Cultural Aspects of Contraception By Dr Sadaf Cheema

Cultural Aspects of Contraception By Dr. Sadaf Cheema GPST 3

Aims: • • Awareness of ethical issues related to contraception Cultural Values Cultural isolation Population migration Religion Migration-Unmet need for contraception Politics of contraception - control and freedom • • • Emergency contraception - hormonal or coil insertion Termination of pregnancy Contraception, abortion and STIs • • • Doctor has a conscientious objection to a particular procedure Employing and contracting bodies - contractual requirements Under 16 years guidance - Contraception, abortion and STIs

Why its important for us!!! • Primary care is responsible for issuing around a third of all EC prescriptions. • It is estimated that 40% of all pregnancies are unplanned out of which 60% end up as abortions

Cultural Values • Culture matters for contraception decisions. • Other historical factors such as religion, women’s literacy, and education experiences may also play a role. • Demand for the pill depends on women’s fertility, education and career decisions.

Differences in cultures regarding sex and contraception instilled by parents and reinforced by others in the community which may influence women’s decisions to adopt the pill.

Culture • Unfortunately, cultural expectations mean that the burden for arranging contraception falls on women. So, despite the wide availability of contraceptive methods, it is still perceived as a woman's problem. • Although female sterilization is more invasive than vasectomy, it is still the more common procedure - approximately 100, 000 women and 90, 000 men are sterilized annually.

Religion • Religious beliefs can limit a patient's contraceptive choices. When 'artificial' contraception is forbidden, a few natural methods may be acceptable: • Coitus interruptus - at best, 4% failure rate per annum • Mucothermic method: – These methods are better suited to older couples where fertility is reduced. – This group of patients is less likely to use emergency contraception or seek termination.

Orthodox religions • These include Judaism, Islam, Hinduism and Sikhism. Orthodox followers of all these religions tend to: 1. Regard sex outside marriage as taboo. 2. Forbid abortion and regard menses as unclean. 3. Extend the taboos against sex before marriage to sex outside marriage, i. e. adultery. 4. Forbid seeing any other man the husband in intimate circumstances. 5. Consider a male physician often as not acceptable, even with a chaperone. 6. The punishments for adultery or sex before marriage in certain countries/cultures can be death. These cultural taboos are followed more closely in some cultures than in others, even if they are of the same religion. • NB: medical indications can override many prohibitions.

Christianity • Contraception and abortion are forbidden in Catholicism. Mucothermic methods of contraception are acceptable. • The best course is to ask the patient if there any special considerations you need to be aware of in view of their religion or background. This gives you a better picture of what they consider important.

Islam • Birth control is permissible in Islam for married couples because sex is considered to be a wholesome pleasure in and of itself. • The two criteria for contraception use are that it doesn't cause permanent damage to the (male or female) reproductive organs and that it prevents fertilization. Condoms, diaphragms, spermicidal creams, intrauterine devices, oral contraceptive devices, Norplant, tubal ligations, and vasectomies are all permissible. Ø There is no problem in prescribing oral contraceptive to single girls when medically indicated, such as for menorrhagia. 
 Ø The vast majority of scholars consider life to begin at the time of conception. Abortion, defined as the willful evacuation of an embryo or fetus, is considered equivalent to murder and is not ordinarily permitted, except when the mothers life is at stake, and the fetus is <4 months old. It is not permissible if the pregnancy was attributable to adultery or premarital sex, or because of minor or significant deformities.

Population migration • In recent years there has been an increase in movement between countries in Western Europe and asylum-seeking. This can lead to problems in communication. • This may involve not only language, but style of communication. • Problems may be experienced when cultures clash, particularly over issues such as attitudes to women and sexual morals.

Cultural isolation • Some cultures disapprove of the education of women. This can result in women becoming isolated, particularly when they emigrate with their family to a different country with a different primary language. • A special need exists for their education about the availability of different choices of contraceptive methods so that they can be empowered to control their fertility according to their needs.

Politics of contraception - control and freedom • One of the effects of contraceptive control has been to liberate the tie between sex and reproduction. • This gives women the freedom to time their pregnancies to fit in with a more independent lifestyle. • It also allows them freedom to follow other paths such as study and employment, and releases them from dependence on the men. • It has liberated them from uncontrolled large families (they can still have them but now it's by choice). • One of the results of this has been to empower women within their societies. • Contraceptive control can have effects on political control. This means that controlling the availability of certain contraceptive choices can manipulate the population's behaviour – e. g. some governments or religious organizations may give inducements for using, or not using, contraception.

Emergency contraception - hormonal or coil insertion Some groups find this an acceptable remedy to contraceptive failure - e. g. , slipped sheath or unprotected sex, when they would not accept termination. In some religious groups, such as the Roman Catholic church, this is seen as a form of termination, i. e. interfering with a fertilized ovum. In certain risk-taking teenage culture groups this may be seen as a form of contraception rather than an emergency intervention. One way of remedying this is by making sure that the longterm contraceptive needs of such persons are addressed. There is also need to inform culturally isolated women about the availability of such methods.

Termination of Pregnancy Conscientious Objection • If carrying out a particular procedure or giving advice about it conflicts with your religious or moral beliefs, and this conflict might affect the treatment or advice you provide, you must explain this to the patient and tell them they have the right to see another doctor. You should make sure that information about alternative services is readily available to all patients. • Children and young people in particular may have difficulty in making alternative arrangements themselves, so you must make sure that arrangements are made for another suitably qualified colleague to take over your role as quickly as possible. • You must treat patients fairly and with respect whatever their life choices and beliefs. • You must not express your personal beliefs (including political, religious and moral beliefs) to patients in ways that exploit their vulnerability or are likely to cause them distress. • You must not unfairly discriminate against patients or colleagues by allowing your personal views to affect your professional relationships or the treatment you provide or arrange • In this guidance, GMC explain how doctors can put these principles into practice. Serious or persistent failure to follow this guidance will put your registration at risk.

Employing and contracting bodies - contractual requirements • Employing and contracting bodies are entitled to require doctors to fulfill contractual requirements that may restrict doctors’ freedom to work in accordance with their conscience. This is a matter between doctors and their employing or contracting bodies. • You may choose to opt out of providing a particular procedure because of your personal beliefs and values, as long as this does not result in direct or indirect discrimination against, or harassment of, individual patients or groups of patients. • You should also be open with employers, partners or colleagues about your conscientious objection. You should explore with them how you can practice in accordance with your beliefs without compromising patient care and without overburdening colleagues.

Under 16 years Guidance Contraception, abortion and STI • You can provide contraceptive, abortion and STI advice and treatment, without parental knowledge or consent, to young people under 16 provided that: – a. they understand all aspects of the advice and its implications – b. you cannot persuade the young person to tell their parents or to allow you to tell them – c. in relation to contraception and STIs, the young person is very likely to have sex with or without such treatment – d. their physical or mental health is likely to suffer unless they receive such advice or treatment, and – e. it is in the best interests of the young person to receive the advice and treatment without parental knowledge or consent. • You should keep consultations confidential even if you decide not to provide advice or treatment, other than in the exceptional circumstances.

Reference • GMC website • www. pt. co. uk • Gpnotebook