Measuring Iranian women's sexual behaviors: Expert opinion

Abstract

The cultural compatibility of sexually related instruments is problematic because the contexts from which the concepts and meanings were extracted may be significantly different from related contexts in a different society. This paper describes the instruments that have been used to assess sexual behaviors, primarily in Western contexts. Then, based on the instruments’ working definition of ‘sexual behavior’ and their theoretical frameworks, we will (1) discuss the applicability or cultural compatibility of existing instruments targeting women's sexual behaviors within an Iranian context, and (2) suggest criteria for sexually related tools applicable in Iranian settings. Iranian women's sexual scripts may compromise the existing instruments’ compatibility. Suggested criteria are as follows: understanding, language of sexuality, ethics and morality. Therefore, developing a culturally comprehensive measure that can adequately examine Iranian women's sexual behaviors is needed.

INTRODUCTION

In order to assess sexual well-being and provide treatment or education for Iranian women's sexuality, it is necessary to understand their sexuality and the meanings they give to sexual behaviors. We therefore sought a tool appropriate to measure their sexual behaviors. ‘Sexual behavior’ is a complex concept that is difficult to measure. According to Webster's online dictionary,[1] ‘behavior’ means ‘the manner of conducting oneself’ and ‘sexual’ simply means whatever relates to ‘sex’, ‘the sexes’ or ‘sexual reproduction’. Thus, sexual behavior would be an act by someone that expresses their sexuality. In the Archive for Sexology, Erwin J. Haeberle[2] introduces ‘sexual’ as a word with double meaning, referring to “human anatomy as well as to human behavior”. He defines ‘sexual behavior’ as erotic behavior. Therefore, in contrast with Webster, the Critical Dictionary in the Archive for Sexology defines human reproduction as “asexual behavior” because it concentrates on “the biological facts without reference to the erotic feelings of the man and the woman involved”.[2]

The functional analysis of sexual behaviors has led researchers to develop instruments to gather observable data. In order to change subjective meanings to observable data, the researchers need to extract meanings from the contexts and populations they seek to measure. Many sexually related measures and instruments have been published; they measure perceptions, attitudes, beliefs and so on. However, the contexts from which the concepts and meanings were extracted to develop these instruments vary. Doubtless, their reliability in measuring sexual behaviors as socially constructed, complex and dynamic phenomena can be questioned. In order to determine a research approach for the context of Iranian women's sexuality, review and assessment of existing instruments was essential.

After a brief overview of the existing instruments measuring “non-risky” sexual behaviors among heterosexual women, we look at their cultural appropriateness to measure sexual behaviors within an Iranian context. Finally, because we find these instruments insufficient, we suggest criteria for cultural-specific sexually related measures in the Iranian settings.

MATERIALS AND METHODS

For the purpose of this paper, we searched literature using Medline, Pub-Med, PsychInfo and CINAHL from June 2006 to June 2011. A variety of mesh terms were used to access the sexually related measures. The mesh terms used to search title and abstract included “sexuality”, “sexual behavior”, “questionnaire” and “sexual behavior AND questionnaire” or “sexually related measure”, “sexually related tools” limited to “human, female, English AND reproductive age”.

Focused exclusively on the concept of sexual behavior, we screened titles and abstracts. Considering that not all abstracts highlighted the specified population and name of the applied tools, these articles were found in full, and methods sections were reviewed to identify populations and the tools used. Retrieved articles were included if they used a structured instrument(s) to measure sexual behaviors of the female population. We excluded those studies whose outcome of interest included risky sexual behaviors or sexual behaviors measured among same sex relationships. We excluded same sex relationships because this form of relationships is illegal and deniable in Iran. We searched for the original articles which introduced the instrument. If the original paper was unavailable, we selected the article that used the given tool to measure the study outcomes. In this stage, tools in languages other than English, those employed just for menopausal women and those not related to sexual behaviors were excluded. Using Gagnon and Simon sexual script theory[3] as the theoretical framework, cultural appropriateness (i.e. understanding and language of sexuality, ethics, and morality) was our selection criteria for the instruments. This decisive factor was proved by three experts. All questions in a given tool were qualitatively assessed by two researchers.

RESULTS

Evaluation of the 143 articles revealed that a majority of them (65%) had utilized the Female Sexual Function Index (FSFI) in their research.[4] The second most used scale was the Pelvic Organ Prolapsed/Urinary Incontinence Sexual Function Questionnaire (PISQ-12), utilized in 10.4% of the final articles. The Golombok-Rust Inventory of Sexual Satisfaction (GRISS) and the Arizona Sexual Experience Scale (ASEX) were the next most used instruments by 6.9% and 5.6% of articles, respectively. We reviewed all instruments and determined the subscales as well as measurement types [Table 1]. We categorized these instruments into three groups based on their working definitions of ‘sexual behavior’ and theoretical frameworks. These instruments were reviewed by the authors, who are Iranian experts in sexology, reproductive health, and epidemiology. Of 50 instruments, we found 19 tools applicable in the Iranian culture [Table 2]. For Iranian settings, 10 instruments were found culturally problematic [Table 3]. The third group included those which were focused on a specific sexual problem rather than looking at sexual behaviors overall [Table 4]. The multidimensional Derogatis Sexual Functioning Inventory (DSFI)[53] did not fit into any of those three categories. With this overview, it appears that there are significant challenges to using these instruments in Iranian contexts.

Table 1.

Instruments features including the subscales

Table 2.

Compatible scales for Iranian culture

Table 3.

Instruments incompatible with Iranian culture

Table 4.

Problem-focused instruments

DISCUSSION

Inspiring Gagnon and Simon's description of sexual behaviors defined with ‘social scripts’,[2] understanding and language of sexuality, ethics, and morality are the main cultural determinants of sexual norms in the Iranian society.

Understanding and language of sexuality

In her linguistic analysis of sexuality expression of Iranian women, Merghati-Khoei[54] has revealed the ways of developing terminology and cultural explanations, which are juxtaposed with the exploration of the development of women's sexuality. Iranian women expressed their sexuality differently from Western women even though they understood and talked about the same issues. Iranian women frankly speak about all the physical aspects of sexuality. These conversations include open teasing about the physical side of sexuality. There is, however, a hesitation when it comes to discussing or reporting the emotional aspects of sexual encounters.[55] The power of culture in dictating daily language for females has been highlighted in Morocco[56] as an Arab-Islamic context. Similarly, culturally meaningful ambiguity in language guides Iranian people's behavior.[57] Even though Persian vocabulary, concepts and expressions about sexual matters exist in art, poetry and the beauty of nature, these linguistic resources are not applied in daily life to express sexuality. Thus, expressing sexuality in day-to-day conversation is limited. Therefore, employing instruments which use sexually explicit items is insufficient. For example, the Sexual Attitude Scale (SAS),[30] certainly a well-designed tool for use within many cultures measures a person's awareness toward her/his sexual interests and needs as well as sexual-self judgment. Communication of sexual needs or interests with others is another feature of this tool. As a neglected subject matter in the Iranian culture, questioning people about their sexual needs and interests or sexual-self concept seems impractical. Sexuality is an unspoken issue, and individuals might not be linguistically skilled to communicate their sexuality with an interviewer.

In sum, the art of using a rich vocabulary of metaphors and euphemisms is a characteristic of Iranian speech, used to communicate and encapsulate matters not normally spoken explicitly. For example, for fluent English speakers phrase ‘marital life’ may indicate all kinds of relationships within a marital framework, while in Farsi zendegi-e-zanashoyi (literally marital life) has sexual connotations and is usually understood to mean the sexual relationship between husband and wife.

Another difficulty in asking about sexuality during a study is the struggle between conscious embarrassment and sexual talk. By conscious embarrassment, we mean the shame, prohibition and modesty about sex. They are part of Iranian women's sexual script. The majority of the women who participated in Merghati-Khoei's qualitative study pointed out that they were not culturally expected to be straightforward or frank in expressing sexual matters.[54] For example, the Sexual Desire Inventory[26] tends to measure sexual desire as a biologic factor. Out of 14 items, 4 focus on masturbation and 2 items ask about having interest in casual sex. In Iranian contexts, none of these 6 items would be posed by researchers or responded to by the participants. Why human have sex? (YSEX) is another example, which measures number of variables. For instance, some of the items focus on motivations leading people to out-of-wedlock or casual sex. Although casual or extra marital sex happens in every society, questioning Iranians about these behaviors is not ethically and religiously possible or feasible. This assertion is based on the common assumptions. In Iran, people strongly hold onto the traditional culture of sexuality based on ‘purity’ (paki), ‘chastity’ (nejabat), ‘honour’ (aberoo) and ‘honesty’ (sedagat) underlying the family structure. There is also the belief commonly permeating Iranian society that people are fairly innocent in terms of sexuality compared with non-Muslim or Western societies.[54] However, with these assumptions we cannot minimize the impact of factors such as modernization, worldwide communication and cultural transformations in younger generations and the way they learn about sex, practice and develop their sexual understandings. Undoubtedly, these factors change behaviors and attitudes.

Social conduct and religiosity define the ethical aspect of sexuality in the Iranian culture. In Iran the teachings of Islamic principles tie strongly to Shi’a interpretations, which form the basis for Iranians’ understandings of sexuality”.[55] The expression of sexuality is considered legitimate only within the framework of Islamic marriage (Nikah). Moreover, as shown in Merghati et al. study, sexual obedience was seen as the primary goals of the committed Muslim woman. The concept of Nejabat (modesty) is the most important ethical code applied to an Iranian woman who is not sexually expressive. In contrast, Islamic scholar Morteza Motahari pointed out the Islamic clear guidelines toward sexuality, “leading neither to any sense of sexual deprivation and frustration, nor to any repressed or inhibited sexual desire”.[58]

However, in the Islamic doctrine ‘freeing sexual desire and lifting of traditional moral restraints’ is not accepted.[58] As a criterion, religiosity has significant effects on Iranian women's sexual understandings; and that experts working in the fields of gender and sexuality need to be sensitive to the notion that some Muslim women may not speak out their sexuality as an indicator of submission to religious codes, of modesty and of being an idealized Muslim wife.[55]

CONCLUSION

To investigate sexual behaviors in an Iranian context, we recognize the importance of identifying or developing an instrument to assess sexual behavior domains among women in the particular context of Iranian culture. We thought that such an instrument would be essential tool for achieving a more systematic and in-depth understanding of Iranian women's sexuality, may be useful in applied settings, and would advance sexuality research as a whole. No matter the context or use, however, measuring a construct such as sexual behavior is subjective and therefore entirely dependent on self-report. It has been argued that Iranian women may not report properly if they believe sexuality has nothing to do with health.[55] For example, a woman's inability to gain sexual pleasure due to painful intercourse might not be defined as a sexual health problem to be reported, whereas other people would consider it as a sexual health problem for the woman. This suggests the idea that the culture of sexuality affects people's interpretations of sexually related problems.

Developing a contextualized instrument to measure the domains of sexual behavior would allow sexuality and gender researchers to better answer questions related to the influence of culture in those domains, sexual scripts across diverse cultures, and other factors influencing sexual health outcomes.

In the 1970s, Gagnon and Simon's Sexual Conduct represented the first truly sociological analysis of sexual behavior.[2] Gagnon and Simon defined ‘sexual behavior’ within a new theoretical framework of ‘social scripts’. They produced a critique that moved us beyond the objective definition of sexual behavior:

Our concern here is to understand sexual activities of all kinds … as the outcome of a complex psychological process of development, and it is only because they are embedded in social scripts that the physical acts themselves become possible … it is neither fixed by nature or by the organs themselves. The very experience of sexual excitement that seems to originate from hidden internal sources is in fact a learned process and it is only our insistence on the myth of naturalness that hides these social components from us.[3]

The ‘script’ metaphor emphasizes that sexual behaviors originate from socially determined norms of sexuality. Individuals acquire their sexual ‘character’ through a ‘cultural scenario’ in which they take up, internalize and enact culturally prescribed normative roles; ‘interpersonal scripts’ in which they make a suitable identity based on desired expectations and ‘intrapsychic scripting’ in which they make ‘the self’ in relation to social life.[59] Thus, sexual practice is separated from the biology of the body and one's sexuality is strongly formed by the very complex social world. Sexuality has been regarded as the product of societies and histories.[2,60,61,62] Having investigated the history of human sexuality, we believe sexuality is influenced by the society, culture and era in which people live.

Within an Iranian context, we therefore recognized existing instruments targeting “non-risky” sexual behaviors among heterosexual women are insufficient to measure sexual behaviors. We categorized instruments as culturally compatible or incompatible based on the sexuality domains they tend to measure. The instruments, by which the biological aspects of sexual behaviors are measured were found applicable for any given community or population, the Iranian context included. Alternatively, those measuring outcomes related to subjects’ attitudes, understanding or sexual scripts’ were identified as culturally incompatible.

Most of the tools seem reasonable candidates for use in the Iranian culture and society with minor revisions [Table 1]. Review of these instruments shows that most of them are functional based, such as the most used scale in literature, (FSFI). Other well known tools, such as the Arizona Sexual Experience Scale (ASEX) and the Golombok-Rust Inventory of Sexual Satisfaction (GRISS), are also functional based. Some other tools are problem-focused [Table 3] and specific to measure only disorder-based outcomes.

We argue that the medically oriented instruments employed in the field are drawn from concepts and meanings based on investigations conducted in Western societies. These very well-structured tools are constantly applied to the clients. Yet as researchers, we sometimes found ourselves disappointed by the level of difficulty, which we professionals encountered in fitting our participants into those biomedical frameworks. These instruments may not project the understandings of those who participate in our studies.

The culture-bound nature of sexuality limits the research-based information in Iran. In our society, the lack of information in the sexual domain will be most productively addressed first through research attention to subjective concepts. Lack of sufficient knowledge in the field of sexuality in Iranian contexts, makes it important to identify normative sexual behaviors qualitatively before applying problem-oriented tools in research.

FINAL CONCLUSION

There are social and cultural challenges arising from the recognition that Iranians use culturally specific sexual expressions. These expressions may construct different ways of perceiving sexuality that are not easily translatable or even understandable by outsiders. This means that sexuality is a complex phenomenon embedded in various meanings and understandings, not merely objective and measurable behavior. Explaining those meanings and perceptions makes sexuality a ‘dynamic’ phenomenon through one's life time. ‘How we know what we know’ changes periodically and therefore, creating an epistemological crisis in knowledge as well as the research process.[63,64] However, scholars in science and human behavior such as Skinner[65] have powerfully questioned the reliability of subjective measures of private events such as sexual behaviors.[65]

The basic sexuality criteria of Iranian women are relatively argued. We concluded that the published instruments are well-designed and used worldwide; however, we must also acknowledge that the sexual scripts of Iranian women define ‘sexual behaviors’ differently, limiting their communication in the research setting and compromising the compatibility of these instruments. Therefore, exploring and analyzing the lexicon and expressions used by the Iranian women creates a ground for developing a culturally comprehensive measure, which can adequately examine how these women explain their sexual behaviors.