Adolescents and Young People’s Sexual and Reproductive Health in Iran: A Conceptual Review

ABSTRACT

This paper reviews the evidence on the sexual and reproductive health (SRH) of young people in Iran from 2001 to 2019 and maps needs, challenges, and opportunities in this area. From among 125 papers, 43 articles were examined for this review. Findings indicated that although the majority of youth abstain from sex before marriage, significant minorities are sexually active before marriage, with a huge heterogeneity based on gender and geographical region. A gender disparity is apparent in high-risk sexual behaviors. Multiple partners, inconsistent condom use, and younger age at sexual debut were more prevalent among men than women. There is a need to narrow gender disparities that expose young women to greater risks, expand health awareness and relevant skills, and enable access to SRH services. While the government has reaffirmed many commitments for young people’s wellbeing, policy development falls far short of realizing these commitments. Future success requires increased evidence on the SRH of youth as well as political will and strategic commitment to SRH for young people. The challenge is to develop comprehensive and culturally appropriate SRH education and confidential and nonjudgmental youth services. Due to the importance of families and parents, such programs need to engage families.

Introduction

Young people constitute a considerable proportion of the population in Iran. In the most recent national census, there were approximately 16 million young people aged 11–24 years, accounting for about 20.4% of the Iranian population (Statistical Centre of Iran, 2016). Young people are at a greater risk of human immunodeficiency virus (HIV) and account for about half of the new HIV infections in many nations (UNAIDS, 2014). This important period of life is critical for social development, and for promoting healthy attitudes and behaviors.

Figure 1. PRISMA diagram for identification of papers reviewed.

Due to a rapid increase in age at marriage in Iran over the past four decades, particularly for women, there has been a sharp decline in the proportion of post-pubescent young people who are married. The mean age at marriage for women and men, respectively, rose from about 20 and 23.6 in 1986 to 23 and 27 in 2016 (Statistical Centre of Iran, 2016); as a result, the proportion of adolescent females aged 15–19 who had ever been married fell from 33% to 21%, a 36% decline (Statistical Centre of Iran, 2016). These data suggest a widening window during which young people may engage in premarital sexual activities. Women’s aspirations for continuing education and the unemployment rate among youth, particularly among those with advanced education, are responsible in part for the delayed marriage (Danaei et al., 2019)

Sexual culture in Iran is historically conservative, which was further enforced after the 1979 Islamic Revolution (Shadpour, 1999; Shahidian, 1996). In this cultural context, premarital sex is strictly proscribed (Khalajabadi-Farahani & Cleland, 2015) and sexual intercourse between men and women outside of marriage is legally forbidden (Article 221, Islamic Criminal Law, 2013). If a man has sex with a young woman in the same age band with her consent and with promises of marriage, he will be sentenced to jail from three months to one year. If the girl is younger than 15, the punishment is harsh. If the victim is satisfied with marrying the man, the man will not be convicted (Saeednia, 2006). In addition, communication about sexual matters in the society is considered a taboo and is mainly indirect (Latifnejad-Roudsari et al., 2013). Young people tend to receive a range of implicit messages against sexuality before marriage through religion, parents, media, and legislation. A gender double standard is seen in messages provided for men and women, with women tending to receive more restrictive messages than men about sexual activity before marriage (Khalajabadi-Farahani, Mansson et al., 2018).

Virginity is defined differently in different cultures and over times. For instance, involvement in vaginal sex (vaginal-penile intercourse) means losing virginity to some people, while some might also consider other kinds of genital sex as virginity loss (Carpenter, 2002). In Iran, traditionally and culturally, having an intact hymen for an unmarried woman has been a sign of her virginity. It is considered a valuable asset that needs to be kept until marriage and may even need to be proven by bleeding at first intercourse or by a certificate from a physician. In fact, it is assumed that virgin girls with an intact hymen have not been involved in any sexual relationship and the loss of virginity before marriage risks the reputation of a girl and her family (Ahmadi, 2016; Robatjazi et al., 2015). As a symbol of virtue and promise, it is a primary condition for a woman’s first marriage. Half of the grooms in a recent study in Kerman city reported that they had a violent reaction when they encountered no bleeding at first intercourse and it negatively affected their marital relationship (Niki-Rashidi et al., 2020). The considerable number of virginity certificates issued by the Legal Medicine Organization in Iran both indicates the cultural significance of virginity and carries connotations of anxiety for those who lack it. However, a recent systematic review found that not only does hymen examination not predict virginity status accurately or reliably, it could cause physical, psychological, and social harms to the examinee (McKeon-Olson & Garcia-Moreno, 2017). Some sexually active women in Iran seek hymen repair (Ahmadi, 2016), mostly those women who feel they have a right to sex but at the same time, are too afraid to openly defy the social norms. Many are from the conservative classes. Some hope to marry their current boyfriend or an open-minded suitor who would overlook their non-virginity. But a majority of young men maintain a double standard: They want to date and have intercourse with a woman from their own social class, but they also want to marry a virgin. Moreover, according to the legislation, a man can claim divorce on the grounds that he was duped about his wife’s virginity. Because of this double standard, women prefer to have hymen repair instead of telling their fiancé about their previous sexual experience. Some believe hymen repair reinforces existing power relations and affirms the patriarchal order (Kaivanara, 2016). Others suggest that widespread operations are gradually making virginity meaningless because “real” and “fake” virginity cannot be distinguished anymore (Afari, 2009).

Within such a cultural context, the age of marriage and age of first sexual intercourse are highly correlated, particularly for women in Iran. Due to the importance of such social norms surrounding physical proof of virginity, some unmarried women who become engaged in premarital sex might hesitate to have vaginal penetrative sex. Instead, they tend to engage in alternative penetrative sexual practices or non-penetrative sexual activity to preserve their intact hymen (Khalajabadi-Farahani, Mansson, et al., 2018). Hence, in this review when we use the term virginity, it means having an intact hymen.

Gender issues, including gender roles and expectations, are important factors shaping sexual behaviors of men and women in every society. Religious beliefs and the patriarchal framework of Iranian society provide an important context for many gender role disparities between men and women. Gender differences in some of the Shiite jurisprudence, such as different rights of heritage, divorce, witnessing, and blood money, have caused important debates among promoters and activists for gender equality. However, in the 40 years after the 1979 revolution, selected gender reforms led to a significant rise in women’s aspiration for higher education and also some improvement in their social participation in the labor force (Mir-Hosseini, 2004).

Gender beliefs about premarital sexuality of men and women have been rooted in the cultural and traditional beliefs that girls and women are the property and honor of their fathers and husbands. Hence, any restriction on their appearance and relationship with men is conceived to be the only way of preserving this property. In contrast, men’s sexual desire is considered as God-given and natural (Mir-Hosseini, 2004) and is promoted along with polygyny and temporary marriage. Within this religious framework, women need to be responsive to every sexual need of their husband in return for his financial support (Mehryar & Tashakkori, 1978). In fact, bride price is something that is determined as a sign of a woman’s chastity at the time of marriage. In addition, premarital sex or sex outside marriage for women constitutes social and moral dishonor and carries greater social stigma and stress compared to men. There is also evidence of greater approval of premarital sex for men than women, which suggests a dominant gender-based double standard in premarital sexuality (Khalajabadi-Farahani, 2008; Mohammadi et al., 2006).

Sexuality before marriage in such a cultural context has important adverse outcomes because young people do not receive any education on relationships and sexual health. Women who live in a conservative society with a strong endorsement of virginity are more vulnerable to violence, abuse, and honor-related killing if they get involved in premarital sex (Cinthio, 2015), as well as an increased rate of sexually transmitted infections (STIs). A cross-sectional study in Iran showed that the prevalence of male urethral discharge was 0.40% and for genital ulcers in women and men was 3.68% and 0.16%, respectively; these conditions may be symptoms of STIs. The incidence of gonorrhea, Chlamydia, and syphilis per 1,000 women was 2.44, 5.02, and 0.04, respectively, and per 1,000 men was 0.43, 0.82, and 0.005 (Nasirian et al., 2015). A study among youth in Shiraz showed that about 7% of sexually experienced youth (n = 528) reported a diagnosis of gonorrhea and only about 5% received treatment (Honarvar et al., 2015).

The mode of HIV transmission has shifted recently from unsafe IV drug use to unsafe sex in Iran (Haghdoost et al., 2011; Nasirian et al., 2012; National AIDS Committee Secretariat, 2015). This trend reflects a possible rise in unprotected or high-risk sexual behaviors, particularly among young people (National AIDS Committee Secretariat, 2015). Access to global media and exposure to liberal sexual mores can also create paradoxical and liberal sexual attitudes among youth (Motamedi et al., 2016). Because of wide access to the Internet, a considerable proportion of young people in the metropolitan areas inevitably have access to sexually explicit materials (Khalajabadi-Farahani, 2019a). This exposure might be a reason for uncertainty and ambivalence in sexual values among youth (Azad-Armaki et al., 2011; Khalajabadi-Farahani & Cleland, 2015). Access to the Internet and lack of education on sexual health has become a major concern among parents as well (Babayanzad et al., 2020).

In recent decades, some important structural changes have occurred. Greater preference among women for higher education, access to global media, urbanization, greater social participation of women, and increased heterosexual socialization are among these transformations (Movahhed et al., 2009). However, little is known about the SRH health needs of young people in the current situation. Although some small- and large-scale investigations have been conducted, these studies, due to cultural sensitivities, have avoided sensitive topics such as attitudes about sexual relations, the prevalence of risky sexual behaviors, and rates of STIs. Instead, researchers have focused on topics such as puberty and opinions on family planning. Cultural sensitivities may also be a factor in young people’s poor knowledge about reproductive health. In Iran, few programs provide effective sexuality education to adolescents or enable youth to ask questions and correct misconceptions about reproductive health (Javadnoori et al., 2012). Indeed, large numbers of young Iranians lack information about safe sex and the skills necessary to negotiate and adopt safe sex practices.

Some programs with a focus on high-risk groups are providing HIV prevention services. For instance, women’s centers offer SRH services and harm reduction by female health care providers to high-risk women, including women who use drugs and sex workers (Ghorashi, 2015). A wide range of education and counseling are offered in these specialized centers. Finally, Positive Club, a non-governmental organization in Iran, provides prevention and psychosocial support to HIV-positive people to empower them to manage and improve their life skills as well as reduce stigma and discrimination (Ghorashi, 2015). Youth are, however, poorly informed of such services. Education on pubertal changes is also provided by some schools through inviting psychologists to speak to parents and youth, but this depends very much on the school authorities and their level of concern. There is no formal comprehensive education on HIV and sexual health in schools in Iran (Javadnoori et al., 2012).

Recently, the government has recognized the importance of addressing the sexual health needs of different groups of people, including adolescents and youth (Ameli, 2019). In addition, culturally and religiously appropriate education on sexual health for young people and students is another issue which has been considered with the cooperation of the Ministry of Education (Ameli, 2019). These efforts are hampered by the lack of comprehensive data regarding the SRH knowledge and sexual behavior of unmarried young people.

The present conceptual review reports data from different studies that aimed to break the silence on adolescent SRH in Iran and fill important information gaps regarding sexual behavior and associated factors among adolescents and young people. We sought to determine adolescents’ and young peoples’ high-risk sexual behavior, SRH knowledge, and educational needs, challenges, and strategies for SRH. It is hoped that the findings can inform the current programs and policies on sexual health promotion among youth (Ghorashi, 2015) in Iran and other conservative cultures.

SRH in this study was defined as “A state of physical, emotional, mental and social well-being, not merely the absence of disease or infirmity in relation to sexuality, reproductive system, its functions and processes” (Starrs et al., 2018). Full consideration of all components of SRH among youth is out of the scope of this review. Reproduction and abortion among unmarried youth are two neglected issues in Iran, because of strict social norms around sexuality and reproduction before marriage. Moreover, diversity in sexual orientation and gender identities is neglected in Iran due to extreme sensitivity and religious prohibitions around these topics. In this review, we only focus on premarital sex, high-risk sexual behaviors such as inconsistent condom use, multiple partners, alcohol and sex, sexual coercion, SRH knowledge and attitudes and educational needs, and challenges and strategies for youth’s SRH.

In addition, due to recent concerns of sexual transmission of HIV in Iran, most studies conducted on sexuality have focused on sexual risks associated with HIV/STIs, while contraceptive use and abortion have received little attention in the literature. Therefore, in this review, we excluded issues of abortion and contraception. For similar reasons, issues of pleasure, pornography, sexual orientation, and gender identity were not considered in this review, due to the lack of sufficient data in Iran.

In summary, we aimed to determine the status of SRH among adolescents and young people in Iran between 2001–2019, to assess their SRH needs, and also to determine challenges and strategies.

The main topics of this review comprise:

1. Premarital sexual behavior/high-risk sexual behavior, SRH knowledge/attitudes

2. Sexual/reproductive health needs among youth

3. Challenges and strategies for youth SRH

Method

We conducted a conceptual review and used terms to search relevant studies and papers according to each area of interest. Relevant articles were identified through searches of electronic databases, including PubMed, Google Scholar, Science Direct, Research Gate and Scopus, and the national Persian Databases of MAGIRAN, IRANDOC and SID, GIGALIB. Finally, relevant citations from identified papers were also included. The search was conducted using the following Mesh terms and keywords with different combinations: “Adolescence”, OR “Adolescents”, OR “ Adolescent”, OR “Female Adolescents”, OR “Male Adolescents”, OR “Male Teenagers”, OR “Female Teenagers”, OR “Teens”, OR “Youth”, AND “Sexual behavior”, OR “Anal Sex”, OR “Oral Sex”, OR “Premarital Sex Behavior”, OR “Sex Behavior”, OR “Sexual Activities”, OR “Sexuality”, OR “Sex education”, OR “Reproductive behavior”, OR “Reproductive Health”, OR “Sex”, OR “Sexual partners”, OR ”STDs”, “STIs”, OR “Sexually Transmitted Infections”, OR “AIDS”, OR “Acquired Immune Deficiency Syndrome Virus”, OR “High-Risk Sex”, OR “Unprotected Sex”, OR “Condom”, OR “Contraceptive”, AND “Iran”, AND “Knowledge”, OR “Attitude”, OR “Needs”, OR “Barriers”, OR “Challenges”, OR “Strategies”, OR “Services”.

The process continued and the cycle was repeated until a saturation point was reached.

Inclusion Criteria

The inclusion criteria were all types of research papers related to SRH and behaviors of adolescents and young people in one or several cities of Iran in both English and Farsi languages. All types of studies, including surveys, qualitative studies, randomized clinical trials, and observational studies were included. The surveys with sample size lower than 100 were excluded for the review on prevalence of premarital sex. The age range of studies was between 10 and 29 years old and the majority of published studies were conducted among adolescents aged 10–19 or college students or non-students under age 30 years. The dates of publications were between 2001 to 2019. Articles for which full text was not available or gray literature were excluded.

Once the articles were identified, their abstracts were carefully read and articles were included on the basis of their relevance to the review objectives, inclusion criteria, and their quality. From among the 460 articles identified, 125 met the inclusion criteria. After careful reviewing of the full text of the papers, 74 were further excluded because of indirect relevance to the topic or poor methodological quality and eight papers excluded because they were duplicates. In total 43 articles were examined for this narrative review (Figure 1).

It should be noted that the majority of the studies published from 2005 onward had been conducted earlier in 2001–2004, but to the sensitive topic and the long publication process, they appeared as published papers in 2006 and 2007 or later. Some papers had information on more than one area of research interest; for instance, some authors reported both the prevalence of sexual behavior and their predictors. Between 2011 to 2015, a significant rise was observed in the published literature on SRH among young people in Iran. Notably, the importance of studies related to HIV/STIs in driving this rise is apparent (Figure 2).

Figure 2. Number of published papers on youth SRH in Iran by area of research and year of the publication (2001–2019).

Critical Assessment

In order to evaluate the fitness of articles for the review, we used the STROBE checklist¹ to assess the appropriateness of the study design for the research objective(s), the choice of outcome measures, sampling method, statistical analysis, quality of reporting, and generalizability. According to the STROBE checklist for observational cross-sectional studies, we selected those papers which successfully reported about two-third of items in the STROBE checklist (from among 22 items). In this way, the quality of reporting of observational studies was assessed.

Results

The research findings comprise responses to the three key study topics presented earlier. Hence, the results are divided into three sections:

First, the status of SRH among young people is reviewed. We present the prevalence of premarital sex, differentiated by gender, as well as high-risk sexual behaviors (multiple sexual partner and unprotected sex). In addition, some aspects of sexual behavior such as age at first sex, sexual coercion, alcohol consumption before sex, and age and type of sexual partners, and predictors of premarital sex and high-risk sexual behavior are reviewed. SRH knowledge and attitudes as two important individual-level predictors of sexual behavior are also reviewed. Second, we review SRH needs of adolescents and young people in Iran. Third, the challenges of SRH among youth and suggested strategies in Iran are reviewed based on relevant published papers.

The Status of SRH among Young People in Iran

Prevalence of Premarital Sex

Thirteen studies, published between 2006–2019, have asked male and female adolescents about sexual conduct before marriage. According to the reviewed papers, the rate of premarital sex among both young men and women ranged from 13.5% to 50.0%. Two surveys, one in Shahroud city and the other in Shiraz city, reported a relatively higher rate of premarital sex. The survey among 1500 college students in Shahroud universities showed a total rate of 41.0% for premarital sex (Vakilian et al., 2014). They used an indirect method named “the crosswise model” to make sure the student reported their sexual behaviors in a confidential manner to reduce social desirability bias. In addition, a population-based study among 1976 people with an age range of 25 ± 5.8 in Shiraz showed a prevalence rate of 50% for premarital sex. Although this was a comprehensive study with a large sample and the majority of participants were below age 30, 11.5% of the sample were older than 30 years of age; thus, the reported rates might also be an over-estimation (Honarvar et al., 2015).

If we consider all the included surveys during 2001–2019, the range of prevalence rates for premarital sex among young people aged 19 and over was between 14.9% and 50%. Apart from the lowest and highest estimations for rates of premarital sex, other rates reported in studies are fairly comparable. These rates ranged between 13.5% and 18.3% among adolescents (both males and females) in Tehran (Hamzegardeshi, 2011; Marashi & Ramezankhani, 2019). The corresponding rates among youth in Mashhad (15.1%), Khoramabad (16.1%), and Kerman (14.9%) were comparably lower than the rates among youth who resided in Tehran, except for one study in Tehran (16.4%), but it is important to keep in mind that these surveys were conducted among different samples with different age groups and in different years.

Premarital Sex by Gender

As seen in Table 1, studies published between 2006 and 2019 reported a range of 3.4% for premarital sex among women with a mean age of 20.5 years in Kerman (Zahedi et al., 2019) and 39% for female college students in Shahroud city (Vakilian et al., 2014). The wide range of the prevalence rates might be because of different age groups samples and the years the studies were conducted.

Table 1. Prevalence of premarital sexual intercourse, multiple partner, and unprotected sex among sexually experienced by gender.

						Males (%)			Females (%)			Total
Denominator						All	Among sexually experienced		All	Among sexually experienced		All	Among sexually experienced
Citation		City	N	Gender	Mean age/age range	Premarital sex/intercourse	Multiple sexual Partners (> 1 lifetime partner)	Unprotected last sex (ULS)/inconsistent condom use (ICU)	Premarital sex/intercourse	Multiple sexual Partners (>1 lifetime partner)	Unprotected last sex (ULS)/inconsistent condom use (ICU)	Premarital sex/intercourse	Multiple sexual Partners (>1 lifetime partner	Unprotected last sex (ULS)/inconsistent condom use (ICU)
Adolescents	(Mohammadi et al., 2006)	Tehran	1385	M: 1385	16.6	27.7% (Any type)	73%	28.3 Never used condom	-	-	-	-	-	-
	(Hamzegardeshi, 2011)	Tehran	1151	M:572 F:579	15–18 y	18.1%	40%	43% ULS	9.0%	15.4%	74.4% ULS	13.5%	30.6%	53.6 ULS
	(Marashi & Ramezankhani, 2019)	North Tehran	245	M: 54 F: 191	15–18 y	-	-	-	-	-	-	18.3%*	-	73.3% ULS
Youth	(Momennasab et al., 2006)	Khorramabad	700	M: 231 F: 469	21.3	-	15.6	-	-	1.7%	-	16.1%	32.0%	84.7% ICU
	(Khalajabadi-Farahani, 2008)	Tehran	1743	F: 1743	21.90	-	-	-	11.6%	61.5%	81.8% ULS	-	-	-
	(Khalajabadi-Farahani, Kazempiour, et al., 2011)	Tehran	1722	M:529 F:1193	22.5	21.9%	-	-	13.9%	-	-	16.4%	-	-
	(Hedayati-Moghaddam et al., 2015)	Mashhad	590	M: 169 F: 421	20.8	32.9%	-	-	7.6%	-	-	15.1%	61.2%	59.4% ULS
	(Vakilian et al., 2014)	Shahroud	1500	-	18–24	45.0%	-	-	39%	-	-	41.0%	-	-
	(Ahmadabadi et al., 2008)	Tehran Tabriz	2566	M: 1206 F: 1360	22.0	31.3%	16.4%	8.9%	9.2%	2.5%	2.1%	19.9%		-
	(Khalajabadi-Farahani et al., 2017)	Tehran	1322	M: 1322	22.0	35.0%	85%	54%	-	-	-	-	-	-
	(Zahedi et al., 2019)	Kerman	1730	M: 1035 F: 695	20.5	22.6%	-	-	3.4%	-	-	14.9%	-	-
	(Shokoohi et al., 2016)	13 provinces	4950	M: 2456 F:2412	21.8	31.7%	-	73.9% ICU	9.6%	-	92.9% ICU	20.8%	-	78.2% ICU
	(Honarvar et al., 2015)	Shiraz	1076	M: 634 F: 442	24	-	-	-	-	-	-	50.0%	50.0%	42.2%

*Khalajabadi-Farahani, Kazempiour, et al., 2011. The term used for sexual relationship was “advanced relationship with the opposite sex”. Verbally, it had been explained for college students that “advanced relationship with the opposite sex” in this research meant sexual intercourse. This was due to the barriers in using the term “sexual intercourse” in a questionnaire to be used in the university system.

Compared to women, the prevalence of premarital sex among male adolescents and young people is considerably higher. It ranges between 18.1% (Hamzegardeshi, 2011) and 45% (Vakilian et al., 2014). A survey among college students in Mashhad city showed a rate of nearly 33% (Hedayati-Moghaddam et al., 2015) and another survey among college students in Tabriz and Tehran also showed a fairly similar rate (31.3%) (Ahmadabadi et al., 2008). These rates are also in line with another survey of 1322 male college students in Tehran, which found that 35% of male college students had reported premarital sex (Khalajabadi-Farahani et al., 2017). Although other surveys showed lower rates of premarital sex among men, this might be due to younger age of the samples, the earlier dates of the studies, or cultural differences.

These rates are consistent with the reported rate from a comprehensive study on a large sample of 4950 young people (mean age of about 22 years) in 13 provinces (Shokoohi et al., 2016). This study revealed that about 32% of young men and about 10% of young women had engaged in sex before marriage (Shokoohi et al., 2016). From these comparisons, we can conclude that at a minimum, about one-tenth of young women and about one-third of young men in Iran practice sex before marriage, with a strong heterogeneity by gender, age, and province (Table 1).

High-Risk Sexual Behaviors among Sexually Experienced Youth

Having multiple sexual partners (engaging in sexual activities with two or more people within a specific time period) (WHO/UNAIDS, 2015) and lack of condom use (inconsistent condom use or unprotected last sex) which expose youth to greater risks of HIV/STIs, unintended pregnancy, and unsafe abortion are reviewed in this section. From among studies that assessed young people’s sexual behaviors, only a few asked details of sexual behaviors such as number and type of sexual partners and consistent condom use (only 4–6 studies). Some studies reported condom use at last sex as a measure of safe sex (WHO/UNAIDS, 2015). It is important to assess these high-risk behaviors broken down by gender and age to show the influence of gender roles in sexual health.

Multiple Sexual Partners, by Gender and Age

The total rate of multiple partners among sexually experienced youth has been reported to vary between about 31% among sexually experienced adolescents in Tehran (Hamzehgardeshi, 2011), to 61.2% among sexually experienced youth in Mashhad (mean age 21 years) (Hedayati-Moghaddam et al., 2015). Comparing the rate of multiple partners among sexually experienced youth by gender revealed a marked variation across different studies. About 61% of sexually experienced female college students (n = 282) had more than one lifetime sexual partner (47.2% reported three and more sexual partners) (Khalajabadi-Farahani, 2008). The other two studies reported much lower rates of multiple partners among women. In a study of female sexually experienced college students in Tehran and Tabriz, 2.5% reported more than two lifetime sexual partners (Ahmadabadi et al., 2008). Less than 2% (1.7%) of sexually experienced young women in a study in Khoramabad reported multiple partners (Momennasab et al., 2006).

Young men were significantly more likely to report multiple sexual partners (range: 15.6% to 85%) than women. A recent study showed that 85% of sexually experienced male college students in Tehran (n = 462) reported multiple lifetime sexual partners (Khalajabadi-Farahani et al., 2017), which is a concerning issue. An earlier study in Tehran in 2001 showed that 73% of sexually experienced adolescent males (n = 382) reported multiple sexual partners (Mohammadi et al., 2006).

Inconsistent Condom Use/Unprotected Last Sex

Some studies assessed condom nonuse at last sex and other studies asked about inconsistent condom use; these showed a significant proportion of young people reported either inconsistent condom use or unprotected last sex. Inconsistent condom use was reported by 78.2% of sexually experienced youth in 13 provinces of the country in 2013 (Shokoohi et al., 2016) and unprotected last sex was reported by 73.3% of adolescents in northern Tehran (Marashi & Ramezankhani, 2019).

There is also a gender difference in condom-protected sex, with women tending to report less protection at sex than men. For example, in a study among adolescents in Tehran, unprotected last sex was about two-fold higher among female adolescents compared to male adolescents (74.4% vs. 43.0%) (Hamzehgardesh et al., 2011). This difference was also evident in a study among 495 sexually experienced youth from 13 provinces which showed greater unprotected last sex among women compared to men (92.9% vs. 74%) (Shokoohi et al., 2016). The only study that showed a very low rate of unprotected last sex among both male and female college students (8.6% vs. 2.0%, respectively) was conducted among college students in Tehran and Tabriz (Ahmadabadi et al., 2008).

Aspects of Sexual Behavior among Youth

Sexual Debut

As expected, age at first sex among adolescents was lower than among young people over 19 years old. Since younger age at first sex is associated with greater sexual risks such as unprotected sex and multiple sexual partners, the percentages of sexually experienced youth who had their first sex younger than 15 years, or younger than 18 years, are also reported in some studies.

The percentage of youth who had sexual debut before age 15 years ranged between 55.0% (Mohammadi et al., 2006) to 3.4% (Khalajabadi-Farahani et al., 2017). While nearly 24% of sexually experienced male college students had their first sex before age 18 years (Khalajabadi-Farahani et al., 2017), the corresponding rate among females ranged between 19.2% (Khalajabadi-Farahani, 2008) to 30% (Ahmadabadi et al., 2008). Surprisingly, 19% of sexually experienced female adolescents in another survey had experienced their first sex when they were younger than 13 years (Hamzehgardesh et al., 2011).

The mean age of first sex among male adolescents was reported to be 14.8 (SD = 2.0) (Mohammadi et al., 2006) and among male college students was 19.0 (SD = 2.8) (Khalajabadi-Farahani et al., 2017) and 17.0 (SD = 4.4) (Honarvar et al., 2015). Based on two surveys, the reported mean age at first sex among women was 19.6 (SD = 2.5) (Khalajabadi-Farahani, 2008) and 19.9 (SD = 4.4) (Honarvar et al., 2015). Accordingly, young men initiate their first sex significantly earlier than young women (Table 2).

Table 2. Mean age at first sex, mean age at first sexual partner, sexual coercion & sex with alcohol use among sexually experienced adolescents and young people.

					Males						Females						Total
Citation	City	N	Gender	Mean age (Years)	Age 1st sex <15 (%)	Age 1st sex<18 (%)	Mean age at 1st sex	Mean age at 1st sex Partner	Sexual coercion /coerced	Alcohol consumption before sex	Age 1st sex <15 (%)	Age 1st sex<18 (%)	Mean age at 1st sex	Mean age at 1st sex Partner	Sexual coercion /coerced	Alcohol consumption before sex	Age 1st sex <15 (%)	Age 1st sex<18 (%)	Mean age at 1st sex	Mean age at 1st sex Partner	Sexual coercion /coerced	Alcohol consumption before sex
(Mohammadi et al., 2006)	Tehran	387	Male	16.6	55%	-	14.8 (SD = 2.0)	15.6 (SD = 4.3)	-	25.3%	-	-	-	-	-	-	-	-	-	-	-	-
(Hamzegardeshi, 2011)	Tehran	162	M F	15–18 y	22.2% (1st sex <13 y)	-	-	-	-	25.3%	18.9% (1st sex < 13 y)-	-	-	-	-	13.2% (CI: 5.5–25.3)	21.1% (1st sex <13 y)	-	-	-	-	21.1% (CI: 14.9–28.4)
(Marashi & Ramezankhani, 2019)	North Tehran	45	M: F:	15–18 y	-	-	-	-	-	-	-	-	-	-	-	-	22.2%	-	-	-	-	18.2% (alcoholic consumption in last sex)
(Khalajabadi-Farahani, 2008)	Tehran	364	F.	21.90	-	-	-		-	-	5.6%	19.2%	19.6 (2.5)	26.1 (SD = 12.6)	21%	-	-	-		-	-	-
(Hedayati-Moghaddam et al., 2015)	Mashhad	78	M: 169 F: 421	20.8	-	-	-	-	-	-	-	-		-	-	-	24%	50% (< age19)	17.6 ± 3.3	-	-	-
(Ahmadabadi et al., 2008)	Tehran Tabriz	403	M: 307 F:96	22.0	16.7%	17%	-	-	4.3% (1st coerced sex)	8.1%	9.1%	3%	-	-	11.8% (1st coerced sex)	1.6%	-	10%		-	-	-
(Khalajabadi-Farahani et al., 2017)	Tehran	462	M: 462	22.0	3.4%	23.6%	19.0(SD = 2.8)	19.9 (SD = 4.89)	22.2% (coerced eider male, female, both), 17.6% (was forced)	15.9% (Psychoactive drug)	-	-	-	-	-	-	-	-		-	-	-
(Shokoohi et al., 2016)	13 provinces	1029	M: 779 F:250	21.8	-	-	-	-	-	39.8%	-	-		-	-	40.3%	-	-	19 (CI: 18.5–19.5)	-	-	40.0%
(Honarvar et al., 2015)	Shiraz	538	M: 634 F: 442	24	-	-	17.0 ± 4.4	-	-	-	-	-	19.9 ± 4.4	-	-	-	25%	50%	17.5 ± 4.5	-	-	-

Mean Age of Sexual Partners

One notable fact is that young men tend to have their first sex with older women. For example, a study among adolescent males showed that while their mean age at first sex was 14.8 (SD = 2.0), the mean age of their first sexual partner was 15.6 (SD = 4.3) (Mohammadi et al., 2006). The same pattern was observed in a study of male college students where the mean age at first sex was 19.0 years (SD = 4.9), while the mean age of their first sexual partner was about 20 years (SD = 4.9) (Khalajabadi-Farahani et al., 2017). This finding was unexpected and further research should be done on the type of first sexual partners among young men.

For women, as expected, the mean age of the first partner was higher than among men. One study showed that the mean age at first sex among female college students was 19.6 years (SD = 2.5) and of their partner 26.1 years (SD = 12.6) (Khalajabadi-Farahani, 2008). As is evident, the mean age of sexual partner had a large standard deviation. Some studies reported mean age at first sex in their total sample, without disaggregating by gender. For example, the mean age at first sex in a study across 13 provinces was 19.0 years (CI: 18.5–19.5) (Shokoohi et al., 2016) and in another study in Shiraz was 17.5 years (SD = 4.5) (Honarvar et al., 2015). Moreover, in total, the percentage of youth who had sexual debut younger than 15 years ranged between 24% (Hedayati-Moghaddam et al., 2015) to 25% (Honarvar et al., 2015). The percentage of youth who reported sexual debut younger than 19 was 50% (Hedayati-Moghaddam et al., 2015), and in one study, 50% reported their sexual debut was when they were 17 years old or younger (Honarvar et al., 2015) (Table 2). Hence, a considerable percentage of sexually active young people report first sex before age 18 which has important public health implications.

Sexual Coercion

Due to the adverse consequences of forced sex, such as HIV/STIs and unintended pregnancy, forced sex is another focus of this paper. A survey in 2017 showed that among sexually experienced male college students, 22.2% reported ever having forced sex or coerced sex (Khalajabadi-Farahani et al., 2017). Similarly, ever experience of coerced sex among female college students was 21% (Khalajabadi-Farahani, 2008). However, forced sex at sexual debut was significantly greater among women than men. For example, in one study, forced sex at sexual debut occurred among 12% of sexually experienced women compared to 4.3% of men (Ahmadabadi et al., 2008). Hence, the rate of forced sex is alarming and needs greater attention in future research and also interventions. Young women in particular are at greater risk of forced sex at their first experience than men (Table 2).

Alcohol Consumption and Sex

Because consuming alcohol can adversely affect sexual decision making and practices such as unprotected sex and multiple partners (Mmari & Blum, 2009; Zadeh-Mohammadi & Ahmadabadi, 2008), we reviewed papers on this topic. Despite the fact that alcohol consumption is illegal in Iran, in a study in north Tehran the prevalence of alcohol consumption before sex was 18.2% (Marashi & Ramezankhani, 2019) and it was 40% in another study across 13 provinces of the country (Shokoohi et al., 2016). The corresponding rates among young men were greater than among women. Among young women, the prevalence of alcohol consumption before sex ranged from 1.6% to 40.3% (Table 2). This is also an important and concerning issue which needs greater exploration and attention.

Type of Sexual Partners

The type of sexual partner is also important, because if young people have sex with high-risk partners without using protection, they will be exposed to the risk of adverse sexual health outcomes. Only a few studies asked about type of sex partner. Among men, the majority reported that their first sex partner was their steady girlfriend. About two-thirds (64.3%) of sexually experienced male college students in Tehran and Tabriz reported a girlfriend as their first sex partner (Ahmadabadi et al., 2008) and in another survey, 74.5% of sexually experienced male college students in Tehran reported their girlfriend as their first sex partner (Khalajabadi-Farahani et al., 2017). Other studies showed that the last sex partner was reported as a girlfriend by 70% (Ahmadabadi et al., 2008) and 76.2% (Khalajabadi-Farahani et al., 2017) of men.

Among male college students, a same-sex partner was the second most common type of partner at first sexual experience (22.6%) (Ahmadabadi et al., 2008). However, the details of such sexual experiences are not clear in these surveys. The possibility of having simultaneous sex partners from different groups (steady girlfriend and older non-virgin girls) among men can be also a possibility that would explain greater multiple partners among men than women. This question needs greater attention because it might have important implications for the sexual health of young people. Notably, about 11% of sexually experienced male college students in Tehran and Tabriz had their first sex with a sex worker (Ahmadabadi et al., 2008). The corresponding rate was about 7% among male college students in Tehran (Khalajabadi-Farahani et al., 2017) and about the same percentage had ever had casual sex (6.9%). Considering these rates, we can estimate that nearly one-third of sexually experienced men have had high-risk partners at their first sexual experience. Interestingly, high-risk partners at first sex are reported more often than at last sex (22.6% vs. 14.1%) if we assume that same sex partners are high-risk partners. In addition, having a sex worker partner was significantly more likely at first sex among men than at their last sex (11.0% in first sex vs. 7.6% in last sex).

Among young women, a greater percentage reported their first sexual partner as their boyfriend; 86.4% of sexually experienced female college students in Tehran reported their first sexual partner was a boyfriend; only 1.4% reported a casual sex first partner. Similarly, 87% reported their last sex partner was their boyfriend and only 1.5% that they were a casual sex partner (Khalajabadi-Farahani, 2008). Hence, these findings show that unmarried women (adolescents and college students) have fewer high-risk partners than men; however, if their boyfriends had ever had unprotected sex with high-risk partners (such as sex workers), they could also be considered as at potential risk of HIV/STIs. Another study among female college students in Tehran and Tabriz showed that for 74% of the women, boyfriends were reported as their first sex partner, and 81% reported boyfriends as their last sex partners. For women, only 4% reported a casual partner at first sex and at last sex, only 1.1% did so. The percentages of same-sex partners were nearly equivalent for both first and last sex (11.1% vs. 11.6%) (Ahmadabadi et al., 2008) (Table 3).

Table 3. Sexual partners of adolescents and young people at first and last sexual experience by gender.

					Males								Females								Total
					1st sexual partner				Last sexual partner				1st sexual partner				Last sexual partner				Ever had sex with a partner who was
Citation	City	N SE**	Gender	Age Whole sample	Steady Girlfriend	Sex workers/ paid	Casual	Same sex	Steady Girlfriend	Sex workers/ paid	Casual	Same sex	Steady boyfriend	Sex workers/ paid	Casual	Same sex	Steady boyfriend	Sex workers/ paid	Casual	Same sex	Sex workers/ Was paid	Casual	Same sex
(Khalajabadi-Farahani, 2008)	Tehran	364	F.	21.90	-	-	-	-	-	-	-	-	86.4%	-	1.4%	-	87%	-	1.5%	-	-	-	-
(Ahmadabadi et al., 2008)	Tehran Tabriz	403	M: 307 F:96	22.0	64.3%	11.1%	8.8%	22.6%	70%	7.6%	7.9%	14.1%	74.0%	1.05	4.0%	11.1%	81%	1.1%	1.1%	11.6%	-	-	-
(Khalajabadi-Farahani et al., 2017)	Tehran	462	M: 462	22.0	74.5%	6.9%	7.1%		76.2%	3.8%	7.9%	-	-	-	-	-	-	-	-	-	19.5%	-	10.2%
(Honarvar et al., 2015)	Shiraz	538	M: 634 F: 442	24	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	6.1%
(Hedayati-Moghaddam et al., 2015)	Mashhad	78	M: 169 F: 421	20.8	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	-	35.0%

Factors that Determine Variations in Sexual Behavior among Youth in Iran

Reviewing papers which have assessed factors that predict or are associated with premarital sex and high-risk sexual behaviors in surveys and qualitative studies led us to three main domains for predictors of premarital sex: personal, family, and peers and community. This classification reflects the complexity of factors related to sexual behavior and is based on a review of risk factors and protective factor of teens’ sexual behavior (Kirby & Lepore, 2007).

Personal Factors

Studies have demonstrated that age is an important factor which is positively and significantly associated with experience of both premarital sex and high-risk sexual behaviors (Yazdi-Feyzabadi et al., 2019). Male gender was another predictor of both premarital sex and high-risk sex (Alimoradi et al., 2017; Hosseini-Hoshyar et al., 2018; Yazdi-Feyzabadi et al., 2019). Involvement in other risky behaviors such as alcohol use was significantly associated with high-risk sexual behaviors and premarital sex (Alimoradi et al., 2017). In addition, poor HIV knowledge and motivation to protect against HIV (Bahrami & Zarani, 2015; Khalajabadi-Farahani et al., 2017), poor knowledge about condoms (Hosseini-Hoshyar et al., 2018), and poor sexual knowledge and negative attitudes (Alimoradi et al., 2017; Keramat et al., 2013; Khalajabadi-Farahani, Akhondi, et al., 2018; Noroozi et al., 2015) were significantly associated with high-risk sexual behaviors among youth. Low HIV/AIDS risk perception and misperceptions about condoms were also associated with high-risk sexual behaviors among youth (Bahrami & Zarani, 2015; Noroozi et al., 2015). Interestingly and unexpectedly, active involvement in sport was associated with high-risk sexual behaviors among adolescents in one survey (Ahmadabadi & Zadeh-Mohammadi, 2012; Alimoradi et al., 2017); this needs greater attention in future studies. Poor religiosity was another factor which was associated with both premarital sex (Khalajabadi-Farahani, Mansson, et al., 2018) and high-risk sexual behaviors (Yazdi-Feyzabadi et al., 2019). A qualitative study suggested liberal attitudes toward virginity and lower marital motivation as factors associated with premarital sex among educated women (Khalajabadi-Farahani, Mansson, et al., 2018).

Family and Peer Factors

Family factors have been shown to be very important determinants of sexual behavior. Both family structure and family function have been significantly associated with premarital sex and high-risk sexual behavior (Alimoradi et al., 2017). Lack of intact family and having parents with high-risk behaviors (such as parents who abuse drugs) were associated with premarital sex and high-risk sexual behavior. In addition, adverse family function, including family control versus freedom, obligation vs. persuasion, indifference vs. warmth, lack of intimacy, lack of responsibility and cooperation, lack of fulfillment of adolescents’ needs, having poor parent–child relationship and lack of family support, lack of family approval, negligent parents, both strict and liberal parental monitoring, have all emerged as determinants of high-risk sexual behavior (Ahmadi et al., 2013; Alimoradi et al., 2017; Keramat et al., 2013; Khalajabadi-Farahani, Cleland, et al., 2011; Khalajabadi-Farahani, Mansson, et al., 2018; Yazdi-Feyzabadi et al., 2019; Zadeh-Mohammadi & Ahmadabadi, 2008). Higher maternal education and lower family income were also identified as determinants of high-risk sexual behaviors among youth (Alimoradi et al., 2017). Studies have also shown that affiliations with peers who engage in high-risk behaviors (Ahmadi et al., 2013; Alimoradi et al., 2017) and peer pressure are associated with premarital sex and high-risk sexual behavior (Yazdi-Feyzabadi et al., 2019).

Community Factors

Finally, factors at a more distal level such as institutional and community factors have been associated with high-risk sexual behaviors such as poor social opportunities for youth to meet their needs for connectedness and relationships (Alimoradi et al., 2017). One study showed a significant association between premarital sex and liberal perception of social norms on sexuality before marriage (Khalajabadi-Farahani, Mansson, et al., 2018). Societal atmosphere and acculturation to liberal sexual attitudes received from global media and cultural and social changes have also been associated with high-risk sexual behavior (Alimoradi et al., 2017; Keramat et al., 2013). With regard to new sexual attitudes and values, some studies suggested that access to global media influence youth to choose new role models in sexuality. Access to sexually explicit materials on the Internet has become much easier and this might be responsible for greater involvement of youth in premarital sex (Khalajabadi-Farahani, 2019a; Taleghani et al., 2017) (Table 4).

Table 4. Predictors of premarital sex and high-risk sexual behavior among adolescents and young people.

Study characteristics
Citation	Outcome Variable	City	Study Type	N	Gender	Age	Predictors of Premarital Sex and High Risk Sexual Behaviors
(Khalajabadi-Farahani, Kazempiour, et al., 2011)	Premarital sexual relationships (any type of sexual contact including sex by touch, oral, anal and vaginal sex)	Tehran	Survey	1378	Females	21.4	Predictors of “premarital sex” Having very strict parental control during adolescence Not living with both parents (odds ratio:2.0) Having a family with more liberal values (odds ratio:1.3) Lack of a close and intimate parent–child relationship (odds ratio: 0.7).
(Ahmadi et al., 2013)	High risk sexual behaviors	Tehran	Survey	1266	M: 529 F: 737	16.07	Affiliation with deviant peers Parental monitoring
(Alimoradi et al., 2017)	High risk sexual behaviors	Cities of Iran	Systematic Review of papers published in Farsi or English in local and foreign journals, searched	16 published papers	Male and Females	Adolescents	Personal factors: Older age, male gender, being active in sport (Athletes), negative indicators of mental health, other risky behaviors such as alcohol use, educational level, lack of accurate sexual knowledge and attitude and improper sexual information sources Family: Family structure: lack of intact family structure, addicted parents or having parents who are involved in high-risk behaviors. Family function: Control versus freedom, obligation vs., persuasion, indifference vs. warmth, lack of intimacy between family members, lack of responsibility and cooperation. Lack of fulfillment of adolescents’ needs for attachment to family, having bad parent–child relationship and lack of support from family, lack of self-esteem and approval in the family, negligent parental style, strict parental monitoring, higher mothers’ academic education and lower family income (poverty and economic constraint) Peers: Friendship with opposite sex, affiliation with deviant peers Schools & Community: Lack of external control over the students’ actions, lack of social opportunities for students to meet youth needs for connectedness, relationships, and approval at school, cultural and social change in the community
(Bahrami & Zarani, 2015)	HIV risk taking sexual behaviors	Kermanshah city	Survey	151 male students	Males	23.0	The level of HIV risk perception The level of HIV knowledge The motivation to avoid HIV infection
(Hosseini-Hoshyar et al., 2018)	Condom use at last penetrative sex	National study	Survey	633 men & women who reported premarital sexual intercourse	Males and Females		Being female or male (25.7% vs. 38.5%) Not having a stable job Lack of knowledge of condom use and sexual transmission of HIV Experience of sex under the influence of substances
(Khalajabadi-Farahani, Mansson, 2018)	Premarital sexual relationships	Tehran	Qualitative study (in-depth interviews)	30 IDIs	Females	18–24 years (age range)	Predictors of premarital sex: Having different attitudes toward marriage meaning and motivations Reduced importance of virginity for marriage Importance of sexual compatibility between marital partners Marital motivation; a justification for or against premarital relations Compliance with family values and expectations Respecting family’s values Poor relationship with family members Good relationship with family members Severe restrictions by parents Moderate or light supervision and control Perceived social and gender norms of premarital sex Perceived social stigma of premarital sex Gender-based double standards Importance of religiosity Importance of religious beliefs Sexual knowledge and self-efficacy Misconceptions and lack of knowledge Self-efficacy
(Noroozi et al., 2015)	High risk sexual behavior	Isfahan	Qualitative study	30 IDIs	M: 13 F: 17	18–24 Years (age range)	Gendered sexual script” Male power Limited knowledge of females about STIs/HIV/AIDS and unpleasant experiences with condoms Limited knowledge among men about various sexual modes of HIV and STIs transmission Low-risk perception on HIV/STIs among men Beliefs about role of condom in reducing sexual pleasure Cultural scenarios of interpersonal interactions
(Taleghani et al., 2017)	Premarital sexual relationships	Isfahan	Qualitative Study	26 IDIs with boys and girls, 12 IDIs, other participants		18–24	International media is the role model for youth sexuality International media make access to sexual content easy International media makes the heterosexual interaction and relationships easy
(Yazdi-Feyzabadi et al., 2019)	Risky sexual practice, drug abuse and alcohol consumption	Iran	Systematic Review	12 studies	Males and females	Adolescents aged 15–19 years	The most frequent main factors were: Family factors (Anti-social behaviors in family, Mother’s employment, Inappropriate parenting style, Poor parental intimacy, Absence of parents) Higher age, Male gender, Weak religious beliefs, Low self-esteem, Lack of appropriate recreation Peer pressure
(Ahmadabadi and Zadeh-mohammadi, 2008)	Risky behaviors such as violation, smoking, drug use, alcohol drinking, and sexual relations	Tehran	Survey	1204	Males and Females	Adolescents	Lack of family cohesion Lack of family adaptability in boys was associated with increased violence and substance use Lack of authoritative parental style Having neglectful or permissive parents Parental demanding behaviors with authoritative style parenting Mother’s higher education Family economic wellbeing
(Ahmadabadi & Zadeh-Mohammadi, 2012)	High risk sexual behavior	Tehran	Survey	406	M:271 F: 135	High school students	Being active athlete Being in athletes’ camp
(Keramat et al., 2013)	Premarital sex	Shahroud	Qualitative study	4 FGDs (20 college students)		21.0 ± 1.2	Family atmosphere Society atmosphere Individual attitude Lack of acculturation against Western sexual ideology Increased age at marriage
(Khalajabadi-Farahani et al., 2017)	HIV risk taking behaviors (multiple sexual partners, inconsistent condom use)	Tehran	Survey	1322 males college students	M	22.0 ± 2.76	- Predictors of multiple sexual partners: Early sexual debut (<18 years), studying in a private university, ever watching pornography and work experience -Predictors of inconsistent condom use: Younger age at sexual debut, having one lifetime sexual partner and poor HIV knowledge were considerable predictors of inconsistent condom use over the preceding month.

SRH Knowledge and Misperceptions

Although evidence suggests that protective factors in the lives of young people such as connectedness to parents, peers, and school may be important in reducing involvement with sexual risk behaviors (Kirby, 2002), the majority of studies have focused on individual-level risk and protective factors such as knowledge, attitudes, and skills as important (Mmari & Blum, 2009). Hence, SRH knowledge and attitudes as two important individual-level factors for young people’s sexual behaviors are reviewed in this section.

HIV/STI Knowledge and Misperceptions

When a significant minority of youth are involved in premarital sex, it is important to know to what extent they are aware of HIV and STIs. Several studies have assessed adolescents’ and young people’s knowledge about HIV and STIs (Ahmadabadi et al., 2008; Bazarganipour et al., 2013; Honarvar et al., 2015; Khalajabadi-Farahani, 2008; Khalajabadi-Farahani, Akhondi et al., 2018; Mohammadi et al., 2006; Shokoohi et al., 2016; Tavoosi et al., 2004), while only a few assessed their knowledge about fertility and contraception (Bazarganipour et al., 2013; Khalajabadi-Farahani, 2008; Malek et al., 2012). This can be explained by the fact that HIV has provided a platform for addressing sexual health, because it deals with health and wellbeing, while fertility and unintended pregnancy are less tangible among youth and are assigned a lower priority.

Our review of the literature showed that the majority of young people in Iran have heard about HIV/AIDS, but they have important misperceptions about the symptoms of the disease and its modes of transmission; information related to sexual transmission and condom use was especially poor. Despite the fact that in one study about 95% of adolescent males in Tehran had heard about HIV/AIDS, a considerable proportion had misperceptions about HIV/AIDS symptoms, mode of transmission, prevention, treatment, and a vaccine (Mohammadi et al., 2006). A significant minority were not aware of HIV symptoms and the possible healthy appearance of HIV-positive people (23%) (Mohammadi et al., 2006). Similarly, in another study, 14% of college students in Tehran and Tabriz did not know about the possible healthy appearance of HIV-positive people (Ahmadabadi et al., 2008). In a study among youth in Shiraz, 72% of young people could not name one symptom of HIV/AIDS, about 95% could not name three symptoms of HIV and 48.5% did not know about the asymptomatic nature of HIV infection (Honarvar et al., 2015). Another study among 4641 adolescents in Tehran revealed that 10% of adolescents had a misperception that they could recognize HIV-infected people from their appearance (Tavoosi et al., 2004).

In one study, 37% of male adolescents in Tehran believed that HIV was curable (Mohammadi et al., 2006). About 35% of college students in Tehran and Tabriz did not have correct knowledge about HIV treatment; 11.4% believed it was curable and 24% were uncertain (Ahmadabadi et al., 2008). Another study among adolescents in Tehran also revealed that 9% thought HIV was curable and 11% thought that there was a vaccine for HIV (Tavoosi et al., 2004).

Research has demonstrated that correct knowledge among youth about the mode of HIV transmission in metropolitan areas of Iran is very diverse. In one study participants had a relatively average general knowledge about the mode of HIV transmission, while comprehensive information about the more sensitive aspects of HIV transmission was poor (Khalajabadi-Farahani, Akhondi, et al., 2018). Between 4% and 33% of adolescents in Tehran held incorrect information about the mode of HIV transmission (Tavoosi et al., 2004), while misinformation in this regard was even greater among college students in Tehran (ranging between 13% and 58%) (Khalajabadi-Farahani, Akhondi, et al., 2018). In a study in Tehran, adolescents’ main misperceptions were about HIV transmission through mosquito bites (33%), public swimming pools (21%), and public toilets (20%) (Tavoosi et al., 2004). Similar misperceptions were observed in another survey among youth in Qom; 62% of young people had incorrect knowledge about HIV transmission through sharing bathrooms and toilets; 58% believed that HIV was transmitted through mosquito bites (Bazarganipour et al., 2013). Studies have shown that youth are relatively knowledgeable about HIV transmission through blood transfusion and sex. For example, about 95% of college students in Tehran and Tabriz had accurate knowledge about HIV transmission through blood transfusions, 93.1% about transmission through sexual relations from an infected man to a woman, and 92.1% from sexual relations from a woman to a heterosexual partner (Ahmadabadi et al., 2008). While participants had some misperceptions regarding HIV transmission through anal sex and oral sex, they believed that there was a greater risk for HIV transmission through vaginal sex than anal and oral sex. About 93% knew that HIV can be transmitted through vaginal sex, while 25.2% did not recognize anal sex as a mode of HIV transmission and 63% did not know that HIV can also be transmitted through oral sex (Ahmadabadi et al., 2008). A survey showed similar findings about HIV transmission through vaginal sex compared with other types of sex. Fifty percent of respondents thought that HIV was mostly transmitted by vaginal sex rather than anal sex and oral sex and 28% were uncertain (Honarvar et al., 2015). Similarly, college students seem to have a good general knowledge about sexual transmission of HIV (87%), but detailed understanding about the riskiest type of sex and HIV transmission was relatively poor (Khalajabadi-Farahani, Akhondi, et al., 2018). There is an unmet need among youth to learn about the most sensitive and detailed information about HIV/AIDS transmission which needs to be considered in interventions.

Other misconceptions were about the protective role of condoms in the prevention of HIV, which was addressed in only a few studies. About one-third of youth in Shiraz (mean age 22 years) did not know that condom use has a protective role in HIV infection (Bazarganipour et al., 2013). About the same percentage of non-medical students (33%) in Qom city did not know about the protective role of condoms (Bazarganipour et al., 2013). Another survey showed that 36.5% of youth in Shiraz did not know how to prevent HIV (Honarvar et al., 2015). Other misconceptions were related to the risk of HIV transmission from men to women and vice versa. About one-third of youth in a survey in Shiraz believed that women who are HIV-positive are more likely to transmit the virus than HIV-positive men; 33.5% were unsure about this (Honarvar et al., 2015) (Table 5).

Table 5. SRH knowledge & attitudes among adolescents and young people in Iran, A review.

Citation	City	N	Gender	Age	HIV Knowledge & Misperceptions	STI Knowledge & Misperceptions	Fertility, Puberty and Contraceptive Knowledge	Attitudes and Beliefs & Risk Perceptions
(Mohammadi et al., 2006)	Tehran	1385	M: 1385	16.6	95% had heard about STIs/HIV/AIDS. Misconceptions were widespread. 37% did not know that AIDS is not curable 23% did not know that people infected with HIV can be asymptomatic. Mean scores were moderate on the nine-point STI/HIV/AIDS scale (3.86; SD = 2.13)	Poor knowledge on signs & symptoms of STIs such as: - Discharge from the penis in men (28%), - Pain during urination (34%), - Ulcers/sores in the genital area (28%). Knowledge about signs and symptoms of STIs in women was even lower	72% heard about condoms 53% had never seen a condom Knew more about condoms & OCP (58%), than other methods (IUD (22%), injectable contraceptives (14%).emergency contraception (16%), withdrawal (14%), jelly or foam (13%) and the implant (12%). 13% unfamiliar with any contraceptive method. Of ten contraceptive methods, adolescents were aware of 3.14 (SD = 2.36). Of the three-point condom awareness index (1.50; SD = 1.20)- Poor to moderate level of awareness on reproductive physiology	55% were against premarital sex (56% for females & 41% for males) 34% were even against premarital heterosexual friendships 76% were against homosexuality 43% believed women would regret premarital sex, only 32% believed the same for men 53% believed that masturbation is harmful to human well-being; only 14% disagreed. 40% approved temporary marriage.
(Malek et al., 2012)	Tabriz, Uremia, Ardebil	2700	MF	High school students	-	Only 1% had good STI knowledge 50% had moderate STI knowledge 49% had poor knowledge on STIs	No gender difference in general sexual knowledge Knowledge on fertility physiology (14%: low, 53% average & 33% good) Knowledge on puberty: (18% low, 59% average & 33% good) Knowledge on contraception (56% low, 34% average & 10% good)	-
(Tavoosi et al., 2004)	Tehran	4641	M: 45% F:55%	High schools	The majority of students had accurate knowledge about HIV/AIDS modes of transmission, with 67–96% correctly answering each question. Many misconceptions were still noted relating to HIV/AIDS, with 9% of students believing that children would never be affected by HIV/AIDS, 10% believing that HIV-positive people can be recognized by their appearance, 9% and 11% believing that there is a cure and vaccine for AIDS, respectively. Mosquito bites (33%), public swimming pools (21%), and public toilets (20%) were incorrectly identified as routes of transmission Ninety-four percent of students expressed a wish to know more about HIV/AIDS.	-	-	71% believed best way to fight HIV is investment on youth education Vaccination (10%) & treatment (4%) 93% believed that AIDS is a threat to Iranian population Negative attitudes toward HIV-infected individuals were common 46% believed that a HIV positive student should not be allowed to enter an ordinary school 35% preferred not to sit near a HIV positive student [no gender difference) Only 23% would shake hands with an HIV positive person Poor knowledge was associated with negative attitudes
(Khalajabadi-Farahani, 2008)	Tehran	1743	F: 1743	21.90	92.2% correctly knew that HIV infected people may have healthy appearance. 68.9% correctly knew that condoms are an effective method against HIV	-	71% correctly knew that a woman can get pregnant on the very first time that she has sexual intercourse 75.8% correctly knew that oral pills are an effective method against pregnancy	47% and 48% agreed to have friends of opposite sex for boys and girls, respectively 51% were supportive of dating. Only 34% agreed to premarital physical intimacy 68% had a negative view toward premarital sex even in a love relationship 76% believed that boys will not respect women who agree to have premarital sex 74% believed that women would regret premarital intercourse 82.5% considered virginity very important before marriage 75% of disapproved of any type of premarital sexual contact Respecting family values (82%) and religious beliefs (72%) were two important rationales for preserving virginity, though the former appeared to be slightly more important. Nearly three-quarters supported gender equality in premarital sex
(Ahmadabadi et al., 2008)	Tehran Tabriz	2566	M: 1206 F: 1360	22.0	Majority were well informed about non-sexual modes of HIV transmission From infected blood transfusion (95.4%) From infected woman to same sex partner (67.7%) From infected woman to heterosexual partner (92.2%) From infected man to woman (93.1%) From infected man to homosexual partner (81.7) Via vaginal sex (92.8%) Via anal sex (74.8%) Via oral sex (37.0%) 11.4% believed that AIDS was curable, 24% had doubts 7% believed AIDS only affects homosexual and injecting drug users 12.6% believed AIDS occurs among people with multiple partners 14.4% disagreed that an HIV positive person can have a healthy appearance About one third disagreed that sex after alcohol consumption or abusing drugs increases the risks of HIV transmission About 8% believed that if someone is strong and healthy, they do not get HIV 8.1% disagreed that sex with sex workers increases the risk of HIV transmission	-	-	13% believed that AIDS is God punishment 22.3% believed women become a greater role in HIV transmission than men One third disagreed that sex after alcohol consumption and substance use increase the HIV transmission About 8% believed if they are healthy, they would not have become infected with HIV 8% disagreed that having sex with sex workers would increase risk of HIV transmission
(Khalajabadi-Farahani, Akhondi, 2018)	Tehran	1357	Male college students in Tehran	22.0	Incorrect responses about various modes of HIV transmission varied from 13% to 58%. Most misbeliefs and misinformation comprised ‘transmission through insect, blood transfusion using a clean syringe, touching infected blood, using common toilet, using common syringe, sexual contact with infected partner’. The mean score of knowledge about HIV transmission and sexual transmission of HIV was at an average level. There was an important heterogeneity with regard to the mode of HIV transmission. Despite the fact that 87% of male college students were aware of transmission of HIV through sexual contact with infected partner; detailed information about sexual transmission of HIV was poor. About 50.3% and 37.7% of respondents were not aware of HIV transmission through non-vaginal penetrative sex [oral sex and homosexual relations].	-	-	Only 6.5% of sexually experienced men were highly concerned about HIV over the past year. About 17% had a moderate and 22% a low risk perception, About 45% were not worried at all about contracting HIV in the preceding year Only 3.4% were highly worried about contracting STIs in the future About 23% were somewhat worried and 25% had no fear at all.
(Shokoohi et al., 2016)	13 provinces	4950	M: 2456 F:2412	21.8	Most knew the main routes of HIV transmission and could correctly identify the risk of piercing (84.6%) and tattoos (83.4%) with HIV-infected equipment, sharing injection needles/syringes (88.2%), and unprotected sex with PLHIV (87.9%) in transmitting HIV. Around half of the participants knew that HIV can be transmitted through breastfeeding (51.5%), or that it cannot be spread through the sneeze, cough or saliva of PLHIV (52.9%). Misconceptions existed about the transmission of HIV through mosquito/insect bites across all age groups (31.7% correct response). Most participants knew that PLHIV cannot be identified by their appearance (78.6%), and HIV testing is the only diagnostic measure (73.5%). Around 70% knew that condom use reduces the chance of HIV transmission. Most knew that having multiple sexual partners and preexistence of sexually transmitted diseases (STD) could increase the chance of HIV infection (74.4% and 69.9%, respectively). Knowledge about HIV treatment was relatively low, and 55.0% believed that an HIV vaccine exists. More than one-third (35.3%) knew that antiretroviral therapy could reduce the chance of HIV transmission. Around two-third (67.9%) of them knew that early diagnosis and treatment increases the life expectancy of PLHIV	-	-	About 38% had a tolerance for working or studying with PLHIV. 57% rejected the misconceptions of viewing HIV as a fair punishment for the sins of the past (57.0%) or quarantining PLHIV as the best HIV preventative intervention (61.8%). 88.3% believed that PLHIV should be supported and receive treatments 47.7% evoked feelings of disgust when thinking about kissing or hugging PLHIV. About 62% declared that AIDS is not only exclusive to high-risk populations such as PWID or female sex workers; about 51% would not break up their contacts with PLHIV The poorest attitudes were observed toward sharing a table with PLHIV (46.3% positive attitudes) and feelings of despair in the case of testing positive for HIV (40.1% positive attitudes)
(Honarvar et al., 2015)	Shiraz	1076	M: 634 F: 442	24	Regarding AIDS, 28.5% and 4.9% could explain one symptom and three symptoms, respectively 14.9% did not know the routes of transmission of HIV 36.3% did not know anything about preventive methods for HIV. 27.5% did not know that HIV-positive persons may transfer the virus when they are asymptomatic, 4.7% claimed that HIV infected persons could be diagnosed by their appearance and about 21% did not know whether this was true or not. 33.3% believed that HIV-positive females are more likely to transmit the virus than HIV-positive males, 35.5% did not know the answer 50% believed HIV is more likely transmitted by vaginal sex than anal or oral sex, 28% did not know the answer.	38.1% could name one STD, 18.4% could name three of STDs, 11.2% could name one STD symptom, and 6.2% could name three symptoms. 52% knew that condoms completely prevent STDs in sexual contact, 17.4% claimed that condoms had an intermediate effect and 16.4% denied such efficacy. 67% noted that their knowledge about their partners’ STIs was important if they wanted to have sexual contact with them and 43% asked their partners whether they had STDs	-	Only 52% believed that condoms could completely prevent STIs, 17.4% believed an intermediate effect and 16.4% denied the efficacy of condom in prevention of STIs. 83.6% were in favor of STI screening before marriage About 12% did not know where to obtain HIV testing Only 2.5% knew that they can visit HIV/AIDS behavioral counseling center (BCC) affiliated with medical university 17.4% of sexually experienced youth had been tested for HIV
(Karamouzian et al., 2017)	5 provinces (Kerman, Khorasan Razavi, Tehran, Fars)	742 male and female college students		Mean age (SD): 21.8 ± 3.3	-	49%, 42% and 9% of the respondents had low, moderate and high STI knowledge scores, respectively. Online sources (62%) and friends (32%) were their main sources of information about STIs, and those who were older, ever-married or more educated were more knowledgeable than other respondents	-	-
(Bazarganipour et al., 2013)	Qom	400	-	Mean age: 21.82(±1.14) (non-medical universities)	About 66% correctly knew about HIV transmission via sharing syringe and sharp instruments 53% correctly knew the possibility of HIV transmission from infected mother to her infant. About 62% had a misperception on HIV transmission by sharing bathroom and toilet and 58% had a misperception about insect bites as mode of HIV transmission. About 67% had a correct knowledge on protective role of condom in HIV infection	About 62% had correct knowledge about STDs and AIDS	35.3% believed that use of IUDs is suitable contraceptive method for nulliparous women 55.2% reported that the content of family planning courses in universities should be more comprehensive About 75% had knowledge about family planning	59.5% believed that unmarried youth don’t need education about reproductive health because they haven’t had sexual relations before marriage 53% reported that reproductive health and sexual health education increase prevalence of high risk sexual behaviors, STDs, AIDS and unwanted pregnancy

Only a few studies have assessed adolescents’ and young people’s awareness of STIs (Honarvar et al., 2015; Karamouzian et al., 2017; Malek et al., 2012; Mohammadi et al., 2006). Reviewing these studies clearly showed that young people are poorly informed about STIs and its symptoms. For instance, in one study, only 28%, 34%, and 28% of adolescent males were aware that discharge from the penis, pain during urination, and genital ulcers were, respectively, symptoms of STIs (Mohammadi et al., 2006). Regarding gender disparity in knowledge about STIs, in one study, men were less knowledgeable than women (Mohammadi et al., 2006). About 38% of young people in Shiraz could name one type of STI and 18.4% could name three STIs. Their knowledge about symptoms was poor; only 11.2% could name one symptom of STIs and 6.2% could name three symptoms (Honarvar et al., 2015). Poor STI knowledge was also shown in a survey among 2700 high school students in Tabriz, Uremia, and Ardebil (Malek et al., 2012) (Table 5).

Knowledge on Fertility and Contraception

Similar to STIs, a very limited number of studies have assessed adolescents’ and young people’s knowledge about contraception and fertility issues. A study among high school students in Tabriz, Uremia, and Ardebil showed that only 33% had a good knowledge about fertility physiology. Similarly, only 33% had a good knowledge about puberty (Malek et al., 2012). Misinformation about the probability of pregnancy from an act of sexual intercourse was also not negligible. A study among 1743 female college students in Tehran showed that about 31% did not know that a woman can get pregnant the very first time that she has sexual intercourse. About 24% did not know that oral contraceptive pills are an effective way to prevent pregnancy (Khalajabadi-Farahani, 2008). Misinformation regarding the intrauterine device (IUD) was also shown in a study among youth in Qom. About 35% misbelieved that the IUD was suitable for nulliparous women as a contraceptive method. The same study also showed that more than half of youth reported that the content of family planning courses in universities is not comprehensive (Bazarganipour et al., 2013) (Table 5).

SRH Attitudes

Some studies have examined attitudes of adolescents and young people toward various issues related to SRH. These include sexuality before marriage for men and women, condom use, people living with HIV (PLHIV), stigmatization of HIV-positive people, and finally, sexual health education for adolescents and youth.

Studies have demonstrated that a significant proportion of adolescents and youth were against premarital sex, particularly for women compared to men. More than half of male adolescents (56%) in Tehran in 2001 were against premarital sex for women and 41% were against premarital sex for men (Mohammadi et al., 2006). A greater percentage of female college students in Tehran (75%) were against any type of premarital sex; 52.5% disagreed that women could have a premarital friendship with a man (Khalajabadi-Farahani, 2008). More than two-third (76%) of female college students believed that men would not respect a girl who agreed to have premarital sex and the same percentage (76%) believed that girls would regret premarital sex. For 82% of female college students, virginity was very important. Respecting family values and religious beliefs were the two important reasons for deciding not to have premarital sex (82% and 72%, respectively) (Khalajabadi-Farahani, 2008). Hence, despite a trend toward more liberal attitudes toward heterosexual communication and friendship, a majority of young people, particularly women, still endorse family and religious expectations with regard to hesitating about having sex before marriage. Hence, high-risk sex among some youth happens in such a social and cultural context in Iran.

Attitudes toward HIV were also examined in some studies. A study among high school students showed that 93% believed that AIDS was a threat to the Iranian population; negative attitudes and stigmatization toward HIV-infected individuals were common and widespread. Forty-six percent believed that an HIV-positive student should not be allowed to enter an ordinary school, 35% preferred not to sit near an HIV-positive student, and only 23% would shake hands with an HIV-positive person (Tavoosi et al., 2004). There were no gender differences in these attitudes. Another survey among youth in 13 provinces showed that about 38% had a tolerance for working or studying with PLHIV. Fifty-seven percent rejected the view that HIV was a fair punishment for the sins of the past or that quarantining PLHIV was the best HIV preventative intervention (61.8%). About 88% believed that PLHIV should be supported and receive treatments. About 48% expressed feelings of disgust when thinking about kissing or hugging PLHIV. About 62% reported that AIDS is not only exclusive to high-risk populations such as female sex workers; about 51% would not terminate their contact with PLHIV. The poorest attitudes were observed toward sharing a table with PLHIV and feelings of despair in the case of testing positive for HIV (Shokoohi et al., 2016).

Attitudes toward STIs/HIV and condom use were examined in another survey in Shiraz. Only 52% believed that condoms could completely prevent STIs. About 84% were in favor of STI screening before marriage, but about 12% did not know where to obtain HIV testing. Only 2.5% knew that they could visit HIV/AIDS behavioral counseling centers (BCC) affiliated with medical universities and only 17.4% of sexually experienced youth had been tested for HIV (Honarvar et al., 2015).

Less stigmatizing attitudes prevailed among college students in Tehran and Tabriz toward PLHIV. Only 13% believed that AIDS was God’s punishment, 22.3% believed women had a greater role in HIV transmission than men, and only one-third had a perception that sex after alcohol consumption and substance use was associated with greater HIV transmission. The majority believed that having unprotected sex with a sex worker would increase the risk of HIV (Ahmadabadi et al., 2008).

Studies have also shown that HIV risk perception was very low among youth. A study among male college students reported that only 6.5% of sexually experienced college students were highly concerned about HIV over the preceding year. About 22% had a low-risk perception and about 45% were not worried at all. Only 3.4% were highly worried, 23% somewhat worried, and 25% had no worry at all about contracting STIs in the future (Khalajabadi-Farahani et al., 2017) (Table 5).

Knowing the current status of SRH of young people in Iran, it is helpful to know what different studies have detected as youth’s SRH needs.

SRH Needs of Adolescents and Young People in Iran

Several qualitative studies (Keramat et al., 2013; Latifnejad-Roudsari et al., 2013; Mirzaii-Najmabadi et al., 2018; Shakour et al., 2018), surveys (Bazarganipour et al., 2013; Hajikazemi et al., 2014; Pourmarzi et al., 2013; Zare et al., 2017) and mixed-method studies (Shahhosseini & Hamzegardeshi, 2015) in Iran have examined and assessed SRH needs and challenges of different groups of adolescents and young people. The type of education and services they need and the best time and setting for SRH education have also been studied (Hajikazemi et al., 2014). A review of these studies indicated that overall, both adolescents and young people are aware of the importance of SRH. They acknowledge the need to be informed of different aspects of SRH, obtain communication skills about sexuality and sexual health with their parents, and have access to appropriate SRH services.

A common belief among youth was their essential need to be informed about physical and psychological changes during puberty, e.g., about menarche among girls and adaptation to puberty changes among adolescent males (Shakour et al., 2018; Zare et al., 2017). Puberty health education as a high priority was stressed in a mixed-method study among 1274 adolescents in Sari (a city in the north of Iran) (Shahhosseini & Hamzegardeshi, 2015) and in a qualitative study among adolescents in Isfahan city (Shakour, Salehi, et al., 2018).

Interestingly, in the light of poor knowledge about sexuality and sexual health as a barrier for adolescents and young people’s sexual wellbeing, the majority of youth and their parents acknowledged the need to educate youth about sexual health (Bazarganipour et al., 2013; Keramat et al., 2013; Mosavi et al., 2014; Pourmarzi et al., 2013). About 93% and 97% of adolescents in urban and rural areas, respectively, of Sari reported a need for sexual health education (Shahhosseini & Hamzegardeshi, 2015). Another survey among college students in Ghazvin city found a relationship between quality of life and improving SRH of youth (Simbar et al., 2003). In a study in Tehran, although sexual health was perceived as an essential educational need for adolescent boys aged 13–18 years, its importance was lower (65/100) compared to physical and psychological changes in puberty (85/100 and 79/100, respectively) (Zare et al., 2017). Hence, despite a positive attitude toward SRH education in most studies carried out in Iran, some studies showed some opposition and disagreement against SRH education. For instance, although in one study high school students believed that HIV education was the best tool for HIV prevention (Tavoosi et al., 2004), in another survey in Qom, a religious city in the south of Tehran, nearly 60% of youth believed that unmarried youth did not need education about SRH because they are not involved in premarital sexual relations. Fifty-three percent reported that such education might lead to greater involvement in sexual behavior and high-risk sex, STIs/AIDS, and unintended pregnancy (Bazarganipour et al., 2013). Hence, across different studies there is heterogeneity and some uncertainty with regard to the need for sexual health education for young people.

Another issue that was stressed as an educational need for youth was sexual orientation (Shakour et al., 2018). Young people also need good counseling on SRH (Shakour et al., 2018). In some studies, young people were in favor of existing premarital educational courses (88%) (Shahhosseini & Hamzegardeshi, 2015). An educational need cited for couples about to marry was the best physical, psychological, and social conditions for childbearing and pregnancy (Pourmarzi et al., 2013).

Apart from information, building skills on how to communicate and negotiate about sexual issues with parents and other adults in order to seek help is also needed. About one-third of non-medical students in a survey in Qom reported difficulty in discussing sexual health with their mothers (Bazarganipour et al., 2013). Similarly, building skills was mentioned as a reproductive health need among male youth in Shahroud (Keramat et al., 2013).

Apart from educational and skills needs, some studies indicated that youth need appropriate services for reproductive health and they believed that current services are insufficient (Bazarganipour et al., 2013). The main rationale provided for such services was poor SRH knowledge among youth, easy access to inaccurate information, cultural and social changes, rise in risky behaviors among youth, the emphasis of religion on the training of children and youth on sexual health, and the existence of cultural taboos (Mosavi et al., 2014).

Studies have also explored and assessed the type and quality of SRH education needed for adolescents and young people. The majority of adolescents (92.5%) in a mixed-method study in a city in the north of the country thought that an ideal education should be non-judgmental (Shahhosseini & Hamzegardeshi, 2015). About 94% were in favor of education through fun, recreational programs, about 92% were in favor of peer education, and about 56.5% were in favor of group education. Confidentiality, involvement of youth in educational programs, and using recreation programs emerged as features of ideal education (Shahhosseini & Hamzegardeshi, 2015).

Since an important concern about SRH education for adolescents and young people is parental opposition, the assessment of parents’ view on SRH education is also valuable. In one survey about two-thirds (67%) of parents of adolescent women believed that communication with their daughters about SRH would have positive effects on their health and wellbeing (Hajikazemi et al., 2014). There was a significant positive association between such beliefs and mothers’ employment. However, nearly 58% of parents were not in favor of talking with their daughters about contraceptive methods, although more positive attitudes in this regard were associated with higher educational level of mothers. About 35% believed that the best time for teaching about contraceptives was at the time of marriage. Teaching in the classroom and school as the best source was reported by 42% and 57%, respectively (Hajikazemi et al., 2014).

It seems that one-third of parents had not yet recognized the importance of SRH education for their adolescents. This proportion might be greater when parents of other provinces are considered, as most of the evidence reported to date has been generated from parents in Tehran, the capital of Iran, and other provinces are expected to be more conservative. Moreover, educating adolescents about contraceptives is not widely accepted among parents in Iran. These issues need greater attention by national programs and policies relating to youth sexual health in Iran (Table 6).

Table 6. Sexual & reproductive health needs, challenges of adolescents and young people’s SRH in Iran and suggested strategies.

Citation	City	Study Type	N	Gender	Age	SRH Educational Needs	Challenges/Barriers for Sexual Health of Adolescents and Young People
(Bazarganipour et al., 2013)	Qom	Survey	400		Non-medical students	One-third of the participants reported difficulties to discuss about sexual health with mothers. Most believed barriers for female youth reproductive health are: Insufficient female youth reproductive health servicesLow knowledge about reproductive health were the main barriersMany misconception and negative attitude needs to be addressed.	Main barriers: Insufficient female youth reproductive health services (55.2%) Low knowledge about reproductive health (55.2%) Suggested strategies: A health education program through parents, peers, mass media campaign More comprehensive family planning curriculum in universities to overcome misconceptions and spread awareness.
(Mosavi et al., 2014)	Mashhad, Tehran, Shahroud, and Qom.	Qualitative FGD with adolescent girls and their mothers IDIs with school counselors, sociologists, health providers, state and nongovernmental directors of health programs, clergy, and health policy makers				Majority recognized the need for SRH services for adolescent girls. Main Reasons: Lack of adequate knowledge about SRH, Easy access to inaccurate information sources, Cultural & social changes Increasing risky sexual behaviors among adolescents Religion’s emphasis on sex training of children and adolescents The existence of cultural taboos	-
(Pourmarzi et al., 2013)	Tehran	Survey	450 about to married men and women in Tehran	Females and males		Need to provide education to unmarried people before marriage about health and wellbeing in sexual relation or sexual health Need for education to married couples about best physical, psychological and social conditions for childbearing and pregnancy	-
(Shahhosseini & Hamzegardeshi, 2015)	Sari (north of Iran)	Mixed method study (qualitative and quantitative)	1274	Female and male adolescents		93.3% and 93.4% of urban and rural adolescents agree to puberty health education, respectively 93.4% and 96.8% of urban and rural adolescents agree to sexual health education, respectively 87.6% and 87.8% of urban and rural adolescents agree to premarital education 70.6% and 81.2% of urban and rural adolescents agree to same sex counselor 92.1% and 92.8% of urban and rural adolescents agree to non-judgmental counseling, respectively Only 53.3% and 59.7% of urban and rural adolescents agree to group education 95% and 93.1% of urban and rural adolescents agree to entertaining educational program, respectively 90.7% and 91.1% of urban and rural adolescents agree to peer education, respectively Qualitative finding; Need to have right educator in terms of confidentiality and nature of education: Confidentiality of the educator Involving adolescents in reproductive health education programs Group education of reproductive health in recreational programs Need to receive a range of SRH education Puberty hygiene education Sexual health education Prenuptial education	–
(Shakour et al., 2018)	Isfahan	Qualitative	Female: 10 adolescent girls, aged 13–15 years Male: 10 adolescents boys, aged 14–17 year			Reproductive health needs of girls comprised of: Menarche and puberty health, Discrimination in family and society, Sexual orientation, Education and consultation demands Reproductive health needs of adolescent boys comprised of: Adaptation with changes in puberty, Sexual orientation, Educational and consultation demands. Adolescents need more education and consultation support about puberty which will be possible with education of families and teachers	-
(Zare et al., 2017)	Tehran	Survey	Adolescent boys aged 13–18 Years			Priorities of health needs as follows: Sexual health (highest score from 100, 62.5) Social health, (highest score from 100, 75.0) Psychological health (highest score from 100, 78.8) Physical health.(Highest score from 100, 85.4)	-
(Simbar et al., 2003)	Ghazvin	Survey	111	Mae: 457 Female: 654		Majority of students perceive the risk of AIDS and STDs. They perceive the benefits of reproductive health. Majority of them believe that the risk of these diseases is moderate and youth’s ability to practice health behavior is low or moderate. Majority of them believe that the services are not adequate. Thus, an interventional program is the demand of youth of Iran. Majority recognized the relationship between quality of life and improving of reproductive health. Some facts that justify students perceive a need for RH: Moderate RH knowledge among students Positive attitude about reproductive health. Some realities among students such as; premarital intercourse, sexually transmitted diseases, unwanted pregnancies and unsafe abortion	The main barriers for youth reproductive health promotion: Non-advocating environment Low knowledge of youth.
(Bahrami et al., 2013)	Iran	Review conceptual paper				-	Challenges of adolescent sexual health comprised of: Religious beliefs and spirituality (abstinence); Lack of sexual education (false beliefs and knowledge about sexual function; adolescents’ attitudes toward risky behavior and sexual relations; information sources of adolescents; skills to “say no”); Community and youth issues (gender differences, relationships with peers, monitoring and control by the family, communication challenges between teen and parents Socio-economic factors (Centers for reproductive health services to adolescents; adolescent’s sexual relationship outcomes; risk of sexually transmitted disease).
(Latifnejad-Roudsari et al., 2013)	Mashahd & Ahvaz	Qualitative studies (IDIs and FGDs)		Female adolescents (14–18 yr.), mothers, teachers, authorities in health and education organizations, health care providers and clergies		-	Main challenge of education is: “Taboos surrounding sexuality”. This is comprised of the following categories: Denial of premarital sex, Social concern about negative impacts of sexual education Perceived stigma and embarrassment Reluctance to discuss sexual issues in public Sexual discussion as a socio-cultural taboo Lack of advocacy and legal support Intergenerational gap Religious uncertainties Imitating non-Islamic patterns of education. Importance of cultural resistances and religious prohibitions that affect the nature and content of sexual health education. Despite existence of salient socio-cultural doubtful issues about sexual health education for adolescents, the emerging challenges are manageable some extent. Strategy: Overcoming the cultural taboos and barriers as major obstacles
(Hajikazemi et al., 2014)	Tehran	Survey		Iranian parents of 10–19 years old high school girls living in Tehran		66.7% of parents believed that talking with their daughters has a positive effect on their health. A significant relationship between mothers’ positive perspective about talking with their daughters and mothers’ job (p < .05). 58.2% of parents disagreed on talking with their daughters about contraceptive methods. A positive significant relationship between mother ‘education and their positive perspective about contraceptive methods education (p < .001). 35.3% of the parents believed that the best time for teaching is at the time of marriage. About 41% of parents believed that teaching in classroom is the best method and 56.7% mentioned schools as the best source for teaching. Majority of the parents (98%) disagreed with learning this issue via internet	Challenges: Parents are not still prepared to teach the issues related to reproductive health to their daughters and do not easily let other sources such as health centers talk about these topics.
(Mirzaii-Najmabadi et al., 2018)	Mashhad, Tehran, Shahroud, and Qom	Qualitative study 247 IDIs & FGDs with adolescent girls and 71 IDIs with health policymakers, governmental, nongovernmental and international health programs managers, health providers, mothers, teachers, sociologists and clergy in four cities of Iran				-	The main challenges: Political challenges such as lack of an adopted strategy by the government Social and cultural challenges such as taboos Structural and administrative challenges such as inappropriate structure of the health system Nonuse of religious potential. The concept of adolescent reproductive health has not been well understood and is very controversial. Government leaders and policymakers should try to provide reproductive health services that are consistent with the community’s cultural and religious values for adolescent girls to overcome the challenges of access.
(Akbari et al., 2013)	Tehran	55 in-depth interviews with key informants and six FGD					Barriers against access to sexual and reproductive health services were classified in both national and international levels. The negative attitude of clergymen to providing these services and the lack of international funding for providing these services were major obstacles at international level. At the national levels, governmental and community play a barrier role, interchangeably
(Keramat et al., 2013)	Shahroud	Qualitative study			4 FGDs (20 college students)	Reproductive health needs among male youth: Educational needs Lack of skills among males and stakeholders Lack of education on SRH for youth Lack of services on SRH for youth

Challenges of SRH among Youth and Suggested Strategies in Iran

There is some overlap between the SRH needs of young people and current challenges in the SRH among youth. For instance, poor SRH awareness at a proximal level has been an important challenge of youth SRH; accordingly, SRH education as a strategy is needed (Bazarganipour et al., 2013). Poor SRH knowledge among youth in Iran and non-advocating environments were also stressed as main obstacles for youth’s SRH wellbeing (Bahrami et al., 2013; Simbar et al., 2003). Lack of communication skills, low self-efficacy (Bahrami et al., 2013), and low-risk perception were among other challenges (Mirzaii-Najmabadi et al., 2018).

Despite individual factors such as poor knowledge, attitudes and skills, and religiosity, other factors at a more distal level were identified as challenges to the SRH of youth, e.g., cultural taboos surrounding sexuality, gender issues, and challenges in communication with parents and relationship with peers (Bahrami et al., 2013; Latifnejad-Roudsari et al., 2013). A main challenge for adolescents and young people’s SRH in the conservative society of Iran was related to sexual health education considered as a sensitive issue for unmarried youth. A qualitative study in Mashhad and Ahvaz explored socio-cultural challenges of sexual health education for adolescents and concluded that “taboos surrounding sexuality” was the main challenge in this regard. This challenge included “social denial of premarital sex among youth, social concerns about negative effects of sexual health education on young people’s sexual behavior, perceived stigma and embarrassment, reluctance to discuss sexual issues in public, sexual discussion as a socio-cultural taboo, lack of advocacy and legal support, intergenerational gaps, religious uncertainties, and sexual health education imitating non–Islamic pattern of education” (Latifnejad-Roudsari et al., 2013). The authors of this study claimed that cultural resistance seems to be even more important than religious prohibition regarding adolescents’ and young adults’ SRH (Latifnejad-Roudsari et al., 2013, p. 101). A comprehensive qualitative study among adolescent girls and other stakeholders such as health policy makers and program managers, health providers, mothers, teachers, sociologists and clergies in four cities of Iran (Mashhad, Tehran, Shahroud, and Qom) similarly identified “cultural taboos” as the main challenge in this regard. In addition, this study recognized another challenge: religion has not employed its full capacity with regard to promotion of sexual health among young people. In fact, this study showed that religious scholars acknowledge sexual desire and sexuality and religion has many principles on sexuality. This potentially need to be employed appropriately by religious scholars in promotion of sexual health among adolescents and youth (Mirzaii-Najmabadi et al., 2018).

Consistent with cultural and social resistance, parents are also an important challenge for educating youth in Iran about SRH. A survey among Iranian parents of adolescents aged 10–19 years living in Tehran showed that they are still not well prepared to communicate about SRH issues with their adolescents. Moreover, most parents do not easily allow and accept that health care providers and school teachers address these issues with their children (Hajikazemi et al., 2014).

At a more distal level, political challenges such as a lack of strategy adopted by the government and structural and administrative challenges such as the inappropriate infrastructure of health systems are among other challenges in promoting youth’s SRH in Iran (Akbari et al., 2013; Mirzaii-Najmabadi et al., 2018). In fact, the concept of SRH has not been well understood by policymakers in Iran and it is still very much a controversial issue.

Some strategies such as the development of policies related to SRH of young people and sexual health education have been suggested. For example, a survey among 400 non-medical college students recommended a health education intervention through involvement of parents, peers, mass media campaigns, and development of comprehensive family planning curriculum in universities. These interventions are envisaged to be effective in removing misperceptions among youth and promoting their SRH (Bazarganipour et al., 2013). Importantly, in a qualitative study in Mashhad (North-East of Iran) and Ahvaz (South-West of Iran), overcoming cultural taboos was suggested as an important strategy to improve youth SRH (Latifnejad-Roudsari et al., 2013). Moreover, some strategies have been suggested which focused on policy makers and programs leaders to provide SRH services available for youth in a culturally appropriate manner and consistent with religious values and cultural sensitivities for adolescent girls (Mirzaii-Najmabadi et al., 2018) (Table 6).

Discussion

This review shows that studies focused on adolescents’ and young people’s SRH have sharply increased since 2011 in Iran. In particular, studies with a focus on sexual health interventions and policies and its challenges have increased significantly since 2016 (Figure 2). Although information about sexual behavior is important to inform preventive strategies and to correct misperceptions in public perceptions of sexuality, increased research in this area in the past two decades in Iran provides a historically unique opportunity to safeguard the sexual health of young people. Gaps in knowledge still remain as main obstacles to sexual health policies and programs and in this social context, no comprehensive programs target SRH among unmarried adolescents and young people. Despite the fact that some policymakers acknowledge the importance of addressing this issue (Ameli, 2019), there is a lack of consensus in this regard. This review highlights the SRH status, needs, and challenges of young people in Iran and can help inform appropriate strategies, policies and, programs for young people in a conservative society such as Iran.

Heterogeneity in Premarital Sex by Gender and Geographic Area

Of the papers published on Iranian youth’s SRH, only a few have reported the prevalence of sexual activity before marriage, disaggregated by age and gender. These studies are mainly based on surveys in metropolitan areas and do not reflect the heterogeneity of the country and the rates at a national level. Some surveys were conducted among adolescents and some among college students, some were population-based and others institution-based, such as university-based surveys. Reviewing the prevalence of premarital sex by gender and geographical region reflects a huge gender disparity and disparity across different provinces. Comparing these results (and disregarding the two rates reported from studies in Shiraz and Shahroud that appeared to be overestimates), among young men, rates of premarital sex ranged between 18% and 35%; a lower rate of premarital sex was reported among women (between 3.4% and 14%). The rates among women are fairly consistent with the rates of premarital sex among youth in neighboring countries such as Turkey. For example, among female college students in Turkey, the rates of premarital sex ranged from 3.4% to 11%. The rates among male college students in Turkey were between 57% and 50.3%, significantly greater than the corresponding rates for men in Iran (Golbasi & Kelleci, 2011; Varol- Saraçoğlu et al., 2014).

This review highlights a great gender disparity in premarital sexuality in Iran (Khalajabadi-Farahani et al., 2012), similar to what has been reported in other parts of the world (Wellings et al., 2006). This is due to the significance of virginity for women and gender double standards in sexuality before marriage in Iran (Khalajabadi-Farahani, 2008). In fact, unmarried women tend to under-report their sexuality before marriage because the majority still comply with social norms (Khalajabadi-Farahani & Cleland, 2015) and endorse family values even if they do not consider premarital sex as problematic (Khalajabadi-Farahani, Mansson, et al., 2018). Similarly, studies in other countries have shown that men tend to over-report their sexual activity. Reporting of multiple partnerships is more common in men than in women globally (Wellings et al., 2006). According to studies reviewed in this and other reviews (Khalajabadi-Farahani, 2016), we can estimate that the rate of premarital sex among young men in Iran seems to be three-fold that of the corresponding rate among young women.

There was little evidence on premarital sexuality in provinces with stronger marriage norms and younger age at marriage. Due to strong religious and cultural emphasis on the initiation of sex within marriage, we can expect a direct relationship between age at marriage and the prevalence of premarital sex. It is expected that with the rise in marriage age and the increasing gap between puberty and marriage in metropolitan cities with lower social control, a rise in premarital sexuality happens and vice versa. Due to huge provincial heterogeneity in age at marriage, the rate of premarital sex seems to be very diverse. For example, the maximum difference between the age at marriage in the provinces with the highest and lowest marriage age is 4 years. In Tehran, men tend to marry at age 28 years, while this rate is about 24.5 in South Khorasan, north east of the country. Economic disadvantage such as unemployment and divorce rates at the macro level have been responsible for district-level differences in age at marriage in Iran (Torabi & Mesgarzadeh, 2017). Although child marriage is associated with poverty and gender inequality (Kazemipour, 2004) and is higher in disadvantaged provinces of Iran, it can also be a strategy of families to prevent premarital sexuality. These provinces are expected to have lower rates of premarital sexuality. Thus, it is important to note that risk-reduction programs and messages should respect diversity and preserve choice around the country. Young people need to be helped to postpone their first sex and achieve the best timing of first sex to reduce forced first sex experiences and sexual exploitation (Wellings et al., 2006).

Methodological Issues in Studying Sexuality in Iran

Due to the small number of studies with large samples that have focused on the prevalence of premarital sex, we decided to include two comprehensive surveys of college students in Shahroud (Vakilian et al., 2014) and young people in Shiraz (Honarvar et al., 2015), even though the rates of premarital sex in these surveys seem to be higher than expected. The study in Shahroud employed the indirect method Crosswise method for asking sensitive questions which tends to inflate estimate rates (Nasirian et al., 2018). The survey in Shiraz also collected data from youth with a wide age range (24 ± 5.8 years) using a convenience sampling method with those who were willing to be interviewed in streets, parks, and shops in different regions of the city (Honarvar et al., 2015). We decided to retain these surveys in this review to highlight how methodological issues can affect the rates; these issues need to be considered in interpretations of surveys on sensitive issues in conservative societies (Khalajabadi-Farahani, 2014).

Due to the sensitivity of the subject, many researchers could not ask direct questions on “sexual intercourse”, or “type of sex”; hence, some used other less sensitive terms such as “sexual contact”. Since some youth might consider any sexual intimacy, including non-penetrative sexual contacts and kissing as sex, this might have led to methodological errors in the estimation of sexual behaviors. Overall, researchers have little experience in conducting these types of studies and only a few studies have been conducted with an optimal methodology (Smith, 1992; Wellings et al., 2006).

This reflects the limitations of conducting research on sensitive issues among adolescents and young people using a representative sample in a conservative society. Same-sex sexual relations are also against the law and religion in Iran and considered a punishable crime (Yadegarfard, 2019). Due to the fact that physical virginity (an intact hymen) is important for women in Iran, many women might have had non-vaginal sex and they do not report this as sexual intercourse. A previous study among female college students showed that students tended to consider only vaginal sex as “complete” sexual relations (Khalajabadi-Farahani, 2008). This might lead to underreporting of premarital sex among women. A recent study among female college students in Tehran showed that about 9% of unmarried girls were not willing to report on their sexual relationships (Khalajabadi-Farahani, 2019b); culturally, brides’ chastity and virginity is still very important for young men and their families in Iran (Niki-Rashidi et al., 2019).

This review indicates that nearly one-tenth of women and one-third of men in Iran have engaged in premarital sex, but a majority of women and men (over 80% and about 65%, respectively) still abstain from intercourse before marriage. The prevalence of premarital sex reported in a meta-analysis of 15 studies since 2001–2015 reported the rate to be 29.1% among men and 12% among women, with a national rate of 16%. These rates are consistent with the ranges reported in this review (Khalajabadi-Farahani, 2016).

Synthesis of the Status of SRH among Young People and Their Needs in Iran

This review has found that young men are involved in premarital sex at a significantly younger age than women. This was also the finding of another systematic review in developing countries (Mmari & Blum, 2009). Young men have a greater number of sex partners and they are more likely to have their first sex with older sex partners and higher-risk partners such as sex workers. Compared to men, young women reported less protection during sex and greater forced sex at their sexual debut. These findings might reflect their lower agency in sexual activity compared to men. First sex younger than 18 years and alcohol consumption before sex were two important and common phenomena among sexually experienced youth in Iran. The above gender differences need to be considered in both research and SRH programs for young people in Iran.

Prominent differences between men and women in sexual activity are explained in part by a tendency for men to over-report and women to under-report. Patterns of age mixing and the age structures of populations can also help explain the differences. Men are having sex with women in age groups or geographical areas not included in the survey sample; women with large numbers of partners, such as sex workers, are under-represented in the sample (Wellings et al., 2006). Due to the emphasis on virginity for unmarried women, important groups of young men tend to have sexual partners who are older than themselves, particularly their first sexual partner. These might be non-virgin women who are willing to have vaginal sex or they might be divorced or widowed women or sex workers. Although about two-thirds of young men’s first sex partners were reported to be their steady girlfriends, we do not know much about their marital status or transactional sex. Same-sex partners at first sex (23%) and first-sex partners who were sex workers (11%) are also concerning issues and have public health implications, if young men have unprotected sex with multiple partners. In addition, men had more high-risk partners than women, particularly at their first sexual event. The sexual partners of adolescents and young people need greater attention in future research.

Multiple sexual partners are also very common among sexually experienced young men (Khalajabadi-Farahani et al., 2017). This, in addition to inconsistent condom use, expose men and their girlfriends and future wives to greater risks of STIs/HIV. One study reported a growing trend of HIV infection among homosexual men and sex workers in Iran (Mirzazadeh et al., 2014). HIV cases attributed to sexual transmission have been steadily growing and the prevalence of HIV among female sex workers was 4.5% in one study (Haghdoost et al., 2011). One possible reason for the lack of condom use among youth is low HIV risk perception among young people (Khalajabadi-Farahani et al., 2017).

Unprotected sex appears to be even more common among women than among men (Hosseini-Hoshyar et al., 2018). This is particularly important because of the rise in HIV infection among women in recent years (Haghdoost et al., 2011). Increases in sexual transmission of HIV among women might be due to many factors, such as greater unprotected sex among women and the fact that some women practice non-vaginal sex or use the withdrawal method because they are more concerned about pregnancy than STIs/HIV. Studies have demonstrated that poor knowledge (Hosseini-Hoshyar et al., 2018), lack of self-efficacy to use condoms, and low HIV risk perception (Adih & Alexander, 1999) are some of the barriers to condom use.

Experience of sex under the influence of alcohol use was significantly associated with reduced odds of condom use at last sex (Mmari & Blum, 2009). Although alcohol consumption is forbidden in Islam and in Iran, the 2011 national Iran mental health survey reported that in the previous year 6.3% of participants (11% of men and 1.6% of women) had used alcohol and 2.4% (4.4% of men and 0.4% of women) had a history of binge drinking (at least five drinks consecutively) (Sharifi et al., 2015). Alcohol use has been much more prevalent than use of other illicit substances among young people in Iran (Danaei et al., 2019). Hence, alcohol and high-risk sex needs greater attention in both research and youth programs in Iran. Youth need to be aware of the consequences of alcohol consumption in terms of high-risk sexual behavior and adverse sexual outcomes such as unintended pregnancy, STIs, and HIV. Research suggests that sex under the influence of alcohol and other substances tend to be unprotected (Hosseini-Hoshyar et al., 2018) and recent evidence suggests a rise in unprotected among youth in Iran sex when illicit substances are used (Moradvand-Badie et al., 2020). Due to the link between substance use and high-risk sex, some prevention programs for STIs have focused on substance use (Fortenberry, 1995).

Higher rates of unprotected sex are reported by young women than men. This might be explained by the fact that women are more concerned about pregnancy than STIs and condoms are used mainly to protect against pregnancy and not HIV/STIs. Lower condom use among women should be a subject of greater scrutiny in future research. Studies have shown that young women might practice non-vaginal (anal and oral sex) or non-penetrative sex (manual stimulation) to preserve their physical virginity or hymen (Khalajabadi-Farahani, Mansson, et al., 2018). A study among youth in Shiraz showed that only 11% of sexually experienced youth used condoms for prevention of STIs and more than half (54%) used condoms for both pregnancy and STI prevention (Honarvar et al., 2015). There is a misperception that only vaginal sex is linked with transmission of STIs and HIV (Khalajabadi-Farahani, Mansson, et al., 2018). Men’s sexual partners might be older women who are less concerned about virginity and more likely to carry condoms. This needs more investigation. Moreover, evidence shows that young people, particularly young women, face some barriers in purchasing condoms. A study among college students in Tehran and Tabriz showed about 16% encountered closed pharmacies, about 34% were embarrassed to ask for condoms due to the seller’s behavior, and in 24% of cases they changed their mind about purchasing condoms (Ahmadabadi et al., 2008). Although Internet and online purchase of sex products, including condoms, is widely available, we still do not know much about how often adolescents and young people use such online services. More research is needed on condom and contraceptive use among sexually active youth in this conservative society and the barriers to their use.

More qualitative exploration is required about how often unmarried youth who are sexually active have experienced unintended pregnancy and what have been the outcomes of these pregnancies. Since abortion is illegal, unsafe abortion exposes youth to a greater risk of mortality and adverse mental health. One report suggested an estimate of an annual incidence of 129,000 non-health-related abortions in 2011 (Rastegari et al., 2014), but it is not clear how often unmarried women undergo abortion. Unsafe abortion is a silent phenomenon with adverse physical and psychological outcomes for women and societies (Grimes et al., 2006).

Regarding the predictors of premarital sex, it seems that two different types of unmarried youth in Iran engage in premarital sex and high-risk sex. One group comprises modern unmarried youth, with high social class and income and educated parents, who are surrounded by sexually experienced peers and are less religious and less likely to endorse social norms. They may socialize frequently with friends and are involved in other risk-taking behaviors such as smoking and drinking. The second group consists of unmarried youth who are disadvantaged both economically and socially. They may have separated parents, very strict parents, or a poor family atmosphere and low communication with parents about morals and norms. They are also likely to have low self-efficacy due to their poor family background and family support. Access to the Internet and pornography serve as a source of sexual arousal and an agent for encouraging youth to practice sexual relationships. The Internet and social networking have provided a platform for easier communication with others, finding and dating a sexual partner in the real world, and greater involvement in sexuality before marriage among youth (Khalajabadi-Farahani, 2019a). However, the Internet and social media might also provide a source of knowledge about SRH issues. In fact, it is not clear to what extent youth use such information, when they search for information, and whether this information is reliable or not. Do they tend to search for such information after having had sex or before? These topics need further exploration among youth in Iran. Public health interventions should address the broader determinants of sexual behavior, such as gender and poverty, in addition to individual behavior change.

A review of studies which assessed adolescents’ and youth’s SRH awareness showed that youth have an average knowledge about HIV and puberty, but do not have comprehensive and accurate details about HIV, STIs, condom use, contraceptive use, fertility, and sexual violence and abuse. In HIV campaigns and programs in recent years, it seems that the only focus has been on HIV awareness without enough emphasis on consistent condom use and related skills and removing misperceptions about the sexual transmission of HIV. Youth still have important misperceptions regarding HIV transmission through different types of behavior (such as kissing, anal and oral sex), through mosquito bites, public bathrooms and swimming pools, mother to infant transmission, and through sharing syringes (Khalajabadi-Farahani, Akhondi, et al., 2018, Shokoohi et al., 2016). Misperceptions about HIV treatments and vaccines and gender-related risks of transmission were also widespread. Knowledge on the protective role of condom use in the prevention of HIV and STIs was insufficient. This may be related to the strong societal taboos on talking about condoms, contraception, and sex. Culturally appropriate programs in Iran need to find a way to overcome these taboos to be able to promote the SRH of young people.

Many who opposed sexual health education for youth believed that young people are not involved in premarital sexual relationships and that education might encourage premarital sex (Bazarganipour et al., 2013). This perception should be also tackled by generating convincing evidence on high-risk sexual behaviors among young people. This is an important challenge which needs to be overcome in a culturally acceptable way.

Studies have shown that parents need to be better educated about the importance of SRH education. Parents seemed to be less in favor of SRH education compared to young people. Among adolescents in Sari, a city in the north of Iran, between 93% and 93% were in favor of sexual health education (Shahhosseini & Hamzegardeshi, 2015). In another study in Tehran, only 42% of parents were in favor of such education before marriage (Hajikazemi et al., 2014). This evidence is consistent with many countries in Asia and sub-Saharan Africa, which have found that less than three-fifths of adults support the provision of education about condoms to young people (Santhya & Jejeebhoy, 2015). From our review, we found that parents prefer imparting such information nearer to the time their children get married. It seems that there is a substantial gap between young people’s perceived SRH needs and the parents’ views of the SRH needs of youth (Mohammadi et al., 2007). While it is expected that educational programs will be helpful, multi-sectoral approaches (e.g., individual, community, and structural-level interventions) are required to change sexual behaviors, increase safe sex practices, and reinforce negotiating condom use among youth (Hosseini-Hoshyar et al., 2018). The realization of this education has become a matter of debate between policymakers and the public in Iran in recent years.

Challenges and Strategies of SRH among Youth

Poor awareness about SRH among different stakeholders and also non-advocating environments (parents, school) have been identified as main challenges for adolescents’ SRH and sexual health education. The lack of skills to communicate about sex, low self-efficacy, and low-risk perception among youth are other challenges that can result in poor knowledge and misperceptions about sexual health. Apart from the lack of comprehensive knowledge on SRH, poor knowledge on available services for HIV counseling and testing is also an important issue that needs to be addressed in HIV prevention programs for youth.

At a broader level, socio-cultural taboos, gender, and religious beliefs make the situation even more difficult for addressing adolescents’ and young people’s SRH in Iran. Some gender stereotypes make high-risk behaviors more acceptable for young men than women. Multiple partners are much more commonly reported by men than women. Due to stigma, many young people try to hide their sexual relationships and do not receive any counseling, services, and support. Taboos surrounding sexuality also inhibit education on sexual health. Taboos about sexual health education arise from social denial of premarital sex. The lack of generalizable scientific evidence on the prevalence of premarital sex might be a reason for resistance about sexual health policies and programs for young people. Even for researchers and scholars in Iran, communication and conducting research about sex is very difficult. The only acceptable way that researchers can address premarital sex is through a focus on the prevention of HIV/STI risks. Among sociologists and other researchers, there is no consensus about the extent to which youth are involved in premarital sex due to the lack of a national survey on the sexual life of Iranians, including youth. One major concern is that education about these issues might negatively affect sexual values and ethics among youth and encourage premarital sex (Latifnejad-Roudsari et al., 2013).

On the other hand, due to stigma and social taboos, people are reluctant to discuss sexual issues in public and an intergenerational gap exacerbates this issue. Cultural taboos seem to be even more important than religious opposition. Many believe that religion has a good capacity to be employed in the promotion of sexual health and make such education more acceptable to the public (Mirzaii-Najmabadi et al., 2018). Studies have demonstrated legal and policy constraints related to the age and marital status of young people as challenges for SRH. Stigma and cultural taboos associated with teenage sexuality and pregnancy have been reported as other challenges of youth SRH (Emmanuel et al., 2014).

Parents’ unpreparedness to accept and communicate about SRH to their children is another challenge. They need knowledge and skills on the SRH of young people (Salehin et al., 2018). Parents tend to disagree with sexual health education delivered to youth by others such as schoolteachers and health care providers.

Lack of advocacy and legal support have also been identified as major challenges for sexual health education and services for youth. At the policy level, to date adolescents’ sexual health has not been a priority in Iran. However, recently more attention has been given to the sexual health programs and policies for young people (Damari et al., 2016; Khalajabadi-Farahani, 2015; Mohsenzadeh- Ledari et al., 2017).

At the policy level, only high-risk youth in Iran are targeted by HIV prevention, counseling, and testing services by the Ministry of Health and Medical Education (WHO/UNAIDS, 2015). Strategies need to focus on policymaking for sexual health education among the general population of young people, parents, peers, and media, with greater comprehensive educational programs based in schools, universities, and health care systems. The provision of sexual health services for youth in a culturally appropriate manner and consistent with cultural values and religion has also been suggested as a potential effective strategy (Mohsenzadeh- Ledari et al., 2017). This review also highlighted some forms of sexual violence and exploitation among adolescents and youth which need greater exploration and attention both in research and practice.

Limitations

Data related to sexual behaviors are based on self-report and are susceptible to error. They are especially prone to a social desirability bias – the tendency for participants to respond according to social expectations of what is “right”. Few opportunities exist to assess internal or external consistency of the data in published studies. The quality of the data obtained can, however, be enhanced by the use of well-designed questionnaires and well-trained interviewers. Most of the data obtained by studies reviewed in this paper came from surveys done by experienced teams. Many of the surveys used validated questionnaires, which increases the comparability of results. However, the wording of questions in some studies was altered between surveys so that, for some indicators, data from earlier surveys might not be strictly comparable with those from surveys done more recently. Unpublished reports, which because of their sensitive data were not available, were excluded. Due to time constraints and no funding available for this review, this review did not include gray literature and studies conducted by non-governmental organizations.

Conclusions

Ambiguity is seen with regard to the SRH of young people in Iran due to both the importance of marriage and virginity and the emergence of premarital sex among a significant minority of young people. The enhancement of SRH among young people needs political will and support. Strengthening data generation in this field is the first step because available data are based on small-scale studies, often without disaggregation by age and gender. A national survey of sexual behavior and attitudes could potentially help to generate reliable evidence on the sexuality and sexual health and risks among different groups, including adolescents and young people. Finally, the main challenge is the development of a “culturally appropriate sustainable comprehensive model of SRH education and service for youth” with the cooperation of all stakeholders. This model needs to engage youth, parents, schools, community, policymakers, the legal system, religious scholars, and health care providers. A promising approach might be one of both encouraging abstinence and also comprehensive sexual health education. In fact, comprehensive behavioral interventions that take account of the social context, and social norms, and tackle the structural factors that contribute to risky sexual behavior among youth are essential.

Notes

¹ https://www.strobe-statement.org/fileadmin/Strobe/uploads/checklists/STROBE_checklist_v4_combined.pdf.