WHAT YOUNG

PAKISTANIS WANT TO
KNOW ABOUT

Population, Reproductive
Health and Family Life
1

A Resource Book for Students of

10th to 12th Grade

Compiled by: Javed S. Ahmad

Former Adviser, Labour and Population (IEC)

ILO

January 17, 2016

All rights are reserved. No part of this publication may be reproduced, or transmitted in
any form or by any means including but not limited to electronic, mechanical,
photocopying, recording , or otherwise or used for any commercial purpose whatsoever
without written permission of the copyright owner.

Copyright Javed S. Ahmad, 2016

First published: 2016
ISBN:

Book title: WHAT YOUNG PAKISTANIS WANT TO KNOW ABOUT

Author: Javed Sajjad Ahmad

Disclaimer:
The opinions expressed in this book are those of the author and do not necessarily reflect the
views of the publisher/ Publisher hereby disclaims any liability to any person or organization
caused by the errors and omissions in this publication whether such errors or omissions results
from negligence, accident, or any other cause.

Contact author:
javedsahmad@gmail.com

FOREWORD
In Pakistan as well as in most of the less developed countries, bulk of the
population is young. Traditions and religious beliefs have prevented this
population to access knowledge on sexuality, resulting in horrible
consequences such botched up abortions, deaths and permanent sterility
of young women. This situation should not be tolerated by any society that
cares for its young ones.
This book was written with a view to give a comprehensive and balanced
picture of population issues, sexuality, and Islamic view of family planning.
The focus of the book is Pakistans 30 million youth the book is relevant to
other youth in all LDCs. Realizing that no institution will be willing to
publish this book in Pakistan, fearing religious and conservative political
opposition to its frank and candid content, the author decided to e-Publish
the book.
Please read this book and pass it on to your friends. And let the author
know via email, what you think of its usefulness.
Javed S. Ahmad
jsahmad@hotmail.com
.

UNMARRIED ADOLESCENTS

Available evidence from countries in Asia suggests that an increasing proportion of unmarried
adolescents are sexually active. This behavior places them at risk of unintended pregnancy and
STIs. A review in India showed that 20-30% of adolescent males and up to 10% of adolescent
females were sexually active before marriage.53 A study in Bangladesh found high rates of
premarital sexual activity among adolescents in rural areas, where 38% of unmarried males and
6% of unmarried females were sexually active by age 18.54 In yet another study in Bangladesh,
14% of married and 11% of unmarried adolescent males reported premarital sexual activity.
However, the reported portion of married and unmarried female adolescents with premarital
sexual experience was less than 1%.55 In a study in one district in Nepal, one in 10 rural,
unmarried 15-19-year-old males reported sexual activity.56 In Vietnam, a study of unmarried 1724-year-old urban students found that 15% of young men and 2% of young women reported
sexual experience.57 Similarly, in a survey of sexual behavior of adolescent students in
Indonesia, 20% of young men and 6% of young women had experienced sexual intercourse. 58
Very little is known about the contraceptive behaviors of unmarried adolescents in the countries
discussed in this paper. DHS and other national surveys have largely excluded this group.
Despite an extensive search of Medline and Popline, we were able to find only a few studies that
explored the contraceptive behaviors of unmarried adolescents in these countries. Because
relatively few unmarried adolescents report being sexually active, data on contraceptive use
from these studies may not accurately reflect their contraceptive behaviors. These studies
indicate, however, that a large majority of unmarried, sexually active adolescents do not use a
contraceptive method. Those who report practicing contraception often use traditional methods
that are more difficult for adolescents to use consistently and effectively because they require
accurate knowledge of the reproductive cycle and active cooperation of the partner.

From the South Asia Conference on the Adolescent, held on 21-23 July 1998 in New
Delhi, India. International Family Planning Perspectives, Volume 28, Number 4, December 2002.

TABLE OF CONTENT
Page No.
A Note for Parents and Teachers
I.
II.
III.

IV.

V.

VI.

POPULATION OF PAKISTAN
ADOLESCENTS REPRODUCTIVE
HEALTH ISSUES IN PAKISTAN
HUMAN DEVELOPMENT
Reproductive Anatomy and Physiological Process
Male Reproductive System
Female Reproductive System
REPRODUCTIVE HEALTH AND SEXUALITY
Adolescents Reproductive Health
Sexual Behaviour and Reproductive Health
The Choice of Partner
Adolescent Fertility
Unwanted Pregnancy
How to Protect Oneself from Pregnancy
Preference for Sons and Daughters: Islamic View
Sexually Transmitted Diseases
Common Reproductive Tract Infections
HIV/AIDS
Relationship of RTIs, STIs and HIV Infection
What are the possible consequences on peoples health?
Counseling Adolescents on Human Sexuality and
How it Affects our Behaviour

13

Sexual Dysfunction
Sexual Variation
Sexual Abuse
FAMILY AND MARRIAGE IN ISLAM
Improved Communication Between Spouses
Role of the Family
The Relationship between Husband and Wife
Marriage as a Solemn Covenant
Rights of Children in Islam
Value of Children in Muslim Societies
Rights of Parents in Islam

79
80
82
86
86
87
87
88
89
89
90

SOCIETY, CULTURE, AND GENDER

92

Differing Values and Attitudes Towards Sex and Sexuality

Gender and Sex, Various Sex Stereotypes and
How often they Affect Boy-Girl Relationship
The Status of Women
Sexual Violence and Abuse
Sexuality and the Law

23
28
28
30
33
49
49
52
56
59
60
58
68
72
75
78
78
79

92
92
93
98
98

References
6

VII. FREQUENTLY ASKED QUESTIONS

102

APPENDIXES:
Appendix-1:
Appendix-2:

Islam and Family Planning: Fatawa

Resources for Students, Teachers and Program Managers

A Note for Parents and Teachers

Among Muslim parents, raising children in todays environments of relaxed sexual
attitudes has become a challenge. Many youngsters want to postpone marriage in
order to complete their education while others dont want to be burdened with child-birth
even when married at a young age.
One of the fundamental characteristics of Islamic law is the principle of liberty or
permissibility ibaha that is, everything is lawful unless explicitly designated otherwise
(Abd al Ati, 1975). Two other important characteristics are mentioned by Omran,
(1992) as follows:
1. It (Islam) is a religion of ease (Yusr) not hardship (Usr): in all its institutions and
regulations, Islam addresses itself to reason and keeps in harmony with mans
natural character (fitrah). Quran says:

Allah desires for your ease (Yusr); He desires not hardship for you (Usr) (2:185)

And has not laid upon you in religion any hardship [haraj] (22:78)

Allah desires to lighten your burden, for man was created weak. (4:28)

This is a general ruling that is invoked by jurists in religious judgments particularly in

the absence of a categorical text of prohibition.
2. Islam is a religion of moderation. Islam sponsors moderation and discourages
excesses, extremism, rigidity, and undue restrictions. The Quran says: Allah tasks
not a soul beyond its capacity (or limits). (2:286) i
During the Prophet (pbuh)s life, sex education was given side by side with other
teachings of Islam. The followers (men and women) used to ask about their sexual
problems, and the Prophet (pbuh) used to clarify what was obscure. In addition, women
used to ask Aisha the Prophets wife, about some aspects of reproductive health.
Sexual relations are mentioned in the Quran and the Hadith.
Some parents fear that contraception; sex and AIDS education may encourage sexual
activity in young people, and needs a second look. There is research evidence from
several countries around the world that indicates it is not so. On the other hand, these
researches have shown there was a good chance that young people having received
accurate and timely information would act with greater responsibility and would delay
their first sexual encounter. After appropriate lessons of sex education, fewer

adolescent pregnancies, early marriages and unsafe sexual practices are likely to be
the expected experience of parents and communities.
According to a WHO paper entitled: Does Sex Education Lead to Earlier or Increased
Sexual Activity in Youth? that presents a brief summary of the findings of a review of 19
studies conducted world-wide:
The nineteen studies conducted in Australia, Denmark,
Mexico, Switzerland, Thailand and USA indicated a clear
trend:

In no study was there evidence of sex education

leading to earlier or increased sexual activity in the
young people who were exposed to it.

In six studies, sex education lead either to a delay in

the onset of sexual activity or to a decrease in overall
sexual activity.

Two
studies showed that access to
counseling and contraceptive
services did not encourage
earlier or increased sexual
activity.

In ten studies, sex education

increased adoption of safer
practices by sexually active
youth.

The review concluded that school

programmes which promoted both postponement and protected sex when sexually
active were more effective than those promoting abstinence alone. Also school based
sex education programmes were found to be more effective when given before young
people become sexually active, and when they emphasized skills and social norms
rather than knowledge.
What is the global view on sexuality and reproductive health education of adolescents?
There couldnt be a better reference to such a view than the resolution of the The
International Conference on Population and Development 1994, (ICPD) which has
underscored the importance of informing the adolescents on reproductive health issues

in paras 7.41 to 7.48 of the Programme of Action. The POA signed by the Government
of Maldives, together with all other nations, states:
The reproductive health needs of adolescents as a group have been largely ignored to
date by existing reproductive health services. The response of societies to (such)
needs should be based on information that helps them attain a level of maturity required
to make responsible decisions. In particular, information and services should be made
available to adolescents to help them understand their sexuality and protect them from
unwanted pregnancies, sexually transmitted diseases and subsequent risk of infertility.
This should be combined with the education of young men to respect women's
self-determination and to share responsibility with women in matters of sexuality and
reproduction. This effort is uniquely important for the health of young women and their
children, for women's self-determination and, in many countries, for efforts to slow the
momentum
of
population
growth.
Motherhood at a very young age entails a
risk of maternal death that is much greater
than average, and the children of young
mothers have higher levels of morbidity and
mortality. Early child-bearing continues to
be an impediment to improvements in the
educational, economic and social status of
women in all parts of the world. Overall for
young women, early marriage and early
motherhood can severely curtail educational
and employment opportunities and are likely
to
have a long-term, adverse impact on their
and their children's quality of life.
Poor educational and economic opportunities and sexual exploitation are important
factors in the high levels of adolescent child-bearing. In both developed and developing
countries, adolescents faced with few apparent life choices have little incentive to avoid
pregnancy and child-bearing. Sexually active adolescents of both sexes are increasingly
at high risk of contracting and transmitting sexually transmitted diseases, including
HIV/AIDS, and they are typically poorly informed about how to protect themselves.
Programmes for adolescents have proven most effective when they secure the full
involvement of adolescents in identifying their reproductive and sexual health needs and
in designing programmes that respond to those needs.

Recognizing the rights, duties and responsibilities of parents and other persons legally
responsible for adolescents to provide, in a manner consistent with the evolving
capacities of the adolescent, appropriate direction and guidance in sexual and
10

reproductive matters, countries must ensure

that the programmes and attitudes of
health-care providers do not restrict the access
of adolescents to appropriate services and the
information they need, including on sexually
transmitted diseases and sexual abuse. In
doing so, and in order to, inter alia, address
sexual abuse, these services must safeguard
the rights of adolescents to privacy,
confidentiality, respect and informed consent,
respecting cultural values and religious beliefs.
In this context, countries should, where
appropriate, remove legal, regulatory and
social barriers to reproductive health information and care for adolescents.
Countries and governments, with the support of the international community, should
protect and promote the rights of adolescents to reproductive health education,
information and care and greatly reduce the number of adolescent pregnancies. in
collaboration with non-governmental organizations, and are urged to meet the special
needs of adolescents and to establish appropriate programmes to respond to those
needs. Such programmes should include support mechanisms for the education and
counseling of adolescents in the areas of gender relations
and equality, violence against adolescents, responsible
sexual behaviour, responsible family-planning practice,
family life, reproductive health, sexually transmitted
diseases, HIV infection and AIDS prevention.
Programmes for the prevention and treatment of sexual
abuse and incest and other reproductive health services
should be provided. Such programmes should provide
information to adolescents and make a conscious effort to
strengthen positive social and cultural values. Sexually
active adolescents will require special family-planning
information, counseling and services, and those who
become pregnant will require special support from their
families and community during pregnancy and early child care. Adolescents must be
fully involved in the planning, implementation and evaluation of such information and
services with proper regard for parental guidance and responsibilities.
Programmes should involve and train all who are in a position to provide guidance to
adolescents concerning responsible sexual and reproductive behaviour, particularly
parents and families, and also communities, religious institutions, schools, the mass
media and peer groups. Governments and non-governmental organizations should
promote programmes directed to the education of parents, with the objective of
11

improving the interaction of parents and children to enable parents to comply better with
their educational duties to support the process of maturation of their children,
particularly in the areas of sexual behaviour and reproductive health.
Finally, it is up to the parents to allow this information be seen by their adolescent boys
and girls, in privacy of their homes or in school, or both. If schools are chosen then the
teachers may have to acquire not only thorough understanding of the subject matter,
but also correct attitude to teach the subject properly. For this purpose they will need
training.

12

CHAPTER I:POPULATION OF PAKISTAN

Abstract
The most authoritative population estimates and projections contained in the latest
UN publication World Population Prospects provide revealing insight into the
population situation of the world including Pakistan. The report shows global
population to rise to 10.9 billion by the end of century. By 2100, among the twenty
most populous countries in the world, eight will be least developed countriesthe
United Republic of Tanzania, the Democratic Republic of the Congo, Ethiopia,
Uganda, Niger, Bangladesh, Sudan and Mozambique. The population of Tanzania, for
instance, will become the sixth most populous country, pushing Pakistan to the
seventh position. UN projections further show that by 2028, the population of India
will surpass that of China and taken together the two countries will account then for
about 35 per cent of the world population. By the year 2100, Pakistans population
will be on a declining trend, projected to reach 263.3 million.
Population of Pakistan is young and according to the demographers, offers a once
only demographic dividend to the country that can be cashed by giving technical
and vocational skills to youth. If this opportunity is missed, dividend can become a
disaster. Pakistans population growth rate began to decline beginning 1985-1990
period. It is estimated to be 3.22 by 2010-2015, and projected to decline from 2.65
in 2020-25 to 1.99 by 2045-2050. By 2065-70, growth rate will come to 0 and enter
negative territory thereafter. Current life expectancy at birth for Pakistanis is 66.5
years that will rise to 76.8 by 2100, lagging behind Bangladesh and India. The
terrible news is that each year 630 thousand infants and children under 5 are dying
from largely preventable causes, in Pakistan, a grim reality that rulers cannot ignore
for too long.

Introduction
At the outset it must be admitted that Pakistan is not poised to make a definitive
judgment about its current demographic status or confidently project its future. To
do that a country regularly conducts population census, at equal intervals of five or
ten years, that provides the data and trends to make reasonable estimates and
projections. Pakistan has been delaying its population head count that was due in
2008. The reasons can be many, but security situation in the country is most
probably, the main cause of this delay. Due to the security or rather insecurity
situation in Pakistan, even a harmless public health campaign of polio vaccination,
despite international support and pressure, has failed to achieve its critical goals.
Population census, a low priority activity in the national agenda, is on the back
13

burner, because neither is there international pressure on the government, nor is

there a palpable political will to pursue it. Voices of political factions who would
expect to benefit from a proper population census, via better resource allocation,
also oscillate to no effect.
The national institutions primarily responsible for providing population estimates are
the Bureau of Statistics and the National Institute of Population Studies that must
rely on the archaic data of the 1998 population census. International community
finds other ways to calculate, estimate, interpolate and project, statistics from
various credible sources, including previous census data, sample surveys, and other
demographic enumerations, if any. United Nations Statistics Division periodically
publishes its analysis, estimates and projections for the worlds population, in its
report World Population Prospects. These reports are respected and relied upon
by the experts as authoritative, world-wide. The 2013 report provides basic
demographic characteristics for the world, its major and sub regions, and individual
countries for 2012. The data about Pakistan are eye opening. Users may interpret
these findings as good news on some counts, yet bad news on other fronts.
However, it might be interesting to view Pakistans demographics in the light of the
broad global population situation as follows.
Global Population Situation and Projections about the Future
United Nations report on the worlds population situation, shows that in 2103 the
world population reached 7.2 billion with 5.9 billion (or 82.5 per cent of the worlds
total) living in the less developed regions (such as South and East Asia and Africa).
By 2100, the world population is projected to reach 10.9 billion persons. One of the
reasons for continued population growth is the ratio of the young population to the
total population of a country. A high ratio of young people means that these young
people will form families of their own and have children. Hence population will
continue to grow. Currently the population of the less developed regions is still
young, with children under age 15 accounting for 28 per cent of the population and
young persons aged 15 to 24 accounting for a further 18 per cent. In fact, the
numbers of children and young people in the less developed regions are at an all
time high (1.7 billion children and 1.1 billion young people), posing a major
challenge for their countries, which are faced with the necessity of providing
education and employment to large cohorts of children and youth. The situation in
the least developed countries is even more pressing, as children under age 15
constitute 40 per cent of their population and young people account for a further 20
per cent.
In Another 14 Years, Nearly Every Third Person on Earth Will Be an Indian
or Chinese
UN projections further show that by 2028, the population of India will surpass that of
China and taken together the two countries will account then for about 35 per cent
14

of the world population. (In other words, in another 14 years, nearly every third
person on the globe will be an Indian or Chinese). By 2050, five least developed
countriesBangladesh, Ethiopia, the Democratic Republic of the Congo, the United
Republic of Tanzania and Ugandawill be among the twenty most populous
countries in the world. By 2100, among the twenty most populous countries in the
world, eight will be least developed countriesthe United Republic of Tanzania, the
Democratic Republic of the Congo, Ethiopia, Uganda, Niger, Bangladesh, Sudan and
Mozambique.
Total fertility rate (TFR) is an indicator of the population growth. This rate means the
average number of children a woman will have in her lifetime. A TFR of 2.1 would
mean zero population growth rate or the population will stop growing because births
and deaths will be equal. By 2005-2010, almost all developed countries had reached
fertility levels below 2.1 children per woman (only Iceland and New Zealand have
fertility levels equal or just above 2.1). Among them, 12 had reached historically
unprecedented low fertility levels (below 1.4 children per woman), with Austria,
Bosnia and Herzegovina, Germany, Hungary, Italy, Japan, Malta, Poland, Portugal,
Romania, Slovakia and Ukraine exhibiting the lowest levels in the developed world.
This means negative growth of population, which is another dimension of the
population picture. Many of these countries are apprehensive about their future
because there will be fewer younger people to support the burden of older
population, among other concerns.
Pakistans Annual Population Growth Rate Started to Decline During 198590 Period
According to the UN Report, in 1950, Pakistan was worlds 38 th largest country,
population wise. By 2013, it went up to become 6 th largest most populated country
in the world. It is projected to retain same position in 2050, but (unlike to popular
opinion), she will slide down to 7 th position by 2100, when Tanzania will become the
6th largest country in the world.
In 1950, Pakistans population was 37.5 million. In the next 63 years, Pakistans
population grew nearly five-folds, to 182.1 million. Given the present fertility rates
and trends, Pakistan will add almost 36 million more persons in the next 11 years,
crossing the mark of 218 million, by 2025. This translates to adding on average 3.3
million people per year. Pakistans population growth will not stop here. By the year
2050, UN projects Pakistans population exceeds 271 million. Thereafter, the
expected decline in fertility rate will begin to slow down growth. By the year 2100,
Pakistans population is projected to be over 263.3 million. Of course, these
estimates and projections will change when periodic population censuses are held
and their data are analyzed.
Demographic Dividend

15

Pakistans population is young, as is the case in most developing countries. In

1959, population of very young (aged 0-14) was only 15.1 million. (Table 1). By
2010, it more than quadrupled to 61.4 millions. The population in the age group of
15-64, went up from 20.3 million in 1950 to 104.3 million, i.e., it grew more than
five folds. Unlike developed countries, the number of elderly population of persons
aged 65+ was only 7.5 million in 2010 in Pakistan. Projections for the next 90 years
show that very young (age 0-14) will reach a peak in 2020 when their numbers will
be 63,619 thousands. It will start a slow decline thereafter. The population in the
age group of 15-64, potential labor force, is projected to until 2070, before it begins
a slow decline. The number of elderly of age 65+ is projected to increase at a faster
rate. By 2100, there will be over 56 million seniors.
Demographers regard the bulge in population of persons of young age as a window
of opportunity because if a nation provides adequate skills and education to them, it
can ensure a bright and prosperous future for itself. This phenomenon is described
as demographic dividend, because it can happen only once in the life cycle of a
population. Well-educated and skilled young people become not only the engine for
economic development of the country; they also ensure a comfortable future for the
aged because of a favourable dependency ratio. Situation in Pakistan is a matter of
concern, since only a fraction of its youth are able to find opportunities of technical
and academic training or quality education, and most enter labour markets with no
marketable If governments and political leaders continued to ignore youth, so-called
demographic dividend can easily become demographic disaster.
Table 1: Pakistan Population by broad age group, major, estimates: 1950-2010,
Population (thousands)
1950

1960 1970

1980 1985 1990 1995 2000 2005

2010
Population aged 0-14.
15 142
Population aged 15-64
20 306
Population aged 65 or over
7 484

18 192
25 375
2 094

25 499
31 476
1973

20152020 2030

34 596
42 374
2230

40 864
50 330
3 015

48 433
58 428
3 589

54 856
66 934
4 230

59 626
78 526
4899

60 289
91 165
5 680

61 361
104 304
6 517

2040 2050 2060 2070 2080 2090 2100

Population aged 0-14

61 777 63 619 63 593 60 870 57 574 54 160 50 682 47 712 45 204 43 038
Population aged 15-64
118 069 130 351 154 639 175 346 187 539 189 455 187 367 181 148 172 632 164 149
Population aged 65 or over.... 8 298
9 382
13 511 18 554 25 969 36 492 43 864 49 338 53 651
56 133

16

120
100
80
0-14

60

15-64
65+

40
20
0
1950 1960 1970 1980 1985 1990 1995 2000 2005 2010

Figure 1 Population estimates 1950-2010 by broad age categories

At last, fertility is on the declining curve

Population growth is linked to number of babies a woman has in her life time or the
Total Fertility Rate, (TFR). Pakistans TFR was estimated to be 6.6 in 1975-80. It is
estimated to be 3.22 in 2010-2015 period. It is projected to decline only after 202025 from 2.65 to 1.99 by 2045-2050. These are medium variant projections,
assuming no significant interventions will take place affecting populations fertility
and other related indicators. UNs long-term projections of Pakistans population
growth rates are shown in Table 3. It is notable from the Table, that the declining
trend in Pakistans population growth rate began in 1985-1990 period. At the same
time it is worth noticing that these projections indicate population will nevertheless
keep growing until 2065-2070 period when growth rate is projected to become 0.0.
Thereafter, population will begin a declining trend.
Natural growth of population is a function of the crude birth rate less crude death
rate. Pakistans current crude birth rate is estimated to be 25.4. (Table 2). This rate
is projected to be declining in the coming years. By the period of 2045-2050, it will
be 14.5 and by the end of the 21 st Century, the crude birth rate is projected to fall
an all time low of 10.7 births per thousand population.
Table 2: Crude birth rate Pakistan 2010-2100: Medium variant
(Births per 1,000 population)
2010-2015 2015-2020 2025-2030 2035-2040 2045-2050 2055-2060 2065-2070 2075-2080 2085-2090
2095-2100

17

25.4
10.9

23.5
10.7

19.6

16.6

14.5

13.0

11.9

11.3

Table 3 shows the trend in the death rates. Current rate is estimated to be 7 deaths
per 1000 population per year. The assumptions are that if improvements in life
expectancy continue at the same pace, and both infant and child mortality rates
begin to decline, the overall death rates will also decline until 2020, and thereafter,
start rising owing to ageing of the population, as shown.
Table 3: Crude death rate (deaths per 1,000 population), Pakistan (20102100)
2010-2015 2015-2020 2025-2030 2035-2040 2045-2050 2055-2060 2065-2070 2075-2080 2085-2090
2095-2100

7.0
13.9

6.8

6.9

7.5 8.6

10.0

11.6

12.8

13.5

As noted earlier, difference between birth rate and death rate is the rate of natural
growth of population. The estimates of the crude birth and death rates up to the
year 2100 yield the annual rate of change in percentage, for Pakistan. (Table 4).
According to the data shown, current rate 0f population growth is about 1.66
percent of the population, which is about the same rate Pakistan started with in
1950-55. It seems that population growth peaked in 1980-85 period to 3.40 percent
per year. Thereafter it completed a demographic cycle and began to slowly decline.
The table shows that population will continue to increase but on a declining trend
until 2060 when it will begin its descend into the negative territory by 2075-2080.
That is state where many European and industrialized nations have already entered.
Chart: Birth and Death Rates, Pakistan (Five year Intervals: 2010-2100)
30
25
20
15
10

Birth Rate
Death Rate

5
0

18

Table 4: Annual rate of change (per cent) Medium Variant, Pakistan

1950-1955 1960-1965 1970-1975 1975-1980 1980-1985 1985-1990 1990-1995 1995-2000 2000-2005
2005-2010

1.65

2.56
1.84

2.82

3.20

3.40

3.17

2.63

2.54

1.88

2010-2015 2015-2020 2025-2030 2035-2040 2045-2050 2055-2060 2065-2070 2075-2080 2085-2090

2095-2100

1.66
-0.26

1.55
-0.32

1.21

0.86

0.54

0.26

0.00

-0.17

Life Expectancy of Pakistanis at Birth:

An indicator of populations health and longevity is life expectancy at birth. For
Pakistan it is around 66.5 years and is expected to improve slowly to reach 76.8 by
2100. Comparatively, Bangladeshis would expect to live 80.1 years by 2045-2050
and 87.3 years by 2100. Indians will have a life expectancy of 80.6 by 2100. One
reason for poor performance of Pakistan in this sector is high infant and child
mortality rates. While Bangladesh and India are busy preventing infant and children
mortality, Pakistan is lagging behind, as following tables show.
Over Six hundred thirty thousand Pakistani Infants and Children Under 5
Per Year are Dying Each Year, Mostly from Preventable Causes
Pakistan has one of the highest mortality rates for infants and children, outside of
Sub-Saharan Africa. Please refer to Table 5 below. Pakistans current (2010-2015)
infant mortality rate is estimated to be 65.1 infant deaths per one thousand live
births. This is twice that for Bangladesh.
Pakistans IMR, sadly, will take nearly 85 years to come down to 12.1, still twice high
than for India and six times against Bangladesh. These data are also presented
below in a chart below. However, rates and ratios do not give correct impression to
the reader. For example, in 2013, Pakistans population was 182,143 thousands. In
this case, in one year the number of actual births 182,143 X 25.4 birth rate per
thousand population = 4,626, 432 births took place. Multiplying the infant mortality
rate of 65.1 to 4,626.432 results in 301,181. In other words, every year over three
lakhs infant die in Pakistan. This is much larger figure than deaths of Pakistanis
owing to wars, terrorism, accidents, and all unnatural causes in the last 65 years.
These numbers are mind boggling and hence not presented to the public. These
deaths are mostly preventable if government and society at large commit itself to
prevent them, as the Government in Bangladesh, India and many other countries
have done it.
Table 5: Infant Mortality Rates for Bangladesh, India and Pakistan, (2000-2100)
(infant deaths per 1,000 live births)

19

Country or area
2000-2005 2005-2010 2010-2015 2015-2020 2020-2025 20452050 2095-2100
Bangladesh........................... 55.4
43.7
32.3
24.7 19.0
7.1
2.1
India ......................................58.3
50.6
43.8
37.8 33.0
17.1
6.6
Pakistan.................................76.6
71.4
65.1
58.7 52.9
31.8
12.1
90
80
70
60
50
40

Bangladesh

30

India

20

Pakistan

10
0

Under-five mortality
Children are not dying only in their infancy. Even a larger number die before
reaching the age of five years. (Table 6). To arrive at the actual number of children
dying before age five, we can use the same number of births as denominator as for
IMR, i.e., 4,626, 432. Multiplying 4,626 thousands by 71 yields 328,477. This means
3.3 lakh children are dying every year before reaching age five. Once again most of
these deaths are preventable through parents action, public health services,
specialized and accessible maternal and child health services. It is the tragedy of
macabre proportions for Pakistanis that only exists because people of Pakistan are
generally are fatalists as well as unaware of their rights.
TABLE 6: Under-Five Mortality In Bangladesh, India and Pakistan, Projections, 20002100
(A comparison of deaths under age five per 1,000 live births)
Country or area 2000-2005
2045-2050 2095-2100

2005-2010 2010-2015

2015-2020 2020-2025

20

Bangladesh ....
73.9
2.9
India................ 77.4
21.4
8.1
Pakistan ......... 89.4
35.3
13.7

56.0

41.8

32.1

24.9

64.4

55.8

48.0

41.9

77.7

71.0

64.2

58.0

9.6

90
80
70
60
50
40

Bangladesh

30

India

20

Pakistan

10
0

Figure 2 Under 5 Mortality Projections Bangladesh, India and Pakistan (2000-2100)

Discussion
Pakistan was one of the first few countries that had launched a national family
planning programme in mid sixties. However, within few years of its forceful
launch, under the leadership of a highly motivated civil servant, the campaign
began to attract religious opposition. A series of rumours against contraceptives
quickly spread and found allies from the political parties opposing the rule of the
then President, Ayub Khan, who seemed to have overstayed his welcome, after
taking the country through a military coup. The situation created by the religious
activists against family planning had to be diffused to save presidency. So
government quickly began to deflate family planning programme, in a gesture of
appeasement to religious opposition. This policy shift continued thereafter, no
matter who was at the helms of affairs for the next half century.
Since external support for family planning programme was generous and offered
much needed dollars, from numerous donors, Pakistan decided to continue the
programme, though at a low key. Hence, nation-wide infra-structure of services
continued, under the newly named Ministry of Population Welfare, a nomenclature,
less likely to irk religious zealots. However, frequent absences of service providers,
missing contraceptives, inadequate information, education and client counseling,
remained a perennial complaint. Was it a lack of commitment at the top leadership
or typical working of the bureaucratic structure, or both, the inefficiencies in the
21

programme were rarely addressed. A good portion of the donor money was
routinely spent on never-ending cycle of training and retraining of the same
functionaries, both in the country and abroad, as well as numerous evaluation
exercises and surveys, were noticeable features, except there was little evidence of
the impact of any of these activities. Largely dull, unimaginative awareness
messages, delivered through mass media advertising, promoting small family norm,
gave the impression as something was actually happening.
Was it the performance of Population Welfare Programme or was it the spiraling cost
of living, rapidly increasing young population without work, congestion in housing,
and high cost of raising children, the factors responsible for middle class and urban
people to realize that small family was all they could afford, is yet to be determined.
The fact is that sometime between 1985 and 1990 Pakistan TFR began a slow but
sure descend.
While family planning was the darling of donor community, prevention of the
extremely high infant and child mortality were a low priority, for a very long time.
The argument was that if couples practiced family planning, the few children they
had would survive. At the provincial level, Department of Health was responsible for
providing mother and child health services. But the fact of the matter was that
these services were hardly adequate, and if at all, it mostly served urban
population. Majority of the rural women delivered babies at home, helped by family
members or by mid-wives only some of whom were trained in safe delivery
methods. Birth complications, hemorrhage, infection, and a lack of timely medical
assistance were some of the reasons for the high infant mortality rate. They still are,
though slightly better. Diarrhea, pneumonia, infection, gastro-enteritis diseases, and
poor access to health care, especially in rural areas, are some of the causes of child
mortality.
Since Pakistan had signed the UN resolution in 2000, proclaiming the Millennium
Development Goals, that included specific targets for the reduction of IMR and
Maternal Mortality Ratio, Ministry of Health had to take new initiatives to attain
these goals. MDGs became a raison dtre for donors to allocate grants tied to these
programmes. It was decided, and rightly so, that training of the field functionaries
would be the top priority. Programme was renamed Maternal and Neonatal Child
Health (MNCH), which was further modified to be called Integrated Management of
Neonatal Child Illnesses (IMNCI).
A brief history of the donor involvement in MCH is quoted from a TRF, a donor
established research entitys report, covering a ten year period of interventions. The
report stated: Capacity development for an integrated system of service delivery is
one of the major components under the MNCH Programmes PC-1 2006-2012. The
11 day in-service Integrated Management of Neonatal and Childhood Illnesses
(IMNCI) trainings started back in 1999, under the National Programme for Primary
Health Care and Family Planning, which were continued by the National MNCH
22

Programme (NMNCHP). ENC trainings were initiated about 10 years back by the
Save the Newborn Lives Initiative (Save the Children US), and were taken up by the
MNCH programme in the last 2 years. The PAIMAN and PRIDE projects, UNICEF, WHO
and Save the Children US have been major contributors to both the trainings. The
number of trainings and implementation of guidelines vary across all provinces. Also
the funding available for trainings have varied in different provinces. As of now,
there is no budgetary allocation available for trainings with the provincial MNCH
Programmes, except for Sindh where funding is available through Norwegian
support and the Child Survival Programs PC-1. 1.
Donors were committed to support Government of Pakistan in lowering the IMR,
CMR, and MMR, but inherent deficiencies in the system, are tremendous hurdles in
reaching MDGs. Even though there is no opposition to provide services for MCH,
programme it is not high in the list of official agenda, as health sector receives one
of the lowest allocations in national and provincial budgets. These allocations are
hardly enough to meet the payroll, much less finance the programmed
interventions. Poor governance makes administration of even funded programmes
inefficient and ineffective.
TRFs report concluded: In-service trainings have not affected substantial change in
service delivery and quality of care. It further stated: The analysis of the review of
both in-service trainings reveals that the expected effectiveness on service delivery
has not been realized, given the effort and finances invested. A similar IMNCI review
showed that knowledge retention among trained physicians in Pakistan (38%) was
lower than midwives in Afghanistan (59%).
The 2012 evaluation report shows a bleak picture of the results of serious
interventions made for maternal and child health, throughout Pakistan.
Major funding agencies for both in-service trainings have been the WHO, USAID,
UNICEF, Merlin, SC-US, PAIMAN, PRIDE and the UNFPA. The major organizations
responsible for conducting the trainings especially in the initial stages were WHO
and UNICEF. Later on, the PAIMAN became a major contributor along with SC-US,
PRIDE and UNFPA. TRF was established by the Department for International
Development (DFID) and Aus-Aid, to provide strategic technical assistance to help the
Government achieve its goal of improving peoples access to quality health care services, with a
focus on poor people and marginalized groups. TRF sponsored several studies to assess
financial, technical, and programmatic activities funded by donors, and made its reports
accessible to the government. TRF was mandated to publicize its findings to the entire country,

1 Technical Resource Facility, Final Report: Reviewing implementation and effectiveness

of In-service IMNCI and ENC trainings, 22 October 2012

23

launching an advocacy campaign, but it is not surprising that project was toned down and
downgraded.
Conclusions
Population of Pakistan is declining slowly. It will continue to decline following global
trends. However, country is unable to cater to the population it has, and additional
load of population is almost guaranteed to face hardships. Services that public
sector normally provides to people, such as basic education, primary health care,
roads and transportation infra-structure, social services, and so on, are lagging
behind ever since Pakistan received independence. There is little chance that new
entrants of the population will be any better off than their older cohorts.
The future of Pakistan depends on how well she treats its human resources. Better
educated and skilled Pakistani youth can turn around the country and put it on a
prosperous path. Saving lives of mothers, infants and children, is not an option but a
serious responsibility. How can rulers of Pakistan get any sleep while so many
innocent souls are being wasted every day. Saving lives is plausible provided
people in power make a real commitment.

CHAPTER II. ADOLESCENTS REPRODUCTIVE HEALTH ISSUES

IN PAKISTAN
What Pakistans youth, males and females know about sexuality, what are their
attitudes, and what is their behavior about sexual matters, are questions, answers
to which will determine how well their future will be. A lack of knowledge of their
anatomy, sexuality, sexually transmitted diseases, and childbirth, creates numerous
complications and problems that can sometimes end in disability or even death. A
lack of knowledge about conception, can result in conception and an extreme
embarrassment for the girl and her family. Knowledge of what happens when young
boys and girls grow up can save them from unnecessary fears and anxiety. An
accurate understanding of the reproductive process makes life easier for newlyweds and acceptance of the natural phenomenon of childbirth.
Some facts about the youth in Pakistan are presented below taken from the latest
national Demographic and Health Survey of 2012-2013:
24

Young men and women are marrying late now a-days. For instance, only 4.5
percent of the ever-married women and 1.1 percent of young men of ages 1519, were married. By age 29, nearly 40 percent girls and almost 25 percent
boys were married.
Significantly, among ever married women, over 57 percent had no education,
compared to about 29 percent males. Only 27 percent of the women had
education up to middle or higher. About 16 percent women had only primary
level education.

Have they heard about AIDS?

Only 20.4 percent of ever-married women of ages 15-24 had heard of AIDS.
Over 37 percent of older cohort of women of ages 20-24 said they had heard
of AIDS. This compared to nearly 58 percent males.
The percentage was higher for married women (42 percent) and married men
(over 69 percent).
The differential between urban and rural respondents was stark. (69 percent
versus 28 percent).
Rural males were considerably better informed of AIDS than females. Still,
there were significant proportion of both groups who had not heard of AIDS.

The survey findings were clear that messages of AIDS education did not reach those
who were not educated.

Only 18 percent females compared to about 39 percent males had heard

about AIDS.
Awareness of AIDS was directly and positively correlated with level of
education.
Nearly all respondents with higher education had heard of AIDS.

Apparently, awareness of AIDS was limited to hearing about AIDS, as a majority of

female respondents had no idea of how to prevent AIDS.

Over half of the males of higher age groups (25-39 years) knew that one
could protect from AIDS by limiting sexual contact with one uninfected
partner.
Comparatively urban respondents were better informed than rural ones,
although still in low proportions. Even the best informed were those with
higher education (62 percent of females and 69 percent of males).

These findings provide clear evidence of the need for better informing the young
generation at all levels of education, about how to protect themselves from a
disease such as AIDS. It is probable that their knowledge of sexually transmitted
diseases (STDs) is not any better. Particularly when AIDS education has been going
on for decades in Pakistan, and almost none of the other STDs have been
addressed.
25

Knowledge of prevention of any disease is incomplete until population

understands well, how someone could get infected or mode of
transmission of the disease. For example, government of Punjab spared no pains
in educating the population about the spread of Dengue fever. One would expect
that most residents of the urban areas in particular, know how Dengue germs are
transmitted and how to prevent growth of mosquito population that carry Dengue
virus. As a result, it is possible that people in Punjab did not suffer from the
epidemic as much they could have without the awareness of the mode of
transmission of the disease and methods of prevention.
There is more evidence about health sexual awareness, attitudes and practices of
youth in Pakistan. This evidence has been gathered through a national survey,
conducted under the auspices of the Population Council in Pakistan. Its report
provides a snap shot of the situation that pertains to over 60 percent of the
population.
Following are some of the key findings of the survey:

Girls age at puberty (onset of menstruation) was 13.5 years and for boys, 15
years (when they notice bodily change).
Only 29 percent of the girls of ages 15-19 said they were informed about
puberty, compared to 41 percent of boys in the same age group.
Interestingly, 72 percent of the girls and 63 percent of the boys wished they
were informed about the onset of puberty.
47 percent of females and 14 percent of males are married before the age of
20.
Rural females marry early than urban.
On average, girls married 5.3 years older boys and boys married 1.9 years
younger girls.
80 percent females and 85 percent males reported marrying with relatives.
A large majority of females live in their husbands houses after marriage.
A small percentage lived with their spouses (without in-laws).
Mental maturity, physical maturity, ability to manage household and financial
means/job were the pre-requisites mentioned for marriage. Financial means
mostly for boys.
Lack of economic resources was the main reason for delayed marriages.
By age 20-24, 89 percent of females were pregnant or had experienced
pregnancy
Urban, richer, educated women received antenatal care but rural, poor and
uneducated received less or no antenatal care. Antenatal care can save a
child and mother by early action and treatment in case of any signs of
abnormality.
Married males desired 4 children and unmarried desired 3 children. Females
desired fewer children by a fraction.

26

Pakistani societies makes exception to chastity of their children and as a rule, never
admit, that their children could ever be engaging in premarital sex, especially
daughters. This may be considered a backwardness of the parents concerned, but
the stark reality is that girls whose sexual relations can ever be known, their
marriage will be doomed forever. That is a fate neither parents nor do girls want.
Therefore, one cannot suggest ever in public that youth should be given sex
education much less that contraceptives be made accessible to unmarried youth.
This is another matter that many parents know from observation or gossip that their
son or daughter having relationships but still would believe it does not involve sex.
Their sons do not engage in self-satisfaction, or homo sexuality and daughters know
nothing about sex. They are totally innocent. This may be the case for many, but
not all. We should not conclude Pakistani society is hypocrite. Societys beliefs are
based on ground reality. Also many other non-European, specially Asian and Middle
Eastern societies hold same or similar views. Even Western societies held similar
views a hundred years ago.
While being cognitive of the social norms in Pakistan, we should also be realistic.
The facts are that each year unmarried girls do get pregnant, and many seek out
abortions from fake practitioners. They take the risk of dying or losing their
procreative abilities forever. These are unnecessary deaths and disabilities because
they are preventable. But first we should establish the facts. Lets identify the
sexual habits and practices of the youth and teenagers. But this is a very difficult
task since society does not allow any strangers to ask sensitive questions about sex
to their unmarried children. But there is one organization that has been engaged in
the field as long as Pakistan has been in existence. This organization has actually
succeeded to conduct a survey. A near impossible task.
Family Planning Association of Pakistan took a bold step and under its programme of
Joining in Educating Adolescent and Teenagers (JEAT), supported a survey using
three methods of data collection. It included a non-representative sample survey of
15-25 year old boys and girls, (20% married) youth. A total of 594 male and female
respondents in equal numbers, participated in the survey. Sample was stratified by
taking representative numbers from both urban and rural areas of four provinces. It
was also skewed in favour of educated middle class. Considering this was the first
survey of its kind, the findings can be still interesting. (Following findings refer to
male youth or boys and adolescent girls):

Two-third of males and 82% of girls mentioned starting of beard and

moustaches as sign of puberty among males. Other sign was voice becoming
heavier, mentioned by 47 percent of males and 51% of girls. 34% of boys
mentioned night emission, 26% mentioned appearance of pubic hair.
Same percent of boys and girls (70%) mentioned breast development as the
main sign of puberty for girls. 90 percent of girls and 43% of boys mentioned
starting of menstruation. Other signs were mentioned by fewer than 20%
except 30% girls mentioned increasing height.
27

41% of the boys said they felt pleasure from nocturnal emission but 20
percent felt embarrassment.

Friends were source of information for 87% boys about nocturnal emission.

Girls were mostly (86%) scared, embarrassed , or even cried or felt bad as
the first reaction to menstruation.

On average age girls reported start of menstruation at age 13.52.

Some 76% girls were not aware of menstruation before it actually happened.

A case study: a girl did not know how to manage menstrual blood. She
started using a cloth, washed and dried the cloth in secret where insects got
into it. Eventually, she got badly infected and had to get hysterectomy
(removal of her uterus) at age 15. She would not be able to have children
after this procedure.

Friends were mentioned as the source of information about sexual matters by

70% boys and 34% girls. Boys (12%)and girls 9% got information from books
and magazines. Pornographic films were mentioned by 13% boys and 7
percent girls.

Their preferred source of information on sex matters is friends for boys (male
youth)(44%) and for girls (adolescent) 27%. Next preferable source is parents
for 28% girls but only 8% boys. Only 17% males and 7% females mentioned
doctor or Hakim. Other sources of information were mentioned by a fraction
of the either group. Internet or mobile were not mentioned by anyone.

Boys said appropriate age for giving sex information was between 17 and 18
years. Girls however, and rightfully so, suggested almost 16 years age.

Gay relationships are now widely being recognized in the world. However,
only 15% male youth said they had a sexual contact with males, compared to
only 2% of adolescent girls.

Two/third of the males and females said that they should be able to meet
opposite sex, alone, before marriage.

A majority of 80% agreed that engagement before marriage was a good

ritual.
Two third of the adolescent girls and 76% of male youth thought
books/magazines were better source of information about guidance for the

28

newly married couple. 30% girls and 7% boys suggested friends for the same
purpose.

Interestingly, 53% males thought females had higher sexual needs, and 58%
girls said the same for boys.

One third of the respondents agreed that incest exists in or society. 12% of
the girls felt it was common though 50% thought it is occasional.

Incest was between father and daughter 27% boys, 33% girls. 10% boys and
17% girls felt it was between brother and sister. More girls than boys felt
incest was between uncle and niece. However, people just abhor those
indulging in incest and back bite. 40% boys and 21% girls had personal
knowledge of incest. A few had even personal experience.

Majority of respondents felt that sex education can be given between 8 th and
9th grades or age 15.

Findings of the JEAT survey might be somewhat skewed because of the difficulties in
obtaining a totally unbiased random sample. However, these findings are generally
reflective of the young generation, as they do not display extreme emotions. This
survey was taken in year 2000. At that time mobile phones and internet were
uncommon. Now, if similar survey is conducted, we may find young generation
more knowledgeable and open to discuss their sexual feelings and attitudes. A
healthy and responsible attitude towards sex is all we hope for, that respects
females and restraints machismo. A society free of rape and incest in which
perpetrators of such acts are given exemplary punishment. At the same time, young
couples entering marital bliss with necessary knowledge of sexuality and
parenthood.

29

III. HUMAN DEVELOPMENT

Young people of high school age are curious
about many things, not the least of which is their
own bodies. This is a healthy curiosity, and one
which you should be able to satisfy as much as
possible while you are in high school. How often
have you thought or said, "I wish I could find out
more about this business of reproduction? I
would like to know what the parts of my
reproductive system are and how they work.
How are babies born and how do they grow? I
wish I could get a book to tell me about all this."

Reproductive Anatomy and Physiological Processes

Puberty
During the time you are in junior high or senior high school most of you have the
experience of going through a period of life known as puberty. This word comes from
the Latin word pubertas, and means "age of maturity." Someone has spoken of it as a
"growing up" time. During this time you leave the boy or girl stage and become a young
man or a young woman. Puberty generally takes place between the eleventh and
sixteenth years, and is likely to occur a few years earlier in girls than in boys.
During puberty your sex organs get ready to function, and at the same time begin to
secrete into the blood stream a chemical substance called hormone which acts upon
the development of your mind and body. At this time the boy's voice deepens, hair
begins to grow on his face and body, and he loses his "little boy" shape, becoming more
angular and muscular-a young man. In girls the hips widen, the breasts develop, the
contours of the body become more rounded, hair grows on the body, and the girl
becomes a young woman. Neither the boy nor the girl is any longer a child, but a young
person who begins to experience new things in life, not the least of which is an interest
in young people of the opposite sex.
After you have gone through puberty you are old enough to become parents, but you
are not old enough to assume the responsibilities of fathers and mothers. So you enjoy
a period of development during which the body grows and finally reaches its mature
30

size. This is known as adolescence. This is the teen-age time, one of the finest periods
of your life.
During adolescence, and sometimes before, you may develop a liking for a person of
the opposite sex. This liking eventually develops into your first love, which is called in
the West, puppy love. This may be a very serious affair and seems to be of great
importance in your life. At this time there is no one quite so nice as that other boy or girl.
You write notes, hold hands, day dream, walk together in school halls and to and from
school, loaf in streets, go to cinema, and think up all kinds of excuses to be together.
As you get older, you will discover that there are other
boys and girls that you never knew about, and
generally after several important, and more or less
serious "puppy loves" you will find a young man or
woman who means all the world to you. During
courtship you will discover that he or she is as dear to
you as life itself, that your life cannot be complete
without the other person. Courtship is a period of
learning to understand the other person, and finally,
when you no longer live apart, you pledge your love in
an engagement, after which marriage takes place.
Your wedding day will be one of the happiest days of
your life. It is the time when your hopes and dreams of
having that other person forever will come true.
When you were a child, you probably were not interested in the parts of your body, or in
how they worked. You played with other boys or girls without regard to their sex. You
and your playmates were too busy having a good time and playing make believe to be
concerned about the things young people of high school age find important. But when
you reached the teen age you began to wonder about your own reproductive system
and that of the opposite sex. All of you know that there is a male and a female sex, and
that each sex has its own part to play in the scheme of life. Now you shall have the
opportunity to find out about both the male and the female reproductive systems.

31

Male Reproductive System

The external parts of the male reproductive system are the penis and scrotum. The
internal sex organs are the testes and their ducts, and several glands of which the most
important is probably the prostate. Many people refer to the testes as testicles; the two
words are interchangeable.
The penis is a hanging structure which is fastened to the extreme lower part of the front
of the body. It is about the size and shape of a thumb. It rests upon the scrotum. The
body of the penis is called the shaft. At the free end there is an enlarged head, or
glens, which is covered by a foreskin or prepuce, which can be drawn back over the
glans. The edge of the glans contains a number of very sensitive nerve endings called
genital corpuscles; these are not found at any other place in the male reproductive
system.
The glans also contains certain glands which secrete a whitish, cheesy substance
called smegma. This secretion has a bad odor and, if left to accumulate between the
glans and the foreskin, becomes very objectionable. As a matter of bodily cleanliness, it
is necessary that the foreskin be free enough so that it can be drawn back over the
glans, and that the glans be washed frequently with soap and water.
In some boys the prepuce covers the gland so completely and tightly that it has to be
cut away. This very minor operation is known as circumcision (ser kum sizh' un).
Among Jewish and Muslim people circumcision is part of a religious ceremony. Today
many boy babies are circumcised a few days after they are born so that it will be easier
to keep the glans clean.
But the penis does not always hang limp. Under sexual excitement it becomes rigid and
stands upright. This is made possible because the penis contains many small cavities in
which blood accumulates, causing it to become larger and firm. This is a very necessary
condition in order that the penis can enter the female vagina to discharge the male
sperm cells. When the penis is rigid and erect it is in a state of erection.
A tube called the urethra runs the length of the penis. The inner end of this tube is
connected with the bladder and makes it possible for the urine to be discharged from
the body. This tube also carries the sperm cells to the outside of the body. In the male
the urine and the sperm cells both pass through the same tube. In the female there are
separate tubes for the urine and the eggs.

32

The scrotum, or bag, is a sac of loose skin which hangs down from the front of the
crotch. In it are the two testes. Under the influence of cold the scrotum becomes much
smaller and fits up tighter into the crotch; when heat is present the scrotum becomes
loose and allows the testes to descend farther from the body. This is a necessary
adjustment because excessive bodily heat is destructive to sperm cells.
Inside the scrotum are two testes; these are the organs which make the male sex cells,
the sperms. (The singular of testes is testis.) The left testis hangs a little lower in the
scrotum than the right. This keeps the two testes from rubbing or becoming injured
when the male walks.
A testis is longer than it is broad and is slightly flattened from side to side. It is about 1.5
inches in length and about 1 inch wide. These are average figures. Some boys have
larger testes than average; other boys have smaller ones. These are normal
variations. Internally the testis is made up of many, many feet of tiny tubules (tubes) in
which the sperm cells are made. These tubules eventually empty into a duct called the
vas deferens, which passes out of the scrotum, through the lower pelvic region
(internally, of course), turns to the back of the bladder, and finally opens by means of
the ejaculatory duct into the urethra, which empties the bladder through the penis. (The
word ejaculatory comes from two Latin words which mean "to throw out.")

Sperms and Semen

Sperm
cells
are

produced
in
almost
unbelievable numbers in the tubules of the
testes. They are being made all the time, and when they are mature they are set free in
the central cavity of the tubules. Since the tubules open up into the vas deferens,
mature sperms must be present in that duct. Near the end of the vas deferens there is
an enlargement called the ampulla (am pul' lah; from a Latin word which means "flask"),
and here sperms collect in a reservoir.
A sperm cell is about 1/500 of an inch long. Each sperm cell has an expanded head
containing a large nucleus, a narrowed neck back of the head, and a long thin tail,
which when wiggled drives the sperm forward at the rate of about one quarter of an inch
per minute. It has been estimated that there are as many as 200,000,000 sperm cells
33

discharged from the body at one time; of this enormous number only one is needed to
fertilize the female egg and so start a new life.
The sperms are contained in the seminal fluid or semen (se' men), which is thick,
whitish in color, and has a characteristic odor. The fluid part of the semen is produced
by secretions from both the prostate gland and the seminal vesicles (ves' ik ls).
Therefore, the sperms, plus the secretions from the prostate and seminal vesicles,
make up the semen. In this fluid the sperms swim and are thus able to make their way
into the interior of the female's body. The semen is just as necessary to the sperm as
tracks are to a train.
The testes also produce a hormone which is discharged into the blood stream. This
male hormone causes the hair to grow on the boy's face and body, changes his voice
to a tenor or bass, broadens his shoulders, and makes a young man of him. If the
testes are removed from the body the male hormone is no longer produced, and a man
loses his manly characteristics. Removing the testes is called castration (kas tra' shun).
A man that has been castrated is called a eunuch (u' nuk). This word is found in several
places in the Bible. In oriental countries eunuchs often occupied positions of great
authority.

Nocturnal Emissions or Wet Dreams

Once the testes begin to function they continuously produce sperms. This process goes
on day and night, and eventually the tubes become loaded with sperms and other
secretions which constitute semen. This accumulated material is discharged from time
to time, usually during sleep. The penis becomes erect and the semen spurts from it,
making a wet spot on the pajamas and often on the sheet of the bed. When this semen
dries, it hardens and makes the pajamas and sheet have a starched-like, or stiff place.
Sometimes, though not always, this discharge is accompanied by a dream of some
sexual incident
This discharge is called a nocturnal emission (nok tur' nal e mish' un), or "wet dream,"
and is the result of normal bodily activity over which the individual has no control. It
does not, however, occur at regular intervals as does the sexual discharge of girls, of
which we shall learn later. The nocturnal emission is just as much a part of the normal
working of the body as swallowing or breathing, and should be treated as such. Boys
need not be ashamed of nocturnal emissions, and it is never necessary to see a doctor
to be cured of them. Boys should not listen to talk about the harmful effects of wet
dreams. They are not harmful. Under no circumstances should boys go to a strange
doctor to be cured of them.
As a rule men's testes do not cease functioning between 40 and 50 years of age as do
the ovaries of women. The testes can produce sperms for many years, and men 70
34

years old have become fathers. A newspaper account in late 1955 told of the birth of a
baby in Kentucky to a 92-year-old father; it was his 19th child. However, after middle life
a man's sexual activity slows down gradually, until in old age he may have no sexual life
at all.

Female Reproductive System

The reproductive system of the female is quite different from that of the male in that very
little of it is visible externally. At the lower part of the front of the body there is a bone
which is a part of the hip girdle and is called the pubic (pu'bik) bone. In the male the
penis is attached below the top of this bone. In the female this bone is covered by a
mound of fatty tissue called the mons Veneris (monz Ven' eris; meaning the "hill of
Venus"). After puberty the mons Veneris is covered by pubic hair. Extending down and
back between the legs from the mons Veneris are two folds of skin called the labia
majora (la' be ah majo' ra; from two Latin words which mean the greater lips); these are
separated by a cleft or line between them. Posteriorly toward the anus these lips unite
and the cleft is obliterated. The lips are soft and are covered with hair on the outside,
while inside they have a smooth lining like the lining of the mouth. Inside the labia
majora, toward the front, there is a pair of small lips called the labia minora (la' be ah
mino' ra); from two Latin words meaning "the lesser lips"). These are covered by a
smooth and moist membrane like that cover the inside of the labia majora. These lips
do not run as far posteriorly as do the large lips. Where the labia minora meet in front
there is a small structure called the clitoris ( klit' o ris; from a Greek word which means
"to close"), just like a little penis with the exception that the urethra does not go through
it, nor does it contain certain structures associated with the urethra in the penis of the
male. This clitoris has a shaft and a glans as does the male penis, and the glans
contains genital corpuscles which are very sensitive to touch. These genital corpuscles
are not found at any other place in the female reproductive system. The shaft contains
a spongy tissue as does the male penis, and when this tissue becomes gorged with
blood due to sexual excitement the clitoris becomes erect, although not to the same
degree as the penis. The function of the clitoris is to excite the female in the sexual act.
About an inch back of the clitoris there is the small opening of the urethra, which
empties the bladder. Immediately back of the urethral opening is the opening of the
vagina (vaj i' nah); which in girls who have never had sexual intercourse may be more
or less covered by a membrane called the hymen ( hi' men; from a Greek word
meaning "membrane").
The hymen may be variously shaped, or may be entirely
absent. Its absence or small size, however, does not mean that a girl is not a virgin.
The active life of modern girls often causes this membrane to be ruptured or torn away
long before sexual intercourse occurs. All of these parts--labia major, labia minora,
clitoris, opening of the urethra, and opening of the vagina--are collectively spoken of as
the vulva(vul' vah; this Latin word means "covering").
35

In the lower part of the abdominal cavity between the pelvic bones each female has two
ovaries (o' va rees; from the Latin word for "egg") which produce eggs. These ovaries
are held in place in the pelvic cavity by a membrane called the broad ligament (lig' am
ent; from a Latin word which means "to bind"). Each ovary is about the size and shape
of a small almond. Its surface is covered by a peculiar kind of tissue in which there are
many small cavities called Graafian follicles. Each follicle contains a human egg, which,
when mature, comes to the surface of the ovary and breaks out. A human egg is about
1/120 of an inch in diameter, having a small nucleus surrounded by a yolk and covered
by a transparent outer coat. From the time of puberty until a woman is 50 or so years of
age, one egg is produced about every 28 days. This is known as ovulation (o vu la'
shun) and is now thought to occur sometime between the tenth and sixteenth day after
the beginning of the menstrual (men' stru al) cycle (The menstrual cycle will be
explained later.) It is quite possible that many of the eggs produced by the ovaries never
find their way into the uterus (uter us) but are lost in the body cavity and are absorbed
by the body tissue. In almost all of the higher animals except the apes and man, the
female is sexually excited when an egg, or eggs, is produced, and we say she is in
heat. It is then that breeding takes place--the male inserts the penis into the vagina and
discharges sperms. Among such animals, when not in heat, the female will not accept
the attentions of the male and breeding is not possible.

Female Body Changes

36

In addition to eggs the ovaries secrete hormones which produce the secondary sexual
characteristics of females--widening of the
hips, development of the breasts,
roundness
of
the
female
figure,
menstruation, and the growth of hair under
the arms and in the pubic region of the
body. Other hormones produced by the
ovaries bring about changes in the uterus,
vagina, and breasts during menstruation.
Extending outward from each side of the
upper end of the uterus is a tube called the
oviduct. It is located in the broad ligament.
An oviduct is about 4 inches in length.
Where it joins the uterus the opening
through the oviduct is very, very narrow, but as it extends outward from the uterus the
tube increases in size.
The outer end is enlarged into an expanded funnel-like
structure that has finger-like projections, called fimbriae (fim' bre e), around its edge.
One of these projections is fastened to the ovary. The projections work the egg from
the ovary into the expanded end of the oviduct. The oviduct is lined with cilia (sil' e ah;
little hair-like structures) which move the egg along toward the uterus. If the egg does
not meet a male sperm in its passage through the oviduct, fertilization usually does not
take place and the egg is broken up and absorbed or passes from the body.
The uterus, or womb, is a hollow structure about the size and shape of a pear, with the
broad end up, and the small end opening downward into the vagina. It is about 3 inches
long, 2 inches broad at its upper part, with walls about 1 inch thick, and weighs from 1 to
1 1/2 ounces. The walls are composed largely of involuntary muscles. The uterus is
located in the lower part of the abdominal cavity behind the bladder, but in front of the
rectum, and is held in place by the broad ligament, plus several other ligaments. It is
not perfectly erect, but is tipped slightly so that the broad upper end is nearer to the
front of the body. The cavity inside the uterus is small because the walls are so thick.
These walls contain many blood vessels. The narrow, lower end of the uterus is called
the cervix (ser' viks; a Latin word which means "neck") and extends into the upper end
of the vagina. During pregnancy the uterus enlarges tremendously, may weigh from 1
1/2 to 3 pounds, and may be 15 inches in length by 10 inches in width.
After birth takes place, the uterus becomes nearly normal in size and weighs from 2 to 3
ounces, but its cavity never becomes as small as in the virgin state. In old age it shrinks
in size.
The lower end of the uterus projects into the vagina or birth canal. This
muscular tube is lined with a mucous (mu kus) membrane and connects the uterus with
the outside of the body. Its front wall is about 4 inches long, while the posterior wall is
between 5 and 6 inches in length. It is located between the rectum and the bladder. It
37

extends downward and forward from the uterus and opens externally into the vulva
between the opening of the urethra in front and the anus behind. The internal walls of
the vagina have a series of folds which allow for great expansion when a baby is being
born. The vagina is the tube into which the penis is inserted in sexual intercourse, and
into it the sperm cells are discharged. During birth, the baby passes out of the mother's
body through this tube. And through the vagina the menstrual flow leaves the body.

Menstruation
Girls have a sexual discharge which occurs more or less regularly in 28 day cycles and
is known as menstruation (derived from the Latin word menstrualis, which means
"monthly"). During menstruation a bloody fluid is discharged from the body. This fluid is
made up of secretions from glands in the uterus, covering cells from the lining of the
uterus, and blood from broken capillaries in the lining of the uterus. The discharge is a
result of the regular preparation of the uterus for a fertilized egg. As such, menstruation
is a part of the continuation of human life. Years ago it was thought that menstruation
was the result of some nervous relationship between the ovaries and the uterus. But
when the ovaries of monkeys (the human female and the higher monkeys and apes are
the only animals that menstruate) were removed and transplanted into other parts of the
body, menstruation continued to occur just as if the ovaries were in their correct place in
the pelvic cavity. This proved to the physiologists that menstruation was not caused by
any nervous "hookup" between the ovaries and the uterus
But if the ovaries are
removed from the body then menstruation ceases; therefore, it must be dependent upon
the ovaries. It is now known that the menstrual flow is caused by a hormone produced
by the ovaries and carried by the blood to the uterus, where menstruation originates.
You have already learned that a human egg is produced about every 28 days. It is
thought that the egg is released from the ovary from 10 to 16 days after the beginning of
the menstrual cycle. After the egg is freed from the ovary, a secretion, called a
hormone, passes into the blood stream and is carried to the uterus. As a result more
blood is brought to the uterus, and certain cellular changes take place as the uterus
gets ready for the reception of the recently released egg. If the egg is fertilized in its
passage through the oviduct, the uterus will be fully prepared to receive and care for it
by the time the egg gets there. It takes from three to five days for the egg to slowly
move through the oviduct to the uterus. If, however, the egg is not fertilized, it is
absorbed or passed out of the body through the vagina. If this happens, the uterus has
no work to do and consequently tears down its preparation, casting off some of the
material that was collected there for the fertilized egg; this cast-off material is a part of
the menstrual discharge. Menstruation generally occurs about every 28 days, and lasts
from 4 to 5 days. During this time between 100 and 200 cubic centimeters of menstrual
fluid are lost. (There are 473 cubic centimeters in a pint) The fluid is absorbed by
sanitary napkins or pads. Sanitary napkins are sold in the market under different
names and different designs. In recent years internal- absorbing types of sanitary
38

protection, called tampons, have been developed; these are used by many older girls
and women. Some of these are sold under the name of Tampax, Fibs, and Meds. A
tampon is a plug of highly absorbent
material which is inserted into the vagina
and there absorbs the menstrual
discharge.
Menstruation generally does
not occur during pregnancy.
This
remarkable preparation of the body for a
fertilized egg continues from puberty until
about 45 or 50 years of age, when the
cycle loses its regularity and eventually ceases. This is known as the climacteric (kli
mak ter' ik) or menopause (men' o pauwz), or "change of life." During this time the
ovaries, oviducts, uterus, and breasts begin to atrophy (at' ro fe) or wither, and eggs are
no longer produced. When ovaries cease to produce eggs, a woman can no longer
bear a child. As these changes occur, certain adjustments are made in the body. These
changes may be accompanied by dizziness, muscular pains, and nervous disorders.
Every girl, and every boy, should remember that menstruation is a normal process, and
it should be accepted as such. There is nothing unusual or harmful about it. In the past
there were many superstitions connected with it, but these false tales, untruths, and silly
ideas are not a part of the make-up of present day girls and boys. In one country some
women will not touch can food if they are menstruating because they think the food will
spoil. In France a menstruating woman was not allowed in the sugar factories because
it was thought she would cause the sugar to turn black. In Mexico women were not
allowed in the silver mines lest one who might be menstruating cause all the silver to
disappear. And in the United States you can still hear it said that a menstruating girl is
"sick." (Menstruation is not a sickness and should not be called that--it is a normal
process.) Modern girls consider this discharge as a part of being alive--a sign of
growing up, of approaching womanhood Islamic view.

Breasts
Closely associated with the female reproductive system are the breasts or mammary
(mam'are) glands. Each human being, both male and female, has two breasts, but they
do not develop in the male. In the very small unborn animal there is a "milk ridge" on
each side of the body; from this ridge develops the series of breasts in pigs and dogs,
and the one pair of breasts in the human, the ape, and the elephant. The breast is
considered by most biologists to be a modified sweat gland. During childhood both
boys and girls have undeveloped breasts. About the time of puberty, when the sex
organs begin to function, the breasts of girls develop and enlarge. The female breast is
a rounded structure which extends from the second or third rib to the sixth or seventh
rib, and from the breast bone to the side of the body. The left breast is generally a little
39

larger than the right. A little below the center of each breast there is a conical nipple
(nip'l), surrounded by a pinkish-colored area called the areola (ar e'o lah). The areola
is larger in some individuals than in others. When the tissue of which the nipple is
composed is mechanically excited, either by fingers or the nursing child, it can cause
the nipple to become somewhat erect. Near the base of the nipple, and on the areola,
there are glands which secrete a fatty substance which protects the nipple while the
child is sucking. In women that have never been pregnant, the areola is pink; during
pregnancy it becomes a darker color.

The Sex Act

The act by which the male discharges semen into the vagina of the female is called
sexual intercourse. Before sexual intercourse takes place the spongy tissue of the
penis becomes gorged with blood due to sexual excitement, the penis becoming rigid
and erect and increasing in length and diameter. In this condition it is possible for the
male to insert the penis into the vagina of the female. Due to highly complex emotional
factors which are associated with the nervous system, the semen containing the sperm
cells is forced out through the penis into the vagina. This is called an orgasm (or'gasm).
The spongy tissue of the clitoris may also become gorged with blood, and then it too
becomes larger and somewhat rigid. When the clitoris is in this condition it is possible
for the female to experience an explosive feeling, also called an orgasm. You will
remember from the discussion of the sperm that it has a tail, which , when moved,
drives the sperm forward. Since the inside of the vagina is moist, the sperms work their
way from the vagina, through the cervix, into the uterus. They continue their forward
movement from the uterus into the oviducts, and, if an egg happens to be in one of the
oviducts, one of the many millions of sperms may penetrate the egg. As soon as the
head of the sperm gets into the egg the tail disappears. Then the nucleus of the sperm
unites with the nucleus of the egg, and fertilization takes place. At that moment a new
life begins. Since only one sperm can unite with an egg the others die.

Human Embryology
1st week--fertilized egg divides repeatedly and forms a mass of cells 2nd week-ectoderm, mesoderm and endoderm form; villi present on the chorion 3rd week-beginning of the digestive system and heart 4th week--beginning of the brain and spinal
cord; blood vessels connect with heart 5th week--beginning of upper and lower jaws; tail
bud visible; first indication of limbs; beginning of eyes, lungs, and liver 6-8 weeks-embryo from 1/4 to 1 inch in length; body becomes straight; face develops; external
parts of eye, ear, and nose appear; tail becomes less conspicuous; umbilical cord
complete; heart and liver prominent; external sex organs appear; 3rd month--eyelids
fuse; nails begin; sexes can be distinguished 4th month--muscles work, causing mother
to feel fetus moving inside uterus; body covered with hair 5th month--hair on head 6th
40

month--eyebrows and eyelashes grow 7th month--skin is driedup, red and wrinkled; eyelids no longer fused 8th month--testes
descend into scrotum 9th month--wrinkles smoothed out; nails
fully mature 10th month--term, ready to be born.
The
material contained in this chapter is rather
complicated.
What you have
read is a very
simplified version of the development of
a human being.
The study of the
development of the chick, the pig, the
human, and other animals is called
embryology, and while difficult, is very
interesting.
Embryology, as such, is
usually not taught in high school.

41

1st Trimester

2nd Trimester

3rd Trimester

The changes that are described in the next two paragraphs take place as the fertilized
egg slowly moves through the oviduct to the uterus. After fertilization has taken place
the 1-celled egg begins to divide and goes through a 2-celled, 4-celled, 8-celled stage,
and so on; this is known as cleavage (kle'vaj). Continued division results in the
formation of a ball-like mass of cells, which is then overgrown by an outer layer of cells,
this layer being but one cell thick. Further development results in a hollow ball with a
mass of cells suspended from the top; this is the blastula stage. The mass of cells at
the top of the ball becomes the embryo ( em bre o'; developing baby), while the single
layered outer wall develops into a membrane which will later aid in exchanging food,
oxygen, water, and waste between the mother and embryo. Now the cells of the mass
at the top of the hollow ball increase in number and separate into two layers, an outer
ectoderm and an inner endoderm; this is the gastrula stage. Between these two layers,
a third layer, known as the mesoderm, is formed. This results is a ball composed of
three layers--an outer ectoderm, a middle mesoderm, and an inner endoderm . These
42

layers are somewhat joined. From these three layers of cells are developed all the
tissues of the body. During the formation of these three layers the cilia which line the
oviduct move the egg on until it reaches the uterus. Now two membranes are formed
which surround the three-layered embryo. The inner of the two membranes is called
the amnion (am'ne on), within which is the watery amniotic fluid which cushions the
embryo, thus protecting it against jars, and equalizes pressure. To keep the embryo
from being reduced to a soft mass by the soaking action of the fluid, the embryo is
covered by a fatty secretion. The outermost of the two membranes, called the chorion
(ko're on), is formed very early in development from the outer layer of cells The chorion
forms branching processes called villi (vil'e), which become fastened into the wall of the
uterus in a kind of snap-button fashion. The attachment of the embryonic sac (embryo
and the two membranes surrounding it) to the wall of the uterus is known as
implantation. During continued development the amnion and chorion fuse. That part of
the chorion which develops villi becomes implanted in the uterus wall and helps to form
the placenta (pla sen' tah; from a Latin word which means "a flat cake"). The placenta
is made up of two parts--one from the chorion of the embryo, the other from the wall of
the uterus. Blood of the embryo circulates in the chorion portion, while blood of the
mother circulates in the uterus portion. There is no direct connection between the blood
system of the mother and the blood system of the embryo. Food, oxygen, and water
pass by diffusion from the blood in the uterus part of the placenta into the blood in the
chorion portion; likewise, wastes from the embryo's blood pass into the blood of the
mother in the reverse direction. The blood vessels in the chorion part of the placenta
branch into the villi which project into corresponding cavities in the uterus wall. The
placenta is connected to the embryo by means of the umbilical (um bil'ik al) cord, a
tubular structure which forms during the sixth week of growth. This cord is about 1/2
inch in diameter, and approximately 20 inches long; it contains two arteries and one
vein, but no nerves. One end of the cord is fastened near the center of the placenta,
while the other end is attached to the abdomen of the embryo. Through this cord
circulates the blood which supplies all the food, oxygen, and water for the developing
embryo, and likewise carries away its wastes. The navel (na'vel indicates the place
where the umbilical cord was fastened to the abdomen. After the three layers-ectoderm, mesoderm, and endoderm--have been formed the embryo begins to develop,
a process which continues until the fetus (fe'tus) is born. (During the first eight weeks
the developing child is called an embryo because it would be difficult to distinguish it
from a rabbit, or a chick, at that stage of development. After the second month it
resembles a human being and is called a fetus.) Internally the various organs of the
body are being formed, while externally the embryo begins to look more and more like a
human being as the face, the arms, and the legs take form. From the ectoderm the
brain, nervous system, and sense organs develop.
Mesoderm forms muscles, bones, heart and blood vessels, kidneys, and sex organs.
The endoderm develops into the lining of the digestive system, the liver, pancreas, and
43

lungs. Very early in the formation of the embryo there is a difference between the front
and the hind end of the body. The head end is the largest and never loses that
distinction during development. Even in a new-born child the head is larger than any
other part of the body. The face is made by the fusion of certain structures which form
the nose, the nostrils, and the upper and lower jaws. At first the nostrils are far apart,
but gradually they come closer together. At eight weeks the nose of the human looks
very much like that of an animal, "with the nostrils set far apart and directed forward."
Later the bridge of the nose is formed, and the nostrils are directed downward A hare
lip is formed when certain fusions do not take place in the formation of the nose,
resulting in a groove extending downward from the nostril through the upper lip. By the
fifth week limb buds appear. Front limb buds form arms, forearms, and hands, while the
hind limb buds develop into thighs, legs, and feet. Fingers and toes form on hands and
feet respectively Shortly before birth the nails are formed. The front limbs are longer
than the hind ones until the second year of life. At ten weeks it is possible to distinguish
the male from the female fetus by the characteristics of their external sex organs. Both
the penis and the clitoris have the same origin. Likewise the under surface of the rear
end of the penis originates from the same structure as the little lips (Labia minora) of the
vulva , and the scrotum has the same origin as the large lips (Labia majora).

Sex Determination

Many

authorities
think that the sex of the
fetus is determined by the chromosome make-up of the nucleus of the sperm.
According to the principles of heredity chromosomes always occur in pairs. In humans
the sex chromosomes are designated XX for female, and XY for male. Also, according
to the principles of heredity, an egg contains only one of the pair of X chromosomes,
and a sperm contains either an X or a Y chromosome. If, in fertilization, an egg with its
X chromosome should receive a sperm with an X chromosome, the resulting fetus
would have an XX combination, and would be female. If, on the other hand, an egg with
its X chromosome should receive a sperm with a Y chromosome, the resulting fetus
would have an XY combination, and would be a boy. Thus, you see that the sexdetermining chromosome is carried by the sperm. It should be remembered, though,
that the union of the sperm is by chance, and that the male cannot in any way
determine the sex of the fetus. The skin, hair, oil and sweat glands come from the
ectoderm. The first hair is silky, and all except that on the face is shed soon after birth.
44

Then the regular hair comes in. At the same time these external changes are taking
place the organs and internal structures of the body are developing in a most interesting
manner. Their formation is very complex, and in some instances not completely
understood. Following is a summary of the changes that take place during the first ten
lunar months of development.

Pregnancy and Childbirth

45

While the embryo or fetus is growing in the mother's body, she is pregnant (pregnant;
from a Latin word which means "being with child"). During this time the quality of the
mother's blood and her general health can affect the development of the fetus.
Because of this, proper food, sunshine, and rest are of vital importance. Mothers today
make regular visits to their doctor during pregnancy for periodical check-ups. This is
done to forestall any trouble that might otherwise arise.
Some people have
superstitious ideas regarding the influence of the mother on the developing fetus.
Modern young people know that evil thoughts on the part of the mother cannot affect
the mind of the growing fetus; that birthmarks are not caused by pinching or bruising of
the mother's skin; that "hocus-pocus" cannot deform a baby; that the mother cannot
determine the sex of the child by thinking that she wants a boy instead of a girl. These,
and many other unfounded superstitions, have been dispelled by modern medical
science. Sometimes during pregnancy the mother has a fall or bad jar, and then the
embryo or fetus may be expelled from the uterus before it is time for it to be born; this
misfortune is called a spontaneous abortion or miscarriage. There are times when it is
necessary to remove the embryo or fetus to save the life of the mother; such an
operation is called a therapeutic abortion. In some societies abortions performed on
mothers in illegal and unsafe environment to rid them of an unwanted embryo or fetus
are criminal offenses and are punishable by law.
Such criminal abortions are very dangerous
because of the under covered ways in which they
are performed, the unsterile conditions that are
apt to exist, and the "quack" nature of physicians
who do such work. Any one guilty of performing,
or attempting to perform, a criminal abortion is
subject to very severe punishment under the
laws. A lawful or therapeutic abortion is usually
performed by a surgeon in a hospital equipped
for that kind of medical work.
It is well to remember that reproduction is a
perfectly normal process.
In most cases no
difficulties are encountered, and such slight ones as may develop can be cared for by
the attending physician. During pregnancy the walls of the uterus enlarge until the top
of the uterus is just under the lower end of the breast bone; the number of muscle cells
in the wall of the uterus also increase, and the entire structure adapts itself
physiologically to the growing embryo and fetus. Long before the fetus is born the heart
begins to beat, the blood circulates in the body, the kidneys cast off waste, and for
several months before birth the muscles are strong enough to enable the fetus to turn
and kick. Normally the fetus assumes a head downward position in the uterus. Its arms
and legs are folded, its eyelids are closed, and it does not breathebut it is alive. It
secures its food and oxygen from the blood of the mother. At the end of 280 days (9
46

calendar months or 10 lunar months) from the beginning of the last menstrual period,
labor usually begins. (A lunar month is the same as a moon month--28 days.) This may
last from 12 to 18 hours, but sometimes is shorter, sometimes longer. The first stage of
labor is the stage of dilation, during which the mouth or cervix of the uterus is enlarged,
and the amniotic sac (sometimes called "the bag of waters") usually breaks so that the
amniotic fluid flows from the mother's body through the vagina. This fluid helps to
lubricate the passageway. In the meantime the muscles in the wall of the uterus begin
to contract, and aided by the contractions of the muscles of the abdominal wall, the
fetus is pushed out of the uterus into the vagina, and from thence to the outside of the
body. This is the stage of descent or birth. Usually the child is born head first. If the
feet should be born first it is known as a breech birth. Sometimes the amniotic sac fails
to break before birth, and then the child may be born with some of the sac (a
membrane-like structure) adhering to its head. This is known as a caul (kawl) or veil.
Some people attach a mystic significance to this event After the child is born the sac is
removed from its head. A physician is generally/present during the process of birth, and
by his/her skillful handling of the mother and baby, or a trained birth attendant expected
to be he/she can forestall any unfavorable conditions that may arise. If the new-born
baby does not automatically begin to breathe, the physician may have to spank it to
make it gasp, thus causing air to rush into the lungs and breathing to begin. The doctor
also ties the umbilical cord in two places, then cuts through the cord between the tied
places, leaving a short stump attached to the baby. In a few days this stump dries up
and falls off; the mark left on the abdomen is the navel. Thus the child is freed from the
mother and is no longer a parasite The doctor also puts a solution of silver nitrate in
the eyes of the baby to prevent infection from a venereal (ven ne're al) disease known
as gonorrhea (gon or e' ah) that might have been picked up by the passage of the baby
out of the body. In this way many cases of blindness are prevented. A physician who
specializes in childbirth is an obstetrician (obstet'rish un). Some babies are born during
the seventh or eighth month of pregnancy. These premature babies must sometimes
be put in an incubator for several weeks to give them additional protection. It is possible
for such babies to live, and if properly cared for they will grow and develop normally.
Occasionally the structure of the bones of the mother's pelvis is such that the baby
cannot be born normally. In that case a surgeon performs a Caesarean (se za' re an)
section in which the baby is removed through an incision in the abdomen of the mother.
Caesar was supposed to have been born this way, and thus the name Caesarean.
During labor the physician may give a drug that will ease and help the patient. When
necessary he administers a mild anesthesia during the last few minutes of childbirth. In
the last few years some physicians have been instructing their pregnant patients as to
what happens in childbirth, and how the patients can aid the process of birth. By having
the mother-to-be relaxed and help in the birth, much of the distress disappears. This is
known as Natural Childbirth. The third, or placental (placental) stage is the final stage
of childbirth. After the child is born the placenta begins to separate from the wall of the
uterus. When the separation is completed the placenta with the attached cord will be
47

forced out of the body

as the after birth This
is plate-shaped, a little
less than an inch thick,
and about 7 inches in
diameter
It weighs a
little more than a
pound. Animals will eat
their afterbirth if they
have a chance.
It
contains
some
chemical
substance
which is of value to the
mother's body. This is
also a sanitary measure
as it removes from the
nest in which the young
are kept any material that might rot and
foul the nest and young. After birth has
taken place the uterine wall contracts,
and in this way extensive bleeding from the area to which the placenta was attached is
prevented The contraction pinches the blood vessels shut. In about 6 to 8 weeks the
uterus is back to normal size and in its normal position in the pelvis. The period of
gradual reduction in size and return to normal is known as involution. The average baby
weighs between 6 and 8 pounds and is about 20 inches long at birth. When it is born its
head is still proportionally larger than the other parts of its body. As we all know, it is
absolutely helpless and needs its mother's care for a long time after being born. Before
birth takes place the breasts or mammary glands begin to prepare for the production of
milk. Soon after birth the mother's breasts begin to function and produce milk, which is
considered to be the best food for babies. The baby
continues to grow rapidly so that by the time it is six
months old it will
probably weigh twice as much as it
did at birth
Between six months and its first
birthday it will cut its first teeth and may begin to
walk. After the first year it will begin to say simple
words. In the eyes of parents babies all too soon
become boys and girls, and then young men and
young women. So life goes on and on, and the
human race continues on earth.

Milk
48

After the birth of a child the areola never becomes the same
color it was in the virgin state. Internally the breast is made
up of from fifteen to twenty lobes of glandular tissue, each
lobe opening by means of a duct near the base of the nipple.
Here each duct has an enlargement which serves as a
reservoir where the milk may collect. Then the duct narrows
again, and opens, together with the ducts from the other
lobes, on the end of the nipple.
The various lobes are
connected by fibrous tissue, while between the lobes and
beneath the skin there is a fatty tissue which gives roundness
to the breast and serves as protection. After fertilization has
taken place, there is a marked change in the breasts of the female. They grow larger
and firmer, the areola changes to a dark pink, brown, or even black color, the nipple
becomes more evident, and the gland tissue gets ready to produce milk. Before the
baby is born a thin, yellowish fluid called colostrum (ko los' trum) is produced. This is
the food the child takes during the first few days of its life. Several days after the birth
of the child, the mother's breasts begin to produce milk and will generally continue to do
so for a number of months if the child is nursed. For several weeks after a baby is born,
a milky substance called "witch's milk" is produced in its breasts. When the baby's
breasts become so congested or swollen, they should never be pinched or squeezed to
force out the "milk," as this action may damage the tissues and harm the breast.
Human milk contains water, proteins, fat, sugar, and various minerals such as calcium,
phosphorus, and sulphur. The water, sugar, and minerals are secreted by the glandular
tissue.
It is thought that the proteins and fat come from the gland cells which
disintegrate. Some women are unable to nurse their children and so must use cow's
milk as a substitute for human milk. The two are not exactly alike; they contain the
same ingredients but in different proportions, as is shown in the table below.

Human (Average)

Cows (Average)

Water

88.4

87.1

Proteins

1.5

3.2

Fat

3.3

3.9

Lactose (sugar)

6.5

4.9

Salt

0.3

0.9

49

Notice that human milk has a greater percentage of water and sugar than
does cow's milk. Therefore, it is necessary to dilute cow's milk with water
and add sugar to it, before it can be fed to new babies. For feeding babies,
human milk has a number of advantages over cow's milk. The curd of
human milk is made up of loose, small flakes, whereas cow's milk forms
large, compact curds. Because of this a baby may not be able to digest the
cow's milk and will vomit it . The fat droplets in human milk are larger and
fewer than in cow's milk. Human milk is almost neutral in chemical reaction,
while cow's milk is slightly acid. Human milk is sterile as drawn from the
breast, while cow's milk must be handled by human and may contain
bacteria. Human milk contains antitoxins and bacteria fighters from the
mother's blood which serve to keep the child well. Cow's milk may also
contain disease fighters, but by the time the child gets the milk they are
destroyed. Some young women think they will harm their figure if they nurse
their children. However, this is not according to medical fact, and doctors
generally encourage mothers to nurse their children if they can do so,
especially during the first few months of the child's life. The quantity of milk
produced by the human breast increases for the first twenty-seven weeks,
then gradually decreases. A nursing mother may produce a quart or more of
milk a day, but this figure would vary greatly in different women. It is
definitely known that frequent nursing stimulates the breasts to produce
more milk.

50

IV. REPRODUCTIVE HEALTH AND SEXUALITY

A.

Adolescents Reproductive Health

The normal physical growth and maturation of adolescents may be adversely affected by inadequate diet, untimely or inappropriate
physical stresses on the growing body, or pregnancy before a young woman is fully mature. Inadequate information on which to
base decisions about behaviour, inappropriate choice of behaviour, for whatever reason, and lack of support to make the
appropriate choice possible are also likely to result in risks to the health of young people

Nor are the hazards of infectious diseases

totally absent during adolescence. For young
people who have not been immunized and have
not acquired natural immunity to such infections
as poliomyelitis and mumps during childhood,
the consequences--such as paralysis following
poliomyelitis and infertility following mumps are
often more frequent and more severe than for younger children. The
combination of the energy demands of the adolescent growth spurt and an
inadequate diet may contribute to tuberculosis. Adolescent girls require 10%
more iron than boys to make up for the losses in menstrual blood. By
adulthood, women require 33% more iron than men, which they rarely
receive; as a consequence, anemia is twice as frequent in adolescent and
adult women as in men.

Sexual Behaviour and Reproductive Health

The burgeoning sexuality associated with puberty is often seen as the
starting- point for the transition from childhood to adulthood. This passage
may be marked by religious rites after which young people, especially girls,
are treated differently and are more closely supervised in their dealings with
the opposite sex. This is because of the awakening of the sexual response
system, which, although not new to adolescence, may now lead to unwanted
pregnancy. Another major concern arising from premarital sexual activity
among young people is the possibility of contracting a sexually transmitted
disease, including infection with the human immunodeficiency virus (HIV).
While sexual feelings can be expressed in many ways that are not in
themselves harmful to health, expression of the sexual urge is often greeted
with anxiety or anger by adults, and frequently with fear, guilt and shame by
51

the young people themselves. These responses combine

to drive both sexual feeling and sexual behaviour
underground, making communication about the healthy
development of sexuality within affectionate and
responsible relation- ships more difficult.
Sexual Relations Before Marriage

Reflecting differences in cultural and social values, both between and within countries, there is variation in the age at which young
men and women begin sexual relations. Studies on adolescent sexual behaviour in different parts of the world show that young
people's premarital sexual encounters are generally unplanned, infrequent and sporadic.

A much higher percentage of men report having premarital sex than women.
Recent studies show that, in Brazil, 64% of 15-17-year-old men reported
engaging in sex before marriage as against only 13% of women. In the
Republic of Korea, 16% of men aged 15-17 reported having premarital sex,
as against 5% of women in the same age group. For the age group 20-21
years, the percentages were 91% for men and 46% for women in Brazil, and
51% for men and 12% for women in the Republic of Korea.
Although there have been very few studies in developing countries, it would
appear that sexual activity before marriage among young women is more
common in developed countries and in Africa and the Caribbean than in Latin
America, Asia or the Eastern Mediterranean. In the late 1970S and early
1980s, in Europe, between one-fifth (Belgium and Yugoslavia) and a half
(Federal Republic of Germany) of 17-year-old single women reported having
had intercourse. In the United States, three-quarters of unmarried 19-yearold women had experienced sexual intercourse. In Mexico, 11% of unmarried
17-year-olds and 17% of 18-year-olds reported having had intercourse. In
Costa Rica, the figures were 14% and 26%. By contrast, in Thailand only 5%
of unmarried women under 19 years of age reported having had
intercourse.arriage
Throughout history, societies have dealt with the problem of premarital sex
and illegitimacy by strictly supervising young girls so that sexual activity
does not begin until marriage, by ensuring that young girls marry at the
onset of puberty, or by physical violence towards, and ostracism of,
unmarried pregnant girls and mothers.
In many parts of the developing world, especially in rural areas, girls marry
shortly after puberty and sometimes even before. There is often considerable
pressure on the young married woman to bear a child almost immediately.
She will often have no status in the community until she bears a child, and in
many societies, until she bears a son. In some instances, she will have to
52

prove that she is fertile for the desired marriage

to take place or, once married, in order to avoid
being abandoned and left destitute. Raising the
legal age of marriage is an essential first step
towards reducing early childbearing, but this will
have little effect unless the social and cultural
factors that put such a high value on early
fertility are also addressed.
In all regions, educated women tend to marry
later, delay childbearing and practice family
planning more than those without education.
They generally have fewer and more widely
spaced births. Women with no schooling have almost twice as many children
on average as those with seven or more years' schooling.
Surveys have found that in Bangladesh, 25% of 14-year-old girls are married,
and in Nepal, 34% of l5-year-old girls are married. In south-east Asia, Africa,
and Latin America, 24%, 44%, and 16% of women under 20 are married. By
contrast, the highest percentage of young men aged 15-19 who are married
is 12% in India, and in most countries it is around 2% or 3%.
Islamic View Point
Marriage is thus a grave responsibility and as such it should be planned for,
with a view especially to ensuring the ability of a man to care for a wife and
a household and for the couple to raise their children as pious, healthy,
educated, useful and well-behaved citizens. Otherwise, marriage should be

postponed. The Quran says

Let those who find not the wherewithal for marriage, keep themselves
chaste, until Allah gives them means out of His grace.
al-Nour (Sura 24:33)
The Prophet says

53

0 young men! Those of you who can support a wife and household should
marry. For, marriage keeps you from looking with lust at women and
preserves you from promiscuity. But those who cannot, should take to
fasting which is a means of tampering sexual desires.
Are Marriage and Children Necessary?
Imam al-Ghazali (d-ADIIII) uses the interesting argument that as marriage
can be postponed or bypassed altogether by some Muslims (which is legal)
so can begetting children. He used this argument in his discussion of the
legality of al-azl (withdrawal or coitus interruptus) as a method to avoid
pregnancy.'

There are also general references in the Quran regarding the age of marriage
and the age of sound judgment, without specifying a fixed age.
And make trial of orphans until they reach the age of
marriage; and if then you perceive in them a sound judgment,
then hand over their property to them, but consume it not
wastefully nor in haste against their growing up.
al-Nisa'(Sura 4: 6)
Imam Abu Hanifa is reported to have mentioned an age of 18 for boys and
17 for girls (See al-Saih 1974). These were the figures used in the Ottoman
Family Law before the First World War (1914). Modifications have been
introduced since then in the region formerly controlled by the Ottoman
Empire.

The Choice of Partner

There are some practical considerations in choosing a life partner. In some
cultures such considerations can become quite critical. For example, in
54

Maldives where marriage between cousins and close relatives is common,

some serious health problems such as Thalassemia are also common. This is
important to understand why genetic factors should be looked into when
deciding to marry.
Genetic Considerations
In order to avoid genetic problems, the Prophet (PBUH) instructed that these
genetic traits be considered.

He said

Choose where you deposit your sperm for the line of descent is conducive.

Authenticated by Ibn Maja

Inbreeding is discouraged.
It is also a common advice (not hadith):

Marry from outside your kin and kith, lest you beget
puny children.

Caliph Omar told the clan of al-Sa'ib, who concentrated marriages within
their clan:

You have had puny children, you should marry outside the clan.

Authenticated by Ibrahim al-Harbi

Imam al-Ghazali emphasized that the wife should not be from among the
close relatives (first cousins) lest the children would be puny (weak).8
Modern medicine has found that certain genetic disease conditions prevail
with repeated consanguinity and inbreeding. These include sickle cell
55

anemia, cystic fibrosis (of the lung and pancreas), thalassemia (a blood
disease), and phenylketonuria (PKLI) (a deficiency of an essential liver
enzyme).

All these diseases result from

the marriage of two carriers
of
the abnormal genes.
The
genes are called recessive,
because if only one spouse
carries them and the other is
normal, no disease results
among the offspring, though
some may become carriers
of
the harmful genes.
With
inbreeding or with repetitive
consanguinity
from
grandparents, to parents, to
the couple concerned, and in
families known to have these
diseases or to carry the
harmful
genes,
the
probability increases of a marriage between two carriers leading to affected
children. Figure i.i. may simplify this technical issue.
From the pedigree it is apparent that each offspring has:
(a)

a 25 per cent chance of being normal (NN);

(h) a 25 per cent chance of being affected (rr);

(c)

a 5o per cent chance of being a carrier (Nr) like the parents.

Should the carrier son or daughter marry a carrier spouse the same risk
(shown in pedigree 2) of transmitting the disease to the next generation
occurs.
Close to 1,000 conditions are inherited recessively and are usually more
severe than the conditions transmitted dominantly. Examples include the
following:

Cystic fibrosis
Phenyiketonuria (PKU) a deficiency of an essential liver enzyme
56

Sickle cell anemia

Thalassemia, a blood disease

Genetic defects occurring within consanguineous marriages are of this

recessive
variety.

In choosing their husbands, women have the same rights as men. There is a
difference, nevertheless, between the matron (widow or divorcee) and the
virgin.
On the authority of Abu Huraira, the Prophet (PBUH) said

A matron should not be forced into marriage. She should give her preference explicitly. A virgin should also give her consent. He
was asked: How to get her permission? He said: her silence.

Agreed upon
Islam endorses a woman's consent to the extent that a marriage could be
annulled where it has been forced on a woman by her guardian. According
to al-Bukhari and Muslim, the Prophet (PBUH) annulled the marriage of
Khansa' bint Khudham al-Ansariya because her father forced her to marry
someone she did not like. (See also the hadith on this topic).
What is Thalassemia?
Thalassemia major (Cooley's anemia), the homozygous form, evident in
infancy, is recognized by anemia, fever, failure to thrive, and enlarged spleen
(splenomegaly). It is confirmed by characteristic changes in the red blood
cells. Frequent transfusions are needed to keep up the oxygen-carrying
capacity of the blood. Red cells are rapidly destroyed, freeing large amounts
of iron to be deposited in the skin, which becomes bronzed and freckled. The
iron is also deposited in the heart, liver, and pancreas, which become fibrotic
57

and dysfunctional. The spleen may become so large that breathing

movement is blocked, and the stomach organs are crowded. Headache,
stomach pain, weakness, and loss of appetite often occur. There is no cure.
The child is uncomfortable. Growth and sexual development are usually
slowed. Rarely, a child with thalassemia major is able to function without
transfusions, thereby avoiding the massive ill effects of accumulated iron
deposits. 2

Adolescent Fertility
Adolescent Fertility
Young women who bear their first child during adolescence are likely to get
pregnant again sooner than women who bear their first child when they are
in their twenties. In all countries, the early onset of childbearing is associated
with high fertility. Early pregnancy therefore has a tendency to lead to larger
families, with serious consequences for health and wellbeing.
In addition to its harmful effects on the health of mothers and children, this
phenomenon has implications for population growth. Where girls marry at
15, the age gap between successive generations may be less than 20 years;
this gap may widen to as much as 30 years where the age at marriage is 25.
Worldwide fertility rates for women under 20 are declining, as are those for
other age groups. Total numbers of births among adolescents are increasing,
however, because the adolescent population is increasing.
The number of children born to women under 20 ranges from 4 per 1000
women in Japan to 239 per 1000 in Niger. In most countries, fertility patterns
among young women reflect their age at marriage. In countries where
women marry young, such as Bangladesh, fertility rates among women aged
15-19 are high -- over 200 per 1000 women in that age group. Where women
marry later, as in developed countries and most countries of the Eastern
Mediterranean and East Asia, fertility rates among women aged 15-19 are
lower.
The Social Consequences of Early Motherhood

2Excerpted from Mosby's Medical Encyclopedia. Copyright (c) 1994-5, 1996, 1997 The
Learning Company Inc.

58

The implications of differences in control and supervision

between young girls and boys are not limited to their
developing sexuality. Inevitably, measures adopted to
prevent premarital sexual activity and pregnancy involve
considerable restrictions on all the young girl's activities and
usually entail confinement to the domestic sphere. In this
way, a young girl's potential for acquiring skills to deal with a
wide range of experiences in the outside world is severely
limited compared with that of boys.
Whether or not a woman is married, having a child at a
young age severely limits her education and employment
prospects.
In many countries of the developing world,
marriage and the inevitable childbearing mark the end of
schooling. The resulting lack of education limits women's
ability to make informed choices and to find paid work. Early parenthood
reduces economic opportunities for young men as well. Recent studies have
shown that men who become fathers under the age of 19 are less likely to
graduate from secondary school and therefore have fewer employment
opportunities than those who have children after the age of 24.
In a study in the United States of America, it was found that women who had
a child during adolescence held jobs of lower status in their twenties than
women who delayed childbearing. In the Caribbean, where one-third of
pregnant women are under 19, a large proportion abandon their education
and are not readmitted to school. In Costa Rica, 51% of pregnant adolescents
gave up studies because of pregnancy and 61% gave up work. In Nigeria, a
study showed that 52% of pregnant adolescents were expelled from school.
In developed countries, pregnancy in the unmarried teenager may lead to an
economically and socially depressed future as a single parent, or to forced
marriage before she or her partner is ready, with a greater likelihood of
divorce. In most countries of the world, unmarried adolescent mothers face
social and legal sanctions because they are single.
Unwanted Pregnancy (Early Childbearing)

Childbearing at any age involves some risk. Maternal mortality rates in the
developing countries average about 450 per 100 000 live births, compared
with 30 per 100 000 in the developed countries. Young women who have not
reached full physical and physiological maturity are almost three times as
likely to die from complications in childbirth as older women. Data from
studies in several countries consistently show a higher risk of maternal death
among teenage girls compared with women aged 20-34 years. The risk for
59

very young teenagers (10-14

years) is much greater than for
older teenagers (15-19 years).
In Jamaica and Nigeria, it has
been found that pregnant women under 15 are 4-8 times more likely to die
during pregnancy and childbirth than those aged 15-19. In the United States
of America in 1981, the maternal death rate among mothers under 15 was
2.5 times higher than the rate among mothers aged 20-24.
Women in Algeria, Bangladesh, Ethiopia, Indonesia and Nigeria who became
pregnant when aged 15-19 ran a greater risk-sometimes twice as high--of
dying from pregnancy-related causes than pregnant women in their twenties
and early thirties.

Some complications are

more
common
in
adolescents than in older
women.
Hypertensive
disorders of pregnancy, if
untreated, can lead to
eclampsia which if often
fatal. Obstructed Tabour
may result if pregnancy
occurs
soon
after
menarche
when
the
pelvis is not developed,
or if the young girl has
not received adequate
nutrition
during
her
adolescent growth spurt,
resulting in stunted growth. If skilled assistance is not available-and this is
common in developing countries-mother and baby may die.
Vesicovaginal fistula or rectovaginal fistula may follow obstructed labour and,
if not repaired, will severely affect the woman's life; urinary and faecal
incontinence not only cause constant irritation, but may render her a social
outcast. A high proportion of women suffering from fistula are adolescents: in
Niger, 80% were aged 15-19, and in Nigeria 33% were younger than 16.

60

Female circumcision, especially the Pharaonic type,* may contribute to

obstruction of labour when the opening of the birth canal is so narrow that
the baby's head cannot pass without some form of intervention.
Health Consequence

Not surprisingly, the adverse effects of early childbearing on the mother are
matched by disadvantages for her baby. Babies of adolescent mothers have
a lower chance of survival. Low birth weight is more common in babies of
adolescent mothers. In Kenya, 40% of mothers aged 13-14 had low-birthweight babies compared with 25% of those aged 19 years. In Nigeria, the
highest rate (36%) was in the 15-19-year age group. In the United States of
America, the rate of low birth weight for mothers aged 15 years or less was
twice that for those aged 20-24 years. Babies weighing less than 2500 g at
birth are much more susceptible to illness and infection than heavier babies.
If they are much under that weight, they are likely to die.
Perinatal and infant mortality rates, especially in developing countries, are
consistently higher where mothers are under 20 than when they are in their
twenties and thirties. In Zimbabwe, for example, infant mortality rates were
78 per 1000 live births for children of mothers under 20 years of age, and 48
per 1000 for those born to mothers aged 20-29. The figures for Trinidad and
Tobago were 43 per 1000 and 28 per 1000, respectively.
Prenatal care can substantially reduce mortality and complications from
pregnancy and childbirth, especially in very young women. However, below
the age of 17, even the very best prenatal care cannot offset certain physical
risks of childbearing. In many parts of the world, prenatal care is inadequate.
In poor communities in the developing world, it is simply nonexistent, for
both married and unmarried women. In countries where it is available, the
younger the woman is, the less likely she is to attend early in her pregnancy.
There are a number of possible reasons for this: she may not recognize the
signs of pregnancy or she may not know where to go for advice. If she is
unmarried, she may not want to believe she is pregnant, or may be too
ashamed to tell anyone.
Not only are babies of very young mothers physically at risk during birth and
throughout early life, but their psychosocial and material wellbeing is
compromised in a number of different ways. The child born outside marriage
** Also known as infibulation, Pharaonic circumcision consists of excision of the clitoris, labia
minora and most of the labia majora, and sewing together of the remaining flesh, leaving a
small hole for passage of urine and the menstrual flow.

61

suffers indirectly, from the disapproval, social isolation and consequent

stress suffered by the mother, and directly, from the material deprivation
faced by mothers raising children alone. The child born to a very young
woman within marriage may be less well cared for because the woman still
has some of the emotional needs of a child herself. These may remain
unfulfilled and her own psychosocial development may be cut short or
distorted by the inappropriate responsibilities forced upon her. These
problems may be much less acute in an extended family, but where
traditional family structures have been destroyed through migration and
urbanization, the young mother often has to face these problems without any
social support.

Unwanted Pregnancy
An unwanted pregnancy may lead to an induced abortion, which in the case
of an inexperienced or ashamed adolescent is likely to take place later in the
pregnancy and involve greater risks to life, health and future fertility. If the
procedure is illegal, it will probably be performed under unsafe conditions,
increasing the risk even further.
The proportion of adolescents who seek abortion rather than continuing an
unwanted pregnancy has been increasing, especially among younger
adolescents (15-17 years). However, abortion rates among 15-19 year olds
have fallen considerably or stabilized in recent years in most developed
countries.
Abortion is legal in many developed countries, and abortion rates among
women aged 15-19 range from 5 per 1000 in the Netherlands to 44 per 1000
in the United States of America. Abortions on young women account for more
than 10% of all abortions performed in most countries with complete records,
and exceed 25% in several of these countries. However, young women in
developed countries are less likely to become pregnant than in the past,
probably owing to a greater use of contraception.
In countries where abortion is illegal-a majority in the developing world-it is
impossible to document its prevalence among young women. The major
source of information is hospital records of women treated for complications
of abortion, and this indirect evidence points to high rates of abortion in the
younger age groups. In Congo, Kenya, Liberia, Mali, Nigeria and Zaire,
between 38% and 68% of women seeking treatment for abortion
complications are under 20; in Malaysia the proportion is more than 25%,
62

and in Brazil, Chile, Guatemala, Peru and Thailand, more than 10%. In
Canada in 1984, 24% of women undergoing legal abortion were under 20
years old.
Illicit abortion involves major health risks. Young women are at greater risk of
severe complications of abortion because they often wait until well into the
second trimester of pregnancy. Even where abortion is legal, the risk in the
second trimester is four times higher than before the twelfth week. The
complications that arise include pelvic infection, haemorrhage, uterine
perforation and tetanus. Left untreated, many of these complications can
result in sterility, structural damage to the reproductive organs or death.
Between 150000 and 200000 women die every year from the complications
of unsafe abortion. In 10 hospitals in Zaire, one in every 50 women admitted
for complications of illicit abortion in 1982 and 1983 died in the hospital. A
study in Nigeria showed that 16% of all maternal deaths were due to
adolescent abortion. Even in developed countries, the risks are higher. A
study in the United Kingdom showed that the risks associated with abortion
were some three times higher in girls under 16 than in older adolescents.
How to Protect Oneself from Pregnancy
There are a number of reasons why unmarried
adolescents are relatively unsuccessful in avoiding
unwanted pregnancy. Sexuality is a taboo subject in
most societies, and young adolescents frequently
have little knowledge about contraception or the
basic facts of conception. They are naturally
impulsive and less likely to plan as the act of
intercourse may be unexpected as the subsequent
pregnancy.

The use of contraception among unmarried young women is considerably

greater in developed countries than in developing countries. The rates vary
from 7% in Spain and 19% in Hungary to 70% in Denmark and 91% in the
United Kingdom.
In developing countries, fewer than 30% of married women aged 15-19 use
family planning. In some countries, the figure is as low as 2% or 3%. Except
in Central and South America, few young women use contraception between
marriage and first pregnancy. By contrast, in developed countries the rates
63

of contraceptive use by married women aged 15-19 vary from 52% in Spain
and 59% in the United States of America to 87% in the United Kingdom.
Married or unmarried, young people in developing countries tend not to use
contraception, or to use ineffective methods. For example, recent surveys
have shown that, in Colombia, 47% of sexually active 15-19-year-olds were
not using adequate contraceptive methods, even though they wanted to
prevent pregnancy. In Liberia, the majority of sexually active adolescents
were not using any method to avoid or delay pregnancy.
Very few data exist on the extent of contraceptive use by young men.
Available information suggests low utilization. In Brazil and Jamaica
respectively, 19.5% and 11% of men aged 15-24 used contraception at their
first sexual encounter.
Many unwanted pregnancies occur during adolescence, when young women and
their partners become sexually active before they are fully aware of the need for
contraception or have had access to appropriate services. Emergency
contraception can be useful in these circumstances.
An unwanted pregnancy has psychosocial and health consequences for the
adolescent mother and her newborn baby. How serious these consequences
are depends largely on the degree of support provided by the young
woman's partner, family, health services and society in general.
Socio-economic and cultural factors influence the age at which young women have
their first sexual intercourse and whether or not they are likely to practice
contraception. Thus, the frequency with which adolescent pregnancy occurs varies
across countries and socioeconomic levels. Fertility rates range from 54 to 153 per
1000 women aged 15-19 years in Latin American countries, and from 23 to 236 per
1000 in African countries, with Central Africa being the region with the highest
proportion of pregnant adolescents (the mean rate is 207 per 1000 women). By
contrast, the fertility rate in developed countries is around 30 per 1000 women
aged 15-19 years, with the lowest rates - below 20 per 1000 teenage women found in parts of Europe and Eastern Asia. As a general rule, rates tend to be
highest among the poor and among less. educated women - precisely those who are
least equipped to cope with the negative consequences of teenage pregnancy.
(United Nations, 1995; Paxman J et al., 1993).

The idea of adolescent sexuality is not easily accepted by the family, the
school or society at large. For this reason, adolescents in many countries are
denied education on sex or family life, or else the education they are given is
inadequate and fails to take account of their real needs. Furthermore,
64

adolescents seldom have proper access to reproductive health care and

contraceptive services.
Adolescent sexuality is typically characterised by difficulties in negotiating
behaviour with partners, by unstable relationships, conflicting emotions,
secretiveness, sometimes rebellion, and often by unprotected intercourse especially in the early days of sexual activity. Adolescent women who get
pregnant may sometimes perceive motherhood as the route to recognition as
adults or even as a pathway to the desired status of marriage.
Emergency contraception is useful in preventing unwanted pregnancies in
adolescents, and there is no evidence that knowledge of this method of
contraception has the effect of encouraging sexual activity among young
people. On the other hand, the need for emergency contraception may be
the stimulus that brings adolescents into contact with health care
personnel, thus providing opportunities for counseling on responsible
sexual behaviour, contraception, and the prevention of sexually
transmitted diseases (STDS), including HIV/AIDS.
Combined Oral Contraceptives (Pills)

Mode of action

Combined oral contraceptives (COCs) contain

oestrogen and progestin and prevent
pregnancy by temporarily stopping ovulation
and thickening the cervical mucus.

Typical first year failure rate

1-8%

Resupply requirement

Monthly or less frequently if several cycles

can be obtained at once.

Effect on STD risk

May protect against some forms of pelvic

inflammatory disease (PID). May increase risk
of infection with some STDS.

Appropriate for breast-feeding

women

Not earlier than six months postpartum.

Return to fertility after

discontinuation

May be delayed for several months.

Side effects

Although some side effects of OC use have

been reduced with low- dose pills, some
65

women still experience nausea, weight gain,

headaches, skin colour changes, and other
side effects that may go away after several
months or continue as long as OCs are taken.
Complications

Increased risk of cardiovascular disease in

women over 35 years old who smoke, and
increased risk of hypertension; possible
increased risk of cervical cancer; risk of
breast cancer unclear.

Progestin-Only Minipills

Mode of action

Progestin-only minipills prevent pregnancy by

temporarily thickening the cervical mucus
and often stop ovulation.

Typical first year failure rate

3-10%

Resupply requirement

Monthly or less frequently if several cycles

can be obtained at once.

Effect on STD risk

Unknown.

Appropriate for breast-feeding

women

Hormonal methods are not the preferred

choice for lactating women. If minipills are
selected, however, use should not be
initiated before six weeks postpartum.

Return to fertility after

discontinuation

immediate or after slight delay.

Side effects

Users may experience irregular

menstrual bleeding (longer bleeding
episodes, amenorrhoea, or spotting).

Complications

Studies to date have shown no long- term

complications.

66

Condoms

Mode of action

The condom is a thin latex rubber

sheath that is worn over the erect
penis throughout sexual intercourse.
It prevents semen from entering the
vagina and uterus.

Typical first year failure rate

12%

Resupply requirement

Frequent.

Effect on STD risk

Protective.

Appropriate for breast-feeding women

Yes.

Return to fertility after discontinuation

Immediate.

Side effects

Some users experience sensitivity to

latex rubber or lubricants

Complications

None.

Natural Family Planning

Mode of action

Natural family planning (NFP) involves identifying

the woman's fertile period and abstaining from
intercourse during that time. Depending on the
type of NFP method used, the length of
abstinence can range from 7 to 14 days each
month. The woman's fertile period can be
determined in several ways, including using a
calendar, monitoring cervical mucus, and
monitoring changes in body temperature.

Typical first year failure

rate

20%

Resupply requirement

None.

Effect on STD risk

Not protective.

Appropriate for breast-

No.
67

feeding women
Return to fertility after
discontinuation

Immediate.

Side effects

None.

Complications

None.

Withdrawal
Mode of action

When man removes himself before ejaculation

takes place, thus preventing sperm from entering
the woman.

Typical first year failure

rate

18%

Resupply requirement

None.

Effect on STD risk

Not protective.

Appropriate for breastfeeding women

Yes.

Return to fertility after

discontinuation

Immediate.

Side effects

None.

Complications

None.

Service delivery
considerations

Providers should tell clients how to use the

withdrawal method correctly, emphasizing that
some sperm may be released before ejaculation
and that both partners must have self control for
it to be an effective method. If clients cannot use
other methods or temporarily do not have access
to contraceptive supplies, using withdrawal is
better than using no method at all.

68

Postcoital Methods or Emergency Contraception

In some areas, postcoital family planning methods may be available. Postcoital methods
are intended for emergency use only and currently are not recommended for use as a
regular family planning method. They are highly appropriate in cases of unplanned,
unprotected intercourse; suspected contraceptive failure, for example, by a broken
condom, dislodged diaphragm, or missed pill; and rape or incest. To reduce the need for
repeated use of postcoital methods, providers should- discuss other contraceptive
options with their clients.
The most frequently used postcoital method involves administration of steroid hormones
(oestrogens or oestrogen/progestin combinations) within 72 hours of unprotected
intercourse. Hormonal treatment prevents implantation, probably by causing changes in
the endometrium. A commonly used dose regimen consists of taking 0.1 mg of
ethinyloestradiol and 0.5 mg of levonorgestrel as soon after exposure as possible and
again 12 hours later. Most reported failure rates for the combined oestrogen/progestin
treatment range from 0 to 2.0%. Although no serious complications or long-term effects
of postcoital hormonal treatment have been reported, possible side effects include
nausea and vomiting, irregular uterine bleeding, breast tenderness, and headache.
Insertion of a copper-containing WD up to five days after intercourse can also be used
to prevent implantation of a fertilized egg. Since 1976, over 1300 postcoital insertions
have been reported with only one failure recorded. The side effects and
contraindications described for general IUD use also apply to postcoital use.
Women receiving postcoital methods should return to the provider one month after
administration to confirm the absence of pregnancy or receive counseling in the case of
method failure. In the unlikely event that treatment fails, the possibility of ectopic
pregnancy should be considered; postcoitally administered steroid hormones usually
prevent uterine pregnancy but not ectopic implantation.

Preference for Sons or Daughters: Islamic View

In many societies, especially in the developing countries, son-preference has
been noted to be paramount. Sons have been preferred over daughters for
various reasons: sons are perceived to provide security in old age;
inheritance stays within the family; sons carry on the name and trade of the
father; they provide physical protection to the family, etc. However, unlike
some other cultures, Islam strictly forbid making distinction between sons
and daughters, as the following excerpts from Islamic literature points out:

69

Islam disallowed preferential treatment and urged equity between males and
females from their first day of life.
The Qur'an reprimands

And when one of-them receives tidings of the birth of a female child [for him], his face darkens in sadness and disappointment. He
hides himself from the folk because of the disgrace of that of which he has had tidings. [He argues with himself shall he keep it in
contempt, or bury it alive? Verily! Evil is their judgement.

al-Nahl (Sura i6:58, 59)

As to burying girls alive (wa'd) this was a common practice in the pre-Islamic
period (fahiliyya).
Islam categorically prohibited that practice and
considered it a great sin. Other forms of killing children are prohibited (see
Chapter 2 for Qur'anic rulings). To have female children was blessed by the
Prophet:

Do not hate having daughters, for they are the comforting dears.
Authenticated by Ahmad and al-Tabarani

70

It is a woman's blessing to have a girl as her first child, for Allah says 'He
bestows female children upon whom he will, and bestows male children upon
whom he will'.
al-Shura (Sura 42:49)
Authenticated by Mardaweih and Ibn Asakir

Sexually Transmitted Diseases

Sexual Problems

Young people, like adults, sometimes have sexual

problems. These include sexual dysfunction,
sexual variation, and sexual harassment or
abuse, especially of girls by older men. Sexual
variation,
particularly
homosexual
feeling
(though it may not be labeled as such), is
common but transient in young adolescents.
Perhaps 5-10% remain homosexuality oriented
throughout their lives, although many more are
bisexual. Because homosexuality meets with
disapproval in most societies, it is a special cause
of anguish. These problems may be especially
frightening for young people, who encounter them before they have a wide
experience of the world.
Sexual abuse of young people is an important problem in most societies.
Intercourse with a minor (other than a spouse), whether forced as in rape, or
enticed, as sometimes in incest or pedophilia, is universally condemned.
Prostitution, whether by the young male or the young female, is also
denounced, although it is sometimes recognized as arising from economic
need or family disruption. Many feel that premature marriage before a girl
has had a chance to develop fully is also a form of maltreatment.
Another potential consequence of unprotected sexual activity in
adolescence, besides pregnancy, is the acquisition of a sexually transmitted
71

disease (STD) or sexually transmitted infections (SITs), often with devastating

effects on future fertility. The incidence of STIs among adolescents has
increased markedly in the past 20 years world-wide.
STIs are the most common group of communicable diseases reported in the majority of
countries, and they continue to occur at unacceptably high levels, particularly among
young people. Changes in sexual and social behaviour as a consequence of
urbanization, industrialization, mass communication and ease of travel are factors that
have contributed to this public health problem. Young people between the ages of 10
and 24 years constitute both an important target group and a potential force for the
prevention of STI.
RTIs include a variety of bacterial, viral, and protozoal infections of the lower
and upper reproductive tract of both sexes. Many RTIs are sexually
transmitted.
Though most STIs are RTIS, some STIS, such as syphilis, hepatitis B and AIDS, are
also systemic diseases. Many STIs also affect the mouth, rectum, and urinary tract, the
latter being part of the reproductive tract in males but not in females.
Female RTIs originate in the lower reproductive tract (external genitals,
vagina, and cervix) and, in the absence of early treatment, they can spread
to the upper tract (uterus, fallopian tubes and ovaries). Infections can ascend
from the lower to the upper tract spontaneously to cause pelvic
inflammatory disease (PID), but the risks of upper tract infection rise
dramatically during procedures such as IUD insertion, abortion, and childbirth
when instruments are introduced through the cervix.
What are the common causes of these infections?
RTIs are comprised of:
a) iatrogenic infections, which are related to inadequate medical procedures, such as
unsafe abortions,
(b)

endogenous infections, which may be

associated with inadequate personal, sexual
and menstrual hygiene practices, and

(c)

sexually transmitted infections (STIs).

The major determinants and pathways of RTIs in the

Indian context have not yet been investigated in detail.
In particular, it is not clear what is the contribution of
personal, sexual and menstrual hygiene practices.

Reproductive tract infections (RTIS)

pose grave threats to women's lives
throughout the world. RTIs include
sexually transmitted infections (STIs);
infections related to procedures such
as unsafe deliveries and abortion or
IUD insertion; and infections due to
overgrowth of organisms normally
found in the genital tract. Men also
experience RTIS, particularly STIS,
but
the
prevalence
and
the
72 much
consequences for women are
more severe.
Source: Mueller and Wasserheit, 1991

However, it is clear that iatrogenic infections do occur, and medical personnel have a
responsibility to make sure that medical procedures, such as deliveries, insertions of
IUDS, sterilizations, and medical termination of pregnancy, are conducted under safe
and sterile conditions and do not lead to RTIS.

How common are RTIs and STIs?

In view of the proximity, frequency of visits by Maldivians to India and vice-versa, the
situation of STDs in India is of interest. All community-based prevalence studies of
women and men's health that have now been conducted in India indicate that rates of
RTIs are very high. For example in a study conducted among women in two villages in
Maharashtra, the prevalence of clinically- diagnosed RTIs was 46%. In other studies
conducted in four different sites (rural West Bengal and Gujarat, and urban Baroda and
Bombay), the prevalence of such infections ranged from 19% to 71%. Finally, in a study
conducted in rural Karnataka, over 70% of women had clinical or laboratory evidence of
RTIS. Many of the women in these studies had signs or symptoms. For example, in the
Karnataka study, 38% of women complained of excessive vaginal discharge or
abdominal pain.
Men suffer from RTIs as well. A study of male reproductive morbidity conducted in rural
Maharashtra suggests that a substantial proportion of men have problems such as
urethritis, and genital skin infections.
Some of these RTIs are sexually transmitted. For example, in the Karnataka study,
evidence of an STI was found in 10% of all women. Based on a number of communitybased and facility-based studies and a review of the scientific literature, the annual
incidence of STIs in India is estimated at 5%, which indicates that approximately 40
million new infections occur every year.

73

Marked variation has been found across the

studies that have been conducted so far in
terms of patterns and levels of morbidity. It is
plausible that innate differences exist across
population groups and that no single set of
estimates for RTIs and STIs could apply in such
a large and diverse country as India. However,
it is also the case that fundamental differences
exist across studies with respect to study
designs and research methods. Nonetheless, collectively these studies leave little doubt
that morbidity levels associated with RTIS, including STIS, are unacceptably high, and
constitute a major public health problem among poor Indian women and men.
Infections with human papillomavirus (genital warts) and with the bacterium
Chlamydia are the most prevalent STDs in industrialized countries. The
disease that has increased most in incidence over the past two decades is
genital herpes. In developing countries, the classical "venereal" diseases
such as gonorrhoea, syphilis and chancroid remain very frequent. HIV
infection, which is mainly sexually transmitted, is the most costly in financial
and human terms.
The highest rates for notifiable STDs are usually observed in the 20-24-, year
age group, followed by the 15-19 and 25-29-year age groups. Where STDs
are a major health problem, the incidence tends to be higher in women aged
15-19 than in men of the same age group. Among sexually active young
people, STDs are most frequent in the youngest.
In the United States of America, women in the age groups 15-19 and 20-24
years have the highest incidence of gonorrhoea, nearly three times that of
the group with the next highest frequency, those aged 25-29 years. Men
account for 60% of cases of gonorrhoea reported in persons below the age of
20 years. This sex ratio is reversed in people above the age of 20 years.
Men aged 20-24 years have the highest incidence of gonorrhoea among
males, 80% higher than that among those 25-29 years old, who have the
second highest frequency.
Forty per cent of the women with chlamydial infections seen at a family
planning clinic in New Zealand were younger than 20 years of age. In a study
in Kenya, 44% of reported cases of STD were in people aged 15-25 years,
and 57% of the female patients were under 20. In Uganda, the highest
incidence of reported STD was among young women aged 15-19 years.

74

The frequency of STD is higher among single, divorced and separated

persons than among married people. Individuals from the lowest socioeconomic groups and prostitutes have the highest rates.
Although the overall morbidity rate is higher for men than for women, the
complications caused by the infection are generally much more severe in
women. This is partly because men tend to seek diagnosis and treatment
earlier than women because the symptoms are more obvious.
The list of complications associated with STDs has grown considerably during
the past ten years because many previously unsuspected and late
complications have become apparent. These complications include the
sequelae of pelvic inflammatory disease (PID), genital cancers, infection of
newborn babies and infants, narrowing of the urethra and infertility in men.
Among women treated for PID, 20% experience infertility or ectopic
pregnancy because of tubal damage. Infertility caused by infection is now
recognized as a serious problem throughout the world. In Africa, almost 50%
of women seeking evaluation for infertility had bilateral tubal occlusion,
mostly attributable to STD.
In the United States of America, the number of ectopic pregnancies
quadrupled between 1970 and 1983. Many of these were thought to be a
result of tubal damage caused by STD.
A number of cancers, including cervical, penile and anal cancer, are highly
correlated with human papillomavirus infection. In the United Kingdom, the
mean number of deaths attributable to cervical carcinoma in women aged
less than 30 years has increased from 18 per year during the years 19681974 to 31 per year for the years 1975-1980. This is consistent with the
increased incidence of STD.
Three of the major obstacles to the control of these diseases among
adolescents are the ignorance of young people of the symptoms of STDS, the
asymptomatic nature of some STDS, particularly in women, and the
reluctance of young people to ask for help because they expect to be met
with anger and hostility. Two of the diseases-genital herpes and acquired
immunodeficiency syndrome (AIDS)-re at present incurable. The former may
have severe psychosocial effects on the individual because of its
unpredictability and the risk of infecting others, the latter because of its
devastating and deadly nature and the reaction of others to infected people.

Common Reproductive Tract Infections

75

Genital Ulcers and Other Lesions

Syphilis is declining in some countries but increasing in others. The primary and most
infectious stage consists of painless ulcers that are often unnoticed by women. If
untreated, the disease proceeds to a secondary stage of generalized infection, followed
by a prolonged stage with few symptoms. In pregnant women, early stages of syphilis
can result in intrauterine growth retardation, premature birth, stillbirth and congenital
infection of the infant.
Genital herpes, caused by the herpes simplex virus, produces painful genital ulcers
that heal spontaneously but recur, the initial outbreak being the longest and most
intense. Although there is no medical cure yet, symptoms can usually be controlled with
therapy. Herpes is most infectious when sores are open, but the disease can also be
spread to sexual partners by individuals who are not aware of any symptoms. Although
childbirth during an active outbreak of a mother's primary infection is rare, 20-25 percent
of babies born under these circumstances will be infected at sites such as the eyes,
skin, mouth, central nervous system or lungs. The majority of infants with infections
extending beyond the skin, eyes, and mouth will suffer permanent neurological damage
or death.
Chancroid occurs frequently in developing countries. While this disease usually causes
a painful ulcer in men, it may occur without symptoms in women. As with other genital
lesions, chancroid appears to increase the risk of HIV transmission.
Genital warts are small painless growths caused by the human papillomavirus (HPV),
and may be the most common viral STI in industrialized countries. The precise
prevalence of HPV infections is unknown, however, because most HPV infections are
asymptomatic. These infections are difficult to treat and recurrent infections are
common. Preliminary data have established a link between genital warts and HIV
infection. Several of the over 50 types of HPV appear to be associated with increased
risk of cervical cancer.
Vaginal Infections
Bacterial vaginosis (BV) is probably the most common of all vaginal infections. It can
occur without symptoms, or be accompanied by excessive vaginal discharge that has
an unpleasant odour. The organisms causing BV are normally found in low numbers in
the vagina. BV results from their rapid multiplication due to a variety of factors that upset
the normal balance of bacteria in the vagina. BV may cause upper tract infections. In
pregnant women, this may lead to the birth of a premature infant; in non-pregnant
women, infertility or tubal pregnancy may result.
Candidiasis, like BV, results from overgrowth of normal vaginal flora. Symptoms
include vaginal discharge, irritation, and vaginal itching, although no long-term or severe
76

complications result. Candidiasis is a common infection, occurring among II -25 percent

of women tested in 17 studies conducted in developing countries. Pregnant women and
women taking antibiotics are especially vulnerable.
Trichomoniasis, a very common STI, may be associated with profuse discharge,
burning during urination, bad odor or, occasionally, lower abdominal pain. Preliminary
studies show an association with increased risk of HIV transmission.
Bacterial vaginosis, candidiasis and trichomoniasis are all treatable infections.
Cervical Infections
Chlamydia, the most common bacterial STI in some industrialized countries, is
particularly difficult to control for three reasons. First, the majority of women with
chlamydial cervicitis have no symptoms so they rarely seek care.
Second, accurate tests for chlamydia re technically demanding and expensive. Finally,
at least a week of therapy is required to eradicate lower tract chlamydial infection, in
contrast to the single dose regimens available for many other bacterial STIs.
Chlamydia can lead to extremely serious complications. Infection in the upper tract
frequently causes infertility. During pregnancy, chlamydia may cause stillbirth,
premature birth, and congenital infections such as pneumonia or eye infections. It also
appears to be associated with an increased risk of HIV transmission.
Gonorrhea is believed to be the most common preventable cause of PID and tubal
infertility worldwide. It is spread easily: a man's risk of acquiring the disease in a single
heterosexual encounter with an infected partner is approximately 20-25 percent, while a
woman's risk is probably higher because infected secretions from the male are retained
in the vagina following intercourse. In women, symptoms of cervical infection can
include abnormal vaginal discharge and burning during urination; upper tract infection
may be associated with lower abdominal pain and abnormal menstruation; and a bloodborne phase of infection may be manifested by rash and painful joints. Cervical
gonorrhea is, however, asymptomatic in at least 20-50 percent of women. Gonorrhea
can produce spontaneous abortion, prematurity, and potentially blinding eye infections
in newborns. Preliminary data now link gonorrhea with an increased risk of HIV
transmission. Although gonorrhea can be treated with antibiotics, and increasing
number of strains are resistant to those antibiotic medications most readily available in
the developing world.
Cervical cancer, although not an infection, appears to be causally related to lower tract
infections from some subtypes of HPV which also cause genital warts. About half a
million new cases are diagnosed each year worldwide, more than three-quarters of
which are found in developing countries.
77

Upper Reproductive Tract Infections

Pelvic inflammatory disease (PID) consists of infections of the uterus, fallopian tubes.
and ovaries. Although PID can occur without significant pain, symptoms usually include
abdominal pain and abnormal vaginal discharge. Acute cases may require
hospitalization. The spread to the upper reproductive tract of gonococcal and chiamydial
infections and of bacterial vaginosis organisms is often facilitated by IUD insertion,
unsafe abortion or childbirth. PID can cause severe inflammation and scarring of the
fallopian tubes and ovaries, and damage increases with the severity of inflammation
and with each recurrent episode.
Long-term consequences of PID include infertility, potentially fatal tubal pregnancy,
chronic pelvic pain, and recurrent bouts of upper tract infection. Upper tract infections
during pregnancy raise the possibility that a fetus will abort spontaneously or that an
infant will be born too soon and too small.
RTIs resulting in blockage of the fallopian tubes are the major preventable cause of
female infertility in developing countries. About 15-25 percent of women who develop
PID become permanently infertile because of tubal scarring following infection. Before
the advent of antibiotics, infertility rates as high as 60-70 percent were noted following
PID. Although men may be responsible for up to one-third of all cases of infertility in
many developing countries. the blame most often falls on women. A vicious cycle may
occur in which STIs introduced by the husband's extramarital contacts result in a wife's
post-infectious infertility. He then abandons her, infects other women, and she may turn
to prostitution as the only means of supporting herself.

HIV/AIDS

AIDS (Acquired Immune Deficiency Syndrome) is a major

concern for young people today. The number of diagnosed
AIDS cases among adolescents and young people severely
underestimates
the
threat posed by
HIV (Human
Immunodeficiency Virus) infection, given the long incubation
period of the disease. At least half, and probably the majority,
of HIV-infected people will develop AIDS within 10-15 years of
becoming infected. It can thus be assumed that most young
adults with AIDS were infected during their teens.

78

Worldwide, between 20% and 25% of HIV infections are estimated to occur
among young people. In Brazil, more than
30% of the accumulated AIDS cases in 198092 were diagnosed in young people aged 1529 years, and it is clear that young people in
many countries account for a large
proportion of AIDS cases.
Blood and sexual secretions from an HIVinfected person are known to be capable of
transmitting the virus to another person
provided they are given a portal of entry into
his or her body. This entry point can be:
-

mucous membrane (the thin lining of the rectum, vagina, urethra,

and mouth;

skin anywhere on the body that has cuts, sores, abrasions, or other
lesions; or
the eye.

HIV does not penetrate intact skin.

The battle between HIV and the immune system is fought in three stages.
The first, known as primary (acute) HIV infection, begins at the time of
infection and lasts until the bodys initial immune response gains some
measure of control over viral replication, usually within a few weeks of
infection. During this period CD4+ T-cell count drops dramatically, and
between 30 and 70 percent of people experience flulike symptoms. These
usually disappear within three weeks, as the CD4+ T-cell count rebounds.
The disease enters its second stage, which is generally asymptomatic and
accounts for about 80 percent of the time from infection to death. Only at
the beginning of the second stage do antibodies to HIV become detectable in
the blood stream. Since most HIV tests work by detecting these antibodies, it
is usually not possible prior to this stage to determine if a person is infected.
Most HIV-infected people remain clinically healthy during this stage, while
the immune system wages an invisible but intense struggle against the virus.
Ultimately, the disease enters the third and final stage of HIV infection
clinical AIDS. Some of the illnesses that strike people with AIDS are
communicable, such as TB; others, like HIV related cancers, are not. Some
are common infections that usually become severe like sinusitis or
pneumonia, while others are rare diseases.
79

Epidemiological studies throughout the world have shown only three modes
of HIV transmission. Sexual intercourse, whether
heterosexual or homosexual, is the major route
of transmission. Transmission also occurs through
HIV
infected
blood,
blood
products,
or
transplanted organs and tissues, for example by
direct blood transfusion or through the use of
improperly sterilized needles and syringes that
have been in contact with infected blood. Finally,
HIV can be transmitted from an HIV infected
woman to her fetus or infant before, during, or
shortly after birth.
In the world as a whole, heterosexual intercourse has rapidly become the
dominant mode of transmission of the virus. As a result, in the developing
countries there are already as many newly infected women as men, and in
developed countries, HIV incidence in women is approaching that in men. In
Africa, there is a relatively consistent preponderance of HIV infections in
sexually active women in the 15-24-year age range compared with men of
the same age. HIV is transmitted among young people primarily through
unprotected sexual intercourse.
The second commonest mode of HIV transmission among young people is
through the sharing of contaminated equipment (e.g., injection needles) by
injecting drug users. HIV infection among this group has been reported from
over 50 countries. Perinatal transmission
(from infected mother to her infant) is
also increasing; often young women find
out that they are infected with HIV only
when their babies become sick and are
diagnosed as having AIDS. Transmission
through contaminated blood transfusion
has
been
virtually
eliminated
in
developed countries and is being reduced in developing countries.
Adolescence can be a period of profound physical and psychological change,
and experimentation. Behaviour that increases the probability of HIV
infection is therefore common among adolescents and young people, and
includes unprotected sexual intercourse, sharing of needles by injecting drug
users, and use of alcohol and other drugs that result in reduced sexual
inhibition and impairment of judgement.

80

Girls and young women are particularly vulnerable to HIV infection; they are
likely to marry older and more sexually experienced men, they often have
less access to education and less power in negotiating sexual matters,
including safer sex, and they may be unaware of having a sexually
transmitted disease, which is a significant co-factor in HIV transmission.
Violence is common: about 20% of a sample of sexually active girls aged 1219 years in one African country reported that they were physically forced at
the time of their first sexual intercourse.
Furthermore, increasing numbers of young people are homeless and live on
the streets, where the dangers, violence and the need to obtain money to
survive make them very vulnerable to HIV infection. In countries severely hit
by the AIDS epidemic, the rise in the number of deaths in the adult
population has also led to an increase in the number of
orphans and street children.
Many young people are therefore affected by AIDS even
if they are not themselves infected: children and
adolescents whose parents die of AIDS face the double
trauma of bereavement and stigmatization, with
consequences for their emotional and mental health,
They also tend to leave school at an early age, as they
have to provide and care for the family.
The ambivalent attitude of adults towards young people's sexuality is a
major obstacle to programmes aimed at preventing HIV infection and STD.
Young people need to be aware of the possible consequences of unprotected
sexual intercourse and use of injecting drugs; even more, they need to
develop skills that will protect them from infection, such as how to resist
pressure for unwanted sexual intercourse and sharing of injecting materials,
how to negotiate safer sex, and how to practice it through the use of
condoms.

It is increasingly recognized that prevention of HIV and STD among young

people is most effective when set within the context of activities to
promote sexual health.

Relationship of RTIS, STIs and HIV infection

The relationship between STI and HIV infection is threefold. First, STI and HIV infection
are associated with the same risk behaviours, that is unprotected sexual intercourse
81

with multiple partners. Thus, the same measures that prevent STI also prevent sexual
transmission of HIV infection.
Secondly, the presence of STI has been found to facilitate the acquisition and
transmission of HIV infection. A 10-fold increased risk for HIV transmission has been
associated with infections that cause genital ulcers, such as syphilis, chancroid and
herpes. The risk associated with diseases causing discharge, especially Gonorrhea,
chlamydial infection, trichomoniasis and bacterial vaginosis, is up to 4-fold. Thus, early
diagnosis and effective treatment of RTI can contribute significantly to a reduction in
FUV transmission.
Lastly, there is mounting evidence that some RTI pathogens are more
virulent in the presence of HIV related immune-deficiency. This might have
consequences for treatment recommendations for RTI, although more studies
need to be carried out before changes can be proposed.

What are the possible consequences on people's health?

RTIs and STIs represent a serious threat to the health and well-being of Indian women
and men. They are exposed to the pain and discomfort of acute illness, and often
experience long-term impairment of their reproductive function as a consequence of
these infections. Some complications, such as infertility, are a source of psychological
distress and family disruption. Others, such as ectopic pregnancy and cervical cancer,
represent a significant source of mortality. Some infections may also cause fetal death
or affect child survival by causing pre-term deliveries of low birth weight infants, or by
infecting newborns during delivery. RTIs and STIs are therefore responsible for a large
amount of female, male and infant morbidity and mortality and form an enormous public
health burden in India.

Islamic View:

Islam ordains the taking of all steps to protect against disease in accordance with the advice of medical
experts. Prevention leads to protection. This includes immunization against communicable diseases and
keeping away from sources of infection.3

The Prophet (pbuh) said,

3 World Health Organization, Health Promotion through Islamic Lifestyles: The Amman
Declaration, Regional Office for the Eastern Mediterranean.1996, p.28

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Whoever takes measure o f prevention is protected.

Do not harm yourselves or others.
There shall be no contagion and no evil omen.
Do not let those infected transmit their disease to those who are
healthy.

Counseling Adolescents on Human Sexuality

and How it Affects our Behaviour
Sexual Dysfunction
The term sexual dysfunction is usually used to refer to some form of
impairment of the ability to achieve sexual satisfaction during intercourse.
Thus it is not considered a problem unless it is perceived as such by one or
both partners. Some dysfunctions are more common in adolescence than
others. In this session it is usually best to explain how you are using the
term and to indicate briefly the working definitions of the terms described
below. The words used by adolescents will usually differ from the technically
"correct" term. Some discussion of the words which are used will be
valuable. While some participants may find it embarrassing, they should be
reminded that they will be hearing such terms in the counseling situation. If
the language used by some of the participants in their own setting is
different from the language used in the workshop, ask them to write down
the technically correct terms and the words more like to be used by
adolescents in their own cultures.

Impotence (or erectile dysfunction) an inability to achieve or maintain

an erection of the penis. Primary impotence is defined as never having
achieved an erection. this is rare and usually the result of organic problems.
Secondary impotence is much more common and is usually caused by
anxiety about the situation or about the erection itself. It is likely to be
temporary if the anxiety is dealt with. A young man who is anxious about
sexual intercourse or its consequences may experience secondary
impotence. If he isn't aware of the cause or its commonness it may lead to
long-standing sexual problems and an immediate loss of self-esteem.
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Premature Ejaculation an inability to control ejaculation so that it occurs

soon after arousal and before either the adolescent boy or his partner wishes
it to occur. Because of the quick arousal experienced by adolescent boys
this is likely to be a fairly common problem.
Retarded Ejaculation is the reverse, i.e. it occurs later than desired.
Vaginismus Spasm of the vaginal muscles which prevent penetration.
Dyspareunia Pain experienced on penetration of the vagina for which there are
multiple causes. this can cause considerable psychological stress as well as have an
adverse impact on long term relationships.
Lack of Sexual Desire a perception by the young person that they are not sexually
aroused when they think they ought to be and perhaps especially in relation to a sexual
partner.
Excess Sexual Desire the perception that sexual arousal occurs more often or more
strongly than they wish. This is not an uncommon complaint expressed by boys who
may find their concentration on other things lapsing because of sexual thoughts and
desires.
Anorgasmia an inability to experience orgasm when desired. Given the greater
likelihood of rapid arousal in boys and a somewhat slower (but longer lasting) arousal in
girls, there may be anxiety (in either partner) that the girl hasn't achieved orgasm.
However, many people enjoy sexual experience without experiencing orgasm, and
simulatneous orgasm is probably not the rule, but rather the exception. Young people
may not be aware of this.
The discussion should focus on what participants believe to be the most common
difficulties experienced by young couples, and on the problems which arise when they
attempt to communicate with others on these subjects. The participants should be
encouraged to consider at least one of these situations for role play.

Sexual Variation
Sexual variation is more commonly referred to as sexual deviation since, narrowly
defined, it means being able to achieve orgasm only through stimulation of the kind
described below. While many of the variations in achieving sexual satisfaction listed
below often contribute to sexual arousal to some degree, exclusive dependence on
them is much less common. Since "deviation" is usually used as a pejorative term, and
since sexual orientation is not a matter of choice, it is best to avoid language which is
derogatory. It is useful, at this age, to remind participants of the distinction made earlier
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between feeling sand behaviour. Whereas an individual may be able to achieve orgasm
only through a particular variation, or has a preference for the manner of sexual arousal,
that does not necessarily mean that they engage in such behaviour, or do so often.
Some variations are not necessarily harmful to the individual or sexual partner.
Participants should be encouraged to discuss their views on this subject. However, the
amount of time spent on this subject should depend on its relevance to the adolescent
community served by the participants. The fact that a particular problem may be
unusual, should not be a cause for avoiding discussion. The counsellor needs to be an
able and sympathetic listener to any such problem, and it is precisely the more unusual
ones which are likely to have been kept secret and for which the adolescent may be in
greatest need of help.
Sado-Masochism the achievement of orgasm only by giving (sadism) or receiving
(masochism) pain to or from a sexual partner.
Transvestism Dressing in the clothes of the opposite sex as the sole means of
achieving orgasm. This is not usually related to sexual orientation although many
participants may assume that it is an expression of homosexuality.
Voyeurism Observation of people engaged in sexual acts or those which may have
sexual overtones, as the sole means of achieving orgasm.
Exhibitionism Achieving orgasm exclusively by displaying sexual organs, usually to
strangers in a public place.
Fetishism Arousal by an object or material such as a shoe, or rubber, as the exclusive
means of experiencing orgasm.
Transsexualism Feeling trapped in the body of the wrong sex, a relatively rare but
powerful phenomenon which is usually present from early in life. If does not correspond
to homosexuality but in recent times has come to be recognized as a phenomenon
which is sometimes treated by surgical means. Although surgery will not enable the
individual to have the reproductive capability of the "new" sex, it often makes the
individual much more comfortable and capable of leading a life which is appropriate for
them. This is not truly a sexual variation, but really a difference in felt gender.
Paedophilia sexual arousal through sexual interaction with children (also see Sexual
Abuse, below).
Homosexuality sexual attraction only to members of the same sex but a rather special
case in early adolescence since it may subsequently evolve into heterosexual (or
bisexual) orientation (see below). There are two essential points of which participants
need to be reminded that sexual preferences are not chosen and are exceedingly
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difficult if not impossible to change, and that many people who might be
appropriately described in this way do not necessarily engage in homosexual behaviour.
The converse is also true, i.e. that young people living exclusively with members of their
own sex may engage in homosexual behaviours without having a homosexual
orientation. It is also the case that not all such behaviours are necessarily harmful, a
point the group might wish to discuss. Adolescents, especially younger ones, are not
fully developed sexually so that sexual relations with adults are likely to be
inappropriate. Strong inclinations toward the variations described above are likely to be
exceedingly disturbing to the adolescent who will need help to deal appropriately with
the situation.
Bisexuality attraction to bother sexes. This merits special discussion. Many
adolescents go through a period in which attraction to members of the same sex
become very intensive. It is often a time of having a "best friend" of the same sex, or
hero worship of an older person of the same sex. Some sexual arousal may be a
natural part of this attachment, and sometimes it will be expressed in sexual activity
other than sexual intercourse. It is also commonly reported that when adolescents live
together in same-sex quarters homosexual experiences occur. Most young people who
experience this will eventually become primarily heterosexual in their orientation.
However for a certain percentage of adolescents, the homosexual orientation will be
lifelong. Since in virtually all societies this is seen in a negative light it will inevitably
mean that the adolescent with a homosexual orientation, will face difficulties. Given
these problems and since homosexuality heterosexuality lies on a continuum, many of
those with strong homosexual inclinations will suppress that part of their nature and do
their best to lead primarily heterosexual lives. They may marry, without losing the
homosexual feelings and lead a bisexual life in fantasy or reality. An adolescent with a
profound homosexual orientation may at the same time have an equally profound wish
to be purely heterosexual. This can be the source of great misery since one cannot
intentionally change sexual orientation although it may evolve over time. Others with a
homosexual orientation may be content with that but recognize that they will have to
deal with antagonism from some others perhaps within their own families. An important
task of counselors is to help young people through these difficulties.

Sexual Abuse
The purpose of this discussion is to help the participants recognize situations which are
harmful or distressing to the adolescent, arising from the behaviour of other people
toward them, either against their will or without adequate consent because of their
immaturity. Sexual abuse or harassment can take many forms and may differ
considerably between cultures. It is appropriate for the facilitator to explain how the
term is being used and ask the participants themselves to provide examples of what
they see as sexual abuse. Just as sexual behaviour may take many forms and is not
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restricted to sexual intercourse, sexual abuse covers a wide range of behaviours. It

may, for example, be purely verbal rather than physical; it may overlap with the previous
topic as in the case of the practice of paedophilia. Sexual abuse can have long-term
consequences. Many abusers have a history of being sexually abused themselves.
Following the discussion the transparency can be shown, although it is more useful to
elicit behaviours identified by the participants and record them on a transparency during
the discussion. Some of the more frequently cites kinds of abuse are listed below.

Incest This can be defined operationally as sexual relations which occur between two
people in the same family such as father and daughter or mother and son, but situations
which are almost as disturbing may involve those who are not blood relations such as a
step-father and step-daughter. Again, for purpose of the discussion on sexual abuse,
incest may include sexual activity which falls short of intercourse. Incest is almost
universally censured and under-reported. Some participants will find the subject
shocking and may begin by saying that it is extremely rate in their own cultures.
However that opinion may be somewhat modified in the group discussion. Incest is a
particularly difficult subject for the adolescent to raise for reasons which include shame,
embarrassment, often a sense of guilt that they have somehow consented or
encouraged it, fear of the reaction of the mother, for example, if it has occurred between
a girl and her father or step-father, fear of consequences to herself such as being sent
away, and the possibility that the family will be broken up, anxiety about legal
implications, etc. Role playing a girl who tries to tell her mother of an incestuous
situation will help to illustrate some of these difficulties.
Rape the forcing of sexual intercourse on an unwilling male or female.
Rape may be particularly traumatic for an adolescent with no prior
experience of intercourse and may be accompanied by additional physical
(as well as psychological) abuse. In many countries sexual intercourse with a
minor however defined is treated as statutory rape, even if the minor
consents, since the young person is not considered to be mature enough to
make an informed judgement.
Incest may also occur when a young
adolescent doesn't feel able to refuse the attentions of an older member of
the family.
Prostitution the involvement of adolescents in exchanging sex for money
or other favours is often seen as sexual abuse since some adolescents are
forced into this, some will do it out of desperation, and others will be too
young to make a mature voluntary choice. In many developing countries it is
most prevalent in tourist zones. In some countries young people are being
sought out by adults on the assumption that they are more likely to be free
of the AIDS virus.
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Paedophilia as in the above categories a child or young adolescents may

be either obliged or persuaded to have sex with an older person to fulfill the
latter's sexual desires and is a form of sexual abuse because of the
immaturity of the child (also see Sexual Variation, above).
Sexual Harassment this may take many forms including repeated teasing
or embarrassment often, but not always, by boys or men toward girls. How
that is constituted in the cultures of the participants should be discussed.

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Islamic View on Sexual Relations

Islam forbids sexual intercourse during menstruation and
allows all kinds of sexual intercourse as long as they are carried
out through the vagina.ii
God said:

So keep aloof from women during menstruation

(2:222)
Your wives are as a tilth unto you: so approach
your tilth when or how you will. (2:223)
The Prophet (pbuh) said: Do not approach women
through their anuses.

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CHAPTER V.FAMILY AND MARRIAGE IN ISLAM

Improved Communication Between Spouses

Islam orders that the relation between husband and wife be based on love,
compassion, collaboration and kindness; all of these are a guarantee for the
mental health of the husband and the wife and all the family.iii
Allah (SWT) said:

And He has planted love and kindness in your hearts

(30:21)
Live with them on a footing of kindness (4:19)
And consult together in all reasonableness (65:6)

The Prophet (pbuh) said:

The best of you is best for his wife.

Do not force women to do what they do not like.
The best among you are the best for their wives.
Do take full care of women.

Definition and Functions of Family, Relationships and Responsibilities

For Muslims, marriage is necessary in order to found a family, for physical,

mental and sexual tranquility and to preserve the species. That is why Islam
call for marriage and warns against celibacy, and urges young people to
marry if they are fit physically as well as financially. iv The Prophet, peace be
upon him (pbuh), said:

Marry the one who is pious.

Marry loving and fertile women.
If any among yourself asks for the hand of a woman then you
should be able to see for yourself the qualities for which you have
decided to marry her.
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Look at her; this will ensure harmony among them.

Both Abu Bakr and Umar asked the Prophet (pbuh) for the hand of
his daughter Fatima. He replied that she was young.

In Islam, women have the same rights in choosing their husbands, as men.
There is a difference, nevertheless, between a matron (widow or divorcee)
and the virgin (never married?). The Prophet said, A matron should not be
forced into marriage. She should give her preference explicitly. A virgin
should also give her consent. He was asked: How to get her permission?
He said: her silence. v
Islam endorses a womans consent to the extent that a marriage could be
annulled where it has been forced on a woman by her guardian. According
to al-Bokhari and Muslim, the Prophet (pbuh) annulled the marriage of
Khansa bint-e-Khudham al-Ansariya because her father forced her to marry
someone she did not like.
The family is the basic social unit in Islamic society, and marriage is the
fundamental Islamic institution. Marriage and family formation are grave
responsibilities and are subject to specific regulations. Their planning is,
therefore, in order.
When Islam came to Arabia, there were several forms of marriage. All were banned save one - a marriage with the free consent of
the wife, as practiced today. Polygyny is allowed but monogamy is preferred. An equity condition (to treat all wives equally) is an
important restriction and suggests that polygyny is conditionally allowed. Marriage is to be made public; the dowry and financial and
household needs are the responsibility of the husband.
Contemporary Muslim families are undergoing change, becoming less extended, with more wives educated and gainfully employed.
Arranged marriages are declining and the age of marriage is rising; modem contraceptives are slowly becoming more prevalent in
certain communities.

Islam stopped short of making marriage mandatory for every Muslim (fard
ayn). Some Muslims may, for financial, personal or other reasons, choose to
postpone marriage until their circumstances improve. Marriage can also be
bypassed altogether by a few for good reasons.

Role of the Family

Islam has a pervasive social character and the family is the core of its
society. Islam tends to consider the family as something absolutely good and
almost sacred.
Besides providing tranquility and mutual support and
understanding between husband and wife, the obvious function of a family is
to provide a culturally and legally acceptable way of satisfying the sexual
instinct as well as to raise children as the new generation.

The Relationship Between Husband and Wife

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The husband and wife are the principals of family formation.

Their
relationship in marriage is described in the Qur'an as of two major qualities:
love (passion, friendship, companionship) on the one hand, and mercy
(understanding, reconciliation, tolerance, forgiveness) on the other within the
overall objective of tranquility. The Qur'an says
And one of [Allahs] signs is, that He has created for you mates from yourselves, that you may

dwell in tranquility with them, and has ordained between you Love and Mercy.

al-Roum (Sura 30: 21)

Marriage as a Solemn Covenant

Marriage, is a solemn covenant and not a casual arrangement. The Qur'an
calls marriage 'a solemn covenant' (mithaq ghalith).

And they [the wives] have taken from you a solemn covenant.

al-Nisa'(Sura 4:21)
This is contrary to the 'western' concept of marriage. Western writers tend
to describe it as a status that one can get in and out of with ease. They
refer, of course, to the legality of divorce in Islam. The notoriety of 'Islamic
divorce' in western literature relates more to its permissibility than to its
prevalence. Despite its permissibility, divorce is gravely discouraged in
Islam, but, if inevitable, it can be practiced. The Prophet (PBUH) says

Verily, the most hateful to Allah of the lawful things is divorce.

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Authenticated by Abu Dawoud and Ibn Maja

Marry but do not divorce. For, Allah does not like men and women who
desire only a taste of marriage.

Rights of Children in Islam

Children are considered a joy, an adornment as well as a way to continue
one's descent. Islam enjoins us to have children, but it insists at the same
time that they should be good and righteous which requires an intensive
effort to raise them correctly. The ability to raise children correctly is an
inherent requirement of marriage in Islam.

Value of Children in Muslim Societies

Children are highly valued in many societies, but particularly so for the
Muslims.
There are religious, economic, socio-psychological and child
survival related rationales for this phenomenon.
The ten cardinal rights of children in Islam
1.The right to genetic purity.
2. The right to life.
3. The fight to legitimacy and good name.
4. The right to breast-feeding, shelter, maintenance and support,
including health care and nutrition.
5. The right to separate sleeping arrangements for children.
6. The right to future security.
7. The right to religious training and good upbringing.
8. The right to education, and training in sports and self-defense.
9. The right to equitable treatment regardless of gender or other
factors.
1o. The right that all funds used in their support come only from legitimate
sources.

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Children have rights to genetic purity, to life, legitimacy and good name, breast-feeding,
shelter and maintenance, independent sleeping arrangements, future security, religious
training, education, equitable treatment, and a wholesome source for their care. The
ability to fulfill these rights should be considered in planning a family.

Rights of Parents in Islam

Islam endorses the natural child-parent relationship by specifying the rights
and obligations of one to the other. Parents are to command tender loving
care and respect throughout their lives, and should receive special care in
old age.
Parents are held at the highest position in regard to love and loyalty by their
children. In several places, the Qur'an puts tender loving care (ihsan) of
parents next to belief in Allah. This is repeatedly stated in several Qur'anic
verses:

And serve Allah, ascribe nothing as partner unto Him, and bestow tender
loving care unto your parents.
Al-Nisa (Sura 4:36)

Say: Come, I will recite unto you that which your Lord has prohibited you from; ascribe none as
partner unto Him and bestow tender loving care unto your parents.

al-Isra' (Sura I7:23)

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Al-Isra (Sura 17:23)

This
last verse goes on to address the important problem of elderly parents. With
the increasing life expectancy in societies in the twentieth century, the
problem of the elderly is a growing concern. The over-nuclearization of the
family and the unduly exaggerated independence of children from their
parents, mean that many parents in western societies find themselves alone
in old age without the material or emotional support and companionship of
their children. Many end up in sanitaria or homes for the aged which can
never replace family care. Islam has tackled this problem at the grassroots
level by securing a continued relationship with, and support of the elderly.
Your Lord has decreed that you worship none save Him, and that
you bestow tender loving care unto your parents.
The previous verses continue:

Whether one or both of them attain old age with you, say not 'Fie' unto them,
nor repulse them, but speak to them graciously.
And bestow kindness, humility and submission unto them and say: 'My Lord!
Have mercy on them both as they did care for me when I was little'.
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al-Isrd (Sura I7:23, 24)

CHAPTER VI. SOCIETY, CULTURE AND GENDER

Differing Values and Attitudes Towards

Sex and Sexuality
In most parts of the world, sexual relations begin during adolescence. In
general, the onset of sexual activity in South Asia occurs largely within the
context of marriage. It is probably even more true for Muslim girls who live in
heavily segregated environment. The median age at first intercourse among
women has increased in many countries. Continued education and delayed
marriage may account for some of it. While first intercourse tends to occur
at a later age than in the past, it increasingly occurs before marriage.
Adolescence, therefore, is a critical period which lays the foundations for
reproductive health of the individuals lifetime.
All over the world, age at puberty is declining while age at marriage is rising.
Because of an increase in time period young people spend between puberty
and marriage, first sexual experience may take place for some during this
time. Because of the inequity between sexes that pervades all societies,
adolescent girls are particularly vulnerable to the risks associated with
misinformed and unprotected sexual relations and the hazards of teenage
pregnancies.vi
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Gender and Sex, Various Sex Stereotypes

And How Often They Affect Boy-Girl Relationship.
Commencement of puberty is usually associated with the beginning of
adolescence. The end of adolescence on the other hand varies from culture
to culture. In some societies, adolescents are expected to shoulder adult
responsibilities well before they are adults; in others, such responsibilities
come later in life. Although it is a transitional phase from childhood to
adulthood, it is the time that adolescents experience critical and defining life
events physical changes that distinguish them as boys and girls, start of
menstruation for girls, ejaculation for boys, and for some, first marriage and
first sexual relations (not necessarily in that order) and first childbirth and
parenthood.

The Status of Women in Islam

The Prophet (pbuh) said:
He who has a daughter and has not buried her alive,
humiliated her or preferred his son over her will go to
heaven.
Be equitable in dealing with your children just as you
would like them to be equitable in dealing with you.vii

Islam championed all movements to improve the status of women, at a time

when societies were overtly traditional and socially underdeveloped. The
woman is considered equal to man in religious, social and patriotic
responsibilities but defers to the husband in family affairs. She cannot be
forced into marriage by her family or guardian; she has to give her consent.
In marriage, she can keep her maiden name. She is completely independent
financially and can do with her money as she pleases while the husband (or
the father or brother) is responsible for providing for her and her children. In
inheritance, she, as a daughter, gets half of her brother's share, but under
other circumstances she gets as much as or even more than other men in
the family. As a mother she is placed ahead of her husband in regard to the
children's loyalty and affection. She is given the privilege to speak up for her
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rights (within the decency of Islamic tradition) and she did, even to the
Prophet (PBUR).
The status of women in Islam is seriously misunderstood for many reasons.
It is wrongly implied that the behavior of individual Muslims and Muslim
communities invariably reflects the laws and orthodoxy of Islam. This is
compounded by misconceptions about the status of women in Islam or gross
abuse of Islamic family laws among some uninformed Muslim groups. We
should also not discount the factor of underdevelopment in some countries, a
situation commonly associated with the low status of women in not only
Muslim but also in many non-Muslim countries of the Third World.
On the other hand, some Muslim writers are guilty of reverse bias. In their
zeal to prove Islam's modernity, they select only the components that would
parallel western systems. This distortion presents only a part of the totality
which is the Islamic culture. Contrary to common beliefs, Islam raised the
status of women and gave them human, civil, social and economic rights
never previously given to women. The Muslim woman has an independent
personality, equal to man in religious duties, in the right to education, in
reward for her deeds as well as in defending her beliefs. She has complete
and total control of her possessions. She is free to choose her marital
partner, and has the right to demand the power of divorce plus the power at
the time of the marriage contract to disallow polygyny by her husband.
Furthermore, she can keep her maiden name after marriage, if she so wishes.
She is also responsible for her family but the man has the primary
responsibility.

Thus Eve is exonerated of the evil persuasion of Adam. Of course she shares
the sin equally with him since both of them ate the forbidden fruit. Ale first
quotation dismisses Adam's (and Eve's) sin after they repented. Thus, no sin
was transmitted to their progeny.

Moses
Four women figured predominantly in the life of Moses: his mother, his sister,
the wife of the Pharoah (who raised him) and the daughter of Shoib who later
became his wife. An excerpt from the Quran reads

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And we sent this inspiration to the mother of Moses. 'Suckle him, and when
you fear for him, then cast him into the river and fear not nor grieve. Lo! We
shall restore him to you and We shall make him one of our Messengers,'
al-Qasas (Sura 28:7)

Mary and Jesus

The story of Mary (Maryam) is told in the Qur'an in the most beautiful and
compassionate terms depicting her anguish on conceiving immaculately and
her fear of facing her people, and her raising the child to become a
messenger of Allah.

At length she brought [the baby] to her people, carrying him [in her arms].
They said 'Oh Mary! Truly an amazing thing have you brought. 0 sister of
Aaron! Your father was not a man of evil, nor your mother a woman
unchaste!'

The Question of Equality

Men and women were made equal; the only difference in their worth is
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related to piety not gender. The Qur'an says

O mankind. We created you from a male and a female, and made you into
nations and tribes that you may know One another. Lo! The most favored of
you are the most righteous.

al-Hujurat (Sura 49:13)

An in the Prophets hadith

Men and women are equal halves.

Authenticated by Ahinad and Abu Dawoud

Equality in Education
Learning and scholarship are central to Islamic faith and culture. The first
verse in the Quran is a direct instruction for learning.
The Prophet
considered the learned as the successors of the Prophets. To him the 'ink of
scholars is worth more than the blood of the martyrs'. At the time when the
Arabs were still confined to their peninsula Muslims were instructed to seek
knowledge, 'even in China'.
The woman was equally required to learn as much as men. The Prophet said

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Learning is a duty [farida] for every Muslim, [male and female].

Authenticated by al-Bukhari
Equality in the Principle of Jihad (Religious War)
Islam made women equally responsible for the defense of their religion and
land (shad). It is justly inferred that women were included in the instruction:

Go forth, light-armed or heavy-armed, and strive with your wealth and your lives in the
cause of Allah.
al-Tawba (Sura 9:41)
While women were included in this, they were not expected to carry arms
and fight battles like men, but they used to accompany men to battle,
encourage them, carry the wounded, remove the dead from the field,
transport arms and material, etc. In so doing they were equally exposed to
death or capture by the enemy. Married women are expected to seek their
husband's permission before doing so, whereas unmarried women have no
such obligation. However, where the enemy attacks, all women can join the
battle freely, and can carry arms and do anything that men do in order to
defend their religion and land
Islam disallowed preferential treatment and urged equity between males and
females from their first day of life.

Right to Share in Public Life

Islam has also guaranteed for women the right to participate in religious and
worldly affairs as well as the right to work and be involved in trade and
commerce. Historical records show that in the early days, reflecting the true
Islam, women appeared at public functions, studied and taught in learning
classes and schools, traded in markets, sat on consultative councils and, as
already mentioned, participated in battle, mostly as supporting lines but
sometimes as first line fighters.
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 Women's Privileges Over Men

Inequalities do exist, some of which favor the woman and others the man.
The women's privileges include the following.
Keeping her maiden name (if she so wishes) as a token of her personal
independence.
The power, according to the majority of Islamic schools of jurisprudence,
to allow or disallow al-azl or coitus interruptus in marriage as a method of
contraception. (Some jurists levy a fine as a form of punishment on the
man who neglects to obtain his wife's permission.)
The right to greater affection, as a mother, from children.
Economic independence and equal legal capacity: Islam gives the woman
equal legal capacity with the man. This means that she has the ability to
enter into all kinds of contractual arrangement and to conduct business
on her own without the need for her husband's consent. Such a legal
right, given in the seventh century, is yet to be completely achieved by
the married woman in some contemporary societies where the husband
has a certain right to oversee his wife's affairs. French women did not

achieve this legal right until 1965.

Men are the protectors and maintainers of women, because Allah has given
one more (strength) than the other, and because they support them from
their means.

al-Nisa (Sura 4:34)

Sexual Violence and Abuse

One of the most pervasive, yet relatively hidden, issues in today's world is
violence against women. The adolescent is especially vulnerable. In 1993,
the United Nations General Assembly adopted a declaration against
physical, sexual and psychological violence to women.

102

The adolescent girl is especially vulnerable to violence of all kinds because

of her relative lack of power, physically, socially and economically. She will
often have lower status in the household, lower status in the workplace, and
less opportunity for education, training, employment and inheritance rights,
all of which contribute to greater vulnerability. It is not only the acts of
violence which are damaging, and unquestionably under-reported, but also
the implicit or explicit threat of violence which may determine much of what
she is obliged to do. Before reaching adulthood the female is vulnerable to:
a) sex-selective abortion, battering during pregnancy, and coerced
pregnancy prior to birth; b) female infanticide, differential access to food
and care in infancy; c) child marriage, genital mutilation, sexual abuse by
adults in and outside of the family, child prostitution; and d) dating and
courtship violence in adolescence, economically coerced sex, sexual
harassment and abuse at the workplace, forced prostitution.

Sexuality and the Law

Islam also encourages breast feeding; it protects the childs health by giving
him/her the best food and protects the mothers health by child spacing.
Islam is not against family planning since it helps the mother and her baby to
stay healthy.
Quran said:

Mothers should breast-feed their children two full years. (2:233)

And his weaning takes two years. (46:14)

The Prophet (pbuh) said:

Interrupt coitus if you want.

103

References

Chaudhury, R. H., A Socio-Demographic Profile of the Population of Maldives, AsiaPacific Population Journal, Vol.11, No.4, (3-26).
Hassanein, M. Dr., Islamic Perspective on Gender and Reproductive Rights,
(Reference Paper presented at the ECO/UNFPA Conference on The Role of Men in
Population and Reproductive Health Programmes, Baku, Azerbaijan, 20-24
September, 1998.
IPPF Videos, (http://www.ippf.org/pubs/videos.htm).
Mariella, B. Peter Aggleton, G. Slukten, Does Sex Education Lead to Earlier or
Increased Sexual Activity in Youth?, World Health Organization, Geneva, 1993
National Guidelines Task Force, Guidelines for Comprehensive Sexuality Education,
Kindergarten 12th Grade, SIECUS, New York, May 1994
Omran, A.R., Family Planning in the Legacy of Islam, United Nations Population
Fund, New York, 1992.
Sarwar, G., Sex Education: The Muslim Perspective, The Muslim Educational Trust,
December 1992
United Nations, AIDS and HIV Infection Information for United Nations Employees
and their Families, New York, 1995

UNESCO Handbook for Educating on Adolescent Reproductive and Sexual Health,

(Book One: Understanding the Adolescents and their Reproductive and Sexual
Health: Guide to Better Educational Strategies), UNESCO PROAP Regional Clearing
House on Population Education and Communication, Bangkok, 1998
UNESCO Handbook for Educating on Adolescent Reproductive and Sexual Health,
(Book Two: Strategies and Materials on Adolescent Reproductive and Sexual Health
Education), UNESCO PROAP Regional Clearing House on Population Education and
Communication, Bangkok, 1998
UNFPA Country Support Team, The South Asia Conference on Adolescents, (Country
Paper: Maldives), Kathmandu, 1999.
UNFPA India, Questions and Answers on Reproductive Tract Infections and Sexually
Transmitted Infections, by Population Council, South & East Asia Regional Office

104

(circa: 1998).
WHO Counseling skills training in adolescent sexuality and reproductive health: A
facilitators guide, Division of Family Health, Geneva, August 1993.
WHO Health Promotion through Islamic Lifestyles: The Amman Declaration, The
Right Path to Health; Health Education through Religion, WHO Regional Office for
the Mediterranean, Egypt, 1996.
WHO Adolescent Health and Development, The Key to the Future, (Paper prepared
for the Global Commission on Womens Health), Geneva, January 1995.
WHO Providing an appropriate contraceptive method choice, What health workers
need to know, Division of Family Health, Geneva, 1993.
WHO The Community Health Worker, Working Guide, Geneva, 1990.

World Bank, Confronting AIDS: Public Priorities in a Global Epidemic, A World Bank
Policy Research Paper, Oxford University Press, New York 1997

105

CHAPTER VII.FREQUENTLY ASKED QUESTIONS

Q.
Do women also have orgasm? Is it only possible through
intercourse?
A.

Yes. Women also have orgasm, but not necessarily through intercourse. It doesn't
matter whether it happens during self-stimulation or intercourse, or any other form of
stimulation. The experience may differ, but the physiological response cycle is the same
(from excitement through resolution). Orgasm is the point at which all the tension is
suddenly released in a series of involuntary and pleasurable muscular contractions.
Women feel the contractions in their vagina, uterus and/or rectum, although some
women describe orgasms without any contractions at all. Since most women need
direct clitoral stimulation to orgasm, and it's very difficult to get direct clitoral stimulation
during intercourse, most women do NOT have orgasms through intercourse alone.
Manual or oral stimulation of the clitoris is most usually a prerequisite for climax. There
are many variations of a woman's orgasm, and a wide range of accompanying feelings.
What works, what feels good, and what is satisfying for a woman at any given moment is
what counts.

Why is a man allowed four wives?

A.

Marrying more than wives is called polygyny. Polygyny denotes

multiple wives, polyandry denotes multiple husbands; polygamy
includes both polygyny and polyandry.

Permissibility of Polygyny
Polygyny in Islam is notorious not because of its prevalence but because of
its possibility. Certainly the license to marry more than one wife has been
grossly abused by some Muslims who did not appreciate it as a conditional
permission. Even with that abuse its occurrence is no more than 3 per cent
and with the increasing education of women and reformed understanding of
the real Islam, polygyny is on the decline.
The license to practice polygyny, which was a restricting order to limit the
number of wives, came from the following verses in the Qur'an:

106

And if you are apprehensive that you shall not deal justly with orphans, then,
marry women of your choice, two, three or four. But if you fear that you shall
not be able to deal justly [with them], then only one.
al-Nisa7 (Sura 4:3)
Later in the same Sura, the Qur'an says

And you will not have it in your power to treat your wives equitably, even if it
is your ardent desire.
al-Nisa' (Sura 4:129)
Q.

What is the meaning of a virgin woman?

A.

A virgin woman is the one who did not experience sexual intercourse.
Presence or absence of hymen is not a necessary precondition of
virginity, as hymen may not be present intact owing to biological
factors or may have been destroyed due to exercise, etc.
At what age does religion stresses for marriage?

A.

Islam does not prescribe a particular age for marriage.

Q. What happens when somebody dies of old age without any previous marriage?
A.

Marriage is Sunnah, not a Farz. In other words, if someone dies without ever getting
married, he or she will be judged for the good deeds and adherence to Islam, and not for
marriage.

Q. Is marriage accepted for a woman during her menstrual period?

A.

There is no restriction on marrying a woman during her menstrual

period. It is the consummation of marriage (sexual intercourse) which
will have to wait until the period is over.

107

Q.

Is marriage acceptable before the consent of the father?

A.

If a girl getting married is under age of maturity, her fathers consent

is required. Such consent is not mandated for a matured girl or the
one who is divorced or a widow.

Q. What is the penalty for a marriage without knowing that the woman is pregnant?

A.

If the pregnancy was due to another person, this could be a ground for
divorce, (and possibly, refund of the mehr paid), unless the husband is
willing to own the child.

Q. How can children be accepted without marriage?

A.

Islam does not punish children.

punished/punishable by law.

Its

the

parents

who

are

Q. What kind an act is required when a woman repeatedly keeps on asking for a divorce
from the husband?

A.

Islam does not look at divorce favourably. It is said that divorce is the
least liked act allowed in Islam. Husband should reflect on why is wife
asking for divorce? Are their differences reconcilable? Is husband
willing to change and yield to make adjustments to wifes demand and
satisfaction? If the answer is a definite no, the husband should agree to
her demand for divorce, an do it amicably.

Q.

Is it allowed to get married after marrying for a third time?

A.

One can marry as many time as one wants, so long there are no more
than four wives at a time. However, one should not make marriage a
mockery of a sacred institution.

Q. There are great changes that are transpiring with trends, How does Islam see the
woman who fails to cover herself properly after marriage?

A.

Women are expected to observe Islamic hijab before and after

marriage. However, it also depends upon the husbands attitude. If a
108

married woman does what other married women of her class are doing
and the purpose is just to be fashionable, husband may decide to let
wife use her judgement.

109

Appendix-1

Views of Sheikh Jadel Haq Ali

Jadel Haq, the Grand Imam of
Al-Azhar , on family planning
Given in 1979 and 1980 and published as fatwas in 1983 (subtitles added)

THE LEGALITY OF CONTRACEPTION

The Qur'an and the Sunnah
The reference sources of Shari'ah law as to permissibility (halal) or prohibition
(haram) are the glorious Qur'an and the tradition (Sunnah) of messenger (PBUH).
A thorough review of the Qur'an reveals no text (nuss) prohibiting prevention of
pregnancy or diminution of the number children, but there are several traditions
of the Prophet that indicate its permissibility. This was accepted by jurists of
Islamic Shari'ah. While there is also in the Sunnah what can appear to be
prohibiting, the majority (jumhour) of jurists (fuqaha') in the legal schools
(madhahib) agree with the permissibility of al-azl (coitus interruptus) where the
husband ejaculates outside his wife's vagina.
Position of legal schools (maddhahib)
In his book Ihya' Ulum al-Din, Imam al-Ghazali, who is a Shafe'i, classified earlier
and contemporary opinions of his time into four groups: unconditional permission;
permission if wife consents and prohibition if she does not; permission with slave
but not with free wives (now obsolete); and unconditional prohibition. Al-Ghazali
then said 'The correct way to us (in the Shafe'i school), is that it is permitted'. He
then specified five acceptable reasons for preventing pregnancy which include
preservation of the wife's beauty and fitness and protecting her life from the
dangers of labour (talq), and the need to avoid economic embarrassment and
physical hardship entailed in having to work to support too many children. AlGhazali said 'to reduce economic embarrassment sustains piety'.
Al-Ghazali made a clear distinction between prevention of conception and abortion,
permitting the former and rejecting the latter.
The Hanafi school permits coitus interruptus (al-azl) with the wife's consent, while
later scholars allowed her consent to be bypassed in 'bad times' (times of religious
decline) and to avoid 'bad' offspring (lacking piety). The opinion in the Maliki and
110

Hanbali schools is permission with wife's consent, as it is in the Zaydi Shi'ite

school. The Imami Shi'ites prefer to obtain the wife's permission at the time of the
marriage contract.

Imam Shawkani adds that 'among the reasons for al-azl is to protect a suckling
child from the dangers of changed milk from a pregnant mother; another is to
avoid getting too many children or avoiding getting them at all [al- firar min
husulihim min al-azl].'
From this brief review of jurisprudence, it is evident that al-azl for temporary
prevention of pregnancy is permissible (ja'iz). The sahaba themselves practised alazl at the time of the Prophet (PBUH). He came to know about it and did not
prohibit them according to Jabir's tradition reported in Muslim, and while the
Qur'an was being revealed as reported in al-Bukhari.* Thus, prevention of
pregnancy is lawful as stated above.

MODERN METHODS
It is true that early scholars of Islamic law did not mention other methods because
al-azl was the method known to them at the time and before their time. By
analogous reasoning (qiyas) alternative methods of contraception can be allowed
as long as the purpose is to prevent pregnancy. Some of these methods may be
barriers used by the man or the woman, or medicines prescribed by physicians for
temporary contraception. There is no harm in allowing, by analogy, the modern
methods as long as they will not destroy fecundity or the ability to procreate.
That is why the Hanafi jurists extended permission to blocking the mouth of the
uterus, with the husband's consent. For the same reason the Shafe'i scholars
allowed temporary delay of pregnancy for a period of time.
Hence temporary methods like contraceptive pills or the coil (IUDS) or other
methods are permitted as long as there is no permanent impairment of fertility.
Actually the modem methods are better than al-azl because they allow normal and
complete marital relations.
*Muslim's and al-Bukhari's are the two leading compilations of prophetic
traditions; each is called sahih or 'the accurate'.
Al-tawakkul and rizq
Such temporary contraception is no contradiction to reliance on Allah (tawakkul)
because the use of these methods is to take expedients while putting trust in Allah,
as Muslims always. do. The Prophet advised his Companion, saying

111

Hobble her and put your trust in Allah.

Reported by al-Tirmidhi, al-Baihaqi and al-Tabarani
That is how the Prophet (PBUH) interpreted tawakkul. Imam al-Ghazali who is an
authority on tawakkul, said that al-azl to escape economic embarrassment is not
unlawful. As to the verse in the Qur'an which says

There is no moving creature on Earth, but its sustenance is on Allah.

This does not mean that a person should be lazy and neglect to earn a living while
asking Allah to provide for them without work. The real meaning of tawakkul is
that given by Sayyidna Omar Ibn al-Khattab, who equated it with' a farmer who
puts the seeds in the earth and puts his trust in Allah (for a good crop). Hence,
tawakkul should be associated with taking expedients (al-akhth bilasbab).terilization
Other than for pressing health reasons, sterilization through surgery or through
drugs is not permissible if it causes permanent loss of fertility. Sterilization may be
used when it is established that a hereditary disease may pass to children or
causes pain. In that case sterilization becomes mandatory, based on the juristic
principle of permitting an injury to avoid a greater injury. This is conditional on the
diseases being incurable and must take into consideration advances in medical
technology.

Abortion
The Hanafi opinion supports abortion provided it is performed within 120days of
conception. During this period the fetus is not believed to be a complete human
soul. Early abortion is held to be makrouh, (disliked but not forbidden) when it
lacks valid reasons or justifications. Reported valid reasons included a woman's
inability to breast-feed her baby and the family's inability to afford a wet nurse.
Some Shafe'i scholars share these Hanafi views. Others like al-Ghazali do not. The
Zaydi Shiite school allows abortion unconditionally with or without valid reason,
provided it precedes 'ensoulment', calling it ja'iz or permitted. The Zahiri and
Maliki jurists forbid it under all circumstances, calling it haram but some Hanbali
jurists allow it before 40 days.

112

Juristic consensus exists only on the point that abortion after a period of four
months from the date of conception amounts to taking a life. Yet this limit may also
be set aside if, according to medical opinion, there is a definite risk of death to the
mother. The mother's life takes precedence over the child's life on the juristic
principle: 'the root is more valuable than the branch.'

PREDESTINATION
Ways of Allah are unknown to man. Man lives in the small world of cause and
effect, of action and reaction. It does not lie in the power of man to defy Allah's will
whatever means man may use to carry out his intention. This is the reasoning used
by the Prophet himself when he was asked about contraception. On the authority
of Abu Said al-Khudri, the Prophet (PBUH) said 'If Allah wills to create a soul, no
one can stop Him.'
TWO ADDITIONS FROM AN INTERVIEW WITH THE
GRAND IMAM, ALSO PUBLISHED WITH THE FATWA
Question
Is birth control a form of killing i.e. does it come under the meaning of the verse
'Do not kill your children in fear of want'?

Answer
Prevention of pregnancy is neither a killing nor an abortion of a fetus, because the
semen (nutfa) from which a fetus is created, is not in itself a human being. After
the semen mingles with the woman's ovum in the process of fertflization, a fetus is
formed which, as we already indicated, would not become an ensouled creature
(khalqan a'akhar) until after 120 days.
Prevention of pregnancy is the act of preventing the semen of a man from
mingling with the ovum of the woman and this is not killing. What the verse is
referring to is the pre-Islamic custom of burying children in fear of poverty.e state
can help but no coercive laws
Question
Is it lawful for the state to make laws which compel parents to limit family size,
particularly if such laws are in the national interest?

Answer
Islam goes to the extent of ensuring that, on the question of family size, one parent
does not impose his or her will on the other. How can it sanction coercive laws
which may ignore the needs and circumstances of individual families?
The state can, of course, help people take correct decisions by providing them with
opportunities to act on these decisions and also creating conditions which abolish
the need for a large family. This means wider, but sensible use of mass media and
113

other educational channels for showing the advantage of a small family, with easier
availability of contraceptives and of relevant information about the technological
changes available to help reduce the family's dependence on its manpower as an
economic unit. The last is very important. Posters, slogans and TV programmes
cannot alter human behaviour if social and economic conditions obstruct the
change.

Source
Al-Fatawa al-Islamiyyah, vol. 9, PP. 3087-92, PP. 3110-13, and PP. 3093-3193, High
Council of Islamic Affairs, Cairo (1983) (includes the interview quoted above).
Issued by Darel-Ifta' al-Masriyyah under the supervision of the Grand Imam, the
Minister of Religious Affairs, the Mufti of the Republic and the Secretary General
of the High Council of Islamic Affairs.

114

Appendix-2

Resources
for
Students,
Programme Managers

1.

Teachers

and

Advocates for Youth

This is an advocacy organization which

Advocates for
Youth

deals with US and international issues on

youth, sex education, contraception, drugs

http://www.advocatesforyouth.o

and alcohol, and relevant decision-making. It offers overviews and

descriptions of programmes on HIV/AIDS prevention, international
programmes, peer education, media projects, sexuality education and teen
pregnancy prevention. "Proud Pete' is online, demonstrating safe and correct
condom use. it also includes a bulletin board for peer education trainers,
provides legislative updates, and maintains a specialized library supplying
information on youth issues.

115

2.

Mezzo

Mezzo

This is an online guide to love and

http://www.ippf.org/mezzo/main.ht
m

relationships for young people by young

Address: c/o International Planned

people. Guidelines on the rights of young

people and their proper treatment by health professionals are provided. The
section on teen lifestyle offers advice on sexual relationships and discusses
issues on healthy loving. The section on safe sex offers a guide to
contraceptive choice. The website provides an interactive discussion forum in
the Dear Pramilia section, which offers consultation and counseling on youth
problems. A youth discussion forum, one of the website's highlights, deals
with topics of immediate interest, such as friendship, sexuality, love and
relationships, marriage and choice of a partner, contraception, pregnancy and
parenthood, STD, HIV/AIDS, abortion, and education.

116

3.

ETR Associates
This website offers a complete line of

ETR Associates
http://www.etr~associates.org

innovative, practical health education

books, pamphlets, curricula and videos,

providing youth and adults with critical health messages. Materials cover the
full spectrum of health education topics from reproductive and maternal/child
health to HIV/AIDS, STDS, substance abuse, injury prevention, violence and
self-esteem. The website also includes facts about ETR. An online catalog and
ordering service are provided. In addition, the ETR Program Services Division
provides services for health and sexuality education, including teacher and
staff training, research project and programme evaluation, development of
model programmes, technical assistance in programme implementation,
curriculum and materials development and clearing house services.

4.

Family Health International

117

This is the website of Family Health

Network:
Adolescent
Reproductive
Health, Spring
1997, Vol.17,

International. This magazine's Volume

17 No. 33 issue is wholly devoted to
adolescent reproductive health. The full
text of all the nine articles included in

this issue is provided. The topics include an introduction to the concept of

adolescent reproductive health; contraceptive methods for young adults; how
gender norms affect adolescents; how education protects health and delays
sex; key factors that help programmes succeed; the role of the media in
promoting clear understanding of adolescent health and the pressures that
the youth are usually subjected to.

5.

World Health Organization

WHO's worldwide programmes and activities on adolescent reproductive

health have given the organization extensive experience and data on ARH.
This website's library catalogue offers easy access to ARH materials. Included
in this information resource collection are training materials for developing
counseling skills in adolescent sexuality and health problems. It suggests
policies, legislation and programmes to promote adolescent health. A
compendium of projects and programmes dealing with different approaches
to adolescent health and development is provided. Also available are
research guides and methods for studying behavioural patterns of young
118

people, as well as materials for research

World Health
Organization

and training workshops in adolescent

reproductive health. Materials dealing

with policy and strategy concerning different; aspects of adolescent

reproductive health, such as adolescent pregnancy and public policy, and
premature adolescent pregnancy and parenthood

119

i Ibid, p.1
ii

iii Ibid, p.29

iv World Health Organization, Health Promotion through Islamic Lifestyles: The Amman
Declaration, Regional Office for the Eastern Mediterranean.1996
v Hassanein (1998), p.15
vi Ibid, p.1
vii Hassanein (1998), p.13