The Barriers We Create

The global political agenda for sexual health and rights has made it to the negotiating table, albeit contentiously. International documents, foreign aid agencies and advocacy groups have all latched on to sex -- either to promote the right to safe, healthy sexual lives or much more increasingly, to forbid its mention. Vociferous debates focus on condom promotion versus abstinence-only education, women's rights to control their bodies, and the acknowledgement of homosexuality in public health policies and programs. There is a common barrier throughout these disputes: unwillingness to recognize the reality of sex.

Given the political climate, where does that leave everyday South Asians, you and I, in our private lives? Barriers to open sexuality are everywhere in South Asia and the diaspora: restrictive menstrual practices, a sterilized lexicon, and censored entertainment are only a few examples. Although there are clearly exceptions, South Asians largely do not acknowledge sex -- before, within, or outside of, sanctioned relationships. And even while some do question the social and cultural implications of our taboo, I wonder, do we recognize the consequences of these barriers on our health?

Reproductive health problems for men and women abound throughout South Asia, and the spread of HIV/AIDS threatens to continue unabated. In the diaspora, sexual taboo and battles around cultural identity threaten health through decreased use of information, services, and care. The degree to which sexual taboo affects health obviously varies greatly by country, context and circumstance. Yet I contend that an overwhelmingly simple, overarching thread -- fear and refusal to acknowledge sexuality -- links the health barriers manifest in politics, social norms and private lives. Unless and until we really address the reality that people have sex, our health is at stake.

Suburban New Jersey. The doctor came back with the test results: the lesions caused by HPV, human papillomavirus, could be treated with a simple procedure. My 26 year old South Asian-American friend, rather than be relieved that she could prevent cervical cancer, was horrified. If she had to ask her parents to help pay, she would have to tell them that she was having sex. Her solution? She borrowed the money and paid a tremendous sum for a 10 minute laser procedure. Her financial privilege saved her. Had it not, she, along with many young South Asian Americans, would risk her health to avoid addressing her sexuality with her parents.

Ahmedabad, India. Fifteen young women had gathered for our first "Know Your Body" session on reproductive and sexual health. Throughout the afternoon, the discussion focused on menstrual hygiene, birth control and marital relations -- without ever broaching the topic of the "s" word. Given cultural norms and the more important task of ensuring that women understood their reproductive health options, the fact that we did not talk about sex didn't bother me at the time. Why make everyone uncomfortable when information was getting across? In retrospect, however, I wonder what unspoken questions remained unanswered, and regretfully consider the health ramifications.

Barriers to Health

When faced with societal barriers to discussing sexuality, individual reproductive health and well-being suffers. HIV and STD prevention efforts are essentially thwarted by a refusal to openly acknowledge sexuality. Lessons from around the world demonstrate that public recognition of sexual behavior, such as in Uganda, is a cornerstone of effective HIV prevention programs. Also, taboo has impacts on young people's ability to access information and services.

Yet a majority of reproductive health efforts in South Asia and its diaspora continue to work "around" sex. In my experience with a UN agency in Bangladesh, a senior official once commented that, after five years of promoting government condom distribution efforts, she felt she had finally reached the golden status: she could use the word sex in official speeches. Not so fast. Bangladesh recently integrated sexual education into public school curriculums, an important advancement in preventing sexually transmitted diseases. Although the Ministry of Finance supported the efforts to advance sexual health awareness, there was an important caveat. They warned us not to turn their children into Western youth -- who are oversexed because they know too much. Thus, curricular efforts focus on understanding body changes and childbirth, with the enabling act of intercourse carefully omitted.

The logic, at least from the perspective of public health, is unclear. Statistics show that knowledge about sexuality does not significantly alter age at initiation or behavior. Rather, it may lead people, particularly adolescents, to prioritize safety when they do choose to engage in sexual activity. If public health is not the priority, is it only for culture and comfort that we continue to create these barriers?

The Comfort

At the individual and community level, suppression of sexuality preserves entrenched gender and cultural norms, and simply may be more comfortable. Public officials often argue that, despite the growing importance of acknowledging sex, it is simply not politically feasible to confront the issue. A senior World Bank expert shared his opinion with me that treating AIDS might be easier than preventing it: at least we don't have to talk about sex.

Indian Minister of Health Sushma Swaraj recently commented that condom promotion may encourage promiscuity, and accordingly censored safer sex media efforts. Again, the logic is unclear. Eighty-five percent of HIV infections in India are sexually transmitted, and married women in monogamous relationships are emerging among the most vulnerable to infection. In this case, to acknowledge the sexuality of a populace would endanger the notion of family inherent in right-wing political ideology, and would allow reality to overcome an imagined ideal. Despite the public health rationale, barriers prevail.

Barriers Also Travel

I recently interviewed South Asian female friends in America on if, and how, they deal with sexuality and its impact on reproductive health. Woman after woman recounted hiding contraceptive use, clandestine visits to health care providers, and most commonly, dealing with guilt for one's sexual behavior. One friend had fabricated menstrual problems to explain her birth control pills, while another would regularly cancel gynecologist visits so her physician, a close family friend, would not discover her "lost" virginity. Yet another spoke of difficulty in intimate relationships because of deeply ingrained notions of honor and shame. Things could also be more extreme: a woman with mixed laughter and tears recounted how her mother told her ovarian cysts were her own fault because she had been "with boys."

In a transplanted environment, sexuality becomes the ground upon which cultural battles are fought. Like the government's rationale in Bangladesh, sexuality becomes a negotiating factor between East and West, tradition and modernity. Growing up in suburban America, I, alongside almost everyone I knew, was regularly excluded from religious events during menstruation. As teenagers, rather than the birds and the bees, my friends and I were reminded by our parents to remain "Indian" and know our limits in our dating practices. In college, trite notions of "fast" women persisted despite group efforts to discuss our -- notably hetero -- sexuality. Interestingly, although we commonly questioned determinants of cultural identity, we seldom extended the analysis to their impact on our sexual health.

Moving Beyond

There is a simple yet commonly ignored thread to these anecdotes and observations. Whether in a political negotiation in Geneva, focus group in South Asia, or doctor's visit in New Jersey, the barriers and their ramifications are essentially the same. Refusal to acknowledge sexual realities is endangering our health. Despite the evidence, ineffective programs and policies persist -- and in today's political environment, accelerate.

Open education and discussion of sexuality, as facilitated by some grassroots programs throughout South Asia and the diaspora, can create a safe, healthy environment for private and public benefit. HIV/AIDS, pregnancy and unsafe abortion can be addressed in much-needed civic forums, with potential for collective action. Lobbying for sexual rights, promotion of mass media campaigns, and creation of broad-based programs are crucial to fostering change. It is with these efforts -- often politically contentious and vociferously opposed -- that barriers are broken, taboos are purged, and realities are confronted. And public health is improved.

It is important to remember that, while recognizing that the public health impact of addressing sexuality is crucial, it is not enough. Sexuality viewed through the public health prism alone threatens to sanitize human behavior, and to define sexual behavior as a determinant of ill health alone. A strict public health approach runs the risk of creating notions of what is deemed "healthy," and of mainstreaming safer sex at the expense of leaving sexual pleasure and rights at the margins. To truly build an affirmative model of sexuality -- to protect our health and our freedoms -- it will prove crucial to not only tear down social and political barriers, but also to force ourselves to question those which we ourselves create.


Sex is a very sacred act and should be treated with outmust respect and with regard. I am fearful that there will come a time when people don't treat it as special. - Missed Fortune
perhaps the most important social factor is the generaal discomfort of people in discussing sexuality because of nations culture, it is taboo in our society.

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