Current Status of Sexual Health and Rights Indicators in Iran: An Overview.

Sexual health and rights indicators provide essential tools for monitoring the status of individuals' sexual health and its rights, in various countries. This paper discusses sexual health and rights indicators in Iran. The indicators under study are derived from similar indicators developed by Asian-Pacific Resource and Research Center for Women, for the 15th anniversary of the International Conference on Population and Development monitoring project. Four HIV-related and three other indicators, including legal age of marriage, median age of women at marriage, and status of violence against women (VAW) were examined in this study. Iran has made several achievements in combating HIV/AIDS, with the focus on injectable drug users, and has countered a series of challenges in the determination of VAW prevalence, the increase of high risk behavior in adolescents, and sexual education for this group. The most important message of this paper is that special attention to challenging issues in Iranian individuals' sexual health could promote their current status.

1. Introduction

Sexual health has been defined by the World Health Organization (WHO) as “a state of physical, mental, and social well-being, related to sexuality; it is not merely the absence of disease, dysfunction or infirmity”. Sexual health is an important part of overall physical and mental well-being and has an impact on the quality of life for both men and women (1). Its importance is more pronounced in Iran because the unspoken climate around sexual issues, which originates from the sociocultural status of the country, leads to embarrassment and discomfort in discussing sexual health (2).

To achieve and sustain sexual health, the sexual rights of all persons must be respected, protected, and fulfilled. The WHO has defined sexual rights as the right of all persons to access the highest possible standard of sexual and reproductive health care services and information; to respect bodily integrity; to choose a partner; to engage in sexual relations by mutual consent; to decide whether or not to have children; and to engage in a satisfying, secure, and gratifying sexual life (1).

Indicators are ways to measure the performance of a system (3). It seems that sexual health and rights indicators could generally express an overall viewpoint of the government commitments towards improving its individuals’ sexual health.

In this article, authors examined seven sexual health and rights indicators, which were introduced by Asian-Pacific Resource and Research Center for Women (ARROW), a regional non-profit women’s non-governmental organization (NGO) for the 15th anniversary of the International Conference on Population and Development (ICPD + 15) monitoring project in the Asian-Pacific region. These indicators consist of 1) status of violence against women (VAW), 2) legal women/men’s age of marriage, 3) median age at marriage for women (age group 25 - 49), 4) estimated number of adults and children living with HIV, 5) estimation of HIV prevalence in adults (age group 15 - 49), 6) percentage of adults and children with advanced HIV infection receiving antiretroviral therapy (ART), and 7) estimated number of women aged ≥ 15 living with HIV (4). Although these indicators have no universal validity for all world regions, they provide an accessible tool for evaluating sexual health and rights in different countries. Therefore, this study was conducted to examine current status of sexual health and rights in Iran, using the aforementioned indicators.

In several local studies, the prevalence of domestic violence has been reported to 15‒43.7% for physical, 30.9 - 42.4% for sexual, and 81.5 - 82.6% for psychological abuse, in various regions of Iran (5-7).

In the latest amendment of article 1041, legal age of marriage for women and men was determined at 13 and 15 years, respectively (8). In 2012, the mean age at marriage for women was reported 24 years, in Iran (9). According to the data of the 2011 National Population and Housing Census of Iran, 1.74 and 0.48 percent of women and men, aged less than 15 years old, have been married at least once (10).

According to the United Nations Program on HIV and AIDS (UNAIDS) report in 2013, the estimated number of people living with HIV in Iran was 70000 (47000 - 110000), although, based on the data of case registry system, 23497 people were infected with HIV until September 21st, 2011 (11, 12). The latest estimate showed that HIV prevalence rate in adults aged 15 - 49 years was 0.1 - 0.2%, and it remained constant from 2011 to 2013. The estimated number of women aged ≥ 15, living with HIV, in Iran, was 19000 in 2013 (11-13). The United Nations General Assembly Special Session (UNGASS) country progress report, in 2012, showed that 7.8% of the total people who needed ART, in Iran, received it. The people were comprised of 684 females and 2068 males (13).

2. Arguments

Despite special attention of the Islamic Republic of Iran to fulfill sexual health and rights, several problems impede their achievement. For instance, domestic violence prevalence cannot accurately be determined because of underreporting, sampling selection bias, and different data collecting tools. According to a qualitative research, experts believe that the existing laws of the country introduce an unclear definition of domestic violence against women. The ambiguous rules with weak law enforcement are the main legal obstacles to prevent and deal with the violence (14).

Although Iranian laws have determined an age limit for marriage and the mean age at marriage for Iranian women was constant from 2010 to 2012 (9), the possibility of early marriage and its adverse impacts have remained a challengeable issue. Information from the Center of Disease Control of the Ministry of Health and Medical Education of Iran indicated that the rates of high risk behaviors, which could lead to HIV/AIDS, are increasing quickly (15). Additionally, access to various communication technologies has changed social traditions about prohibition of pre-marital sex in young people (16, 17). Sexual relationships could increase the likelihood of HIV infection, maternal mortality, and domestic violence, in the age group (18). According to the World Bank report, in 2012, adolescence fertility rate was 31 births per 1000 married and single women aged 15 - 19 years, in Iran. Despite a constant rate from 2010 to 2012 (19), the situation confirms the necessity of sexual health education and provision of sexual and reproductive health services, for adolescents (20). Several studies showed that cultural taboos surrounding sexuality are major obstacles to sexual health education and services for the group (20, 21). Although education in schools can provide an opportunity to transfer correct information about sexual and reproductive health and rights, fears of parents’ objection and lack of legal support lead to banning or restricting the education (21).

Iran has provided an effective model entitled “Triangular Clinics” for HIV prevention, care, and support in injectable drug users, the most important group influencing the prevalence of HIV in the country. The clinics provide harm reduction interventions (needle syringe programs and methadone maintenance treatment), sexually transmitted infection services, and care/support for people living with HIV/AIDS (22). Consequently, 91.72% of all people who injected drugs used a sterile needle on their last injection. The progress was very significant in comparison with the previous report, in 2010, which was 74.5% (8).

Despite the implementation of the National Harm Reduction program, sexual transmission of HIV has become another top concern in the prevention program. Although the use of condom in sexual relationships represents one of the preventive strategies in the transmission of HIV, studies have shown that nearly 50% of women and men aged 15 - 49 years with multiple sexual partners did not use condoms during their last sexual intercourse. The indicator was reported 15% and 57% in injectable drug users and female sex workers, respectively. It should be noted that most of the study population in the sex worker group was composed of women integrated in specific Drop in Centers, who have received a certain amount of information. Therefore, generalizing the findings to all female sex workers should be treated with caution (11, 12). Furthermore, the accessible evidence indicates protective behaviors based on condom use were low among at risk populations (23, 24). Additionally, “Lack of perceived threat, absence of protective motivation, inadequate knowledge, perceived lack of control, negative attitudes towards condom, misperception, unsupportive environments, and cultural norms” have been identified as barriers to condom use among at risk women (25). The situation could be a trigger for planning a better targeted education of high-risk groups.

Other best practices for combating HIV/AIDS in Iran consist of counseling hotlines for individuals, positive clubs for people living with, and affected by HIV, counseling centers for vulnerable women, educational programs for inmates, and protection of anti-discrimination laws for people living with HIV (12, 13). In terms of HIV treatment, despite the increased number of individuals who receive ART, there is a discordance between the growth coverage of treatment and need for ART. Several experts believe that this problem has occurred due to software overestimation in need of ART (12). This is because the AIDS-related mortality patterns from 2005 to 2011 showed no change or decrease of less than 25%, in the country (13).

3. Conclusions

In conclusion, Iran has successfully made certain achievements in sexual health and rights, whereas in the future steps, focusing on critical challenges could fulfill Iranian individuals’ sexual health. Some of these include: delivering HIV preventive services to the “hidden” population of injectable drug users and sex workers, investments in HIV treatment with pace of increasing demand, engaging men and youth in national AIDS programs and anti-VAW plans in format of youth-friendly and male-friendly services, monitoring the implementation of sexual health education for adolescents with parental supervision in schools, integrating anti-VAW programs in public health systems, supporting NGOs with culturally sensitive activities in VAW-related matters for the target group of men, and providing evidence and population-based data in relation to VAW.