Psychosocial consequences of widespread of torture and sociopolitical pressure in Iran
Siroos Mirzaei, Homayoun Alizadeh, Seyed Zarei, Reem Alksiri
Background: Violence and political repres-
sion in general may have a complex psychosocial impact on societies. Studying these effects in countries with a high grade of repression based on reliable data from inside the country is difficult, mainly due to risks facing researchers. Methods and results: The authors developed a strategy to integrate available data from inside Iran, exiled survivors, and reliable international sources to investigate the psychosocial situation in the coun- try, where torture and execution are used frequent- ly. Data on human rights violations, including violence against women, persecution of political activists, and torture and execution of teenagers indicate pervasive strategy of repression in Iran in the last four decades. This thereby has caused sub- stantial long term public mental health impact and continue to cause other social and economic prob- lems and to create a burden on the Iranian popula- tion. Conclusion: Although, general psychosocial
health of a society is determined by multiple fac- tors, we conclude from the very limited data avail- able from inside Iran that political repression is not the only such factor, but can be assumed to be at least contributing significantly to the increasing physical and mental health problems in the country, creating a difficult position for health profession- als especially in detention facilities. Key words: Iran, mental health, torture, repression, trauma.
Violence and political repression may have a psychosocial impact on different levels of a society. Studying these effects in countries with a high degree of repression such as Iran is difficult from inside the country. A number of international organizations, including the World Medical Association (WMA) and UN institutions have nonetheless provided an objective and frightening picture of the situation in this country.
Iran signed the CCPR – International Cove- nant on Civil and Political Rights – prior the pre- sent regime (4.4.1968) but has after change to the present regime not signed standard humanitarian documents such as the UN Convention against Torture, nor the important OPCAT (Optional Pro- tocol to the Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Pun- ishment) (1).
The United Nations (UN) has repeatedly voiced concern regarding widespread indiscriminate use of the death penalty in Iran. Reports from the UN Special Rapporteur on the Situation of Human Rights in the Islamic Republic of Iran indicate that prisoners of conscience, including journalists, individuals with dual citizenship, and protesters are being detained arbitrarily on vaguely worded charges, held in poor condition and denied access to health care (2). This represents a violation of the Minimum
Organization for Support of Victims of Torture and War, Viena, Austria.
Homayoun Alizadeh. MA.
Independent HR expert, Viena, Austria. Correo-e: firstname.lastname@example.org
Hemayat Organization for Support of Victims of Torture and War, Viena, Austria.
Independent HR expert, Viena, Austria.
Received: July, 2019. Accepted: November, 2020. Conflict of interests: none
Statement of Human Rights: This publication does not involve any human participants or animals.
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Standard rules for the treatment of prisoners (Mandela rules).
Additionally, the Iranian Government has over decades denied all nominated UN- Special Rapporteurs on Human Rights in Iran access to the country (2).
Obviously, there are nearly no research data available on the prevalence and respective impact of different aspects of persecution in Iran from inside the country. In this manuscript, authors follow a review of secondary independent sources such as UNHCR and Amnesty International, in addition to selected peer reviewed publications related to the discussed issues from inside Iran and from exiled survivors. Available data and observations show that torture and execution are used frequently (2), and a high corruption index (rank 140/180) has been reported by transparency international (https://www.transparency.org/en/countries/iran).
Restrictions for physicians in following their ethical guidelines
According World Medical Association (WMA) health professionals have been prevented from treating patients, raising concerns about the veracity of documentation related to the cause of death of patients, and physicians have been forced to support clinically inaccurate documentation to hide human rights violations (3).
Persecution of perpetrators in international courts will be difficult as Iran has not ratified the Rome statute that would permit a court on crimes against humanity in situation where the local government ignores investigation and prosecution of crimes, but Universal Jurisdiction might be an effective instrument to persecute perpetrators in other countries (4).
HIV has been neglected in Iran probably because of the fact that those at risk for this disease are primarily homosexuals and patients with substance abuse, groups who are discriminated against and are at highest risk for
detention or execution. Two physicians, Kamiar and Arash Alaei, who provided medical care for these prisoners have been arrested (2). Iranian doctors face a difficult choice between threats of persecution and violation of national and/or international medical ethics.
Historical events with impact on public health
A total of 30 studies looking for depression in nurses were investigated. The overall prevalence of depression in nurses in a review of 30 studies was 22%, which was higher than the prevalence of depression among the general population. There is a need for psychologically healthy nurses at hospitals 6).
The relatively high prevalence of many indicators of distress and mental health problems in Iran might be related to a number of social, economic or other factors, indicating persecution or a repressive society.
The effects of the long-lasting war between Iran and Iraq (1980-1988) have been partially studied in regard to post-traumatic stress disorder (PTSD) in veterans and their family members as secondary victims. The authors of that study found decreased cortisol levels in progeny of veterans after rearranging the groups to reflect previous history of PTSD, possibly indicating to a transgen- erational effect of trauma (7). On 17 July 1988, Iran notified the Secretary-General of its formal acceptance of resolution 598, which was already proposed by the UN in 1987 (8). Until this time, Ayatollah Khomeini had blocked all attempts to end the war, which Iraq initiated (9). He used op- portunity of the “forced war” to eliminate the po- litical opponents by numerous executions and planned to expand the revolution to neighbor countries (10). In 1988 there was a series of execu- tion of political prisoners. Amnesty Internation- al recorded the names of > 4,400 disappeared pris- oners during this time (11). Execution is also used on homosexual teenagers and child offenders against strong criticism by the UN bodies, even in those with mental disabilities (2).
Widespread of Torture
Data on the widespread use of torture have been published by the UN (2) and data of Iranian refugees as discussed later confirm the wide spread use of torture.
Ahmadreza Djalali is a physician of disaster
medicine who has been wrongfully sentenced to death in Iran. He is an Iranian-born resident of Sweden, who teaches at universities in Italy and Belgium, and whose work involves international scientific collaboration. Since his arrest in 2016, he has been refused medical care despite
deteriorating health (5).
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Our own data from examining of survivors of torture from Iran using the “Istanbul protocol” (12) indicate the use of systematic torture methods such as psychological torture, beating the whole body, suspension, falanga, burns with cigarettes, and sexual torture of women and men. This has been confirmed to a major extent in other studies (13- 15).
Busch et al. reported that in a group of Iranian refugee survivors of torture different methods were used, including burning (38%), electrical torture, and sexual torture (25%) (13). Dehghan recently reported on the high prevalence of sexual torture of Iranian and Kurdish refugees (14). There are also reports of anal torture with hard objects in men (15). The wide-spread historical use of torture in Iran, including the time prior to “revolution”, is even documented in a dedicated torture museum (16). There have been elsewhere legal prosecution of perpetrators and successful reparation for survivors of other nationalities, but in countries as Iran, such due procedure is close to impossible since torture is practiced by state officials based on religious codes (17).
As the assassinations of Iranian Kurdish lead- ers in Vienna and Berlin (18) have demonstrated, safety is absent for opposition members even in democratic host countries. Morville followed a group of asylum seekers in Danish asylum centers. Forty-three persons, largely torture survivors, aged 20-50y, including Iranians demonstrated to a con- siderable degree activities of daily living (ADL) impairment secondary to psychological and physi- cal injuries (19). Priebe et al. investigated long- term mental sequelae of torture in the country, and explored differences between treatment-seekers and non-treatment-seekers (20). Thirty- four torture victims suffering from endur- ing mental sequelae and living in Germany were examined. Depression, anxiety, and somatoform disorders were diagnosed with a high degree of comorbidity, with Post Traumatic Stress Disorder (PTSD) being the most frequent diagnosis. Treat- ment seekers had a higher level of psychopatholo- gy, particularly PTSD symptoms of intrusion and increased arousal.
and Abdolreza Soudbakhsh, from Kahrizak prison, were murdered after having examined inmates who had been tortured and raped (21).
Members of minorities constitute a significant part of the prison population. Further, minorities suffer from discrimination in the academics, for example, many Baha’i have been reportedly expelled from universities or their applications of admission are rejected (2).
Systematic Violence against Women
In a patriarchal society, with many restrictions on females, economical pressure, physical and/or sexual violence threaten women’s health.
According to the
(OHCHR) Iran has not ratified the Convention on the Elimination of All Forms of Discrimination against Women (EDAW) (1). According to civil law, women are denied equal rights, including in marriage, divorce, child custody, and there is ongoing repression of them in relation to their objection to compulsory veiling. Women who do not wear a hijab in public can be sentenced to flogging, up to two months in prison, and/or be fined (2). Several defenders of women’s rights
have been imprisoned (22).
In this context, immediate removal of
disparities and use of all necessary means, including legislative, administrative, budgetary, promotional, and judicial measures in Iran have been recommended to accomplish decrease domestic violence (23), also perpetrators should be punished and support for victims accomplished.
A recent study revealed that it is essential to improve healthcare providers’ performance in recognizing and treating domestic violence, paying attention to other related factors, i.e., training and codifying guidelines (24).
In another study, victims of sexual violence had significant differences not only in mental health but also in terms of sexual arousal, sexual orgasm, sexual lubrication, pain and sexual satisfaction (25).
Reportedly, among women who participated in the Shiraz Women’s Health Cohort Study, the According to the above data and various re- most prevalent disorder was social dysfunction
ports, torture constitutes an epidemic problem in Iranian prisons. But there is de facto no way to follow up on these allegations by the justice sys- tem. Two medical doctors, Ramin Pourandarjani
(78%), followed by somatic symptoms (62%). Mental disorders were 64% most prevalent among married women. In a total group of 265 participants whose husbands were in prison, 65%
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Office of the United Nations
High Commissioner for Human Rights
had mental disorders. The results of this study showed a considerably higher prevalence of mental disorders among this group of women affected by wide-spread imprisonment, in comparison with the general population. Policy- makers were suggested to pay greater attention to the mental health status of underprivileged Iranian women (26).
Additionally, violence against women was studied in the Northeastern Iran. Some socioeconomic characteristics, such as educational level, occupational status of men, heavy smoking and drug abuse were associated with the occurrence of violence against one’s intimate female partner (27). Furthermore, there are vigilantes who attack women and activists for standing against forced hijab laws.
Psychosocial health in the society and among prisoners:
Health-related quality of life (HRQoL) among elderly Iranian individuals is generally low. Poli- cy-makers have recommended HRQoL strategies among the elderly by providing social, economic, and psychological support (28).
Noorbala et al., studied mental health status of Iranians and found an increase in suspected cases of mental disorders among Iranians over age 15 between 1999 to 2015. An interesting finding of this study was that in 1999, rural residents were more at risk of mental disorders, while in 2015, urban residents were more prone to have them. The risk of possible diagnosis of men- tal disorders increased with age, and was higher in people 65 and above, as well as in widowed, di- vorced and illiterate individuals (29). The preva- lence of common mental disorders in Iran has increased from 21% in 1999 to 32% in 2015. The authors concluded that it is vital for policymakers and health officials to act in order to improve and maintain mental health status of people who are at risk in the country (29).
Given repression in Iran, the prevalence of psychiatric disorders among 180 Kashan prisoners (mean age 32 ± 9y) was 43%. The most frequent disorders were major depressive disorder (28 %), PTSD (17%) and substance use disorder (17%). History of head trauma in prisoners with psychiat- ric disorders was 52% (30). About half of all pris- oners suffered from them. Treatment of psychiatric
disorder in this group was therefore “essential for prevention of crime”.
In the following we present some indicators of psychological consequences of repression in the Iranian community:
In another review the most frequent cause of attempted suicide was family conflict (32%). Other related factors included marital problems (26%), economic constraints (12%), and educational failures (5%). It was concluded that social factors, such as family conflicts and marital problems, had a noticeable
role in Iranian suicide research (31).
Thus, suicide seems to be a growing concern
in recent years. According to another report, Iran rates third highest among Islamic countries (32). According to statistics, each day >13 people take their lives by suicide in the country; most are aged 15–35. Economic problems, mental illnesses, cul- tural obligations, political issues and social pres- sures are the major factors for suicide in the coun- try (32).
There are differences in the prevalence of mental disorders among children and adolescents, compared Iran with other countries. Prevalence rates of obsessive-compulsive disorder (ranging from 1% to 11.9% among Iranian children and adolescents) were higher than other regional coun- tries with reported prevalence rates of 0.03% to 2.6%. Social phobia prevalence rates of 8% to 23.5%, and were higher among Iranian children and adolescents than in four non-Iranian commu- nities reporting prevalence rates of 0.08% to 0.9% (33).
Children on death row face additional stress after legal proceedings violating any international- ly accepted standards, including fear of their im- pending execution and the lack of information regarding the date it will take place. The continu- ous anticipation of imminent death result in addi- tional suffering for alleged child offenders and their families (2).
At both the individual and population levels,
the suicide rate has long been understood to correlate with cultural, social, political, and
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The consumption of illegal drugs has in- creased in Iran in the last decades. In 2017, offi- cials claimed that the number of drug addicts had doubled in the past six years (34). Alcohol, opium and cannabis are the most frequently used illegal drugs, but there are new emerging problems with anabolic steroids, ecstasy and stimulants. Lifetime rates of opiate use is between 1.2 and 8.6% in different parts of the country (35). The phenome- non of dramatic increase of drug addiction is a very possible consequence of shortcomings in social, economic, cultural and political system in the community. The Iranian Ministry of Health and Welfare declared that eight hundred thousand addicts were registered in the country, with an increase of 100% in only 9 years (36). The UN estimates that opium-based drugs are abused by 1,7%-2,8% of the Iranian population, compared with 0,3% of the population in Western Europe (37).
A high percentage of prisoners are drug- addicted, and they even have a significantly higher suicide rate than the already high suicide rate in the general population (42% vs. 35%) (35).
d) Emotional distress in journalists
Another target group under constant political repression is journalists. Iran ranks 173 out of 180 countries on an index of press freedom. Recently, the psychological stressors on wellbeing of Iranian journalists, had 65.8% being in the diaspora, were studied.
The detected stressors included arrest (41,2%), torture (19,3%), assault (10.5%), intimidation (51.4%) and threats to families (43.1%), which were associated with intrusive and arousal PTSD and depressive symptoms. Almost a third of Irani- an journalists used barbiturates regularly (38).
Medical staff inside and outside of Iran can play an important role in defending human rights of prisoners. This can be achieved by documenta- tion of possible torture sequelae, beyond the treatment of injuries, as it has been described in Istanbul protocol (12). Health professionals in Iran can face serious repercussions. The National socie- ties of physicians must report the threats to all relevant authorities and also to the World Medical Association and Amnesty International.
There are other corporal punishments (cruel and unusual punishment as prohibited by Article 5 of the Universal Declaration of Human Rights, 1948) which are performed on the streets, such as amputation or flogging (39). All intentional cor- poral injuries must be documented (12) and re- ports should be sent to the relevant authorities, such as WMA and UN, as Iran does not permit regular monitoring, i.e., by UN Special Rappor- teurs.
As a consequence of the difficulties to carry out social research in Iran, there are very limited scientific reports from inside the country. However, available reports and studies indicate an increase in mental health problems, such as suicide and substance abuse rates –even in younger individu- als– as well as violence against women. Further- more, there is credible evidence of widespread use of torture, execution of teenagers, and other sub- stantial human rights problems on the background of non-compliance and failure to sign international conventions.
We conclude that political repression can be an important factor in the increasing physical and mental health problems found in Iran. Nonetheless, there is hope to educate health care professionals and policy makers on the situation there, to bring local and international pressure to bear on the country’s leaders, to achieve a more just and safe country.
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