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Prevalence and Associated Factors of Physical and Sexual Violence against People Who Inject Drugs in Iran :A Nationwide Survey in 2023

A 2023 nationwide survey of 2,361 people who inject drugs in Iran reveals alarmingly high rates of physical (27.0%) and sexual (15.1%) violence, which are significantly associated with structural vulnerabilities like homelessness and low income, as well as specific risk factors such as mental disorders and female gender.

Original authors: Kamiar Izadpanah, Seyed Aria Nejadghaderi, Masoud Rezaei, Soheil Mehmandoost, Fatemeh Tavakoli, Maliheh Sadat Bazrafshani, Naser Nasiri, Mahkameh Rafiee, Matin Bazargani, Maryam Taghipur, Hamid Sharif

Published 2026-07-08

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CC BY 4.0

Original authors: Kamiar Izadpanah, Seyed Aria Nejadghaderi, Masoud Rezaei, Soheil Mehmandoost, Fatemeh Tavakoli, Maliheh Sadat Bazrafshani, Naser Nasiri, Mahkameh Rafiee, Matin Bazargani, Maryam Taghipur, Hamid Sharifi, Hossein Mirzaei

Original paper licensed under CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). ✨ This is an AI-generated explanation of the paper below. It is not written or endorsed by the authors. For technical accuracy, refer to the original paper. Read full disclaimer

Imagine a group of people living on the very edge of society, navigating a stormy sea where the waves are made of addiction, poverty, and stigma. This study is like a lighthouse survey that sailed out to count how many of these people got hit by the waves (violence) and why.

Here is the story of what the researchers found, told in simple terms.

The Big Picture: A Dangerous Neighborhood

The researchers looked at 2,361 people who inject drugs across 17 different cities in Iran. They didn't just ask "Did you use drugs?" they asked, "Has anyone hurt you?"

Think of this group as living in a neighborhood where the streetlights are broken. The study found that in the last year:

1 out of every 4 people had been physically hurt (hit, choked, or threatened with a weapon).
1 out of every 7 people had been forced into sex against their will.

These aren't just numbers; they represent a high rate of danger that is even worse than what is seen in some other parts of the world.

The "Why": What Makes the Waves Bigger?

The researchers tried to figure out what makes someone more likely to get hit by these waves. They found two different sets of reasons for physical hurt versus sexual hurt.

1. Why Physical Violence Happens (The "Survival Storm")

Physical violence seemed to be a result of a person's entire life falling apart. It's like trying to walk through a minefield while carrying a heavy backpack. The study found that people were more likely to be physically hurt if they had:

No Home (Homelessness): If you are sleeping on the street, you are much more likely to get attacked. It's like being a target in an open field.
No Money: Being poor made the risk higher.
Mental Health Struggles: People dealing with depression or anxiety were more vulnerable.
Overdose History: Having overdosed before was a sign of a chaotic life that led to more violence.
Low Social Support: If you have no friends or family to catch you when you fall, the fall is harder.

The Takeaway: Physical violence wasn't just about bad luck; it was about a "syndemic"—a perfect storm where poverty, homelessness, and mental health issues all crashed together to make people unsafe.

2. Why Sexual Violence Happens (The "Gendered Storm")

Sexual violence told a different story. While money and homelessness mattered here too, the biggest factor was gender.

Women were in much more danger: Women who inject drugs were three times more likely to experience sexual violence than men.
Unstable Relationships: Being divorced, separated, or widowed increased the risk.
Low Support: Just like with physical violence, having no one to rely on made the risk higher.

Interestingly, the study found a strange twist: people who had many sexual partners were actually less likely to report sexual violence. The researchers suggest this might be because people who do this often develop specific strategies to stay safe, or perhaps those who were hurt stopped having partners afterward. It's a complex puzzle that needs more looking into.

How They Did It

The researchers used a method called "Respondent-Driven Sampling." Imagine a game of "telephone" but for finding people. They started with a few trusted people in the community (seeds) and gave them "coupons" (like tickets) to invite their friends to join the study. This helped them find people who are usually hidden away and hard to reach.

They asked these people honest questions about their lives, their health, and their experiences with violence, ensuring their names were kept secret so they wouldn't get in trouble with the law.

The Bottom Line

This study paints a picture of a population that is being battered by multiple forces at once.

Physical violence is a sign that a person's basic needs (a roof, money, mental health care) aren't being met.
Sexual violence is a specific, gendered danger that hits women much harder, often tied to unstable relationships and a lack of support.

The researchers conclude that to stop the violence, we can't just tell people to "be careful." We have to fix the storm itself: provide housing, support mental health, and create safety nets, especially for women in this community. Without fixing these underlying cracks, the waves will keep hitting.

Technical Summary: Prevalence and Associated Factors of Physical and Sexual Violence against People Who Inject Drugs in Iran (2023)

Problem Statement
People who inject drugs (PWID) globally face disproportionate health and social harms, including heightened risks of blood-borne infections, overdose, and structural inequities. In Iran, where the PWID population is estimated at approximately 345,308, these challenges are exacerbated by a syndemic of co-occurring issues such as mental health disorders, housing instability, and incarceration. Despite the known vulnerability of this group, there remains a significant gap in the literature regarding the specific prevalence and correlates of physical and sexual violence among Iranian PWID. This study addresses this knowledge gap by providing the first nationwide data on the prevalence of violence against this population and identifying the sociodemographic, structural, and behavioral factors associated with these experiences.

Methodology
The study analyzed data from the 2023 Fifth National Bio-Behavioral Surveillance Survey (BBSS), conducted between May and August 2023 across 17 cities in Iran.

Sampling: A Respondent-Driven Sampling (RDS) methodology was employed to recruit a target sample of 2,200 participants, with a final analytical sample of 2,361 PWID. This approach was selected to access hard-to-reach populations lacking a standard sampling frame.
Participants: Inclusion criteria required participants to be aged 18 or older, report injecting drugs at least once in the preceding 12 months, and provide verbal consent.
Data Collection: Trained, gender-matched staff conducted face-to-face interviews using a standardized questionnaire based on World Health Organization (WHO) guidelines.
Variables:
- Outcomes: Self-reported physical violence (e.g., being hit, choked, or threatened with a weapon) and sexual violence (e.g., being tricked or forced into sex) within the last 12 months.
- Covariates: Sociodemographic factors (age, gender, marital status, education, income), structural factors (homelessness, imprisonment, social support), substance use history (age of first use, daily injection, overdose history, treatment enrollment), and behavioral factors (sexual behaviors, HIV status).
Statistical Analysis: RDS-weighted prevalence and 95% confidence intervals (CI) were calculated using RDS-Analyst software. Bivariable and multivariable logistic regression models were used to identify independent associations, with a backward elimination procedure applied to final models (significance level $p < 0.05$ ).

Key Results
The study revealed alarmingly high rates of violence among Iranian PWID:

Prevalence: The RDS-weighted prevalence of physical violence in the last 12 months was 27.0% (95% CI: 22.9–31.1), and for sexual violence, it was 15.1% (95% CI: 12.0–18.2).
Physical Violence Correlates: In the multivariable analysis, physical violence was independently associated with:
- Recent homelessness (within the last 12 months): Adjusted Odds Ratio (AOR) = 3.11.
- History of mental disorders: AOR = 2.29.
- Low monthly income (<100 USD): AOR = 1.75.
- Lifetime history of overdose: AOR = 1.43.
- Low social support: AOR = 2.02.
- Alcohol consumption (≤4 times/month): AOR = 1.59.
Sexual Violence Correlates: Sexual violence was distinctly gendered and associated with:
- Female gender: AOR = 3.32 (women faced over three times the odds compared to men).
- Low income: AOR = 2.31.
- Low social support: AOR = 2.61.
- Marital instability (divorced/separated/widowed): AOR = 1.77.
- History of homelessness (prior to the last 12 months): AOR = 2.07.
- Substance use during the last sexual encounter: AOR = 1.54.
- Protective/Inverse Associations: Having multiple sexual partners in the last six months (AOR = 0.33) and no history of HIV testing (AOR = 0.62) were associated with lower odds of sexual violence, though the authors note these findings may reflect complex mechanisms such as risk-mitigation strategies or reverse causality.

Significance and Claims
The authors claim that this study provides robust, localized data demonstrating that physical and sexual violence are highly prevalent among Iranian PWID, with rates comparable to or exceeding those found in other global settings and general populations.

Structural Determinants: The study emphasizes that violence is not merely an individual risk but is strongly predicted by structural and health vulnerabilities, specifically homelessness, economic precarity, and mental health disorders.
Gendered Nature of Violence: The findings highlight that sexual violence is a distinctly gendered issue, with women facing significantly higher odds, further compounded by marital instability and economic dependency.
Policy Implications: The authors conclude that interventions must be tailored, gender-sensitive, and address underlying structural determinants and health syndemics. They advocate for the integration of routine screening for violence and trauma-informed support services into existing harm reduction and addiction treatment programs in Iran.

Limitations
The authors acknowledge limitations inherent to the study design, including its cross-sectional nature, which precludes causal inferences (e.g., determining whether mental health disorders preceded or resulted from violence). Additionally, reliance on self-reported data may introduce social desirability bias, and the predominantly male sample (94.9%) limits the statistical power to analyze specific factors among female PWID.