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The challenge of getting family planning “right”: Professor Amy O. Tsui on sexual and reproductive health in India

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The challenge of getting family planning “right”: Professor Amy O. Tsui on sexual and reproductive health in India

2019-11-26

With India facing a plethora of issues related to sexual and reproductive health, ranging from sex-selective abortion to rising rates of infertility, Health Issues India interviewed Professor Amy O. Tsui, PhD of the Johns Hopkins Bloomberg School of Public Health, to discuss India’s family planning, female sterilisation, infertility, female foeticide, and other issues in the field of sexual and reproductive health affecting India.

  • Professor Tsui, thank you for agreeing to speak with Health Issues India. First of all, could you lend an insight for our readers into the work you do?

I am a social demographer interested in population and fertility trends. As I am a faculty member based in a school of public health, I have an interest in social interventions that influence fertility levels, including marriage, abortion, and contraception. Most of my recent work has been based in Sub-Saharan African countries but I have an enduring interest in the population and fertility dynamics of South Asian countries as well. I largely collect and analyse survey data, whether of women of reproductive age, health facilities or clients.

  • What do you perceive to be India’s major challenges in the field of family planning?

Getting family planning care “right” at the societal level is a challenge for many countries, including the United States. Globally sexual and reproductive rights are often politicised and remain contentious even as contraceptive use becomes widespread. India faces several major challenges in family planning, the first of which is the prominence of female sterilisation as the most used contraceptive method and one promoted by the government. Although other methods are available (condoms, pills, IUDs [intrauterine devices, or the coil] and recently injectables), female sterilisation accounts for three quarters of contraceptive use. As a result, a second challenge is expanding contraceptive method choice, including vasectomy. Even though India has a history of providing the latter in the late 1970s, today while slightly over one third of married women are using female sterilisation, fewer than 0.5 percent report their spouses having a vasectomy. Other than condoms, there is relatively little use of other methods, especially for spacing births. A third family planning challenge for India is ensuring equity in couples having informed choice for all family planning decisions, whether to prevent unintended pregnancies or to achieve desired ones. Presently the more privileged segments of society enjoy access to such information and means.

  • Can you identify an area, or areas, where India has made progress in the field of family planning in the past few decades?

Two areas come to mind, firstly India’s progressive record in legislation on elective termination of pregnancy since 1971, amended further in 2002 and, secondly, the transition in norms around family size to where the average women of childbearing age now has just over two births (2.2) and wants just under two births (1.8). Given there are nearly 370 million Indian women of reproductive age today and each has a mother who likely had two or more times that number of births, this transformation of fertility across just two generations is quite profound. Women’s capacity to manage their reproduction has definitely improved. Regarding access to safe abortion, there is still progress to be made but the MTP [Medical Termination of Pregnancy] Act in 1971 preceded the legalisation of abortion in the US by two years. It is easier today for low-income couples to obtain medical abortion pills discreetly from private health providers in India than in the US. I suspect that with more constrained choice of contraceptive methods in India–largely condoms and female sterilisation–some women have felt it necessary to seek out abortions to end unintended pregnancies as a consequence.

  • Can you identify any current programmes targeting female empowerment, fertility, or sexual and reproductive health which are making a difference in India?

Certainly the Government of India’s national family welfare program, which is the oldest in the world, and implemented through the states has had a major impact on couples’ fertility levels, through the promotion of female contraceptive sterilisation use. While by no means perfect, the government’s universal primary education scheme, along with parents’ own investments in private schooling for their children, has led to a dramatic reduction in the proportion of women under age twenty with no schooling. In 2015, the National Family Health Survey of nearly 700,000 households found 31.0 percent of females with no schooling compared to 41.5 percent ten years before. For female welfare, education and access to birth control are powerful drivers of empowerment.

I have brought in two colleagues into this conversation. We are collaborating on analyses of the National Family Health Survey data from 1992-93 to 2015-16 — Dr. Abhishek Singh and Dr. Kaushalendra Kumar from the International Institute for Population Sciences in Mumbai.  They note several government programmes, such as Beti Bachao Beti Padhao, Sukanya Samridhi Yojana and Pradhan Mantri Jan Dhan Yojana which have particularly targeted the girl child and women. BBBP focuses on states and districts in northern India where the child sex ratio at birth is very imbalanced (in favour of males) and seeks to raise awareness of gender equity. SSY encourages parents’ savings for young daughters’ education and marriage expenses. PMJDY has helped open bank accounts with no minimum deposits required to enable females and males to access modern-day financial services more readily. While these are all relatively recent initiatives under Prime Minister Modi, they have the potential to significantly improve educational opportunities for girls and women (and thus their employability) and transform their resource base. It will take time before the full impact of these schemes can be appreciated but they are steps in the right direction.

  • India’s sex ratio is heavily skewed, with far fewer girls and women than there should be. What drives this imbalance?

Imbalanced sex ratios, in the sense of more boys than girls being born over what is naturally expected, is a problem in China, South Korea, Taiwan and other places in Asia, although not to the extent as is observed in India. Social norms around male roles in society sustain the desire of couples to ensure a male heir among their offspring. Patriarchal customs can protect land ownership with only males having property rights. At the same time social norms evolve around female roles, such as high dowries commanded to marry daughters off, which lowers the value of females and enhance that of males.

Paradoxically, as India’s fertility rates reach replacement level (2.1 births per woman on average), the demand for sons appears to be increasing. It also appears to be strongest for first births and among the better educated females and wealthier couples. The challenge here is to reduce felt pressures by couples to bear sons and also expand opportunities to females to achieve economically and politically on par with males.

  • Sex-selective abortion is illegal in India but continues to be practised. What do you perceive to be gaps in the legislation allowing for this practice to continue?

This is a very difficult situation to enforce because private conversations of couples around foetal sex are impossible to monitor and health providers are not permitted to facilitate any type of prenatal sex selection decisions of clients.  While authorities will need to persist in enforcement where possible, the eventual solution requires a social re-valuation of sons and daughters until parity in gender value is achieved. The norms around son preference are changing and vary geographically across India; but private decisions can still aggregate up to revealing concentrated imbalances in sex ratios at birth at the national level.

  • As sex selective abortions are continuing to occur despite being illegal, could factors such as providing information to the public help in reducing cases?

I suspect the public is quite aware of gender preferences and discriminations against females. It will be important for social influencers, whether in government or civil society, to promote gender equality and neutralise longstanding opinions about the lesser rights and value of females. One transformative source of influence on public beliefs and opinions is mass media, particularly television and film and their associated celebrities. Positive modelling of the value of females and their lifelong contributions can gradually and permanently alter peoples’ beliefs and behaviors. India has tremendously talented actors, actresses and film producers who could appeal to the social conscience with strong visuals, story lines and re-balance gender preferences. This and continuing education of each generation can correct misguided thinking and actions.

  • Unsafe abortions are commonplace in India. What are the reasons behind this?

It is very difficult to estimate the number of abortions, both unsafe and safe, in most countries.  A recent study estimates nearly sixteen million abortions in 2015 with only one-fourth happening in public health facilities. Another study in nine Indian states suggests that as many as two thirds of induced abortions are unsafe. There are a number of reasons why unsafe abortions appear commonplace – the sheer number of them given unplanned pregnancies resulting from unprotected sex, the legal status of abortions and relatively easy access to abortion means outside of the public sector, and the modest levels of contraceptive use for birth spacing, driven primarily by use of condoms, which have high failure rates. If a woman is not ready for permanent contraception and has limited knowledge of and access to other birth control methods, she is likely to experience an unplanned pregnancy and seek resolution with an abortion. Medical abortion pills are readily available from pharmacies and other private retailers.  However, unless proper counselling and monitoring of the use of pills are provided, which often are not, such access is considered “unsafe”.

Lastly, even though a legal procedure, induced abortion often carries social stigma. Females are embarrassed to report seeking and terminating a pregnancy which means they often resort to informal abortion care or unsafe means.

  • Infertility is on the rise in India. What are the factors contributing to this?

I think the apparent rise needs to be first examined in terms of whether it is voluntary or involuntary childlessness that is increasing.  Possibly it is both. Infertility has as its causes both male and female factors—semen quality, uterine structural issues from pelvic inflammatory disease, exposure to environmental chemicals and toxins and stress for example.  A first challenge is to properly measure the prevalence of these conditions in males and females by which careful analyses can be conducted to determine the patterns and causes.

  • How do you evaluate the Indian government’s approach to issues such as in-vitro fertilisation and commercial surrogacy?

I am not knowledgeable enough about the Indian government’s approaches but certainly a comprehensive national family planning program will address couples’ reproductive intentions, whether to space, limit or have desired births.  This includes addressing infertility issues. Denmark’s public health system, for example, supports assisted reproduction services (in vitro fertilisation) for women irrespective of marital status and sexual orientation and the proportion of births assisted with IVF is rising.

  • In regard to family planning, is there a disproportionate focus on sterilisation, and female sterilisation in particular, as the primary method of family planning in India?

I would say yes.  One finds few countries in the world, particularly with populations as large as India’s, where permanent contraception occupies such a prominent role as a means of birth control.  Female sterilisation is favoured in Central America and China, but women there also use other methods. While female sterilisation is a terminal use status for many Indian women, they appear not to access other contraceptive choices as readily if they wish to space births.  Striking is the extent to which female sterilisation has become the birth control option for less educated and low-income women.

  • Do you feel the emphasis on sterilisation occludes access to other mechanisms of family planning such as contraceptive devices (e.g. condoms)?

The government’s Family Welfare program has recently introduced two spacing methods – Chayya, a once a week oral contraceptive pill, and Antara, a three-month injectable contraceptive.  These offer protection against unplanned pregnancies to breastfeeding women and require minimal attention to use. These help complement the other government-sponsored methods. In addition, the government has been promoting immediate postpartum IUD insertions so that women can leave the birth facility protected with a highly effective method.  With major surveys such as the National Family Health Survey conducted every few years, it will be possible to monitor the uptake of the new methods and observe how the family planning intentions of couples are being realised.

  • Finally, do you have anything you wish to add?

Nearly one in every five women on this planet is Indian (seventeen percent).  Each of them deserves to be born a wanted daughter, be educated, live a healthy productive life and be a contributing member of society.  India should not squander this human resource, which can potentially help accelerate the country’s future economic growth.

Amy O. Tsui, PhD is a Professor in the Department of Population, Family and Reproductive Health of Johns Hopkins Bloomberg School of Public Health and a senior scholar of the Bill & Melinda Gates Institute for Population and Reproductive Health.

Her research interests include family planning, fertility, and related health issues in developing countries and her current research is on the effects of various family planning and health service delivery models on contraceptive, fertility, and sexual health outcomes in sub-Saharan African and other low-income countries. She obtained an MA degree from the University of Hawaii in 1972 and her PhD from the University of Chicago in 1977. Among her honours are the Champion of Public Health award from the Tulane School of Public Health and Tropical Medicine, 2005; the AMTRA Award, JHSPH, 2006-07; the Golden Apple Award, JHSPH, 2009; and the Carl S. Schulz Lifetime Achievement Award, Population, Reproductive and Sexual Health Section from the American Public Health Association, November 2010. 

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If you were a girl: Men, this is what you need to understand about women and violence

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If you were a girl: Men, this is what you need to understand about women and violence

COMMENT

The body swap is an old Hollywood trope: Boy meets girl, boy swaps bodies with girl, boy has epiphany about love, life and patriarchy. Too bad that in 2019, this kind of empathy is still just the stuff of movies

The brutal rape and murder of 19-year-old Uyinene Mrwetyana by Luyanda Botha, a post office clerk, in August this year left us all shaken, battling to make sense of our excruciatingly violent world.

Mrwetyana went to collect a parcel from her local post office on Saturday morning and never made it out alive. The sheer banality of the circumstances sent shockwaves through social media.

She was wearing brown corduroy pants and a white t-shirt.
She was not drunk. She was not walking home late at night. She hadn’t been at a shebeen or a club. There was nothing about the circumstances that could be used to “victim shame” her.

Nevertheless, on social media, many commentators suggested what women could do to “avoid” being raped, for instance — taking self-defence classes, carrying pepper spray, sending live locations to friends when they leave a venue.

A tweet, posted on the official Government of South Africa account, read: “Violence and abuse against women have no place in our society. Govt is calling on women to speak out, and not allow themselves to become victims by keeping quiet. Women who speak out are able to act, effect change and help others.”

It received widespread backlash on social media. Black Twitter acted fast to offer a correction to the tweet, much like a schoolteacher would take a red pen to a student’s exam paper.

This was the correction: “Violence and abuse by men have no place in our society. Govt is calling on men to speak out, and not allow themselves to create victims. Men who speak out are able to act, effect change and help others.”

The post went viral.

Some years back there was a film called “What Women Want”, a romantic comedy which body swapped the male character and his female love interest so he could understand what she wanted from him as a lover and a partner.

While this would be great, it will sadly remain in the land of Hollywood.

However, if men listened closely to the outpouring of women’s grief, fear and frustration after yet another act of violence, they would hear not only what we want, but also what we urgently need.

Women do not have the power to stop rape. We cannot simply break our silence or act in certain ways to effect change.

What we need is for men to speak out boldly in public and private spaces.

We need all men, from all walks of life, to call out their male friends, family and colleagues whenever they say or do anything that condones or excuses rape.

When men do speak out against rape, they should counter the narrative that they are doing so because women are their mothers, wives, sisters or friends.

We want men to speak out because they believe women are people who have a value in society equal to that of themselves.

Fathers must teach their sons what enthusiastic and continuous consent means and that it is non-negotiable in all their interactions with the girls and women in their lives.

Today, begins the annual 16 Days of Activism against Gender-Based Violence campaign, which runs from 25 November, also known as the International Day for the Elimination of Violence Against Women until International Human Rights Day on 10 December. This year, the United Nations Secretary-General’s UNiTe campaign against gender-based violence has run the theme: “Generation equality: stand against rape!”

But we need 365 days of sustained action in order to eliminate gender-based violence.

Gender-based violence is directed at an individual based on his or her biological sex or gender identity. It includes physical, sexual, verbal, emotional, financial and psychological violence or abuse, in public or private life.

Rape is rooted in the notion that women are inferior to men and motivated by the rapist’s violent need for power and control.

Women who are raped are more likely to contract HIV, less able to exercise their sexual and reproductive health rights and more likely to be exposed to other forms of gender-based violence throughout their lifetime than those who are not.

Exact numbers of rape and sexual assaults are difficult to estimate due a culture of impunity for perpetrators, stigma towards survivors and their resulting silence.

UNAids’ latest global report shows that around 30% of women in South Africa, Uganda and the United Republic of Tanzania have experienced violence at the hands of an intimate partner in the last 12 months, according to surveys.

There are structural changes that we need make to achieve meaningful and sustainable gender equality, access to justice and human dignity. These will take some time and we will continue to advocate for changes in laws and policies in the eastern and southern African region that will help us reach our goal.

What we can do in the next 365 days, though, is write a scene in the script of our own Hollywood romcom, where this time next year, through simple and deliberate changes, we are living in a world a less violent than it is now.

Catherine Sozi is Director of the UNAids Regional Support Team for Eastern and Southern Africa. Follow them on Twitter at @UNAIDS_ESA.

This story was produced by the Bhekisisa Centre for Health Journalism. Subscribe to the newsletter.

Does Sexual Wellbeing Lead to Better Life And Leadership Skills? This Sextech Company Wants To Find Out

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Does Sexual Wellbeing Lead to Better Life And Leadership Skills? This Sextech Company Wants To Find Out

The connection between sexual well-being and mental and physical health has been recently attracting more interest. Sexual wellness brands -many of which endure constant advertising censoring– advocate to position sexual health and wellness as part of the health conversation, to make it more accessible to all.

A rich body of research confirms that sexual satisfaction affects relationship satisfaction, which is key to earning potential. For example, in one longitudinal Harvard study, the data revealed that fulfilling relationships are the key to happiness, health and longevity. And not only that: Those with the most fulfilling relationships earned an average of $141,000 a year more at their highest earning point. 

This study, however, was focused exclusively on male subjects, and it inspired a recent study conducted by sexual wellness company Womanizer (WOW Tech) in partnership with The What Collective, a women-centered organization founded by dot com entrepreneurs Gina Pell and Amy Parker. The former co-founders of Splendora (acq. by JOYUS) recently hosted a gathering called The What Summit at the secretive and exclusive Skywalker Ranch. The survey was completed by over 200 high-earning attending women. 80% of respondents were ages 35-64 and in director, management and C-suite positions. 

The preliminary results showed some interesting insights: More than 50% of respondents perceived that having a healthy fulfilling sex and relational life would positively impact all other aspect of their lives, including their careers.

The Deficit in SexEd Addressed By Wellness Brands

When it comes to sexuality only 3% of respondents said they had learned at school or with their families. The majority cited the following sources of sex education: peers and friends (34%), magazines and books (28%), and the Internet (10%). In fact, 77% of women who received some sex education stated that it never mentioned that sex should be pleasurable and 70% say there was no discussion about consent. Additionally, 62% state that they have experienced shame around sex and sexuality.

Global expenditure on wellness products and services is on the rise, highly driven by women, and the women’s empowerment movement has added to the conversation issues such as the orgasm gap between men and women, and the right to body autonomy and pleasure of women. This context creates an opportunity for Sextech and Femtech businesses to create innovative solutions to educate and offer resources in underserved categories for people of all ages. Both industries have been estimated at $30 and $25 billion, respectively.

Stephanie Keating, Head of Marketing of WOW Tech, which comprises Womanizer and We-Vibe, said: “Womanizer partnered with The What Summit to facilitate conversations amongst women about pleasure and all that it brings our lives. For many women, experiencing self-pleasure builds confidence, comfort, and agency – yet 75% of us were not taught that sex should be pleasurable. Traditional sex education has failed us. For too many women, pleasure is associated with shame. That limits us in so many other aspects of our lives. The conversations that Womanizer and our experts are having with women free us to talk to each other about this essential part of our lives.  

Personal Fulfillment As A Source Of Confidence And Wellbeing

When asked about the impact of their personal sexual wellness in other areas of life, the majority of women believed that feeling fulfilled positively impacted how they showed up in other areas of their lives. Specifically, 51% stated that this translated into a positive impact on their professional lives. Many respondents pointed to the correlation between fulfillment and “confidence”, “lowered stress”, increased overall “happiness and motivation”, feeling “empowered” and “powerful”, and the positive correlation with overall “well-being”.

Emily Morse, Doctor of Human Sexuality, relationship therapist and author, says “Sexual wellness impacts body image, confidence, … These factors can put a strain on our mental health. If you are not connecting with your partner, it is going to affect your day to day life. Additionally, being able to ask for what you want is a skill that translates into other areas of life.”

Sexologist and relationship expert,  Dr. Jessica O’Rielly, PhD, said: “Sexual fulfillment, relationship fulfillment and life fulfillment are all positively correlated. It follows that investing in your relationships and sex life (however you define it) and fulfilling those needs leads to greater self-assurance, improved mood, increased motivation and even greater assertion skills — all of which can benefit your career.”

Educators, researchers, entrepreneurs… The business of sexual wellness is a growing one and the merger of Womanizer and We-Vibe, which is about to become the largest sexual wellness toy manufacturer, approaching $100 million in sales, wants to push forward a healthier narrative around sexuality: “ Our flagship products were created to help women achieve personal sexual fulfillment and their pleasure potential. WOW Tech’s mission is to be the premier provider of sexual health and wellness products — products that enable people all over the world to increase the satisfaction of their personal and sexual well-being,” concludes Keating.

Estrella JaramilloContributor ForbesWomenWomen’s Health Advocate and Entrepreneur.

Positive Pregnancy Test: “But, I Am Not Sexually Active!”

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Positive Pregnancy Test: “But, I Am Not Sexually Active!”

I can still recall her young face overcome with concern as she learned of her positive pregnancy test. She was just 16 years old and a relatively new patient at the time. Her situation was complicated by the fact that her grandmother, her legal guardian, was sitting in the waiting room. Grandma had met me prior to the appointment and clarified that, although she respected the fact that I wanted to see her ward alone, she absolutely did not want me “putting ideas into the child’s head” by offering her any form of birth control.  Grandma further stated that she would not be here with her granddaughter today if someone had not talked about “these things” with her own teenage daughter 16 years ago.

Confidentiality in our pediatric and adolescent practices 

 is often the key to engendering confidence and trust within our patients.  In their article published in the October issue of Pediatrics in Review, Drs Maslyanskaya and Alderman discuss the need to educate both adolescents and caregivers about the importance of confidential care to ensure the patient’s emotional and physical wellbeing. This applies particularly in the sensitive domains of sexual health, substance use, and mental health. Research has shown that adolescents, if not guaranteed privacy, are less likely to access health services for reproductive and substance use issues. The authors further describe that physicians should consider multiple factors when weighing the ability of the adolescents to interpret health information and make health care decisions autonomously.

Laws regarding confidentiality and consent may vary drastically from state to state, especially with regards to consent for reproductive health needs (including abortion). Maslyanskaya and Alderman advise that pediatricians faced with these dilemmas understand the limits of confidential care for adolescent patients and provide resources relevant to different states in the United States. Physicians should be aware that minors may gain legal status as adults under certain state and federal laws, including the concepts of “mature” and “emancipated” minors. The authors emphasize that federal laws like HIPPA, Title X , SAMHSA and MEDICAID override state laws and, thus, familiarity with both is essential to the provider. Pediatricians should also be aware that there are instances when they must “break” confidentiality, in the best interest of the patient, as in cases of child abuse or when there is a risk of suicide or homicide. For public health reasons, sexually transmitted infections (STIs) also must be reported to the local health department to ensure that partners are treated and to prevent the spread of the disease.

Finally, the authors discuss that, with the increased use of electronic records, pediatricians should ensure that they are careful to protect confidential information. Strategies may include blocking sensitive information from after-visit summaries and advocating for institutional policies restricting the use of internet portals by parents of teenagers.

In our case, the teenager chose to continue the pregnancy and consented to her grandmother being included in the conversation and planning for the future. She was also made familiar with different long-acting reversible contraceptive methods that are available to prevent future pregnancies.

Nupur Gupta, MD, MPH, Editorial Board Member, Pediatrics in Review November 25, 2019

A staggering one-in-three women, experience physical, sexual abuse

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A staggering one-in-three women, experience physical, sexual abuse

Here is the grim reality, in numbers: A third of all women and girls experience physical or sexual violence in their lifetime, half of women killed worldwide were killed by their partners or family, and violence perpetrated against women is as common a cause of death and incapacity for those of reproductive age, as cancer, and a greater cause of ill health than road accidents and malaria combined.

The prevalence of the issue, “means someone around you. A family member, a co-worker, a friend, or even yourself” has experienced this type of abuse, Secretary-General António Guterres said in his message to mark the Day.

“Sexual violence against women and girls is rooted in centuries of male domination”, he added, reminding the world that stigma, misconceptions, under-reporting and poor enforcement of laws perpetuate impunity in rape cases.

“All of this must change…now”, the UN chief urged.

Damaging flesh, imprinted in memory

To spotlight the scale of the problem, on this year’s International Day of the Elimination of Violence against Women, the United Nations is sharing the many ways in which the scourge manifests itself in physical, sexual and psychological forms, and the organisation is underscoring the life-altering, adverse consequences women suffer as a result.

  • intimate partner violence (battering, psychological abuse, marital rape, femicide);
  • sexual violence and harassment (rape, forced sexual acts, unwanted sexual advances, child sexual abuse, forced marriage, street harassment, stalking, cyber- harassment);
  • human trafficking (slavery, sexual exploitation);
  • female genital mutilation
  • child marriage.

The Declaration on the Elimination of Violence Against Women, issued by the UN General Assembly in 1993, defines violence against women as “any act of gender-based violence that results in, or including threats of such acts, coercion or arbitrary deprivation of liberty, whether occurring in public or in private life”, the UN highlighted on the Day.

Rape isn’t an isolated brief act. It damages flesh and reverberates in memory.–Executive Director of UN Women

Beginning Monday, and for the upcoming two years, the UN chief’s UNiTe to End Violence against Women campaign will focus on the issue of rape as a specific form of harm, encouraging people to join the initiative and “Orange the World.”

UN Women’s Executive Director, Phumzile Mlambo-Ngcuka, expressed her concerns when it comes to rape specifically.

She said the end of the horrendous act would mean eliminating a “significant weapon of war from the arsenal of conflict”, the absence of a daily risk assessment for girls and women who actively work to avoid an incident that could leave them scarred.

“Rape isn’t an isolated brief act. It damages flesh and reverberates in memory. It can have life changing, unchosen results – a pregnancy or a transmitted disease”, Ms. Mlambo-Ngcuka stressed, adding that consequences of a one-time act can sprawl into damaging long-term effects.

“It’s long-lasting, devastating effects reach others: family, friends, partners and colleagues”, she continued. ­

In addition, research by the World Health Organization (WHO), details disturbing impacts of violence on women’s physical, sexual, reproductive and mental health:

Women who experience physical or sexual abuse are twice as likely to have an abortion, and the experience nearly doubles their likelihood of falling into depression. In some regions, they are 1.5 times more likely to acquire HIV, and evidence exists that sexually assaulted women are 2.3 times more likely to have alcohol disorders.

More women abused than not, in US

Some national studies examining incidents in the United States show that up to 70 per cent of women have experienced physical and or sexual violence from an intimate partner, according to UN Women.

The agency cited that nearly a quarter of female college students reported having experienced sexual assault or misconduct in the US, but harm targeting women and girls knows no bounds. 

Multi-country investigations by WHO show partner violence to be a reality for 65 per cent of women in some parts of sub-Saharan Africa, and around 40 per cent of women in South Asia, as well as Andean parts of Latin America.

Meanwhile, even in regions where incidents are less likely, as in East Asia and Western Europe, more than 16 per cent and 19 per cent of women have experienced intimate partner violence, respectively.

Psychological violence is another layer to the problem, with some 82 per cent of women parliamentarians in a recent study, reporting having experienced remarks, gestures, threats, or sexist comments while serving – most often via social media.

While gender-based violence can happen to anyone, women who identify with the LGBTI community, migrants and refugees, indigenous minorities, and those living through humanitarian crises, are particularly vulnerable to gender-based harm.

“Almost universally, most perpetrators of rape go unreported or unpunished”, Ms. Mlambo-Ngcuka explained. “For women to report in the first place requires a great deal of resilience to re-live the attack…In many countries, women know that they are overwhelmingly more likely to be blamed than believed.”

Attacks targeting women continue to be an obstacle to achieving equality, and impede the promise of the Sustainable Development Goals (SDGs) to leave no one behind.

Several public events are being coordinated for this year’s International Day to commemorate the fight against gender-based violence, spotlighting rape specifically.

Criminalizing the offense, placing women in positions of power, and strengthening the capacity of law enforcement, are some steps to increase accountability in incidents of sexual assault.

The effects of such violations suppress voices and traumatize, at “an intolerable cost to society”, said Ms. Mlambo-Ngcuka.

“No further generations must struggle to cope with a legacy of violation.”

A staggering one-in-three women, experience physical, sexual abuse

#TherapistDiaries: Understanding genophobia, the fear of physical intimacy

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#TherapistDiaries: Understanding genophobia, the fear of physical intimacy

2019-09-19

By Zaofishan Qureshi Published: June 23, 2019

Almost a decade ago, I heard a story about a villager that stuck with me for quite a while. I was in my sophomore year of my psychology degree back then, and my novice brain was quite struck by the story of a teenage villager who screamed at the top of her lungs every time her husband tried to touch her. She had been married for four months, but due to her reactions, no physical intimacy had been initiated.

Initially, the mother-in-law and the women of the house laughed it off, terming it as mere shyness, even though the girl’s entire body would shake and tremble for hours and it looked like she had endured a disaster. After a few attempts at physical intimacy, the husband did not use any kind of force to coerce her into the act.

Assuming the girl screamed because she didn’t like her husband, she would be questioned about why she had agreed to the marriage in the first place. She claimed that she loved her husband and enjoyed spending time with him, but not the physical intimacy. She claimed that no one had neither explained nor prepared her for this and hence she was clueless about this aspect of a marriage.

According to her:

“I thought that marriage was what I saw in the Star Plus soaps; wearing cool clothes, dining out, doing shopping and such things. My first night was the most terrorising experience of my life and I hate how nobody informed me about this.”

Our professors assessed her and concluded that there was no form of asexuality or intellectual disability present; she was simply not prepared.

Marriage holds a lot of importance in a patriarchal society like ours, more than it should. Our entire lives and career choices revolve around marriage. A lot of people, particularly women, are forced to give up their identity, life goals and dreams, just to be married by a particular age. Considering all this then, it is quite ironic how sex education is not provided to people before getting married, neither is there any demand for pre-marriage counselling in the country.

In my clinical practice, I have come across the dire consequences of lack of awareness and sex education. Fear of physical intimacy, or genophobia, is a commonly occurring phenomenon that I have observed during my practice. There are a lot of women who have this phobia in such extreme forms that it inhibits them from consummating any or most form of physical intimacy through the entirety of their marriage.

A senior of mine once narrated a genophobia case to me. Dr Niazi* was an established medical doctor who had been working in the field for a very long time. She had been married for over a decade and disclosed to my colleague the reason for her frequent absences from work and distress. She was on the verge of getting divorced and quite contrary to everyone’s belief, not having any children was not the root cause of it.

“Would you believe me if I tell you that an accomplished female doctor like me, a mature woman in her late 30s, has never been physically intimate with her husband? Because I’m so afraid?”

She further added that despite of every possible cooperation on part of her husband, she was unable to let go of this fear.

Similarly, Miss Sheikh, a girl in her mid-20s, encountered the fear even before getting married. She had three different surgical procedures done in her life for various illnesses and yet she believed that physical intimacy would be more horrific than that. In this case too, the husband was extremely supportive.

However, there are many cases in which the spouse is unable to understand the situation and marital rape becomes a norm as we are neither culturally sensitive to consent nor very aware of this phobia. There are a lot of instances when patients have a hard time coming to terms with being diagnosed with such a condition, or that such a condition even exists.

Even when the husbands are understanding and not forceful, they do fail to identify this as what it is: a form of anxiety disorder. Couples believe there is no solution for a condition such as this and the best they can do is visit a urologist and ask for tips to improve their foreplay or approach to physical intimacy. Whereas, the actual treatment is counselling.

The very reason for genophobia in our society can be seen through a cultural lens. Though it is true that the reasons for this phobia are rooted in a form of sexual abuse, particularly sexual abuse as a child, but most of the women I have come across have genophobia without an adverse life experience.

Furthermore, the practice of arranged marriages makes it more difficult since there are expectations of consummating the marriage on the wedding night. How could it not scare an already fearful, anxious woman? Genophobia is only a natural reaction in such a scenario.

The treatment of genophobia has a fair prognosis. If an adverse sexual experience is involved, it is treated as a product of trauma. In cases where no adverse experience is involved, we work with systematic desensitisation and cognitive behavior therapy as a treatment plan. Considering the cultural inconsideration surrounding sex education, the patient is also educated about their own anatomy in relation to this. Therapies such as Sensate-focus are also used with couples to improve and overcome the situation together.

Shame and shyness are so inclusive in our culture that they breed a care-avoiding attitude in our women regarding their most intimate issues. We shouldn’t be shaming women about these issues and instead encourage them to seek help.

(*Names have been changed to protect identities and doctor-patient confidentiality.)

https://blogs.tribune.com.pk/story/84621/therapistdiaries-understanding-genophobia-the-fear-of-physical-intimacy/

Am I immoral because I’m attracted to my husband?

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Am I immoral because I’m attracted to my husband?

By Shahid Wafa Published: May 15, 2016

During a conversation with a female friend, she let me in on a strange secret. She said,

“Once, my husband doubted my morality,”

I remained silent, mostly out of curiosity. She continued and said,

“It happened when I tried to get intimate with him; not with a stranger but with him, my own husband.”

“What exactly do you mean?” I asked bewildered.

“He hadn’t come home from work and I was missing him. Aroused, I approached him, thinking he’d appreciate that. In return he gave me a stern look and said, what is wrong with you? Why are you behaving so immorally?”

This was expressed with a dejected and forlorn look on her face. Naturally, this would affect any wife.

Surprised by her story, I tried to convince her that Pakistani men were neither this judgmental nor as narrow-minded.

“No that’s not the case. A man may approach his wife whenever he wants, because he is the husband, but when his wife wants to exercise the same right, she is immediately labelled as immoral,” she replied angrily.

“Perhaps, your husband has some sort of psychological knot in his head.”

I responded, in an effort to try and figure out the reason behind his strange behaviour.

“If this sort of mentality is prevalent in all men, then it’s safe to say that the entire male population in our society has psychological issues – not just my husband.” she added.

I was honestly beginning to get a bit impatient and bothered by her generalised accusations. How was she finding it so easy to blame all men for her husband’s fault?

“What do you mean?” I asked out of politeness.

“Just so you should know Mr Shahid, newly wed brides are instructed by elder females in the family to show deliberate ‘self-control’ during intimacy, especially in the early days of marriage. Now isn’t that an example of unfair moral policing? The slightest expression of natural desire towards one’s own husband is enough to declare a woman as morally corrupt. Isn’t that completely absurd?

Women are also human beings and have feelings, just as men do. They also need comfort and pleasure like any other human, regardless of their gender. How can anyone associate this with one’s morality and character? It makes no sense.” She added.

After listening to her, I figured there may be some truth in what she told me. It really couldn’t have been based on imagination.

So, in order to evaluate her accusations and stereotypes, I asked an elderly man whether it should or is considered ‘incorrect’ for a wife to initiate intimacy with her husband.

“How can it be wrong? She has every right to. There really is no objectionable element in such behaviour, but during these 40 years of my marriage, my wife has never done this. Not even once.”

Concluded the elderly man with great pride.

That satisfaction on his face validated my colleague’s heartfelt allegations.

To further probe into this warped mind-set, I discussed the matter with one of my friends. He handed me an old book on morals, traditions and ethics and advised me to read the chapter “Azdwaaaji Zindagi kay Adaab” (Ethics of married life). I didn’t even know such a book existed!

What is so ‘filthy’ and ‘unnatural’ about reproductive sex, Pakistan?

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What is so ‘filthy’ and ‘unnatural’ about reproductive sex, Pakistan?

By Dureen Anwer Published: September 9, 2016

A close friend of mine recently had an STI (sexually transmitted infection) scare. Despite being in excruciating pain, she was scared to ask her husband how she got the infection. After a few days of discomfort and suffering, she consulted a doctor who put her mind to rest by confirming that she had a yeast infection because of diabetes. But during this whole episode, I was surprised to find out how ignorant she was about sexual health.

First, she was adamant that she couldn’t get an STI from her husband because he was absolutely fine, which is irrelevant and factually incorrect because some STIs are asymptomatic – meaning the person who has the infection don’t show any symptoms. Second, after ruling out her husband, she suspected getting the infection from a toilet since it was shared between her and a relative. This wasn’t the first time I had heard an absurdly naive theory about how people get STIs in Pakistan. I remember the days when I was working for a trade association and was told by a colleague that people get HIV, STIs and even diabetes by using public toilets! Yes, someone said that and that someone wasn’t illiterate. That person was an accomplished professional and an independent woman.

Several years later, now that I am working for the healthcare sector in the UK, I observe how young people are educated about these potentially serious and deadly diseases. Let me clarify a few things particularly for the crowd that proudly claims: Pakistani kids do not have sex before marriage so they don’t need sex education.

What they teach here in the UK isn’t just about sex; they call it relationships and sex education for a reason. Secondly, young people in Pakistan do exhibit some risky behaviour before marriage – be it in a serious relationship or with a random stranger. I don’t think I need to elaborate on how young boys are often dared to experiment with transvestite street performers. Even if we were to believe that the Pakistani youth does not indulge in sex before marriage, they do get married and trust me the advice given by elders (for marital bliss and expression of physical desires when someone is getting married) is often not the best advice.

Boys are not told that some girls are born without a hymen and girls are not given the courage to say no to their husbands during intimacy when they are being disrespectful. Expressing your carnal needs is looked down upon if done by a woman and deemed natural if done at the most inappropriate hour by a man. I have known people who accidentally lost their virginity because no one told them when to stop physical advances by someone they weren’t in a serious relationship with. And the cherry on top is that we always assume that it’s only women who can be physically abused.

In Pakistan, we are embarrassed to talk about sex because we think of it as filthy and unnatural. But the truth is that the experience could contribute positively to one’s mental health if done respectfully and with the right person. The ‘no sex talk’ policy only results in ignorance which is often confused with innocence and purity. In today’s world, you don’t want your children to be ignorant about sex because people will (and they do) take advantage of that. They will hurt your children physically, mentally and emotionally.

Imagine a scenario where a spouse tells their better half that they don’t like certain things about their partner’s physical appearance. Surely we change, adapt and improve for the people we love but some things are beyond human control, such as a physical feature. Wouldn’t you all agree that such conversations could be detrimental to not only one’s confidence but to the relationship as well? So how can we stop marriages from falling apart without blaming women liberation and western influence? We must educate our youth about respecting their partners and it being okay to expect the same in return.

Also, protecting one’s health (including sexual health) is a basic human right. Why is it generally acceptable in Pakistan for men to have sexual encounters outside their marriage and bring several diseases home? Why aren’t they taught how to be safe and also protect their partners? Why can’t their wives be assertive about their own marital rights?

Case in point: The friend who was too scared to talk to her husband about her STI scare because she didn’t want to upset him.

I think we, as a nation, are pretentious and have double standards when it comes to intimacy. Why do we cringe while watching a condom advertisement on television but are perfectly okay to watch vulgar dances in movies? Why do we have these stigmas, fears, misconceptions and misinformation about sex and sexual health? Surely, our religion is practical and in no way oppressive or unreasonable.

Our double standards about sex and sexual health are evident when we look at the statistics. According to UNAIDS, 100,000 people were living with HIV in Pakistan during 2015. In 2014, an 11% increase was reported in mortality rates from HIV/AIDs in Pakistan and if you want to learn further about STIs/STDs then read this article published in Express Tribune.

I am a mother and I do plan to teach my children how to love themselves and their bodies. Anyone telling them that they are inadequate or ugly doesn’t deserve to be a part of their lives. I will teach my children their rights about fertility, safety and pleasure. I will tell them that they have to prioritise their own health and well-being in all circumstances that no relationship is worth compromising your own mental or physical health. I will give them the confidence to say no and to be okay with their feelings.

But for those mothers who are not in a position to do all of this, why can’t a trained professional deliver lectures to youth in colleges and universities? If it is so shameful, perhaps have separate lessons for different genders and sexual orientations. What is so taboo about healthy relationships and physical health? Would you rather have your child learn about sex at the right time by the right person or would you let them go out and discover things on their own (which might result in life-altering damages)?

https://blogs.tribune.com.pk/story/39986/what-is-so-filthy-and-unnatural-about-reproductive-sex-pakistan/

Gay ‘Chemsex’ Linked To Rise in HIV Cases in Europe

blog, Sexual Health

Gay ‘Chemsex’ Linked To Rise in HIV Cases in Europe

Chemsex parties, when people get high and have sex for days with a number of partners is gaining popularity in Europe, which has led to a rapid spread of HIV.

During chemsex, people use drugs such as crystal meth to enhance their arousal and pleasure, NBC News reported. Rusi Jaspal, a professor of psychology and sexual health at De Montfort University in the Britain who studies the spread of HIV and the chemsex scene, says the mix of drugs and sex increases the spread of viruses in groups subject to HIV, like the gay community.

“People are not scared anymore of HIV,” Ignacio Labayen de Inza, a chemsex expert who works at U.K. clinics said, according to NBC News. “Many people I see say they think ‘it’s only a matter of time anyway, so I might as well have some fun.'”

In a U.K. study, 30 percent of HIV positive men surveyed said they had participated in chemsex in the past year.

What Can Brain Scans Tell Us About Sex?

blog, blog-home, Sexual Health

What Can Brain Scans Tell Us About Sex?

Men have a far greater appetite for sex and are more attracted to pornography than women are. This is the timeworn stereotype that science has long reinforced. Alfred Kinsey, America’s first prominent sexologist, published in the late 1940s and early 1950s his survey results confirming that men are aroused more easily and often by sexual imagery than women. It made sense, evolutionary psychologists theorized, that women’s erotic pleasure might be tempered by the potential burdens of pregnancy, birth and child rearing — that they would require a deeper emotional connection with a partner to feel turned on than men, whose primal urge is simply procreation. Modern statistics showing that men are still the dominant consumers of online porn seem to support this thinking, as does the fact that men are more prone to hypersexuality, whereas a lack of desire and anorgasmia are more prevalent in women. So it was somewhat surprising when a paper in the prestigious journal P.N.A.S. reported in July that what happens in the brains of female study subjects when they look at sexual imagery is pretty much the same as what happens in the brains of their male counterparts.