Saturday, October 31, 2009


When I look back at my teenage years growing up in a conservative Muslim and traditional Pukhtoon culture I realize that such an environment was not conducive towards a healthy attitude towards human sexuality. Most of us grew up ignorant about the subject and were full of feelings of fear, shame and guilt. We could not talk about our sexual feelings with our parents or teachers, as the subject was a taboo. There was no sex education at home or in the school. Adults did not prepare their children to be aware of their choices and make responsible decisions about their sexual lives. Parents believed they knew the best about their children. Many aspects of human sexual relations were considered unnatural, illegal or immoral. It took me a long time of studying medicine and psychology and living in the Western world and enjoying loving relationships to feel comfortable discussing it with my fiends and patients. I consider it as one of the most significant aspects of human relationships.

You have asked me what are the ten things I wish I knew about sex as a teenager. I admire your courage to ask such questions. I hope that you and your friends do not live in the same darkness and with the same inhibitions as I did thirty years ago. I sometimes wonder that in those thirty years, so much and so little has changed.

When I thought about your question the following things came to my mind.
1. It is quite normal for boys to have wet dreams as teenagers.
2. It is quite natural for girls to have menses when they reach puberty.
3. Semen is a secretion not excretion
4. Masturbation is self-pleasuring not self-abuse
5. It is better for all of us to know about male and female sexual anatomy and physiology.
6. It is better for all of us to be aware of different stages of sexual development.
7. Foreplay and after-play is as important as sexual play
8. Mutual orgasm (cuming together) is not the most important part of love-making
9. We should all be knowledgeable about different forms of contraception to experience different forms of sex (to choose between reproductive, relational and recreational sex)
10. We should learn to accept rather than judge others who have different sexual tastes and lifestyles.

Dear Zeeshan! I have no idea what Pakistani parents feel about their children’s sexual lives. Who they think will give them sex education. There seems to be no preparation for accepting the puberty. Boys are not told that when their sexual hormones become active, alongside change in their voice and facial hair, they will also have erotic and sexual dreams which will be associated with nocturnal emission. I think they need to be reassured as it can be quite a scary experience. They have to know it is quite natural and there is nothing to worry about. Reaching puberty can be far more scary for girls than boys, as their menses can start during the day and can last a few days. I met many girls who were terrified when they had their first periods. Some of them had that experience when they were in school. As they were not prepared they did not know what to do. They were terrified, some even felt they were dying. They could not even discuss with their parents as there was no open communication. Many of them were as mystified when bleeding stopped after a few days it had started, not to know that it would return every month. They were also not aware that periods could also be associated with abdominal pain and mood changes. Since girls also have changes in the breasts it can also be embarrassing in front of relatives, friends and class-fellows. Most teenagers need a lot of emotional support and reassurance so that they do not feel abnormal or unclean. In our culture it is usually the opposite. Not only teenagers are not reassured and supported they rather have to face social embarrassment and humiliation. Many make fun of them. Many of them might have acne and other facial changes that they cannot hide. Since many teenagers are sensitive about their looks and body image, such changes make it far more challenging. Many girls like to do make up and wear adult clothes and jewellery identifying with their mothers. It is unfortunate that many parents do not see it as an innocent experimentation, they rather condemn and criticize. It broke my heart to see many parents tell their teenage daughters, ‘ When you do make up, you look like a whore.’ It is so devastating for girls to hear that from their own parents, while they are exploring their own sexuality. It is ironic that parents forget their own teenage years so quickly.

It is also sad that in many Eastern cultures people do not discuss human anatomy and sexual physiology without making reference to religious morality. Everything is discussed as right and wrong, good and bad and teenagers are overwhelmed with the feelings of sin and guilt. Many religions as institutions have great difficulty accepting that sex can be innocent and loving even spiritual. It is presented as unclean and filthy. I was told that after I have wet dreams I could not pray because semen was unclean and I was supposed to take a bath to cleanse myself. Semen is considered an excretion in many Eastern cultures. It took me a long time to discover that it is a secretion not a excretion and that is why in the West it is called love-milk and many women swallow it as part of lovemaking. I met so many Muslims who enjoyed having oral sex but would not kiss their lovers afterwards. When I asked ‘ Why not?’ they said, ‘ Because she had semen in her mouth?’ and when I gently confronted, ‘ It was your semen after-all’ they kept quiet as they were lost for words.

Similarly many teenagers are ill-informed about masturbation. I have read horror stories in the local magazines and digests in Pakistan in which masturbation was associated with all kinds of physical and mental illnesses including blindness and mental retardation. It is also ironic that there are thousands of quacks earning millions of rupees treating those teenagers who are confused about their sexuality. I have not met very many Eastern parents who can give blessing to their teenage children about masturbation. They cannot say ‘ it is a form of self-pleasuring’ rather than self-abuse. Masturbation becomes even more important form of sexual expression in a culture in which young men and women are not allowed to date.

Most teenagers in Pakistan are not familiar with the basic human anatomy and physiology. Many girls are not aware of the relationship between their vaginas, uterus, fallopian tubes and ovaries. They do not know when they ovulate and do not know what function does menses serve. It is unfortunate that there are no words in Punjabi and Urdu to have a serious discussion with teenagers about sex. Many words used for different anatomical parts are slangs and sound vulgar and obscene. One cannot talk about penis, testicles, vagina, clitoris, uterus or orgasm in Urdu and Punjabi as one can talk in English. I think writers and linguists and psychologists and intellectuals have to meet with parents and teachers to coin words and expressions in Urdu that would make it easier for teachers and parents to provide sex education to their teenagers. In my book about Gay and Lesbian literature I had introduced a few expressions to bridge that gap (for example jinsi mairage for orgasm and dehni mubashirat for oral sex). I vividly remember that when I was in grade twelve and we were studying physiology one of our professors once drew the whole reproductive system of rabbit on the blackboard and uttered every word except penis and vagina. He was so inhibited he could not even utter the words. I used to wonder why we had poor role-models and how could those adults help sexually liberate us who were inhibited themselves.

It took me a long time to realize that the word sex has many meanings and can be used for different things. I became aware of it when I learnt about different stages of sexual development and learnt the differences between hermaphrodires, transvestites, transexuals and homosexuals. Many Easterners I met did not know the differences between them and sometimes used them synonomously.

Many teenagers and even male adults do not realize that the act of love making is more than just having sex. I met many women in my clinical practice who complained that their lovers, boyfriends were not sensitive enough to their feelings as they did not pay attention to fore-play and after-play. After they had their orgasm they rolled over and fell asleep. They did not cuddle and hug and hold them before or after making love. They said in a sarcastic way, ‘ For them it is screwing not making love. Slam bang thank you ma’am.’ For many women it is as important to go out for a nice candle light dinner, dance and have pillow talk about intimate things as it is to have intercourse. Many men I met are not tuned into such feelings of their partners.

There is also a lot of misunderstanding about the concept of mutual orgasm. Most couples do not realize that female and male sexual responses are significantly different. Many women take longer to have orgasm. That is why fore-play is very crucial for them to fully enjoy making love. It is interesting to know that most men who come for sex therapy complain of premature ejaculation. They want to reach orgasm later while most women who come for sex therapy complain of having orgasm too late. Men want to cum late and women want to cum early. It is the issue of timing. Many men I see in my practice I encourage them to stimulate their lovers and spouses other than genital stimulation by kissing and touching different parts of the female body so that women are ready to have orgasm before they have intercourse. It is also important for some couples to accept that some women may not always have an orgasm while having intercourse if there is nor enough clitoral stimulation. I think the more young men and women are comfortable with their bodies and are able to stimulate themselves individually to the point of having orgasm, the easier it is for them to enjoy making love. I encourage my patients to learn and enjoy masturbation if they want to enjoy intimate relationships with their lovers and spouses. It is ironic that many women in the East as well as in the West never experienced orgasm. Many men and women do not know that women can have multiple orgasms in a short time and not have to wait a long time before having second orgasm.

Because of lack of sex education many young men and women are not aware of their reproductive system and cannot choose different forms of contraception. Many are not aware about the methods of rhythm method, condoms, intra-uterine devises and contraceptive pill. They do not even know that pregnancy is directly related to ovulation. Since human ovum and sperm are only alive for 24-36 hours it is only a couple of days before and after that women are most likely to get pregnant. Many infertile couples have been trying to conceive but unsuccessful because they are not aware of this basic human physiology. On the other hand many unwanted pregnancies take place because of the same lack of awareness and planning. It is also ironic that in conservative Eastern cultures those contraceptives are not freely accessable to young men and women. I was shocked to find out in my medical school that most medical graduates believed that family planning was against Islam and that is why they did not recommend different forms of contraception to their patients. I met dozens of young women while doing my internship in women’s hospital, who wanted to stop having babies but their husbands did not support them. They did not allow them to take contraceptive pill or use intra-uterine device while they themselves did not use condoms as they believed they did not enjoy sex while wearing a condom.

It is unfortunate that in many traditional and religious cultures sex is only approved for the cause of reproduction. For couples to have sex to express their profound love for each other or just have fun is not accepted and blessed. So couples who have sex not to have babies feel guilty.

Because of the religious control couples are conditioned to have sex only in the bedrooms and only in certain positions (many religious institutions only bless missionary position, when man is on the top). For women to be on the top or have sex in many other possible positions is discouraged. No wonder after a while sexual relationships start to lose its spontaneity and sense of adventure. In the East there is also an issue of privacy. Many couples have to make love in the dark very quietly. They do not want to disturb others. No wonder in such circumstances many men have not seen the naked body of a woman even after being married for a number of years.

Religious institutions usually do not bless sexual experimentation and varied lifestyles. Many consider homosexuality and having more than one sexual partner as sin. They also have double standards. Many things are ok for men but not ok for women. In Muslim countries men can have more than one wife but women cannot have more than one husband.

When I was a teenager there was also no discussion about venereal diseases. No body discussed how men and women contact syphilis, gonorrhea or infectious mononucleosis. In the recent past there is lack of education about AIDS (auto-immune deficiency syndrome). Most young people do not know that AIDS can be contacted with other body fluids (exp blood) and may not necessarily be sexually contacted.

I feel that for young boys and girls, men and women to make adult choices and take responsibility for their actions, they need to be informed about the relationships of sex with pregnancy and venereal diseases. People who have multiple partners have to know the risks they are taking. I was surprised to meet three monogamous women who suffered from syphilis. They had never slept with anyone other than their husbands. They got it from their husbands who were promiscuous. So to be responsible one does not only have to take responsibility for one’s one sexual lifestyle but also for the lifestyle of one’s partner. For such choices we need open and honest dialogue between lovers and spouses and between children and parents and teachers.

I think time has come for the families and communities to create an environment for people to be sexually liberated and enjoy their romantic lives rather being burdened with fear, shame and guilt. I think that rather than associating sex with sin, we should associate it with love and spirituality, which are foundations of healthy loving relationships, families and communities. Sexuality is part of our humanity and we have to accept its responsibility individually and collectively. Sex education, I believe is the first step in that direction.


Sex education may also be described as "sexuality education," which means that it encompasses education about all aspects of sexuality, including information about family planning, reproduction (fertilization, conception and development of the embryo and fetus, through to childbirth), plus information about all aspects of one's sexuality including: body image, sexual orientation, sexual pleasure, values, decision making, communication, dating, relationships, sexually transmitted infections (STIs) and how to avoid them, and birth control methods.

Sex education may be taught informally, such as when someone receives information from a conversation with a parent, friend, religious leader, or through the media. It may also be delivered through sex self-help authors, magazine advice columnists, sex columnists, or through sex education web sites. Formal sex education occurs when schools or health care providers offer sex education.

Sometimes formal sex education is taught as a full course as part of the curriculum in junior high school or high school. Other times it is only one unit within a more broad biology class, health class, home economics class, or physical education class. Some schools offer no sex education, since it remains a controversial issue in several countries, particularly the United States (especially with regard to the age at which children should start receiving such education, the amount of detail that is revealed, and topics dealing with human sexual behavior, eg. safe sex practices, masturbation, premarital sex, and sexual ethics).

In 1936, Wilhelm Reich commented that sex education of his time was a work of deception, focusing on biology while concealing excitement-arousal, which is what a pubescent individual is mostly interested in. Reich added that this emphasis obscures what he believed to be a basic psychological principle: that all worries and difficulties originate from unsatisfied sexual impulses.[1]

When sex education is contentiously debated, the chief controversial points are whether covering child sexuality is valuable or detrimental; the use of birth control such as condoms and hormonal contraception; and the impact of such use on pregnancy outside marriage, teenage pregnancy, and the transmission of STIs. Increasing support for abstinence-only sex education by conservative groups has been one of the primary causes of this controversy. Countries with conservative attitudes towards sex education (including the UK and the U.S.) have a higher incidence of STIs and teenage pregnancy.[2]

The existence of AIDS has given a new sense of urgency to the topic of sex education. In many African nations, where AIDS is at epidemic levels (see HIV/AIDS in Africa), sex education is seen by most scientists as a vital public health strategy. Some international organizations such as Planned Parenthood consider that broad sex education programs have global benefits, such as controlling the risk of overpopulation and the advancement of women's rights (see also reproductive rights).

According to SIECUS, the Sexuality Information and Education Council of the United States, 93% of adults they surveyed support sexuality education in high school and 84% support it in junior high school.[3] In fact, 88% of parents of junior high school students and 80% of parents of high school students believe that sex education in school makes it easier for them to talk to their adolescents about sex.[4] Also, 92% of adolescents report that they want both to talk to their parents about sex and to have comprehensive in-school sex education.[5


The state of sex education programs in Asia is at various stages of development. Indonesia, Mongolia, South Korea have a systematic policy framework for teaching about sex within schools. Malaysia, the Philippines and Thailand have assessed adolescent reproductive health needs with a view to developing adolescent-specific training, messages and materials. India has programs aimed at children aged nine to sixteen years. In India, there is a huge debate on the curriculum of sex education and when should it be increased. Attempts by state governments to introduce sex education as a compulsory part of the curriculum have often been met with harsh criticism by political parties, who claim that sex education "is against Indian culture" and would mislead children.[4] (Bangladesh, Myanmar, Nepal and Pakistan have no coordinated sex education programs.[9])

In Japan, sex education is mandatory from age 10 or 11, mainly covering biological topics such as menstruation and ejaculation.[10]

In China and Sri Lanka, sex education traditionally consists in reading the reproduction section of biology textbooks. In Sri Lanka they teach the children when they are 17–18 years. However, in 2000 a new five-year project was introduced by the China Family Planning Association to "promote reproductive health education among Chinese teenagers and unmarried youth" in twelve urban districts and three counties. This included discussion about sex within human relationships as well as pregnancy and HIV prevention.[11]

The International Planned Parenthood Federation and the BBC World Service ran a 12-part series known as Sexwise, which discussed sex education, family life education, contraception and parenting. It was first launched in South Asia and then extended worldwide

The Netherlands

Subsidized by the Dutch government, the “Lang leve de liefde” (“Long Live Love”) package, developed in the late 1980s, aims to give teenagers the skills to make their own decisions regarding health and sexuality. Professor Brett van den Andrews, a medical research scientist who graduated from ISHSS (International School for Humanities and Social Sciences),[19], has suggested that exposing children aged 4–7 to sex education will greatly reduce the risk of future pregnancies and health issues. Of course his theories have been the subject of much scrutiny under the NIGS (Netherlands Institute of Geooracular Sciences). Nonetheless, he is widely appreciated in the medical society and has been featured in many medical journals.[20] Nearly all secondary schools provide sex education as part of biology classes and over half of primary schools discuss sexuality and contraception. The curriculum focuses on biological aspects of reproduction as well as on values, attitudes, communication and negotiation skills. The media has encouraged open dialogue and the health-care system guarantees confidentiality and a non-judgmental approach. The Netherlands has one of the lowest teenage pregnancy rates in the world, and the Dutch approach is often seen as a model for other countries.[21]


In Switzerland, the content and amount of sex education is decided at the cantonal level. In Geneva, courses have been given at the secondary level since the 1950s. Interventions in primary schools were started more recently, with the objective of making children conscious of what is and isn't allowed, and able to say "No". In secondary schools (age 13-14), condoms are shown to all pupils, and are demonstrated by unfolding over the teacher's fingers. For this, classes are usually separated into girl-only and boy-only subgroups. Condoms are not distributed, however, except among older adolescents engaged in state-run non-compulsory education (age 16-17).[cita

United Kingdom

In England and Wales, sex education is not compulsory in schools as parents can refuse to let their children take part in the lessons. The curriculum focuses on the reproductive system, fetal development, and the physical and emotional changes of adolescence, while information about contraception and safe sex is discretionary[22] and discussion about relationships is often neglected. Britain has one of the highest teenage pregnancy rates in Europe and sex education is a heated issue in government and media reports. In a 2000 study by the University of Brighton, many 14 to 15 year olds reported disappointment with the content of sex education lessons and felt that lack of confidentiality prevents teenagers from asking teachers about contraception.[13] In a 2008 study conducted by YouGov for Channel 4 it was revealed that almost three in ten teenagers say they need more sex and relationships education.[23]

In Scotland, the main sex education program is Healthy Respect, which focuses not only on the biological aspects of reproduction but also on relationships and emotions. Education about contraception and sexually transmitted diseases are included in the program as a way of encouraging good sexual health. In response to a refusal by Catholic schools to commit to the program, however, a separate sex education program has been developed for use in those schools. Funded by the Scottish Government, the program Called to Love focuses on encouraging children to delay sex until marriage, and does not cover contraception, and as such is a form of abstinence-only sex education.[24]

A sex survey by the World Health Organization concerning the habits of European teenagers in 2006 revealed that the birth rate among 15- to 19-year-olds in the UK was 27.8 births per 1,000 population.[25]

United States

Almost all U.S. students receive some form of sex education at least once between grades 7 and 12; many schools begin addressing some topics as early as grades 5 or 6.[26] However, what students learn varies widely, because curriculum decisions are so decentralized. Many states have laws governing what is taught in sex education classes or allowing parents to opt out. Some state laws leave curriculum decisions to individual school districts.[27]

For example, a 1999 study by the Guttmacher Institute found that most U.S. sex education courses in grades 7 through 12 cover puberty, HIV, STIs, abstinence, implications of teenage pregnancy, and how to resist peer pressure. Other studied topics, such as methods of birth control and infection prevention, sexual orientation, sexual abuse, and factual and ethical information about abortion, varied more widely.[28]

Two main forms of sex education are taught in American schools: comprehensive and abstinence-only. Comprehensive sex education covers abstinence as a positive choice, but also teaches about contraception and avoidance of STIs when sexually active. A 2002 study conducted by the Kaiser Family Foundation found that 58% of secondary school principals describe their sex education curriculum as comprehensive.[27]

Abstinence-only sex education tells teenagers that they should be sexually abstinent until marriage and does not provide information about contraception. In the Kaiser study, 34% of high-school principals said their school's main message was abstinence-only.

The difference between these two approaches, and their impact on teen behavior, remains a controversial subject. In the U.S., teenage birth rates had been dropping since 1991, but a 2007 report showed 3% increase from 2005 to 2006.[29] From 1991 to 2005, the percentage of teens reporting that they had ever had sex or were currently sexually active showed small declines.[30] However, the U.S. still has the highest teen birth rate and one of the highest rates of STIs among teens in the industrialized world.[31] Public opinion polls conducted over the years have found that the vast majority of Americans favor broader sex education programs over those that teach only abstinence, although abstinence educators recently published poll data with the opposite conclusion.[32][33][34]

Proponents of comprehensive sex education, which include the American Psychological Association,[35] the American Medical Association,[36] the National Association of School Psychologists,[37] the American Academy of Pediatrics,[38] the American Public Health Association,[39] the Society for Adolescent Medicine[40] and the American College Health Association,[40] argue that sexual behavior after puberty is a given, and it is therefore crucial to provide information about the risks and how they can be minimized; they also claim that denying teens such factual information leads to unwanted pregnancies and STIs.

On the other hand, proponents of abstinence-only sex education object to curricula that fail to teach their standard of moral behavior; they maintain that a morality based on sex only within the bounds of marriage is "healthy and constructive" and that value-free knowledge of the body may lead to immoral, unhealthy, and harmful practices. Within the last decade, the federal government has encouraged abstinence-only education by steering over a billion dollars to such programs.[41] Some 25 states now decline the funding so that they can continue to teach comprehensive sex education.[42][43][44][45] Funding for one of the federal government's two main abstinency-only funding programs, Title V, was extended only until December 31, 2007; Congress is debating whether to continue it past that date.[46]

The impact of the rise in abstinence-only education remains a question. To date, no published studies of abstinence-only programs have found consistent and significant program effects on delaying the onset of intercourse.[31] In 2007, a study ordered by the U.S. Congress found that middle school students who took part in abstinence-only sex education programs were just as likely to have sex (and use contraception) in their teenage years as those who did not.[47] Abstinence-only advocates claimed that the study was flawed because it was too narrow and began when abstinence-only curricula were in their infancy, and that other studies have demonstrated positive effects.[48]

It is estimated that more than half of all new HIV infections occur before the age of 25 and most are acquired through unprotected sex. According to the experts on AIDS, many of these new cases come about because young people don’t have the knowledge or skills to protect themselves. To try and resolve this problem the American Psychological Association (APA) is recommending that comprehensive sex education and HIV prevention programs become more available to the youth. The young people need this to help protect them from HIV/AIDS and other STDs they might get if they decide to have sex. Willenz, Pam.