there are an estimated 3.5 million middle aged women in iran . ; this number is growing due to the increased life expectancy among women ( 2 ) . due to advances in medical care , about 95% of women reach the age of menopause in their middle age ( 3 ) . hot flashes , night sweats , and vaginal / urinary symptoms are the physical symptoms of menopause . in addition to the physical symptoms , irritability , mood disorders , anxiety , stress , low self - esteem , emotional instability , and slow memory are among the psychological symptoms of menopause . these disorders can have negative impacts on the physical , psychological , and sexual health of women ( 4 ) . as a number of previous studies have indicated , sexuality has an undeniable impact on marital satisfaction ( 57 ) . furthermore , quality of life is lower in menopausal women due to the high prevalence of sexual dysfunction ( 2 ) . in a previous study , the frequency of sexual dysfunction was 38.5% and 72.4% among premenopausal and postmenopausal women , respectively ( 8) . also , the prevalence of sexual dysfunction among iranian women has been estimated at 31.5% ( 9 ) . based on the literature , the prevalence of sexual arousal , lubrication , orgasm , and pain disorders was 66.4% , 38% , 34.8% , and 38.4% , respectively among iranian women ( 10 ) . although physical factors ( particularly low levels of hormones such as estrogen ) play an important role in sexual dysfunction among middle - aged women , the significance of psychological factors can not be ignored . factors such as depression , anxiety , psychotic symptoms , low self - esteem , negative body image , and low sexual activity are the primary psychological symptoms of menopaus . body image is an individual s perception of the aesthetics or sexual attractiveness of his / her body . body image , which is related to an individual s perception of his / her body , includes beliefs , thoughts , and feelings about physical appearanc . an individual s social and marital function , interpersonal relationships , and quality of life can be affected by negative body image ( 11 ) . middle age is associated with high psychosocial functioning , major changes in life ( such as the loss of a supportive relationship ) , biological changes , negative attitudes towards menopause , uncertainty regarding one s future , and depression . therefore , maintaining a high quality of life is relatively difficult during this period ( 12 , 13 ) . unfortunately , there is insufficient data regarding body image and its impact on life among postmenopausal women . therefore , in this study , we aimed to determine the relationship between body image and sexual function in middle - aged women . in this cross - sectional study , 437 middle - aged women , who were referred to public healthcare centers of ahvaz , iran during 20142015 , were selected through simple random sampling . considering the scarcity of similar research , a pilot study was performed on 67 qualified women ; the sample size was calculated at 437 cases . literate , married women , who were sexually active , were recruited in this study . the exclusion criteria were as follows : 1 ) prior history of surgical interventions , e.g. , hysterectomy and mastectomy ; 2 ) depression or other mental disorders ; 3 ) polygamy ; 4 ) having a partner with a mental illness or sexual disorder ; 5 ) chronic diseases such as cardiovascular diseases , diabetes , and asthma ; 6 ) history of infertility and use of medications affecting sexual activity ; and 7 ) obesity ( body mass index  30 kg / m ) or malnourishment ( body mass index  18.5 kg / m ) . in this study , a demographic questionnaire , consisting of two sections , was applied . the first part included demographic information , while the second part was related to sexual matters . the reliability and validity of this questionnaire have been assessed by zolfaghari and zargar shoushtari ( 13 ) . in addition , female sexual function index ( fsfi ) and body shape questionnaire ( bsq ) were used for data collection . fsfi is a multi - dimensional , self - report instrument for evaluating one s satisfaction with his / her sexual relationships . it is composed of 19 items , assessing six domains of sexual function in women , i.e. , sexual desire , arousal , lubrication , orgasm , sexual satisfaction , and pain . the score of each domain is calculated by adding up the item valuation and multiplying the sum by the domain factor . the total fsfi score is calculated by determining the collective total of all six domains of sexual function , with higher valuation indicating better sexual function . the validity and reliability of fsfi had been assessed by fakhri et al . in 2008 , satisfactory findings were reported with a cronbach s alpha of 0.66 ( or above ) for sexually dysfunctional samples and a cronbach s alpha of 0.70 ( or above ) for sexually active samples ( 15 ) . bsq is composed of 34 items , assessing one s body shape satisfaction and body shape preoccupations , particularly bulimia nervosa and anorexia nervosa over the past four weeks . to determine the outcome , a five - point likert scale is applied , with valuation ranging between 34 and 170 ; higher valuations indicate greater dissatisfaction with body shape . the reliability and validity of this scale had been previously assessed by zeyghami and colleagues ( 16 ) . in total , 10 public healthcare centers were selected through simple random sampling ( five from each region ) among 23 public healthcare centers in ahvaz , iran . middle - aged women who were eligible for the study ( with an even record number ) were selected and invited to participate in the study . volunteers who failed to meet the inclusion criteria were excluded from the study and replaced . overall , 750 women were assessed based on the inclusion and exclusion criteria , among whom 500 cases were considered eligible . by reason of the majority of the participants being arabs , a native assisted us with data collection . the demographic questionnaire , fsfi , and bsq one - way analysis of variance ( anova ) and chi - square tests were used to analyze the quantitative and qualitative data , respectively . also , spearman s rank correlation coefficient test and logistic regression analysis were used to assess the relationship between body image preoccupations and sexual function in women . data were analyzed using spss version 21 ( ibm corp . , armonk , ny , usa ) . this study was approved by the research ethics committee of ahvaz jundishapur university of medical sciences ( code : ajumc.rec.1393.2204 ) . written informed consents were obtained from all the participants prior to data collection . in this cross - sectional study , 437 middle - aged women , who were referred to public healthcare centers of ahvaz , iran during 20142015 , were selected through simple random sampling . considering the scarcity of similar research , a pilot study was performed on 67 qualified women ; the sample size was calculated at 437 cases . literate , married women , who were sexually active , were recruited in this study . the exclusion criteria were as follows : 1 ) prior history of surgical interventions , e.g. , hysterectomy and mastectomy ; 2 ) depression or other mental disorders ; 3 ) polygamy ; 4 ) having a partner with a mental illness or sexual disorder ; 5 ) chronic diseases such as cardiovascular diseases , diabetes , and asthma ; 6 ) history of infertility and use of medications affecting sexual activity ; and 7 ) obesity ( body mass index  30 kg / m ) or malnourishment ( body mass index  18.5 in this study , a demographic questionnaire , consisting of two sections , was applied . the first part included demographic information , while the second part was related to sexual matters . the reliability and validity of this questionnaire have been assessed by zolfaghari and zargar shoushtari ( 13 ) . in addition , female sexual function index ( fsfi ) and body shape questionnaire ( bsq ) were used for data collection . fsfi is a multi - dimensional , self - report instrument for evaluating one s satisfaction with his / her sexual relationships . it is composed of 19 items , assessing six domains of sexual function in women , i.e. , sexual desire , arousal , lubrication , orgasm , sexual satisfaction , and pain . the score of each domain is calculated by adding up the item valuation and multiplying the sum by the domain factor . the total fsfi score is calculated by determining the collective total of all six domains of sexual function , with higher valuation indicating better sexual function . the validity and reliability of fsfi had been assessed by fakhri et al . in 2008 ( 14 ) . also , according to a previous study by mohammadi et al . , satisfactory findings were reported with a cronbach s alpha of 0.66 ( or above ) for sexually dysfunctional samples and a cronbach s alpha of 0.70 ( or above ) for sexually active samples ( 15 ) . bsq is composed of 34 items , assessing one s body shape satisfaction and body shape preoccupations , particularly bulimia nervosa and anorexia nervosa over the past four weeks . to determine the outcome , a five - point likert scale is applied , with valuation ranging between 34 and 170 ; higher valuations indicate greater dissatisfaction with body shape . the reliability and validity of this scale had been previously assessed by zeyghami and colleagues ( 16 ) . in total , 10 public healthcare centers were selected through simple random sampling ( five from each region ) among 23 public healthcare centers in ahvaz , iran . middle - aged women who were eligible for the study ( with an even record number ) were selected and invited to participate in the study . volunteers who failed to meet the inclusion criteria were excluded from the study and replaced . overall , 750 women were assessed based on the inclusion and exclusion criteria , among whom 500 cases were considered eligible . by reason of the majority of the participants being arabs , a native assisted us with data collection . the demographic questionnaire , fsfi , and bsq one - way analysis of variance ( anova ) and chi - square tests were used to analyze the quantitative and qualitative data , respectively . also , spearman s rank correlation coefficient test and logistic regression analysis were used to assess the relationship between body image preoccupations and sexual function in women . this study was approved by the research ethics committee of ahvaz jundishapur university of medical sciences ( code : ajumc.rec.1393.2204 ) . according to the obtained results , 46% of the subjects had more than four children , while 54% had less than four children . approximately 55% and 47% of women were in the postmenopausal and premenopausal stages , respectively . in 36% , 14% , and 3% of postmenopausal women , 15 , 610 , and > 11 years had passed since their menopause , respectively . the results showed that 22% , 11% , 9% , and 3% of the subjects had used condoms , hormonal contraception , intrauterine devices , and tubal ligation for family planning , respectively . the demographic characteristics of the subjects and their partners are presented in table 1 . according to the bsq results , 58% of the participants were satisfied with their body image , 35% were mildly dissatisfied , and 7% were moderately dissatisfied . among women with optimal sexual function , 74% , 21% , and 5% were satisfied , mildly dissatisfied , and moderately dissatisfied with their body image , respectively . also , among women with adequate sexual function , 55% were satisfied with their body image , 38% were mildly dissatisfied , and 7% were moderately dissatisfied with their body image . overall , there was a significant relationship between body image and sexual function ( p=0.01 ) . the mean and standard deviation of sexual function domains , based on women s perception of body image , are shown in table 2 . according to this table , there was a significant relationship between the subjects sexual desire and their perception of body image ( p=0.001 ) . also , there was a significant relationship between body image and sexual arousal ( p<0.0005 ( , sexual orgasm ( p=0.001 ) , sexual satisfaction ( p<0.0005 ) , and pain ( p<0.0005 ) . however , there was no significant relationship between lubrication and women s perception of body image ( p=0.31 ) . the results showed a significant relationship between sexual arousal and sexual function ( r=0.50 , p<0.0005 ) . the confounding variables for women s perception of their body image are presented in table 3 . according to this table , arab women were more likely to be satisfied with their body image , compared to others ( or=4.195 , ci=0.63727.636 , p=0.136 ) . with regard to a woman s occupational status , probability of body image satisfaction in employed women was 7.729 times higher than housewives ( or=7.729 , ci=1.30845.68 , p=0.024 ) . also , probability of body image satisfaction in women whose partners were retired was 0.164 times greater than women whose partners were employed ( or=0.164 , ci=0.0380.711 , p=0.016 ) . in addition , probability of body image satisfaction in women with two or more unmarried children was 0.297 times higher than women who did not ( or=0.297 , ci=0.0881.002 , p=0.05 ) . finally , body image satisfaction in women who took the initiative in sexual interaction was significantly higher than women whose husbands took the initiative ( or=0.043 , ci=0.0020.937 , p=0.045 ) . according to the obtained results , 46% of the subjects had more than four children , while 54% had less than four children . approximately 55% and 47% of women were in the postmenopausal and premenopausal stages , respectively . in 36% , 14% , and 3% of postmenopausal women , 15 , 610 , and > 11 years had passed since their menopause , respectively . the results showed that 22% , 11% , 9% , and 3% of the subjects had used condoms , hormonal contraception , intrauterine devices , and tubal ligation for family planning , respectively . the demographic characteristics of the subjects and their partners are presented in table 1 . according to the bsq results , 58% of the participants were satisfied with their body image , 35% were mildly dissatisfied , and 7% were moderately dissatisfied . among women with optimal sexual function , 74% , 21% , and 5% were satisfied , mildly dissatisfied , and moderately dissatisfied with their body image , respectively . also , among women with adequate sexual function , 55% were satisfied with their body image , 38% were mildly dissatisfied , and 7% were moderately dissatisfied with their body image . overall , there was a significant relationship between body image and sexual function ( p=0.01 ) . the mean and standard deviation of sexual function domains , based on women s perception of body image , are shown in table 2 . according to this table , there was a significant relationship between the subjects sexual desire and their perception of body image ( p=0.001 ) . also , there was a significant relationship between body image and sexual arousal ( p<0.0005 ( , sexual orgasm ( p=0.001 ) , sexual satisfaction ( p<0.0005 ) , and pain ( p<0.0005 ) . however , there was no significant relationship between lubrication and women s perception of body image ( p=0.31 ) . the results showed a significant relationship between sexual arousal and sexual function ( r=0.50 , p<0.0005 ) . the confounding variables for women s perception of their body image are presented in table 3 . according to this table , arab women were more likely to be satisfied with their body image , compared to others ( or=4.195 , ci=0.63727.636 , p=0.136 ) . with regard to a woman s occupational status , probability of body image satisfaction in employed women was 7.729 times higher than housewives ( or=7.729 , ci=1.30845.68 , p=0.024 ) . also , probability of body image satisfaction in women whose partners were retired was 0.164 times greater than women whose partners were employed ( or=0.164 , ci=0.0380.711 , p=0.016 ) . in addition , probability of body image satisfaction in women with two or more unmarried children was 0.297 times higher than women who did not ( or=0.297 , ci=0.0881.002 , p=0.05 ) . finally , body image satisfaction in women who took the initiative in sexual interaction was significantly higher than women whose husbands took the initiative ( or=0.043 , ci=0.0020.937 , p=0.045 ) . this study was aimed at determining the relationship between body image preoccupations and sexual function in middle - aged women . according to our study , moreover , women with a positive body image had higher sexual function valuation , compared to women with a negative body image . in the present study , there was a negative linear relationship between all six domains of sexual function and women s perception of body image . in other words , sexual desire , arousal , and orgasm improved as body image valuation increased . on the other hand , sexual function valuation decreased in women who were dissatisfied with their body shape . various studies have emphasized on the role of body image in various aspects of sexual activity and sexual function . in line with our study , the relationship between women s body image , self - image , and sexual behavior was assessed in a study by ackard and colleagues . as the results indicated , sexual activity , sexual orgasm , and positive social interactions were more observed in women who were satisfied with their body image . also , positive body image was associated with overall satisfaction , which was a predictor of sexual activity ( 17 ) . . showed a positive relationship between body image , sexual function , and sexual satisfaction . weight concerns , physical conditions , sexual attraction , and preoccupations with physical appearance during sexual activity were the main factors contributing to sexual dissatisfaction . the study also found that different aspects of body image were strong predictors of sexual satisfaction in women ( 18 ) . according to a previous study , negative body image and negative genital self - image were common among women with dyspareunia ( 8) . additionally , davison et al . examined the relationship between various aspects of body image and sexual function in middle - aged individuals and showed a relationship between poor body image and problematic social and sexual functioning . poor body image was also found to be associated with depression and anxiety symptoms ( 19 ) . performed a study to determine the relationship between body appreciation and sexual function , and assessed the impact of body size in women . according to their study , the majority of subjects reported body dissatisfaction , while the majority had high self - esteem . as the results indicated , women could overcome a negative body image by improving their self - esteem ( 20 ) . , albertson et al . showed that self - esteem could decrease body shape dissatisfaction . in fact , self - esteem had a strong association with psychological health and could discourage individuals from comparing themselves with others , based on physical appearance ( 21 ) . in the present study , it was revealed that the chance of body image satisfaction was higher in fars women , compared to arabs , lurs , and other ethnicities . moreover , body image satisfaction was more prevalent among employed women , compared to housewives . furthermore , women with employed partners were more satisfied with their body image , compared to those whose partners were retired . the findings also revealed , women with less than two unmarried children had a higher probability of body image satisfaction , compared to those with two or more unmarried children . additionally , in our study , probability of body image satisfaction in women who took sexual initiative was lower than women whose husbands took the initiative . , sexual initiative and positive social relations were more prevalent among women who were satisfied with their body . these women were willing to try new sexual activities and satisfy their partners ( 17 ) . there is a significant positive correlation between body esteem and happiness ; in other words , body image is a major contributor to overall life happiness ; this correlation can be observed among women at any age ( 22 ) . on the other hand , the correlation between depression and obesity , which strongly influences women s perception of their body , has been confirmed in multiple studies in middle - aged women ( 16 ) . in fact , decreased physical activity and negative body image are the main mechanisms of the correlation between obesity and depression ( 11 ) . according to a study by moin et al . , body image , sexual self - esteem , sexual satisfaction , and life satisfaction were lower in women with physical disability , compared to women with no physical disability , while sexual needs and desires of disabled women were similar to healthy women . in total , a significant positive correlation was observed between sexual satisfaction and happiness ( 23 ) . also , khorshid et al . performed a study to investigate the body image of postmenopausal women . the body image of the majority of these women was generally positive and women with a good body image had more positive health behavior than other women . also , there was no major difference between women undergoing hysterectomy ( or reaching menopause ) and others , in terms of body image perception ( 24 ) . according to a study by steer and tiggemann , sexual satisfaction is a major predictor of sexual function ( 25 ) . to the best of our knowledge , however , some studies have shown that the overall self - satisfaction has a more significant impact on sexual behavior ( 17 ) . as noted above the concerns of people , particularly women , about how others may evaluate their body can significantly affect their sexual activity and quality of life . these concerns are affected by various social , cultural , and ethnic factors ( 5 ) . considering the design of the present study ( cross - sectional research ) , one of the limitations was that causal relationships between the variables could not be evaluated . also , iranian women may feel too embarrassed to express their genuine feelings towards sex due to cultural barriers . the present study showed that women with a positive body image had higher sexual function valuation , compared to those with a negative body image . since body image is an important aspect of sexual health , our findings could help improve women s general health status . further research is required to determine other effective factors for sexual health and to assess the effects of occupational status on body image , sexual performance , and sexual satisfaction . moreover , future studies should focus on the effects of counseling on sexual satisfaction and sexual function in order to improve the body image of middle - aged women and assess the relationship between body image satisfaction , and sexual function in pre- and post - menopausal women .
introductionan individual s social and marital function , interpersonal relationships , and quality of life may , sometimes be affected by negative body image . 
 this study is aimed at determining the relationship between body image and sexual function in middle - aged women.methodsin this cross - sectional study , 437 middle - aged women , who were referred to various public healthcare centers in ahvaz , iran during 20142015 , were selected . 
 the female sexual function index ( fsfi ) and body shape questionnaire ( bsq ) were used for data collection . 
 chi - square , one - way analysis of variance , spearman s correlation test , and logistic regression analysis were performed for statistical analysis.resultsapproximately 58% of the participants expressed satisfaction with their body image , 35% were mildly dissatisfied , and 7% were moderately dissatisfied with their body image . 
 body image had a significant negative relationship with sexual satisfaction and sexual function ( p=0.005 ) . 
 furthermore , there was a significant relationship between body image and sexual desire ( p=0.022 ) , pain ( p=0.001 ) , sexual arousal ( p<0.0005 ) , sexual orgasm ( p=0.001 ) , and sexual satisfaction ( p<0.0005).conclusionas the results indicated , body image is an important aspect of sexual health . in this study , women with a positive body image had higher sexual function valuation , compared to women with a negative body image . 
 also , body shape satisfaction was a predictor of sexual function .