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Muslims' Perspectives on Key Reproductive and Sexual Health Issues

Research and Capacity Building for the Promotion of Sexual Health and Well-Being in the West Africa Region
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Reproductive health strategies are built around a core belief that women as full, thinking, feeling personalities, shaped by the particular social, economic, and c
ultural conditions in which each of them lives, are central to their own reproduction (Freedman and Isaacs, 1993). Consequently, these authors argue, health policies and programmes cannot treat reproduction as mere mechanics, as isolated biological events of conception and birth; rather they must treat it as a lifelong process inextricably linked to the status and roles of women in their homes and societies.

Evolution of the Concept of Reproductive Health 
The available literature reveals a high degree of overlap between definitions of reproductive health, sexual health and maternal health. The major international encounters that have taken place since the Cairo conference have shown that reproductive health has tremendous potential to bridge gaps between diverse constituencies. But the concept of reproductive health is also a cultural product that emerged as a result of a particular historical, legal and ethical evolution. Implementing it involves not merely the application of principles and the selection of measures, but a process of translation across cultures. Therefore, a cultural perspective that clarifies the link between the global and the local must be developed. 

According to various definitions, the basic elements of reproductive health are: responsible reproductive/sexual behaviour, widely available family planning services, effective maternal care and safe motherhood, effective control of reproductive tract infections (including sexually transmitted diseases (STDs and HIV/AIDS), prevention and management of infertility, prevention and treatment of malignancies and elimination of unsafe abortion. These definitions call for action to consider these demands as human rights.

Examining the different definitions, one observes that reproductive health is not defined by strict criteria. The concept extends beyond reproductive ages, reproductive events or reproductive organs, toward a broader perspective on reproduction as situated within a socioeconomic context. As a result, there are no precise guidelines about the exact scope of the concept, or explicit standards for inclusion or exclusion. 

Several major international conferences in the population and health fields have taken up the call for comprehensive reproductive health strategies, and have begun to elaborate what this would entail. Discussions of reproductive health strategies acknowledge the close relationship between health and the social and cultural contexts in which people live and exercise their health behaviour.

The concepts of 'autonomy' and 'choice' which are pivotal in international population debates, are influenced by social and cultural factors that vary widely, even within one region or country. Jacobson (1994:26) defined autonomy as 'an individual's ability to think and act independently of others to achieve her\his interests'. However, the Western notion of autonomy which is based on concepts of privacy and individual rights may be less relevant to Muslim women who value the interdependence of individuals, families, and communities. 

A husband and wife form the nucleus of a family. Their relationship is described in the Quran as having two major qualities: love (passion, friendship, companionship), and mercy (understanding, reconciliation, tolerance, forgiveness) within the overall objective of tranquility (Omran, 1992). The Quran explains what this means:

"…and one of Allah's 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" (Sura 30:21)

Many authors indicate that the status of Muslim women evokes two contradictory sets of images (Obermeyer, 1992). While the demographers, sociologists and anthropologists indicate that the women in Muslim countries have a lower status (Freedman and Isaacs, 1993; Weeks, 1988), the theologians argue that Islam itself gives women a high status (Omran, 1992). Based on the interpretation of the Quran, the theologians argue that a woman is considered to be equal to a man in many social and economic aspects (Omran, 1992). For instance, she has the right to choose her husband; in marriage, she has the right to keep her maiden name; she can be completely independent financially and has the right to do with her money as she pleases, while the husband is responsible for providing for her and her children (Omran, 1992).

The first image, which is painted by the demographers, sociologists and anthropologists, implies that the lower status of the Muslim women is part of the explanation of high fertility in most of the Muslim countries. The relation between lower status and high fertility is believed to operate in two mutually reinforcing ways (Obermyer, 1992): first lower status means restricted access to education and employment; and second, a woman's economic dependence puts her in an insecure position, making the threat of divorce and polygamy more menacing. These, thus, limit her choices with regard to childbearing because the one chance to improve her bargaining power and to insure against risk of divorce is to produce sons whom she can influence and rely on for support. 

The second image of the Muslim woman is that painted by the theologians. Omran (1992), argues that the status of women in Islam is seriously misunderstood for many reasons. It is wrongly implied, he observes, when the behaviour of individual Muslims and Muslim communities are interpreted as reflecting the tenets of Islam. This is further compounded by misconceptions about the status of women in Islam based on the gross abuse of Islamic laws among some ignorant Muslim groups. In addition, most of the Muslim communities exist in the Third World which is associated with the low status of women. 

Obermyer (1994) argues that there are aspects of Islamic doctrine that could be used to reinforce the case for women's autonomy and equality, which have received a great deal less attention than the aspects of the doctrine which tend to promote inequality. The author maintains that many Muslims believe that statements in the scriptures that stress equality of believers before God are the authentic message of Islam, while those suggesting discrimination against women are merely reflections of the temporal conditions in which the religion developed, and a distortion of its inherent egalitarianism.

Many researchers have made efforts to link human rights and reproductive health (Freedman and Isaacs, 1993; Cook, 1993). The idea of reproductive choice has become the focus of systematic elaborations based on legal and ethical principles. One of the central elements that define reproductive choice is autonomy, which means that a woman can make decisions in matters of reproduction and that she has access to the information and services that can make her choice an reality.

Islamic laws are often seen as incompatible with international human rights (Obermyer, 1994, 1992). However, some Muslim authors retort that the standards governing rights and choice as defined by the West are contrary to Islam (Omran, 1992). They maintain that certain infringements on women's freedoms are mandated by Islam. However, applying the criteria derived from international conferences to the analysis of reproductive choice in Islam is difficult, because of the existing differences in views on the relationship between Islam and women's status (Obermyer, 1994). 

Ahmed (1992) argues that there is a basically egalitarian ethos in Islam that was distorted by patriarchal forces. In his view, the religious texts can and should be interpreted in a more egalitarian manner. This perspective would be in harmony with the Western notion of women's reproductive choice. Obermyer (1994) supports this notion and argues, further, that there are several aspects of Islamic doctrine that are clearly compatible with such an interpretation. She notes that a number of statements in the scriptures stress the idea that God does not wish to burden the followers, and suggest that quality is as important as quantity in child bearing. In addition, a generally positive attitude exists toward sex in marriage in the Islamic context, as does a clear recognition of woman's right to sexual enjoyment.

Obermyer (1994) examined two case studies that represent interesting links between state goals, gender issues, and reproduction. The first is Tunisia, where the state carried out pervasive reforms to improve both women's status and reproductive choice without violation of the Islamic tradition. The second case is that of Iran, where successive regimes have implemented contrasting policies that have had a direct impact on women and reproduction, and where issues related to women have been affected by political struggles at local, national, and international levels. She concludes that the constraints on reproductive choice are a function of state politics rather than a reflection of religious doctrine, and that leaders do, in fact, use Islam to justify divergent positions on gender and reproduction. She states that: 

"Like other religious doctrines, Islam has been used to legitimise conflicting positions on gender and reproductive choice. The ways in which the ethical code of the religion is translated into policies affecting women's status have been a function of the ideology of groups in power and have been influenced by changes in the economic, political, and social spheres." (p:49)

The following sections examine the concept of choice regarding certain aspects of reproductive health, namely, abortion, sexuality and contraception in the context of culture.

The main concern for theologians is whether the Shari'ah is supportive of abortion or not. From this general question, a list of sub questions would arise: 

  • At what stage during the term of pregnancy does the fetus become a human being? 

  • What are the circumstances in which Islamic law permits abortion and under what circumstances is abortion prohibited?

In the interpretation of the Quran and Hadith, direct reference is made to the “ensoulment” of the foetus 120 days after fertilisation. At the same time, some of the commentators of the Quranic texts, hold that the words 'Khalqan akher' (i.e. another act of creation) in the Quranic verses signify the "ensoulment" of the foetus; and that the stage of 'mudghat ghayer' (i.e. the lump not yet completely created) in the Quranic verse refers to the stages when no soul had yet been breathed into it (Madkour, 1974).

In summary, there are three main stages in a pregnancy that influence Islamic scholars' assessment of abortion:
i. Before 40 days
ii. Before 120 days, and
iii. After 120 days. 

As was mentioned earlier, the fundamental question for the Islamic law is at what point during the process of development does a foetus become a human being? According to Mussallam (1978), Muslims believe that point is at the end of the fourth month of pregnancy, when the foetus becomes “ensouled”. There is another view, which locates that point at the end of 42 days, when organ differentiation starts (Omran, 1992; Mussallam, 1978; Madkour, 1974).

In summary, there is a consensus among Islamic scholars that abortion after 120 days is not allowed. However, Islam gives women a right to abort in cases of severe maternal health problems. However, these rights are relative and should still be weighed against other alternatives.

Right to Contraception
The right to contraceptive use is discussed by many scholars in detail (Omran, 1992). Most of the theologians are of the opinion that non-permanent methods of contraception are allowed in Islam provided that they are safe and they are accepted by both husband and wife. However, the question of permanent methods (male and female sterilisation) still needs clarification. Most of the theologians are of the opinion that these methods are not allowed except in cases where the health of the mother is in danger.

The objection to sterilisation arises from the perception that the woman may possibly regret this decision at a future date due to a renewed desire to conceive (Rispler-Chaim, 1993), especially within the context of the irreversibility of sterilisation. Another argument is that it is an attempt to change what God has created (Jad el Haq, et al 1992). In addition, some scholars indicate that sterilisation is by analogy like castration, which is prohibited by the Prophet (Madkour, 1974).

Abdullah observes:

We used to participate in the holy battles led by Allah's Apostle and we had nothing [no wives] with us. So we said, "shall we get ourselves castrated?" He forbade us and then allowed us to marry women with a temporary contract and recited to us [from the Quran]: 'O you who believe! Make not unlawful the good things which Allah has made lawful for you, but commit no transgression.'
(Sura 5:87)

Rispler- Chaim (1993) and Omran (1992) argue that sterilisation, if reversible, could be viewed as one more variation of “legitimate contraceptives”. Furthermore, sterilisation is not similar to castration. While castration involves impact on virility and fertility and the level of the hormones, sterilisation affects fertility only. It is argued that if the short-term methods are allowed, then, the long-term methods should also be allowed (Rispler-Chaim, 1993). 

On the other hand, Serour, (1998) suggests that the argument that sterilisation is reversible is not true, the success rate of the procedure is very low, it is expensive and needs advanced techniques. 

This following section argues that Islam provides both women and men the right to proper sex education, good sexual health, and sexual enjoyment. 

Reproductive Health and Sex Education in Islam
At the time of the Prophet, 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 used to clarify what was obscure. In addition, women used to ask 'Aisha', the Prophet's wife, about some aspects of reproductive health. Sex education is mentioned in the Quran and the Hadith as follows:

  • Sexual Positions. Any position in sexual intercourse may be taken namely, sitting, standing, and leaning on one side:
    According to the Quran: “Your wives are as a tilth* unto you so approach your tilth when or how ye will." (Sura 2:223). 
    (* Tilth literally means a farm).

  • Family Planning. Abu Sa'd Al-Khudrei says: 
    We got female captives in the war booty and we used to do coitus interruptus with them. So we asked Allah's Apostle about it and he said, "Do you really do that?" repeating the question thrice, "There is no soul that is destined to exist but will come into existence, till the day of Resurrection." Al Boukhari.

  • Extreme forms of Sexual Behaviour. Ibn Abbas narrates:
    A man came to the Prophet and said: Verily I have got a wife who does not retract the hand of a toucher [nymphomania?]. The Prophet said: "Divorce her". He said : "I love her". The Prophet said: "Keep her in that case." (Al Boukhari). 
    It is worth to noticing that the Prophet did not punish the woman.

  • The Importance of Foreplay. Jabir bin Abdullah narrates: 
    When I got married, Allah's Apostle said to me, "What type of lady have you married?" I replied, "I have married a matron." He said, "Why, don't you have a liking for the virgins and for fondling them? Jabir also said: Allah's Apostle said, "Why didn't you marry a young girl so that you might play with her and she plays with you?" (Al-Boukhari)

Rights and Duties in Sexual Relations 
All scholars indicate that the right to sexual enjoyment is one of the rights of a wife (Omran, 1992). They do not deny her right to sexual fulfilment. Sexual fulfilment for women was understood to depend on the completed act of intercourse, something which withdrawal was not (Mussallam, 1978). 

Accordingly, some scholars disallow withdrawal without the consent of the wife as they believe that it would interfere with her enjoyment of the act. 

However, these rights are balanced by women's duties. Many Hadiths state that a woman should not refuse her husband. The Prophet said: "If a man invites his wife to sleep with him and she refuses to come to him, then angels send their curses on her till morning." Al Boukhari. Also, he said: "If a woman spends the night deserting her husband's bed [does not sleep with him], then the angels send their curses on her till she comes back [to her husband]." Al Boukhari.

Islam and Sexual Health 
Islam forbids all acts which are believed to be harmful to sexual health, such as castration, sex during menstruation, and anal intercourse. It is believed that applying these teachings will help in maintaining sexual health and prevent sexually transmitted diseases including HIV/AIDS.

Sex Outside Marriage: Islam forbids all types of sexual relations outside marriage, whether premarital or extramarital. Islam advocates a number of specific measures to reduce the temptations that may lure one into such relationships. 

  1. The Prophet encourages all followers (especially the youth) to get married if they can, so that their natural desires are legitimately fulfilled:
    "Whoever is able to marry, for that will help him lower his gaze and guard his modesty (i.e. his private parts from committing illegal sexual intercourse)." Al Boukhari. 

  2. Polygamy is allowed by Islam in a bid to reduce the number of unmarried women in a society. 

  3. There are clear instructions to women to cover themselves and to appear in a modest way so as not to attract men. 

  4. Boys are not allowed to associate with girls after puberty. This tends to limit the boy/girl friend (dating) practice. 

  5. Alcohol consumption, parties, dancing involving both sexes – practices and settings which can lead to sexual relations outside marriage - are forbidden.

  6. Meetings between a man and a woman where they are without other company is forbidden. 

  7. Islam restrains women from the kind of speech which may stimulate sensual passion - "If ye fear God, be not too complaisant of speech, lest the man of unhealthy heart should not lust after you." (Quran Sura 33:32). The restraint also extends to posturing and the manner of walking - "And let them not strike their feet together, so as to discover their hidden ornaments" (Quran Sura 24:31). Indecent exhibition is also prohibited : "And that they display not their ornaments except those which are external" (Quran Sura 24:31).

Furthermore, the Prophet instructs his followers that they should have sexual intercourse with their wives if they get excited according to the following Hadith. Jaber narrates:

The Prophet said: "Verily a woman comes near in the form of a devil, and goes behind in the form of a devil. When one of you is pleased with a woman and she falls unto his heart, let him be inclined to his wife and have sexual intercourse with her, because it drives away what is in his mind." Al Boukhari.
Sex outside marriage is considered in Shari'a not only as a sin but also as a crime which is punishable under law.

Castration: The Hadith indicates, as narrated by Sa'd bin Abi Waqqas - Allah's Apostle forbade Uthman bin Maz'un to abstain from marrying (and other pleasures) and if he had allowed him, we would have gotten ourselves castrated.. Al Boukhari 

Sex during Menstruation: Islam forbids sex during menstruation - Sura 2:222 - 
They ask thee Concerning women's course*. Say: They are a hurt and a pollution: so keep away from women in their courses, and do not approach them until they have purified themselves. Ye may approach them as ordained for you by Allah For Allah loves those who turn to Him constantly and He loves those who keep themselves pure and clean." (*Course literally means menstruation)

Anal Intercourse: As narrated by Khusaimah bin Sabet: The Prophet said: Verily Allah is not ashamed of truth. Don't approach women by their backs (anal intercourse). Al Boukhari. Also, as narrated Abu Hurairah, the Prophet said: “Cursed is he who goes to his wife by her back.” Al Boukhari.

In summary, Islam gives women and men the right to sexual health by forbidding all what is believed to be harmful. In addition, it provides them the right to sex education and sexual enjoyment. However these rights are not to be practiced outside of legal marital relations.

A growing literature of social, and anthropological studies shows that Islam is interpreted differently in different countries and by different social groups. Religion is not the only factor, although it is very important, that determines social outcomes. Traditions, customs, and geographical differences are other factors. Moreover, Islamic texts are flexible and could be adapted for all places and all times. Some of the current theologians tend to quote from the classics, even with regard to old medical opinions whose errors have been brought to light and which have since been superseded by other more scientifically-grounded ideas. These factors could explain some of the gaps between Islamic ideology, as expressed by the Quran and Hadith, and the practices which are based on customs and traditions but misinterpreted as grounded in Islam. 

From the Islamic point of view, two different positions on reproductive choice may be taken. The more traditional position gives women little freedom to make decisions that bear on reproduction. The second argues that constraints on reproductive choice that exist in some Muslim countries are not inherently Islamic. Hey further argue that the egalitarian elements in the sacred texts should be the guide to a reinterpretation of the doctrine that would be fully compatible with ideas of human rights and reproductive choice.

Contraception rights in Islam have been discussed in detail in many other publications (see the work of Omran, 1992). The majority of these authors indicate that Islam gives women absolute right to contraception. However, there is a diversity of opinions regarding the permanent methods (surgical sterilisation). 

Regarding abortion, there is consensus among the theologians that abortion after 120 days is not allowed except to save the life of a mother. However, there is no unified position among Muslim scholars on abortion before 120 days. All the schools of thought agree that Islam gives women a right to abortion when their lives are in danger in the case of a high risk pregnancy. Also, some schools agree on the right to early abortion in cases of health, social, mental and economic problems. There is a clear indication of the need to revise and unify the Islamic laws regarding abortion in the context of recent advances in medicine and technology. 

Regarding sexuality, Islam gives women the right to sexual health by discouraging all that was believed to be harmful, such as anal intercourse and sex during menstruation. Islam also gives women the right to proper sex education and the right to enjoy sex. However, all these rights should not be practiced outside of marital relations. 

Rereading of reproductive health definition: Taking into cognisance the socio-cultural dimensions of reproductive health, the international definitions of reproductive health can be adapted to make them acceptable to, and adoptable by Islamic countries. The proposed adaptations are as follows:

Reproductive Health in Islam: A Redefinition
Within the framework of Islamic teachings, reproductive health implies the ability of women and men to live from birth to death with reproductive choice, dignity and, to be reasonably free of reproductive health diseases and risks. In addition, the ability of a married couple to enjoy marital sex without fear of infection, unwanted pregnancy, or coercion; to regulate fertility without risk of unpleasant or dangerous side effects; to go safely through pregnancy and childbirth; and to bear and to raise healthy children.

Ahmed R. A. Ragab. Dr. Ragab is the Associate Professor of Reproductive Health, International Islamic Center for Population Studies and Research at Al-Azhar University, Egypt.

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