Madeeha Syed

Understanding Coercive Control And Identifying Its Telltale Signs

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Saad Ullah Siddiqui

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Time For Men To Share The Burden Of Pregnancy

Introduction

A fast-growing population is one of the greatest challenges currently faced by Pakistan. Increasing poverty, food shortage, health challenges, depletion of natural resources, and overcrowding are just some of the problems associated with overpopulation. According to the 2017 Census of Pakistan, with a population of more than 207 million, the country is the fifth most populated country in the world<a href="#accordion">[1]</a>. Therefore, effective birth control methods are a need of the hour to prevent the risks associated with overpopulation.

However, the use of contraception is largely stigmatized in Pakistan due to various reasons. As per the Pakistan Demographic and Health Survey (PDHS), the current contraceptive prevalence rate (CPR) is only 34%<a href="#accordion">[2]</a>. Moreover, the use of contraceptive methods among men is extremely low. Thus, resulting in the burden of pregnancy and contraception lying largely with women. This could probably be due to a lack of awareness among men regarding various contraceptive methods that are readily available. Raising awareness about these methods is the first step in ensuring that the financial and emotional burden of <a href="https://merisehat.pk/article/how-to-practice-safe-sex">safe sex</a> is shared among both partners in a couple.&nbsp;

Almost 200 years ago, humans invented the world&#39;s first condom, and for a long time that was the greatest discovery in the world of contraception. However, scientists soon discovered methods specifically designed for women that could aid further in population control. Several female contraceptive options ranging from hormonal pills to invasive tubal ligation were introduced. However, each of the proposed methods comes with its side effects. Contraception methods have been widely politicized and various speculations exist regarding the reasons behind the disparity among male and female contraceptives. However, it is important to mention that male contraceptive methods are generally safer than their female counterparts, which is why in recent years significant work has been done to search for effective male contraceptive options. This shift in tide is also perpetuated in part by the increasing awareness among men and their willingness to use contraceptives.&nbsp;&nbsp;

&nbsp;

Understanding Male Contraceptives

Currently, two widely acceptable male contraceptive methods exist: condoms and the invasive vasectomy.

&nbsp;

<h5 dir="ltr">Condoms</h5>

These are a form of barrier method and stop the sperm from entering and fertilizing the egg. Along with being an effective and inexpensive birth control, condoms also prevent sexually transmitted infections (STIs). However, incorrect use is associated with a high failure rate, and they can easily break or get damaged. In Pakistan, condoms are the most used form of contraceptive method, with a frequency of 65.5%<a href="#accordion">[3]</a>.&nbsp;

In recent years, the Pakistani government has stepped up its social media campaigns in a bid to educate the public regarding the use of condoms and other effective family planning methods. This is aimed at controlling the growing population by promoting birth spacing and awareness of women&#39;s fertility. Doorstep availability and affordable prices have significantly increased the use of condoms among the general population.&nbsp;

Unfortunately, misconceptions about condoms and other family planning methods still need to be overcome.&nbsp;

&nbsp;

<h5 dir="ltr">Vasectomy</h5>

Also called male sterilization, the surgical procedure has been in use since the 1970s. The procedure involves cutting or blocking the vas deferens that carry sperm to the urethra. As a result, the semen is devoid of sperm and the egg cannot be fertilized. It is not easily reversed; therefore, it is mostly advised to men who are sure of not wanting children or who believe their family is complete.&nbsp;

With a success rate of 99.85%, it is the most reliable contraceptive option. Moreover, compared to tubal ligation in women, it is less invasive, has fewer risks, and has a quicker recovery time. However, only 2.4% of men around the world have undergone the procedure<a href="#accordion">[4]</a>. In Pakistan, the prevalence is only 0.4%<a href="#accordion">[3]</a>.&nbsp;

The lack of knowledge regarding vasectomy plays a major role in its low acceptance. Moreover, a majority of men hold the view that it leads to impotency or reduces sex drive. However, a recent study has found that men in Pakistan are becoming more accepting of vasectomy and recognizing their role in sharing the responsibility of family planning<a href="#accordion">[5]</a>.&nbsp;

&nbsp;

While female birth control pills have been around for more than 50 years, researchers have only recently started looking into pills for men.&nbsp;

In 2019, a team of scientists conducted a clinical trial for a male birth control pill among 82 healthy men<a href="#accordion">[6]</a>.&nbsp;They administered dimethandrolone undecanoate (DMAU) in varying doses over a period of 28 days. The two active hormones, progestin, and modified testosterone, helped suppress levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in the study participants. Thus, suppressing sperm production without causing symptoms of low testosterone levels.&nbsp;

Although the study did not measure sperm count, the pill was found to be safe, even in high dosages. The team is currently conducting a longer trial to assess the drug&#39;s effect on sperm production and any long-term effects on the body.&nbsp;

However, men are often hesitant to use hormonal options due to the presence of adverse effects. Therefore, a team at the University of Minnesota have developed a non-hormonal male contraceptive pill. According to early results from a trial in mice, the contraceptive was 99% effective at preventing pregnancy<a href="#accordion">[7]</a>. Moreover, it had no obvious side effects in the mice.

Called YCT529, the non-hormonal pill works by targeting a protein called the retinoic acid receptor alpha (RAR-&alpha;). Through inhibition of this receptor, the retinoic acid in the body is unable to cause cell growth and differentiation, both of which contribute to sperm formation. As a result, the contraceptive helped cause reversible sterility in male mice.&nbsp;

Researchers now plan to conduct human trials for the compound. However, it is too early to tell whether the results in mice will also translate to humans.&nbsp;

&nbsp;

Conclusion

Pakistan faces several challenges to the acceptability of various family planning methods. These range from religious and cultural beliefs, low literacy levels, misconceptions about side effects, lack of knowledge regarding various options for men and women, and reluctance to adopt a method. According to a study from Karachi, fear of side effects was the most common reason for low prevalence among users<a href="#accordion">[8]</a>.&nbsp;

Several trials are currently underway to look for safe and effective male contraceptive pills. However, it can take years till a pill is available in store. Even then, its availability will not matter until there is a change in beliefs regarding family planning.

Despite the safety and availability of male contraception, men are reluctant to use the contraception methods due to various reasons ranging from misconceptions about side effects to a lack of knowledge about safe sexual practices.&nbsp;

Therefore, there is a need for campaigns aimed at educating men about the importance of adopting contraception methods.&nbsp;

&nbsp;

Key Points

<ul>
</ul>

<ul>
	<li>A growing population poses several challenges to a country&#39;s health and economic stability.</li>
	<li>Effective implementation of family planning measures can help control overpopulation.</li>
	<li>In Pakistan, use of contraceptives is highly stigmatized due to various reasons.</li>
	<li>While several advances have been made in the search for female contraception, men have only been presented with two options: condoms and vasectomy.</li>
	<li>Condoms are the most commonly used form of contraception; however, there is a need to raise awareness on its correct usage.</li>
	<li>Vasectomy is the most effective male contraceptive method, but the lack of education and widespread myths regarding its side effects has resulted in a low frequency (0.4%) of the procedure in Pakistan.</li>
	<li>Recently, scientists have begun testing various hormonal and non-hormonal compounds as male contraceptive pills.&nbsp;</li>
	<li>In 2019, a team of scientists tested varying doses of dimethandrolone undecanoate (DMAU) among healthy males and found it was well-tolerated. They are now planning long-term clinical trials to test the compound&#39;s effect on sperm production.</li>
	<li>Recently, a team at the University of Minnesota developed a non-hormonal contraceptive pill. They tested the compound in mice and found it to be 99% effective, with no observable side effects. The team now plans to conduct human trials of the compound.</li>
	<li>The development of male contraceptive pills can help men share some of the burden of contraception and pregnancy.</li>
</ul>

&nbsp;

[1] Statistics, P. B. o., 2021. Brief on Census - 2017. [Online].

[2] Meherali, S., Ali, A., Khaliq, A. & Lassi, Z. S., 2021. Prevalence and determinants of contraception use in Pakistan: trend analysis from the Pakistan Demographic and Health Surveys (PDHS) dataset from 1990 to 2018. F1000 Research, Volume 10.

[3] Shattuck, D., Perry, B., Packer, C. & Quee, D. C., 2016. A Review of 10 Years of Vasectomy Programming and Research in Low-Resource Settings. Global Health, Science and Practice, 4(4), pp. 647-660.

[4] Siddiqui, M. et al., 2020. Prevalence and Predictors of Contraception Usage in Karachi, Pakistan. Cureus, 12(10).

[5] Hatesh, H., Maheshwari, B. K., Shah, S. Q. & Kumar, D., 2020. Males’ perception and motivation for Vasectomy. Pakistan Journal of Public Health, 10(4).

[6] Thirumalai, A. et al., 2019. Effects of 28 Days of Oral Dimethandrolone Undecanoate in Healthy Men: A Prototype Male Pill. The Journal of Clinical Endocrinology & Metabolism, 104(2).

[7] Society, A. C., 2022. A non-hormonal pill could soon expand men’s birth control options. [Online].

[8] Bibi, S., Memon, A., Memon, Z. & Bibi, M., 2008. Contraceptive knowledge and practices in two districts of Sindh, Pakistan: A hospital based study. Journal of the Pakistan Medical Associatio, 58(5).

Nimrah H. Sattar

Birth Control: The Female Prerogative, Female Health

Despite advancements in modern medicine, prophylactic administration is a concept less practiced in current-day Pakistan. As is the case in the rest of the world, contraceptive measures, maternal medical assistance, and infant health care are fundamental for safeguarding the strength and wellbeing of Pakistani women, their families and wider communities.

&nbsp;

Statistics from comprehensive surveys in 2017 have found that women in Pakistan have an average of 3.8 million accidental pregnancies every year<a href="#accordion">[1]</a>. A vast majority of these pregnancies result from the lack of accessibility to modern contraception methods<a href="#accordion">[1]</a>.&nbsp;

&nbsp;

Approximately 52% of married women of reproductive age (15-49 years) in Pakistan, who want to avoid pregnancy, are unaware of available contraceptive methods<a href="#accordion">[1]</a>. Fulfilling these contraceptive needs can help cause 3.1 million fewer accidental pregnancies per year, 2.1 million fewer pregnancy terminations, and almost 1,000 fewer maternal deaths<a href="#accordion">[1]</a>.&nbsp; 
&nbsp;

Understanding Female Contraceptives

According to health reports by the state capital, female sterilization and condoms rank above other commonly practiced contraceptive strategies in Pakistan, representing 71% of all the methods common amongst married women<a href="#accordion">[2]</a>. Moreover, 10% of married women depend on injectables, 9% on IUDs, 7% on the pill, and 2% on the implant<a href="#accordion">[2]</a>. 
&nbsp;

&nbsp;

<h5>1. Female&nbsp;Sterilization (Tubal Ligation)</h5>

Sterilization also referred to as tubal ligation is the most effective method of preventing unplanned pregnancies, since it&rsquo;s a permanent solution. The surgery involves cutting the fallopian tubes, or obstructing their path by sealing them<a href="#accordion">[3]</a>. In general language, it is occasionally alluded to as getting your reproductive ability limited. The surgery is performed via a minimally invasive medical procedure called laparoscopy. Therefore, it can be conducted soon after a vaginal delivery or a cesarean delivery (commonly known as a C-section).&nbsp;

&nbsp;

Nonsurgical methods include the insertion of devices within the fallopian tubes to seal them. These devices are placed through the vagina and uterus, and the arrangement can proceed manually without the need for an incision. This intercepts the egg from travelling to the uterus and holds the sperm back from entering and fertilizing the egg. By acting as an impediment to fertilization, the individual is unable to conceive<a href="#accordion">[3]</a>. In Pakistan, women generally opt for tubal ligations after exceeding the age of 30 and conceiving six children. More factors, such as urban residence, can also increase its probability. However, due to its nature of irreversibility, tubal ligation is a last resort and cannot be considered a viable contraceptive method<a href="#accordion">[4]</a>.&nbsp;&nbsp;

&nbsp;

<h5>2. Injectables</h5>

The contraceptive injection Femiject and Novaject discharges the hormone progestogen into your circulatory system<a href="#accordion">[5]</a>. The hormone progestogen prevents unwanted pregnancies by delaying ovulation. Moreover, it thickens the cervical bodily fluid, making it hard for the sperm to travel through the cervix. And it diminishes the uterine lining, so a fertilized&nbsp;egg is less inclined to embed itself<a href="#accordion">[6]</a>. These are normally injected in an individual&#39;s bottom, but can be administered in the upper arm as well.&nbsp;

&nbsp;

According to research, injectable contraceptives can be actively recommended due to their promising continuation rate, signs of contentment, and bleeding profile of combined injectable contraceptive (CIC) users<a href="#accordion">[7]</a>. However, such contraceptives only last for a limited duration, ranging from 8 to 13 weeks. Additionally, they are unable to protect against sexually transmitted diseases, and some individuals may witness a gain in weight after switching to injectable contraceptives.

&nbsp;

<h5>3. IUDS&nbsp;</h5>

Called an intrauterine device, it is carefully inserted inside an individual&#39;s uterus<a href="#accordion">[8]</a>. IUDs generally have a long active period. Non-hormonal copper IUD (ParaGard) can last up to 10 years, while <a href="https://www.merisehat.pk/article/what-is-hormonal-acne">hormonal</a> IUDs should be replaced after 3-5 years. The two kinds of IUDs make it harder for sperm to fertilize&nbsp;the egg.&nbsp;

&nbsp;

Less than 8 out of 1,000 women with IUDs get pregnant<a href="#accordion">[8]</a>. They are preferred by women all around the world because of their low maintenance, and the association with lighter and shorter menstrual cycles. However, IUDs are not the most affordable contraceptive method. Moreover, copper IUDs are more painful and can also disrupt menstrual cycles.&nbsp;

&nbsp;

The Marie Stopes Society set out its portable outreach service program to encourage and expand the current demographic of users of IUDs, and to improve the accessibility of quality contraceptive administrations. The program is especially aimed at women residing in difficult and inaccessible regions. Medical care professionals ought to be prepared in dealing with clients&#39; concerns about the IUDs, and provide alternates in case they choose to discontinue<a href="#accordion">[9]</a>.&nbsp;

&nbsp;

<h5>4. Birth Control Pills</h5>

There are two main types of birth control pills readily available in Pakistan:

&nbsp;

<ul>
	<li>Combination Pills</li>
</ul>

The combination oral contraceptive pill (COCP) likewise alluded to as &quot;the pill&quot; is a contraception pill that constitutes a blend of two engineered hormones, estrogen and progestin<a href="#accordion">[10]</a>. They are generally taken daily, for 28 days to resemble the period of an average cycle for a woman. However, before jumping on the COCP bandwagon, it is important to consult with a gynecologist to discuss the dose of such pills, the preferred brand, and the period of use to ensure maximum viability. Common COCPs in Pakistan include Diane-35 which may also be prescribed to regulate polycystic ovarian syndrome (PCOS) symptoms such as excessive hair growth (hirsutism) and cystic acne<a href="#accordion">[11]</a>. COCPs are productive and convenient, and if administered properly, can be 91% effective, considering possible human errors such as missed doses<a href="#accordion">[10]</a>. However, they do not protect against sexually transmitted diseases (STDs) and may lead to breast tenderness in some individuals. 
&nbsp;

<ul>
	<li>Progestin-Only pills</li>
</ul>

One more kind of contraception pill is the progestin-only pill (POP), also known as the mini-pill<a href="#accordion">[10]</a>. Contrary to its equivalent, this conception prevention pill is just comprised of progestin. This is an efficacious method of contraception, especially in women who are unable to naturally produce estrogen because of health complications. Apart from a few exceptions, a wide variety can select the scaled-down pill as their favored conception prevention strategy. Additionally breastfeeding women favor the mini-pill as it is known to influence breast milk supply<a href="#accordion">[10]</a>. Gynecologists may prescribe any POP which is readily accessible in most pharmacies in Pakistan. Adverse side effects may include weight gain, nausea, breast tenderness, and increased blood glucose levels<a href="#accordion">[11]</a>. 
&nbsp;

<h5>5. Implants</h5>

Norplant sub-dermal implant system spans a thorough and protracted duration. Developed by the International Committee for Contraception Research (ICCR) of the Population Council, the implant provides a conveniently reversible and promising contraceptive option<a href="#accordion">[12]</a>.&nbsp;

&nbsp;

It comprises six adaptable enclosed capsules made of Silastic (dimethyl siloxane/methyl vinyl siloxane copolymer). The intention of inserting the Silastic cases under the skin assists with guaranteeing that they can be eliminated effectively later, if the individual chooses to discontinue.&nbsp;

&nbsp;

Once the doctor has effectively placed all the six capsules and they are set up, the healthcare professional conducting the procedure closes the point of incision with the help of a cement bandage. No stitches are required, and dressing over the whole region with compresses and gauze is purely for the prevention of possible infections at the site of entry. The entire procedure generally requires 8-10 minutes<a href="#accordion">[12]</a>. However, implants are not the most sustainable form of contraception as each implant is expensive, may influence menstrual cycles, and does not protect from sexually transmitted infections (STIs).

&nbsp;

Despite Pakistan generously and liberally disbursing an average of US$81 million every year on contraceptive administrations, there remains an inexplicable gap in such services reaching pertinent individuals<a href="#accordion">[1]</a>. While critics would hold this evident deficit as a reflection of the annual insufficiency of US$92 million to cater to the magnitude of the situation, there are deeper, and more intricate factors that hinder a woman&rsquo;s prerogative to choose a contraceptive method.&nbsp;

&nbsp;

A detailed research study highlighted six major obstacles that may hinder or result in unprecedented hesitation to use contraception<a href="#accordion">[13]</a>. Such impediments included:

&nbsp;

(i) A woman&rsquo;s reluctance to delay pregnancy as an ode to motherhood

(ii) Lack of sufficient knowledge and awareness of contraception

(iii) The societal stigma associated with contraception

(iv) Priority of a husband&rsquo;s desire and preference

(v) Perceived myths of health risks due to contraception

(vi) Inaccessibility to affordable and quality contraceptive services.

&nbsp;

If the above concerns are responded to through an erudite discussion, and in a compassionate tone, then more women will practice healthy methods of family planning and contraception.&nbsp;

&nbsp;

This could curb the exponential population growth, the extrapolating economic crisis of an average family, and diminish the increasing health risks associated with unplanned pregnancies.

&nbsp;

[1] Sundaram, A., Hussain, R., Sathar, Z. A., Hussain, S., Pliskin, E., & Weissman, E. (2019, September). Adding It Up: Costs and Benefits of Meeting the Contraceptive and Maternal and Newborn Health Needs of Women in Pakistan.

[2] National Institute of Population Studies (NIPS). (2019). Pakistan Demographic and Health Survey 2017-2018. Islamabad: NIPS and ICF.

[3] Brito, J. (2018, September 27). What Every Woman Should Know About Female Sterilization. Healthline.

[4] Khan, A. A., Khan, A., Abbas, K., Tirmizi, S. F., & Islam, Z. u. (2013). Specific Issues in Family Planning in Pakistan. Journal of the Pakistan Medical Association, Volume 63, Issue 4.

[5] Greenstar. (2022). Injectables.

[6] NHS. (2018, February 7). The contraceptive injection.

[7] Izhar, R., Husain, S., Tahir, M. A., & Husain, S. (2020). Femiject, a once-a-month combined injectable contraceptive: experience from Pakistan. The European journal of contraception & reproductive health care: the official journal of the European Society of Contraception, 25(5), 359-364.

[8] Johnson, T. C. (2020, May 6). What Are Your Birth Control Options? WebMD.

[9] Azmat, S. K., Hameed, W., Mustafa, G., Hussain, W., Ahmed, A., & Bilgrami, M. (2013). IUD discontinuation rates, switching behavior, and user satisfaction: findings from a retrospective analysis of a mobile outreach service program in Pakistan. International journal of women's health, 5, 19–27.

[10] Oladoc. (2022, January 26). Birth Control Pills in Pakistan: Here’s What You Need to Know.

[11] Anwar, O. (2022, June 16). Everything You Need to Know About Birth Control Pills in Pakistan. Healthwire.

[12] Shamim, N., Rehan, N., & Inayatullah, A. (1994). Use of Norplant in Pakistan: Two Years Experience. Journal of the Pakistan Medical Association, Volume 4, Issue 1, 3-7.

[13] Casterline, J. B., Sathar, Z. A., & Haque, M. (2001). Obstacles to Contraceptive Use in Pakistan: A Study in Punjab J. Studies in Family Planning, Volume 32, 95-110.

Zarlish Kazmi

Overview

Coercive control is a form of psychological abuse that involves manipulation, dominance, and the systematic exertion of power over another person. Unlike physical abuse, it leaves no visible scars, but its impact can be just as debilitating. This article delves into the intricate nature of coercive control, its manifestations, and offers insights into recognizing the signs, ensuring individuals can break free from its suffocating grasp. 
&nbsp;

Understanding Coercive Control

Coercive control is a pattern of behavior where an individual seeks to control every aspect of another person&#39;s life, eroding their autonomy, self-esteem, and freedom. This often extends beyond the realm of romantic relationships, seeping into friendships, familial bonds, and even workplace dynamics. Coercive control is not merely an isolated incident; it&#39;s a calculated strategy that leaves the victim feeling trapped, powerless, and emotionally scarred. 
&nbsp;

<ol>
	<li>Isolation: Coercive controllers often isolate their victims, cutting them off from friends, family, and support systems. This isolation limits the victim&#39;s access to help and validation, strengthening the controller&#39;s grip.</li>
	<li>Constant Surveillance: Controllers monitor their victim&#39;s activities, either overtly or subtly, creating an atmosphere of constant scrutiny and fear.</li>
	<li>Financial Dependence: By controlling finances and access to resources, controllers force victims into financial dependence, making it difficult for them to leave the relationship.</li>
	<li>Emotional Manipulation: Manipulative tactics like guilt-tripping, playing the victim, or twisting facts are employed to confuse and control the victim&#39;s emotions and thoughts.</li>
	<li>Threats And Intimidation: Controllers use threats, both direct and implied, to maintain control. This can include threats to harm the victim, their loved ones, or even themselves.</li>
	<li>Gaslighting: Similar to emotional abuse, gaslighting is a tactic where the controller distorts reality to make the victim doubt their own perception, memory, or sanity.</li>
	<li>Monitoring Communication: Controllers may control the victim&#39;s communication, reading texts, emails, or listening in on phone calls, further invading their privacy.</li>
	<li>Gradual Erosion Of Autonomy: Coercive control doesn&#39;t happen overnight; it&#39;s a gradual process. The controller may start by making small decisions for the victim and escalate to controlling major life choices. 
	&nbsp;</li>
</ol>

Recognizing The Signs

<ol>
	<li>Trust Your Instincts: If you feel constantly anxious, fearful, or trapped in a relationship, it&#39;s crucial to trust your instincts. Emotional distress is often a strong indicator of coercive control.</li>
	<li>Maintain A&nbsp;Support System: Keep connections with friends, family, and colleagues. Isolation is a powerful tool of control; maintaining relationships outside the controlling dynamic can provide a lifeline.</li>
	<li>Document Evidence: Keep records of coercive incidents, conversations, or actions. This documentation can be useful when seeking help or legal intervention.</li>
	<li>Seek Professional Help: A therapist, counselor, or support group can provide an objective perspective and help you navigate the complex emotions tied to coercive control. 
	&nbsp;</li>
</ol>

Bottom Line

Coercive control is a silent predator that preys on an individual&#39;s emotional and psychological well-being. Recognizing the signs is the first step toward breaking free from its grip and reclaiming your autonomy. Remember, nobody has the right to control your life, emotions, or choices. By educating yourself and seeking support, you can liberate yourself from the chains of coercive control and pave the way to a healthier, empowered future.