The Silent Wound of Birth: The Effects of Genital Self-Image on Postpartum Sexual Function and Dyspareunia in Primiparous Women with Episiotomy – A Path Analysis Study

The Silent Wound of Birth: The Effects of Genital Self-Image on Postpartum Sexual Function and Dyspareunia in Primiparous Women with Episiotomy – A Path Analysis Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Silent Wound of Birth: The Effects of Genital Self-Image on Postpartum Sexual Function and Dyspareunia in Primiparous Women with Episiotomy – A Path Analysis Study ESRA GÜNEY, MEVHİBE ÇOBAN This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6278770/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Problem: The present study sets out the hypothesis that there is a link between genital self-image in women who have undergone an episiotomy and postpartum sexual function and dyspareunia. However, more research is needed to understand the nature and effects of these associations. Background: The effects of genital self-image on an individual's body perception and sexual functioning is a crucial factor in the study of human sexuality. The occurrence of episiotomy during the postpartum period can result in a range of physical recovery challenges and psychosocial effects. Aim: The present study set out to ascertain the effect of genital self-image on postpartum sexual function and dyspareunia in primiparous women who have undergone an episiotomy. Methods: The present study was conducted as a cross-sectional investigation. It was conducted between February and August 2023 in the postpartum ward of a public hospital located in eastern ………..The study included 309 women who had a healthy vaginal delivery and resumed vaginal sexual activity within 6 to 8 weeks postpartum. Results: The study established a correlation between genital self-image and postpartum sexual function and dyspareunia in primiparous women who underwent an episiotomy (p 0.05). Discussion: The results indicate that there is an absence of a robust direct correlation between genital self-image and postpartum sexual function, as well as dyspareunia, in primiparous women who have undergone an episiotomy. However, it is crucial to acknowledge that sexual function and dyspareunia are influenced by numerous factors. This underscores the necessity for a multidimensional approach in research endeavours pertaining to this subject. Conclusion: The path analysis's findings showed that genital selfimage has little influence on dyspareunia and sexual function. It is recommended that holistic and biopsychosocial strategies be created to promote women's sexual health and wellbeing during the postpartum phase. body image dyspareunia episiotomy midwifery path analysis sexual dysfunction Figures Figure 1 Figure 2 INTRODUCTION A surgical incision known as an episiotomy is made in the perineum at the end of the second stage of labour when the fetal head distends the perineum, widening the posterior vaginal wall (Barjon et al., 2024 ). The American College of Obstetricians and Gynecologists (ACOG) has recommended episiotomy for the prevention of severe maternal lacerations, facilitation of difficult deliveries, and prevention of maternal and fetal complications (ACOG, 2006).However, studies have shown that assisted vaginal delivery significantly impacts postpartum sexual dysfunction (Galbally et al., 2019 ; Klein et al., 2009 ). Specifically, episiotomy and perineal trauma, which are common obstetric interventions, have been associated with increased body image concerns and sexual dysfunction in women (Sobhgol et al., 2022 ). Genital self-image, a subdimension of body image, can be perceived positively or negatively, with sociocultural factors, social experiences, and sexual experiences serving as influential factors (Amorim et al., 2015 ). A negative perception of one's body or genital organs has been shown to significantly increase the likelihood of developing sexual dysfunction in women (Brondani et al., 2022 ). Conversely, research indicates that women who have a favorable genital self-image are more likely to report feeling attracted to men, have sex more often, and be more satisfied with their sex (De Maria et al., 2019 ). The postpartum period is characterised by physical, hormonal and emotional changes that can result in decreased genital self-image, leading to reduced sexual desire, arousal difficulties, orgasmic dysfunction and vaginal dryness (Fernández & De Medina-Moragas, 2024). In turn, vaginal dryness can cause dyspareunia during sexual intercourse. Although ACOG recommends a comprehensive postpartum evaluation within six weeks after delivery (McKinney et al., 2018 ), very few women are assessed for dyspareunia. Many women experience difficulty in expressing sexual concerns, and healthcare professionals often prioritize postpartum recovery, lack sufficient sexual health knowledge, face time constraints during appointments, and assume that sexual problems will resolve spontaneously, all of which contribute to the persistence of dyspareunia (Harris et al., 2025 ). It is imperative that the effect of genital self-image on postpartum sexual function and dyspareunia in primiparous women who have undergone episiotomy is identified. While there are studies in the literature that have investigated the outcomes of episiotomy, there is a paucity of research specifically examining the impact of genital self-image on postpartum sexual function and dyspareunia in primiparous women who have undergone episiotomy. This study aims to answer the following research questions: How is genital self-image related to postpartum sexual function in primiparous women with episiotomy? How is genital self-image related to postpartum dyspareunia in primiparous women with episiotomy? Does genital self-image have direct or indirect effects on postpartum sexual function and dyspareunia? How can the effects of genital self-image on postpartum sexual function and dyspareunia be modeled using path analysis? METHODS Design and sample of the study In order to investigate the impact of genital self-image on postpartum sexual function and dyspareunia in primiparous women who had episiotomy, this cross-sectional study was carried out between February and August 2023. Women who had a healthy vaginal delivery with a mediolateral episiotomy, needed perineal repair because of a second-degree tear, and resumed vaginal sex within 6 to 8 weeks after giving birth were included in the study population. The study excluded women with illnesses that negatively affected their sexual life or those who had difficulties that required repeat episiotomy. The study population consisted of postpartum women admitted to the maternity ward of a public hospital in the eastern Anatolian region of Türkiye. The sample size was not determined on the basis of a prior power analysis or sample calculation; instead, all eligible primiparous women who fulfilled the requirements for inclusion and consented to take part in the study (February–August 2023) were included. The total number of participants recruited was 309, a figure deemed acceptable in light of the sample sizes of analogous studies (Bağlar et al., 2025 ; Sönmez et al., 2024 ; Barbara et al., 2016 ) and practical feasibility. The inclusion and exclusion criteria were meticulously applied to ensure the study's validity. Data Collection Tools Data were collected using a personal information form developed by the researchers, the Female Genital Self-Image Scale (FGSIS), and the Carol Postpartum Sexual Function (Carol's Scale) and Dyspareunia Assessment Scale. Personal Information Form This form, designed by the researchers, includes questions aimed at determining the sociodemographic characteristics of the participants. Female Genital Self-Image Scale (FGSIS) The FGSIS was developed by Herbenick and Reece ( 2010 ) to assess women's perceptions of their genital self-image. The scale consists of seven Likert-type items, with total scores ranging from 7 to 28. Higher scores indicate a more positive genital self-image. The validity and reliability study of the scale in the Turkish population was conducted by Karadeniz ( 2019 ), who reported a Cronbach’s alpha (α) coefficient of 0.90 (Karadeniz, 2019 ). In the present study, the Cronbach’s alpha (α) value was found to be 0.809, indicating good internal consistency. Carol Postpartum Sexual Function And Dyspareunia Assessment Scale (Carol's Scale) The scale, developed by López-López Lapeyrere et al. (2018), consists of 11 items and four subdimensions, and was designed to assess sexual function and the presence of dyspareunia in women who have resumed sexual activity through vaginal intercourse after vaginal delivery. The scale gathers information about discomfort or pain intensity experienced during different phases of sexual activity, contributing to the evaluation of postpartum dyspareunia. Evcili (2018) investigated the scale's validity and reliability and found that its original Cronbach's alpha (α) value was 0.79.The following are the scale's subdimensions:: Preparation for Sexual Activity : This subdimension is divided into two areas: libido and lubrication, which should be evaluated separately. Items 1 and 2 assess libido, while Item 3 measures lubrication. The total score for the libido domain ranges from 0 to 8, with higher scores indicating better function. A score of 6–8 indicates ‘no libido dysfunction,’ 3–5 represents ‘moderate libido dysfunction,’ and 0–2 indicates ‘severe libido dysfunction.’ The total score for the lubrication domain ranges from 0 to 4, with higher scores representing better function. A score of 3–4 indicates ‘no lubrication dysfunction,’ 2 represents ‘moderate lubrication dysfunction,’ and 0–1 indicates ‘severe lubrication dysfunction.’ The Cronbach’s alpha (α) value for the preparation for sexual activity subdimension was found to be 0.69. In the current study, the Cronbach’s alpha (α) value was 0.677. Discomfort or Pain When Touching the Vulva : This section assesses two aspects: ‘frequency of pain or discomfort when touching the vulva or perineum’ and ‘intensity of pain or discomfort when touching the vulva or perineum.’ It consists of two items (Items 4 and 8), with total scores ranging from 0 to 14. Lower scores indicate less discomfort. A score of 0–4 is interpreted as ‘no/mild discomfort or pain,’ 5–7 as ‘moderate discomfort or pain,’ and 8–14 as ‘severe discomfort or pain.’ The Cronbach’s alpha (α) value for this subdimension was reported as 0.86. In the current study, the Cronbach’s alpha (α) value was 0.777. Discomfort or Pain During Vaginal Intercourse : This section is divided into two areas: ‘pain during penetration’ and ‘pain during vaginal intercourse.’ These areas are evaluated separately. The ‘pain during penetration’ domain is measured by two items (Items 5 and 9), and the ‘pain during vaginal intercourse’ domain is measured by two items (Items 6 and 10), totaling four items. Scores for both domains range from 0 to 14, with lower scores indicating less discomfort. A score of 0–4 represents ‘no/mild discomfort or pain,’ 5–7 indicates ‘moderate discomfort or pain,’ and 8–14 signifies ‘severe discomfort or pain.’ The Cronbach’s alpha (α) value for this subdimension was reported as 0.93. The Cronbach's alpha (α) score in the current study was 0.901. Discomfort or Pain After Vaginal Intercourse : This section assesses ‘frequency of pain or discomfort after vaginal intercourse’ and ‘intensity of pain or discomfort after vaginal intercourse’ through two items (Items 7 and 11). The total score ranges from 0 to 14, with lower scores indicating less discomfort. A score of 0–4 is interpreted as ‘no/mild discomfort or pain,’ 5–7 as ‘moderate discomfort or pain,’ and 8–14 as ‘severe discomfort or pain.’ The Cronbach’s alpha (α) value for this subdimension was reported as 0.86. In the present study, the Cronbach’s alpha (α) value was 0.751. Data Collection The data collection instruments were administered by the researchers to women who gave birth in the postpartum ward of ………. Training and Research Hospital. The data collection phase of the study, which was performed between 28 February 2023 and 1 August 2023, was carried out as follows: First Follow-up (Within 24 Hours Postpartum) During the initial follow-up, face-to-face interviews were conducted, and the Personal Information Form and the FGSIS were administered. Efforts were made to ensure a quiet environment to maintain privacy and comfort, and single-patient rooms were used during data collection. Participants were informed about the purpose and methodology of the study, and informed consent forms were read and signed. A total of 309 participants were included at this stage. Second Follow-up (16 Weeks Postpartum) The second follow-up was conducted through telephone interviews, scheduled at times convenient for the participants. Participants were provided with information regarding the continuation of the study, and their verbal consent was secured for the second follow-up. The Carol’s Scale and Dyspareunia Assessment Scale and the FGSIS were re-administered. Of the 309 participants who completed the first follow-up, 283 were successfully reached. The remaining 26 participants could not be contacted due to various reasons (e.g., change of phone number, inability to reach the participant, refusal to participate in the interview). Statistical Analysis of Research Data IBM AMOS V24 and IBM SPSS V23 were used to analyze the data. Normality of data distribution was assessed using the Kolmogorov-Smirnov test. Non-normally distributed dependent variables over two time points were analysed using the Wilcoxon test. The relationship between non-normally distributed variables was examined using Spearman's rho correlation. In structural equation modelling, normality was assessed using the multivariate normality assumption. The structural model was tested using path analysis with maximum likelihood estimation as the method of calculation. While categorical data were displayed as frequencies and percentages, quantitative data were displayed as mean ± standard deviation and median (min-max). Cronbach's alpha coefficient was used to evaluate the scales' reliability. The threshold for statistical significance was p < 0.05 (Tabachnick & Fidell, 2007 ). Ethical Considerations The Ethics Committee for Non-Interventional Clinical Research of ………. University granted ethical approval for the study (meeting date: 06.09.2023, decision number: 11, protocol number: 2023/4401), and the hospital where the study was conducted provided the necessary permissions. Participants were informed of the purpose of the study prior to data collection. Each participant was given information about the study, and verbal and written consent was obtained from those who agreed to participate. The study was conducted in accordance with the Declaration of Helsinki, with the principle of voluntary participation as the basis for the selection of participants. The following ethical principles were observed Informed consent, where participants were informed of the aims of the study; confidentiality and data protection, ensuring that all data collected remained confidential; respect for autonomy, meaning that only those who voluntarily agreed to participate were included; and non-maleficence and beneficence, ensuring that no harm was done to participants while aiming to provide benefit. Participants were informed that they could withdraw from the study at any time. The data collected were used only for the purposes of this research. RESULTS Table 1 Descriptive Statistics of the Participants Variables Mean ± Standard Deviation / Frequency Median (min-max) / Percentage Age 27.38 ± 4.533 27 (18–37) Educational level Illiterate 9 2.9 Only literate 7 2.3 Primary school graduate 49 15.9 Secondary school graduate 165 53.4 University graduate 79 25.6 Employment statu Employe 42 13.6 Unmployed 267 86.4 Income status Income less than expenses 45 14.6 Income equal to expenses 222 71.8 Income more than expenses 42 13.6 Family type Nuclear family 237 76.7 Extended family 72 23.3 Planned pregnancy Yes 284 91.9 No 25 8.1 Pain felt during episiotomy 7.35 ± 2.086 8 (4–10) Mean ± Standard Deviation, Median (Minimum–Maximum), n(%) The median age of the participants was 27 years. Regarding educational level, 53.4% had completed middle school. Additionally, 86.4% were unemployed, 71.8% reported that their income was equal to their expenses, and 76.7% lived in a nuclear family. Moreover, 91.9% of the participants had a planned pregnancy, and the median value of pain experienced during episiotomy was 8. Table 2 Analysis of the Relationship Between Pretest and Posttest Total Scores of the FGSIS Mean ± SD Median (min-max) Test p* Pre-test 20.896 ± 4.252 21 (7–28) -0.703 0.482 Post-test 20.855 ± 4.139 21 (9–28) *Wilcoxon Test; Mean ± Standard Deviation. Median (Minimum–Maximum) The median pretest score of the FGSIS was 21, while the median posttest score was also 21, indicating no statistically significant difference between them (p = 0.482). Table 3 Relationship Between Pretest-Posttest Total Scores of the FGSIS and Subscale Total Scores of the Carol Scale Carol's Scale sub-dimensions FGSIS pre-test total FGSIS post-test total r p* r p* 1.Preparation for the sexual activity 0.007 0.903 0.080 0.18 2.Pain or discomfort on caressing the vulval area -0.170 0.004 -0.119 0.045 3. Pain or discomfort related to vaginal intercourse/penetration -0.121 0.042 -0.116 0.051 3. Pain or discomfort related to vaginal intercourse/ intercourse -0.125 0.036 -0.104 0.080 4. Pain or discomfort after vaginal intercourse -0.033 0.580 -0.050 0.406 *Spearman’s rho correlation, Carol's Scale: Carol Postpartum Sexual Function And Dyspareunia Assessment Scale, FGSIS: Female Genital Self Image Scale A very weak negative correlation was found between the total pretest score of the FGSIS and the second subscale of the Carol scale (r=-0.170; p = 0.004). Additionally, a very weak negative correlation was observed between the total pretest score of the FGSIS and the Carol penetration subscale (r=-0.121; p = 0.042). Similarly, a very weak negative correlation was found between the total pretest score of the FGSIS and the Carol vaginal intercourse subscale (r=-0.125; p = 0.036). No significant correlation was found between the total posttest scores of the FGSIS and the subscales of the Carol scale (p > 0.05). Table 4 Path Analysis Results Between Dependent and Independent Variables Dependent variables/ sub-dimensions Independent variable β1 β2 Standard Error Test Statistics p R2 1.Preparation for the sexual activity <— FGSIS difference -0.094 -0.063 0.039 -1.593 0.111 0.009 2.Pain or discomfort on caressing the vulval area <— FGSIS difference -0.057 -0.06 0.062 -0.956 0.339 0.003 3. Pain or discomfort related to vaginal intercourse/penetration <— FGSIS difference 0.025 0.03 0.072 0.422 0.673 0.001 3. Pain or discomfort related to vaginal intercourse/intercourse <— FGSIS difference -0.004 -0.004 0.074 -0.059 0.953 0.000 4. Pain or discomfort after vaginal intercourse <— FGSIS difference 0.046 0.052 0.068 0.767 0.443 0.002 β1: Standardized beta coefficient; β2: Unstandardized beta coefficient, Carol's Scale: Carol Postpartum Sexual Function And Dyspareunia Assessment Scale, FGSIS: Female Genital Self Image Scale When examining the multivariate normality of the model, the critical ratio for multivariate normality was found to be 8.968. As this value is less than 20, the assumption of multivariate normality was met. Maximum likelihood was used as the estimation method. There was no significant effect of the independent variables on the dependent variable (p > 0.05). The goodness of fit indices were obtained as follows CMIN/DF (10.525 / 4) = 2.631, AGFI = 0.937, GFI = 0.988, IFI = 0.992, TLI = 0.969, CFI = 0.992 and RMSEA = 0.076. ( Bentler, 1990 ; Bollen, 1989 ; Byrne, 2010 ; Jöreskog and Sörbom, 1996 ; Steiger, 1990 ; Tucker and Lewis, 1973 ). DISCUSSION In this study, weak negative correlations were found between certain sub-dimensions of the Carol scale and the total pre-test score of the FGSIS. Specifically, statistically significant but very weak negative correlations were found between the pre-test score on the FGSIS and the sub-dimensions of pain or discomfort when stroking the vulva (r = -0.170; p = 0.004), pain or discomfort during vaginal intercourse/penetration (r = -0.121; p = 0.042), and pain or discomfort during vaginal intercourse/coitus (r = -0.125; p = 0.036). These results suggest that there may be some degree of association between the constructs measured by the subdimensions of the Carol scale and those assessed by the FGSIS. However, the low correlation coefficients indicate that this association is not strong and that other variables may also be influential. The observation that these weak correlations in the pre-test did not attain statistical significance in the post-test (p > 0.05) indicates that the relationship may have weakened over time or that the variables may not be directly associated. Several interpretations of these results are possible. One potential factor influencing the absence of a strong relationship between the Carol scale subdimensions and the FGSIS is the high mean scores observed in both the pre-test and post-test assessments of FGSIS (Table 2 ). High baseline scores may have contributed to a lack of significant change in body perception over time, leading to weak or nonsignificant associations between variables. A positive body image and a high genital self-image may contribute to reduced anxiety and increased self-confidence in sexual experiences. Indeed, some studies have shown that a higher genital self-image is positively associated with women's sexual satisfaction, quality of sexual life, and overall life satisfaction. A meta-analysis conducted to determine the correlation between genital self-image and sexual function found a positive relationship between genital self-perception and sexual functioning (Alavi-Arjas et al., 2023 ). Similarly, a study investigating the relationship between body image and genital self-image in women reported that as genital self-image increased, sexual satisfaction also increased (Komarnicky et al., 2019 ). This result highlights the significance of childbirth and postpartum processes as critical research areas regarding their impact on sexual function and body perception. Similarly, the long-term effects of episiotomy on sexual function and body image remain controversial in the literature. Some studies suggest that episiotomy may have both short- and long-term effects on sexual function. A study investigating the effects of episiotomy on postpartum sexual function found that women who underwent episiotomy had higher average levels of sexual satisfaction in the postpartum period (Leal et al., 2013 ). This result may be explained by the fact that women with a high genital self-image may recover their sexual function more quickly in the post-episiotomy period due to their positive perception of their bodies. Another key result of our study was the path analysis conducted to examine the relationships between the dependent and independent variables. The goodness of fit indices obtained for the developed model (CMIN/DF = 2.631, AGFI = 0.937, GFI = 0.988, IFI = 0.992, TLI = 0.969, CFI = 0.992, RMSEA = 0.076) indicated that the model had an acceptable fit to the data. However, the lack of a significant effect of genital self-image on sexual dysfunction and dyspareunia (p > 0.05) did not support the expected relationship. This result can be interpreted in a number of ways. First, genital self-image may not have a direct effect on sexual dysfunction and dyspareunia after episiotomy, or this effect may be moderated by other variables not included in the model. The literature also suggests that sexual dysfunction is multidimensional and complex, influenced by interactions between individual, surgical and psychosocial factors. A narrative review examining the biopsychosocial variables influencing female sexual function and dysfunction highlighted that sexual function and dysfunction are shaped by the interaction of biological, psychological, and social factors, necessitating multidimensional approaches to treatment strategies (Thomas & Thurston, 2016 ). Furthermore, a mixed-methods study investigating the effects of pelvic floor surgery on female sexual function discussed that surgical interventions can lead to sexual dysfunction, but individual and psychosocial factors also play a crucial role in this process (Roos et al., 2014 ). Considering these examples, the results of our study suggest that there is no direct or strong relationship between genital self-image and sexual dysfunction or dyspareunia after episiotomy. However, given the multidimensional nature of sexual dysfunction and dyspareunia, it is important to evaluate this result in the context of other individual, surgical and psychosocial factors. Strengths and Limitations of the Study In evaluating the strengths and limitations of this study, it is useful to consider the methodology, analytical approach, sample characteristics, and scientific contributions. The most significant strength of this research is its use of path analysis, an advanced statistical method, to examine both direct and indirect effects between variables. In contrast to previous studies, which have predominantly utilised descriptive and correlational analyses (Da Silva et al., 2024 ; Barbosa et al., 2020 ), this study employs path analysis, a more advanced statistical method, to provide a more in-depth analysis by modelling the direct and indirect effects between variables. This approach offers a more comprehensive perspective on post-episiotomy sexual function and dyspareunia. This methodological approach enhances the study's rigor and allows for a more detailed examination compared to previous research. A further strength of the study is the satisfactory model fit indices, including CMIN/DF, AGFI, GFI, IFI, TLI, CFI, and RMSEA, which indicate that the data adequately fit the proposed model. This strengthens the reliability of the results. Moreover, the study utilised validated and reliable measurement tools (FGSIS, Carol's Scale), further supporting its methodological robustness. However, the study is not without its limitations. Firstly, the sample size may not be sufficient to generalise the results to a broader population, particularly in the context of complex statistical methods such as path analysis, where larger sample sizes would enhance the generalisability of the results. Secondly, no statistically significant relationship was identified between the independent variable, genital self-image, and the dependent variables, sexual dysfunction and dyspareunia, in the path analysis (p > 0.05). This result indicates that the study does not provide a definitive answer to the research questions and that a strong causal link between the examined variables could not be established. Moreover, the cross-sectional nature of the study imposes limitations on the capacity to ascertain causal relationships between variables. A longitudinal study design would offer a more comprehensive evaluation of the long-term implications of episiotomy. Sexual dysfunction and dyspareunia in women who have undergone episiotomy are influenced by a multitude of factors, including genital self-image, psychological well-being, partner relationships, hormonal changes, and cultural influences. The absence of a comprehensive exploration of these variables in the study may restrict the interpretation of the results. Recommendations for Future Research It is recommended that future studies employ longitudinal designs to assess the long-term effects of genital self-image on postpartum sexual function and dyspareunia in women who have undergone episiotomy. This approach would provide clearer insights into the temporal dynamics and potential causality between variables. In order to enhance the generalizability of results, it is advised that future research include larger sample sizes and participants with diverse demographic and cultural backgrounds. This would allow for a more robust examination of potential moderator and mediator factors. In light of the multidimensional nature of sexual function and dyspareunia, future research should incorporate additional variables such as psychological well-being, partner relationship quality, hormonal changes, and sociocultural influences. These factors may help explain the complex interactions between episiotomy, genital self-image, sexual function, and dyspareunia. In addition to quantitative analyses, employing mixed-method approaches that integrate qualitative data would allow for a deeper understanding of postpartum women's subjective experiences. The use of qualitative research methods such as interviews and focus groups could yield valuable insights that may not be captured by quantitative approaches. Furthermore, intervention studies that evaluate the impact of programs designed to enhance genital self-image on sexual function and dyspareunia following episiotomy could provide beneficial insights. Randomized controlled trials could play a crucial role in determining the effectiveness of such interventions. Implications for practice The absence of a significant relationship between genital self-image and sexual dysfunction/dyspareunia in women with episiotomy, as indicated by the path analysis, suggests the need for healthcare professionals – particularly midwives who are in primary contact with women during the postpartum period – to adopt a more holistic approach to postpartum sexual health. Psychological, relational, and physiological factors that may influence sexual function after episiotomy should be considered collectively. Midwives and healthcare professionals should provide comprehensive counselling services to postpartum women and offer education on the various factors affecting sexual function. This process should include discussions on body image, pain management, and emotional well-being, with particular attention given to women who have undergone episiotomy. Implementing a multidisciplinary approach in postpartum care would ensure a thorough assessment of sexual function and dyspareunia. Such an approach could facilitate timely and effective interventions, leading to improved outcomes. The development of targeted interventions that support both physical and emotional recovery could be facilitated by collaboration among obstetricians, midwives, psychologists, and sex therapists. Conclusions and Recommendations This study examined the effects of genital self-image on postpartum sexual function and dyspareunia in primiparous women who had undergone episiotomy. The results of the path analysis did not reveal a statistically significant relationship between genital self-image and either sexual dysfunction or dyspareunia, suggesting that additional psychosocial and physiological factors may play a role in postpartum sexual health. While no significant differences were observed in overall sexual function between pregnancy and the postpartum period, the increased pain during intercourse commonly reported by postpartum women highlights the need for targeted interventions in this area. Based on these results, several recommendations can be made for future research and clinical practice. Firstly, longitudinal studies utilising larger and more diverse samples are required to facilitate a more profound comprehension of the long-term implications of genital self-image on postpartum sexual function and dyspareunia in primiparous women who have undergone episiotomy. Secondly, future research should encompass additional mediating factors such as psychological stress, relationship dynamics, and hormonal changes that may influence postpartum sexual health. From a clinical perspective, the importance of a multidisciplinary approach in postpartum care should be emphasised, with collaboration between obstetricians, midwives, psychologists, and sex therapists encouraged to adopt a comprehensive approach that supports both physical and psychological recovery. Additionally, healthcare professionals should provide extensive counselling and education to women on postpartum sexual changes, pain management strategies, and emotional well-being. Furthermore, policymakers should consider developing initiatives to expand postpartum counselling services and improve their accessibility. The implementation of these recommendations has the potential to enhance both research and clinical practices, ultimately leading to improvements in postpartum sexual health outcomes. Abbreviations FGSIS: Female Genital Self Image Scale Carol's Scale: Carol Postpartum Sexual Function and Dyspareunia Assessment Scale Declarations Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper Funding sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution Authors' Contributions:• Concept and Design: E.G, M.Ç• Data Collection / Literature Review: E.G, M.Ç• Data Analysis and Interpretation: E.G• Manuscript Preparation: E.G, M.Ç• Final Approval for Publication: E.G Acknowledgement We sincerely thank all participants for their contributions to this study and the healthcare professionals who assisted in the data collection process. References Alavi-Arjas F, Goodman MP, Simbar M, Majd A, Nahidi H, F. 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Fisioterapia Brasil. 23(3), 427–439. https://orcid.org/0000-0002-4983-7544. Byrne BM. Structural equation modeling with AMOS: Basic concepts, applications, and programming. 2nd ed. Routledge/Taylor & Francis Group; 2010. Da Silva ML, Moraes RS, Prada MB, Júnior MDS, Cunha KDC, Jácomo R, Alves AT. Association of Body Image and Genital Self-Image with Female Sexual Function: A Systematic Review. J Sex Marital Ther. 2024;50(7):906–15. https://doi.org/10.1080/0092623X.2024.2386430 . De Maria AL, Meier SJ, Dykstra C. It’s not perfect but it’s mine: Genital self-image among women living in Italy. Body Image. 2019;29:140–8. https://doi.org/10.1016/j.bodyim.2019.03.011 . Evcili F. Turkish Version of the Carol Postpartum Sexual Function And Dyspareunia Assessment Scale: A Validity and Reliability Study. J Anatolia Nurs Health Sci. 2019;22(1):49–57. https://dergipark.org.tr/en/download/article-file/687765 . Fernández-Fernández MJ, De Medina-Moragas AJ. Comparative study of postpartum sexual function: Second-degree tears versus episiotomy outcomes. Arch Obstet Gynaecol. 2024;309(6):2761–9. https://doi.org/10.1007/s00404-024-07494-2 . Galbally M, Watson SJ, Permezel M, Lewis AJ. Depression across pregnancy and the postpartum, antidepressant use and the association with female sexual function. Psychol Med. 2019;49(9):1490–9. https://doi.org/10.1017/S0033291718002040 . Harris C, Hastie C, Donnellan-Fernandez R, Gabriel L. Exploring Australian midwives’ experiences providing sexual health information to women in the postnatal period. Midwifery. 2025;104315. https://doi.org/10.1016/j.midw.2025.104315 . Herbenick D, Reece M. Outcomes assessment: development and validation of the female genital self-image scale. J Sex Med. 2010;7(5):1822–30. https://doi.org/10.1111/j.1743-6109.2010.01728.x . Jöreskog KG, Sörbom D. LISREL 8: User's reference guide. Scientific Software International; 1996. Karadeniz ZC. 2019. Adaptation of the female genital self-ımage scale and examination of its psychometric properties. Akdeniz University Institute of Health Sciences, Department of Nursing Master Thesis. Klein K, Worda C, Leipold H, Gruber C, Husslein P, Wenzl R. Does the mode of delivery influence sexual function after childbirth? J Womens Health. 2009;18(8):1227–31. https://doi.org/10.1089/jwh.2008.1198 . 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. https://doi.org/10.1080/0092623X.2019.1586018 . Leal IP, Lourenço SN, Oliveira RLV, Carvalheira AA, Maroco J. The impact of childbirth on sexual functioning in women with episiotomy. PsychOpen. 2013;2:307–16. https://doi.org/10.5964/pch.v2i3.58 . López-Lapeyrere C, Serna-Gómez N, Hernández-López AB, Pérez-García MF, Tejeda-Esteban A, Solís-Muñoz M. The development and validation of a new postpartum sexual function and dyspareunia assessment tool: The Carol Scale. Midwifery. 2018;58:27–36. https://doi.org/10.1016/j.midw.2017.11.008 . McKinney J, Keyser L, Clinton S, Pagliano C. ACOG Committee Opinion 736: optimizing postpartum care. Obstet Gynecol. 2018;132(3):784–5. 10.1097/AOG.0000000000002849 . Roos AM, Thakar R, Sultan AH, De Leeuw JW, Paulus AT. The impact of pelvic floor surgery on female sexual function: a mixed quantitative and qualitative study. BJOG. 2014;121(1):92–101. https://doi.org/10.1111/1471-0528.12412 . Sobhgol SS, Smith CA, Thomson R, Dahlen HG. The effect of antenatal pelvic floor muscle exercise on sexual function and labour and birth outcomes: A randomised controlled trial. Women Birth. 2022;35(6):e607–14. https://doi.org/10.1016/j.wombi.2022.02.009 . Sönmez T, Koç Ö, Alver E. The effect of genital self-image on sexual satisfaction and stress in women after vaginal delivery. Rev Assoc Med Bras. 2024;70(10):e20240692. https://doi.org/10.1590/1806-9282.20240692 . Steiger JH. Structural Model Evaluation and Modification: An Interval Estimation Approach. Multivar Behav Res. 1990;25(2):173–80. Tabachnick BG, Fidell LS. 2007. Experimental designs using ANOVA (Vol. 724). Belmont, CA: Thomson/Brooks/Cole. file:///C:/Users/ASUS/Downloads/Experimental-Designs-Using-ANOVA.pdf Thomas HN, Thurston RC. A biopsychosocial approach to women’s sexual function and dysfunction at midlife: A narrative review. Maturitas. 2016;87:49–60. https://doi.org/10.1016/j.maturitas.2016.02.009 . Tucker LR, Lewis C. A Reliability Coefficient for Maximum Likelihood Factor Analysis. Psychometrika. 1973;38(1):1–10. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6278770","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":432413010,"identity":"3fd518a9-2622-466a-bda7-4c2e12bf30ed","order_by":0,"name":"ESRA GÜNEY","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYHAD5gMHoCwDYrWwJSBpSSBKCw/ccPxa+PnPPvzA8OtwHr9EzsfDBRV3EhvYm7dJMP64h1OL5Ix0YwnGvsPFkjNyNxyeceZZYgPPsTIJhoRinFoMbrAxSDD2HE7ccAOohbftcGKDRI4ZUAtul9mfP8b8A6Rl/42cBxAt8m/wazFgSGOTYPgBtEUihwFqCw9+LRI30tgsEhvSE4HeMDjMc+awcRtPWrFFQhpuLfz9x5hvfPhjndjfnvz4M0/FYdl+9sMbb3ywwa0FDBLbgIQAVBEbiCCgAQj+gOw7QFDZKBgFo2AUjFAAAJkIV36uUNbJAAAAAElFTkSuQmCC","orcid":"","institution":"Inonu University","correspondingAuthor":true,"prefix":"","firstName":"ESRA","middleName":"","lastName":"GÜNEY","suffix":""},{"id":432413011,"identity":"3a8cdb56-fea7-498d-af21-1bddb9df54a5","order_by":1,"name":"MEVHİBE ÇOBAN","email":"","orcid":"","institution":"Inonu University","correspondingAuthor":false,"prefix":"","firstName":"MEVHİBE","middleName":"","lastName":"ÇOBAN","suffix":""}],"badges":[],"createdAt":"2025-03-21 15:08:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6278770/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6278770/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79576241,"identity":"5d93aa54-7171-4890-bc61-cf1f4810a2f2","added_by":"auto","created_at":"2025-03-31 11:19:47","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":277858,"visible":true,"origin":"","legend":"\u003cp\u003eUnstandardized path coefficients\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6278770/v1/d8781393fdf9a270e8026f40.jpeg"},{"id":79576236,"identity":"46dfd8b6-26a1-47f1-9c72-7f1ebd697059","added_by":"auto","created_at":"2025-03-31 11:19:47","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":269821,"visible":true,"origin":"","legend":"\u003cp\u003eStandardized path coefficients\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6278770/v1/27c602e87c6ee3fdd709838a.jpeg"},{"id":79749356,"identity":"d4ff5e92-a1fc-435b-b349-035a29b9e27c","added_by":"auto","created_at":"2025-04-02 09:09:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1458289,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6278770/v1/357c0924-a101-4c10-9c13-c72074b2d1ea.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Silent Wound of Birth: The Effects of Genital Self-Image on Postpartum Sexual Function and Dyspareunia in Primiparous Women with Episiotomy – A Path Analysis Study","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eA surgical incision known as an episiotomy is made in the perineum at the end of the second stage of labour when the fetal head distends the perineum, widening the posterior vaginal wall (Barjon et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The American College of Obstetricians and Gynecologists (ACOG) has recommended episiotomy for the prevention of severe maternal lacerations, facilitation of difficult deliveries, and prevention of maternal and fetal complications (ACOG, 2006).However, studies have shown that assisted vaginal delivery significantly impacts postpartum sexual dysfunction (Galbally et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Klein et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2009\u003c/span\u003e). Specifically, episiotomy and perineal trauma, which are common obstetric interventions, have been associated with increased body image concerns and sexual dysfunction in women (Sobhgol et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGenital self-image, a subdimension of body image, can be perceived positively or negatively, with sociocultural factors, social experiences, and sexual experiences serving as influential factors (Amorim et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). A negative perception of one's body or genital organs has been shown to significantly increase the likelihood of developing sexual dysfunction in women (Brondani et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Conversely, research indicates that women who have a favorable genital self-image are more likely to report feeling attracted to men, have sex more often, and be more satisfied with their sex (De Maria et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe postpartum period is characterised by physical, hormonal and emotional changes that can result in decreased genital self-image, leading to reduced sexual desire, arousal difficulties, orgasmic dysfunction and vaginal dryness (Fern\u0026aacute;ndez \u0026amp; De Medina-Moragas, 2024). In turn, vaginal dryness can cause dyspareunia during sexual intercourse. Although ACOG recommends a comprehensive postpartum evaluation within six weeks after delivery (McKinney et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), very few women are assessed for dyspareunia. Many women experience difficulty in expressing sexual concerns, and healthcare professionals often prioritize postpartum recovery, lack sufficient sexual health knowledge, face time constraints during appointments, and assume that sexual problems will resolve spontaneously, all of which contribute to the persistence of dyspareunia (Harris et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt is imperative that the effect of genital self-image on postpartum sexual function and dyspareunia in primiparous women who have undergone episiotomy is identified. While there are studies in the literature that have investigated the outcomes of episiotomy, there is a paucity of research specifically examining the impact of genital self-image on postpartum sexual function and dyspareunia in primiparous women who have undergone episiotomy.\u003c/p\u003e \u003cp\u003eThis study aims to answer the following research questions:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow is genital self-image related to postpartum sexual function in primiparous women with episiotomy?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow is genital self-image related to postpartum dyspareunia in primiparous women with episiotomy?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDoes genital self-image have direct or indirect effects on postpartum sexual function and dyspareunia?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow can the effects of genital self-image on postpartum sexual function and dyspareunia be modeled using path analysis?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"METHODS","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eDesign and sample of the study\u003c/h2\u003e \u003cp\u003eIn order to investigate the impact of genital self-image on postpartum sexual function and dyspareunia in primiparous women who had episiotomy, this cross-sectional study was carried out between February and August 2023. Women who had a healthy vaginal delivery with a mediolateral episiotomy, needed perineal repair because of a second-degree tear, and resumed vaginal sex within 6 to 8 weeks after giving birth were included in the study population. The study excluded women with illnesses that negatively affected their sexual life or those who had difficulties that required repeat episiotomy.\u003c/p\u003e \u003cp\u003eThe study population consisted of postpartum women admitted to the maternity ward of a public hospital in the eastern Anatolian region of T\u0026uuml;rkiye. The sample size was not determined on the basis of a prior power analysis or sample calculation; instead, all eligible primiparous women who fulfilled the requirements for inclusion and consented to take part in the study (February\u0026ndash;August 2023) were included. The total number of participants recruited was 309, a figure deemed acceptable in light of the sample sizes of analogous studies (Bağlar et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; S\u0026ouml;nmez et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Barbara et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) and practical feasibility. The inclusion and exclusion criteria were meticulously applied to ensure the study's validity.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection Tools\u003c/h3\u003e\n\u003cp\u003eData were collected using a personal information form developed by the researchers, the Female Genital Self-Image Scale (FGSIS), and the Carol Postpartum Sexual Function (Carol's Scale) and Dyspareunia Assessment Scale.\u003c/p\u003e\n\u003ch3\u003ePersonal Information Form\u003c/h3\u003e\n\u003cp\u003eThis form, designed by the researchers, includes questions aimed at determining the sociodemographic characteristics of the participants.\u003c/p\u003e\n\u003ch3\u003eFemale Genital Self-Image Scale (FGSIS)\u003c/h3\u003e\n\u003cp\u003eThe FGSIS was developed by Herbenick and Reece (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) to assess women's perceptions of their genital self-image. The scale consists of seven Likert-type items, with total scores ranging from 7 to 28. Higher scores indicate a more positive genital self-image. The validity and reliability study of the scale in the Turkish population was conducted by Karadeniz (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), who reported a Cronbach\u0026rsquo;s alpha (α) coefficient of 0.90 (Karadeniz, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). In the present study, the Cronbach\u0026rsquo;s alpha (α) value was found to be 0.809, indicating good internal consistency.\u003c/p\u003e\n\u003ch3\u003eCarol Postpartum Sexual Function And Dyspareunia Assessment Scale (Carol's Scale)\u003c/h3\u003e\n\u003cp\u003eThe scale, developed by L\u0026oacute;pez-L\u0026oacute;pez Lapeyrere et al. (2018), consists of 11 items and four subdimensions, and was designed to assess sexual function and the presence of dyspareunia in women who have resumed sexual activity through vaginal intercourse after vaginal delivery. The scale gathers information about discomfort or pain intensity experienced during different phases of sexual activity, contributing to the evaluation of postpartum dyspareunia. Evcili (2018) investigated the scale's validity and reliability and found that its original Cronbach's alpha (α) value was 0.79.The following are the scale's subdimensions::\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003ePreparation for Sexual Activity\u003c/em\u003e: This subdimension is divided into two areas: libido and lubrication, which should be evaluated separately. Items 1 and 2 assess libido, while Item 3 measures lubrication. The total score for the libido domain ranges from 0 to 8, with higher scores indicating better function. A score of 6\u0026ndash;8 indicates \u0026lsquo;no libido dysfunction,\u0026rsquo; 3\u0026ndash;5 represents \u0026lsquo;moderate libido dysfunction,\u0026rsquo; and 0\u0026ndash;2 indicates \u0026lsquo;severe libido dysfunction.\u0026rsquo; The total score for the lubrication domain ranges from 0 to 4, with higher scores representing better function. A score of 3\u0026ndash;4 indicates \u0026lsquo;no lubrication dysfunction,\u0026rsquo; 2 represents \u0026lsquo;moderate lubrication dysfunction,\u0026rsquo; and 0\u0026ndash;1 indicates \u0026lsquo;severe lubrication dysfunction.\u0026rsquo; The Cronbach\u0026rsquo;s alpha (α) value for the preparation for sexual activity subdimension was found to be 0.69. In the current study, the Cronbach\u0026rsquo;s alpha (α) value was 0.677.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eDiscomfort or Pain When Touching the Vulva\u003c/em\u003e: This section assesses two aspects: \u0026lsquo;frequency of pain or discomfort when touching the vulva or perineum\u0026rsquo; and \u0026lsquo;intensity of pain or discomfort when touching the vulva or perineum.\u0026rsquo; It consists of two items (Items 4 and 8), with total scores ranging from 0 to 14. Lower scores indicate less discomfort. A score of 0\u0026ndash;4 is interpreted as \u0026lsquo;no/mild discomfort or pain,\u0026rsquo; 5\u0026ndash;7 as \u0026lsquo;moderate discomfort or pain,\u0026rsquo; and 8\u0026ndash;14 as \u0026lsquo;severe discomfort or pain.\u0026rsquo; The Cronbach\u0026rsquo;s alpha (α) value for this subdimension was reported as 0.86. In the current study, the Cronbach\u0026rsquo;s alpha (α) value was 0.777.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eDiscomfort or Pain During Vaginal Intercourse\u003c/em\u003e: This section is divided into two areas: \u0026lsquo;pain during penetration\u0026rsquo; and \u0026lsquo;pain during vaginal intercourse.\u0026rsquo; These areas are evaluated separately. The \u0026lsquo;pain during penetration\u0026rsquo; domain is measured by two items (Items 5 and 9), and the \u0026lsquo;pain during vaginal intercourse\u0026rsquo; domain is measured by two items (Items 6 and 10), totaling four items. Scores for both domains range from 0 to 14, with lower scores indicating less discomfort. A score of 0\u0026ndash;4 represents \u0026lsquo;no/mild discomfort or pain,\u0026rsquo; 5\u0026ndash;7 indicates \u0026lsquo;moderate discomfort or pain,\u0026rsquo; and 8\u0026ndash;14 signifies \u0026lsquo;severe discomfort or pain.\u0026rsquo; The Cronbach\u0026rsquo;s alpha (α) value for this subdimension was reported as 0.93. The Cronbach's alpha (α) score in the current study was 0.901.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cem\u003eDiscomfort or Pain After Vaginal Intercourse\u003c/em\u003e: This section assesses \u0026lsquo;frequency of pain or discomfort after vaginal intercourse\u0026rsquo; and \u0026lsquo;intensity of pain or discomfort after vaginal intercourse\u0026rsquo; through two items (Items 7 and 11). The total score ranges from 0 to 14, with lower scores indicating less discomfort. A score of 0\u0026ndash;4 is interpreted as \u0026lsquo;no/mild discomfort or pain,\u0026rsquo; 5\u0026ndash;7 as \u0026lsquo;moderate discomfort or pain,\u0026rsquo; and 8\u0026ndash;14 as \u0026lsquo;severe discomfort or pain.\u0026rsquo; The Cronbach\u0026rsquo;s alpha (α) value for this subdimension was reported as 0.86. In the present study, the Cronbach\u0026rsquo;s alpha (α) value was 0.751.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eThe data collection instruments were administered by the researchers to women who gave birth in the postpartum ward of \u0026hellip;\u0026hellip;\u0026hellip;. Training and Research Hospital. The data collection phase of the study, which was performed between 28 February 2023 and 1 August 2023, was carried out as follows:\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eFirst Follow-up (Within 24 Hours Postpartum)\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eDuring the initial follow-up, face-to-face interviews were conducted, and the Personal Information Form and the FGSIS were administered.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEfforts were made to ensure a quiet environment to maintain privacy and comfort, and single-patient rooms were used during data collection.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Participants were informed about the purpose and methodology of the study, and informed consent forms were read and signed. A total of 309 participants were included at this stage.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eSecond Follow-up (16 Weeks Postpartum)\u003c/h3\u003e\n\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e The second follow-up was conducted through telephone interviews, scheduled at times convenient for the participants.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Participants were provided with information regarding the continuation of the study, and their verbal consent was secured for the second follow-up.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe Carol\u0026rsquo;s Scale and Dyspareunia Assessment Scale and the FGSIS were re-administered.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eOf the 309 participants who completed the first follow-up, 283 were successfully reached. The remaining 26 participants could not be contacted due to various reasons (e.g., change of phone number, inability to reach the participant, refusal to participate in the interview).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis of Research Data\u003c/h2\u003e \u003cp\u003eIBM AMOS V24 and IBM SPSS V23 were used to analyze the data. Normality of data distribution was assessed using the Kolmogorov-Smirnov test. Non-normally distributed dependent variables over two time points were analysed using the Wilcoxon test. The relationship between non-normally distributed variables was examined using Spearman's rho correlation. In structural equation modelling, normality was assessed using the multivariate normality assumption. The structural model was tested using path analysis with maximum likelihood estimation as the method of calculation.\u003c/p\u003e \u003cp\u003eWhile categorical data were displayed as frequencies and percentages, quantitative data were displayed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation and median (min-max). Cronbach's alpha coefficient was used to evaluate the scales' reliability. The threshold for statistical significance was p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 (Tabachnick \u0026amp; Fidell, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003eThe Ethics Committee for Non-Interventional Clinical Research of \u0026hellip;\u0026hellip;\u0026hellip;. University granted ethical approval for the study (meeting date: 06.09.2023, decision number: 11, protocol number: 2023/4401), and the hospital where the study was conducted provided the necessary permissions. Participants were informed of the purpose of the study prior to data collection. Each participant was given information about the study, and verbal and written consent was obtained from those who agreed to participate. The study was conducted in accordance with the Declaration of Helsinki, with the principle of voluntary participation as the basis for the selection of participants.\u003c/p\u003e \u003cp\u003e The following ethical principles were observed Informed consent, where participants were informed of the aims of the study; confidentiality and data protection, ensuring that all data collected remained confidential; respect for autonomy, meaning that only those who voluntarily agreed to participate were included; and non-maleficence and beneficence, ensuring that no harm was done to participants while aiming to provide benefit. Participants were informed that they could withdraw from the study at any time. The data collected were used only for the purposes of this research.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics of the Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation / Frequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (min-max) / Percentage\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27.38\u0026thinsp;\u0026plusmn;\u0026thinsp;4.533\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27 (18\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducational level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIlliterate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnly literate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary school graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary school graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e165\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e53.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUniversity graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment statu\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmploye\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIncome status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome less than expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome equal to expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e222\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e71.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIncome more than expenses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFamily type\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNuclear family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e237\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtended family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlanned pregnancy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e284\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePain felt during episiotomy\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.35\u0026thinsp;\u0026plusmn;\u0026thinsp;2.086\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8 (4\u0026ndash;10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation, Median (Minimum\u0026ndash;Maximum), n(%)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe median age of the participants was 27 years. Regarding educational level, 53.4% had completed middle school. Additionally, 86.4% were unemployed, 71.8% reported that their income was equal to their expenses, and 76.7% lived in a nuclear family. Moreover, 91.9% of the participants had a planned pregnancy, and the median value of pain experienced during episiotomy was 8.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalysis of the Relationship Between Pretest and Posttest Total Scores of the FGSIS\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian (min-max)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePre-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e20.896\u0026thinsp;\u0026plusmn;\u0026thinsp;4.252\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (7\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e-0.703\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.482\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePost-test\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e20.855\u0026thinsp;\u0026plusmn;\u0026thinsp;4.139\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (9\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Wilcoxon Test; Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;Standard Deviation. Median (Minimum\u0026ndash;Maximum)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe median pretest score of the FGSIS was 21, while the median posttest score was also 21, indicating no statistically significant difference between them (p\u0026thinsp;=\u0026thinsp;0.482).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationship Between Pretest-Posttest Total Scores of the FGSIS and Subscale Total Scores of the Carol Scale\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eCarol's Scale sub-dimensions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFGSIS pre-test total\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eFGSIS post-test total\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ep*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003er\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep*\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.Preparation for the sexual activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.007\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.903\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.18\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.Pain or discomfort on caressing the vulval area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.170\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.004\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.119\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.045\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Pain or discomfort related to vaginal intercourse/penetration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.121\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.042\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.116\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.051\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Pain or discomfort related to vaginal intercourse/ intercourse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.125\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e0.036\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.080\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Pain or discomfort after vaginal intercourse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-0.033\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.580\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.050\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.406\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003e*Spearman\u0026rsquo;s rho correlation, Carol's Scale: Carol Postpartum Sexual Function And Dyspareunia Assessment Scale, FGSIS: Female Genital Self Image Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA very weak negative correlation was found between the total pretest score of the FGSIS and the second subscale of the Carol scale (r=-0.170; p\u0026thinsp;=\u0026thinsp;0.004). Additionally, a very weak negative correlation was observed between the total pretest score of the FGSIS and the Carol penetration subscale (r=-0.121; p\u0026thinsp;=\u0026thinsp;0.042). Similarly, a very weak negative correlation was found between the total pretest score of the FGSIS and the Carol vaginal intercourse subscale (r=-0.125; p\u0026thinsp;=\u0026thinsp;0.036). No significant correlation was found between the total posttest scores of the FGSIS and the subscales of the Carol scale (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePath Analysis Results Between Dependent and Independent Variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"9\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDependent variables/ sub-dimensions\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIndependent variable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eβ1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eβ2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStandard Error\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eTest Statistics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eR2\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1.Preparation for the sexual activity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFGSIS difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.094\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.063\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.039\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-1.593\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.111\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.009\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2.Pain or discomfort on caressing the vulval area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFGSIS difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.057\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.062\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.956\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.339\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Pain or discomfort related to vaginal intercourse/penetration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFGSIS difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.025\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.072\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.422\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.673\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3. Pain or discomfort related to vaginal intercourse/intercourse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFGSIS difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e-0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e-0.004\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.074\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e-0.059\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.953\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.000\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4. Pain or discomfort after vaginal intercourse\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026mdash;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFGSIS difference\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.046\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.767\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e0.443\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"9\"\u003eβ1: Standardized beta coefficient; β2: Unstandardized beta coefficient, Carol's Scale: Carol Postpartum Sexual Function And Dyspareunia Assessment Scale, FGSIS: Female Genital Self Image Scale\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWhen examining the multivariate normality of the model, the critical ratio for multivariate normality was found to be 8.968. As this value is less than 20, the assumption of multivariate normality was met. Maximum likelihood was used as the estimation method.\u003c/p\u003e \u003cp\u003eThere was no significant effect of the independent variables on the dependent variable (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). The goodness of fit indices were obtained as follows CMIN/DF (10.525 / 4)\u0026thinsp;=\u0026thinsp;2.631, AGFI\u0026thinsp;=\u0026thinsp;0.937, GFI\u0026thinsp;=\u0026thinsp;0.988, IFI\u0026thinsp;=\u0026thinsp;0.992, TLI\u0026thinsp;=\u0026thinsp;0.969, CFI\u0026thinsp;=\u0026thinsp;0.992 and RMSEA\u0026thinsp;=\u0026thinsp;0.076. ( Bentler, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e1990\u003c/span\u003e; Bollen, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e1989\u003c/span\u003e; Byrne, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; J\u0026ouml;reskog and S\u0026ouml;rbom, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e1996\u003c/span\u003e; Steiger, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e1990\u003c/span\u003e; Tucker and Lewis, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e1973\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this study, weak negative correlations were found between certain sub-dimensions of the Carol scale and the total pre-test score of the FGSIS. Specifically, statistically significant but very weak negative correlations were found between the pre-test score on the FGSIS and the sub-dimensions of pain or discomfort when stroking the vulva (r = -0.170; p\u0026thinsp;=\u0026thinsp;0.004), pain or discomfort during vaginal intercourse/penetration (r = -0.121; p\u0026thinsp;=\u0026thinsp;0.042), and pain or discomfort during vaginal intercourse/coitus (r = -0.125; p\u0026thinsp;=\u0026thinsp;0.036). These results suggest that there may be some degree of association between the constructs measured by the subdimensions of the Carol scale and those assessed by the FGSIS. However, the low correlation coefficients indicate that this association is not strong and that other variables may also be influential.\u003c/p\u003e \u003cp\u003eThe observation that these weak correlations in the pre-test did not attain statistical significance in the post-test (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) indicates that the relationship may have weakened over time or that the variables may not be directly associated. Several interpretations of these results are possible. One potential factor influencing the absence of a strong relationship between the Carol scale subdimensions and the FGSIS is the high mean scores observed in both the pre-test and post-test assessments of FGSIS (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). High baseline scores may have contributed to a lack of significant change in body perception over time, leading to weak or nonsignificant associations between variables. A positive body image and a high genital self-image may contribute to reduced anxiety and increased self-confidence in sexual experiences. Indeed, some studies have shown that a higher genital self-image is positively associated with women's sexual satisfaction, quality of sexual life, and overall life satisfaction. A meta-analysis conducted to determine the correlation between genital self-image and sexual function found a positive relationship between genital self-perception and sexual functioning (Alavi-Arjas et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Similarly, a study investigating the relationship between body image and genital self-image in women reported that as genital self-image increased, sexual satisfaction also increased (Komarnicky et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). This result highlights the significance of childbirth and postpartum processes as critical research areas regarding their impact on sexual function and body perception.\u003c/p\u003e \u003cp\u003eSimilarly, the long-term effects of episiotomy on sexual function and body image remain controversial in the literature. Some studies suggest that episiotomy may have both short- and long-term effects on sexual function. A study investigating the effects of episiotomy on postpartum sexual function found that women who underwent episiotomy had higher average levels of sexual satisfaction in the postpartum period (Leal et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). This result may be explained by the fact that women with a high genital self-image may recover their sexual function more quickly in the post-episiotomy period due to their positive perception of their bodies.\u003c/p\u003e \u003cp\u003eAnother key result of our study was the path analysis conducted to examine the relationships between the dependent and independent variables. The goodness of fit indices obtained for the developed model (CMIN/DF\u0026thinsp;=\u0026thinsp;2.631, AGFI\u0026thinsp;=\u0026thinsp;0.937, GFI\u0026thinsp;=\u0026thinsp;0.988, IFI\u0026thinsp;=\u0026thinsp;0.992, TLI\u0026thinsp;=\u0026thinsp;0.969, CFI\u0026thinsp;=\u0026thinsp;0.992, RMSEA\u0026thinsp;=\u0026thinsp;0.076) indicated that the model had an acceptable fit to the data. However, the lack of a significant effect of genital self-image on sexual dysfunction and dyspareunia (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05) did not support the expected relationship.\u003c/p\u003e \u003cp\u003eThis result can be interpreted in a number of ways. First, genital self-image may not have a direct effect on sexual dysfunction and dyspareunia after episiotomy, or this effect may be moderated by other variables not included in the model. The literature also suggests that sexual dysfunction is multidimensional and complex, influenced by interactions between individual, surgical and psychosocial factors. A narrative review examining the biopsychosocial variables influencing female sexual function and dysfunction highlighted that sexual function and dysfunction are shaped by the interaction of biological, psychological, and social factors, necessitating multidimensional approaches to treatment strategies (Thomas \u0026amp; Thurston, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). Furthermore, a mixed-methods study investigating the effects of pelvic floor surgery on female sexual function discussed that surgical interventions can lead to sexual dysfunction, but individual and psychosocial factors also play a crucial role in this process (Roos et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2014\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConsidering these examples, the results of our study suggest that there is no direct or strong relationship between genital self-image and sexual dysfunction or dyspareunia after episiotomy. However, given the multidimensional nature of sexual dysfunction and dyspareunia, it is important to evaluate this result in the context of other individual, surgical and psychosocial factors.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations of the Study\u003c/h2\u003e \u003cp\u003eIn evaluating the strengths and limitations of this study, it is useful to consider the methodology, analytical approach, sample characteristics, and scientific contributions. The most significant strength of this research is its use of path analysis, an advanced statistical method, to examine both direct and indirect effects between variables. In contrast to previous studies, which have predominantly utilised descriptive and correlational analyses (Da Silva et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Barbosa et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), this study employs path analysis, a more advanced statistical method, to provide a more in-depth analysis by modelling the direct and indirect effects between variables. This approach offers a more comprehensive perspective on post-episiotomy sexual function and dyspareunia. This methodological approach enhances the study's rigor and allows for a more detailed examination compared to previous research.\u003c/p\u003e \u003cp\u003eA further strength of the study is the satisfactory model fit indices, including CMIN/DF, AGFI, GFI, IFI, TLI, CFI, and RMSEA, which indicate that the data adequately fit the proposed model. This strengthens the reliability of the results. Moreover, the study utilised validated and reliable measurement tools (FGSIS, Carol's Scale), further supporting its methodological robustness.\u003c/p\u003e \u003cp\u003eHowever, the study is not without its limitations. Firstly, the sample size may not be sufficient to generalise the results to a broader population, particularly in the context of complex statistical methods such as path analysis, where larger sample sizes would enhance the generalisability of the results. Secondly, no statistically significant relationship was identified between the independent variable, genital self-image, and the dependent variables, sexual dysfunction and dyspareunia, in the path analysis (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05). This result indicates that the study does not provide a definitive answer to the research questions and that a strong causal link between the examined variables could not be established.\u003c/p\u003e \u003cp\u003eMoreover, the cross-sectional nature of the study imposes limitations on the capacity to ascertain causal relationships between variables. A longitudinal study design would offer a more comprehensive evaluation of the long-term implications of episiotomy. Sexual dysfunction and dyspareunia in women who have undergone episiotomy are influenced by a multitude of factors, including genital self-image, psychological well-being, partner relationships, hormonal changes, and cultural influences. The absence of a comprehensive exploration of these variables in the study may restrict the interpretation of the results.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for Future Research\u003c/h2\u003e \u003cp\u003eIt is recommended that future studies employ longitudinal designs to assess the long-term effects of genital self-image on postpartum sexual function and dyspareunia in women who have undergone episiotomy. This approach would provide clearer insights into the temporal dynamics and potential causality between variables. In order to enhance the generalizability of results, it is advised that future research include larger sample sizes and participants with diverse demographic and cultural backgrounds. This would allow for a more robust examination of potential moderator and mediator factors.\u003c/p\u003e \u003cp\u003eIn light of the multidimensional nature of sexual function and dyspareunia, future research should incorporate additional variables such as psychological well-being, partner relationship quality, hormonal changes, and sociocultural influences. These factors may help explain the complex interactions between episiotomy, genital self-image, sexual function, and dyspareunia. In addition to quantitative analyses, employing mixed-method approaches that integrate qualitative data would allow for a deeper understanding of postpartum women's subjective experiences. The use of qualitative research methods such as interviews and focus groups could yield valuable insights that may not be captured by quantitative approaches. Furthermore, intervention studies that evaluate the impact of programs designed to enhance genital self-image on sexual function and dyspareunia following episiotomy could provide beneficial insights. Randomized controlled trials could play a crucial role in determining the effectiveness of such interventions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eImplications for practice\u003c/h2\u003e \u003cp\u003eThe absence of a significant relationship between genital self-image and sexual dysfunction/dyspareunia in women with episiotomy, as indicated by the path analysis, suggests the need for healthcare professionals \u0026ndash; particularly midwives who are in primary contact with women during the postpartum period \u0026ndash; to adopt a more holistic approach to postpartum sexual health. Psychological, relational, and physiological factors that may influence sexual function after episiotomy should be considered collectively.\u003c/p\u003e \u003cp\u003eMidwives and healthcare professionals should provide comprehensive counselling services to postpartum women and offer education on the various factors affecting sexual function. This process should include discussions on body image, pain management, and emotional well-being, with particular attention given to women who have undergone episiotomy. Implementing a multidisciplinary approach in postpartum care would ensure a thorough assessment of sexual function and dyspareunia. Such an approach could facilitate timely and effective interventions, leading to improved outcomes. The development of targeted interventions that support both physical and emotional recovery could be facilitated by collaboration among obstetricians, midwives, psychologists, and sex therapists.\u003c/p\u003e \u003c/div\u003e "},{"header":"Conclusions and Recommendations","content":"\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\n \u003cp\u003eThis study examined the effects of genital self-image on postpartum sexual function and dyspareunia in primiparous women who had undergone episiotomy. The results of the path analysis did not reveal a statistically significant relationship between genital self-image and either sexual dysfunction or dyspareunia, suggesting that additional psychosocial and physiological factors may play a role in postpartum sexual health. While no significant differences were observed in overall sexual function between pregnancy and the postpartum period, the increased pain during intercourse commonly reported by postpartum women highlights the need for targeted interventions in this area.\u003c/p\u003e\n \u003cp\u003eBased on these results, several recommendations can be made for future research and clinical practice. Firstly, longitudinal studies utilising larger and more diverse samples are required to facilitate a more profound comprehension of the long-term implications of genital self-image on postpartum sexual function and dyspareunia in primiparous women who have undergone episiotomy. Secondly, future research should encompass additional mediating factors such as psychological stress, relationship dynamics, and hormonal changes that may influence postpartum sexual health.\u003c/p\u003e\n \u003cp\u003eFrom a clinical perspective, the importance of a multidisciplinary approach in postpartum care should be emphasised, with collaboration between obstetricians, midwives, psychologists, and sex therapists encouraged to adopt a comprehensive approach that supports both physical and psychological recovery. Additionally, healthcare professionals should provide extensive counselling and education to women on postpartum sexual changes, pain management strategies, and emotional well-being. Furthermore, policymakers should consider developing initiatives to expand postpartum counselling services and improve their accessibility. The implementation of these recommendations has the potential to enhance both research and clinical practices, ultimately leading to improvements in postpartum sexual health outcomes.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eFGSIS: Female Genital Self Image Scale\u003c/p\u003e\n\u003cp\u003eCarol's Scale: Carol Postpartum Sexual Function and Dyspareunia Assessment Scale\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eDeclaration of competing interest\u003c/h2\u003e \u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding sources\u003c/h2\u003e \u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eAuthors' Contributions:\u0026bull; Concept and Design: E.G, M.\u0026Ccedil;\u0026bull; Data Collection / Literature Review: E.G, M.\u0026Ccedil;\u0026bull; Data Analysis and Interpretation: E.G\u0026bull; Manuscript Preparation: E.G, M.\u0026Ccedil;\u0026bull; Final Approval for Publication: E.G\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe sincerely thank all participants for their contributions to this study and the healthcare professionals who assisted in the data collection process.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAlavi-Arjas F, Goodman MP, Simbar M, Majd A, Nahidi H, F. 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Psychometrika. 1973;38(1):1\u0026ndash;10.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"body image, dyspareunia, episiotomy, midwifery, path analysis, sexual dysfunction","lastPublishedDoi":"10.21203/rs.3.rs-6278770/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6278770/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eProblem: \u003c/strong\u003eThe present study sets out the hypothesis that there is a link between genital self-image in women who have undergone an episiotomy and postpartum sexual function and dyspareunia. However, more research is needed to understand the nature and effects of these associations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eThe effects of genital self-image on an individual's body perception and sexual functioning is a crucial factor in the study of human sexuality. The occurrence of episiotomy during the postpartum period can result in a range of physical recovery challenges and psychosocial effects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim: \u003c/strong\u003eThe present study set out to ascertain the effect of genital self-image on postpartum sexual function and dyspareunia in primiparous women who have undergone an episiotomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eThe present study was conducted as a cross-sectional investigation. It was conducted between February and August 2023 in the postpartum ward of a public hospital located in eastern ………..The study included 309 women who had a healthy vaginal delivery and resumed vaginal sexual activity within 6 to 8 weeks postpartum.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003e\u0026nbsp;The study established a correlation between genital self-image and postpartum sexual function and dyspareunia in primiparous women who underwent an episiotomy (p \u0026lt; 0.05). However, the results of the path analysis indicated that genital self-image did not have a direct significant effect on postpartum sexual function and dyspareunia (p \u0026gt; 0.05).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003eThe results indicate that there is an absence of a robust direct correlation between genital self-image and postpartum sexual function, as well as dyspareunia, in primiparous women who have undergone an episiotomy. However, it is crucial to acknowledge that sexual function and dyspareunia are influenced by numerous factors. This underscores the necessity for a multidimensional approach in research endeavours pertaining to this subject.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe path analysis's findings showed that genital selfimage has little influence on dyspareunia and sexual function. It is recommended that holistic and biopsychosocial strategies be created to promote women's sexual health and wellbeing during the postpartum phase.\u003c/p\u003e","manuscriptTitle":"The Silent Wound of Birth: The Effects of Genital Self-Image on Postpartum Sexual Function and Dyspareunia in Primiparous Women with Episiotomy – A Path Analysis Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-31 11:19:42","doi":"10.21203/rs.3.rs-6278770/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"42366ff2-4bba-49cf-9def-93a3b325e238","owner":[],"postedDate":"March 31st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-04-02T09:09:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-03-31 11:19:42","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6278770","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6278770","identity":"rs-6278770","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}