Sixteen individuals, with an average age of 38 years and about four years of activity in sexual health research, were recruited. Nine participants were female and seven were male. Also, 10 participants were married, while six were single. Overall, three participants were reproductive health experts, three were PhD students of reproductive health, two were psychiatrists with experience in sexual health research, two were Master students of midwifery, one was a clinical psychologist, one was a public health expert, two were specialists in biomedical research ethics, one was a member of a biomedical research ethics committee, and one was a participant of sexual research.
According to the data analysis, three main categories, seven subcategories, and 14 secondary subcategories emerged. The main categories included: 1- challenges related to biomedical research ethics committees, 2- challenges of sexual health researchers, and 3- challenges related to sexual health topics. The subcategories included: issues of topic and proposal approval; evaluation process of sexual health proposals in research ethics committees; ensuring the accuracy of results; critical ability of sexual health researchers; understanding the participants’ rights; issues related to sexual health research topics; and sensitivity of sexual health research. The secondary subcategories are listed in
Table 1. Challenges of Sexual Health Research in Iran
Category Subcategory Second Subcategory A) Challenges related to biomedical research ethics committees Issues of topic and proposal approval - Absence of an expert point of view towards sexual health topics - Lack of emotional and scientific support for researchers Evaluation process of sexual health proposals in research ethics committees - Gender allocation failure in the selection of biomedical research ethics committee members Ensuring the accuracy of results - Localization of sexual health research tools - Surveillance of the research process B) Challenges of sexual health researchers Critical ability of sexual health researchers - Necessity of researchers’ scientific sexual health knowledge - Necessity of sexual health researchers’ practical skills - Special personal/demographic characteristics of sexual health researchers Understanding the participants’ rights - Importance of observing research ethics principles - Importance of attention to the dignity of women and their families C) Challenges related to sexual health topics Issues related to sexual health research ideas - Considering the transformation of society’s needs/problems as a source of ideas Sensitivity of sexual health research - Cultural, social, and religious sensitivities to sexual health research - Topic/subject sensitivity in sexual health research - Possibility of self-censorship in sexual health research 4.1. Challenges Related to Biomedical Research Ethics Committees
4.1.1. Issues of Topic and Proposal Approval
The participants considered academic approval of sexual health topics and proposals as one of the most challenging issues.
- Absence of an expert point of view towards sexual health topics
Almost all participants acknowledged that members of biomedical research ethics committees must have an expert point of view for the approval of sexual health topics and proposals. A reproductive health expert stated:
“...The viewpoint of members of biomedical research ethics committees is incredibly important in sexual health topics. Experts in sexual health should evaluate and decide about sexual health projects and their ethical approval, because they are well-informed about the goals and necessity of the project.”
- Lack of emotional and scientific support for researchers
Most participants experienced frustration and lack of motivation when starting or continuing a sexual health study due to the complexities of the approval process in some biomedical research ethic committees. Also, stigmatization by colleagues causes concerns and doubts among researchers and results in discouragement from sexual health research. In addition, some of the participants complained about the absence of scientific sexual references and lack of comprehensive and reliable information about sexual health status in Iran. In this regard, one of the PhD students in reproductive health stated:
“Unfortunately, most websites about sexual health are filtered, and we are banned from accessing relevant articles. Also, reference books in this field are scarce in Iran…”
Such statements indicate distress and fear of disrepute among most researchers, especially faculty members and university students.
4.1.2. Evaluation Process of Sexual Health Proposals in Research Ethics Committees
Most of the participants, who had experience in the field of sexual health research, noted numerous problems in the evaluation of research projects by some biomedical research ethics committees. In some cases, the research project was rejected entirely by the biomedical research ethics committee without any clear rational explanation. Also, in some cases, the evaluation process took a long time, thereby compromising the researcher’s professional status.
- Gender allocation failure in the selection of biomedical research ethics committee members
Most sexual health research projects are conducted by women on women, while in Iran, most members of the biomedical research ethics committees are men. In this regard, a former research ethics committee member stated:
“The presence of women in biomedical research ethics committees seems necessary in areas related to the health of women and families. However, in many of these committees, there are no women, or there is only one woman who is not empowered for her position most of the time.”
4.1.3. Ensuring the Accuracy of Results
The participants acknowledged the importance of sexual health findings and believed that doubts in the results could have irreversible effects on the community. This main category emerged from two subcategories: localization of sexual health research tools and surveillance of the research process.
- Localization of sexual health research tools
Some participants emphasized on the need to localize global standard tools, based on the context. For instance, a phenomenon, such as violence, may be considered a behavioral disorder in one country, while according to the cultural beliefs of another country, it may be considered a normal variation. Regarding the research tools, a specialist in biomedical research ethics commented:
“... A Western standard tool must be adapted to the context of our country. The original version may be inconsistent with the social, cultural, and religious context of our country; so, we cannot simply translate or copy it.”
This participant also insisted that domestic violence is a family issue and that researchers should not intervene or inquire about it, even if they can obtain written consent forms from family members.
- Surveillance of the research process
Most participants believed that the biomedical research ethics committees should monitor the implementation of ethical principles during the research. A PhD student of reproductive health stated:
“Research ethics in our country is neither seriously nor accurately considered; so, the biomedical research ethics committees have to be strict. Surveillance should not be only done at the beginning of the study, but must be continued throughout the study…”
4.2. Challenges of Sexual Health Researchers
4.2.1. Critical Ability of Sexual Health Researchers
- Necessity of researchers’ scientific sexual health knowledge
The participants acknowledged that sexual health researchers should receive sufficient updated training and have access to the latest relevant scientific achievements and resources. In this regard, a sexual health researcher stated:
“...It is important not to allow every researcher to carry out sexual health research. The researcher must be trained on how to ask questions, how to react, and even how to answer the questions. As sexual health topics are very sensitive, researchers should be careful. Therefore, the study design should be appropriate, and its implementation should be done accordingly.”
- Necessity of sexual health researchers’ practical skills
According to the participants, the required practical skills of sexual health researchers were diverse and substantial in different aspects. They considered some skills, such as communication and practical counseling abilities, as vital. In this regard, one of the researchers said:
“...The researchers should have information about the topic and the required skills. At least, they should have some experience as a research assistant in a research team; this shows that they have become qualified in team work and can study this domain.”
- Special personal/demographic characteristics of sexual health researchers
According to the participants, the personal characteristics of sexual health researchers can affect the ethical aspects of the findings. A limited number of participants emphasized that the involved researcher should be married and that age and gender compatibility between the participant and researcher is necessary. In this regard, a PhD student in reproductive health stated:
“...In my opinion, the researcher must be married. If I were a participant or a person experiencing sexual dysfunction, I would prefer to meet a married expert. If the researcher was single, I would probably feel that he/she cannot understand my sexual experiences. Age is also important to me. If the researcher was too young, I would again feel that he/she is not experienced enough and I cannot trust him/her.”
4.2.2. Understanding the Participants’ Rights
In the opinion of most participants, besides considering the ethical principles, the dignity of participants (mostly women), as well as their families, should be respected.
- Importance of observing the privacy, confidentiality, and beneficence of the participants
Similar to other studies on human subjects, privacy and confidentiality must be fully protected, and in particular, all aspects of security should be taken into consideration. Beneficence means that the advantages of the results should outweigh their disadvantages. In this regard, one of the sexual health researchers said:
“... In every research on human subjects, ethical principles and rights must be respected. The privacy, dignity, and security of the participants must be protected in all aspects. There must be guidelines to protect a person participating in any sensitive study.”
- Importance of attention to the dignity of women and families
The participants emphasized on the importance of sexual health researchers’ familiarity with the position of women in the family, their right to decide independently and freely to participate in sexual health or other sensitive research, and impact of research on women’s stance towards private issues. A reproductive health specialist stated:
“...Sexual health researchers need to know the position of women in the society and be aware of their independence and freedom in their transfer to the study setting, participation in the study, and giving information. They should be also cognizant of the honor of the family.”
Nevertheless, some of the participants paid more attention to women’s autonomy and did not find it necessary to obtain permission from their spouse for entering the research. In this regard, a reproductive health expert stated:
“...A woman as a free human being can express her opinion freely. There is no need for the husband to give his permission or consent for his wife’s participation in a study.”
On the other hand, other researchers highlighted the importance of family dignity in sexual health research. They recommended women to inform their husbands about their participation in the research, while getting permission was not considered necessary. A biomedical research ethics expert stated:
“...When discussing sexual health and reproductive health, the spouse should be also considered. In our culture and many Asian countries, family is very important; so, we have to be careful that the project does not disturb the family foundation.”
4. 3. Challenges Related to Sexual Health Topics
4.3.1. Issues Related to Sexual Health Research Topics
- Considering the transformation of society’s needs/problems as a source of ideas
The participants believed that sexual health researchers should be informed about the transformation of the community’s needs and priorities and design their research accordingly. In this regard, a reproductive health expert said:
“...A sexual health researcher should know the society’s problems and needs in the actual context.”
Also, regarding the innovative aspects of each research project, a sexual health researcher commented:
“... For a long time, I advised women about mostly contraceptive methods in family planning clinics, and I had a close relationship with these women. They talked about their sexual problems and concerns; so, this gave me an opportunity to design valuable research in this area.”
4.3.2. Sensitivity of Sexual Health Research
Most participants, who were sexual health researchers, stated that sexual research has special characteristics and is associated with social, religious, cultural, and thematic sensitivities. It also has certain restrictions including self-censorship by the participants or even researchers.
- Cultural, Social, and religious sensitivities in sexual health research
Most participants described the role of culture, society, and religion in their country and stated that researchers should have enough knowledge about the ethical and religious values, which are closely interlinked. In this regard, an ethical expert in medical research stated:
“...Religious teachings about sexual health and Islamic morals should be taken into account. The moral values of a Shiite society are integrated in the research, and there should not be any inconsistencies with the moral values of the society.”
- Topic/subject sensitivity in sexual health research
Use of ambiguous words with complicated and sometimes different meanings from the original word with a sexual connotation is a common malpractice by sexual health researchers to moderate the sensitivity of sexual health topics. In this regard, one of the sexual health researchers stated:
“...We replaced the word “partner” with “wife”, and some words were discarded, such as “sexual violence”, which was written as “reproductive health”. In addition, “prostitute” was replaced by “vulnerable women.”
- Possibility of self-censorship in sexual health research
Self-censorship in sexual health research is considered the most common and manageable experience of sexual health researchers. However, its effects on the study results cannot be completely discarded. In this regard, a sexual health researcher said:
“...Considering the privacy of participants and their opinions, they (participants) may unconsciously misguide the researcher. They may also describe false information; that is why researchers should be very careful.”
Moreover, researchers may censor some results, as they fear ethics committee judgments.