Very few research projects have been conducted on the subject of rape in Iran compared with Western nations. Conducting studies in this field presents difficulties and challenges all over the world. Some of the many challenges faced by researchers undertaking studies in this field are locating potential participants without revealing to family and friends the purpose of the study or invading the privacy of potential participants, and the need to provide counseling to women who became upset by the interview once located and contacted.1
Mental disorders may occur after a traumatic event. For example, the most common cause of posttraumatic stress disorder (PTSD) among women in Iran is sexual assault. A study conducted in Iran suggests that the rate of PTSD in victims of rape in Tehran is 61.6 percent.2 Another study suggests the prevalence of PTSD in the rape victims of Kohgiloyeh and Boyerahmad Province is as high as 91.2 percent.3 Some researchers have indicated that 74.58 percent and 41.49 percent of individuals met diagnostic criteria for PTSD at the first and twelfth month following sexual assault.4 But the number of female victims of rape who seek help from medical professionals is very low.
In a project we conducted with female victims of rape who were referred to Zanjan Province Forensic Medicine Centers in 2022, we tried to identify the risk factors that lead to an increase in the probability of PTSD arising in these women using the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) questionnaire. CAPS is an extensively validated and widely used structured diagnostic interview for posttraumatic stress disorder.5 Because of a number of difficulties we faced throughout the course of the study, however, we were unable to bring this project to completion (see below).
The Iranian Legal Medicine Organization, as an independent and specialized organization in the Judiciary of the Islamic Republic of Iran with the mandate of finding the truth and helping in the establishment of justice in society, provides expert opinions in the field of forensic medicine, based on scientific, legal, and juridical principles.6,7 The Legal Medicine Research Center of the Islamic Republic of Iran allows these specialists to conduct research related to this field.8 In case of sexual assault, the forensic physician will perform a thorough physical examination of the victim and, if needed, will collect samples. The physician will also complete a form composed of questions, such as when and where the sexual assault happened, how many assailants there were, whether and what type of penetration occurred, if the victim has menstruated since, and so on.
Forensic psychiatry is a special unit of the legal medicine organization. The main duty of forensic psychiatrists is determining the criminal responsibility of persons with mental disorders who committed crimes, but these specialists are not involved in examining and diagnosing the victims of crimes. In our study, however, psychiatrists from Zanjan University of Medical Sciences were allowed to work with female victims of sexual assault who were referred to forensic centers. These participants were interviewed using the CAPS-5 questionnaire and, if PTSD was evident, were referred to the clinics or emergency department of Shahid Beheshti Hospital for further evaluation and treatment. During the interview, if signs and symptoms of other mental disorders such as depression were present, or if the participant was evaluated as having a high risk of suicide, then the participant was referred to specialists who would visit and treat the patient for a fraction of the cost.
Male victims were not included in the study because of the rarity of their presentation. The number of male victims of sexual assault over the age of 12 who would have been eligible to participate in our research was too small to achieve meaningful results. This does not mean there are no male victims of rape, but they do not go to forensic centers; their feeling shameful or thinking they have been stripped of their masculinity may be relevant factors. The same could not be said for male victims of rape under the age of 12. In examining child victims of rape, parental consent is necessary unless parents themselves are suspects, in which case a judge’s order is required. Having a social worker, nurse, or child psychologist present during the interview with the child may be helpful but is rarely accomplished. A separate interview is performed with parents or guardians of the child, followed by a physical examination.
Obstacles to Research
There are multiple obstacles hindering the conduct of research in the field of sexual assault in Iran. Ideological societies are always concerned with presenting a certain image of themselves, both within and outside of their borders, and seek to maintain that image by controlling all aspects of reality. Ideological thinking is divorced from the realities of perception, and insists on a “truer” reality concealed behind all perceptible things, dominating them from this place of concealment and revealed precisely by the ideology, which is taught by the educational institutions. Once these movements have come to power, they proceed to change reality in accordance with their ideological claims.9 They believe that showing social anomalies will spoil this image, and therefore not only do they not support this type of research, but they also create serious obstacles in an attempt to suppress it altogether.
Some religious scholars believe that talking about corruption is the same thing as promoting it or that whoever broadcasts an abominable act and sin is like the one who committed it.10 As a result, Islamic countries emphasize the need to conceal personal and social defects and anomalies. Any kind of research or acknowledgment of the existence of anomalies such as rape exposes social corruption, considered an obscene and objectionable matter in the traditional and religious ethics of Islamic societies. As the Muslim prophet Muhammad has said: “Whoever covers the defects of his Muslim brother in this world, God will conceal his on the day of resurrection” (Ref. 11, p 609). Many researchers worry that they will be questioned by authorities in the event they decide to embark on research projects exposing the occurrence of sexual assault.
There is a very large gap between the educational system and the social application of research, such that universities and the scientific community at large do not have a direct relationship with society, nor is researchers’ work applied directly within society itself. In other words, research remains strictly a theoretical or academic matter, buried in libraries and computers. Complex administrative bureaucracy and lack of interorganizational cooperation can lead to researchers quickly losing interest in taking the long and arduous path of exploring social anomalies such as rape.
A large number of rape victims are never referred to institutions like forensic centers. Fear of being found guilty of adultery is the main driving force preventing men and women from seeking assistance from doctors or the judicial system, as such a finding could carry with it punishment, by the laws of Iran.12 In other words, the Islamic Penal Code prevents the registration of anomalies and the undertaking of any research about them. Also, rape is punishable by death in Iran,13 which means if the judge decides rape has indeed occurred, the rapist will be hanged, and some victims who do not agree with the death penalty will not alert legal authorities.
Many women only go to forensic centers because of family pressure and only with the intent of evaluating their virginity status (see below) and do not want to participate in activities such as research. Virginity, defined as an intact hymen, is considered a sign of purity. In the distant past, family members used to gather by the door of the newlyweds and wait for the blood on the white cloth as a sign of virginity, to celebrate their honorable family. Today, before the marriage is official, the man would take his fiancé to a gynecologist or midwife to check her virginity status. This all means that even though many people are not concerned with having a broken hymen, many women still worry it might ruin their chance of a successful marriage; thus, the custom of the virginity examination continues.14
Many of these women distrust legal institutions and are afraid of having their identities revealed. They believe that participating in such a study would cause records to be created which could later become available to others and therefore lead to their gaining a dishonorable reputation.
Because of the traditional features of Iranian society, women are worried that if other people find out they have been sexually assaulted, they will be chastised and incriminated, rejected from family and clan, forced to drop out of school, unable to find a suitable husband, or even be considered prostitutes. They may also lose their jobs and financial independence, have their spouse and children taken away from them, or be harmed or even killed by their own family.15,16 As noted above, our study did not include male victims of rape; men likely would also prefer to keep such an incident hidden because it violates the traditional role of the man as the masculine protector of the family. Further research needs to be done on this matter.
Many women who participate in research requiring follow-up do not return. Some of the reasons for this may be the mental disorders that could arise as a result of rape, such as depression or anxiety, or persons changing their phone number or address to conceal their identity and whereabouts.
A lot of women who are referred to forensic centers have previously gone to other organizations such as the police force, but did not receive the help they required and were not well treated.15,17,18 For many victims, postassault help-seeking can become a second experience of victimization.19 As a result, they have no desire to participate in the research of other related organizations, having been previously judged or reprimanded instead of being afforded the assistance they needed at the time.
In our original study, we interviewed the eligible participants one month after the incident and we made follow-up appointments until six months after the incident because PTSD may emerge one to six months after a traumatic event. As mentioned before, participants diagnosed with PTSD would be referred to both a psychiatrist and a psychologist for further evaluation and treatment. Our focus was on signs and symptoms of PTSD; however, some of the participants were experiencing other mental disorders, such as depression, eating disorders, or drug and alcohol misuse, and were hoping they could speak more about these concerns and receive treatment for them. Our main focus on PTSD caused some of the participants to not want to return for a follow-up appointment.
For rape victims under the age of 18, the presence and consent of a parent or guardian is required to participate in the research project. In many cases, parents prevent the child from participating in the project to protect the child's feelings and future. The limited number of forensic medical centers available in the provinces, the lower income of most of the victims, and the high cost of transportation all prevent women from participating in multistage research.
Conclusion
It appears that cultural and social factors have an effect on the psychopathology of diseases, in the sense that the cultural characteristics of Iran not only do not allow those in need of help to seek it but even encourage the suppression of signs and symptoms of mental disorders. Because many women victims intend to keep their trauma hidden and believe no good will come of sharing what happened to them, they try to conceal the signs of the rape, whether physical signs such as bruises or scratches or signs of a mental disorder. In our study, we focused on female victims of sexual assault, who may be more dependent on men and for whom the law is not equal (Ref. 20, Articles 907 and 1169). Male victims of sexual assault also face many challenges and are in need of a place in which to speak out safely about their trauma. We must educate our children to not be ashamed and ask for help when they need it. We must remind our physicians to provide a safe environment for their patients and support them. Even an informative pamphlet could be a good first step for victims and their families, something that does not exist at the moment.
For those who would like to research such matters, multistage studies may be a lot more difficult to execute. Providing a safe environment for the participants, covering their cost of travel, and offering outstanding medical and psychological support will be beneficial. Although researchers must be very cautious approaching such matters, they must also be very patient because the path of research on sexual assault, at least in Iran, is quite long. But if they can apply their results in society, it might help prevent crimes, drastically improve people’s lives, or even save some lives.
Acknowledgments
The authors appreciate the executive support of Zanjan Forensic Medicine Center.
Footnotes
The views expressed in the submitted manuscript are the authors’ and not an official position of any institution.
Disclosures of financial or other potential conflicts of interest: None.
- © 2024 American Academy of Psychiatry and the Law