Sexual health and optimal marital relationship provide the basis for strengthening the emotions between couples and prevent the occurrence of mental disorders, disintegration of the family foundation, and social harms by creating a sense of satisfaction, peace, and increased self-confidence. Sexual health is defined as a physical, emotional, mental, and social well-being in relation to sexuality [3]. Recently, sexual health, instead of being a part of reproductive health, has been considered as the foundation and necessary condition for achieving reproductive health. Sexual health recognizes the desire of individuals and couples with all sexual orientations and backgrounds for desirable sexual relations, and its concerns go beyond fertility and reproduction and covers issues such as impotence, sexual dysfunction, and sexual violence [4]. 
Reproductive and sexual health are guaranteed through the rights to access information and to make informed decisions in the field of reproductive and sexual health, free from discrimination and violence [5]. The results of a qualitative study in the UK showed that, according to caregivers and patients, sexual health literacy goes beyond personal health literacy, and the change of unconventional sexual behaviours requires collective effort and inter-sectoral collaboration using older and newer technologies [10]. Given the difference in cultural context and politico-moral foundations of health systems in each country, identifying the challenges of sexual health and adapting reproductive and sexual rights are essential for proper policy-making. This study aimed to identify the challenges of sexual health and the opportunities for its improvement in Iran from the perspective of policymakers and experts.

In this qualitative study using content analysis approach, individual in-depth semi-structured interviews were used to collect data from participants. They were selected using a purposive sampling method from among the experts of the Ministry of Health, members of Supreme Council of Health and Food Security, experienced specialists and faculty members. At first, a list of experts in the fields of sociology, psychiatry, clinical psychology, sexual and reproductive health, public health ethics and law, religious affairs and community medicine was prepared and then snowball sampling was used to select participants who were 16 experts aged 30-60 years old. After coordination by phone call, an interview was conducted with the participants who expressed their verbal consent in a private and comfortable place. A permission was obtained from the participants to record their voices during the interview and they were assured of the confidentiality of their information. After individual interviews and theoretical saturation of data, data analysis was performed using a deductive content analysis method. 
The main questions were: (a) What is the current state of sexual health in the country? (b) What are the barriers and challenges in the field of sexual health? In your opinion, what ethical and legal challenges exist in this field? (c) What are the current measures and existing capacities? (d) What interventions do you recommend to improve the status of sexual health? Recorded interviews were written and read several times and the initial themes were extracted from them. Then, they the main themes were classified based on the similarities. In order to increase the credibility of the study, attempts were made to interview with the experts in various related fields (Triangulation) through establishing good communication and devoting sufficient time. For the dependability of the findings, the reports of some participants were quoted. For the transferability of findings, attempts were made to mention the relevant and effective characteristics of the participants in the quotes. Finally, confirmability was obtained using the trained experts to check the results.

In this study, five main themes including (a) the taboo of sexuality and low public awareness, (b) unconventional sexual behaviors and emerging social ills, (c) stigma and discrimination, (d) lack of the political commitment of the government, (e) lack of statistical indicators and not utilization of existing capacities were identified as the challenges of sexual health in Iran. The opportunities and strategies to address them included: Gaining political support from the government and cooperation with related sectors, revising the laws and guidelines for accessing to reproductive and sexual health services in line with social changes, public education and empowerment with a special focus on the adolescents and young people, promoting the right attitude with focus on banishing stigma and discrimination against groups with high-risk sexual behaviors, collecting indicators and designing interventions using human resources and existing capacities, and promoting professional ethics and gender equity (Figure 1). 

The first and most important extracted theme was the taboo of sexuality and low public awareness about sexual issues and healthy sexual behaviours. The preparation of standard training packages based on needs of people has been recommended in order to enable them to have healthy sexual behaviours [20]. The studies in the Asia-Pacific region have indicated the changing pattern of sexual relations, increasing age of marriage, and decreasing age of sexual intercourse [22]. The results of a study indicated that the related laws are not consistent with the reproductive and sexual health policies and the needs of young people in the Asia-Pacific region, although laws have been or are being amended to banish stigma and discrimination in the provision of reproductive and sexual health services to the adolescents and the groups with high-risk sexual behaviours in most of the countries in this region [23, 24]. Therefore, persuading policymakers and religious leaders to change policies and laws to reduce social ills is the first step in breaking the taboo of sexuality and removing barriers to its education. In recent years, the use of electronic health technologies has provided an opportunity to increase community knowledge about sexual health and quality of life, especially for all types of sex-related stigma. E-Sexual Health is an opportunity to establish and strengthen the communication between people and providers of sexual health services and the access to these services regardless of age, gender and sexual orientation using various methods such online counselling through text, audio and video messaging, while respecting to privacy and confidentiality [25]. 
Using the WHO recommended indicators including social and policy factors, accessibility, service delivery, outcome and impact level [35] to collect and analysis data and indicators by using the existing capacities can be a basis for designing effective interventions and improving the sexual and reproductive health indicators of the society. Political or legal interventions are needed to support the current or new sexual health programs. General laws and policies can provide a framework for implementing health-related policies and programs [3]. The national Constitution law, 20-year national vision document, and a comprehensive health map of the country by developing a roadmap for the involved institutions have provided an appropriate opportunity to amend laws to remove the barriers to the implementation of sexual health interventions. A look at the country’s constitution law, general health and population policies, the Charter of Citizens’ Rights, and the Charter of Women’s Rights and Responsibilities indicates that paying attention to the health of people is one of the most important human rights and politicians and legislators at the macro level have paid special attention to it. These documents and laws imply the approach to the right of health, gender equity, elimination of discrimination, equal legal protection for men and women, and the need to create the necessary political and legal environment to promote sexual and reproductive health in society.
Addressing the challenges and identifying the best indicators of sexual health in Iran requires the political commitment of the government, developing the relevant regulations for education and access to key reproductive health services tailored to social needs, planning for recording and collection of sexual health indicators, adopting a comprehensive approach to design and implement multilevel and multidisciplinary interventions based on the identified challenges using existing capacities, and public education and empowerment with a focus on the adolescents and young people to learn life skills and have healthy sexual behaviours. It is recommended to adopt strategies for inter-sectoral cooperation and public participation in order to banish stigma and discrimination, promote gender equity and improve sexual and reproductive health status of Iran.

The study was approved by the Ethics Committee of Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.RETECH.REC.1398.487).

The study was supported by Medical Ethics and Law Research Center (MELRC), Shahid Beheshti University of Medical Sciences. 

All authors equally contributed to preparing this article.

The authors declare no conflict of interests.
 

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