Abstract
Objective
To determine the mental health of Iranian citizens protesting the actions of their country's Morality Police. Street protests across Iran were met with violent suppression that included security forces reportedly targeting protestors’ eyes.
Method
A group of 63 Iranian protestors (58.7% female; mean age 32.0 [SD = 9.43] years, from all socio-economic classes) who had been part of street protests against the regime's morality police, was recruited by convenience sampling between May and August 2023 by journalists working underground in Iran. The study was conducted in Farsi by telephone (n = 60) and in-person (n = 3). Demographic and psychometric data were collected, the latter including symptoms of posttraumatic stress disorder (PTSD; Impact of Events Scale–Revised) and depression (Beck Depression Inventory–Revised), in Farsi-validated scales. Between-group comparisons were undertaken with one-way ANOVA and post-hoc Tukey comparisons. Significance was set at P < 0.05.
Results
The protestors comprised three groups: not wounded (n = 27: 59.26% female, mean age 34.44 [SD = 12.11] years), non-eye wound (n = 23; 60.87% female, mean age 32.61 [SD = 5.89] years) and eye-wound (n = 13; 53.85% female, mean age 27.54 [SD = 6.58] years). The eye wound group (blinded in one or both eyes) had less severe intrusion symptoms of PTSD (P = 0.048) and depression (P = 0.0001) than the non-eye wound group. The not wounded group had less severe symptoms of depression than the non-eye wound group (P = 0.003). Every protestor who had lost sight regarded their actions, notwithstanding their physical consequences, in a positive psychological light.
Conclusions
Contrary to our a-prior hypothesis, Iranian protestors blinded in one or both eyes were faring better psychologically than protestors with non-eye wounds. Possible reasons for this included higher rates of psychological treatment and social support in the eye-wound group compared to the other two groups post-injury and the nascent development of posttraumatic growth.
Introduction
Iran is an Islamic theocracy, led by powerful clerics. The regime is rated as authoritarian by the Economist's Democracy Index, the country placing a lowly 153 out of 167 on a global index of democracy. 1 Street protests have flared at regular intervals since the 1979 Islamic Revolution. The Students’ Protests in 1999 were followed by the Green Movement Protest in 2009, the Economic Protests in 2017–2018, the Price Hike Protest in 2019, and a protest in 2020 against the government's attempts to paper over the downing of a Ukrainian jetliner. All of these protests were accompanied by protestors being killed and thousands imprisoned. 2
The current study focuses on the aftermath of a single event on September 16, 2022, when Mahsa Amani, a previously healthy 22-year-old Iranian woman died in captivity. 3 Three days earlier she had been arrested by the country's Morality Police for allegedly violating Iran's strict rules requiring women to cover their hair with a hijab, or headscarf. Iranians took to the streets once more, to protest her death. The unrest continued until the spring of 2023 by which time 530 protestors had been killed, seven executed and over 20,000 people arrested. 4 Of note is that The Iran Human Rights Group (IHRNGO) based in Norway claimed that the Iranian security force intentionally targeted the eyes and faces of protestors. 5 IHRNGO documented 138 eye injuries acquired over the months of protests.
The aim of the present study was to ascertain the effects of this violent suppression on the mental health of those protesting the regime. Psychological distress in citizens participating or caught up civic unrest has been well described previously. A systematic review of 52 studies (n = 57,487 participants) from 20 countries/regions has revealed elevated rates of posttraumatic stress disorder (PTSD) ranging from 4% to 41% in areas affected by the unrest. Rates of depression were found to increase on average by 7% irrespective of personal involvement in the events. 6 With these outcomes in mind and given reports showing that people who sustain a loss of vision from a traumatic event have higher rates of PTSD than seen in the general population, 7 we hypothesized that a) protesters who were wounded would show more symptoms of psychological distress than those citizens who were not wounded and that, b) protesters who were blinded in one or both eyes would show more symptoms of psychological distress than protesters whose wounds did not involve their eyes.
Methods
Sample
A group of 63 Iranian protestors was recruited by convenience sampling between May 2023 and August 2023 by journalists working underground in Iran. Recruitment was done by word of mouth and through journalists’ personal knowledge of the protestors. No individual approached declined to participate. There were no exclusion criteria. While the evidence for an eye wound was discernible by simple observation, no other confirmation of wounding or involvement in the protests was obtained.
The study was undertaken in Farsi.
Demographic Data
These data included age, sex, marital status, level of education and occupation.
Conflict-Related Data
The following dichotomous (yes/no) variables were collected by self-report: Wounded, blinded in one or both eyes and if protestors perceived a positive psychological aspect to their actions notwithstanding the negative consequences that could come with joining the protests. The presence of eye wounds only was corroborated by photograph (see Figure 1). The question eliciting the potential positive effects of protesting was: “if you participated in the protests, did this have positive psychological effects for you?”
Portraits of Iranian protestors. These photographs were taken in Iran in 2022 and 2023, as a series of portraits of citizens who were deliberately blinded by security forces during anti-regime protests. The photographer's name is being kept confidential because of the dangers journalists face in Iran. All the subjects shared their stories on social media, and said they wanted these images seen outside Iran so the regime could be held accountable for its alleged crimes. Permission has been obtained to share these photographs from The Globe and Mail. Mercer G. 2024 Jan 12. “You aimed at my eyes, but my heart is still beating”: Blinded Iranian protesters show the brutality of the country's regime. The Globe and Mail. Accessed March 4, 2024. https://www.theglobeandmail.com/Canada/article-you-aimed-at-my-eyes-but-my-heart-is-still-beating-blinded-Iranian/.
Psychiatric Data
Behavioural data were obtained with two self-report psychometric questionnaires. They are considered robust and valid instruments for recording psychopathology that can arise following traumatic events.
The Revised Impact of Events Scale–Revised (IES-R) contains 22 questions that closely follow the DSM-IV criteria for PTSD. Subjects were asked to indicate symptoms that had occurred during the past 7 days only in relation to the protests in Iran. A Persian version of the IES-R has been validated and used previously.8,9 Three subscales look at intrusive (re-experiencing), avoidance, and hyperarousal phenomena. There is a choice of five responses for each question, which are scored 0 = not at all; 1 = a little bit; 2 = moderately; 3 = quite a bit; 4 = extremely, respectively. Each total subscale score is divided by the number of questions in the subscale to give a mean score that equates with the individual ratings as described above. For example, a mean score of <1.00 equals a “little bit,” score between 1.00 and 1.99 reflects “moderately,” 2.00–2.99 equals “quite a bit” and >3.00 equates “severely.” Cronbach α for the intrusive, avoidance, and arousal scales were .925, .903 and .916, respectively.
The Beck Depression Inventory–Revised (BDI-II) was used to capture depressive symptomatology over the past 2 weeks. A Persian version of the BDI-II has been validated and used previously.9,10 The 21 items were scored on a Likert-type scale ranging from 0 to 3 and summed to give an overall index of depression. By convention, scores from 0 to 13 were deemed minimal, 14 to 19 mild, 20 to 28 moderate and >28 severe. Cronbach α for the BDI-II was .933.
Participants were asked if they had ever received psychiatric treatment before and after the protests and if after, whether the treatment was trauma-related or not.
Statistics
Normality of data distribution was assessed and confirmed with the Shapiro–Wilk test before between-group (not wounded vs. non-eye wound vs. eye wound) comparisons were undertaken for the IES-R and BDI-II data with one-way ANOVA and post-hoc Tukey analyses. Ordinal data were analyzed with chi-square test (Fischer's exact test with cells less than n = 5). Significance was set at P = 0.05.
Ethics
The study was approved by the Research and Ethics Board at Sunnybrook Health Sciences Centre, affiliated with the University of Toronto. Informed, verbal consent was obtained from all participants. Participants either read or were read, the consent form which made clear that no personal identifying data were being collected, that participation was completely voluntary, and that they had the right to withdraw from the study at any point. Consent was obtained verbally.
Results
Demographics
The mean age of the 63 protestors was 32.35 (SD =9.43) years and 37 (58.73%) of them were women. Thirty-two (50.79%) of the protestors were married, 20 (31.74%) were single and 11 (17.46%) divorced. In terms of education, 44 (69.84%) had a university degree, 15 (23.81%) had completed high school and 4 (6.35%) had finished primary school. A breakdown of the protestors’ occupations revealed they came from all strata of Iranian society ranging from professional (physicians, lawyers) to unskilled (cleaners, servers) occupations (see Table 1).
Occupations of Protestors.
Demographic comparisons between the three groups, not wounded (n = 27), non-eye wound (n = 23) and eye wound (n = 13), are shown in Table 2. The three groups did not differ statistically with respect to age, sex and marital status.
Demographic Comparisons Between Protester Groups.
Note. SD = standard deviation; Sig. = significance; ANOVA = analysis of variance.
Location of protestors in or outside Iran.
Psychiatric Data
Between-group comparisons on the IES-R and BDI-II are shown in Table 3 and revealed significant differences with respect to PTSD intrusion (P = 0.04) and BDI-II (P = 0.001) scores. The post-hoc Tukey analysis showed that the eye wound group (n = 13) had less severe PTSD-intrusion (P = 0.048) and depressive symptoms (P = 0.0001) than the non-eye wound group (n = 23), whereas the group not wounded (n = 27) had less severe depressive symptoms than the non-eye wound group (P = 0.003).
Between-Group Comparisons of Psychiatric Data and Treatment.
Note. SD = standard deviation; Sig. = significance; ANOVA = analysis of variance.
Positive Psychological Effects of Protesting
This question was answered by 34 (53.9%) of the protestors. The majority of protestors viewed the personal psychological consequences of protesting in a positive light: not wounded (6/9 = 66.67%); non-eye wound (13/15 = 86.67%); eye wound (10/10 = 100%) groups, respectively.
Psychiatric Treatment
Results are shown in Table 3 and reveal significant between-group differences (P = 0.016). A post-hoc analysis revealed that no protestor with an eye wound (n = 13) had received therapy prior to protesting with this percentage rising to 7/13 (54%) after being wounded, which differed significantly from the not wounded (n = 27; P = 0.006) and non-eye wound (n = 23; P = 0.011) groups.
Discussion
Our study of 63 Iranian protestors revealed that those blinded in one or both eyes had fewer symptoms of depression and PTSD intrusion than protestors with wounds not involving their eyes, contrary to one of our hypotheses. In keeping with part of the second hypothesis, we found that protestors who were not wounded had fewer symptoms of depression than those protestors with wounds not involving their eyes. While our study was primarily descriptive and not designed to explore etiology, these results, both anticipated and unexpected, suggest complex factors at play in terms of symptom pathogenesis.
Our finding of more prominent depression in protestors with wounds not involving their eyes compared to protestors who were not wounded at all is supported by a broader trauma literature that links physical injury even without disability to elevated rates of depression 11 and PTSD. 12 However, while rates of depression go up when injury is accompanied by disability, 13 this is not what we found in the protestors with eye wounds. Similarly, previous studies have found that while non-trauma-related loss of vision is not considered a sufficient stressor to trigger PTSD, 14 rates of PTSD become elevated when the cause of the visual loss is physical trauma. 7 This too, was not seen in our sample. Furthermore, in a study limited to female ex-service personnel, visual loss was shown to adversely affect emotional well-being as manifested by drinking to excess and prominent symptoms of PTSD, depression, and anxiety. 15 Once again, our data did not replicate this observation with respect to symptoms of PTSD and depression.
A number of reasons may explain our symptom findings related to protestors who lost vision. First, all but one protestor in the eye-wound group was blinded in one eye only. While this is a grievous wound, retaining sight in one eye may well mitigate the trauma involved. Secondly, the percentage of protestors in the eye wound group who received psychotherapy after protesting was statistically higher than in the other two groups, suggesting a possible treatment effect to account for lesser symptom levels. A third possible explanation is that every protestor who lost an eye because of the actions of the Iranian security forces regarded their own actions, notwithstanding the adverse consequences, in a psychologically positive light. While this positive opinion was generally true of all the protestors, not one of the protestors blinded or partially blinded by the Iranian security forces viewed their own behaviour as anything but positive.
This perception of something positive arising out of a negative event in turn suggests the possible presence of post-traumatic growth. First formulated three decades ago, this concept reveals that traumatic events may elicit not only negative responses and consequences, but positive ones, too. 16 Paradoxically, the presence of PTSD symptoms may be the stimulus promoting post-traumatic growth, rather than negating it. In a study of 3157 veterans, 50.1% of all veterans and 72% who screened positive for PTSD reported a moderate degree of posttraumatic growth in response to their worst traumatic event. 17 Of note was that the association was curvilinear, with posttraumatic growth arising in response to moderate, but not mild or severe PTSD symptoms. This observation gels with the PTSD severity scores in the wounded Iranian protestors which on average fell in the 1.0–1.99 or average range. What is also particularly germane in this regard to the Iranian protestors who were blinded or partially blinded, is the observation that posttraumatic growth has been linked to a purpose in life 17 and social and political antecedents. 18 This resonates with how Iranian protestors who had lost or partially lost their sight, viewed their wounds, namely “as a source of pride and honour, a badge of their having stood up and been counted.” 19 This pride is reflected in the manner in which some of these protestors wanted to divulge their identity and willingly posed for portraits that graphically revealed their disfigurement (Figure 1).
Our study has a number of limitations. The data were collected clandestinely by journalists, not trained mental health research assistants. There was no other way to obtain this information as these intrepid journalists working underground had established links with some of the protestors. Iran has a very poor record when it comes to targeting journalists 9 and ranks 177 out of 180 countries on an index of press freedom. 20 As such, collecting data like these are not without risk to journalists and protestors alike for we have previously described the degree to which Iranian journalists who call out the country's regime on human rights issues are arrested, tortured, intimidated and have their families threatened. 9 Our data limitations include the potential for bias from convenience sampling as we could not reach a bigger sample of those wounded. We also could not rate the severity of non-eye wounds sustained which limited our ability to understand better the psychological differences between journalists with eye wounds and those with non-eye wounds. In addition, we lacked information on the kind and duration of psychotherapy received. We also did not include a psychometric measure of posttraumatic growth for we did not anticipate this possibility, as our a priori hypotheses make clear. In this regard, we do not know why almost half the sample who were wounded did not answer the questions about potential positive psychological effects of protesting which again raises the potential for bias in the data acquired. We also recognize that the wording of the question pertaining to any possible positive effects of protesting may have biased responders to answer in a positive light. Finally, our data were cross-sectional which limits conclusions as to psychiatric and functional outcomes.
Future research, if the opportunity presents itself—which cannot be taken for granted given the instability of the domestic situation in Iran with all its intendant risks for protesters—should include the use of a posttraumatic growth questionnaire (ideally validated in Farsi) and collecting longitudinal data to ascertain the medium to long-term psychological consequences of being wounded/blinded.
Before concluding we acknowledge that clandestinely collecting data potentially places both the journalists and protestors at further risk. However, participation in the study was completely voluntary and all who took part were acutely aware of the risks involved. Moreover, it needs emphasizing that both journalists and protestors involved in this research project required no encouragement to take part as divulging trauma-related symptoms by extension also highlighted the harshness of their country's regime. Willing participation can therefore be viewed as one more opportunity for dissent.
Conclusion
Our conclusions must be considered preliminary given data limitations. The information that we could collect under difficult circumstances is incomplete and we also cannot rule out selection bias in our convenience sample. Our study nevertheless highlights the behaviour of a regime that cannot tolerate dissent while providing a brief window, albeit potentially selective, into personal resilience. Grievous physical injury and symptoms of PTSD and depression may be found alongside perceptions of benefitting positively from protesting. Although we did not directly address posttraumatic growth in our study, our findings raise the possibility that this phenomenon, fuelled by social support, 21 may mitigate the negative psychological effects of exposure to life-threatening violence. Whether these putative benefits endure remains uncertain but surely worthy of further research, preferably longitudinal, circumstances permitting.
Footnotes
Acknowledgements
The authors would like to thank Maziar Bahari and Marija Milosavljevic for their invaluable assistance in conducting this study. We would also like to express gratitude to the Globe and Mail and Liz Sullivan, Deputy Visuals Editor at the Globe and Mail, for permission to use Figure 1.
Data Availability
The data are available for public access by written request to the principal author.
Declaration of Conflicting Interests
The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article:: Anthony Feinstein has received grant support from MS Canada and CIHR, Book Royalties from Cambridge University Press, Johns Hopkins University Press and G Editions and Speaker’s honoraria from Novartis and Merck. Sophia Marchetti declares no conflict of interest.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by Journalism for Change, a not-for-profit organization.
