Female Sexual Functioning, Self-genital Image and Sexual Anxiety: Mediating Role of Awareness the Moment

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Introduction
Female sexual function is often defined as a function related to sexual desire, mental and physical stimulation, orgasm and pain that is an important part of a female's life, which is associated with the relationship of quality and psychological well-being (Gunst, Ventus, Kärnä, Salo, & Jern, 2017).Sexual desire and arousal disorders are very common among female sexual dysfunction.Despite the high prevalence of female sexual disorders, their sexual problems have been neglected.A few types research has examined the psychological and physical aspects of sexual dysfunction in female and fewer treatments for these sexual disorders has been proposed than male with sexual problems (C.Rosen et al., 2000).Dysfunction can occur in any of the four sexual response stages, although some types of research indicate that its high frequency in the first stage.C. Rosen et al. (2000) identified a range of factors that may contribute to creating and maintaining of sexual dysfunctions.The most fundamental psychological factor that focuses on both person and relationship is the sexual performance anxiety (McCabe, 2005).Sexual anxiety is defined as a tendency to experience the tension, discomfort, and anxiety about the sexual aspects of life (Snell, Fisher, & Walters, 1993).However, the sexual anxiety is the central component of other more public structures such as sexual self-concept and sexual distress (Andersen & Cyranowski, 1994).
Sexual performance anxiety occurs among male and female who experience obsessiveconcerns with sexual performance (Masters & Johnson, 1970).The performance anxiety is associated with the excessive need to satisfy the partner's consent in the sexual relationship.
Focusing on performance rather than enjoyment and personal satisfaction, it increases the level of performance anxiety as subsequent failures and acts as a barrier to the proper sexual function of the individual.Performance anxiety leads to the formation and maintenance of erectile dysfunction and other sexual disorders in male as well.Hawton, Gath, and Day (1994) showed that performance anxiety was experienced with erectile dysfunction in male and with orgasmic disorders in female.Female with orgasmic problems may feel that their husbands tried to arouse them or they should experience orgasms in order to attract partner satisfaction.
In this case, they may monitor their arousal levels, and feel anxiety and worry if they feel that they are not aroused quickly enough (McCabe, 2005).
On the other hand, the sexual dysfunction may occur due to various physical or mental issues.Some of researches reveal that one of the most important psychological factors that affect female's sexual health is the body image (Felix et al., 2017).Body image is an important concept for examining satisfaction or dissatisfaction with the sexual relationship.For example, worrying about physical appearance leads to decreasing the self-esteem, desire, and pleasure (Wiederman, 2000).Sexual problems caused by body image are not classified as sexual disorders, but these concerns may prevent female from engaging in sexual pleasure (Stuerz, Piza, Niermann, & Kinzl, 2008), that can have a negative effect on sexual satisfaction and function (de Brito et al., 2012).
Recent types of research have shown that certain elements of body image are more effective on female's sexual experiences.Therefore, researchers have recently focused on the studies on their genital image as one of the body components that is involved in female sexual concerns.The idea of self-genital image has originated from the genital identity.That is now the subset of body image and includes the person feelings and attitudes about his genitalia (Felix et al., 2017).The concept of self-genital image was first introduced by Waltner (1986), who invented the genital identity.The studies showed that self-genital image is a better predictor of female sexual problems.In addition, a positive self-genital image has been correlated with increasing confidence, more satisfied sexual experiences, and more sexual pleasure (Pakpour, Zeidi, Ziaeiha, & Burri, 2014).
The studies on body image have focused on beauty, weight, skin color extensively, and often have ignored questions about self-genital image (Grabe, Ward, & Hyde, 2008).Neglecting of this issue is an important point, because the studies show that female are conflicting with negative self-genital image (L. A. Berman, Berman, Miles, Pollets, & Powell, 2003;Herbenick et al., 2011).Generally, female report more negative feelings about their genitals than male (Reinholtz & Muehlenhard, 1995), as researchers began to develop instruments such as the Female Genital Self Image Scale (FGSIS) (Herbenick et al., 2011), and a Genital Appearance Satisfaction (GAS) Scale (Bramwell & Morland, 2009) to measure the relationship between the self-genital image and body satisfaction.Since genital organs are the center of sexual experiences, dissatisfaction with the appearance of the genitalia causes people to feel dissatisfied with their ability to provide sexual pleasure for their partner in sexual function (Amos & McCabe, 2016).The appearance management turns one person into an observer during sexual intercourse and leads to a reduction or discontinuation of attention to physical feelings.The process of considering physical feelings is a good experience, and it makes when a person is completely immersed in a valuable task and loses his self-awareness temporarily.Person thoughts about the physical appearance of the body lead to the lack of concentration on his senses during sexual intercourse.Some psychologists attribute the lack of arousal and sexual pleasure in female to poor inner consciousness and self-awareness of the body image (D.M. Bishop, 2015) so that sexual problems are accompanied by increasing cognitive distraction during sexual activity (Nobre & Pinto-Gouveia, 2006).This distraction may cause problems for female in regard to sexual feelings of their bodies and damage the sexual desire experience that often appears from sexual arousal (Basson, 2000), because they do not pay attention to emerging arousal, or judge their answers negatively.Hence, mind-awareness can prevent this cognitive distraction.Mind-awareness is an intellectual practice of observing the present moment thoughts, excitements, emotions, and physical feelings in a non-judgmental way (S.R. Bishop et al., 2004), so it regards as an intuitive treatment for sexual problems.Although a few studies have been conducted on mind-awareness and its relation to sexual satisfaction, the studies have focused on each structure separately.
Accordingly, it is possible that aspects related to mind-awareness be associated with greater satisfaction of sexual relationship positively.Those with a higher mind-awareness have a better relationship with their partner and experience more satisfying sexual relationship (Khaddouma, Gordon, & Bolden, 2015).People with a higher mind-awareness may achieve better sexual life and better sexual function than those with lower mind-awareness.Sex therapists often observe that the main cause of sexual dysfunction is their inability to focus on arousing stimuli (Lazaridou & Kalogianni, 2013).
Awareness of the moment is defined as continuous monitoring of experience or focuses on current experience rather than mental activity with past and future events (Cardaciotto, Herbert, Forman, Moitra, & Farrow, 2008).Research on the effects of awareness of the moment has increased as a part of developing research in the field of mind-awareness, dozens of studies have reported that awareness of the moment as a general state is related to psychological benefits such as decreasing anxiety and depression symptoms, reducing stress, increasing mood, and improving well-being (Donald, Atkins, Parker, Christie, & Ryan, 2016).Negative thoughts and feelings often arise from negative mental ruminations about the past or anxiety about the future.Preserving the focus on the present moment requires developing exercises that increase awareness (Brody, Scherer, Turner, Annett, & Dalen, 2018).
Many people are trying to escape these thoughts, feelings, and physical sensations associated with it when facing with anxiety.Unfortunately, strategies that some people take to avoid their anxiety often make this anxiety worse (Chambers, Gullone, & Allen, 2009).Although Masters and Johnson (1970) probably did not have any knowledge of mind-awareness, but Masters and Johnson's sensory focus technique and mind-awareness meditation are similar (Weiner & Avery-Clark, 2014).Anxiety may perceive and direct an individual's automatic thoughts that create and maintain disorders of desire, pain, arousal, and orgasm.As a result, the processes related to anxiety often create useless beliefs about one and sexual desires.
Fortunately, mind-awareness can be a catalyst for changing the relationship context that a person has with her own experiences and by reducing the fusion between him and the thoughts associated with anxiety lead to more emotional regulation (Kimmes, Mallory, Cameron, & Köse, 2015).
As a result, we concluded the various factors influences on sexual function and leads to strengthening or interfering with it.Therefore, in this study, we have tried to predict sexual function through genital image and sexual anxiety.Moreover, we have studied the mediator role of awareness of the moment.

Participants and procedure
Participants included 300 married female aged 18 to 50 years old (M =31, SD = 2.85).Most of the participants had completed high school education (37.1%).The average participant's length of relationship was 5 (SD = 2.25).The researchers invited all female volunteers to participate in the study by referring to different urban areas in order to select the sample.
Each volunteer responded to the physical forms of four questionnaires for 45 minutes.After approval by the Ethics Committee of XXXX (blinded for review purposes), informed consent was obtained from all individual participants included in the study.2000), with 19 questions, measures female sexual function in 6 independent areas of desire, mental stimulation, humidity, orgasm, satisfaction, and sexual pain.According to the questionnaire manual, the score of each area was obtained through the summation of questions' scores in each field and its multiplication by the factor number.Since the number of questions in the areas in the FSFI questionnaire is not equal to each other, the scores are first combined for each area to weigh the areas and then multiplied by the factor number.

Measures
Scores considered for questions 1-The area of desire (1-5) and 2) The area of sexual excitement, 3) Vaginal moisture, 4-Orgasm, 5-Pain (5-5), and 6) Sexual satisfaction (5-1), or 0).A zero score indicates that the person did not have sexual activity during the last 4 weeks.Based on weighing the areas, the maximum score for each field and for the whole scale will be as much as 6 and 36, respectively.The Persian version of FSFI (Fakhri, Pakpour, Burri, Morshedi, & Zeidi, 2012) has a good internal consistency that for each of the areas and the total scale was as much as 0.70 and higher.The instrument validity also revealed that its convergent validity with Luke Wallace's marital adjustment questionnaire was 0.51 that supports its convergent validity and its divergent validity with the DASS questionnaire in three subscales of depression and anxiety and stress was 0.470, -0.270, and -0.370, respectively.The obtained values with the sexual distress questionnaire and with the negative emotion and with positive emotion were as much as -0.560, -0.240, and -0.380, respectively (Wiegel, Meston, & Rosen, 2005).The alpha coefficient of the instrument and its subscales of the present study are presented in Table 1.
Sexual Anxiety Questionnaire: The Sexual Anxiety Subscale of the Multidimensional Sexuality Questionnaire (MSQ) (Snell et al., 1993) used for measuring the anxiety variable.This questionnaire has 20 subscales that can be said it is the most complete questionnaire about sexual self-concept.MSQ has 100 questions and its responses are formed based on a 5point Likert scale of 0 (it is not true at all to me), 1 (it's very low about me true), 2 (to some extent true in me), 3 relatively is true in me), 4 (it is true very much in me).The score of each subscale is from 0 to 20.In this study, only the sexual anxiety subscale of this questionnaire was applied.This subscale has five questions that include questions 1, 21, 41, 61, 82 without reverse-scoring.The internal consistency of MSQ anxiety subscale obtained 0.84 by Snell et al. (1993).The structural and differential validity of the scale was acceptable (Ramezani et al. 2016).The alpha coefficient of this scale in the present study is presented in Table 1.

Self-genital image questionnaire:
The scale of the self-genital image (Herbenick et al., 2011), measure the self-genital image variables.This scale assesses the female's feelings about their genitals.It has seven items and two sub-components: 1-Intrapersonal concerns that include questions 1, 2, 4, 5; 2-Interpersonal concerns that include questions 3.6., 7. The respondent must determine the extent of his/her agreement or disagreement on a Likert scale of 4 -point, from 1 (strongly disagree) to 4 (strongly agree).The range of scores is from 7 to 28.A general score is obtained from the sum of scores and the higher scores represent the more positive self-genital image.The reliability of the Persian version for total scale, factor 1 (intrapersonal concerns), and factor 2 (interpersonal concerns) were 0.81, 0.86 and 0.89 respectively (Pakpour et al., 2014).In terms of validity, all the items of this scale were significantly correlated with each other (Pakpour et al., 2014).Felix et al. (2017) obtained the Cronbach's Alpha as much as 0.81 for this instrument that indicates its high reliability.
Construct validity was also shown through a low correlation with the Rosenberg Self-Esteem Questionnaire.The alpha coefficient of the instrument in the present study is presented in Table 1.
Five Facet Mindfulness Questionnaire (FFMQ): We used FFMQ (Baer, Samuel, & Lykins, 2011) to measure the awareness of the moment.This instrument is a 39-item self-report scale with five factors including acting with awareness, describe, non-judge, non-react, and observe.The respondents must express their agreement or disagreement rate with any phrases on a Likert scale of 5 degrees from 1 (never) to 5 (always).The scores range on this scale is 39-195.A higher score on the FFMQ shows higher levels of mindfulness.Questions 22-12-16-5-8-13-18-23-28-34-38-3-10-14-17-25-30-35-39 has reverse scoring.FFMQ has good psychometric features (Baer et al., 2008).Goldberg et al. (2016) reported internal consistency reliability estimates for the FFMQ in the one study as adequate: α = 0.89, 0.92, 0.89, 0.79, 0.80, and 0.92 for acting with awareness, describe, non-judge, non-react, observe, and total scores respectively.In investigating the psychometric properties of this questionnaire in Iran, the test-retest correlation coefficients were found between r = -0.57(non-judge factor) and r = 0.84 (observe factor).Also, alpha coefficients obtained in an acceptable range (between α = 0.55, on the non-react factor and α = 0.83 for the describe factor) (Heydarinasab, 2013).Johansen et al. ( 2017) also found the reliability of the subscales of this instrument was very good, and Cronbach's alpha for its subscales was from 0.71 to 0.90.The alpha coefficient of the instrument in the present study is presented in Table 1.

Results
Descriptive findings regarding the sexual function and its components, awareness of the moment, genital image and its components, and sexual anxiety were presented in Table 1.Based on the proposed model, sexual function is considered as an endogenous variable, genital self-image and sexual anxiety as an exogenous variable, and the awareness of the moment as a mediator.In using the structural equation modeling method, it is necessary to examine the assumptions before data analysis.In this research, some of the most important assumptions of structural equation modeling method including missing data, outlier data, multivariate normality and multicollinearity were checked.Results showed that all the assumptions were confirmed.Also, the results of the normality data test are presented in Table 2.As can be seen in Table 2, the assumption of normality for all variables was confirmed.The correlation matrix of the research variables is presented in Table 3.

Results related to testing the proposed model
Based on the main hypothesis of the research, genital image and sexual anxiety can predict sexual function mediating by the awareness of the moment.The results of the analyzed model are presented in Figure 1.The results of the direct relationships between variables in the proposed model show that all path coefficients between the variables were significant.The parameters of direct relationships are presented in Table 4.

Table 4. Parameters of direct relationships of variables
To evaluate the proposed model, its fitness indicators were analyzed.The results of the analysis showed that Model Chi Square (CMIN/DF), Root Mean Square Error of Approximation (RMSEA), Comparative Fit Index (CFI), Goodness of Fit Index (GFI), Adjusted Goodness of Fit Index (AGFI), Normed Fit Index (NFI), and Tucker Lewis Index (TLI), were 2.74, 0.06, 0.98, 0.95, 0.92, 0.98 and 0.98 respectively.The fitness indicators imply fitting the model to the data.In general, about 36% of variance of sexual function variable was predicted by model variables.
In this research, the significance of indirect relationships of variables was tested through Sobel test.Table 5 presents the results of indirect mediation testing.As shown in Table 5, the indirect effects of both genital self-image and sexual anxiety variables on sexual function mediated by awareness of moment were significant.

Discussion
Our purpose of this research was to predict the sexual function through the genital self-image and sexual anxiety mediating by the awareness of the moment in married females.The results showed there is a significant relationship between the genital self-image and sexual function in the female so that if the genital self-image was positive, they have better sexual function and the negative genital image is not associated with a proper sexual function.This conclusion is confirmed by other studies (L.Berman & Windecker, 2008;L. A. Berman et al., 2003;Lordelo, Brasil, Lerche, Gomes, & Martins, 2017;Sarhan, Mohammed, Gomaa, & Eyada, 2016).
The apparent beauty is important for humans.The person's body image is the set of perceptions and feelings that a person has about his body.This apparent beauty for females is more important than males because they are equally commended and acclaimed in society.Since the body image in females is more important and they pay more attention to their bodies during sexual intercourse, this issue can cause more stress during the sexual intercourse.Particularly, the genital organs are the center of sexual experience, which are very important.The genital self-image is the person's feelings and thoughts about his genital organs.A positive genital image is associated with higher self-esteem, greater sexual intercourse, sexual health, sexual pleasure, reduced distress, and low sexual anxiety.
The genital organs and its beauty are very important for female.The negative attitude of females towards their genital organs causes them to always pay attention to their genital organs and the partner's response during sexual intercourse.They are concerned that their genital organs are not attractive to their partner and cannot provide enough pleasure to him.This excessive awareness and attention to genital organs cause the person to have no attention to the sexual intercourse and does not enjoy it.This can disturb the female's sexual function.
The results also showed that there is a relationship between sexual anxiety and sexual function.
According to research findings, female with higher sexual anxiety have a weaker sexual function and lower sexual anxiety is associated with a proper sexual function.Female sexual function is affected by physiological and psychological factors.One of these psychological factors is sexual anxiety.Sexual anxiety arises for a variety of reasons.This anxiety can be the cause of many female sexual dysfunctions and it should be given a special attention to the treatment of sexual dysfunction.Sexual intercourse is not just a physical act but also is influenced by the thoughts and feelings of the individual, and if the person has anxiety and concern, the body is not aroused.Female with sexual anxiety for any reason focuses on sexual function and the response of the other party, instead of focusing on sexual intercourse and enjoying it.That makes her mind always engaged in topics other than her current sexual intercourse.When the person's mind is involved and there is no arousal and mental stimulation, physical stimulation is not created.This issue in female makes the vagina moisture insufficient.On the other hand, anxiety during sexual intercourse completely unconsciously causes the vaginal muscles to contract.This contraction of the vagina muscles and lack of adequate moisture in female makes it extremely difficult for them to engage in vaginal ingestion, which causes severe pain, lack of orgasm, and failure in sexual function.This defeat for female means sexual incompetence and makes it possible to avoid sexual intercourse in order to avoid this painful experience that can become a permanent cycle (Bigras, Daspe, Godbout, Briere, & Sabourin, 2017;Lin, Huang, & Chu, 2017); (Bigras, Godbout, & Briere, 2015;Bradford & Meston, 2006;Brassard, Dupuy, Bergeron, & Shaver, 2015;De Lucena & Abdo, 2014;Purdon & Watson, 2011;Van Minnen & Kampman, 2000;Watts & Nettle, 2010).
In the case of relationship between the genital self-image and momentary awareness, our findings confirm current research in this area (Arora & Brotto, 2017;Benedict et al., 2016;Pintado & Andrade, 2017;Prowse, Bore, & Dyer, 2013).The results showed there is a relationship between the genital self-image and momentary awareness.This means that female has a more desirable genital image as well as a higher momentary awareness, and vice versa.The genital self-image is the subset of body image and momentary awareness is one of the components of mindfulness.Female with a higher mindfulness have a better body image.Mindfulness helps these females to improve their body image using acceptance, non-judgment, and the momentary awareness.In fact, mindfulness helps We found that there is a relationship between sexual anxiety and momentary awareness in married females.This finding was consistent with the previous studies (L. A. Brotto, Seal, & Rellini, 2012;Silverstein, Brown, Roth, & Britton, 2011) People who have high momentary awareness have a higher genital self-image and sexual function.
People with a negative genital image also experience difficulty with sexual function because they are concerned about the appearance of their genital organs during sexual intercourse rather than focusing on sexual intercourse and their minds are involved with this issue.The excessive self-awareness of the genital organs and paying attention to the spouse's reaction to their genital organs attracts all their attention and concentration.In this way, female are ashamed of their genital organs.This issue can cause problems in the sexual function.Sexual failure is also accompanied by anxiety, depression, decreased self-esteem, reduced frequency of sexual intercourse and low sexual pleasure.However, those who have high awareness do not let their oppressive thoughts automatically affect their reactions.They confront these thoughts and fully perceive feelings and thoughts about their current experience.They try to enjoy their current sexual intercourse instead of unrelated concerns.
According to the findings of this hypothesis, the momentary awareness seems to modify the relationship between the genital self-image and sexual function.In other words, the person's perception of his\her genital image increases his\her sexual function by focusing on the momentary awareness.It is accepted that a positive genital image with the momentary awareness can improve the sexual function.
The results also confirmed the relationship between sexual anxiety and sexual function through the momentary awareness.People who have a higher momentary awareness have less sexual anxiety and therefore have a better sexual function.Sexual anxiety affects the sexual function of the individual and makes disorders.Anxiety is caused by a variety of reasons, making it difficult for a person to have sexual intercourse and this makes him\her always monitor and review his\her function.This issue makes the person always worried and minded.This mental conflict prevents mental stimulation, followed by the physical inactivity.Therefore, the lack of adequate moisture in the vagina and contraction leads to a painful sexual experience and lack of orgasm.Failure in the sexual intercourse increases the sexual anxiety and avoidance of sexual activity.However, those who have a high momentary awareness do not escape from sexual anxiety but encounter their thoughts and feelings, stop the thoughts, fully understand the moment they are in it, and enjoy sexual intercourse.According to findings from this hypothesis, the momentary awareness seems to modify the relationship between anxiety and sexual function.In other words, sexual anxiety decreases by focusing on the momentary awareness, and thus, the sexual function is improved (Bradford & Meston, 2006;Brassard et al., 2015;Khaddouma et al., 2015;Lazaridou & Kalogianni, 2013;McCabe, 2005;Van Minnen & Kampman, 2000;Watts & Nettle, 2010).
In general, it can be said that one of the factors that cause sexual anxiety is the concern about the appearance of the genital organ.This is especially important for females because beauty and attraction are important for female and they are praised and acclaimed based on the beauty in the community.
Female are more concerned about their bodies and genital organs during the sexual intercourse.On the other hand, those who have higher momentary awareness better respond to the negative genital image that accompanies sexual anxiety and subsequent inappropriate sexual function.This awareness helps female with the negative genital image facing and experiencing their feelings, emotions, and physical feelings with regard to their negative genital self-image and anxiety instead of avoiding sexual intercourse.This will reduce their pain and sorrow.
One of the limitations of our study is the use of an available sampling method.In generalizing the findings should be taken it into account.Also, we used a self-report questionnaire to collect data that could have limitations on self-reporting tools, especially as the content of the tools was related to the private relations of individuals.Another limitation of our study was that it relied on correlational analysis which does not reveal the casual relationship among research variables.Also, the present study was conducted only with females.It is recommended to conduct this research in male in order to provide the possibility to compare the gender variable.It also seems that one of the variables that can affect the genital image, sexual anxiety, and sexual function of a person is the attitude of the spouse.Thus, it is suggested to investigate this variable in future studies.

Figure 1 .
Figure 1.Model of awareness of the moment as a mediator of the relation of sexual anxiety and genital selfimage to sexual function female not judge their oppressive thoughts about their body image and confront them instead of avoiding these thoughts.The genital image is the emotions and thoughts of the individual about his\her genital organ.The negative feeling about the genital organ negatively affects the sexual intercourse.The momentary awareness is the main part of mindfulness and mindfulness is directing the mind towards the moment.The momentary awareness is the expression of the present experience and its perception without judgment.The momentary awareness that focuses on the feelings and thoughts of the present experience prevents the individual from automatically responding to his\her experiences and wants the individual to focus on his\her current experience, thus, it automatically stops the negative thoughts on the genital image.People who have high momentary awareness have a positive genital self-image because they live in the moment and enjoy the moment without grief over the past and worry about the future.

Table 1 .
Descriptive findings of sexual function and its components, awareness of moment, genital image and its components, and sexual anxiety

Table 2 .
Kolmogorov-Smirnov test results for data normality

Table 3 .
Correlation coefficients among sexual function, awareness of the moment, genital self-image and sexual anxiety

Table 5 .
Results of indirect effects of genital self-image and sexual anxiety on sexual function mediated by . People with higher momentary awareness have less sexual anxiety and vice versa.Sexual anxiety is caused by a variety of causes and is the cause of many sexual disorders.People who suffer sexual anxiety try to escape from dealing with anxietyrelated emotions and thoughts as well as anxiety-related physical anxiety.People who have less momentary awareness are more likely to use avoidance strategies, but those who have more momentary awareness try to face the emotions and feelings associated with it and get rid of this anxiety without any avoid.They facilitate the management of anxiety by creating an inferior quality mental state with the momentary awareness.Mindfulness helps one concentrate on the experience of his\her moment without judgments.Sexual anxiety creates inappropriate beliefs about oneself and sexual desires.The momentary awareness helps with better emotional regulation by reducing the association between self and these negative thoughts about anxiety.