Stigma associated with contraceptives

There remains a risk of HIV’s transfer to the uninfected population through sexual networks

KARACHI: At just 14, Iqbal, a resident of the historic city of Bahawalpur is hard at work, helping out at his father’s shop. Since the family cannot afford to send him to school, the teenager makes himself useful at the location of his family’s bread and butter. Like most boys his age, Iqbal has realised that he has certain needs, or to put it more aptly; desires.

He likes the company of young boys and naturally gets attracted towards them. He now puts on his mother’s clothes and tries some make up whenever he is left alone in her room. He finds the action has a soothing effect on him. It has been some time since the realisation that he wants to live as a woman, and not a man, dawned upon him.

One day, his brother catches and remembers that night as one of the most dreadful of his life. He was beaten by both his father and brother. Now leading a miserable existence, he has to come to terms with his inner conflict on a daily basis. However, in fear of more punishment, he confesses to his father that he wishes to live the remainder of his days as a female.

Now, the whole family turned hostile. From father to brother, from uncle to cousins, beating Iqbal is considered an everyday activity.

Their quotidian torture becomes abortive. Instead of being convinced to act straight like a man, Iqbal has decided to leave his house in search for a life free from abuse; one in which he can become the “woman” he always wanted to be. He packed his bags and ended up in Lahore and has been a Lahori ever since.

He finds shelter with Khwaja Siras near Anarkali Bazaar. Driven by his instinctive desires and economic crisis, he cross-dresses and works as a dancer and a sex worker in the city.

Iqbal is now maintaining a to-do list which is topped by a sex change operation. Unfortunately for him, the earnings are not enough for him to afford an operation anytime soon.

He is active in sexual activities and has had many partners. Most of his partners do not agree to wear condoms and prefer unsafe sex.

One day, he experiences flu-like symptoms and ignores them, believing it’s just a bug doing the rounds. Four days later, his condition deteriorates. He goes to a doctor, who tells him to go to an infectious disease specialist.

The specialist asks about his sex life, including the number of partners and if he was using protection. He replies in the negative. The specialist then asks Iqbal to take an HIV test and provide a urine sample.



Iqbal panics. He is not peeing into a bowl and instead goes home. He is now surrounded by his four walls; shaking—thinking about the consequences of unprotected sex with unfamiliar partners.

“HIV, urine sample, but why?” he asks himself.

However, after probing further he learns about a dreaded virus and just the thought of it leaves him terrified. He goes to the doctor again, asking a simple question, “Will I be able to live? If this is the case, will I be cured?”

Finally, one line gives him an inkling of hope. “Though HIV is not curable, there are several treatment options that could decrease the consequences and help avoid transferring it to other partners,” advises the doctor.

After a sleepless night, Iqbal goes to the lab and gets tested. Another day passes as he anxiously awaits the results and prays he tests negative. But in a corner of his mind, he already knows what the report will say.

The next day, he goes to collect the report. He doesn’t open it at the lab. He brings it home and finally opens it; two words crash on him like a tonne of bricks.

“HIV- Reactive”.

At this point in time, Iqbal has been battling the disease for three years. “I wanted to end my life; there was no motivation for me to carry on as there is zero space for our gender in this society. Now I have this infection and it is incurable.”

After many thoughts and discussions with my fellows, I have designated my life for the welfare of Khwaja Siras, says Iqbal. He considers them family and has reserved the rest of his days to their betterment.

Iqbal regrets some of his choices and says he would have been more cautious if he had been aware of the existence of AIDs. Hindsight, as they say, is a great thing.

***

The number of new HIV cases is on a global decline, but Pakistan is among the few countries where the number of infected people has risen drastically.

According to recent report, 0.133 million people are estimated to have HIV currently; a rise of 32,000 in the span of just a year.

The study was conducted by the Global Fund grant and was carried out in 5,000 locations by 60 survey teams who visited 20 cities across the country.

The report tells us that Punjab tops the list of provinces with highest number of HIV/AIDS patients with 60,000. Second comes Sindh with 52,000 infected patients. There are 11,000 in Khyber-Pakhtunkhwa and three in Balochistan. Moreover, 6,000 cases of HIV/AIDS are seen in the federal capital, Islamabad, alone.

Moreover, the report reveals the highest number of infected patients is intravenous drug users (38.4%), transgender sex workers (7.5%), male sex workers (5.2%), male homosexuals (5.1%) and female sex workers (2.2%).

Though the percentage of female sex workers with the infection is the lowest, their rate is increasing at the fastest pace from 0.6% in 2011 to 2.2% in 2017.

Although the overall prevalence of HIV in our population is less than one percent, there remains a risk of its transfer to the uninfected population through sexual networks.

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Human Immunodeficiency Virus is a lifelong disease for which scientists have been unable to find cure. It destroys the white blood cells and harms the immune system, making the body too weak to fend off an infection. AIDS stands for Acquired Immunodeficiency Syndrome and develops when the HIV is not being treated. It is the final stage of infection with HIV and does not develop to that level in all cases.



HIV spreads through unprotected sex with infected partners, contact with blood or semen with a carrier and the sharing of needles. Women can also transfer it to their babies during pregnancy or childbirth.

Though there may be symptoms of HIV like flu, nausea and vomiting, muscle pain, swollen glands etc. Only a HIV blood test can accurately determine whether a person is infected or not.

The cure is not there but there are medicines that can fight the infection and lower the risk of transmission to others. People who get their treatment at an early stage can live life till a normal age.

Sexual transmitted infections are not limited to HIV only. Gonorrhea, chlamydia, syphilis, trichomoniasis and several others fall under the category. Many of these diseases can be protected through the use of contraceptives.

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Possession of contraceptives is often immediately associated with outright fornication, adultery and extra marital sex. This might be true, but that has always existed in our society or in a human society in general. Prostitution is considered to be the world’s oldest profession and Pakistan is no stranger to it, despite its claims of being an Islamic state.

Prostitution is an uglier reality that many societies do not want to acknowledge, but exists and has always existed. Like many other conservative societies, we also turn a blind eye towards this topic so as to contain its influence. But it is crucial to realise that NGOs who are educating prostitutes on safe sex are not promoting either prostitution or promiscuous sex: but that they are promoting a cause of health. After all, there are only a few organisations that seek to protect sex workers from STDs. The fact that people want to avoid talking about it doesn’t mean that the virus doesn’t exist. The Integrated Biological and Behavioural Surveillance found that only 2% of female sex workers reported utilising protection services. The National HIV & AIDS Strategic Framework 2007-2012 (NSF II) seeks to address this issue by: creating an enabling environment, building the right capacity and strengthening the institutional framework. But our government’s efforts in preventing HIV and AIDS will only take roots if we understand that it is about everyone’s health: not just of prostitutes’.

Big cities like Karachi, Lahore and Faisalabad are hub of such businesses. There are numerous underground sex markets operating in these cities and all over the country where sexual partners, both males and females, are available from the highest of prices to the lowest of prices imagined. The sex market caters to the fantasies of both the elites and the slum dwellers. And yet contraceptives, or even a discussion over them, remain a taboo to this day.

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The Agha Khan University Hospital, Karachi Infectious Diseases Section Head and Associate Professor Dr Syed Faisal Mahmood says that sex education should, first and foremost, be associated with healthcare and disease prevention.

He says that the virus or any other sexual infection can even spread and transfer from a legal partner as well. Therefore, it is not about promoting a western cultural edifice, but about promoting health reforms alongside our existing value system, he says.

Dr Mahmood says that our society looks at condoms and concludes it as a “birth control” agent and nothing else. This hesitation over sex awareness shows why so many young Pakistanis are ignorant about the major use of condoms: to prevent STDs and STIs, he adds. “This is what sex education should be about,” he says.

“And it is not just about STDs, it is about unwanted pregnancies as well. The taboo against sexual protection is problematic not only because it has adverse and uncertain health implications, but also has a connection with other issues such as women’s bodily autonomy and rights”, he concludes.

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According to Sindh AIDs Control Programme Project Director Dr Younus Chachar, “The issue is, most assuredly, above all of health and pretty serious.” However, it has been turned into a religious and cultural one through a conservative backlash against organisations which talk about family planning, use of condoms and other health affairs related to intercourse, he says.

“As the topic of sex is taboo in our society, the fast spread of many fatal diseases has gone unnoticed, including the alarming prevalence of HIV in the country,” he adds.

Although a discussion on such issues is categorised as a deviation from the ‘family system’ and traditional values, the unintended implications of the lack of dialogue strikes at the very heart of the family, says Dr Chachar. “It is most severely felt when it affects a woman’s bodily autonomy in the context of the household.” The taboo operates in such a manner that unavailability and lack of awareness on the use of contraceptives hinders a household’s ability to control births itself, he adds.

In fact, religious clerics and educational institutions should condone and come to the forefront to aid efforts combatting the spread of fatal diseases, he says.

But this is not happening. Condom ads were banned by Pakistan Electronic Media Regulation Authority. Even birth control ads were banned to “shield innocent children.” “United Nations agencies say only 27 per cent of people use contraception” in Pakistan. A social experiment and study conducted by Youth Champions Initiative (YCI), implemented by the Public Health Institute (PHI) of California, found that simply buying a condom as a single woman is a taboo in Pakistan. It is hard to find condoms, dozens of convenient stores do not have them. The first question a single woman gets asked if she tries to get a condom or birth control pills from a Family Planning Center is if she is married. In this situation, the onus of family planning is upon women. And yet, women find it so hard to get their hands on a contraceptive.

Both Dr Chachar and Dr Mahmood stressed the need to promote the use of contraceptives and protection in places where sex is commonplace.

Nobody is promoting promiscuous sex, but that protection and awareness of diseases is vital,” says Dr Mahmood.

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The issue of sexual health is a serious, immediate and an alarming one. It is not like the use of alcohol in the country. It is also not like the sale of porn films. It is like the sale of illegal guns and weapons, because it kills. It is directly related to the well-being of young males and females, but also of families and households themselves. So long as the use, possession and discussion over contraceptives and sex education in general remains a taboo in this country, we will continue to face daunting challenges of unwanted and lifelong diseases.