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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.

Sex Workers in Heera Mandi are learning to say no to unsafe sex & protecting themselves from HIV & STDs

Learning to say no

Many sex workers are learning to refuse clients who are unwilling to use contraceptives that guard them against HIV, sexually transmitted diseases and unwanted pregnancies, writes Farahnaz Zahidi Moazzam

The infamous red light district of Lahore, known as Shahi Mohalla, and more famously as Heera Mandi, is home to some 1,500 female sex workers (FSWs). These women, along with some 2,000 children that reside in the area with their mothers, live in conditions of abject poverty. Those who fare better move residences to more upscale areas of town.
Female sex workers are often marginalised and lack the power to negotiate safe sex. Mostly, male clients do not want to use contraceptives. Lack of awareness and not practising safe sex means serious risks of contracting sexually transmitted diseases (STDs) and HIV for both the sex workers and clients. For the past few years NGOs have begun increasing awareness among sex workers and in turn helping their reproductive health get better. This involves advocacy and one-on-one campaigning.

The result is encouraging. Many FSWs are now aware of the risks and refusal to a client not agreeing to practise safe sex has gone up. “If they do not agree, I refuse to oblige. So do most of my friends now. I have three children to feed. It is better to lose out on some money than to die of an illness that I catch from someone,” says 29-year-old Mahi (name changed), a sex worker in the area. According to Mahi most clients are students from schools and colleges, and shoemakers from the adjacent market.

The small clinic set up in the area is run by male doctors who cater predominantly to the male prostitutes, clients and the transgender population. Female doctors often do not want to work in the locality due to the taboos attached. Regular screening or check-ups are few and far between, which is why reproductive health of these women is in jeopardy.

Female prostitutes usually go to small clinics, especially for abortions, in a clandestine manner. “The methods these clinics use for abortions are invasive in nature; old and instrumental methods are used for uterine evacuation” says Lubna Tayyab of the Sheed Society (Strengthening health, education, environment, development) that is working towards providing a better life to sex workers and their children in Heera Mandi. These methods, combined with unhygienic conditions in the clinics, pose problems. Tayyab confirms that unsafe abortions claim many lives in this area.

When complications arise, sex workers would be lucky to be referred to nearby public hospitals where they go under aliases.
Traditional Birth Attendants (TBAs) or daais also provide some basic treatment to these women.

Dr Azra Ahsan of the National Committee for Maternal Neonatal and Child Health (NCMNH) warns that the FSWs are at serious risk of contracting HIV and STDs, and getting health complications that arise out of not practising safe sex, which includes unsafe abortions.

“The answer to their health issues lies in prevention before cure: safe sex and correct use of contraceptives. What is advisable for them is the Double Dutch method,” suggests Dr Ahsan. Double Dutch is a name for using two contraceptives together; ‘the pill’ to avoid pregnancy and other protection to help prevent sexually transmitted infections.

According to HIV surveillance conducted by NACP from 2005 to 2009, the overall prevalence of HIV among female sex workers varies among cities; in 2009, a survey across major urban areas found a prevalence of 0.97 per cent. Lack of related knowledge, unsafe practices, and high mobility are the likely drivers of an increasing number of cases over the past decade and the spread to rural areas. The USAID website quotes that high levels of interaction between IDUs (Injecting drug users) and sex workers, coupled with low levels of practising safe sex and HIV/Aids knowledge among persons belonging to these high-risk groups put Pakistan in danger of a broader HIV/Aids epidemic.

Even though the efforts at awareness are making a difference, the dangerous nature of prostitution as a profession means that these women are never completely safe. The perils of this trade are multiple. But if anyone tries to talk them out of prostitution, they often stop interacting. Generations of these women have been in this trade. Change, if and when it happens, will be slow. Consistent effort at helping them make informed decisions, however, remains a solution.

Lurking within

According to the World Health Organisation reports, sexually transmitted diseases (STDs) cause lasting damage to reproductive health in particular. For example, the damage STDs cause to the Fallopian tubes can result in infertility.

One of the leading STDs that result in symptomatic Pelvic Inflammatory Disease (PID) is chlamydia. If left untreated, 10 to 40 per cent of women suffering from chlamydial infections can develop PID. Complications and post-infection damage from this and other STDs are responsible for 30 to 40 per cent of infertility cases. If a woman contracts chlamydia during pregnancy, there are health risks for both her and the infant after delivery. Similar is the case with early syphilis, which, if left untreated in a pregnant woman, is responsible for one in four stillbirths and 14 of neonatal (newborn) deaths.

One of the deadliest sexually transmitted infections is the Human Papilloma Virus (HPV). Virtually all cervical cancer cases are linked to genital infection with this virus. Cancer of the cervix is the second most common cancer in women, with about 500,000 new cases and 250,000 deaths each year. The new vaccine that prevents the infection could reduce these cervical cancer-related deaths.

Genorrhoea is also an easily contracted STD which accounts for 88 million new cases of curable STDs that occur globally each year. The total number, according to World Health Organisation, is 448 million, in which syphilis, chlamydia and trichomoniasis are included. In fact, a 2011 WHO fact sheet warns of emergence in multi-drug resistant bacteria that results in genorrhoea and the threat of a global rise in untreatable sexually transmitted infections.

According to informative literature provided by the NGO, Aahung, that works on sexual health issues, Pakistan is regarded as a “low prevalence, high-risk” country as far as Aids is concerned. This means that while the number of cases may still be relatively low, the stage is set for an epidemic unless transmission is prevented.

The Joint United Nations Programme on HIV/AIDS (UNAIDS) estimated in 2007 that 96,000 Pakistanis were HIV positive, which is approximately 0.1 per cent of the population. But it is commonsense that people are neither screened enough, nor are all cases reported. In 2010, the National Aids Control Programme (NACP) reported that the number had risen to an estimated 97,400 HIV cases.

Among reported infections, heterosexual sex is the primary mode of transmission, accounting for 67 per cent of infections.
Most-at-risk Populations (MARPs) include IV Drug users (IDUs), homosexuals, those who have undergone blood transfusions with inadequate blood screening and migrant communities. Less than 16 percent of IDUs and sex workers have been tested for HIV and know their results and are at high risk of spreading the virus to their spouses or partners. —F.Z.M.

Tales untold

The dark dingy lanes, strewn with litter, open sewage lines and dilapidated buildings are no reflection of the grandeur that Lahore’s Shahi Mohallah must have boasted of in bygone days. The sound of azaan resonates through the area as we walk towards the homes of female sex workers.

Some of these women are just performers; others prostitutes. Most of them will do anything for a few bucks. Poverty has taken away the choice to turn down offers. Hierarchies are clearly defined. Ooncha Chet Ram Road is reserved for performances while the Neecha Chet Ram Road has residences of sex workers. There are singing teachers, musicians, pimps, and brothel owners. This area is an ostracised whole, where basic human rights like health and education are often too much to ask for.

Entering into the small, cramped one-room residence of 34-year-old Seema (name changed), all I see is two old charpoys, her two children sitting with their frail and tired looking mother and a TV with a DVD player. This is her home as well as her ‘work place’.

“Since generations, women in my family have done this work. I am doing it too. Even though I earn around 20,000 a month, rents in this area are so high. Plus, 40 per cent of my earning goes to my pimp. I also need to buy good clothes and cosmetics.
And mine is a physically taxing job. So I need enough and good food to survive. Medication is the last thing I can afford to spend on,” says Seema. Yet, she vehemently says that, “even if I starve, I will not put myself at risk of contracting STDs or HIV, even if I lose clients.” But has she ever been tested for STDs or HIV? The answer is a straight “No”.

Visiting another building of the area, a broken staircase leads me to the apartment of Zari (name changed). A pretty young girl, Zari is cooking a rice and potato dinner. “I don’t belong to this area,” she says, “Extreme poverty and my husband’s joblessness has led me to take up this profession. Gradually through my work, we saved enough money and today my husband drives a rickshaw,” she says with pride. Then why is she continuing to do this now? “We have children to feed. One bread-winner is not sufficient. But I am not willing to risk my life. I only take clients at home and never go with them. And I say no to them if they are unwilling to practise safe sex,” she explains. — F.Z.M.

Sexually Transmitted Diseases or Genetic Disorders for future offspring – Should there be Pre-marital Screening to protect ourselves?

My Feature in Newsline – June 2011 – Pre-Marital screening for STDs