Sexuality Research in Iran: A Focus on Methodological and Ethical Considerations.

BACKGROUND: Research on sensitive topics, such as sexuality, could raise technical, methodological, ethical, political, and legal challenges. The aim of this paper was to draw the methodological challenges which the authors confronted during sexuality research with young population in the Iranian culture.
METHODS: This study was an exploratory mixed method one conducted in 2013-14. We interviewed 63 young women aged 18-34 yr in qualitative phase and 265 young women in quantitative phase in (university and non-university) dormitories and in an Adolescent Friendly Center. Data were collected using focus group discussions and individual interviews in the qualitative phase. We employed conventional content analysis to analyze the data. To enhance the rigor of the data, multiple data collection methods, maximum variation sampling, and peer checks were applied.
RESULTS: Five main themes emerged from the data: interaction with opposite sex, sexual risk, sexual protective, sex education, and sexual vulnerability. Challenges while conducting sex research have been discussed. These challenges included assumption of promiscuity, language of silence and privacy concerns, and sex segregation policy.
CONCLUSION: We described the strategies applied in our study and the rationales for each strategy. Strategies applied in the present study can be employed in contexts with the similar methodological and moral concerns.

Introduction

Sexuality is a relatively personal and private matter, and it faces subject to varying degrees of social, religious, moral, and legal norms and constraints (1). Research on sensitive topics, such as sexuality, could raise technical, methodological, ethical, political, and legal challenges (2). In other words, topics related to sexuality could be threatening because of unwelcome consequences as far as participants and researchers are concerned. As a result, the relationship between participants and researchers could be influenced by mistrust or concealment (3).

Sensitivity could impact on any stage of the research process from design to implementation, dissemination, and application (4). In Iran, research on premarital sexual behaviors faces an additional difficulty because intimate behavior is culturally and religiously unacceptable and it is legally forbidden (5). Some social constructions and cultural beliefs in the Iranian context make sex research more difficult than that in other societies. The age of marriage has risen in Iran (6); consequently, the gap between puberty and marriage (the only legal way permitting young people to experience their first sexual encounter) has considerably increased. Therefore, people might believe that Iranian youth are remaining sexually virgin during their bachelor lives. However, contrary to the expectation, recent studies reported that the prevalence of premarital relationships is rising among Iranian young people (5, 7). While the report alarms the likelihood of rising risky sexual behaviors (8), there is no comprehensive sex education targeting youth in Iran (9). Sexual health services such as sexual counseling or family planning are planned only for married people and do not target youth, as alleged by advocates and scholars (6, 10). Another concern is the outcomes of premarital sexual relationships that have more devastating outcomes for women comparing to men. If these relationships do not lead to marriage, the emotional and social consequences tend to be greater for women than for men due to the importance of virginity for young women’s marriage prospects (5).

In recent years, there has been increasing number of studies conducted on young people’s sexual behaviors in Iran (9, 11, 12). The findings of these studies will hopefully sensitize health policy makers to sexual risks (HIV, STIs, pregnancy, and abortion) among young people in general population. What are helpful for policy making are precise and unbiased findings which needs more methodological considerations. Some scholars argue that research on sensitive topics cannot be free of political, ethical, and societal influences and values (13). This paper describes and discusses some of the methodological considerations that arose as a result of our current research on the Iranian young women’s sexuality; the study on which this report is based aimed to explore pre-marital sexual behaviors in young women and to develop a culturally appropriate assessment scale.

Methods

Design

Our current study was exploratory mixed method conducted in 2013–14, qualitative (n=63) and quantitative (n=265) in approach. Qualitative approach was based on the rational that there were few data in the field of sexuality in the Iranian context and there were no preconceived hypotheses; so, we employed conventional content analysis (14) to explore the meanings and construction of young women’s sexual behaviors in the Iranian culture.

Participants and data collection

We recruited a group of young women (n = 63) aged 18–34, who volunteered to participate in the qualitative phase of study. A two-step qualitative approach, using focus group discussions (FGD) and individual interviews, was used to data collection. We employed focus group discussions as the primary means of data gathering. In the first step, we used purposive sampling and afterwards, to approach women who engaged in premarital sexual behaviors, snowball sampling was used. The sessions were facilitated by explaining the goal of the study and defining sexual behaviors, and using a semi-structured inventory that began with the open ended questions: ‘How is the sexual life for Iranian young women’. Afterwards, based on the responses obtained from the participants, subsequent questions built upon the discussion. The tow first discussions were managed through non-structured interviews. So, questions were built based on the analysis of conceptions extracted from these two FGDs. FGDs were held in (university and non-university) dormitories and an Adolescent Friendly Center. Interviews were carried out wherever participants tended to, e.g. workplace or dormitory. In the first FGDs, someone else, who was married and familiar with qualitative methods, attended besides the researcher; because the first researcher was single and attending such a person could promote the exploration of participants’ overt and covert sexual behaviors. The duration of the interviews or focus groups was 30–70 minutes, based on the willingness of participants. Audio recording was used to collect the data. We documented our analytic ideas by memo writing (field notes).

Sampling was continued with maximum variation to yield greater transferability of data and saturation (15). To achieve maximum variations, informants were selected from different age groups, different socioeconomic backgrounds, having various types of sexual experiences, and being as high and low level of religiosity. Participants had various educational level. Most were living in dormitories and a few of them were living with their families at the time of interviews. Six focus group discussions were held and twelve participants were interviewed individually. Data saturation was achieved after 5 focus group discussions and 10 individual interviews.

Data analysis

Inspired by Graneheim and Lundman’s approach, we employed qualitative content analysis. In this approach ‘the most suitable unit of analysis is whole interviews or observational protocols’ (16). Data analysis commenced during the data collection. Each focus group discussion and individual interviews was transcribed verbatim and analyzed before the next focus group discussion or interview. We achieved thorough comprehension of the data by reading and rereading. In the next step, the units of meanings were extracted from the statements. Data analysis proceeded using line-by-line coding; codes were created during repeated discussions between researchers. Categories and themes were created based on the codes with similar meanings. An example for the process of theme extraction has been shown in Table 1.

Table 1:

The process of extracting risky sexual behaviors theme

Theme	Sub-themes	Cods	Units of meanings
Risky sexual behaviors	Multi-partner-ship	Engaging in sexual behaviors with more than one person in order to: - Select the best one - Keep one of them for the future	“Sometimes, I had more than one boyfriend; I experienced sexual behaviors with both of them. My goal was to select and keep one of them in my life.”
	Casual relation-ship	- Unplanned sexual relationships - Inability to reject sexual behaviors	“In some of my relationships, I engaged in unplanned sexual relationships; for example, last year, I participated in a party and met a cool guy. Sexual relationships happened in the first meeting and I could not resist it.”
	Lack of contraception use	Lack of perceived risk of pregnancy because of: - Low frequency of sexual intercourse - Vaginal douche after each intercourse	“I did not use contraception because I thought I would not become pregnant because we had intercourse not frequently and I washed my vagina after each intercourse.”
	Lack of condom use	Lack of condom use because of fear of Lose of confidence	“I could not tell my boyfriend to use condom because I think he will miss his confidence to me or he think I have a sexual disease.”

Rigor

There was a second coder in the study who was expert in qualitative method. We asked our five participants to review the summary of the interviews and the findings (member check); these participants were chosen in the first FGDs and interviews. For confirmability of the findings, the substantive codes and themes were checked with four individuals who were familiar with qualitative methods of content analysis (peer check) (15). Maximum variation sampling enhanced the transferability of data (16). Multiple data collection methods (focus group discussion and individual interview) were used to enhance dependability and credibility of data (15).

Ethics

Approval to conduct the study was granted by the Ethics Committee of the School of Medicine of the Tarbiat Modares University in 2013. All participants were given pseudonyms and were informed that participation in the study was voluntary and they could withdraw at any time, their confidentiality would be maintained, and none of the participants would be identified in any publications arising from the study. Informed written consent was obtained from the participants prior to focus group discussions and interviews.

Results

Findings of the study will present in two parts. The themes extracted from the qualitative study will present shortly; afterwards, we will focus on challenges while conducting the study.

Five main themes emerged from data analysis: interaction with opposite sex, sexual risk, sexual protective, sex education, and sexual vulnerability. The themes and subthemes have been shown in Table 2.

Table 2:

Themes and sub-themes of premarital sexual behaviors

Themes	Sub-themes
Interaction with opposite sex
	Social friendship
	Intimate relationship
Sexual risk
	Risky sexual behaviors
	Risky sexual factors
Sexual protective
	Protective sexual behaviors
	Protective sexual factors
Sex education
	Sex education effects
	Sex education barriers
	Sex education principles
	Sex education content
	Organizations for sex education
Sexual vulnerability
	Reasons for sexual vulnerability
	Strategies for preventing sexual vulnerability

Challenges faced when conducting sexuality research

The challenges in the present study were assumption of promiscuity, language of silence and privacy concerns, and sex segregation policy.

Overcoming assumption of promiscuity

One of the ethical dilemmas in the present study was that ethics committee did not approve using focus group discussion (FGD) as an appropriate technique for data collection. The Committee suggested individual interviews in a private place would be more appropriate than FGDs. In result, FGD as an appropriate method for data collection was easily disapproved by the ethics committee in the Iranian academy.

Why focus group discussion was chosen as a technique for data collection?

We provided some reasons to the ethics committee to convince them for using FGD as an appropriate technique for data collection:

- We provided evidences from literature that in qualitative inquiries, FGD is considered as a proper technique, especially in sensitive topics.

- Since sexuality was perceived differently by various participants, we needed to find a culturally appropriate method to open discussion in the interviews. In fact, FGD could facilitate preparation of an inventory of key topics for the second phase of data collection, individual interviews. Also, FGD was helpful to elicit specific terminology related to premarital sexual relationships used by young women.

- FGD was a useful technique to build a further friendly atmosphere to elicit general information and social aspects of pre-marital sexual relationships.

- FGD could facilitate easy access to the target group, women who had engaged in premarital sexual experiences.

- FGD could provide a situation to develop rapport with the participants. As we were able to identify potential informant and invite them for individual interviews.

- Finally, we reassured the ethics committee that personal aspects of sexual experiences would not be discussed in FGDs.

Why we found focus group discussion as an appropriate technique?

In the FGDs, participants conversed, challenged, questioned, and answered each other. Young women with different values, viewpoints, and experiences discussed social aspect of premarital sexual relationships. In this step, data were generated based on predominant social norms regarding sexuality. We believe that both FGDs and individual interviews were necessary for data collection in this sensitive issue, because on the one hand, participants discussed and rephrased each other, therefore, views and opinions revealed in greater complexity than one-on-one interviews. On the other hand, details of personal experiences were discussed in individual interviews. Therefore, we succeed in convincing the ethics committee that promiscuity would not be disseminated in FGDs by discussing general and social aspects of sexuality. Most of Iranian young women spoke about general aspects of sexuality in FGDs. The participants with different levels of religiosity challenged each other’s viewpoints in various aspects of sexuality. Although, women who had premarital sexual activities did not speak openly about their sexual experiences in the discussions, we identified them when they were speaking about their values and beliefs; for example, some of participants with premarital sexual experiences believed that pre-marital sexual behavior is a natural phenomenon and every woman, like a man, should enjoy it. These women were identified and invited to participate in individual interviews.

Overcoming language of silence and privacy concerns

Recruitment of participants is regarded as one of the problems facing research on sensitive topics. Iran has a silent culture; scripted by the idea that a modest woman is not sexual and would hardly express her sexuality. Conception of women as sexually expressive is perceived as completely unfit in an andocentric philosophy. Also, preliminary analysis of our informal encounters with young women showed that they did not trust easily being interviewed using the semi-structured interviews. Such underlying cautions worked toward an unsuccessful attempt to interview the women in depth, even if the women are invited to participate in the study. In order to overcome language of silence and privacy concerns in individual interviews, we a) controlled our speaking style, our look, gesture, and posture, b) consulted participants on their sexual life, if they needed, c) ensured them that their private sexual experiences will only be used for completing the research, d) gave a pseudonym to each woman to achieve anonymity, e) invited potential participants to a dinner in order to establish rapport, and f) organized the questions from simple to complicated, so that participants did not feel we were intruding their private boundaries.

Applying sex segregation policy

In the first step, we designed our study with a focus on both girls and boys. As the first researcher of this study was a woman, the ethics committee did not approve working on boys because of the cross-gendered interviews. Rationales for applying sex segregation policy have been summarized as follow:

Cultural considerations

It was difficult for the first researcher (AR), as a single woman, to speak about sexuality with men. For a significant segment of the Muslim population, as in other conservative societies, talking about sex is taboo. Also, in Persian society, the language of sexuality is culturally scripted. A set of well-defined rules governs how women and men should express themselves in private or in public, particularly regarding sexuality. Women are basically instructed to practice silence (sokoot) as their main choice in sexual interactions, even in general terms (22). In fact, silence is a characteristic of the girlhood before marriage. This rule would be applied when we wanted to have a cross-gendered interview about premarital sexual relationships. Also, modesty named haya in Iranian culture is very important element for an ideal woman. The language of haya has always interfered with the language of sexuality in the Iranian culture. According to this culture, modesty will be tainted if a woman, especially a single woman, speaks about sexuality with men. Bi-haya, which means shameless (23) is applied to someone who lacks modesty and chastity because she talks openly about sexual matters. In the community, females can be easily labelled as bi-haya if they talk openly about sexual matters without indicating embarrassment, especially in public. This cultural situation required us to follow sex segregation policy in the study.

Methodological considerations

After we found that it was difficult to have cross-gendered interviews in the Iranian culture, we thought it would be appropriate to have a male research assistant to cover the gap of cross-gendered interviews. We selected a research assistant who was expert in qualitative studies. In fact, we would have two main researchers, a male and a female. In this case, it was necessary that these two researchers analyze the data through close interaction in order to obtain common understanding about each session and interview. As it was mentioned above, close interaction between cross-gendered researchers is not applicable in the Iranian context because of some cultural and ethical considerations. Although, talking about sexuality between two researchers would be research-based and there was no intimate or personal relationship between them, because of some considerations in the Iranian context (mentioned above), we decided to work only on women.

Discussion

This paper has been focused on challenges conducting sexuality research in the Iranian context; challenges were assumption of promiscuity, language of silence and privacy concerns, and sex segregation policy.

In spite of evidence to the contrary, this belief is still strong that speaking about sexuality would encourage youth to pursue sexual activities. In fact, it is thought youth may learn and try sex if they discuss about sexuality. It seems cultural upbringing and religious perspectives are important factors in formation of these viewpoints among Iranians. Although Iran’s population has a high proportion of Muslims (98%), it seems the main reason that Muslims may disagree with discussing sexuality is because of their cultural upbringing, not merely their religiosity (25). This belief was the main cause that led the ethics committee to disprove using focus group discussions (FGDs) as an appropriate technique for data collection in our qualitative study. The disapproval was based on the assumption that discussing about sexuality in a group would lead the participants to learn and motivate to engage in premarital sexual activities. Also, it could be because of the belief commonly permeating Iranian society that people are fairly innocent in terms of sexuality compared with non-Muslim or Western societies (20). Although Iran’s constitution is based on Islamic law and government policies are guided by Shari’a and Islamic principles, young generation may not believe that speaking about sexuality is against religion or cultural norms (20).

There are different ideas regarding researching on private topics. On the one hand, some researchers believe that research on private aspects of human life is unethical. According to Macintyre (26): “The study of taboo by anthropologists and privacy by sociologists show how important it is for a culture that certain areas of personal and social life should be specially protected. Intimacy cannot exit where everything is disclosed, sanctuary cannot be sought where no place is inviolate, integrity cannot be seen to be maintained- and therefore cannot in certain cases be maintained- without protection from illegitimate pressure (p.188)”. On the other hand, it is suggested that if there are potential benefits to society through conducting a study, research on sensitive subjects can be ethically undertaken. Research on these subjects enjoys knowledge enrichment as well as beneficiary effects for participants. In spite of raising many problems and dilemmas while researching on sensitive subjects; it does not mean that such ones should not be tackled with (3).

We found it is difficult for female researchers to have cross-gendered interview in the Iranian context because of some cultural considerations. ‘Outsider role’ was another reason which leaded us not to work on both genders. When the researcher is an insider, there is at least one sharing in characteristic, e.g. age, gender, or experience, between the researcher and participants (24). In the present study, the main researcher was insider in some characters such as age and outsider in some others including some beliefs and experiences. Although, being an insider may reflect the improper influence of the researcher’s perspective, being an insider is more beneficial rather than an outsider. Being an insider is more welcomed by the participants, thus, it provides a level of trust and openness (24). In fact, if we worked on boys, there was an outsider role in gender; because the first researcher was a woman. Therefore, acceptance; trust; and openness, which are very important in such a sensitive issue, could be deteriorated. There are, also, similar situations in other societies. Similar to our study, some female researchers in the previous studies have reported that “women researchers may be come ‘encapsulated in the stereotypical [gender] role designed by subjects’ and consequently they have limited access to data, especially data in such male-dominated groups” (27). However, Warren explored that researchers can be able to capitalize on the sexism of participants. Her research indicated that since gender issues in the field have been most troublesome for women, male researchers should deal with them at times (28).

The current study has some limitations. Topics related to sexuality, such as sex education, are a relatively personal and private matter. Thus, some people preferred not to speak about their sexual experiences. The main investigator succeeded in decreasing this limitation by establishing rapport and trust. Besides, because of religious and legal considerations, it is possible that only motivated or liberally minded young women participated, even though we invited all young women to participate in the study. In addition, most participants (75%) were students; then, the results of this study will be true for this group. Since all women in this study was Muslim and most of them were educated, further research is recommended in terms of urban/rural, level of education, and religion.

Conclusion

Challenges of the study such as assumption of promiscuity, language of silence and privacy concerns, and sex segregation policy were presented. In order to overcome assumption of promiscuity, we provided enough evidences about suitability of FGD for data collection on sensitive topics. Also, we convinced the ethics committee that only social norms, attitudes, and general aspects of sexuality would be discussed in FGDs and personal sexual experiences would be discussed in individual interviews. In order to overcome language of silence and privacy concerns in individual interviews, we controlled our speaking style, our look, gesture, and posture, consulted participants on their sexual life, if they needed, and so on. Finally, we had to respect the sex segregation policy and exclude men from the study due to the gender of first researcher (AR). Strategies that we applied in the present study to overcome the challenges can be employed in the similar contexts with the same ethical and moral concerns.

Ethical considerations

Ethical issues (Including plagiarism, informed consent, misconduct, data fabrication and/or falsification, double publication and/or submission, redundancy, etc.) have been completely observed by the authors.