Background
According to the World Health Organization (WHO) individual sexuality is, to a large extent, determined and influenced by social norms and family values [
73]. Hence, sexual attitudes and permissiveness are conceptualized and understood differently according to societal contexts [
38,
41]. In fact, social construction of sexuality in any given culture defines sexual behaviours of men and women [
22,
38]. Sexual permissiveness entails accepting a wide range of sexual attitudes and associated behaviours, and is influenced by various cultural factors including religious beliefs and the importance of economic exchange at marriage, as well as increased exposure to external influences due to the expansion of worldwide communications and economic changes [
38].
There have been significant transformations in sexuality and sexual behaviours in special cultural contexts [
36]. Attitudes toward sexuality and its ethical aspects have been altered over the past few decades in many parts of the world [
54,
63,
65,
69]. Increasing concerns exist about the consequences of such transformations in conservative and religious societies versus other liberal societies, because empirical research has documented an inverse association between religiosity and liberal sexual attitudes [
17]. Iran as a conservative and religious society is no exception.
Similar to other countries in Asia (India, China, Philippines; Thailand; Malaysia, Viet Nam and others), Iran has experienced significant social and attitudinal changes over the past decades [
7,
8,
24,
25,
49,
55,
58]. Factors such as westernization, modernization, education, social networks and worldwide communications, information technology; and a rapidly widening generational gap have created grounds for changes in value systems and norms within this country [
37,
51,
56,
62].
What perhaps makes Iran, interesting as a case is that since 1979, religion is the core cement of the Iranian value system and norms due to Islamic Law. Dynamic interactions between cultural traditions, religious cultures, and cultural modernity which focuses on “liberal values” are unavoidable [
22,
41]. Both religious and non-religious scholars have pointed out that pervasive new norms may change the social structure as well as people’s definitions of sexual behaviour (Aghajanian, Family and Family Change in Iran, forthcoming) [
15,
47].
Despite the aforementioned emerging changes, sexual intimacy and sex is only acceptable within the institution of marriage within Iranian society. Premarital sex is considered sinful according to the Islamic religious perspective [
5,
30,
61]. It is also legally prohibited and culturally forbidden in this society [
35]. Despite the socio-cultural pressure in Iran stressing on marriage as the fundamental core for family formation, the younger generation of Iranian females in particular over the last three decades postpone their marriage [
1]. They cite socio-economic reasons for the delay in marriage, or their wish to pursue education [
68]. The increasing trend of delayed marriages possibly explains attitude changes toward premarital sexual encounters in the Iranian context.
Postponing marriage has widened the gap between puberty and marriage and this has led to the higher likelihood of people living in metropolitan contexts to be more open, accepting and engaging in premarital heterosexual interactions including sex [
29,
32,
33]. However, despite this, in certain settings where only marital sex is documented, this may give the mistaken impression that the age of first sexual intercourse has increased [
13].
Sexual behaviours are influenced by a range of factors such as personal attitudes and beliefs, knowledge about sex and its consequences, situational factors, feelings and desires [
9,
57]. According to the Theory of Planned Behaviour, an individual’s behaviour is predicted by his/her intentions, attitudes toward the behaviour, perceived social norms and behavioural control [
6]. In social psychology, it is widely accepted that attitudes are socially learned [
26]. Challenges between traditional and modern values, the advent of technology and its own culture, and the coming of new communication technologies such as social media to people’s life have led to drastic changes in the personal attitudes of Iranians which contributes to changes in previously accepted norms [
10,
70].
Increasing premarital heterosexual friendships and dating with the opposite sex among young Iranians has been documented. In a survey among 1,378 unmarried female college students from four universities in Tehran in 2005–2006, 52 % of females reported ever having a boyfriend [
32].
Since friendship with the opposite sex is not acceptable in Iranian families, in many cases, particularly for females, families are mostly unaware of any such interactions or relationships. Most parents do not play a key role in informing, educating or supporting their young people on how to manage their friendships and the potential risks posed [
39]. Similar to other Islamic states such as Pakistan, in Iran, religiosity is considered to be protective for premarital sex, but it seems that due to the gap between marriage and puberty, and changes in social networks, media and communication technology as well as socio-economic development, the protective role of religiosity is diminishing [
11,
27,
56,
62,
64]. Furthermore, there is no comprehensive sexuality education for singles; hence individuals in intimate relationships including sex are unprepared to deal with potential risks for both physical and mental health such as non-consensual sex, sexual coercion and unwanted pregnancy. Undesirable outcomes such as unwanted pregnancy, unsafe abortion, and HIV/AIDS have been associated with premarital sex, particularly among adolescents and young adults [
71,
72].
Yet, another issue is that reportedly Iran has entered into its third wave of an HIV epidemic, which is one of the most serious health risk issues in the country. Although the HIV epidemic is primarily concentrated among key populations such as injecting drug users, HIV transmission through unsafe sex is on rise among adolescent and young adults, with recent studies suggesting an increase in premarital sexual encounters in Iran [
4,
11,
20,
33]. The main feature of this peak is the significant shift in new cases of HIV infection from intravenous drug use to unsafe sexual practices. Since 1988 till 2005, from among all HIV positive cases (30,183 cases), 67 % was due to injecting drug use and 18 % was because of unsafe sex, while the corresponding rates among HIV positive cases in 2014, was 41 % and 36 %, respectively. These rates show a significant rise in sexual transmission of HIV in Iran [
45].
It is within the interest of the current global health context that this empirical study, focusing on attitudes toward premarital dating and sexual encounters in Iran is both, socioculturally relevant in order to highlight shifting attitudes and perceptions as it is from the point of better elucidating gaps in current public health practices. The purpose of this study is to assess attitudes toward premarital dating and sexual encounters among adults aged 15-49 years in Iran.
Conceptual framework
Studies among female college students have shown that young people believe that social norms are still against premarital sex in Iran [
31,
40]. In contrast, evidence indicates a rise in premarital sex, particularly among young men and women (aged 18–34) in metropolitan cities of Iran [
59]. This contrast persuaded a team of researchers to hypothesize that changes in sexuality in the Iranian contexts might be related to changes in personal attitudes, rather than social norms which are more resistant to change. Social norms influence personal attitudes and behaviors, although the links are complicated and may be bi-directional [
19]. Many factors affect personal attitudes towards premarital sex, including perceived norms and an individual’s own sexual experiences [
9,
38]. However, in this study, the associations between sexual attitudes and age, biological sex, education, religiosity and marital status have been sought out.
Methods
This paper is based on the quantitative data of an original mixed methods study. This cross sectional study was conducted from March 2014 to May 2015. Questionnaires were administered to 800 males and females aged 15–49 years residing in Tehran, the capital of Iran. These individuals were presented with a consent form to sign. Seven hundred and fifty five individuals completed the questionnaire. The participants included 410 women (56%) and 344 men (46%). Forty five people decided to withdraw from completing the study questionnaire. About 12 million people live in the city of Tehran [
67], which is a large metropolis with different cultures and ethnic groups. Given this, the residents are more influenced by modern ideas and social changes than those in small towns and villages.
To obtain a representative sample of adults in Tehran, the city was divided into three regions based on the population density; region with large, medium- and small-population. Each region comprised of several districts. According to the proportion of population to the total population in each district, the required sample was calculated in each section.
Applying Cochran’s formula for estimating sample size, the sample required was calculated as 768 participants (the proportion of sample population size for each region; the large, medium, and small population region was 422, 249, and 97, respectively). Then a district from each region was randomly selected. These districts house a number of community health centers, public parks and public places such as venues for cultural activities. From each district, one community health center, one venue for the cultural activities, and one public park was randomly selected. Upon the ethics committees’ approval (by the Ethics Committee in Tehran University of Medical Science as well as by the Isfahan University of Medical Sciences), trained staff utilized a convenience sampling approach (at different times of day; morning and evening) and recruited qualified individuals to participate. Trained staff explained the objectives of the study to the individuals who agreed to complete the questionnaire. Female staff assisted female participants to complete the questionnaires and male staff assisted the male participants. Same sex interviewers were believed to enhance response rate because of cultural sensitivity of this topic which was strength of this study. Each participant spent 30–45 mins to complete the questionnaire. Only eligible volunteers were recruited for this study. No incentives were provided for participation in this study.
The survey instrument was adapted from the World Health Organization (WHO) questionnaire for assessing sexual and reproductive health of young people [
14]. This questionnaire was designed in order to assess knowledge, attitudes, behaviors and sexual health outcomes. Back-translation from English version of questionnaire to Persian was initially conducted blindly by two independent bilingual (English and Persian) experts and validated in a separate study by the research team [
43]. Content and face validity and reliability of the questionnaire was assessed and confirmed by both qualitative and quantitative methods for the age group 15–49 years and both single and married people. The questionnaire was edited to be suitable as a self-administered questionnaire.
The dependent variable reported in this paper is a scale variable named “personal attitude toward premarital sex”. This scale was constructed by sum of scores of nine aligned items or statements about the acceptability of a range of premarital intimacy situations and sex for unmarried men and women (Table
3). Each items was measured by three-point Likert scale (1- agree, 2- not sure, 3-disagree). The score of attitude scale ranged from 9 to 27 (Cronbach ‘Alpha = 0.80). The higher the score, the more liberal is the attitude towards premarital sex and vice versa. Independent variables included age, sex, education, marital status and religiosity. The sample was also weighted at the stage of analysis to make sure it was similar to the population age structure according to Iran’s 2011 census.
Firstly, socio-economic status and responses to attitudinal statements were described. To compare the attitudinal scale scores by independent variables such as age, educational level, biological sex, marital status and religiosity, t-Test and ANOVA were applied. Finally, those factors significantly associated with personal attitudes and were not highly correlated, were entered into multivariate analysis (linear regression) to detect determinants of liberal personal attitudes toward premarital sex. In this study P-values less than 0.05 were considered significant.