Thematic analyses generated 17 themes, incorporating 35 sub-themes which are listed in document 2 in the Supplementary Materials. In total, 505 quotations were extracted from 25 interviews. Table 1 lists the main themes and numbers of quotations allocated to each theme. Approximately 80% of the interview transcript text was extracted as relevant quotations. All participants contributed multiple quotations across themes. All extracted quotations are presented, by theme and sub theme, in document 4 of the Supplementary Materials. Below we present illustrative quotations that highlight the core meaning of the 17 themes and discuss sub-theme structure. We recorded demographic data including age, gender, socioeconomic status and self-expressed religious beliefs, but we did not find differences in themes attributable to these individual characteristics and, therefore, did not include these data below.
Table 1: 17 Main Themes
Number of Quotes
Sexual Health Knowledge
Perceptions of Personal Sexual Health Knowledge
Sources of Sexual Health Information
Recommended Sources of Sexual Health Information
Perceptions of Availability and Quality / Content of Sexual Health Education
Understanding and Negotiation of Sexual Relationships
Concerns about Sexually Transmitted Infections (STIs)
Concerns about Pregnancy
Knowledge of STI Prevention and Contraception
Availability of Sexual Health Services
Consulting Doctors for Sexual Health Services
Psychological Barriers to Seeking Sexual Healthcare
Socioeconomic Sexual Health Inequalities in Tehran
Gender Power Inequalities in Sexual Relationships
Recommendations for Improved Sexual Health Education and Services in Tehran
Theme 1. Sexual Health Knowledge
Two sub-themes were identified: i) Knowledge of STIs; symptoms and transmission ii) Knowledge of sexual organs (see research question 1).
Sub-theme 1i: Knowledge of STIs; symptoms and transmission
Knowledge of STIs; symptoms and transmission methods was generally poor. Although HIV and HPV were named as known STIs, their symptoms and transmission methods were often unclear. Other STIs were sometimes named but again there was a general lack of understanding of transmission routes.
Gonorrhea, Syphilis, that’s all. I don’t know how they get transmitted, I think from anal sex. Fortunately, I don’t prefer anal sex so I’m not going to get these diseases.
Sub-theme 1ii: Knowledge of sexual organs
Generally, participants expressed a good knowledge of sexual organs.
Theme 2. Perceptions of Personal Sexual Health Knowledge
Participants reflected on their level of sexual health knowledge in comparison to their peers. These assessments were categorized according to whether young people thought their level of knowledge was similar to others (sub-theme 2i), less than others (2ii) or superior to others (2iii). In general, respondents saw themselves as similar to other young people and few thought they knew more.
I don’t think some know more than the others, everyone’s knowledge is about the same level because no one has ever been educated for this.
I think my friends know more than me because I don't know much.
I think I know more than others. Others know less.
Sub-theme 2iv: Deprivation and knowledge of sexual health
Interviewees also spontaneously voiced their opinions regarding the relationship between socioeconomic deprivation and lower sexual health knowledge.
The district you live in plays a determinant role, people in deprived areas are more likely to have unprotected sex that’s why the stats for unintended pregnancy are much higher in these areas. Poverty is a big factor, it causes limitation of options and education.
Theme 3. Sources of Sexual Health Information
The lack of official SHRE, has meant that young adults have turned to self-education. Interviewees highlighted various sources of sexual health information. These information sources are categorized in five sub-themes.
Sub-theme 3i: Internet and social media
Internet and social media were the most quoted sources of information. Interviewees mentioned popular social media apps like Instagram and Telegram along with Google as their source of sexual health information.
I get most of my information from social media. I haven't read any book about this subject. By social media mostly I mean Telegram and Instagram. In Instagram I follow pages about women’s health.
Every time I have an issue, I go and search about that specific subject on the internet.
Sub theme 3ii: Parents
Parents were blamed for not discussing sexual health in the absence of official SHRE. Some participants believed their parents did not intend to discuss a taboo subject. I feel people my age haven’t learned anything from their parents.
Parents don’t inform their kids… so you start to notice and find out things from talking to your friends.
Parents also don’t discuss it. Neither parents nor schools would teach us anything.
Sub-them 3iii: Pornography
Pornography was identified as a learning tool by few male and female participants; some believed in harms it could cause and some viewed it as a beneficial guide.
I watched porn. Porn really did help me, because there wasn’t anything else that would show everything as real as it was. It helped me to see, understand and discover things. However, watching porn is not healthy as it might make you have unrealistic expectations from yourself or your partner.
We got introduced to these things by watching porn. Porn has taught us a lot and with porn we have gained knowledge and experience.
Sub-theme 3iv: Books
A few participants mentioned books as a source of sexual health information, although not always books intended to educate about sexual health.
I…read the books that my mom had about pregnancy.
[There] was nothing in school but my dad had bought me an oxford encyclopedia, I was around 13-14 years old. This book explained everything from A-Z, fertility and other stuff. So when I learned about it I went to school and explained it to my classmates.
Sub-theme 3v: Personal or friend’s experience
Few participants mentioned their sexual experiences as their learning opportunities. Others trusted their friends’ experiences and followed their advice. Contrary to social norms and taboos, only young women mentioned experimenting as a learning tool.
I believe nowadays the knowledge is increased due to exchange of information that kids do between themselves. This can interest others that have no idea what is going on and they’ll go and search further. This education spreads in a very personal level and the knowledge expands in more private groups.
It’s not perfect but the point is that most of the information they get is from their own experience, not from the education anywhere in school or university or anywhere else.
Theme 4. Recommended Sources of Sexual Health Information
Interviewees described sources of sexual health information they would recommend to their friends. In general these overlapped considerably with the sources they themselves had used (see theme 3, above). However, many participants also, highlighted “doctors” as a useful source of information.
Sub-theme 4i: Doctors
While participants did not identify doctors as their source of sexual health knowledge, interestingly they recommended doctors as a source of information for others.
Visit a doctor and ask their questions.
I would tell them to go and see a gynecologist.
Theme 5. Perceptions of Availability and Quality/ Content of Sexual Health Education
Interviewees highlighted the limited sexual health education provided in school, university or pre-marriage classes (research question 1 and 3).
We’ve never had an official sex education class . They always try to keep kids away from this kind of topics and there are no resources for those who get into these kind of stuff.
Our educational system teaches us absolutely nothing about this kind of stuff.
I’ve learned everything I know through experience. No one has taught me anything. There were absolutely zero education.
Theme 6. Understanding and Negotiation of Sexual Relationships
Interviewees discussed how they and other young people would manage sexual relationships and negotiate their needs (research questions 1 and 2). Their responses are presented in 3 sub-themes. These often highlight confidence in managing relationships despite lack of self-management and behavioral skills.
Sub-theme 6i: Familiarity implies health in sexual partners
Duration of knowing a sexual partner was cited as a way of judging STI risk by some participants.
It rarely happens that someone becomes concerned about STIs because they trust their partners and believe that they haven’t been with unhealthy people. They would say I’ve known this person for such a long period as if longevity and duration of knowing someone before sleeping with them is a guarantee of them being sexually healthy. It’s stupid I know, but almost everyone is like that.
Sub-theme 6ii: Confidence and power in managing sexual relationships
Despite lack of formal education and limited sexual health knowledge, participants were generally confident they could manage their sexual relationships.
If someone tries to force me into having sex with them I can always defend myself and get over my shyness. Because If I am honest to myself I know that there are so many people who want to have sex and I don't have to give in to just anyone for the sake of having sex. Therefore, I think I can 100% manage my sex life.
Sub-theme 6iii: Communication in Sexual Relationships
Interviewees rightly emphasized good communication as an important instrument in managing sexual relationships and ensuring both parties’ satisfaction.
I usually try to talk about these kind of stuff before starting any relationship and would tell him about what I want before sex.
Theme 7. Concerns about Sexually Transmitted Infections (STIs)
Participants explained their concerns about STIs in response to research questions 1 and 2. Some concerns were caused by lack of sexual health education, e.g., ambiguity and lack of education on STIs. Their comments are categorised using 4 sub-themes.
Sub-theme 7i: Ambiguity and lack of education on STIs
Participants were concerned about their lack of knowledge (see theme 1 above) and acknowledged that lack of reliable information has led to misconceptions and, at times, poor motivation to prevent STIs.
We haven't been educated for it and this can be as harmful as the diseases itself. We don't consider STIs [to be] serious diseases. We need to learn about them.
Even in university it is vague, they only come and give out names of some STIs. I mean people are not concerned because they don't know about it.
Sub-theme 7ii: Invisibility of STIs
The lack of visibility was seen to make STIs less of a public or shared issue which could undermine discussion and preventive motivation.
You know STIs is something that you get and you are the only one who is gonna know and is gonna be bothered.
The fact that you can hide your STI from others makes them not to be concerned about.
Sub-theme 7iii: Fear and worry about STIs
Some were not concerned because of their perceived skills while others expressed quite serious fears about STIs.
My other partners always insisted on not using a condom but I never accepted. Mostly because of the fear of HPV and AIDS. I’m generally concerned about the STIs.
STIs concern me the most. You know if you give your STI to someone else you might change the course of their lives forever.
Sub-theme 7iv: Perception of other groups’ lack of concern
Participants generally viewed themselves as careful and concerned but saw others as less responsible.
Guys will be very careless most of the times and they are like: Who’s got time and energy for such stuff. There might be so many people who can afford it financially but then that carelessness stops them from seeking medical attention.
I believe people who are younger than us are more careless in their sexual relationships and people around my age are more careful.
Theme 8. Concerns about Pregnancy
Interviewees were more concerned about pregnancy than STIs (research questions 1 and 2), mainly because pregnancy was socially visible and was seen as causing more serious life consequences.
Sub-theme 8i: Fear and worry about pregnancy outside marriage
Since sex out of marriage is not legally supported in Iran, pregnancy out of marriage was considered ruinous by participants, as it would affect one’s social life. The exaggerated fear of pregnancy, might also be attributed to lack of sexual health education, as effective contraception methods have never been taught to young adults.
I’ve had friends who had the phobia of becoming pregnant so they couldn't really enjoy having sex even while wearing condoms or using other preventive methods.
99% of those who have sex are concerned about unintended pregnancy.
Sub-theme 8ii: Visibility of pregnancy leading to social and personal issues
Participants appeared to be strongly motivated to avoid pregnancy; largely due to its social visibility. Cultural norms related to the taboo, shame and embarrassment surrounding sex increased the extent to which participants wanted to hide any evidence of sex outside of marriage.
I think some people are more concerned about unintended pregnancy because of their social image.
I remember that it was around 1 or 2 years ago that we were in a gathering and one of my closest friends came by and she was like 100% sure that [she was] pregnant and we were all scared as hell, not because of the pregnancy itself but because of the consequences… The social judgment that comes with those things ruins your life for good.
Theme 9. Knowledge of STI Prevention and Contraception
Condoms were most frequently identified and only a few participants identified contraceptive pills as a preferred option. Quotes were categorized into three sub-themes.
Sub-theme 9i: Condom availability and accessibility
Condoms were regarded as convenient, available and accessible contraception method.
[Condoms are] accessible everywhere. You can find them in both pharmacies and super markets. Therefore, the accessibility and availability is good.
Sub-theme 9ii: Condom cost
Participants had divided opinions regarding condom cost. Some believed condoms were expensive while others considered them to be reasonably priced.
I think they are expensive. … For foreign condoms as imports are getting more complicated due to sanctions the prices are getting higher so they are more expensive.
Condoms are relatively cheap…
Sub-theme 9iii: Quality of Iranian condoms
Cheaper Iranian condoms were regarded to be unreliable.
From what I’ve heard Iranian produced condoms are not reliable at all.
Iranian condoms are accessible for everyone but lack quality and tear apart easily.
Theme 10. Condom Use
Ease of use and inconsistent use were key points made in relation to condom use and are represented in two sub-themes (see research question 2).
Sub-theme 10i: Ease of use
Condoms were considered not just accessible but easy to use.
Male condoms only because it's the most accessible, easiest and cheapest method.
Condoms. They’re easy to find and use.
Sub-theme 10ii: Inconsistent use
Participants also expressed negative attitudes towards condom use, including reduced pleasure and concerns about reliability (see also above) and acknowledged likely inconsistency of correct use. This theme includes young men’s views on condom use. Women’s views are illustrated in theme “Gender power inequalities in sexual relationships”.
I don’t like using condoms. It doesn’t give the real touching sensation; it is like you are putting it in a plastic. I prefer to be sure of myself and my partner. I mean to be sure that neither of us have any diseases.
In my opinion you’re better off not using condoms because you might be risking with a low quality one, maybe this way you would pull out because you don’t have that trust. Still unintended pregnancy might happen, you would never know. Better to put that trust in yourself rather than piece of plastic.
Theme 11. Availability of Sexual Health Services
Although there are government-funded sexual health centers in Tehran our participants were not aware of them or how to access them (research question 3).
I don't know any sexual health clinics in Tehran though, so maybe for people like me, who have the money to spend, a part of it is the lack of information on where to go and who to trust to spend their money on.
Theme 12. Consulting Doctors for Sexual Health Services
Although doctors were recognized as reliable sources of information, participants identified barriers in approaching doctors, including cost, privacy and trustworthiness concerns (research questions 1 and 3).
Sub-theme 12i: Cost of visiting doctors and sexual health care
Healthcare is mainly privatized in Iran and therefore is very costly for most citizens.
I have so many questions which I don't have the answers to and I can’t afford to visit a doctor to ask them.
Sub-theme 12ii: Trust in doctors
Whilst young people were willing to share personal experiences and personal advice, they appeared unwilling to extend this trust to healthcare professionals. Young adults appeared to have developed trusting relationships, in which sexual health and sexual relationships could be freely discussed. Doctors were not included in this circle and participants were reluctant to discuss their private life, even when seeking advice or medical attention because they feared that these issues will be shared with their families or even law enforcement officials. This lack of trust appeared to reiterate the “shame, taboo and embarrassment” regarding sexual health currently imposed by society.
“We are scared to tell the doctor about our issues, for example to tell them we've had sex out of marriage and they would let our families know about it. I’m absolutely terrified about that”
Doctors are not trustworthy.
Theme 13. Psychological Barriers to Seeking Sexual Healthcare
Interviewees identified other personal and social barriers to seeking sexual healthcare in Tehran (research question 3).
Sub-theme i: Embarrassment as a barrier to sexual protection
Although condoms were the most frequently mentioned method of contraceptive, shame, taboo and embarrassment were recognized as barriers to buying condoms; leading participants to report a lack of accessibility to an available method of contraceptive.
Some people are embarrassed to go and ask for condoms in a pharmacy because it’s usually out of hand reach and you should ask someone to give it to you. If it’s a lady selling it, it’s even worse for men, they would be even more embarrassed.
Sub-theme ii: Taboo shame and social disapproval as barriers
Sexual health is not freely spoken about within Iranian society. That appeared to reduce motivation for seeking appropriate sexual healthcare. Participants discussed how shame and embarrassment would prevent them from seeking medical care; even in critical situations (such as pregnancy – as described above).
I think it’s the fear of getting judged by the others .What others might think of me if they find out that I have sex out of marriage. I know so many guys that believe that their girlfriends are not decent and good people because they sleep with them. They ask “If she’s a good girl why did she have sex with me?”
Sub-theme iii: Health motivation
As highlighted by various social cognition models including the IMB, individual differences in health motivation was identified as an important factor in overcoming barriers to sexual healthcare with a lack of motivation being attributed to others, in contrast to the self.
Sometimes it is because of carelessness though. Some people simply don't care.
About the STIs. from what I know people generally aren't concerned about their health until something happens to the
Sub-theme iv: Denial / fear
Some participants believed that young adults may avoid visiting doctors due to fear of diagnosis and a lack of stress management skills.
Knowing you are ill is scary to some and so many people don't want to face the harsh truth.
Theme 14. Sexual Prohibition
Consistent with the identification of embarrassment and fear of social judgement as barriers to sexual health care, participant acknowledged how existing laws enforced social and cultural norms portraying sex as shameful or unacceptable for unmarried people and sanctify virginity in women (research question 2).
Because in Iran, it is illegal for people to have sexual relationships before getting married. It is something everyone does, but you would be blamed for it. Becoming pregnant out of marriage is way worse, people are getting more open minded but still there are many dogmatic people out there. Unintended pregnancy is definitely much worse because STIs might be treated but you can’t “treat” pregnancy.
I know girls who give in to any form of sexual relationship other than the vaginal intercourse only to protect their virginity, it’s a huge concern for so many people to the extent they put themselves in painful positions to please the guy they’re with but also to stay virgin.
Theme 15. Socioeconomic Sexual Health Inequalities in Tehran
Interviewees highlighted socioeconomic inequalities in sexual health and service availability and quality in Tehran based on socioeconomic status (research question 3). The consensus was that citizens from lower socioeconomic backgrounds face challenges in assessing and paying for sexual healthcare and contraception methods.
And poor areas don't have much of a choice, both with doctors and contraceptives and condoms.
Theme 16. Gender Power Inequalities in Sexual Relationships
Women interviewees indicated that they could not control heterosexual sexual encounters , including condom use, so highlighting power inequalities and the prioritization of male partners’ preferences; even when these young women were highly motivated to avoid STIs and pregnancy (research question 2).
There is this need to please guys in girls, and they tend to agree with whatever guys tell them, like not using condoms or having rough sex. I’ve seen this in my friends’ relationships.
We don’t use condoms because he is not into it.
Theme 17. Recommendations for Improved Sexual Health Education and Services in Tehran
Interviewees offered various recommendations on how sexual health education and services in Tehran could potentially be improved (research question 4). In general, all participants deemed SHRE provision a necessary action and believed sexual health education would have optimal results if started from an early age. They almost unanimously suggested subjects such as contraception and condom use, sexual organs, pregnancy and relationship management skills to be included in a short course or a day workshop. Participants had varying opinions on the gender mix and delivery method of such programs.
It should be started from the beginning of elementary school with teaching about sexual organs, then they should carry it on with sexual health in middle school.
In my opinion it would be better for the classes to be mixed gender, so that we all benefit from it equally.