The term ‘sex education’ immediately alarms many of us in Pakistan. The perceived definition of the term changes across different socio-economic, education and class backgrounds, but it is generally thought of as something that promotes illicit sexual activity and thinking. As a result, there are a host of myths and plenty of misinformation with regards to sex education in the country. This, in turn, leads to a lack of conversation around this topic in Pakistani society.

However, these misinterpretations further reinforce why sex education is so desperately needed in both urban and rural localities. Simply put, sex education consists of providing quality education about sex and gender in relation with social relationships, cognitive thinking, personal relationships and medically accurate physiology.

This article is based on the findings from an ongoing study consisting of interviews of medical professionals, doulas [midwives], married women, married men, unmarried men and pharmacists. The responses gathered during this study reveal just how damaging a failure to provide adequate sex education can be — both at an individual and at a societal level.

TROUBLING TABOOS

The interviewees were divided into three groups for the purpose of this study. Group 1 consisted of 12 middle class Muslim housewives, aged 50-60 years, and three married men in their 40s and 50s. Group 2 consisted of eight women from the age group of 30-40 years and six unmarried men in their 20s and 30s. Group 3 consisted of 20 women from the age group 20-30 years, out of which five were married.

In Pakistan, sex education continues to be regarded as a taboo subject. But the harm that is being done to the citizens of this country, and the myths that continue to be perpetuated by not talking about such matters, far outweighs any potential ‘embarrassment’ caused by openly addressing this topic

No sex education was given to them by their mothers, friends or other female guardians. They were taught about sexual intercourse on their wedding night by their husbands/ mother-in-laws/ elder sister-in-laws, or right before their wedding night by an older female relative, or the bride’s ‘side friend’ (married female who is beside the bride throughout the main wedding event).

This ‘crash course’ consisted primarily of directing the bride to relax, to not say no as it is the man’s right and to “leave it to the man.” No explicit medically relevant and accurate information was given to them about sexual intercourse or the complications that may occur during or after, leaving the women in shock and/or fear.

No medically relevant information was given to the women during prenatal and postnatal care. Three of the 12 women were undergraduates and were the only among this group to have practised family planning. Nine of the 12 women made fun of their husbands for not knowing what they were doing during sex. Two of the 12 women were general physicians and both knew nothing of sexual intercourse until after their wedding night.

One of them pointed out that, in her experience, the first night is unpleasurable for 80 percent of women. The same physician shared that, until her first year of medical school, she believed that women gave birth through their belly buttons. Five of the 12 women interviewed shared how they were brought up by their mothers and were taught by their mothers to fear all men, even their own fathers and brothers. Women who went out for their further studies initially lived in constant fear, until they got used to having men around them.

Group 2 complained of a similar lack of direction from their female guardians and/or friends during the time of their marriage, but they had a vague idea of what sex pertained to, through peer discussions and Facebook. According to them, their husbands knew what they were doing while they had no direction, except being told by their friends and family to relax and to not say no to their husbands. This group was not taught to fear men. They mentioned a lack of understanding of post- and prenatal care during their pregnancies much more than Group 1.

Group 1 and Group 2 received no medically relevant guidance about how to deal with their periods and/or their maturing bodies during puberty. Both groups had mothers who advised them not to take painkillers for dysmenorrhea (pain associated with period cramps) and that it should be appreciated and endured. Both groups associated shame and fear with the first time they had an onset of menses.

Group 2 did not discuss female pleasure and/or lack thereof during sex and felt less at ease discussing sex, whereas women in Group 1 did mention a lack of sexual pleasure and a lack of sexual understanding from their husbands, but said their husbands were willing to help.

Both groups associated birth as a natural process for women. They discussed how doctors today do not provide sufficient information to new mothers and abuse their power and their patients’ lack of awareness of their bodies for their own gain.

Six out of the eight women from Group 2 claimed that medical professionals verbally and physically abused them during the medical procedures they were involved in during their pregnancies or during childbirth. Five out of eight women claimed that they received wrong medical guidance by their doctors and nurses, either during their pregnancy or during childbirth, forcing them into having C-sections and/or misapplied epidurals, from which they still suffer.

Two of these six interviewees had an incorrect understanding of harassment and rape. They believed that men cat-calling and objectifying them was a healthy way to flirt and compliment women and confessed to having at least one emotionally abusive romantic relationship in the past.

A LACK OF UNDERSTANDING

For Group 3, 30 participants were initially approached, out of which 20 agreed to be interviewed. No hesitation was shown by the former two groups. The reasons given by the 10 who opted out of being interviewed were because their mother did not allow them, and/or due to moral or religious grounds and/or because they were uncomfortable discussing anything that may trigger their post-traumatic stress disorder (PTSD).

Six out of 20 interviewees were of middle class backgrounds, studied in government schools and had bachelor degrees. Three of these six interviewees had no siblings/ cousins/ friends from outside of this circle. They had no idea about what sex was and were shocked to learn about it on their wedding night or after their wedding night, through an older woman from the bride’s family/ mother-in-law/ sister-in-law.

Neither of the participants received medically relevant sex education from their mothers but did receive, directly or indirectly, religious and culturally relevant references to a husband’s sexual rights, a man’s sexual prowess and dominance and that nothing can be said against men that cheat on their wife as that ‘is in their nature.’

Two of these six interviewees had an incorrect understanding of harassment and rape. They believed that men cat-calling and objectifying them was a healthy way to flirt and compliment women and confessed to having at least one emotionally abusive romantic relationship in the past.

Sixteen of the 20 women expressed being sexually abused/harassed by men from their own families; of them five had told their mothers about it and four had expressed these concerns to their fathers. While the fathers supported them, the mothers either refused to acknowledge it, acknowledged it and asked their daughters to ignore it and to continue socialising with the harasser, or the mothers dealt with it by talking to their husbands or directly talking to the perpetrator’s parent or directly with the perpetrator, if he was a man/boy of the same age as their daughter. Seven of the 16 women discussed it with neither parent.

Women from all three groups were aware of the #MeToo movement, while only 13 of the 40 women supported the movement. The remaining women associated the movement with the Aurat March and said they did not agree with it on this basis.

All of these women discussed how a lack of sexual education leads to marital problems, while Group 3 also associated it with being one of the root causes of divorce.

Group 3 discussed the lack of understanding of consent. While Group 1 and 2 did not touch on this subject directly, they did point out the dangers of marital rape and abuse due to the wife having insufficient knowledge about sex, the wife being underage and naive, or the wife or the husband being “mentally retarded.”

It is not that we do not have the legal procedures needed to ensure these cases do not occur and to hold the perpetrators accountable, but that people are unaware of the relevant laws or the law is not above the cultural values they hold dear.

The women of Group 2 discussed how sexual abuse victims should be married to their perpetrators and that female sexual abuse victims are to blame to some extent for allowing the abuse. Such dialogues scare away their own children, especially daughters, from speaking up against their abusers.

This also shows a lack of correct understanding of consent. For those who do not understand their sexuality, for those sexually abused and for those who live in constant fear, the lack of sex education can leave them questioning their own existence.

Two of the three men in Group 1 believed that it was the victim’s fault that she was harassed or abused, while five of the six men from Group 2 disagreed and discussed how men, especially young boys, are often sexually abused in schools by their seniors or by both their male and female teachers. Group 1 received some aspects of sex education from their female friends or through the internet, which included the concept of menstruation and its psychosocial outcomes.

The rise in abortions shows a rise in unwanted pregnancies. This can be linked to poverty, illiteracy, lack of government support for pre- and post-natal care, change in community and family structures, extra and/or premarital affairs, and a lack of awareness of or proper use of contraceptives.

Both groups of men were aware of contraceptives, while only the latter group of younger men were aware of modern contraception methods such as intrauterine devices (IUDs) and vasectomies.

One of the six men from Group 2 identified as a gay man. He belonged to the upper class and had formally educated ancestors. He discussed how he spent his adolescence struggling from a personality disorder, body dysmorphia and spent eight years in severe depression. When one day his older brother walked in on him discussing his sexuality on the phone, he encouraged him to disclose it to his parents.

While his mother spent hours praying for a divine sign, the father travelled to Karachi to meet with psychiatrists to find a cure. He was met with by-now discredited ‘solutions’, involving rehab and conversion therapy. Unsatisfied with the savage solutions, he met with Karachi’s leading psychiatrist, who taught him about homosexuality and explained that it is neither an individual’s choice nor is it a mental disability.

His mother said that if this is how God made him, then there can be nothing wrong with it. Today, he spends his life as an openly gay man among his immediate and extended family.

THE SOCIETAL IMPACT

Women in Pakistan are constantly abused and killed in the name of ‘honour’ if they are accused of ‘adultery’ (premarital sex, affairs and, in many cases, for simply knowing a man). There are also cases of women being divorced or killed for not bleeding during the first sexual intercourse after marriage. In many metropolitan and rural areas, women are made to go through a ‘virginity’ test to prove they are ‘innocent’ and viable for marriage.

If the man is unable to be fulfilled sexually or is infertile, his wife might be killed or his sister-in-law may be given to him ‘in exchange’ for his wife. The man on the other hand is not questioned if he is infertile or has children out of wedlock.

Interviews with obstetricians, gynaecologists, urologists and general physicians give us further insight into the situations at hand. They reveal an increase in infertility, hormonal imbalances and other reproductive and sexual ailments that are a result of social prejudice among people of all socio-economic backgrounds.

According to the data provided by the US-based Guttmacher Institute, 2,240,000 out of a total of 9,720,000 pregnancies in Pakistan ended in abortions, from 2015-2019. These figures point towards an increase in unwanted pregnancies. Young working class women are increasingly finding it difficult to regulate reproductive health and often come to the hospital in the aftermath of at-home abortions. However, they are not the only women opting for criminalised abortions.

A veteran female gynaecologist practising in a private clinic in an upper class area in Karachi talked to us about how so many teenagers and young women are coming increasingly for abortions with fake names, and almost all of them pretend to be married. They are willing to pay large amounts of money to remain anonymous. Further interviews with five other gynaecologists confirmed that such situations are becoming much more common than they were a decade ago.

However, these are licensed medical professionals with licensed clinics. Low income areas have illegal abortion clinics with both licensed and unlicensed medical professionals. Lady health workers approach local clinics and offer their services with a share from their earnings, while smaller clinics offer forms of modern contraceptives such as an IUD, locally known as a ‘jaali’ (lattice). However, a lack of adequately trained staff and proper aftercare makes it commonly injurious to the patients’ health, thus resulting in several health complications.

The rise in abortions shows a rise in unwanted pregnancies. This can be linked to poverty, illiteracy, lack of government support for pre- and post-natal care, change in community and family structures — resulting in parents bearing the responsibility of a child alone — extra and/or premarital affairs, and a lack of awareness of or proper use of contraceptives.

Working class women choose much more extreme measures for a clandestine termination, by resorting to self-induced miscarriages. They are supported by their mothers and often even their mother-in-law.

Abortions are common even in women from rural Pakistan. Second year interns at Indus Hospital in Karachi said that rural women from interior Sindh and Balochistan often come to them, accompanied by their mother-in-laws, asking for abortions and modern contraceptives. Rural areas have a much lower rate of contraceptive use, given the fact that women have almost no say in discussing family planning, are far younger than their husbands and thus have a higher fertility rate, have less or no access to medical assistance, and are less aware of contraceptives.

Urologists and male general physicians said there has been an increase in depression and suicide among men due to a lack of awareness about infertility, other male reproductive dysfunctions, sexually transmitted diseases (STDs), and a lack of understanding and acceptance of homosexuality. Patients are unaware of their ailments and whether or not they can be cured. Given the immense amount of shame and fear associated with these ailments, many patients do not ever see a medical professional.

Interviews with pharmacists from large-scale drug stores revealed an increase in the sale of emergency contraceptive pills (ECPs) and condoms, which are also much more accessible due to the introduction of online pharmacies. This caters to the youth more steadily. They also revealed the sale of the abortion pill. Larger pharmacies supply to smaller in-clinic pharmacies at the offices of gynaecologists, to local drug stores, and to lady health workers and midwives.

Medicinal resources and trained human capital is unavailable for safe abortions and pregnancies. A study performed in 1997 revealed that, of 452 women from three provincial capitals of Pakistan who had abortions, 64.4 percent of the women chose to do so because they felt they already had too many children. This was 26 years ago.

A lack of proper access to medicines such as oxycontin, for postpartum haemorrhage and proper neonatal care, causes a high neonatal death rate in Pakistan. In an interview in 2012, a member of the government’s National Commission on Maternal and Neonatal Health said that 80 percent of Pakistani women end up with the need of medical assistance to reduce uteronic bleeding and 27 percent of maternal deaths in Pakistan are a result of postpartum bleeding.

Yet, a lack of proper medical resources persists, while unlicensed medical professionals continue to practise medical procedures on mothers. The maternal mortality ratio of Pakistan in 2019 was 186 deaths per 100,000 live births, and the ratio is nearly 26 percent higher in rural areas as compared to urban areas.

Social media and access to all-inclusive content from Netflix and Youtube provides acceptance and awareness about what challenges people of different genders and sexualities face in their personal and social lives. This exposure can act as a strong catalyst in the sexual revolution in Pakistan, as it leads to a questioning of harmful societal norms.

Guardians and teachers remain largely unaware of or in denial of this sexual revolution. The pervasive social tradition of providing no sex education at home will only result in children continuing to resort to hiding their personal identities and their sexual activities.

SEX EDUCATION FOR ALL

An empowering and equitable socio-economic and political environment is needed to enable people, especially those that the economy and society discriminates against, and to counteract the stigma associated with sex.

New sexual health programmes that are incentivised by the government should be introduced. Existing programmes such as the Lady Health Worker Programmes, which already involve communal midwives, lady health workers, nurses, local physicians and obstetrician-gynaecologists, are well-placed to be used and should be equipped with the resources and training needed to cater to and to spread awareness about sexual health.

The training must take into account socio-economic factors, migration and urbanisation, to delicately and strategically provide the medical resources the citizens are rightfully owed by the government. This would also help the government collect both qualitative and quantitative data that could start to be accumulated as a result of such programmes. Workers and researchers must be paid or offered other insurances, such as health and education, in order to combat their elevated levels of financial and other strains.

Sex education reforms incentivised by the government should be introduced in school curriculums. A legally required school curriculum should be introduced that can be tailored by medical and childhood development and childhood education professionals from kindergarten to grade 12, and should be medically accurate, complete and age appropriate.

Teachers should be trained to provide sex education in a way that connects with the students’ basic self-concept: who am I? Self-concept questions such as, “What five words would you use to describe yourself?” should be linked with questions and activities about gender identity and sexual concepts that would help children learn how their mind, body and sexual orientation are all connected. Developing a positive, confident and resilient self-identity will help students become more empathic and understanding of each other.

Teachers should also be trained to make children comfortable even when discussing subjects that may make some students uncomfortable or shy. Parental committees could be set up in schools, whereby parents and teachers can monitor and discuss issues faced with forming an acceptable sex education curriculum. Both parents and teachers should be monitored.

The curriculum should also include, based on the age of students, their reproductive rights and how their country’s legal framework takes them into account. Knowing their rights, or lack of rights, helps laymen fight injustice, as they are then able to recognise injustice and they are aware of the power they hold over any perpetrators.

Until our school curriculums, teacher training and other social education incentives are not reformed, toxic behaviour patterns among families, especially between parents, will continue to generate apathetic and emotionally stunted individuals, and familial and marital abuse will persist, all while the government continues to not provide legal and social security.

Header image: Illustration by Radia Durrani

The writer is a researcher whose work revolves around social and cultural anthropology.
She can be reached at khadijaimran62@gmail.com

Published in Dawn, EOS, December 17th, 2023