Designing a national plan for improving sexual health in Iran: An experience of an Islamic country.

BACKGROUND: Prevalence of sexual dysfunction varies from 20% to 40% in men and women in different studies in Iran. Despite its high prevalence, it seems that this issue has been neglected, particularly in Islamic countries. The aim of this study was to assess sexual health in Iran. This was a mixed method study.
METHODS: Data were collected through evaluating country's sexual health programs and literature review. Sexual health status was drafted and formed following a sound analysis by stakeholders. After conducting interviews and focus group discussions, the main points of the meetings, influencing factors of the present status and oncoming strategies were obtained upon experts' opinions.
RESULTS: Review of general policies and the literature showed that although there is adequate support for improving sexual health status in the country, sexual health status has been decreased in the last decade. Based on Iranian sexual health indicators and experts' opinions, the focus points could be divided into the following groups: Structural and functional -political, legal-behavior, and cultural.
CONCLUSION: Breaking the taboo of sexual health issues would require attention from the policy makers especially in Islamic nations to facilitate the steps on the road to sexual health. In this regard, clarified vision, strategic goals and interventional policies are proposed. An inter-sectional cooperation is needed to implement interventions to promote sexual health status.

Introduction

The concept of sexual health is not only about reproduction and fertility, but also includes sexual dysfunction and sexual abuse (1). According to the definition by the World Health Organization (WHO), sexual health is “a state of physical, emotional, mental and social well-being in relation to sexuality and not merely the absence of disease, dysfunction or infirmity”.

Although the true extent of the burden of sexual dysfunction and STI is not known (2), it is estimated that sexual and reproductive conditions account for 18.4% of the global burden of disease (3).Moreover, 90% of the global disability-adjusted life years (DALY)s caused by sexually transmitted infections (STIs), excluding HIV, are experienced in low and middle income countries (4). Unsafe sex is one of the most important risk factors for disease, disability, or death in developing nations, and it is the ninth in developed countries. Several factors are known to influence sexual health such as sexual violence, sexual rights and sexuality (5). Sexuality is defined as the dynamic outcome of physical capacity, motivation, attitudes, opportunity for partnership, and sexual conduct (6).In other words, sexuality is an aspect of humans that consists of sexual orientation and gender role and is shaped by social interactions.

Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled. Some indicators have been proposed to evaluate the nature of factors that influence sexual health. These indicators measure issues such as “healthy sexuality”, “sexual dysfunction”, “sexual violence” and “female genital mutilation” (5).

Different studies in Iran revealed that the prevalence of sexual dysfunctions in both genders ranges from 20% to 40% (7-9). Iran is a middle income and an Islamic country (10). Islam has many recommendations about protection and promotion of sexual health, and emphasizes the importance of sexual fulfillment.Religion influences people’s views about sexuality and the Islamic values are among the best means to control sexually transmitted diseases. On the other hand, sometimes sexual problems reach the level of taboo in the Islamic nations and it is hard to make changes (11). The aim of this study was to discuss sexual health status in Iran and prepare a national plan to improve sexual health in the country.

Methods

This study involved an analysis of sexual health of Iranians followed by a stakeholder analysis and consensus building to propose a suitable policy using a qualitative approach.

Data were collected from reviewing documents, and from stakeholders and experts’ opinions through focused group discussions.

The study was conducted in three phases:

Phase One: Literature Review

A review of the literature including previous national policies plans and programs, national reports and statistics in sexual health was carried out to collect data on the current status in the country. By reviewing the documents, a framework for the national plan was devised.

Phase Two: Focused Group Discussions (FGD)s

Two groups participated in the FGD sessions: A) Stakeholders: They were selected according to their power and influences using a stakeholder analysis; B) Experts: Intentional sampling method was used to recruit the experts. They were selected from specialists in 15 fields including sociology, behavioral science, obstetrics–gynecology, criminology, maternal health pediatrics, sexual health promotion, religion Study, urology, psychiatry, child psychiatry, health law and ethics, social work, law enforcement, community medicine and child and maternal health.

A draft of mental health services charter was developed based on the information gathered in the previous phase. The framework of the charter was based on the objectives, structure, routines and standards, management style and resources. Then the charter was reviewed and evaluated by experts in three focus group discussions. In each session, a facilitator raised the questions; and ideas and opinions were collected by assigning a member as the session manager. Discussions were recorded with the group's consent. The main questions were as follows:

How is the sexual health status in Iran?

What factors influence the present status of sexual health?

What strategies are suggested to improve this status?

After three sessions of FGDs, the current status, main problem areas in sexual health, contributing factors in the present situation, and forthcoming strategies were reviewed and finalized in three sections including present status (sexual health indices, their trends, strength and weaknesses of country’s sexual health management system and analysis of current programs), factors affecting the current status of sexual health, and interventions in three different preventive levels. Expert’s committee members also commented on the draft report.

Results

Sexual Health Indices: Impact indicators of sexual health are presented below (12-33): Reviewing Iran’s sexual health management system and SWOT analysis of the current programs revealed that there are some deficits in stewardship, resources and service provision, which are threats to achieve goals.

Reviewing the available documents of strategic programs and sexual health policies show that most actions to improve sexual health take place within reproductive health programs, HIV/AIDS prevention especially in injectable drug users. Although some policies were made to promote sexual health and implement interventions recently, they were not comprehensive and multi sectoral to be implemented simultaneously and tailored. Based on the world recommendations and experts’ ideas, complementary action must cover all domains that are listed below:

Modification and revision of the related laws to reduce violence and gender justice

Adopt national policies to reduce violence (domestic and workplace‏)

Implement the strategy of sustainable development as major factors affecting sexual health

Development of local research and monitoring sexual health‏.

Controlling the diseases that affect sexual health (diabetes, depression, etc‏.)

Prevention and treatment of sexual dysfunction

Equitable access to sexuality counseling service

Development of knowledge, attitudes and skills providers

Code of desirable behavior for regulatory forces in sexual health issues

Expanding the cooperation of government, private and non-governmental agencies

Sexual education considering age – sex, community context and special conditions such as pregnancy

Parenting skill

Changing the community and policy makers’ views on sexual health issues

Understanding the relationship between individual sexual behavior and financial dependence

Education, Society, Economics and Culture:

Most available studies of sexual health in Iran are local and cannot show the trend of indicators. Experts’ opinion analysis shows an accelerating trend for most of indicators. Although there is adequate support for improving sexual health in general polices and some programs in Iran, improving sexual health of the Iranians needs complementary actions along with attainable vision and strategic planning. In this study, experts believed that improving different groups’ sexual health could be achieved through a multi- sectoral participation. Strategic planning should focus on increasing sexual health literacy 30% higher than the baseline. Moreover, all Iranians should have equitable access to sexual health consultation services in rural and urban areas. Furthermore, the accelerating trend of infertility and sexual transmitted infections and HIV-AIDS should be decreased, and violence against women and children should decrease by 20%, and the happiness score and gender gap index of the Iranians should be improved in world ranking. The proposed interventions along with the strategic planning are listed as follows:

Fist plan: Increasing sexual health literacy 30% higher than the baseline:

Empowering teachers, parents and peers in adolescents’ sexual health education

Developing and implementing an education package to improve sexual health for certain groups (pregnant women, elders, and people with physical or mental disabilities‏…)

Establishing policies and interventions to promote indirect sexual education through media‏

Inviting NGOs to be active in this field

Developing document against Stigma that surrounds sex education (with the purpose of breaking taboo of sexual health‏)

Second plan: All Iranians should have equitable access to sexual health consultation services in rural and urban areas.

Developing and implementing an essential package specifically to enable the providers in health centers to provide education on sexual issues

Developing regulations and transparent standards for sexual health counseling centers

Implementing programs to control diseases that affect sexual health (diabetes, depression, etc.) through screening and active surveillance of physical and mental health and social support

Developing support and insurance packages for sexual dysfunctions, infertility and infections

Third plan: Decreasing accelerated trend of infertility and sexual transmitted infections and HIV-AIDS

Providing infertility counseling and treatment centers by providing funding

Accelerating and maintaining the national program to prevent and control HIV infection and AIDS

Preventing infertility and sexually transmitted diseases in population groups by increasing the knowledge of the public‏

Forth plan: Decreasing violence against women and children 20% lower than the current status

Providing public education about root causes of violence and preventive strategies

Introducing or revising laws that protect sexual rights, prevent violence and support victims of violence

Developing national social marketing plan to reduce violence against women and children

Implementing employee assistance programs to prevent sexual violence in the workplace

Assessing the health system to extent fair delivering service to both sexes (nondiscrimination system‏)

Fifth plan: Improving happiness score and gender gap index in world ranking

Developing national happiness promoting plan based on the most reliable strategies in the world (especially the Jakarta World Summit) in the field of tourism development, reducing advertisement that promote social gaps and provincial and local entertainment program‏....

Developing a national plan to improve the gender gap considering four criteria (Economic Participation and Opportunity, Educational Attainment, Health and Survival, Political Empowerment‏)

Revising sexual rights and matching them with the principles of Islam and the national culture

Taking a synergistic approach in developing and implementing laws and policies related to sexual and reproductive health and efforts to remove social and cultural constraints in the community

Discussion

In summary, based on the findings of this survey, the trend of sexual health indicators is deteriorating in Iran. Information about sexual health is not sufficient in Iran due to the lack of a developed surveillance system. Although the status of sexual satisfaction is not directly measured, it can be deduced indirectly from indicators such as divorce and domestic violence.

Laws can play an important role in ensuring accountability at many levels including establishing transparent monitoring and reviewing the processes to record health outcomes across a sexually diverse population or assessing the impact of various health interventions (34). According to WHO, the ability of individuals to achieve sexual health and wellbeing depends on their access to good quality sexual health care and on an environment that affirms and promotes sexual health (35,36).

The availability of these services is a challenge in many countries, including Colombia, Mexico, Peru, therefore, in devising this national plan special attention was paid to an equitable access to healthcare services.

Sexual health promotion programs and policies in other countries are mainly focused on reproductive health, so the comparison is not entirely appropriate.

It is evident that cultural and social constructs could influence the decision makers’ views about sexual issues.

Conclusion

Breaking the taboo of sexual health issues would require the attention of the policy makers to facilitate the steps. In this regard, clarified vision, strategic goals and interventional policies are proposed. An inter-sectional cooperation is needed for implementing interventions to promote sexual health status. In addition, it should be noted that we are not the only Islamic country in the world with respected religious beliefs, culture and values. Successful experiences of countries such as Malaysia (38) and Pakistan (39,40), especially in the promotion of sexual health indices, could be very helpful for Iran.

Ethics

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.

Acknowledgements

The authors would like to acknowledge the grant received through the Internal Ministry of I.R of Iran to explore and learn about new approaches to improve sexual health. The authors gratefully acknowledge the participants for sharing their experience. Without their interest and valuable comments, the authors would not have been able to complete the study.