Reproductive health of Arab young peopleBMJ 2006; 333 doi: https://doi.org/10.1136/bmj.38993.460197.68 (Published 19 October 2006) Cite this as: BMJ 2006;333:849
- 1 Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Riad El Solh, 1107 2020, Beirut, Lebanon
- 2 Unicef Middle East and North Africa Region, PO Box 1551, Amman 11821, Jordan
- Correspondence to: J DeJong
The Arab region, though diverse, is characterised by patriarchal social systems and family structures that give prominence to the role of men in both public and private spheres. Only recently has this situation been challenged by public policies and reforms in family laws. Since the international conference on population and development in Cairo in 1994, governments have pledged to improve the sexual and reproductive health of adolescents by providing integrated health services including contraception for sexually active adolescents and health education. Most regions of the world still fall well short of these recommendations, especially for unmarried young people, but those in Arab countries are particularly underserved.1 2
Demographic changes affecting young people
Focus on the high percentage of young people in the population has tended to sideline other demographic trends in the region with important implications for young people. These include the large recent rise in the average age at marriage for both sexes (nearing 30 in parts of North Africa3) and the rising proportions of young unmarried women in many Arab countries.4 These trends have occurred in a cultural context where marriage is universally expected and sexuality outside marriage, particularly for women, heavily sanctioned and thus have important ramifications for reproductive health. Although research is very limited, premarital sexual relations are reported; in Jordan, 7% of college students admitted to non-marital sex in a study in 1994, as did 4% of the general population aged 15-30 in 1999.5 Among university students in Egypt, 26% of men and 3% of women reported having sexual intercourse at least once.6
Major changes in the institution of marriage in the region are almost completely unexplored. There has been a resurgence of customary ('urfi) marriage, whereby young people obtain a clandestine marriage certificate to engage in sexual relations but are unprotected legally or in terms of health services, in countries such as Egypt.7 Other forms of temporary marriage such as “summer marriages” in Egypt or “business related marriage” in the Gulf countries are increasingly discussed in the Arabic media, but their prevalence is unknown.
Lack of information
Family life in the region is changing because of migration, urbanisation, busy lives, and new lifestyles brought by the mass media and consumerism.1 A rapid increase in access to education and exposure to the global media has widened generational gaps between parents and their children8 and altered the ways in which young people receive information. Although studies show that young people would prefer to learn about puberty and their health from their parents, many parents are reluctant or ill equipped to provide this information. A nationally representative survey of young people and their parents in Egypt in the late 1990s found that, although 42% of fathers reported talking to their adolescent sons about pubertal changes, only 7% of boys reported learning about puberty from their fathers.9
The lack of accurate information about sexuality and reproduction reflects a wider public policy reluctance to provide sex education in schools. Although sex education is increasingly included on curriculums, teachers are often too embarrassed to teach it.
Absence of appropriate health services
Government health services generally do not recognise the special needs of young people or foster a climate that supports them. As a result, private health services are often the only place where young people can seek help on sexual and reproductive health issues, and even if they can afford these services many social barriers persist. A small qualitative study of Jordanian young people aged 10-24 found that most still equate reproductive health with maternal health care and believe that health centres are exclusively for mothers and babies.10 As a 15 year old respondent put it, “If we went to ask a nurse or a doctor, they would laugh at us and tell us to wait till we get older.”10
The exception to this trend is Tunisia, which has initiated adolescent health clinics that are open to unmarried young people. It has also established school health clinics in all major towns. These clinics include counselling and information on reproductive health and refer clients to specialised counselling or treatment if necessary.11
The high social and religious value placed on virginity means that unmarried young women risk stigma and judgmental attitudes from health workers if they try to obtain contraception.1 But young women who marry early also lack knowledge and access to contraceptive services, let alone basic reproductive health services.12 They face strong pressures to have children as soon as they are married. In Oman, for example, less than 1% of women reported using contraception before their first child.13 Only Tunisia has legalised abortion on demand, and unsafe induced abortion is reported elsewhere in the region. Emergency contraception is currently licensed in Algeria, Egypt, Lebanon, Libya, Tunisia, and Yemen.14 Young people, however, are not widely informed about its availability (A Foster, Ibis Reproductive Health, personal communication).
Almost no systematic data has been collected on young people's awareness of HIV/AIDS or their risk behaviours, despite the fact that internationally half % of new infections are estimated to occur among young people. Much greater efforts are needed to ensure confidentiality of HIV testing (as Tunisia has done with legislative reform currently under review) and to reduce stigmatisation associated with HIV and AIDS.
Violence and conflict jeopardise reproductive health
The effects of conflict on the reproductive health of young people are also under-researched. Khawaja found, for example, that during the first uprising against Israeli occupation the age of marriage fell among Palestinian women.15 In Iraq, political instability after 2003 led to a rise in violence against women, for which services are unprepared.16 Civil war has been one of the main drivers of the AIDS epidemic in Sudan, and many cases of sexual and other violence against women in Darfur have been reported.
Arab young people's reproductive health needs are not being fully met due to societal reluctance to address these issues and cultural and religious sensitivities
Health services generally fail to recognise the special needs of this age group, particularly those who are unmarried
Little is known about what young people themselves want in terms of sexual and reproductive health services
Pervasive conflict in the region has grave implications for young people's sexual and reproductive health
Innovative small scale programmes exist that could be built on
Arab young people show ingenuity in communicating, forging relationships, and even tackling some of these controversial topics despite social sanctions and, in some cases, fear of political consequences. New internet sites are becoming accessible to young people that allow them to deal with sexual and reproductive health.17 There have also been pressures to reform family laws in ways favourable to women and young people. Countries such as Jordan and Algeria have enacted reforms to raise the legal age at marriage. Morocco and Algeria reformed the family code giving more rights for women in divorce and made it more difficult for men in Morocco to take a second wife. Algeria has recently granted women married to non-Algerians the right to convey their nationality to their children. Some innovative culturally sensitive programmes models could usefully be shared across the region:
Tunisia, recognising the vulnerability of rural women attending urban universities, introduced a peer education programme on reproductive health in female dormitories18
The Syrian Family Planning Association and Arab Red Crescent recently opened four voluntary AIDS counselling and testing centres targeting 25 000 vulnerable young people and 1500 commercial sex workers (I El Daker, HIV/AIDS project officer, Unicef Syria, personal communication)
Summer caravans toured Morocco distributing 15 000 condoms and providing voluntary and confidential HIV testing and counselling to 7000 young people21
The way forward
Sensitivity surrounding young people's sexual and reproductive health has limited the knowledge base, particularly on young people's perspectives and needs, that could inform legislation, policy, and programmes. Appropriate sex education could be strengthened through working with teachers and parents. Special attention is needed in designing programmes that reach the most vulnerable young people. Above all, government commitment is required to translate the small scale models in the region to national programmes that improve the welfare of all young people.
Action points are given on bmj.com
The statements in this article are the views of the authors and do not necessarily reflect the policies or the views of Unicef. Contributors and sources: This article draws on a larger study based on a literature review and interviews with 51 informants supported by Unicef's Middle East and North Africa office.1 Bonnie Shepard was responsible for the overall design of the study, gave numerous comments, and provided information for the situation analysis. George Ionita and Golda El-Khoury managed the study project and Naheed Aziz reviewed an earlier draft. Julieta LeMaitre reviewed legislation and government commitments. Iman Mortagy and Rana Jawad helped with research. JDJ's research interest is reproductive health and HIV/AIDS in the Middle East region, GE-K has been active in promoting rights-based multi-sectoral policies and programs on young people in the Middle East and North Africa region. JDJ was author of situation analysis, wrote the article, and is guarantor; GE-K drafted some sections of this article, gave many substantive comments on the text, and provided material on programmes reaching young people.
Competing interests None declared.