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The Barriers Facing Gynecological and Reproductive Health Services for Women in the Gulf

After my first visit to a public sector gynecologist in Kuwait three years ago, I didn’t expect to leave the polyclinic in tears. Diagnosed with Polycystic Ovary Syndrome (PCOS) a decade ago, routine blood work every few months is just that—routine—but paying up to 100 KD each time shouldn’t be. Using a free governmental service aimed at making my life easier grew to be a more favorable approach, until it proved otherwise.

Before the unrealistic paperwork they would demand of a visiting unmarried woman, the berating treatment at the front desk set the tone for the entire visit. It was clear from the start that this would be more than just a hassle. This will be humiliating. After finally being allowed to see the doctor, he informed me I would need my father’s civil ID, since I couldn’t bring a husband’s. Apparently, a man’s permission was required for me to find out what was going on inside my own body.

Losing a father is painful enough. Having to relieve that pain during a gynecologist appointment was not something I ever thought I would have to do. I had to explain that my mother was abroad and would not have my deceased father’s ID lying around to send a copy. He told me to “whisper” this to the receptionist to see what she could do. The same conversation ensued with the receptionist in front of the entire waiting room, with her staring blankly at me while tears of degradation ran down my face. That’s when she told me to bring his death certificate. A man, even after he’s dead, has more authority over my body than I do. After I convinced her that I didn’t have access to my father’s death certificate, she checked with the doctor and got me the paperwork I needed.

The clinic had a policy of only providing service on Sundays and Tuesdays to non-pregnant women, while the other five days of the week prioritized those who were pregnant. Not only was I secondhand to married women, but married women were also second class to pregnant women.

When I came back a few days later to do the blood test, the receptionist didn’t remember me and asked for my father’s ID again. This was when I realized I definitely was not the first, nor the last, woman who had been subjected to this ordeal.

Most people are unaware of the fact that there exists no law preventing unmarried women from getting the gynecological or reproductive healthcare they need, according to Shaikha Salmeen, a lawyer in Kuwait. There was an old regulation that isn’t officially recorded, Salmeen said, that stipulated what services doctors could provide to unmarried women. What we’re seeing now is just common practice, rather than actual law.

 Systemic Malpractice

Noor, a photographer, was at her yearly gynecologist check-up in a local private hospital when she discovered the interior of her cervix was inflamed and required immediate surgery. The doctor began asking her how long she’d been married and upon finding out Noor wasn’t married, her demeanor completely changed and she said she couldn’t do the surgery in Kuwait as she would require either a marriage certificate or divorce papers.

“You were just telling me I need to do this surgery within two weeks because it’s dangerous to wait,” Noor told the doctor, who refused to change her mind. At the time, Noor was living in the U.S. and decided to do the surgery there, although she could not afford it. She had to confide in her aunt, but lie about certain aspects of the situation, to ask for money.

“Mentally I was so traumatized by the idea that something could happen to me and they wouldn’t admit me because of a paper,” Noor said. “What if this had happened to another girl who didn’t have the option of traveling abroad?”

Noor was lucky that during her surgery the doctors discovered pre-cancer cells and were able to treat her. Others, according to Noor, have not been so fortunate. A friend of her sister’s died at the age of 30 because she ignored her symptoms for a long time as she couldn’t see a gynecologist since she wasn’t married. “By the time someone convinced her to see a gynecologist, her tumor was really big,” Noor said. “This ignorance among the educated because of customs, traditions, and shame is so sad.”

Others shared similar stories of women losing vital reproductive organs like their ovaries, or their entire uterus, due to the dismissal of symptoms and services being denied due to marital status. Both women declined to be interviewed as they didn’t want to revisit the trauma they had been through.

Lujain, a teacher, went to her local polyclinic to do a routine check-up and blood tests. Out of nowhere, the doctor asked her if she was sexually active. She was not there for a gynecological checkup, but she confirmed that she was anyway. The shock on the doctor’s face was clear as she asked her, “How? You’re not married.”

Lujain, in awe of what she had just heard, stared blankly at the doctor and asked her to repeat herself. “How are you sexually active if you’re not married?” the doctor repeated. Lujain picked up her things and left. “That was in 2016,” Lujain said. “Since then, I’ve been too scared to go to any doctor who might ask me the same question and have a similar reaction.” She began experiencing what she thought was abdominal pain about two years later and put off seeing a doctor for two years because of her previous encounter. In 2020, the pain became unbearable, so she went to a private hospital where the doctor discovered her pain was in her uterus but refused to do a transvaginal ultrasound because she was not married. As an alternative, he suggested opening her up surgically to explore what the issue was. “Instead of giving me an ultrasound, you want me to risk my life on an operating table for you to open me up to explore, when I don’t even know what my issue is, if there even is one?” Lujain said.

Lujain asked a friend of hers, who she knew had done a transvaginal ultrasound before. Her friend was shocked Lujain had even attempted to see a gynecologist in Kuwait; she had traveled to the U.S. and gets her regular check-ups there every year. Lujain devised an alternative. She met with a gastroenterologist and claimed she was having abdominal pain. “I did a CT scan just to see my uterus,” Lujain said.

After seeing three different doctors, Lujain finally found a doctor who would see her and discovered she had several cysts and a fibroid that were causing the pain. This took several months and she wasn’t in the clear until April 2021.

Idealizing Female Virginity

“Men can do anything, they don’t have the burden of ‘virginity,’” Lujain said. “They have no consequences, while we get shunned. We don’t have a safe space.” The long-held myth of virginity plays a significant role in how many of these women were treated, although it has been dispelled by science and medicine long ago.

A hymen is a thin, crescent-shaped membrane located at the opening of the vagina. It is elastic and, most importantly, not a closed membrane, according to Gynecologist Dr. Abeer. If it was a closed membrane that was only “opened” during penetrative intercourse, women would be unable to get their periods, said Dr. Abeer.

An existing medical condition called an imperforate hymen causes adolescent girls severe pain because their menstrual blood is unable to flow down through the hymen. In this case, the girls need to undergo a procedure to surgically open their hymens.

This emphasis on virginity was a crucial factor in how Mariam, a 25-year-old Egyptian, was treated when she began experiencing chronic back pain in February 2020. She decided to get a full body MRI, which revealed she had a five-by-five centimeter mass on her ovary.

Mariam had to see three different doctors until one agreed to conduct the transvaginal ultrasound that she needed. She took these results to a hospital, as all three doctors had told her she needed to have it surgically removed, as well as biopsied, to find out whether or not the mass was cancerous.

The doctor she saw kept reassuring her that there would be no scarring on her body since she was unmarried, which she found to be very inappropriate and tiresome. “This is my health we’re talking about,” Mariam said. “Please stop worrying about my virginity.” After the surgery, she recalls the doctor having a conversation with her mother, reassuring her that he had checked and her daughter was a virgin. “How do you even check that?” Mariam said. “Why are you checking my vagina when you’re supposed to be operating on my ovary?”

Her concern is not baseless, because “confirming virginity” is medically unreliable and has no scientific basis, according to the World Health Organization (WHO). The WHO also states that an emphasis on the “virginity” of women is a type of gender discrimination. The term itself is not a scientific nor medical term, but rather a cultural, social, and religious construct.

The reluctance of any women’s healthcare providers to conduct comprehensive and more precise examinations puts women’s lives at risk, according to Rawan, a feminist activist. Doctors themselves don’t know what the laws pertaining to these examinations are, said Dr. Abeer. “They know that diseases exist, whether they are internal infections, tumors, fungi, etc., which a woman can suffer from without being sexually active,” Rawan said. “Hormonal disorders, menopause, and uterine cysts are all diseases and health symptoms that can’t be underestimated.”

 An Adverse Reality

Women’s sexual and reproductive health is taboo in the Gulf, and remains a neglected subject due to our male-dominated society and the violence of the patriarchal system toward women’s bodies, Rawan said.

The cultural, social, and political context of Kuwait plays into and accentuates the taboos surrounding women’s sexual and reproductive health and this, in turn, leads to misinformation, according to Hessa, a researcher in health and international development whose thesis studied the barriers to sexual and reproductive health services and information for unmarried women in Kuwait.

When conversations do happen, Hessa said, they are solely focused on reproductive health matters rather than sexual health matters. However, it seems even reproductive matters are seen as taboo. When the newly-released Black Widow movie was shown in cinemas, a scene discussing periods, uteruses, and hysterectomies was cut out by the Ministry of Information, who censors scenes that relate to religion, politics, sexuality, vulgar language, extreme violence, or anything that can be deemed inappropriate to the local culture or Islamic religion. This creates a lack of awareness about women’s bodies and sexual health in general, which is a significant part of the problem. As Dr. Abeer said, “sexual education is poor in our community.”

Ending the Stigma through Education and Legislation

The first step to tackle the stigma is to introduce sexual education in schools for all students, according to Hessa, which should be a joint initiative between the Ministry of Health and the Ministry of Education. It should start at a young age and introduce more topics as they progress in their schooling each year, Hessa said. She stressed the importance of incorporating not only the biological perspective, but also the social aspect. “Consent is so neglected in these topics,” Hessa said, leading to an entitlement toward women’s bodies.

Talking to children about their bodies and sexual and reproductive systems helps to reduce sexual abuse, according to Dr. Abeer, because it helps them understand that their bodies are off-limits to others. “We should stop letting kids name their penises and vaginas silly names,” Dr. Abeer said. “Teach children the names of their [sexual] organs.”

Unfortunately, people think that if sex education is introduced in schools, it would sexualize young children and encourage sex at a young age. As Dr. Abeer points out, research has shown that the opposite is true; after introducing sexual education, the onset of sexual activity is delayed and it is reduced in frequency.

A failure to discuss sexual health contributes to a lack of societal knowledge around sexually transmitted infections (STIs).  This is one reason that Kuwait has failed to offer a government-mandated vaccine for Human papillomavirus (HPV), the most widespread sexually transmitted infection. The oncogenic types of HPV are the most common cause of cervical cancer, as well as, genital warts; and anal, penile, vulval, vaginal cancers, and some types of head and neck cancer.

“They argue that those who are sexually active are not the ‘norm’ but this is backward [thinking],” Dr Abeer said. “If a girl is going to have premarital sex, she is going to do it regardless of whether you’ve administered the HPV vaccine.” It also assumes that men would be entering marriages not having had sex before or that they will be faithful within a marriage as well, which is untrue, according to Dr. Abeer.

As of 2017, 74 countries have added the HPV vaccine to their national immunization programs for girls, and 11 countries for boys as well, according to the WHO. The data also shows that the United Arab Emirates is one of those countries, and according to a tweet by the Assistant Undersecretary for Preventive Health in the Saudi Ministry of Health, it will soon be rolled out for girls between the ages of 9 to 13.

The HPV vaccine, which is administered in three doses, is available in some private hospitals in Kuwait, although the price ranges from 57 KD and up to 105 KD per dose at some clinics. It is available in public hospitals, according to Salmeen, for married or divorced women, however, all of those interviewed who were married recently were not informed about nor offered the vaccine.

Things are, however, looking up. In October, 2020, the Kuwaiti parliament established Law 70/2020, which includes specific articles that prevent any doctor from refusing to give medical services necessary to any patient, according to Salmeen. Although the law also states that a medical doctor can refuse treatment under serious and rational reasons, what falls under the definition of “serious and rational” reasons remains unclear. “It’s actually a felony to refuse to give service to a patient for that reason [marital status] or any other reason,” Salmeen said.

Article 11 of the law also stipulates that informed consent for medical services should be taken from the patients themselves, as long as they are above the age of 18, or married, and awake and able to give consent. For surgical procedures, as long as the patient is conscious and above the age of 21, they can consent to their own procedures. Prior to this, many women were asked to bring in their fathers or husbands to sign off on their own surgeries.

If a woman is denied service, she should report it to the employee’s ward or department supervisor, according to Salmeen, and if that doesn’t work, a complaint can be filed with the hospital’s manager or the Ministry of Health. If there are still issues, she can sue for compensation.

Gulf states and societies must conduct a serious evaluation of the harsh, costly, and routinely-dismissed realities women face and struggle to overcome, as well as the systems that foster them. Women in the Gulf face lived experiences and unnecessary expenses that needlessly harm their health. At the extreme, these obstacles can turn fatal. Such a multilayered and consequential problem requires a thorough examination to address.

 

** names in italics have been changed to protect the interviewees’ identities

The views and opinions expressed in this article are those of the authors and do not necessarily reflect the views of the Gulf International Forum.

Reham Alawadhi is a journalist based in Kuwait. The University of Arizona graduate and her research interests focus on human rights and social justice. She currently writes science articles and manages the publication of several science magazines and was previously the managing editor of Khaleejesque magazine.


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