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Sexual reproductive health: Life lessons

Despite being a key issue, Pakistanis still whisper when it comes to sexual reproductive health. DESIGN : TALHA KHAN

“I was nine years old when I started sprouting. I was not made to wear a trainer. Mykhala (aunt) came to me and said ‘no one should know that you are growing up. I will teach you how to hide it.’” She took two big coins, placed them on my chest at the right spot, and tied a long piece of cloth over it tightly.‘Never let a man kiss you, otherwise you will become pregnant’, she said. I was nine! I recall my uncle kissing me on my cheek and me crying all night thinking now I was pregnant and God would never forgive me.” Saima*, an educated working woman from Karachi, is now 39, married, and a mother. Yet, she still feels that the way she looks at sexuality is not normal but is unable to alter her thinking. For the longest time, she could not fully enjoy physical intimacy with her husband either since there was a sense of guilt “as if it is something wrong,” she shares.

This sense of shame that society conditions into people when it comes to matters of the body starts very early on. The man at the grocery store will very deftly look away the moment a woman asks for sanitary napkins and pack them in a brown paper bag. Most Pakistani daughters will not ask their fathers to buy sanitary napkins for them. Menstruation comes as a shock to many Pakistani girls. With a still relatively young average age of marriage of women in Pakistan, many women and even men confess that they did not know enough details of the conjugal relationship till they got married. Zareen*, a USA-based doctor shares that despite having done her MBBS at the time of her wedding, her knowledge was so bookish that she knew almost nothing. “The experience was horrendous,” she says. “My ex-husband was also young at the time and his sources of information about sex had been very wrong. I think we were never able to develop a normal bond.” 

Shame shame

This halo of shame that surrounds any and everything that has to do with a young body morphing into adulthood has dire consequences. Yet, there is still immense reluctance about discussing the matter with young adults.

“Lack of awareness  pushes young people to reach out to any source of information out of curiosity,” says Maliha Zia Lari, lawyer and human rights activist. “Questioning sexuality at a certain age is a natural occurrence, but the social clamp down further fuels the curiosity. As a result, they do learn about it, but they learn it [the] wrong way.” In Lari’s experience, this leads to dangerous things like unnatural experimentation, and often with the wrong people. Even young males are exposed to the risk of contracting sexually transmitted diseases (STDs) or being emotionally exploited by ill-meaning men or women. Lari adds that this is one reason why human rights activists discourage early age marriages. “We teach people to be ashamed of our bodies, not to take ownership. A young mind has so many unanswered questions,” she says. Contrary to popular belief, research also proves that awareness about Sexual Reproductive Health (SRH) does not promote promiscuity in adolescents. In fact, it makes them more cautious.

‘The talk’

Survey of a cross section for this write-up reveals that most parents in Pakistan do not talk to their children about SRH, and if they do, the onus falls on the mothers. According to a study conducted by Marie Stopes Society in selected districts of Pakistan, the onset of menstruation was associated with anxiety in 47% girls as only 13% of them reported receiving information about puberty before the onset of menstruation.

Data from a 2013 baseline study conducted by Aahung (a non-profit organisation that concentrates on SRH) in four districts of Sindh, with adolescents as subjects, showed that only 34% adolescents would talk to their parents about pubertal issues. Nearly 49% of those questioned believed that AIDS is a curable disease, which means they were not aware of the possible dangers of unsafe sex either.

For Hira*, a mother of three, the experience was one typical for most Pakistani girls. “I came to know about puberty the day I had my first period. I went running to my mom who just told me that this happens to girls and that this is ganda khoon (bad blood) that needs to come out of the body. And I must not tell anyone about it as its one big secret,” she shares. She confesses that she learnt about feminine hygiene or issues related to puberty on a trial and error bases. “Only the basic information of how to use depilatory creams was provided, but nothing about when and where.” Her knowledge of the physical intimacy between men and women and how babies are born remained limited to that from Bollywood movies. “I thought you meet a boy, and then two roses dance together in a park, and you have a baby,” she laughs and says that she was told that “achi larkiyaan is baray mein baat nahi kartin”(nice girls don’t talk about these things).

“Once I begun menstruating, my mother would keep drumming one thing in our heads: do not commit adultery, it is one of the major sins,” shares 25-year-old Maria. Such a warning from mothers may not always be a bad idea. However, she acknowledges that her mother’s choice of words was harsh. “For the most part, I thank her for that. I have been tempted many times but never crossed a line and that has saved me from many an emotional disaster,” she admits. Maria’s idea of sex, however is so plagued by a sense of guilt that she fears she will feel guilty initially even with her husband after getting married. “It will take me time. But I would give the same training to my daughters,” she says.

Educationist and motivational speaker Abbas Hussain strongly endorses the practise of parents talking to children about SRH, albeit sensitively. Interestingly, Hussain feels that, “Urban mothers prove to be big prudes, whereas rural mothers see this very important part of human life as a part of nature. Such are the idiocies of urban life that a cow giving birth to a calf is not considered normal,” he adds.

Will daddy talk to his son?

“Fathers take very little interest in the sexual education of their children, even boys, as the common notion is uss key doston ney bata diya hoga (his friends must have told him). Men are generally shier then we think,” says Hira. “My father never talked to me about these things,” shares 20-year-old Shehryar Imran. However, he feels it is very important for adolescents to be adequately informed about the changes their bodies are going through “without having to rely on clandestine conversations with peers who also may not be fully informed,’” he says. “In order to combat the spread of STDs, it is imperative to target the root cause of the problem: breaking the unhealthy taboo surrounding sex.”

The ‘talk’ at school and choice of words

Hussain also stresses the importance of teachers’ role when it comes to SRH. “Senior teachers can play a huge role, but in this I am very clear about the gender segregation — male teachers for boys and female teachers for girls,” he says, adding that sensitive and cultural sensibilities need to be respected. He also stresses the importance of chosing words carefully. “Using the term ‘sex education’ deflects from the real issue; this term is the red herring,” he adds.

Maliha Noor, manager communications at Aahung, endorses using “culturally appropriate language.” Hence, Aahung’s successful awareness programme on the subject is called Life Skills Based Education (LSBE). “This should be included not just in school curriculum but even our medical practitioners in the making should be taught about this,” says Noor. “Often, doctors and nurses know the biological details but don’t know how to handle queries about it.” Aahung’s LSBE curriculum covers a range of issues including pubertal changes, gender discrimination, HIV / AIDS, protection from violence, peer pressure, rights within the nikah nama, and family planning. Part of the programme also concentrates on training teachers. “When students would talk to us about their issues, we would often not take them seriously and even joke about them,” confessed one of the teachers trained by Aahung. After the training, she has learnt how to handle these queries sensitively.

*Names have been changed to protect privacy.

Farahnaz Zahidi is a senior subeditor at The Express Tribune. She tweets @FarahnazZahidi

Published in The Express Tribune, Sunday Magazine, January 25th, 2015.

Cervical Cancer – Save yourselves with a Pap Smear

Cervical cancer is a growing cancer in Pakistan. It is one of the few cancers that are contracted, in more than one ways. It is, however, more often than not, contracted through unprotected sexual contact with a carrier. The human papillomavirus (HPV), a sexually transmitted infection (STI), in its various strains, is what mostly causes cervical cancer. Thus, a sexually active woman is at risk of contracting the virus. Married or not.

Often the carrier, if a man, will not be affected by the virus himself, but will transmit it to the woman. The vaccine that protects against it, though still being studied upon, is available in Pakistan. Expensive, yes, but potentially life-saving. The best time for a girl to get the vaccine is before the years she becomes sexually active. Hence, teenage years are a good time to get vaccinated against HPV. But in Pakistan, we see a resistance to the idea of getting teenage girls getting this vaccine.

The reason for this resistance, according to Dr Azra Ahsan of the National Committee for Maternal Neonatal and Child Health (NCMNH), is this: “We like to idealistically believe that in Pakistan, sexual relations take place only within marriage. Thus we brush aside the issue of safe sex. And even within a marriage, a woman may be at risk of contracting STIs from her husband. Thus, we encourage that the vaccine be given to girls before them becoming sexually active.”

HPV types 16 and 18 are thought to be the causes of nearly 70 per cent of all cervical cancer cases that occur globally. There HPV may also be a cause of other anogenital cancers, and head and neck cancers.

As it can be sexually transmitted, the incidence of cervical cancer in Pakistan is probably much more than we like to believe. The taboos linked with screening for STIs and the lack of awareness even among educated, urban women that a simple Pap Smear test can be a life saver points in this direction.

When asked which groups of women are most likely to develop cervical cancer, Dr Ahsan says, “Women from poor socio-economic status are the most common victims. Reason could be an absence of early detection. Women with multiple sexual partners also fall in the higher-risk group. Also, women who have had many children tend to be more at risk, as each child birth can cause injury or trauma which can trigger a dormant disease.”

In a country where nine per cent of young women aged 15-19 have begun age bearing, and uneducated young women are more than ten times as likely to have started child bearing by age 19 (according to the 2007 Pakistan Demographic Health Survey — PDHS), the clear indication is that a sizable chunk of the female population, especially in rural or underprivileged areas, becomes sexually active at a young age. Within marriage or outside would hardly be a debate of consequence with reference to the HPV vaccine.

The Total Fertility Rate (TFR) in Pakistan, though has declined, still holds steady at 4.1 children per woman on an average (PDHS).

Fortunately for Pakistan, prevalence for HIV is extremely low with only one-tenth of one per cent of the population affected (Reproductive Health at a Glance, April’11, The World Bank). But use of contraceptives, especially as protection against acquiring STIs which includes HPV, remains low, with only 20 per cent of ever married women (age15-49) using condoms (PDHS). However, even condoms do not provide 100 per cent protection against the highly contagious HPV. Apart from monogamous relations with a single uninfected partner, early detection is the key where cervical cancer is concerned, because by the time the patient starts showing signs, it has already progressed considerably. Once a woman is infected, it can take between five and 20 years for the virus to develop into full cancer, with no symptoms in a lot of cases.

Around six decades ago, a doctor from Cornell University discovered that precancerous cells from the cervix could be identified before they turned lethal. The finding made scientists re-think the screening and treatment of cervical cancer. Dr George Papanicolaou’s “Pap Smear” test became popular. Within the following 20 years, deaths from cervical cancer in the USA decreased by 74 per cent.

The situation, however, is drastically different as far as the developing world is concerned. In today’s world, cervical cancer is primarily a disease found in low-income countries. Annually, nearly 500,000 new cases occur, and out of these, 83 per cent are in the developing world. 85 per cent of the 274,000 deaths associated with cervical cancer are from the developing world. South Asia alone is home to one fourth of the cases of cervical cancer.

According to a World Health Organisation (WHO) study from 2008, Pakistan’s incidence of cervical cancer in 2008 was 19.5 per 100,000, compared to less than 9 per 100,000 in 2002.

The study reported that cervical cancer deaths stood at 12.9 per 100,000 nationally, said Dr Muhammad Tayab, speaking at a press conference organised by the Health Awareness Society (HAS) in October 2010.

A solution came to my attention in a bigger way on a recent visit to Ethiopia, as part of a team called “Women’s Edition” of female journalists from developing countries. Population Reference Bureau (PRB) which organises the Women’s Edition is a Washington DC-based organisation that informs people around the world about population, health, and the environment.

On a visit to St Paul’s Hospital’s Cervical Cancer Prevention Unit working under Pathfinder, a starkly simple solution for early detection of cervical cancer in an economical and effective manner stared at me. The Unit consisted of three tiny rooms with the simple most equipment, and an old steel bed for patients. A senior nurse professional met us, who heads the small team responsible for detection of the earliest signs of cervical cancer of so many women, and in turn saving their lives.

Pap Smears can detect it, but Pap Smears are expensive. And people in Ethiopia or Pakistan are often underprivileged. At St Paul’s, they are using a far less expensive method to screen women for signs of cervical cancer. The method is one of direct visualisation with acetic acid and has gained popularity and proven itself as an adequate alternative to PAP smears in developing countries.

In visual inspection with acetic acid (VIA), 5 per cent acetic acid is applied to the cervix with a large cotton swab and left for 30-60 seconds, after which the cervix is visually examined with the naked eye and a lamp. Pre-cancerous lesions, with a higher ratio of intracellular proteins, turn white when combined with acetic acid. Normal cervices without any precancerous lesions, do not change colour. It is low-cost, requires fewer visits to the physician and the efficacy is about 5 years.

“VIA in Pakistan is done in small pockets, but not enough. In Pakistan, there is no structured screening programme for cancers. VIA is a low-cost method. Medical technicians, if trained, can also do it. Thus, it is a good solution. It should be encouraged that VIA units be set-up in public hospitals,” says Dr Ahsan.

It is time that we seriously think about methods like vaccination against cervical cancer, as well as Pap Smear or VIA, depending on affordability, for early detection. Brushing issues of diseases spread through STIs under the rug will not help solve these growing problems. Acceptance and then looking for solutions — that is the key.

Originally published in The News: