The Muslim family

predicament and promise

Muslim families: nuclear or extended?

The traditional Muslim family is extended, often spanning 3 or more generations.2 An extended structure offers many advantages, including stability, coherence, and physical and psychological support, particularly in times of need.
In Muslim culture, akin to other traditional cultures, respect and esteem increase with age. Elderly parents are respected on account of their life experiences and their hierarchic position within the family unit. The opportunity to attend to the needs of one's parents in their later years is viewed as a gift from Allah.
Challenges to the extended family

In practice, it is usual for a new bride to move into the household of her husband. The change is often considerable, and problems in the fledgling relationship between the bride and her in-laws are common. This transition is all the more difficult where Muslims live as minorities because in many cases, migration patterns have resulted in fragmentation of the extended family structure. Many second-generation Muslim migrants have grown up in nuclear families, not having first-hand familiarity with the richness and complexity of living within extended family networks. In addition, despite religious teachings that encourage marriage at an early age, a secular trend to marry late is being seen among Muslims. Some observers have suggested that increasing age curtails a person's ability to adapt to change, adaptability being the hallmark of youth. Finally, and perhaps most important of all, Muslim youth in the West are faced with lifestyle choices not available in more traditional cultures. To some, the opportunities with respect to individual freedom offered by a nuclear family structure far outweigh any benefits of living in an extended family.2
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GENDER AND SEGREGATION

Gender issues and, in particular, the rights of women in Muslim culture, continue to generate much media attention in the West. Muslim women are often portrayed as inferior beings, desperately in need of liberation from the Muslim patriarchal culture that prevents their progress. Segregation of the sexes, a practice encouraged by Islam, is often seen as proof of the suppression of Muslim women.3 Although certainly much can be done to improve the position of women in Muslim culture, the stereotype created in the western media leaves much to be desired. Such misunderstandings are largely due to naive and simplistic attempts to transpose a western set of norms and values onto women with a very different history and culture. A detailed critique of the feminist position is beyond the scope of this article; readers are referred to other texts.4,5

As already noted, Islam clearly demarcates between legitimate and illegitimate human relationships. Societal laws exist to aid Muslims in abiding by this framework. Segregation, therefore, exists primarily to minimize the chances of illicit relationships developing. Physical contact between members of the opposite sex is strongly discouraged, although these rules are relaxed somewhat if medical treatment is required.6 This framework explains why many prefer to see a same-sex clinician, particularly in consultations necessitating examination of the genitalia. On a practical note, if recourse to an interpreter is required, the use of same-sex interpreters offers a considerable advantage. The issue of gender segregation is one that should also be considered when planning health education campaigns, research interviews, and similar ventures.

Gender and role demarcation

The man is considered the head of the family; to many a man, however, this is a poisoned chalice because with leadership comes responsibility. Economic responsibility for maintaining the family falls squarely on the shoulders of the man, irrespective of whether his wife is earning money. Unemployment, then, can greatly affect the integrity of the family, leaving the man in a role limbo. Psychological morbidity in such situations may be high, with ramifications for the family as a whole.

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MARRIAGE

You are a garment to them, and they are a garment for you.

Qur'an7

This succinct Qur'anic simile encapsulates the primary aims of marriage—to provide warmth, comfort, and protection and to beautify. Within the Islamic vision, children have a right to be conceived and reared in a stable and secure environment; marriage is deemed to provide such an environment. In contrast, celibacy and sex outside of marriage are strongly discouraged because they are considered behavioral extremes that are not conducive to a wholesome society.8

In many senses, marriage is considered the union of 2 families, and the parents usually arrange the marriage. Although the free consent of both the bride and groom are essential, parental coercion is often strong.
Some parents are evidently beginning to understand the marital concerns of their children. The practice of choosing marriage partners from within one's community, however, continues to be considered important by young and old.

Consanguinity

Consanguinity (intermarriage) is particularly common in Muslims of south Asian and Arab origin. Among Pakistani Muslims, current estimates are that some 75% of couples are in a consanguineous relationship, and approximately 50% are married to first cousins. This represents an increase from the generation of their parents, of whom only 30% are married to first cousins.9 Consanguinity confers many advantages, which, at least in part, explain its continued appeal. For example, it allows a thorough knowledge of the future marriage partner for sons or daughters—a particularly important consideration in Muslim minority communities where the usual social networks that facilitate the search for an appropriate partner may be lacking.

Whereas consanguinity doubtless results in an increased frequency of familial disorders with an autosomal recessive pattern of inheritance,10 assessing the relative contribution of consanguinity to the high rates of congenital defect and perinatal mortality among Pakistanis is far from easy. Other factors of importance in the birth outcome debate include the high prevalence of deprivation among Muslims, difficulties with access to high-quality genetic and prenatal counseling, and the possible risks associated with culturally insensitive maternity care.11 Appropriate services specifically tailored to meet the needs of Muslims and other minority groups should be considered an issue deserving priority attention.

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SEX AND CONTRACEPTION

Sexual norms

Sex in the context of marriage is a legitimate, enjoyable activity—an act of worship that is deserving of Allah's reward. Conversely, sex outside of heterosexual marriage is considered deviant, deserving of punishment in the here-after.1 In keeping with orthodox Judeo-Christian teaching, homosexuality is considered sinful. A distinction is made, however, between a homosexual inclination and the act itself. The former is acceptable so long as it is not practiced.12

Promiscuity does exist among Muslims, although in all probability its prevalence is considerably lower than in some segments of western society.13 Those who operate outside the Muslim framework often find themselves ostracized and held responsible for bringing the family name into disrepute. The prospect of “coming out” for homo-sexual Muslims is, therefore, not realistic at present.
Despite the positive outlook toward sex, it is not a subject that is openly discussed. Cultural taboos dictate that sex should remain a private matter between husband and wife.8 This explains, at least in part, why Muslims are reluctant to seek help for sexual problems and the long time lag before seeing a physician.

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MENSTRUATION

While menstruating, women are exempt from some of the important religious rites, such as ritual prayer, fasting, and Hajj (the pilgrimage to Mecca). Sexual intercourse is also prohibited at such times. All other forms of physical contact between husband and wife, for example, hugging and kissing, are allowed. Menstruation, therefore, may have many social and psychological ramifications. There are also many possible implications for clinical care. Women may be reluctant to see a physician for gynecologic symptoms, cervical smear tests, or intrauterine device checks for fear of bleeding following a pelvic examination. Many Muslim women are unaware that traumatic bleeding of this kind is distinct from menstrual bleeding, and hence, the religious constraints do not apply. Education is needed both within the Muslim community and among professionals so that the importance and implications of genital tract bleeding are better appreciated.

Women may consult their physician or family planning clinic to postpone their menstrual periods at particular times. The most common situation is in the period before Hajj. For those using the combined oral contraceptive pill, they can be safely advised to either “bicycle” or “tricycle” pill packs. This involves omitting the 7-day break between pill packs, thus avoiding the withdrawal bleeding that ensues.14(p53) Alternatively, progesterone (for example, norethisterone [norethindrone]) may be used daily, beginning 2 to 3 days before the period is due and continuing treatment until such time that bleeding is more convenient.

Additional dimensions in the management of genital tract bleeding
A married woman in her late 30s contacted a friend (a female Muslim physician) to discuss her menstrual problems. She had been bleeding on a fortnightly basis for the previous few months. This was causing havoc with prayer routines because on each occasion she had stopped praying. She was advised that she should continue praying because the pattern of bleeding was unlikely to represent menstrual bleeding. It was suggested that she see her physician for further investigation. Thus far, she had avoided consultation. Contributing to her apprehension were the prospect of not being able to see a woman physician, difficulties in articulating the real reason for her attendance, and the possibility that an internal examination may exacerbate her bleeding.

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FEMALE GENITAL TRACT MUTILATION

Female genital tract mutilation is a practice that is carried out in many regions of the world, including some Muslim countries. This practice is most widespread in parts of Africa, stretching in a band from the Horn through Central Africa and extending to parts of Nigeria.15 The custom's exact origins are uncertain, but it almost certainly predates the arrival of Christianity and Islam to these regions. Female genital mutilation is currently illegal in many countries, including Britain.16
The procedure has different forms and is typically done at the age of 6 or 7 years. The least invasive of these involves removing only the prepuce of the clitoris. Removal of the clitoris, or more extensive procedures, is not approved by religious teaching17; nonetheless, these extreme practices continue in some Muslim regions largely because of the strong influences of tribal and regional custom and tradition.

The most extreme form, infibulation, involves excising the clitoris, the labia minora, and the medial aspect of the labia majora. The sides of the vagina are then sutured, leaving a small opening for the passage of urine and menstrual flow.16 An intermediate form involves removing the clitoris either partially or totally, together with a portion of the labia minora.

The removal of large amounts of genital tissue can cause considerable problems, including difficulties with micturition, recurrent urinary tract infection, dyspareunia, and dysmenorrhea. The emotional and psychological ramifications of such bodily assault are also now being appreciated.

Traditionally, a local midwife performs a deinfibulation immediately after marriage, thus allowing consummation to occur. The recent large-scale migration from Somalia, Sudan, Eritrea, and Ethiopia to parts of Europe has highlighted the difficulties and problems involved with caring for infibulated women. Access to deinfibulation is restricted in the United Kingdom, and women will, therefore, often become pregnant while infibulated, hindering their care in pregnancy and in labor.
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CONTRACEPTION

Many traditions of the Prophet Muhammad extol the merits of marriage, procreation, and fecundity.18 Muslim opinion with respect to contraception is divided, a minority arguing that it is categorically prohibited whereas the majority opinion is that contraception is allowed but discouraged.19 A small minority, confined largely to academic circles, suggests that effective family planning strategies are essential to prevent the global overspill predicted by many in the West.20 The prevalence of contraceptive use in Muslim countries varies widely, reflecting these divergent views, and ranges from less than 5% (in Mauritania, North Yemen, Somalia, and Sudan) to more than 50% (in Turkey, Lebanon, and Tunisia).21

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VIGNETTES

The following vignettes illustrate some of the challenges encountered in the West when dealing with Muslim patients.
Parental rights
On joining the Muslim community, I was astonished that so much emphasis was put on my relationship with my parents. Here are a few sayings of Muhammad on this subject to which I was exposed almost immediately:

May his nose be rubbed in the dust! May his nose be rubbed in the dust! (An Arabic expression denoting degradation). When the Prophet was asked whom he meant by this, he said, “The one who sees his parents, one or both, during their old age but does not enter Paradise” (by doing good to them).
A man came to Muhammad and asked his permission to go to battle. The Prophet asked him, “Are your parents alive?” The man replied “Yes.” The Prophet responded, “Then strive to serve them.”22

Support networks

A 28-year-old woman consulted with a physician because of many “aches” and “pains,” suggesting a strong psychological component to her symptoms. When her notes were reviewed, it transpired that she had had 3 consecutive stillbirths, the last being only 6 months previously at 36 weeks' gestation. The possibility of the stillbirths contributing to her current condition was raised. She acknowledged this, saying that she had been coping well while in Pakistan because there she had the support of her extended family. On returning to England, however, she found her-self more isolated and was struggling to cope. The option of counseling was discussed but was strongly declined. “What has happened to me is a test from Allah and something I will come to terms with. Counselors cannot understand this.”

Family responsibility to aging members
Things are not like they used to be. There is an increasing trickle of Muslims entering nursing homes, and I've actually been thinking of opening a home specifically for Muslims.
Muslim nursing home proprietor
An elderly Bengali man was recovering in a hospital from an episode of pneumonia. He was bed-bound, the result of multiple strokes. On the geriatric team's prompting, the family was approached by social services to discuss a nursing home placement. The family explained that they would prefer to look after him at home. With the support of his physician and social services, he was able to stay in the family home until his death a few years later.

Any questions?

At a seminar on transcultural medicine, junior physicians were asked if they had any particular questions about Islam. Anonymous responses were encouraged to allow the physicians to raise issues of genuine concern without fear of offending the group leader (a Muslim). Two themes dominated: women's rights and fundamentalism.
Barbed wire Zara, a 27-year-old housewife from Sudan, attended for a follow-up appointment at her local hospital. Her physician was on leave, so she was seen by a locum tenens replacement. On entering the patient's room, the physician extended his hand. Zara politely declined, but failed to give her reasons for doing so. The resulting consultation was tense and dysfunctional.

You earn too much!

Mrs Mu'min attended as an “extra” toward the end of a busy morning surgery. An accountant, she was the principal breadwinner and brought home a healthy wage. Her husband, a doctor trained in Somalia, was unable to practice his craft because his qualifications were not recognized in the United Kingdom. During the last 3 years, he had been forced into various manual occupations. The reason for her consultation? Confused, distraught, and visibly shaken, she explained that her husband was threatening to leave her unless she gave up her job.