RANGOON — When she was a young teenager, Pan Ei Khaing never walked too close to boys, heeding a word of advice from her mother about unintended pregnancy.
Her friends in Pegu Division were told by their parents not to have sex. “But my mother said that once I started menstruating, I couldn’t even touch a man, otherwise I would become pregnant,” she says. “I was afraid of that, so I stayed away.”
She busted that myth only about three years ago, when she turned 18 years old and decided to study health so she could become a midwife for the government. But today, despite her medical training, and although she believes communities would benefit from discussions about contraception, she says she is not widely sharing information about safe sex with patients. To do so, she says, would be inappropriate in most villages.
In some parts of Burma, mainly urban centers and towns, health care workers distribute condoms and discuss methods of preventing sexually transmitted diseases. But in the rural parts of Arakan State where Pan Ei Khaing works now, and in many other remote regions across the country where midwives are the sole providers of medical care, reproductive health and safe sex are not normally considered acceptable subjects for discussion.
“The topic is a little strange,” she says. “And using condoms is seen as shameful. In this traditional culture, if you have sex before you marry, it’s like you did something wrong.”
In Rangoon, Burma’s biggest city, a young doctor has taken a different approach. To avoid the embarrassment of speaking face to face about a taboo topic, he moderates a telephone advice hotline for young men who have questions about sexual health. The hotline is an initiative of the Myanmar Medical Association, a professional organization of physicians that has also created a separate line for young women, usually between the ages of 15 and 24, who want to talk about issues such as teen pregnancy, contraception and sexually transmitted diseases.
Some callers are shy at first, says 26-year-old Zarni Win, who has been moderating the boys’ hotline since July last year and answers about five calls daily. “It’s very easy to handle it,” he says, referring to the shyness, “because it’s confidential. They do not need to tell me their name, so they can easily disclose their problems.”
But in a country where an overwhelming majority of people lack access to mobile telephone networks, the hotlines are not a cure-all, and other options for frank discussions are limited. Parents typically do not talk to their children about reproductive health, with some women saying they were unaware of menstruation until after it happened. And although the government has incorporated sex education into the school curriculum, teachers are also wary about discussing sex, fearing their own integrity could be questioned if they show knowledge of the subject.
Burma is trying to find its own approach to a question that remains controversial in many countries: How to balance calls for comprehensive sex education as a tool to prevent teen pregnancies, sexually transmitted diseases and sexual violence, with widespread concerns about protecting traditional religious or cultural values.
Elsewhere in Southeast Asia, in Muslim-majority Indonesia, the health minister’s pledge to promote condom use to young people led to rallies in 2012 by people who worried about encouraging teen sex, although an education official’s proposal last year to institute mandatory virginity testing for high school girls was seen as too extreme. In Thailand, a Buddhist-majority country known for its relative openness about sexuality and its flourishing prostitution industry, activists say teachers are still too embarrassed to frankly discuss sexual health with their students. In the Christian-majority United States, policy makers have heatedly debated the merits and pitfalls of abstinence-only sex education that leaves out information about contraception.
As Burma opens up to the world after decades of international isolation, as its government works to reform an education system that was long-neglected by the former military regime, and as the public takes advantage of new freedoms of expression, similar debates are under way to determine just how far educators should go in teaching a taboo subject.
‘Not Just About Sex’
As is true in many Southeast Asian countries, women in Burma are traditionally expected to remain virgins until they marry. Condoms are available in stores and even sold by roadside vendors on busy streets in Rangoon, but young adults say they fear being labeled as promiscuous if they are caught with one in their bag. Masturbation is considered dirty and shameful, although many health practitioners internationally say it is a safe sexual behavior. Public displays of affection are rare, beyond holding hands, and it is common in Rangoon to see couples taking cover behind umbrellas at public parks so they can cuddle in privacy.
“We will never talk about it,” says Phyu Phyu Win, a 22-year-old student in Rangoon, referring to sex. “It is something both sides are shy to talk about, and it is our culture.”
Her friend Phuu Pwint Aung, a 22-year-old from Mon State, has a boyfriend but says she does not know how to use a condom. “We have to keep our virginity before getting married,” she says. “It is the culture in Burma: If you are not a virgin when you get married, you have no dignity.”
Discussing sex with her parents is not an option. “They would ask why I wanted to talk about something so disgusting. They would say I should be ashamed of talking about this,” she says.
In ninth grade Phyu Phyu Win says she was taught about HIV at school, while Phuu Pwint Aung learned about sexually transmitted infections at a community workshop organized by a local NGO, but neither recalls receiving information about safe sex. After marriage they plan to educate themselves by reading articles online or educational books about reproductive health. “Even now, I watch movies and learn from them,” says Phyu Phyu Win, referring to Hollywood films with sex scenes.
But despite the chaste expectations, Burma is not a place of innocence. Prostitution is illegal but easy to find in big cities such as Rangoon, while drugs to enhance libido are available cheaply on the black market. Near universities, rooms at guest houses are rented by the hour for student couples; under military rule, institutions of higher education were relocated to satellite towns outside major cities, and some say their remote location made them an ideal place to get intimate.
The consequences of poor sex education are numerous, activists say. Young people are commonly forced to marry against their will if caught having sex, while women with unwanted pregnancies must have the baby or undergo an unsafe illegal abortion. Another concern is sexual assault and rape, says Htar Htar, a women’s rights activist known in Rangoon for launching a campaign against sexual harassment on city buses. She says that while young women are expected to remain pure and typically have a very clean understanding of sex, men are expected to have sexual experience and often read pornography suggesting that women are hypersexual. “When these boys and girls meet, they have different expectations. It’s a problem,” she says.
Htar Htar leads a women’s network known as Akhaya and says that people regularly report sexual abuse at monthly sessions to discuss gender roles, sexuality, reproductive health and other women’s issues. More participants are attending the sessions each month, with some women in their 20s and others in their 50s. “Some are domestic workers, others are directors of companies,” she says.
Before forming the women’s network, Htar Htar worked as a sexuality trainer for Burnet Institute, an international organization seeking to prevent and treat HIV in Burma. She said that despite her title, her understanding of sexuality at the time was limited. “We knew it was important to use condoms, but for those who didn’t want to use a condom, what next? The conversation would always stop, because we didn’t know or want to talk about pleasure in sex,” she said. “We also were not trained to talk about sexual relationships, female sexuality. We focused on male sexuality, or more specifically on men who have sex with men.”
In 2008, she and a group of friends met with a visiting Israeli sex therapist to learn about female sexuality and reproductive health, and she decided to educate others in her community. Today she is calling for comprehensive sex education in schools, starting from as early as kindergarten.
“When people say sex education runs counter to Myanmar [Burmese] culture, it is because they do not understand what sex education is. They assume sex education is about intercourse, but no—it is about our organs, which we use in our bodies every second. Right now we are not meant to understand our organs, but we need to understand how they function, how to take care of them,” she says.
“Sex education is not just about sex, but about health, power, violence, law, sexual identities, how you see yourself, your image, your relationships, your communication and decision-making. Knowing about your body is not against culture.”
A Name Game
As it stands now, sex education is largely promoted under the guise of HIV prevention in Burma, where AIDS is a major public health concern and a lack of resources means that a large share of people infected with the virus are unable to receive treatment.
About 200,000 people are HIV-positive in the country, and at the end of 2012 over half of those requiring antiretroviral therapy were not receiving it.
“HIV allows us to talk about safe sex—that seems like the only venue,” says Sid Naing, the country director for Marie Stopes International, which provides integrated sexual and reproductive health care services with a focus in Burma on family planning. “In Myanmar it’s called birth spacing, and in reality it’s contraception. It’s a name game.”
“Reproductive health is not seen by many as a national cause,” he adds. “But authorities—whether administrative authorities, health authorities, local leaders, informal leaders or religious leaders—when they hear about HIV prevention, they believe they need to support it.”
He said it was important to note that the Ministry of Education had already created a sex education curriculum for schools. “They have successfully integrated very basic health information about sex and HIV prevention within the curriculum, starting around 10 years ago,” he said. But he added, “The majority of schoolteachers in Myanmar are women, and their capacity has not been built to confidently talk about safe sex and basic sex education. They are embarrassed, and their biggest fear is that if they talk about sex they will not be respected.”
Sex education is taught to students between the ages of 10 and 16 as part of the “secondary life skills” (SLS) curriculum, which covers a range of topics, from social skills and emotional intelligence to disease prevention, sexually transmitted diseases, reproductive health and drug use. The curriculum was last revised between 2006 and 2011 and is mandatory but co-curricular, meaning students do not have to take exams on the subject at the end of the year.
Reproductive and sexual health are introduced in sixth grade, with lessons on physical growth and emotional changes due to puberty. Students also learn about HIV transmission at this time, according to Unicef, which helped the Ministry of Education develop the curriculum. As seventh graders, students are asked to consider boy-girl relationships to determine an age-appropriate level of closeness, and in 10th and 11th grades they study how to prevent unplanned pregnancies and STIs, with abstinence promoted as the most effective method. They learn that for those who are sexually active, condoms are the only effective means of preventing pregnancy, HIV and other STIs.
“In the past, dialogue on reproductive and sexual health was avoided in Myanmar and teachers were challenged in helping children and adolescents learn about such important issues. As part of the transition to a new Myanmar, there’s now an opportunity to talk more openly about these matters which can seriously affect the health and wellbeing of Myanmar’s children and can have lasting negative effects into adulthood,” said Bertrand Bainvel, a Unicef representative in Rangoon.
He said one method of addressing reticence around such issues was by providing supplementary self-study books so students could learn about key reproductive and sexual health topics in privacy. He said it was also important to ensure that instructors did not use time allocated for the SLS curriculum to teach other core subjects, which has happened in the past to prepare students for school leaving exams at the end of high school.
“Unicef is currently working with the Myanmar government to have SLS embedded in the national education law,” he added.
The government is considering new laws for education as it undergoes a two-year review of the school system to identify key areas for reform, after decades of underfunding and neglect for education under the former military regime.
Outside of schools, other efforts are under way to teach young people about reproductive health. In addition to telephone advice hotlines—which have been launched not only by the Myanmar Medical Association, but also by the government’s Department of Medical Research, the global health organization Population Services International, and Marie Stopes International—a radio program on Shwe FM station offers information on youth issues, including unwanted pregnancies, HIV, family planning, adolescent health and family problems. The weekly program is supported by the UN Population Fund, which provides assistance for the Myanmar Medical Association’s telephone hotline.
Burma also receives international funding for HIV prevention, and last week the princess of Denmark launched a new Danish-funded health care clinic in the country to educate women about contraception and family planning while supporting people infected with the virus.
Community-based organization Girl Determined is trying to introduce sex education into weekly after-school peer groups for marginalized girls who live on the outskirts of urban areas. More than 1,300 girls between the ages of 12 and 17 participate in the peer groups outside Rangoon, Mandalay, and the cities of Sagaing and Monywa in northwest Burma.
“Right now we focus on the prime issue of puberty, but we don’t talk about sex yet—we are still planning the curriculum. We don’t talk about how to use condoms with the girls very much,” says Nant Thazin Min, who helps coordinate the peer groups. “Talking about sex openly can be difficult. So many people, teenage girls and young women, do sexual things but the people don’t talk about it. They need to know about it, to prevent any pregnancy or sexual harassment.”
Some young women say they are in no rush to learn. “I don’t think I need to know more right now,” says Phyu Phyu Win, the 22-year-old student in Rangoon. “I might need to know one day, but I have never had a thought on it right now.”
Minutes later, she had a change in heart. “It is not something you can avoid,” she said. “It’s how you make babies, it’s how we are. We should know about it since we can’t avoid it.”