Silence, Slowly Fading

"You do realize, don't you? Reproductive health is a fairly controversial subject anywhere. But, here? Will you even be able to tell people what you do?"

It was an interesting moment. I was talking with a friend about what I wanted to do after medical school. More than seven years on, I am not always sure I have the answer. On occasion, yes, conversations have come to a halt around the dinner table when I respond to the "what do you do" question.

I am Pakistani. I belong to a fascinating, diverse country rich in culture and tradition. It is also a country where, despite globalization's ongoing cultural shift, talking about sex and reproductive health is still taboo. An exasperated community health worker once told me, "It's almost as if no one here has sex." With Pakistan's rapidly growing population of 165 million, I certainly can testify that is not true!

This reluctance to talk about "all things sex-related" makes access to reproductive and sexual health knowledge and services difficult. The problem is especially acute for young people where the culture of silence surrounding puberty, sex and sexuality creates another barrier to our country's already difficult-to-access health care. Young people who do manage to get care are often discouraged by clinicians' judgmental attitudes.

In rural areas, scant sex education for women means that young women often enter marriages ill-prepared to deal with sex and reproduction. A 15-year-old who had been married for two years confided to me that she was infertile. When I asked her how long she had actually lived with her husband, she replied, "Just the first week after we married, then he went to work in Dubai." She was too afraid to ask other women in the family the numerous questions she had, lest her "infertility" end her marriage. The joy on her face at the end of our discussion stays with me to this day and, sadly, reminds me of the millions of others whose questions remain unanswered.

In urban Pakistan, where sex education has been introduced into the curriculum on a limited scale, students often say, "The teacher is more embarrassed teaching than we are listening." This atmosphere of shame frequently shapes the way these young people view sex.

All of this makes working in reproductive health in Pakistan challenging but also extremely interesting. It means devising innovative ways of getting our message across in this unique social and cultural milieu. It also means continuously learning about families and communities that often challenge our stereotypes.

A senior colleague with 50 years of experience recalls being taken aback by a question during a health education session in northern Pakistan. A man openly asked her about a treatment for impotence because his "brother got married and could not perform so his wife left him. He wants to get married but wants to be treated first." That a man in a very conservative community would ask such a question publicly and to a woman indicates the changing times.

Another sign of change: Some years back, colleagues asked religious leaders in an extremely conservative rural area for their support to initiate a project on male involvement in family planning. They not only agreed but also offered to lead teams educating men about having small families. Even in this very tradition-bound culture, once the initial (almost natural, perhaps?) resistance is overcome, I have seen communities proudly own these programs.

Purdah-observing mothers—usually guardians of tradition—have asked me, "Can you please also have sessions on adolescent reproductive health for our daughters?" Coming from them, the request is a revelation.

Slowly—very, very slowly—the culture of silence surrounding reproductive health is being chipped away. Even in its strongholds.