al. (2016) about predictors of body image dissatisfaction at Qazvin University of Medical Sciences expressed that 27.8% of students had mild to severe dissatisfaction with their body image )19(. Results of Moghimian’s study which carried out on students of Najaf Abad Islamic Azad University showed that 34.4% of students had body image satisfaction levels from moderate to poor. The students of Sport& physical education and Art had the least and most considered attention to their genital appearance, respectively (20); Safavi and colleagues also reported 87% negative satisfaction among students of Tehran Islamic Azad University (21). 
The study by Thomas et al in the United Arab Emirates showed that 8.74% of students were satisfied with their body image (22) and in research by Moussa 21.2% of participants showed image dissatisfaction (23); Chen et al in Taiwan stated that less than 20% of girls were satisfied with body image and mean scores of satisfaction was low (2.7) on the evaluation of appearance (24).
The results by Mellor and colleagues in Malaysia also showed that Chinese girls (15.84±3.85) were dissatisfied compared to Malaysian girls (14.83¬±3.89) and India (14.08±3.88) from different parts of the body (25). In the study by Xu and colleagues (2010) in China, scores of body image satisfaction from different parts of the body were low (26); However, other researchers have achieved opposite results so that based on the findings of the Dehghani and colleagues (2012), body image satisfaction was at the upper limit among adolescent girls which indicated a sense of physical attractiveness and high satisfaction of the subjects’ appearance and satisfaction of various parts of the body (24, 27).
In the study by Kelly and colleagues in Minnesota, 27% of teenage girls were very satisfied with different parts of their bodies (28). The results by Kornblau et al. (2007) study in South Texas, USA also showed high satisfaction of the participant’s body image (29). High research results could be inconsistent due to differences in study populations and the effects of different social and cultural environments on body image satisfaction. The study by Sanchez and Kiefer (2007) showed that the attitude of women of body image during sexual activity may be due to misunderstanding and false standards of physical appearance so that this misunderstanding of the body image causes genital obsession and attention to physical defects (30).
There was no significant statistical relationship between socio-demographic characteristics and genital self-image. The research findings do not match with the study by Moghimian et al (2013) because their study showed a significant relationship between body image and satisfaction with economic status (20). This issue also did not match with the study findings of western societies )31, 32( & India (33).  The lack of a significant relationship between socioeconomic status and body image in the results of Neumark et al (34) confirms the results of the present study. The results by Haghighatian et al. (2012) also showed that family as another vital ingredient of social life has a major influence on the proper formation of body image. This means that if a person is at the greatest risk for negative stimuli by families, the body image score is lower. Friends and acquaintances are also factors that affect the formation of body image among women and the attitude around the body affects the formation quality of body image.  However, when this influence is negative, i.e. what people think is important for the person, their body image might be more negative (7). On the other hand, Moghimian showed no significant relationship between body image and their life (20).
One of the limitations of this study was purposeful sampling which reduces the generalizability of the findings; therefore, as a recommendation, further studies in this area should be done with random sampling in other cities. Moreover, because the questionnaires for gathering data have been filled by self-completing method, the respondents might not have correctly picked the questions and give the correct answers to them. It can also be noted that despite researchers’ assurances about the confidentiality of their information, in some cases, the participants may not give properly correct answers to the questions.