Taqwa, God-consciousness, is central to a pious Muslim and the need for congruence in the presence of non-Muslims acts as enforcer with regard to the required observances. Sexual history taking is always difficult and more so in pious Muslim women for this reason. Expectations tend to create barriers; this holds true for all patients.
I will discuss imaan, yaqeen and ikraam; the position of sexual intercourse in the Muslim household, and the barriers and facilitators to access for sexual problems in Muslim women. Finally, I will make some recommendations in order to improve the services offered to Muslim women.
Imaan. Simply, this is faith – belief in the seen and the unseen, belief in (God) Allah, the eternal soul and the afterlife, belief in Redemption and Divine Justice.
Yaqeen. This is the belief that Allah directly does everything and that only He can do: nothing happens except that He wills it.
Ikraam. This is consideration of another’s welfare, (physical, social and emotional) before attending to one’s own.
Sexual intercourse in the Muslim household
Marital relations are included in the contract of marriage. A wife has a right to refuse the sexual advances of her husband only if there is compelling reason to do so e.g. she is ill or menstruating or sexual intercourse is contra-indicated by a medical problem. A husband has a similar duty to fulfil the sexual needs of his wife and may only refuse if there is compelling reason to do so.
Sexual intercourse is prohibited when a woman is menstruating and when either husband or wife is fasting (compulsory fast). Conjugal relations are permitted at all other times and are recommended at least once weekly, usually on the night of the Sabbath.
A husband has no right to the performance of oral or anal penetration nor does he have the right to intercourse in circumstances where his wife’s modesty will be compromised. A husband does have the right to sexual relief/fulfilment even if his wife is unable to engage in penetrative sex: such relief can be provided by manual stimulation by his wife, but he may not do it for himself. If his wife cannot even do the latter, a man may take another wife in addition to or instead of his wife.
Sexual intercourse is very important in marriage and its lack, consistently over time, is sufficient cause to end a marriage. There is, therefore, strong reason for partners in a marriage to present if the husband is sexually dissatisfied; a woman is less likely to present for such dissatisfaction especially as it may imply criticism of her husband’s ability.
(Mf)
There are several barriers and facilitators to women accessing sexual dysfunction services. The greatest barrier to such access is health professionals’ lack of training and experience dealing with sexual problems. The next is women’s internalised societal expectations regarding their own sexual fulfilment: this is less of a problem than in the Christian tradition, which equates sex with Original Sin. In Islam, women are recognised as sexual with the same drives and desires that men have. The next barrier is ikraam, which requires that a woman hide the faults of her husband. A further barrier is that women will only initiate discussions of sexual problems with female clinicians.
The facilitators to women accessing sexual dysfunction services are: the importance of a husband’s sexual satisfaction in marriage and the recognition that women are sexual and also have needs and desires to be fulfilled.
Ultimately, it is up to the woman in a marriage to decide whether or not a sexual problem experienced by the couple is sufficient cause to present to a healthcare provider dealing with sexual dysfunction. It is very unlikely that a woman will present for enhancement of her sexual experiences if there is no dysfunction.
What can we as healthcare providers do to improve the sexual health services offered to Muslim women? First, we should keep sexual dysfunction in mind whenever a woman presents with a chronic medical or severe surgical condition that can be expected to adversely affect her sexual functioning. In these circumstances, women must be asked, explicitly, “Are there any problems in your marital relations?” or “Are there any problems in your relations with your husband?” It is advisable not to use the words “sex”, “intercourse” or “sexual intercourse” because these terms would tend to make the women uncomfortable. The clinician involved should always ask this screening question, whether or not the clinician is female.
Second, women should preferably be seen by women and if they cannot be seen by a female clinician they should have the option of being referred to one or of having their appointments rescheduled so that they can be attended to by women. If it is not possible to have the patient attended by a female clinician, it will have to be expected that patients will withhold important information and that management will be compromised.
Finally, as with all patients, an assurance of confidentiality and a comfortable, professional environment is a sine qua non.
[Published in South African Sexual Health Association Newsletter 2001.]
