Introduction

Spinal cord injury (SCI) is a life-altering experience, with motor, sensory, and autonomic problems affecting marital life as well as other aspects of one’s life [1, 2]. Globally, the annual incidence of SCI in various countries is significant, ranging from 10.4–83 cases per million [3]. In Iran, the prevalence of SCI is an estimated 318 (95% CI: 312.98–324.54) per million [4, 5].

Marital life is undoubtedly affected by the consequences of SCI. The short- and long-term effects of SCI on marital life have attracted attention from public health scholars [6,7,8,9]. Marital stability, post-SCI difficulties, and divorce are interwoven and provide researchers and experts with many avenues of research. A number of studies have focused on dyadic relationships from the onset of SCI until divorce. DeVivo et al. [6] observed that divorce and separation rates within 3 years of SCI were 18.8% in the USA, which was higher than expected.

According to the literature, individuals who have experienced SCI marry less frequently and divorce more often than those without SCI [6]. Furthermore, those who marry after SCI have a lower divorce rate than those married before the onset of SCI [10].

Much of the existing literature focuses on the factors threatening post-injury sexual and marital life. Marital stability and sexual satisfaction are two aspects of marital life that affect quality of life; the better the quality of life, the higher the life satisfaction and marital adjustment. Individuals with SCI also are no exception [10, 11]. This lifelong physical disability affects the quality of interpersonal communications between couples [7, 12]. It can alter dyadic relationships, sexual behavior, and the fervor for sexual activity previously present in a couple’s marriage. Difficulties associated with sexuality and reproduction are major complications of SCI, the severity of which depend on the location and degree of the injury [9, 13]. Decreased sexual arousal and orgasm in women with SCI, as well as erectile dysfunction and impaired ejaculation and orgasm in men with SCI are well documented [14, 15].

Divorce in Iran and its related factors

Iran is experiencing a rising divorce rate. Research has identified numerous factors contributing to divorce, including economic, psychosocial, and social issues [16,17,18]. Financial difficulties such as a rising cost of housing, a high unemployment rate, and inflation can contribute to divorce. Economic hardship adds stress and increases the risk of marital conflict and the likelihood of marriage dissolution [19]. Other risk factors are psychosocial and social, including a lack of compatibility and understanding, not meeting partners’ psychological needs, domestic violence, personality conflicts, gender inequality, problems with children, lack of responsibility, family interference, cultural differences, differences in educational level, drug and alcohol use, infidelity, and sexual dissatisfaction [20].

Divorce and SCI

To the best of our knowledge, limited research has been conducted on divorce among Iranians with SCI. Recently, according to a study conducted on 119 individuals with SCI referred to the Brain and Spinal Cord Injury Research (BASIR) Center in Tehran in 2012, the rate of divorce in Iranian individuals with SCI compared to the general population was noticeable (men: 2.5% vs. 0.7% and women: 5.3% vs. 1.4%) [16]. A possible explanation is that the available research did not consider the possibility that marital status could be threatened by physical, psychological, and social alterations post-SCI [10]. More explicitly, there is limited research-based knowledge of the culture-bound nature of divorce in the Iranian context: it is yet not a concern of healthcare officials at different levels of the healthcare system. Concerns related to divorce are not officially defined by the health system in Iran and The Social Welfare Organization is responsible for any services to divorcees. Most services focus on social consequences of divorce, thus inadequate emphasis is paid to post-SCI divorce and its determinant factors among affected Iranians. In this study, we sought to delve into the perceptions of Iranians with SCI on divorce.

Methods

Study design and objectives

A qualitative study was conducted from March 2018 to July 2019 aimed at understanding how Iranian individuals with SCI perceive post-SCI divorce.

Participants

First, we found active profiles of participants who registered in ‘Protection Center of Spinal Cord Disables’ and listed individuals who were divorced. Then, by calling with telephone, we invited them to participate in focus group discussions (FGD). From 70 divorcees with SCI, 9 men and 11 women were willing to share their experiences through interviews. They had been referred from all parts of Iran to the ‘Protection Center of Spinal Cord Disables’. Those who were 18 years and older, who were able to speak Persian, and without preexisting factors at play prior to injury in the relationship, were included in the study.

Procedure

A short lecture was given in ‘Protection Center of Spinal Cord Disables’ to post-SCI individuals in which we explained the research goals and invited those who were divorced to be interviewed. Data were collected through ten semi-structured individual in-depth interviews and two FGDs. The interviews were conducted in a manner in which participants could express themselves freely, in their own words, and through an open and flexible process [17]. Each interview lasted for 30–45 min. The interviews focused on the participants’ perspectives on post-SCI divorce.

The third author (FZ) used the interview guides to ask open-ended questions exploring the participants’ viewpoints on divorce in the context of SCI. She is an expert in post-divorce life study. Discussion was opened by asking the main question as “How did you experience divorce after SCI?”. The interviews were audiotaped and transcribed verbatim before data analysis was undertaken. The interviews were conducted in Persian and analyzed in the same language. The quotes used in this article have been translated into English, only after the analysis was carried out. The sampling process continued until we achieved data saturation. The socio-demographic and clinical characteristics of the participants are listed in Table 1.

Table 1 Socio-demographic characteristics of participants with SCI (n = 20).
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Analysis

Braun and Clarke’s thematic analysis approach [18] was applied to extract the meanings the participants used to conceptualize the concept of marriage. Thematic analysis is a type of qualitative analysis that allows one to classify and present themes relevant to the data [19]. Thematic analysis is able to detect and identify factors or variables that influence any topic brought up by the participants. In the present study, each transcription was evaluated as a whole, and fundamental meanings or their general contexts were described in one or two paragraphs. Throughout the six stages recommended by Braun and Clarke, we coded the narratives to familiarize ourselves with the data. Searching, reviewing, defining, naming, and writing themes were the remaining steps we took to complete the analysis.

Trustworthiness

The trustworthiness of the findings was determined as follows. Credibility of the data was established through prolonged engagement, immersion in the data, and member check with ten participants. Dependability was checked by external audits and conformability was ensured by peer review (colleagues from other research centers). We tried to employ maximum variation sampling by selecting participants of varying SCI states and socio-demographic status to enhance the generalizability of the data [20].

Results

The response rate was 28.6% (20 of 70). All participants reported their diagnosis as incomplete paraplegia (Table 1).

One main theme and two subthemes were identified in the analysis of the interviews (Table 2 and Fig. 1). In the presentation of the results below, each sub-theme and its relevant codes have been explained; for each sub-theme, the exact phrases voiced by some of the participants have been quoted in italics.

Table 2 Relationship between themes and subthemes.
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Fig. 1: Relationship between themes and subthemes.
figure 1

Asterisk indicates gender role implicitly as a mediator on post-SCI divorce.

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Post-SCI divorce was conceptualized in terms of ‘some contextual scenarios for post-SCI divorce’. Following the perceived contextual scenarios several efforts had been made to maintain post-SCI marital stability, which had proven fruitless. We explored the scenarios related to post-SCI divorce in terms of its predisposing scenarios and identified them as ground-breaking scenarios for constructing a decision process for post-SCI divorce. The participants’ viewpoints on their post-SCI marital status indicated how they had struggled to maintain their marital stability.

Contextual scenarios for post-SCI divorce

Predisposing scenarios of post-SCI divorce

Most of the participants perceived several ground-breaking scenarios that led to the decision to divorce after injury. The major predisposing scenarios voiced by the participants were, the role of ‘important others’ in their lives, the individual perceptions on the consequences of disability after SCI, perceived threats following SCI, and individually perceived fears after SCI.

The role of ‘Important others’ in post-SCI divorce decisions

Lack of support from spouse’s family

Participants believed that their families affected their decision to terminate marital life. Support from the spouse’s family was less following the injury. In fact, the injured bride or groom received less financial or emotional support from the spouse’s family. To put it simply, blood relations of the uninjured partner more often proposed divorce.

“After the accident I stayed at my mother-in-law’s house for a while. During that time, she told my husband that I was not fit for him anymore, so he should consider divorce.” (35-year-old female)

“After falling I lost my job; my wife told her family about it and they criticized me. They said that I was responsible for living expenses and that we should get divorce.” (40-year-old male)

Interpersonal conflict

The participants believed that SCI affects familial relationships as a communicative link between couples.

“My mother-in-law said: Since your disability is permanent my son deserves to have a healthy woman.” (42-year-old female)

My father-in-law said you are no longer a man [you have fertility problems], my daughter has to become a mother in the future, and you are not fit for her (40-year-old male).

Perceived consequences of disability after SCI

Altered sexual function

Based on the participants’ experiences, SCI affected their sexual activities and reproductive health. They believed that sexual satisfaction and fertility were the most important achievements of marital life. After the injury, altered sexual function affected the durability of their marriage. In fact, the participants perceived that their spouses’ decisions to tolerate or discontinue their marital relationships were strongly influenced by their sexual competence and fertility status.

“In the courtroom, my husband said: I cannot continue with this woman anymore, as I want to have a child and she is unable to give birth to a baby.” (41-year-old female)

“I had no fertility problems; I had a sexual problem my wife told her family about it and they reproached me. They said that I was impotent and that I could not sexually satisfy my wife.” (42-year-old male)

Difficulties in marital relations

Post-SCI conflict between couples is another factor that makes marital dissolution more likely. Participants believed that conflicts arose from feelings related to changes in their physical abilities. Feelings of shame associated with having a physically disabled spouse, feelings of unattractiveness, and feelings of dependency and the need for support for personal chores (such as going to the bathroom), all have negative effects on couples’ relationships.

“Although my husband was the one who had caused the accident, the first time he wanted to push my wheelchair, he said he was embarrassed to do so.” (45-year-old female)

“But after this (SCI) happened to me, I needed help with a simple commute, even for toileting” (40-year-old male).

Perceived threats following SCI

Contrary to the struggle for maintaining the marital relationship on the part of the injured spouse, the uninjured spouse sometimes employed certain tactics to dissolve the relationship. Most of the participants believed that these tactics were associated with financial, emotional, and physical pressures. Although proposing to leave or maintain the marital relationship costs both parties.

Temporary marriages

According to Shiite Islamic jurisprudence, in urgent cases, Muslim men are allowed to marry on a temporary basis. Although it is legally acceptable to marry temporarily when the wife’s injury is proven permanent, most married women with SCI do not tolerate another woman as their husband’s sexual partner, even temporarily. All the female participants with SCI perceived temporary marriage as a threat toward their marriage.

“My husband said he deserved a temporary marriage because I was sexually impotent.” (44-year-old female)

Extramarital relationships

Most female participants believed that after their injury their uninjured husbands were not interested in staying married. They were also looking for opportunities to remarry on a temporary or permanent basis because their husbands believed they deserved to be married to a woman without a disability. The injured wives believed that their husbands were with lower commitment that were not interested in maintaining their marital life with them.

“My husband’s behavior suddenly changed after spinal cord injury. For example, he had long secret telephone conversations with suspicious contacts… I later found out that he dated with another woman.” (47-year-old female)

Physical abuse

Last but not least, one tactic mentioned for ending post-SCI marital life was physical abuse by the uninjured spouse. The participants believed that this tactic pressurized and persuaded them toward divorce.

“I was not interested in divorce. One day my wife was clipping my nails, as my own hands were paralyzed. She cut my nails so badly that my fingertips bled. My mother asked her why she hurt me. She replied: I want to convince him to divorce me.” (40-year-old male)

“Because I was not interested to separate, shortly after my accident he would lock me inside the house before going to work. He would also empty all the stuff in the refrigerator so that I get starved”. (39-year-old female).

Perceived fears following SCI

Most of the participants revealed several inhibitors of divorce-related decisions after injury. Perceived fears of the probable consequences of post-SCI divorce were the main inhibitors voiced by the participants.

Fear of social stigma

Participants believed that regardless of their long-term disabilities, divorce would stigmatize them socially. Feelings of fear of social labels originating from the cultural concept of divorce was another obstacle for not giving up marital life easily.

“I think spinal cord injury is a type of disease, like cancer. So, merely being wheelchair-bound is not a sufficient justification for divorce. I will be stigmatized for divorce as well.” (35-year-old female).

Fear of loneliness

The fear of living alone after divorce was one of the most common psychological concerns expressed by the participants. They believed it would be very difficult to afford daily expenses alone and to perform their daily activities.

“After divorce I began living with my old mother. My only wish is to die before her. If she dies before me, I will have no one to do my chores for me, as my hands are no longer capable.”(39-year-old male)

“I’m so desperate- I can’t stand on my two feet anymore, nor rely on the support of my family.” (40-year-old male).

Inhibiting scenarios of post-SCI divorce

Lack of successful efforts to maintain the relationship

Several efforts to maintain marital stability after injuries were reported by the participants. Usually, couples that experience an injury are not interested in ending their relationship. To achieve this aim, several tactics and efforts are undertaken by these couples.

Perceived appeasement (waiving alimony, dowry, and mahr)

All participants believed that their efforts to stay married cost them a lot in both tangible and intangible ways. Waiving alimony, dowry, and mahr (a Mahr or mehrieh is a mandatory payment, in the form of money or possessions paid by the groom, to the bride at the time of marriage}, are examples.

According to some of the female participants, waiving certain marriage rights –such as alimony and dowry- was an effective means of staying married.

“After I had an accident my husband wanted a divorce. I said: I’ll give you everything I have, but stay with me.” (47-year-old female)

“After the spinal cord injury my husband said we should get divorced. I said that I would waive my alimony and dowry but that I didn’t want to get divorced, because I was afraid of divorce; I feared loneliness.” (42-year-old female)

Sexual silence

Most of the participants of both sexes believed that their low sexual ability because of their physical disability caused them to pretend to experience sexual satisfaction and playing roles during sexual activities. According to them, remaining sexually silent was another way of avoiding marital termination.

“After my injury I did not enjoy sex, but I pretended that everything was normal and that I enjoyed it. I was afraid that if he found out about this defect he would decide to take a break or to embark on a temporary marriage.” (45-year-old female)

Discussion

Maintaining a marriage is a difficult proposition for both men and women with SCI. It seems that marriage, divorce, and sexuality are gender-specific concepts. The results of this study showed in the socio-cultural context of Iran that divorce after SCI is also understood as a gender-specific phenomenon. According to the participants in this study, gender was implicitly used as a mediator for creating contextual scenarios for SCI divorce. Temporary marriages and extramarital relationships were also seen as a threat by women rather than men. Such behaviors were more common in men. In fact, these behaviors in healthy husbands with injured women are reinforced by cultural and religious teaching factors. In such marital relationships, the injured partner is usually unwilling to withdraw from marriage, and is more likely to try to maintain the relationship. However, these attempts appear to be fruitless. In order of priority, participants believed that the effects of ‘important decision-making people’ and the ‘perceived consequences, threats and fears following SCI’ were the most important scenarios causing divorce.

In the traditional frame of marriage and family in Iran, any related issues and decisions will be affected by family structure. Close relatives of the affected couples were the most important predisposing factors for separation and divorce. In other words, the participants believed that their decision to divorce had been influenced by the encouragement of their families who lost loved ones, such as their parents and close friends. It seems that analyzing the concept and nature of the role of family members in understanding this belief would be helpful. It is taken for granted that family is the first and most important social institution. There are differences between the dimension, type, and scope of relations in nuclear and extended families [21]. Despite the emergence of modernity and the development of nuclear families, there is a mutual dependence among Iranian family members, even after a child’s marriage. In other words, a child’s marriage does not result in a complete disruption of relations between parents and child. Hence, the emotional and financial dependencies between children and parents are not completely disconnected after marriage. Accordingly, parents still play determining roles in their adult children’s most important life decisions after marriage, such as those regarding childbearing, divorce, and even re-marriage. Hence, it is the will of the group (family and relatives) [22] that eventually overcomes that of the injured person’s decision regarding his/her marital status.

In Iran, in most cases men are responsible for family finances. After SCI, due to the loss of his job the married man would not be able to afford the family finances. Although the women in this study were more highly educated, far more of them were unemployed housewives and financially dependent on their spouses. The results of our study shed light that for a woman with SCI, instead of helping and supporting, her non-injured spouse’s family is likely to play a persuasive role to ensure divorce. In the opposite scenario, when the husband is injured, a woman would be encouraged by her injured spouse’s family to continue her as a care giver. In this scenario the woman’s femininity is marginalized.

Perceived consequences individuals with SCI conceptualize following SCI prepare the grounds for divorce among the affected couples. Based on the experiences of our participants, some of the most important perceived consequences of SCI were classified under two categories: low sexual ability, and difficulties in marital relations. It is believed that sexual relationships are affected notably by injury. According to a recent qualitative study in Iran, individuals with SCI perceived limitation in their sexual activity resulted from problems such as no genital sensation and inadequate vaginal lubrication.

Moreover, they highlighted sexual problems, including anorgasmia, no genital sensation, as well as low sexual desire and inadequate vaginal lubrication [12, 15].

Fear of the social stigma associated with divorce [23, 24], and fear of disapproval from society were perceived concerns among the injured partners. They believed that they did not deserve to continue to live with a healthy (uninjured) spouse. This belief stems from organ failure, altered sexual function, fertility problems, exclusion, and social disapproval. The role of gender has also overshadowed fears perceived by women. Most women in this study were afraid of being rejected by family and society as well as being stigmatized after a divorce [25]. Divorce seems to be understood and interpreted in Iranian women based on gender, and the social acceptance of an Iranian woman depends on her marital status.

Thus, individuals with SCIs considered the socio-psychological consequences of SCI as one of the most important determinants of the decision to divorce. In line with the participants’ perceptions, scholars believe that divorce is essentially a traumatic phenomenon and crisis, the most important features of which are unsettled conditions and disruption of affairs, affecting all of the individual’s issues [26,27,28]. Therefore, frustration associated with hopelessness for rebuilding an uncertain future nurtures the fear of divorce.

Participants in the study narrated how their marital life had pushed them toward divorce. They believed that their spouses were less likely to maintain the relationship. Therefore, the quest for staying or getting out of the relationship and divorce was accompanied by a series of tactics and strategies. Following SCI, the predisposition of the injured spouse to end the relationship is less compared to the healthy one. Upon analyzing this difference, participants believed that since SCI could affect sexual functioning of the injured spouse, sexual dissatisfaction from altered sexual function was expected in the marital relationship [29, 30].

Hence, the spouse with SCI always finds this inability in himself/herself and seeks and understands sexual dissatisfaction of his or her healthy spouse, and feels embarrassed and guilty of being unable to meet his wife or her husband’s sexual needs. Therefore, they try to sustain the marital relationship by playing roles and pretending to experience pleasure during sexual activities. At times, they stay silent even if they do not experience sexual pleasure.

In contrast, the healthy spouse tends to end the relationship more often by adopting various strategies. Including physical, psychological, and financial pressures on the injured spouse. In perceived inhibitors of post-SCI divorce, gender-based traceability was also perceived by female participants. Most of the injured women in this study were not interested in ending their marital relationship. Therefore, they would not want their mahr as a bargain, to maintain their relationship. Although many of these efforts were fruitless, in many cases they were forced to either forgive the mahr or be satisfied with the divorce.

In general, the tendency to get divorced is different in people experiencing SCI, due to the underlying causes before and after the injury. This means that the tendency to get divorced before the experience of injury among couples with common underlying causes is not significantly different from able-bodied individuals. Hence, the most important underlying reason can be sought in the lack of adaptability of the couples to their marital life. Some of the most common factors are the inability to adopt communication skills, problems related to commitment and sexual satisfaction, addiction or psychological problems of each of the spouses, as well as economic problems. The tendency to discontinue the marital relationship after one spouse has experienced SCI can be due to the intensification of any of the abovementioned factors. In other words, the relationship between the tendency to divorce and SCI cannot be understood as a linear and direct relationship; rather, divorce is brought about by SCI and the relationship between these two concepts is an interwoven one.

Limitations

In this study, we tried to explore the perception of divorce in a sample of Iranian people with SCI. However, we only accessed people who were looking for rehabilitative care and social support in the ‘Protection Center of Spinal Cord Disables of Iran’. All subjects examined had incomplete paraplegia. This may be because these individuals had lower levels of disability and were able to travel without someone’s help. They were able to sit during the FGD, which lasted about 2 h each. People with complete paraplegia and tetraplegia may have had increased mobility issues or could not get to the research center due to the distance, and thus did not participate in the study. Therefore, the results of this study share only the experiences of participants. As the main concern of this study was exploring the post-SCI divorce, we particularly focused on all people with SCI who have divorced. For a comparison and a better understanding of the issues leading to divorce after SCI, considering people with SCI who did not have divorced is suggested. Furthermore, to develop a contextual map of couples’ marital transition post-SCI, further studies with the larger sample sizes, and inclusion of post-SCI cases from multiple centers are recommended. This will aid in the development of the generalizability of the lived experience.

Conclusion

The main message of our study is that the participants’ decision to divorce is influenced by their understanding of contextual scenarios of post-SCI divorce. Based on the participants’ perceptions in this study, conundrum understanding the decision for divorce after SCI was a dilemma. We explored some contextual scenarios pushing individuals with SCI to divorce versus sustain their marriage. Our findings suggest decision makers and health providers work to propagate culturally appropriate marital counseling services for couples with SCI. We further recommend researchers explore post-SCI divorce from the uninjured spouses’ perspectives.