Demographics and a Historical Perspective
1. Basic Sexological Premises
2. Religious and Ethnic Factors Affecting Sexuality
3. Sexual Knowledge and Education
4. Autoerotic Behaviors and Patterns
5. Interpersonal Heterosexual Behaviors
6. Homerotic, Homosexual, and Ambisexual Behavior
7. Gender Conflicted Persons
8. Significant Unconventional Sexual Behavior
9. Contraception, Abortion, and Population Planning
10. Sexually Transmitted Diseases (STDs)
12. Sexual Dysfunctions, Counseling, and Therapies
13. Research and Advanced Education
References and Suggested Readings

Julanne McCarthy, M.A., M.S.N.*

*The information in this chapter was gathered by the author and 28 Bahrain) and expatriate professional colleagues. The organization and presentation of this material was done by Julanne McCarthy.

Demographics and a Historical Perspective

The State of Bahrain is an archipelago of some thirty-three islands, totalling 268 square miles, located in the middle of the southern shore of the Arabian Gulf, almost halfway between Shatt Al-Arab in the north and Muscat to the south. The islands lie approximately twenty miles from the eastern province of Saudi Arabia and two to eighteen miles from Qatar. Bahrain’s neighbors are Saudi Arabia on the west and Quatar on the east. Bahrain has been joined by a causeway to Saudi Arabia since late 1986. This causeway has had a profound effect, and greatly influenced certain aspects of Bahrain society. Bahrain Island, the largest in the group, is the location of the current capital city Manama. It is approximately thirty miles long and ten miles wide and is linked by causeways to the islands of Muharraq on the northeast and Sitra on the east coast. Outside the capital, the landscape is covered by fertile gardens and palm trees in the northern third, and there is the desert with the oil and gas reserves in the remainder. Most of the population lives in the northern portion, while the central desert area contains the remains of the hundred thousand or more tumuli (ancient burial mounds), and a few towns and villages. The southern third of Bahrain Island is mainly a noninhabited restricted area. Most of the islands are now joined by causeways to the main island, except the Hawar Island group which lies offshore.

Bahrain has long been a port of call - for more than 6,000 years - and cuneiform tablets describe in ancient times the fresh water springs, the dates, and the market place in Bahrain which attracted Gulf trading ships to the offshore harbor. These ancient travelers were shuttling between Mesopotamia, Bahrain, and the Indus Valley. Archeological finds have identified Bahrain as “Dilmun, the land of the living” mentioned in the Sumerian epic, Gilgamesh. Other archeologists have suggested that Bahrain was the Garden of Eden. Traditionally, people were farmers, fishermen, and merchants. There were no Bedouins or semi-Bedouins living in Bahrain (Taki, 1974). Since the late nineteenth century, the form of government has been a traditional monarchy with succession passed from father to son (unlike other Gulf and Middle East countries where succession is brother to brother). Between 1861 and 1971, Bahrain was a British protectorate. There were three social classes in Bahrain until 1932 - royalty, merchants, and farmers (Khuri, 1980). The discovery of oil in 1932 led to many changes in traditional customs and initiated the beginning of a middle class in the society.

Bahrain saw a resurgence in its trading and commercial sector, and particularly growth in banking, during the 1970s because of the Lebanese civil war. Many institutions, with their expatriate work force, moved to Bahrain, attracted by its tolerable social environment. There are now expatriates from over sixty countries living in Bahrain and working in various government agencies, private businesses, service institutions, and family homes. There are also tourists from the Gulf and around the world visiting Bahrain. These current commercial activities, and the past contact with traders and people from different cultures, for centuries has given Bahrain a unique cultural pattern and a cosmopolitan air. The latter has not been seen in other Gulf cities, like Dubai, until recently. The people of Bahrain and their respect for, and tolerance of, different cultural values makes Bahrain unique in many ways from its neighbors.

The State of Bahrain has a land area of 268 square miles (695.26 square kilometers) and the 1991 census showed a population of 508,037 individuals including 323,305 (63.6 percent) Bahrainis and 184,742 (36.4 percent) expatriates. The mid-1996 population estimate is 586,000. Bahrain’s population density of 765/square kilometer is one of the highest in the world. The Bahrain birthrate of 2.91 percent for 1981-1991 is still among the highest in the world, however lower than the previous 3.4 percent (Ahmed, A.A. 1995:2).

The 1991 demographic profile shows 50.9 percent of the Bahraini population arc under 20 years of age, while the proportion over 60 years of age is 5.5 percent. Adult literacy is estimated at 84.1 percent (Baby, 1996a). Urban dwellers comprise 82 percent of the population. The structure of the expatriate population differs significantly from the local population as 52.9 percent of this segment are between 20 and 49 years of age, which is understandable as most expatriates are brought in to work. These individuals comprise a significant proportion of the work force, approximately 33 percent, and it should be noted they are living in Bahrain during their most sexually active years. The largest group of expatriates are from South Asia, with approximately 120,000 from India, Pakistan, Bangladesh, and Sri Lanka. Another large group are the Filipinos comprising more than 16,000 workers. The 7996 World Almanac gives the ethnic distribution as Bahraini 63 percent, Asian 13 percent, other Arab 10 percent, and Iranian 8 percent. The main languages used in Bahrain are the official language Arabic, Farsi, and Urdu, (The World Almanac, 1996). English is widely understood and commonly used commercially. The 1993 per capita income was reported as $12,000 (The World Almanac, 1996), while based on GDP the 1996 per capita income is listed as $15,500 (Baby, 1996b:2).

Life expectancy at birth in 1995 is 71 for males and 76 for females. The birthrate is 24 per 1,000 population; the death rate 3 per 1,000, giving a natural annual increase of 2.1 percent. Infant mortality is 18 per 1,000 live births. Medical services are free.

The predominant religion in Bahrain is Islam, which is also the state religion. This has implications on all aspects of daily life and sexuality as there is no separation of church and state, religion and daily life. Religious affiliation is the most important single attribute determining an individual’s social status in Bahrain society (Al-Sharyan, 1987:345). Religion continues as an all-encompassing pervasive guide which directs and divides up the hours of each day. Bahrainis are members of either the Sunni and Shi’ite sects of Islam, 30 percent and 70 percent respectively. The ruling family belongs to the Sunni sect. Many expatriates living in Bahrain are non-Moslem and are free to practice their respective religions openly and at their own places of worship such as churches (Anglican, Roman Catholic), chapels (Interdominational, Dutch Reformed-USA), and other places of public worship (e.g., Hindu temple). Other groups meet in homes or apartments (Mormons, a few local Jewish families) for prayer. Expatriate groups retain their own cultural values and language and generally socialize among themselves. There are many ethnic, cultural, and social clubs which advertise their activities which anyone can attend. The interaction of all these expatriates among their own groups and with Bahrainis will be developed further in this report with regard to aspects of human sexuality.

1. Basic Sexological Premises

There is a dearth of documented data regarding the nature of human sexuality in Bahrain. The data presented here are based on the few documented studies which are available. A thorough search was conducted of all the national bibliographies which have been compiled, government records, and the local print media, including newspapers, and local and regional journals in English. No one until recently conducted research in the realm of human sexuality in Bahrain; however, studies have been carried out on related areas by anthropologists, economists, doctors, nurses, psychologists, and social workers. All this data was pulled together, and with structured interview data, was used to write this basic document regarding the status of knowledge on, or related to, human sexuality in Bahrain according to the outline provided by the Encyclopedias general editor. It is hoped that researchers will be stimulated to study this topic in Bahrain and to present supplementary data from Arabic sources.

There may be a logical explanation why there is a dearth of literature regarding human sexuality, as the local culture, predominantly based on Islam, holds as a core value the suppression of external manifestations of sexuality in public, i.e., one should not present oneself in a sexually provocative manner. Believers are extolled not to draw attention to the body form, therefore the men’s thobe (long, loose shirt-like garment) and the women’s jellabiya (long, loose dress) are the preferred clothing style for many, at home and at work (unless there are uniform or safety restrictions). However, expatriates of all nationalities comment on the sheerness of some of the men’s’ summer white thobes and how a person’s underwear is sometimes visible, which appears in contradiction to the stated norm. Personal preference in dress is allowed so expatriates and Bahrainis are seen wearing a variety of clothing styles. Suppression of sexuality is also seen in the practice of women covering their hair partially (Muhtashima) or fully (Muhajiba), and even their face partially (Burga) or fully (Mutanaqiba). The practice of veiling in public has increased during the last five years and can be seen among young as well as elderly women. Use of make-up, nail polish, and perfumes intending to draw attention are discouraged in public. Modesty in dress extends into the home. If a woman has chosen to veil, then even in the home she must veil in the presence of unrelated male relatives, but not in the presence of women, children, or her immediate male relatives. Covering of the body is also observed among siblings where even sisters, according to the Koran, are not to be uncovered among themselves. Among married couples, dress expectations vary and can cause some dissension. Some men state that in their own home they would like to wear shorts when it is hot but their wives do not approve. The Koran’s injunction is that for the man, the middle area from the waist to the knees not be naked. It is acceptable for men engaged in athletics to wear shorts, and for fisherman or men in certain other occupations. There is an ingrained belief in some communities however that older males can lose their dignity and respect if they run or jog “half naked” in the streets or public parks (Fakhro, 1991:48).

Unrelated males and females are not to touch. The strict conservative definition is that touching is a sin. Great effort is made by everyone not to touch accidentally. As a local sign of respect and to purify oneself, people may spit to the side first before potential contact. This is a local custom and not dictated in Islam. Then in case of a accidental contact, e.g., while handing over change, the person is considered clean. Bahraini informants explained this is a traditional practice, and Catholic nuns reported being the recipients. Most expatriates have never seen or heard of this practice.

Other traditional social controls practiced include animadversion against eye contact between men and women, especially strangers. Lack of eye contact by a man to a woman is a traditional sign of respect. Likewise, a woman who is unveiled is strongly advised not to smile at strangers, (men outside her own family), and men and women should keep their eyes down when walking in public. Today these practices may or may not be followed in the workplace by people who see each other frequently, and also depending on the work situation (e.g., serving the public). However in public places, many people follow these injunctions. More recently, Westernized good manners such as courtesy, politeness, and cordial relations with customers and coworkers have been promoted in the private schools and service industry sector. Bahraini business leaders, through the public media and through in-house newsletters, are promoting good manners as being good for business. Total quality management concepts are being incorporated into the local businesses and society; however some resistance is met due to traditional values, e.g., women should not smile at an unrelated man.

The general aversion of speaking about sexual matters, or even the urogenital system, extends to doctor-patient relationships. Patients are reluctant to discuss their genitalia, and doctors are reluctant to ask about the genitalia and even omit these from a physical exam. This has resulted in junior doctors missing the correct diagnosis, and consultants later correcting the situation. As a result, there is suspected underreporting for various diagnosis, e.g., priapism in children with sickle cell disease (Al-Dabbous, 1991). This same reluctance has influenced studies regarding menopause in women which concentrate on osteoporosis and rarely mention psychosexual symptoms (Sadat-Ali, et al., 1993).

A. The Character of Gender Roles

Gender roles in Bahrain show a variety of manifestations and reflect the person’s education level, socioeconomic level, religious sect, urban or village background, and the degree of contact with local expatriates, as well as travel, study, or work abroad. In Islam, women have the freedom to be a traditional mother or to work (Kahtanie, 1992:6). Women have had opportunities to expand their roles from their traditional roles in Bahrain during the last thirty years. Great strides have been made by many women in the fields of education, medicine, nursing, other health-related professions, finance, clerical work, computers, light manufacturing, banking, and veterinary science, for example. These women in successful jobs are having an effect on the characteristics of gender roles in Bahrain. A comparison between the past and today reveals the significant changes which have occurred, and some of the driving forces which have helped women to achieve higher economic status in Bahrain.

The traditional lifestyle of a Bahraini Shi’a village woman in 1960 was described by Hansen (1967). The Bahraini village lifestyle was similar to that described in Oman in 1974-1976 (Wikan, 1982), however, with a few differences, i.e., the wives of Bahraini fisherman and farmers worked outside the home. The fisherman’s wife helped to clean and sell fish, while the latter helped their husbands in the fields and in marketing (Rumaihi, 1976:153). In contrast, women living in the towns and cities were exposed to very different circumstances as they were restricted to running their household and to child rearing. As a result, they developed very different lifestyles and gender roles. Among the wealthy, the epitome of status was to have nothing to do all day and to have all work done by servants (Waly, 1992).

During the latter part of the 1890s, an agent of change in the status of women was the arrival of the American missionaries sponsored by the Dutch Reformed Church of New Brunswick, New Jersey. The group established, in stages, informal classes in Arabic for boys and girls, then separate classes, and later formal classes, all held in Arabic. Families of various ethnic and religious groups in Manama sent their children to classes for free, and later a fee. There were complaints from conservative men regarding education for women; however, some girls had been taught in Koran schools (al mutawa) prior to this time. The American Mission School, now Al Rajah School, had its first university graduate, a licensed teacher, as school mistress for girls in 1919 (Anthony, 1984:231). The first secular boys school, Al-Hadaya Al-Khalifiya, was opened in 1919. The first secular girls school, Al-Khadija Al-Kubra, was established in 1928, and again there were complaints from conservative males (Belgrave, 1956:94). The Government, in spite of such protests, allowed female education to continue. The Government schools have always been separate but equal for the sexes, and reportedly they follow the same curriculum and use the same textbooks. The complete history of women’s secular education has been reported by Duwaigher (1964).

The early expatriate female teachers, Americans, Egyptians, and Lebanese, became role models for women in terms of possible educational achievements and different clothing fashions. As girls’ schools became more prevalent, women were needed as teachers, and in the 1950s, the first Bahraini women traveled to Cairo and Beirut to study. Opportunities in the field of education working as teachers and principals were the first professional roles for women. The Government did not promote women studying abroad, but neither did it prohibit them.

A hospital-based Nursing School was established in 1959, and in 1961, two male nurses were sent to London for further study. In 1976, the College of Health Science was opened and there were opportunities for women and men in nursing, and later, in other health-related fields. Women continued to travel abroad for their medical studies to Jordan, Beirut, and Egypt, and they now hold positions as Heads of Departments, Deans, and Professors. There were never any Bahrain Government restrictions prohibiting women from traveling abroad for study, even when alone. In other Gulf countries, there are now restrictions on women traveling abroad alone. Of course, family restrictions and concerns determined, then and now, if a woman could travel abroad alone or accompanied. Women who are professionals now, when interviewed, said they knew of Bahraini women who had college degrees (their teachers or relatives), and some who had traveled abroad (doctors, teachers, or relatives), and they were their role models. When they were young, these women hoped that if they had good grades in school, then they also would have these opportunities. Of course, men always had these opportunities and were sponsored by their families or the Government.

Another important force for change was the discovery of oil in Bahrain and the operation of the Bahrain Petroleum Company (BAPCO) refinery under the auspices of Standard Oil of California and Texaco (Caltex). An influx of expatriate workers from the UK, New Zealand, USA, and elsewhere moved to Bahrain and lived in the oil town of Awali. Many Bahraini men obtained training and jobs at the refinery. Some Bahraini women worked in the homes of these expatriates, while men obtained jobs as drivers. Women for the first time now had their own money and became more active in the economic system (Taki, 1974). There had always been merchants in the cities in Manama and Muharraq, but now more of the economy was based on cash wages, and the refinery as a major employer contributed to the development of a new middle class (Khuri, 1980). By 1995, 18.4 percent of Bahraini women and 55.2 percent of expatriate women were working.

Today many females are attending school, which is still noncompulsory. In the past, there was a gender gap; however, now, a higher percentage of girls than boys attend (Baby, 1996b). Some girls still receive schooling only at home due to strict family values. Government standardized exam results show that females receive a disproportionate share of the high and excellent grades over their male counterparts. This trend has been seen for the last forty years (Belgrave, 1960:96). These educational trends have implications for women in terms of admission and access to scholarships to Bahrain University, where in the summer semester of 1996, 52 percent of the new students were women (Ahmed, 1996). Women have long been the majority at the university. Women with high grades are also meeting the criteria for admission to the Arabian Gulf Medical College and the College of Health Science. According to local bank managers who give applicants’ exams, women score higher than men, and many clerical and teller jobs have been given to women, some of whom have worked up to the position of bank branch managers and executive officers (Moore, 1996). These women who have done well and obtained good jobs now have assumed some different roles in society, i.e., they may be supporting their elderly parents partially or fully; they may be making more money than their husbands who may have their Tawyehi (high school diploma) or less. Also, they may be more desirable to some men who want or need a partner who can help support the family and make possible extras, such as travel and private schooling for their children.

Anyone watching the Bahrain Government television channels sees what appears to be a male-dominated culture; and in the political sphere, this view reflects reality as there are no women in the Government at the level of Undersecretary or above. There are, however, eleven Director (head of Directorate) positions now held by women (Noor, 1996). Since the recent 1996 government changes, women holding government positions are less frequently seen on television as keynote speakers. This is the public “persona” of the culture. There is a wide divergence among intellectuals regarding how much power and opportunity are available to Bahraini women in reality.

One school of thought suggests that throughout a history of 6,000 years, women have held more power, authority, and responsibility in Bahrain than in other Gulf countries. Ebtihage Al-A’Ali (1991) states that since Dilmun times, men and women in Bahrain have held complementary positions, not competing positions. There was a Dilmun god of the sea, and a goddess of the land. When pearling was a major source of income, men went off in their boats for months at a time while their wives held their families together on shore (Noor, 1996). Some wives even worked outside the home to supplement their husband’s income. The author states that there is nothing in the Koran prohibiting women from working, only local traditions that have developed. Ms. Al-A’Ali suggests that when Western companies became active in Bahrain after 1930, the reason they did not employ women was because of their cultural values and notions of men being dominating versus complementary. She posits that these formal organizations in Bahrain are based on imported models and thought. She concluded her report stating that one of the unique attributes of Bahraini society is that its island traditions do not restrict the employment of women in top management positions. Her thesis is supported by recent newspaper articles highlighting women who have achieved top positions in private banks and government sector businesses, such as petroleum engineering, and even as Directors in the Government (Moore, 1996; Noor, 1996).

A completely contrasting view regarding gender roles in Bahrain is presented by Farouk Amin (1982). He notes Bahrain was the first Gulf state to have education for women (1928), and female social organizations, e.g. Bahrain Young Ladies Association (1965). However, Faroul Amin also cites values hurting working women. Employers are reluctant to hire women due to their high fertility rates (the average family size in 1983 was 7.9). Many husbands are not in favor of their wives working, so women quit after marriage. Women are responsible for child care. Twenty percent of rural women are not allowed to study in school. Women have the right to refuse a mate suggested by their family, but not the right to choose. The opening of Bahrain University meant it was no longer necessary to send women abroad for study. The Government is not actively helping women through its policy on sex segregation in the schools, and by its policy of providing women study opportunities mainly in socially acceptable jobs, such as teaching, nursing, and secretarial work. In the 1980s, neither government job bonuses nor housing benefits were given to women. In conclusion, Amin (1982) notes that a value on masculinity, based on religious and traditional values, precludes a large number of women from continuing their study, working outside the home, and even choosing their own spouse.

A second pessimistic view of gender roles is presented by Al-Sharyan who states that the division of labor in Bahrain is not just an economic division, but also reflects lifestyle, prestige, and social honor. Also he states that the labor market is made up predominantly of culturally disadvantaged categories, i.e., nondominant women and immigrants (1987:353). Exploitation and sexual inequality have neither been reduced nor eliminated. Women did not demand more rights or could not, so, in order to establish wider access to resources, they tended to act so as to reinforce traditional social norms and values (1987:344). Women concentrated in particular specialities and are thus confined to a fairly narrow range of jobs within the occupational structure. As a result, there is a rigid differentiation in the labor market along sexual lines based on the patriarchal characteristics of the society which are now consolidated (1987:350). This is reflected in women being the leaders of organizations for the blind, deaf, handicapped, and nursing.

Gender roles in Bahrain probably fall in between the two extremes presented by the above studies. A Bahraini economist listed the five social ills which he felt most confined women to an inferior status in Arab society, i.e., the chastity requirement, early marriage, the dowry, polygamy, and divorce (Taki, 1974:11). Changes are slowly being seen in two of these practices, e.g., early marriage and the dowry. Another practice which prohibited women’s development is veiling, which excludes women from many fields of activity (Boserup, 19:127). Some women have made it to top positions in spite of these “social ills,” and 18.4 percent of Bahraini women are working and 55.2 percent of non-Bahraini women are working. No studies have been done on working women regarding marital status and number of children; what sacrifices were made by them; and if they are married, whether there is any correlation with their husbands’ education level. Is there a “glass ceiling” in the Government, withholding jobs from women above the level of Director? What role does a girl’s self-confidence play in pursuit of education, type of spouse, work opportunity after marriage, and family planning? What are the long-term implications of higher school grades of women, and their academic achievements at the college level in terms of their choices of marital partners, marital relations, the stability of their marriage, and the effect of their education on the educational success of their children? Who is the breadwinner and who is the boss? Further studies in these areas would be very informative for government planners and policy makers.

B. Sociolegal Status of Males and Females, Children and Adults

The sociological status of males and females as children, adolescents, and adults are clearly defined in the Koran and interpreted by the Bahrain legal system, which is based on a combination of Sharia law and British jurisprudence which are expressed through codes (Ziskind, 1990:41). All births are recorded and rights are granted according to the nationality of the father. Everyone in the country has access to free medical care after their birth, including expatriates. Bahraini women can sign their own operation permits in hospitals or use their thumb prints; however due to local tradition, the husband, or even other relatives, tend to sign permits. This practice is perpetuated by medical staff who ignore or who are unfamiliar with patients’ rights. This practice has also been witnessed in Saudi Arabia (Abu-Aisha, 1985). Hospitals in Bahrain do not have statements regarding patients’ rights and responsibilities.

All local children can have a place in the Government schools. Education is free for all Bahrainis and a place in the Government schools is provided for all who register. Girls have access to all areas, including religious studies and technical education. Expatriate parents send their children to various private schools, which are based on various preferences: ethnic (French School, Indian, Pakistani, Japanese, or Filipino), religious (St. Christopher’s School - Anglican and Sacred Heart - Roman Catholic), or socio-economic (Bahrain School, Al Hekma). Bahrainis who pass the entrance exam are entitled to attend Bahrain University and scholarships are available. The majority of students to date have been women, and more are of the Shi’ite sect.

Previously, during the 1960s, the Government made efforts to promote full employment for qualified male adults in companies such as BAPCO, the Defense Force, and other government ministries, and companies. However, now this is not economically feasible, so there is much competition for government and nongovernment jobs. Also the World Bank and other financial organizations are stressing the need for less government control and more free-market economic activity in the country. As a result, unemployment is becoming a national concern. How this will affect women’s work opportunities is not known. All workers are protected by various work laws and due process rules for firing workers are enforced.

Men and women can own property inherited from their parents based on the rules of Islam for the distribution of property; however this differs according to Sunni or Shi’ite affiliation. Women keep their family name after marriage and all their property remains in their names, without becoming joint property or being held in their husband’s name (Badawi, 1980:23). Women in Bahrain own many small businesses, shops, boutiques, and compounds of rental villas. All marriages and divorces are registered in the Court to ensure people are legally protected. Family disputes over property can be brought to the Courts for adjudication.

Bahrain had a “Special Treaty Relationship” with the United Kingdom until 1971. Now the political system of the country is a traditional monarchy under an Amir. All officials are appointed and there has been no suffrage for anyone since 1975 when the parliament was dissolved (Curtis, 1977). Formerly, there were elections for municipal councils and women and men both had the right to vote. The one Constituent Assembly election held in 1972 allowed only men to vote and there have been no subsequent elections.

Individuals, who violate the laws of the State or strictures regarding certain behaviors, are brought before the various Courts, and fined or confined. Even expatriates appear before the Bahrain Courts, which are held in Arabic, for traffic violations, medical negligence lawsuits, drug trafficking, theft, and visa violations. Other minor violations, including being seen eating during the daylight hours of Ramadan, may result in fines for expatriates and tourists. During Ramadan, the media informs residents and visitors of all restrictions.

There are certain individuals whose legal rights are not clearly defined due to their unclear birth status. These are the foundlings (laqeet) who have been abandoned, and whose family and nationality is unknown. They are basically homeless and have no papers. Between the early 1920s and the 1950s, the American Mission Hospital had an affiliated orphanage and school for these children. Later, during the 1950s and 1960s, the Government hospital was their legal residence until a job was found for them. Since the 1970s, they have been cared for in the Children’s Home in Gudhaibia, which provides for these children with the help of volunteers.

Life is not easy for these individuals. The foundlings are taken care of and have access to free health care and education; however they have no documents and this prohibits them from obtaining any passport, owning property, procuring government employment, and other social benefits. The female foundlings are easily placed in permanent foster homes of Moslem Bahrainis, as under Islam they are not considered adoptable in the full Western sense. The females fare better and generally marry, and can inherit special gifts if any are willed to them. The males are not placeable in foster homes as they are not related to the women in the family, so rules of seclusion and veiling restrict placement. The males spend their lives in government institutions. They cannot be raised by non-Moslem Bahrainis.

C. General Concepts and Constructs of Sexuality and Love

Sexual suppression, except in a heterosexual marriage, is the expected norm in Bahraini culture. Within a legal marriage, the sexual relationship of the couple is between the husband and wife, and based on their religious beliefs and personal preferences.

Cleanliness is associated with sexuality. A person should be clean and attractive before and after engaging in sexual activity. Cleanliness may include removal of part or all body hair for women, and some or all hair for men also. Activities before sex include at least partial bathing, if not full bathing; use of attractive incense or perfumes; make-up for women depending on the couple’s choice; and attractive lingerie, depending on personal choice and economic status. Some women attend exercise classes to tone up their bodies, however this is not the norm, and obesity among men and women is a problem in the Gulf (Bin Hamad, et al., 1991). Some couples may disrobe while others remain covered or partially covered during sexual activities. There have been no studies on practices related to sexuality in the home or bedroom. After sexual intercourse, all Moslems are expected to wash, and for the woman to wash completely, including her hair. If a woman arrives at a party with wet hair, then jokes may be made about her possibly preceding sexual activities.

Women who smoke are considered to be sexy by young men according to informants. Traditionally some Bahraini women smoked the hubbly-bubbly (Al-gadow) at home, at the village springs, and at parties when offered (Hansen, 1967:89). Bahraini women do not smoke cigarettes openly at work (unlike some expatriates), and are only occassionally seen smoking in their cars or at restaurants. Recently, security guards have noted that a few teenage girls and younger women have been noted to have cigarettes in their purses. The prevalence of smoking among working women in Bahrain is estimated to be 20 percent based on the one study published (Al-Khateeb, 1986). Women have a meeting house in Adliya where they can go to socialize and smoke. Middle Eastern women in countries other than the Gulf area, such as Jordan, Egypt, and Turkey smoke openly, however this is not a local custom. There have been no studies published in Bahrain regarding why women smoke; however a study in Saudi Arabia (AlFaris et al., 1995) stated that relief of stress was the most commonly admitted reason for smoking (48.9 percent), followed by no reason (28.5 percent), and imitation (12.2 percent).

Children are important in an Arab family. The traditional wedding wish says “from the woman children, from the man money.” All men desire a boy to retain their name, and a woman will continue getting pregnant until she has a son to please her husband, and herself. After the birth of the first child, the father and mother relinquish their name to that child, until there is a male child. The man is called “father of Abu... and the “mother of Um... (Curtis, 1977:55). This practice reinforces the importance of children in the society and is not meant to denigrate or detract from a woman or man’s status. If a couple has difficulty conceiving, there are two in-vitro fertilization (IVF) units in the country.

The Western concept of love is used by few members of Bahraini society to describe their feelings for their spouse. Parents will clearly state they love their children and their parents and have a duty towards them. An individual’s relationship, in certain cases, may be closer with their parents, siblings, and children than with their spouse; this depends on the type of marriage they entered into.

The nature of family relationships has been reported in a thesis by Kahtanie (1992) who asked married Bahraini couples about their coping strategies when facing life strains in marital and parental roles. Twenty-five married couples attending a Health Center participated. The researcher noted that marriages in Bahrain are based on mutual understanding, but conflicts and frustration can occur when confronting stress. Participants described the parental role as one of the most important roles in Bahrain (Kahtanie, 1992:1). The participants however were not eager to share their coping mechanisms. Eighty percent said they would rely on God. Traditionally a couple’s support system included parents, grandparents, and/or a neighbor; however now only 84 percent said they would ask these people for assistance. The remainder said they would handle the problems themselves. Twenty percent said the doctor was of no help. The chief causes of marital stress included nonacceptance by spouse, non-reciprocity and lack of give and take in the relationship, and role frustration (Kahtanie, 1992:23). Forty percent of the men said their wife was not a good sexual partner. Most of the couples adjusted to their lives by doing things to avoid differences, solving differences between them by yelling, shouting, and keeping out of the other’s way. Their coping responses included not telling anyone of their problems because Bahrain is small and information can spread. Other coping mechanisms included controlled reflection versus emotional disharmony; comparison to other marriages; passive forbearance versus self-assertion, and selective ignoring. Sixty percent of the participants said they keep most of their feelings to themselves (Kahtanie, 1992:46).

The implications of this forbearance, ignoring, and internalization are mentioned by Kahtanie in conjunction with Chaleby’s 1987 study on how unhappy marriages are reflected in various psychosomatic disorders seen, especially among women in Saudi Arabia. These women reported that incompatibility in intimacy and socializing, not meeting their husband before marriage, and polygamy lead to stress, which was expressed as complaints of backache, headache, pain syndromes, or other symptoms suggesting underlying anxiety (Chaleby, 1987).

An interesting trend detected by Kahtanie was that the higher the education of the woman, the less she was able to cope with problems in the marriage (1992:36). Avoidance coping mechanisms elicited by Kahtanie are reflected in other aspects of family life or work, e.g., people say “its not like we were prevented, we just did not ask or raise this issue.” Personal adjustment and avoidance of confrontation is a core value in Bahraini society. This value is seen in other island cultures around the world (Hall, 1996) and has implications for how change is introduced or not introduced into a society.

2. Religious and Ethnic Factors Affecting Sexuality

A. Religious Values (Din)

The official religion of Bahrain is Islam, which is upheld through the country’s laws, culture, heritage, and traditions. The majority of residents in Bahrain are followers of Islam. During the Friday noontime service in the mosque, the imams teach their congregation the religious point of view regarding all aspects of their life. At the time of the night prayer, special lecture activities are scheduled. There are special religious booklets, e.g.: Al-moamalat Al-islamiyah (about banking, charity, selling, and buying), Al-Ebadat (praying, social conduct, Haj, and fasting) available to guide people in their lives according to the Prophet’s teachings. Non-Moslem expatriates are expected to respect the religion and customs of the country. There are three major illicit acts in Islam: fornication, alcohol consumption, and eating pork. According to Islam, sexual matters are private matters and sexual behaviors are appropriate only between married heterosexuals.

Islamic law requires people to be modest in their dress and the body must be covered in public. For a man, this includes the part from his hips to his knees, while for a woman this comprises all her body from the top of the head to the ankles excluding the face, hands, and feet. Expatriate women are not required to be covered completely in Bahrain, unlike Saudi Arabia; however they are expected to dress modestly in public.

While the practice of veiling exists in Bahrain, the percentage of women wearing a veil has varied through the years, depending on rural or urban habitation and social class. Veiling practices posed a difficulty to the early American mission doctors who were all men, and it was not until the 1930s that there was a female doctor, and then only for two weeks a year. In spite of this, one quarter of the operations at that time were on women, and in increasing numbers, Bahraini women gradually attended the mission hospital and were seen by male doctors (The American Mission Hospital, 1933-34:7). In the early days, a hole was made in the veil and the specific area of the mouth, face, or body was exposed. Today, some women or their husbands still request that the woman be seen only by a female doctor; however this is not always possible. Now more and more families choose to pay and attend the clinic of the “best” doctor in their speciality regardless of gender.

The superego, according to psychoanalytic theory, is the portion of the personality associated with ethics, self-criticism and the moral standard of the community. Two psychiatrists in Saudi Arabia describe Arab culture, particularly in the [Arab] peninsula, as characterized by a deeply rooted set of moral codes, social values, customs, and rituals of behavior. The collective attitude toward such conventions is rather strict and inflexible (Al-Khani and Arafa, 1990).

The traditional extended family (atilab), which has an authoritarian and hierarchical structure, has the main role in transmitting values and securing conformity, and is the basic and most influential social system. Al-Khani and Arafa state that this practice leads to the development of a superego developmental system that is characterized by the cultivation of shame (Ayeb) rather than guilt, and the enhancement of conformity and fear of other’s criticism rather than individualism and self-criticism. A consequence in Saudi Arabia is seen in the number of patients, markedly males, who comprise 97.2 percent of clients who see a psychiatrist for the treatment of social phobias. These statistics reflect a cultural attitude that discourages females from seeking psychiatric care.

The study of superego development in Saudi Arabia and the concept of shame (Ayeb) needs to be considered as a possible explanation for some of the differences seen among Bahrainis in the practice of their stated religious beliefs. Followers of any religion vary from true and fervent believers who practice all aspects of their faith to those who follow certain aspects and disregard others. Situational ethics is a term used in the West to describe why the degree of compliance to religious rules is not always 100 percent, and how people justify their daily practice based on the situations encountered and what is/was the higher right. This term is not commonly used in relation to Islam; however, this report will show that men and women and/or their families decide what religious practices relating to human sexuality they will follow in their personal lives all the time, or some of the time, or which rules they will ignore completely depending on the social situation. Traditional cultural values, such as shame (Ayeb), at times, may supersede the higher religious ideals. Also according to Al-Sharyan, Eastern loyalty remains fixed and strong toward familial and tribal values whatever the influence of modernization (1987:342).

Bahrainis respond to differences in people’s adherence to religious values in a mature way, i.e., people know when they should pray - Shi’ite three times a day and Sunni five times a day. The call to prayer from numerous minarets announces prayer time. People are not forced out of stores and restaurants during the “exact” prayer time. Although the Government television channels announce prayer times, programs are not discontinued for fifteen to twenty minutes as in Saudi Arabia. The attitude in Bahrain is that mature people and true believers know what they should do without coercion.

Islam condones sexual activity in marital heterosexual relationships (Fakhro, 1991). Homosexuality is forbidden (haraam). There is no enforced Bahrain state law prohibiting this practice which does exist. Anal sex is haraam (“the sky shakes when doing it”); however it is practiced between men and women, and men and men. Although prostitution is discouraged in the Koran, it is legal in Bahrain. There were early attempts to regulate it by Court decree (1937). Child abuse, including sexual abuse and incest cases, are seen by health care workers in Bahrain. Divorce is looked upon with strong disfavor by the Prophet; however divorce rates are increasing to the detriment of children and the elderly. Islam is vehemently against drinking alcohol, and prohibits the use for pleasure of any drug that can harm the intellect or the body, including tobacco (Fakhro, 1991). However, all the above practices are prevalent in Bahrain society to the detriment of health promotion programs in the society. As mentioned, while religious teachings expound ideal values, humans cannot always reach the ideal. This report will present some of the ideals and rules regarding aspects of human sexuality, and the current gaps seen between the ideal and reality.

B. Ethnic Values

There are more than sixty nationalities represented among expatriates living in Bahrain and they comprise about one third of the total population. Most of these individuals do not have the option of ever becoming a Bahraini citizen, unless they marry a Bahraini, perform in a special job category, or meet other stringent qualifications, such as religion or five-year residency status. As a result, most expatriates make no effort to become assimilated into the local culture. Some learn Arabic out of necessity due to their job; however, most join social organizations and clubs where they can meet their own compatriots. All these expatriate groups have brought their various religious, moral, and social values with them, and these are reflected in the variety of dress styles seen (sari, sleeveless blouses, tight pants, no bras, miniskirts, and jogging shorts) which are seen on the local streets, and in shops. Likewise attitudes towards alcohol use, pornography, prostitution, and unmarried and extramarital relationships vary from group to group and individual to individual. Concepts regarding degrees of nudity vary greatly and differences among expatriates are reflected where they take their children swimming. There is one private beach attended only by expatriates wearing bikinis and bikini briefs (women and men). Also at this beach, women are seen topless at times when they are changing their clothes. Because of the nudity, some Westerners do not take their children to this beach and limit their outings only to clubs or their residential compound pools.

Bahrainis are very tolerant of the expatriates and their different life-styles. No restrictive dress codes have been passed; no religious police (Muttawa) censure people verbally or physically. People are arrested only for blatant, public violations of the Ramadan fast during daylight hours. Bahrainis must be credited for their highly hospitable culture and tolerance of people from different cultures and religions. Occasionally, situations arise because of the dichotomy of values, particularly regarding dress codes, which are a very obvious difference. Personal or public conflicts sometimes result which require resolution. Bahraini children are taught from a very young age that modesty and covering of the body is proper. Occasionally, a child may experience confusion when their first teacher is wearing a sari and the abdomen and arms are exposed, as well as her hair. Children report feeling uncomfortable at school during their first days because of the “embarrassment” which they feel seeing the teacher’s abdomen. Parents explain about differences in national dress and these issues are resolved. More-public conflicts occur, but rarely, such as that seen in 1994 when mainly male and female expatriate runners in a competition jogged though some conservative villages wearing tank tops and jogging shorts. The local media later reported some stones were thrown at the runners. Such events subsequently have been routed through mainly desert areas away from the villages.

Ethnic attitudes towards other aspects of sexuality such as prostitution vary widely. In some cultures, such as Thailand, women know and accept that their husbands frequent prostitutes, while the Filipinos are mainly Catholic and such activity is considered a mortal sin. In spite of this prohibition, the Filipinos in Bahrain are attracted to the money available through prostitution and have the reputation of being one of the ethnic groups active in this practice.

3. Sexual Knowledge and Education

A. Government Policies and Programs for Sex Education

There is a national curriculum which is taught in the boys and girls schools using the same textbook. The course content offered to Intermediate School students is not labeled as sex education. An introduction to human anatomy and physiology is taught to students around the ages of 10 to 12, depending on a student’s school entry age. This basic course is purely an anatomy and physiology approach to sexuality, and male and female informants said they learned about eggs, sperm, menstruation, etc. Family planning is now also covered in this course. There is no discussion of personal relationships or human sexuality, as this is considered haraam. There is little discussion of sexually transmitted diseases (STDs) as the emphasis is on normal anatomy and physiology. Some informants report that they did understand what their teacher said, so that when they started menarche, they already understood what was happening to their bodies; however, one woman reported that when she started menstruating, she was afraid she had hurt herself and cried, then told her mother. Another informant mentioned that the intermediate-level course was not enough. “She did not know how babies got out of the body, maybe through the rectum?” In her case, she did not understand about the birth process until she took another course in college. At the Tawyehi level (grades ten to twelve), further anatomy and physiology courses are taught only to those in the science stream or curriculum. Students in the arts or commercial streams have no further courses. There have been no studies reported on the effectiveness of these general intermediate-level courses, or senior school science courses, or the extent of knowledge or accuracy of knowledge among students or Tawyehi graduates.

Graduates from the College of Health Science reported that there were classes where students had to present topics and discuss material relating to the genitourinary system. The females said they were very embarrassed in the coed class, and were sweating; however the subject was taught as scheduled. Everyone felt more comfortable with the other subjects in the curriculum.

An expatriate physician in 1987 wrote the only article regarding the sexual responsibilities of physicians seen to date in the national medical journals (Gravesen, 1987). Other physicians have written on related topics such as reproductive fertility (Rajab, 1984), and urogenital problems of the elderly (E. Amin, 1984). In general, the term human sexuality is simply not used.

There have been no studies published in Bahrain regarding knowledge of women about the climacteric (menopause), and the physical changes they can expect, nor its effect on their libido. Two hospitals have started menopausal clinics to meet the needs of older women, and there have been a number of articles in the general press about the advances made in hormone replacement therapy. There are also no data available regarding women’s knowledge regarding mammogram screening, pelvic screening for cancer, osteoporosis, or other preventive measures which are needed and available. Only recently have physicians in Gulf countries reported psychosocial symptoms related to menopause, in Kuwait (Al-Quttan and Omu, 1996) and in Saudi Arabia (Sadat-Ali, 1993). Reportedly, there is a reluctance among physicians to study osteoporosis in this age group, which showed a high incidence of the disease in the pilot study (Sadat-Ali, 1993), or other related topics. The general opinion expressed by female informants is that a lot of older women “suffer at home when going through the change.”

Regarding human sexuality courses for the general public, there are lectures offered at the Primary Health Centers regarding pregnancy care and delivery; however there are no lectures addressing issues associated with “human sexuality.” The Bahrain Family Planning association (B.F.P.A.) also offers lectures; videos and booklets about family planning are available from their library.

B. Informal Sex Education

Informants mentioned a variety of informal sources for their early sex education, as most said parental instruction was rare and consisted of “don’t touch it” or “don’t let anyone touch.” Regarding parental instruction, the range of responses included those who said, “I could never talk to my mother/father about that,” “She/he did not encourage us to ask,” “Mother didn’t tell,” and “We didn’t ask mother,” to those whose parents were supportive and “explained when asked,” to parents who approached them first and “gave them books to read,” and/or “explained everything to them.” Some girls were told riding bikes and horses could be harmful, so they should be careful. All informants, men and women, said they discussed sex-related topics with their friends; some did or did not discuss such sex-related matters with their older or younger siblings. All informants likewise said that the media had an influence on their knowledge, including movies (Indian, Arabic, Western), music (Arabic, Western), and books and magazines. Some mentioned how their friends or coworkers, at the time of their engagement, gave them graphic information on “what to do” and “how to do it.”

Human sexuality teaching to hospital patients can only be confirmed for cardiac patients attending the Shaikh Mohammed Bin Khalifa Bin Salman Al Khalifa Cardiac Center as their patient-teaching booklet (in Arabic and English) covers all aspects of sexual behavior after heart attacks and surgery. Urologists and obstetric/gynecology staff discuss human sexuality topics with their patients; however they have no teaching booklets for them.

4. Autoerotic Behaviors and Patterns

A. Children and Adolescents

Infibulation, clitoridectomies, and other forms of female genital mutilation have never been performed on Bahraini females. The practice is not seen in the entire Gulf region and Hicks clearly mentions this distinction (1993). It was practiced in the Saudi Arabian peninsula, in Yemen (Muhsen and Crofts, 1991). Some expatriate Moslem children and women born elsewhere, e.g., in the Sudan or Egypt who have been circumcised, are seen in Bahrain’s medical facilities. It was only in July 1996 that Egypt banned circumcision of girls in all state medical facilities (“Girl Circumcision Ban,” 1996); however barbers and doctors are still performing the procedure and girls are hemorrhaging to death in Egypt.

Informants report that Bahraini children around the ages of 2.5 and 3 begin to touch themselves in the genital region like children around the world. As soon as relatives see this activity beginning, the child is taught this is not socially acceptable, and every time the behavior is seen, the child is admonished verbally not to do it (physical punishment is not used). Bahraini children do not walk around naked and always have clothes on.

All the female informants report that their mothers from a very early age taught them how to sit with their legs together, to sit carefully and to ensure they are covered properly, and how not to sit (not to squat, and “not to let anything show”). Some report that they were taught how to wash their genitals in a proper way, and now they are teaching or taught it to their female children, e.g., with a closed finger and thumb position, and not with their fingers reaching and feeling. The prevalence of this particular washing method is not known. When girls reach the age of 10 to 12, their general play activities become restricted, and all reported their mothers told them their bodies would be changing and that they needed to behave in a careful manner. The concept of virginity and being careful with sharp objects was instilled in them. The incidence or types of autoerotic behaviors in this age group have not been studied.

B. Adults

Adult autoerotic behaviors have not been studied in Bahrain. A study was conducted in a conservative region of Saudi Arabia regarding women and breast self exams (BSE). Half of the women attending a clinic had information about BSE; however 12.1 percent said they did not think they should touch their breast, and 9.0 percent said it was embarrassing for them to do BSE (Akter et al., 1995). No studies have reported on whether men conduct regular self-exams for testicular cancer or have annual prostate exams. Annual prostate screening is not promoted, and rectal exams are done only upon patient request in many cases. These exams may be deleted due to the sexual overtones and the staff feeling uncomfortable conducting them. Further research on preventive health screening and cultural prohibitions would be informative.

Pornography is prohibited by law; however its definition is not clear. Magazines are seen in the country (e.g., Playboy) which are illegal, while The Sun, the United Kingdom newspaper typically featuring a topless woman on page three, is not. Men bring these magazines into the country and some keep them at their mothers’ houses when their wives do not approve of them.

There are X-rated movies or blue movies available in Bahrain, as well as what may be called provocative movies which include a few seconds of partial nudity, belly dancing, or heavy petting. There have been cases reported of couples making X-rated movies or blue movies for themselves, and later these somehow got into others’ hands which caused great embarrassment to those involved. Other blue movies have been smuggled in from distribution centers in Saudi Arabia or abroad. Expatriates have been arrested at the Saudi Causeway transporting such tapes in their cars.

Another video source of stimulation to men are the wedding party videos from Bahrain, Saudi Arabia, or Qatar which are copied and distributed unknown to the sister, relative, or sister’s friend who held the original. Informants report that some of their brothers have seen and even sold copies of these videos, which include Gulf women with their hair uncovered, dressed in miniskirts, with tight clothes, or low-cut necklines. The adolescent boys and young men watch these movies when available.

Sexual devices are not sold in the country; however they are brought in by people who travel abroad. Informants said that some people keep them for their own use, while others are sold. Sexual devices are not denned as illegal by law. One incident was reported of a Saudi Arabian woman returning to Saudi Arabia who had bought a sexual device elsewhere. Saudi Arabian Customs could not take it from her because such items are not mentioned in customs laws, and the woman retained her device.

Aphrodisiacs from various sources are used; but their prevalence has not been studied. Some compounds from local or imported herbs are thought to have beneficial powers for improving male potency, female fertility, or for curing venereal diseases. Such herbs are available from traditional herbalists (Al Ashab) in the various suqs, or from traditional midwives. References on this topic are limited in content (Bushiri and Davis, 1996; Abdul and Saheb, 1990, and Abu-Zaid, 1966). The latter source in Arabic describes the herbs used in the Gulf and methods of treatment which were brought in from India, Syria, Sudan, and Egypt. Some individuals also request hormone shots from their physicians. Testosterone therapy should be avoided as much as possible; if used, then monitoring of the prostate is needed (E. Amin, 1984:30).

Alcoholic beverages are freely available in Bahrain through retail liquor outlets, hotel bars, and restaurants unlike other Gulf countries. Liquor is served openly to Bahrainis, expatriates, and tourists. Liquor has not always been so available. Traditionally, Arak, the local liquor made from dates, was confiscated by the police (British and local). Then foreigners were allowed to purchase liquor if they held a special permit. At this time, a black market in imported spirits flourished (Belgrave, 1960), and Arak was made by hidden stills. Then retail liquor outlets were licensed and sales flourished. Islam’s prohibition of alcohol is based on its intoxicating effect on the brain (khumr). Modern scholars in the Tufseer advise people “don’t put your hand in a dangerous thing.” Hotel bars, restaurants, and clubs frequented by locals and tourists are also frequented by prostitutes.

Some individuals experiencing difficulties of any psychological or organic nature, including sexual, traditionally would go to the mutta wa (religious man or woman) and ask for assistance. The mutta wa would say words from the Koran to cure the person (Al-Maki, 1996:16). These psychosomatic cures were reportedly effective in some cases.

Fracture of the penis is a urological emergency situation which requires immediate identification and surgery in order to prevent morbidity to the patient. Prior to 1988, there were fewer than 100 cases reported in medical literature (Sandozi et al., 1988). Urologists in the Gulf during the last ten years have reported dozens of such cases. Fracture of the penis may occur during coitus, or by a direct blow, by abnormal bending of an erect penis, or through other sexual aberrations. Men report hearing a crack, then feel a sharp pain with subsequent loss of erection, deformity, discoloration, and swelling, but no micturation (painful urination) difficulties. If surgical treatment is not provided quickly, the condition results in serious morbidity, including deformation of the erect penis, weak erections, and reduced sexual performance. The surgical procedure is described by Taha et al., 1988.

Various reports have been published in the Gulf regarding penile fracture, including eight cases in Kuwait involving seven expatriates living without their wives. Their injury was self-inflicted in four patients and due to accidental trauma in three cases. In one case, a Sudanese male was trying to negotiate a hymen and vagina which had strictures due to the ritual practice of female circumcision and clitoridectomy (Sandozi et al., 1988). Numerous other cases have been reported in Abu Dhabi (Al-Saleh et al., 1985) and Qatar (El-Sherifet al., 1991), with nine cases in four years in the United Arab Emirates (Hamarnah, 1993), Bahrain (E. Amin, 1994), and Iran (Asgari et al., 1996). As mentioned, the incidence of this urological injury is generally low, but review of the literature shows the incidence of this injury is higher in the Arabian Gulf region (Hamarnah et al., 1993). Some authors suggest the various etiological factors include relatively large numbers of single male expatriates, and married men living away from their spouses, in a Moslem country which contributes to the genesis of this injury. Sandozi et al., suggest that excessive libido and sexual urges which cannot be relieved may play a part in the causation of penile fracture (1988). Expatriate workers in Saudi Arabia do not usually socialize with Saudi women and night life activities are rare due to segregation of the sexes, (Abbas and Satwekar, 1989). In Bahrain there are many opportunities to socialize including discos (Belgrave, 1968).

Priapism is a painful, persistent, penile erection without sexual excitement and is due to engorgement of the corpora cavernosa. Priapism can be self-induced with various drugs and occasionally cases are seen at medical facilities. Priapism is also a known complication secondary to sickle cell disease (SSD). Reports from the U.S.A. show that 50 percent of boys/men with SSD can be affected, i.e., report having one occurrence or more of priapism. Studies in the Gulf show that priapism is a common complication of SSD, e.g., in Saudi Arabia with 18.4 percent of SSD patients reporting at least one experience (Al-Dabbous and Al-Jama, 1993). In Bahrain the incidence of priapism prevalence is low at 2.0 percent (Rasromani et al., 1990:114), and the incidence of SSD is 2.0 percent, while the sickle cell trait is 11.2 percent.

Informants were asked about an incongruous aspect of culture seen in Bahrain. For example, American wrestling programs are seen on local television and in other Gulf countries. These programs are very popular and individual wrestlers are known by names. The wrestlers generally have extravagant make ups, hairstyles, and outfits. Some of these outfits are only tight bathing suits and this is shown on local TV. Informants state that wrestlers themselves are not seen as provocative as wrestling is a traditional sport from the days of the Ottomans, and it is seen as exercise, or family entertainment. However, it was noted that if a girl had tapes of wrestling matches and watched wrestling in an “entranced” manner, then that was another issue. Surprisingly, body-building competitions are held annually in Bahrain, and participants are Bahraini men.

While public autoerotic behaviors are infrequently seen in Bahrain, they are occasionally reported. An elderly Western expatriate visitor attending church was horrified as an expatriate male sitting next to her masturbated during the service. She reported she was afraid, but could not get up because the church was so crowded. Female Asian expatriates report situations where taxi drivers have begun masturbating while they were in the taxi. The reputation of this Asian group is rather low morally, which may be why they are exposed to more encounters of this nature. Expatriate women all note that in Bahrain theses incidents are very rare, unlike the frequency of similar incidents they were exposed to in Saudi Arabia, i.e., you could not look men in their eyes or below their chests.

5. Interpersonal Heterosexual Behaviors

A. Children

Sexual Exploration, Sex Rehearsal Play, and Rites of Passage

Children seen touching other children in any suggestive manner are firmly instructed that this behavior is not appropriate. All sexual exploration and sexual rehearsal play, if noted by the parents or relatives, is strongly extolled as forbidden.

All Bahraini boys are circumcised according to the requirement in the Koran. The procedure is usually performed in the first forty days after birth in a hospital or Health Center Day Case Unit. Traditionally, up until about ten to fifteen years ago, boys of 6 of 7 years of age were circumcised by a doctor or a traditional barber. This latter practice has been stopped in Bahrain, although it continues in Saudi Arabia and is thought to be a source of hepatitis C infections in that country (Arya, 1996:229). Traditionally, after the circumcision, money and sweets were distributed to other children in the family and to the boy’s friends and neighborhood children (Curtis, 1977:55). This practice has now almost died out.

There are no ceremonies marking adolescence or adulthood. Children, upon reaching age 7, begin to attend the mosque regularly in order to learn more about their religion, and this is their rite of passage to full membership in the community.

B. Adolescents

There are no female puberty rituals in Bahrain. Women mention that when they reached the age of menarche, they informed their mothers, and the girls in return were told, “they were now a woman,” “they needed to behave like a woman,” “to be careful of covering,” that “they could no longer play outside with children,” and “to be especially protective of their virginity.” Their mothers usually told other female relatives or friends that their daughter was now a woman, but there was no party or ceremony. Women reported gossiping to their sisters and how they were happy that they were normal.

A few studies have been done regarding the experience of menstrual cycle symptoms among Bahraini women (Al-Gaseer, 1990), Saudi women (Atallah, et al., 1990), and Kuwaiti women (Ibrahim et al., 1979). The age of onset of menarche in the region varies from 10 to 17 years of age with an average of 13 years. Women in the younger age groups, 17 to 24 years, report more menstrual symptoms, while educated women report more menstrual and premenstrual symptoms than single women (Al-Gaseer, 1990; Ibrahim et al., 1979). Some women report they called their period “my auntie”; other euphemisms include “Hajiya came,” and “I gave birth.”

Many Arab women reportedly do not use tampons because of the sexual connotation of placing something in the vagina; also they fear tampons will make their vagina wide. A third belief is that “washing out is cleaner” than keeping it inside. Some Westernized married women report using tampons, but they said unmarried girls and teenagers would never use them.

The traditional notion that a menstruating women is unclean (Najis) still pervades the belief system, although Al-Malki states this notion was rejected by the Prophet (1996:19,27). Menstruating women are not to fast on the affected days during Ramadan or on other religious days, but must make up these days later. A woman should not be divorced by her husband when she is menstruating; likewise sexual relations are prohibited during menstruation (Al-Faruqi, 1 988:72).

Once a women’s menstrual cycle has started, there is only one occasion when it needs to be strictly regulated and that is when a women plans to go on Umrah or the Haj. A woman cannot go to Mecca and perform the prayers in the Kaabah or other rituals if she is menstruating. Girls or women with regular periods or irregular periods are given primolat N tablets for 21 days for suppression of the period, or sometimes birth control pills to regulate them, so they can plan on when to make Umrah or Haj, and they are ensured of being “clean.”

The relationships between adolescent unmarried males and females, aside from family relationships, are strictly controlled by families. The majority of boys and girls attend segregated government schools until their graduation from Tawjehi (high school). There have been coeducational expatriate schools for decades in Bahrain, such as St. Christopher’s, Sacred Heart, the Bahrain School (American), and the Indian School, which a percentage of Bahrainis have attended. During the last ten years, expensive coeducational private schools have opened specially catering to Arabic-speaking Bahraini and expatriate Arab students, e.g., Al Bayan, Ibn Khaldoon, and Al Hekma. In all the coeducational schools, boys and girls study together, take school trips with their parents’ permission, and sometimes socialize. Dating in the Western sense is not the norm. This is the only opportunity for some students to meet members of the opposite sex. Students in mixed groups may also socialize in the shopping malls and hamburger and pizza places. Male teenagers are freer to spend time out of the house with friends, expatriate students, and workers.

C. Adults

Premarital Relations, Courtship, and Dating

Bahraini parents strictly control, or at least monitor, their daughter’s meetings with men, and discourage anything more then necessary, talking relationships. As mentioned earlier, dating in the Western sense is not the norm. There are instances known where Bahraini women dated expatriate men, including those in the American military during the time of the Gulf Crisis and Gulf War (1990-1991), and these women actively sought out these relationships. These situations are very rare as most families are very strict. One informant reported recently seeing two Persian Bahraini women trying to pick up two American military men in Manama. The two men quickly declined and kept walking, as these relationships are strongly discouraged by the U.S. Military due to security and other reasons.

Sexual Behavior and Relationships of Single Adults

Single men have premarital sexual relationships, while single Bahraini women ideally do not. Single adults are expected to be chaste in their relations, and the girls are expected to be virgins at the time of marriage. A man may have an expatriate girlfriend or girlfriends, or a boyfriend in Bahrain or abroad. The prevalence of these patterns have not been studied among men, nor their prevalence in relationship to venereal disease in Bahrain.

Some Bahraini single women do have affairs. Reportedly, this behavior is very rare, and the meetings are conducted in hotels or elsewhere in Bahrain, and preferably where there are “no eyes,” or when they are both abroad. A single women who is not a virgin will face difficulty finding a husband if she is known to have lost her virginity, “not by a normal condition,” meaning not through marriage. An affair places her in an abnormal or doubtful situation. The women who are known not to be chaste will find it difficult to ever get married (Taki, 1974:1 1). A few rare marriages do occur, informants reported, but this is not common, as the man’s family will be against the marriage if they have any knowledge that the girl is not a virgin. There have been no reports about Bahraini women traveling abroad for hymen repair surgery.

When expatriate women are seen with a man, it is generally assumed that they are “friends,” or lovers until it is clarified that they are married. This attitude extends to Western or Asian women, all of whom are generally considered to have loose morals until their actions prove otherwise. The Government does not get involved in the affairs of expatriates unless a man files a claim of adultery against his wife. In these cases, the residence permits of the woman and her lover are usually revoked and they are deported. This is done quietly, unlike the 1990s’ case in the United Arab Emirates which received worldwide press coverage.

Conservative Bahraini men and families, if they know someone is having an affair, will enforce certain rules of social behavior in order to protect their wives or families from this person’s influence. They will not allow their wives to invite into their house a married or unmarried woman who is living with a man or who has a male “friend,” even if the woman is the wife’s coworker, compatriot, or friend. These same women are not allowed to sit in the wife’s car seat, i.e., the front right passenger seat so they have to sit in the back seat. In most cases, the husband or extended family (Allah) even ask the woman not to see such a friend at all socially, because being together could affect the wife’s name and they should not be friends. In some cases, an association is allowed to continue with conditions, and in some cases, it is continued in defiance of family wishes when the undesirable person is brought into the house.

Social sanction extends to men who bring their lovers or socially unacceptable partners to a party. One such situation occurred at an Embassy party, when an elderly man arrived with his much younger, diamond bedecked, Filipina guest. Suddenly there was a collective inhaling of breath and staring by the Bahraini dignitaries, and the frosty censure could be felt in the air immediately. The man was greeted as per custom, while the woman was totally ignored and spent her time among the women at the party.

Marriage and Family

Bahrain has the reputation among all the Gulf countries of being a place, “where people can marry who they want.” All informants, males and females, agree this is true to a large extent. Women clearly state that the “woman has the right to say no” to any man who is recommended by her family. Farouq Amin amends this and states women have the right to refuse, but not the right to choose (1986). Men stated that, based on their subjective knowledge, perhaps 50 percent of marriages in Bahrain are arranged. In reality, this figure is 75 percent (Kahtanie, 1992:41). This incidence is much lower than in Oman or the United Arab Emirates. In the latter country, a law was passed in 1996 stating the man should see the woman before their marriage. Regardless of the stereotype in the Gulf that Bahrainis can marry who they want, there are still six different types of marriages seen in Bahrain, according to Kahtanie (1992). They include arranged marriage, cousin marriage, couples who have not met before, couples who met, forced marriages, and educated-later marriages. Both women and men reported that some men are now showing a preference for, and are choosing, educated working women, even those years older, who can be a partner and who can help in providing financial extras for the family (Taki, 1974; Kahtanie, 1992:39).

Marriage selection and choice of mates ideally follows the Islamic pattern, i.e., religion is the first selection factor, while the second factor is the monetary status or potential monetary state of the male and beauty in the female. According to the Koran, individuals cannot marry those who suckled at the same breast and are a milk brother, Akh Bil Radha’a. For all types of marriage, the permission of the father or brother is required, and in addition, for soldiers, military approval is needed. For members of the royal family, Amiri Court approval is required.

Marriage brokers (al khatba) are still used to arrange meetings in spite of telephones and automobiles, and even though 39 percent of marriages are consanguineous marriages (Al-Naser, 1993; Al-Arrayed, S., 1995). Many marriages are still arranged between families. The Islamic associations also play a role in helping individuals find a partner. Men and women can complete a questionnaire at their local association, providing information on education, age, background, and preferences. Association staff match applicants, and they and their families can arrange to meet.

Arranged marriages can succeed or fail. Men stated that the couple may “fall in love” or find they are compatible. A lot of these mainly younger couples also divorce during the First or second year; couples in these arranged marriages stay married, especially after they have a family. In some cases, one of the spouses (either man or woman) falls in love with the other, but this feeling may never be returned, e.g., the wife may say, “our marriage was arranged and he is a good father,” and the man, meanwhile, has much stronger feelings for his wife or vice versa.

The reasons given for women agreeing so easily with their parents regarding arranged marriages include the following: girls are afraid to say no to their parents for any reason because of the way they were raised; the girl may not know any other man or does not have any feeling of attachment to anyone in particular; it is better to be married than unmarried (Taki, 1974); or a girl does not want to wait too long and to be told “the train has left.” For all these reasons, a girl may acquiesce to her parents’ wishes. A man, likewise, may easily follow his family’s choice of wife for his first marriage, but if widowed, or if he marries a second time, the woman will be of his choosing.

Consanguineous marriages now comprise 39 percent of marriages, down from 45.5 percent in previous generations (Al-Arrayed, 1995). This trend for preferential first cousin marriage has serious health implications, including effects on sexual development for the children produced by these couples. The coefficient for inbreeding in Bahrain is 0.0145 (Al-Naser, 1993). The child mortality rate is Bahrain is three times that of Japan, even though Bahrain is ranked as an otherwise low-mortality population. The Bahrain Child Health Survey of 1989 showed that one quarter of births occurred between first cousins. The mortality rate for these offspring during their first month and first twenty-three months is two times higher than children of unrelated parents. The study showed that women who marry relatives, especially their first cousin, tend to marry younger, are illiterate, their parents were illiterate, and they live in rural areas. Other practices contributing to higher mortality include polygynous marriage, remarriage after divorce, short intervals between births, employment of women only in the home, breast feeding for an average of 10.6 months, malnutrition, and lower socioeconomic status. The author of the study suggested that the government needs to discourage first cousin marriage, to raise the marriage age to 18, to teach the illiterate about birth spacing which is part of Islamic teaching, and to allow polygamy only if the man can afford it (Al-Naser, 1993). Sheikha Al-Arrayed disagrees with the contraindications for consanguineous marriage and cites its traditional history and social benefits, even though 42.8 percent of her sample reported familial genetic diseases (1995).

Some Bahraini men marry expatriate women who are Moslems or non-Moslems. They meet while studying at European, American, or Asian universities, while working in hospitals, or while traveling. The man’s family may accept or reject the woman, depending on her religion, country of origin, or other factors. Bahrainis may marry other Gulf Cooperation Council (GCC) nationals with family approval, and occasionally Indian or Pakistani Moslems, but rarely Westerners who have converted to Islam. In these cross-cultural marriages, it is the woman’s choice what passport she wishes to maintain. Holders of non-Bahraini passports cannot own property in Bahrain.

Once the agreement of the two individuals has been given to marry, regardless of the type of marriage, then the families decide upon the monetary arrangements for the dowry (mahr), which is a gift symbolizing love and affection (Badawi, 1980:17). According to Islamic law, there is a marriage contract (Al-Rayd) for all Moslem marriages. This contract specifies the money the man and/or his family will pay at the time of the official engagement in the mosque, any “seconds” if all the money is not available at once, and the “last” money to be paid at the end of the marriage upon divorce or death. The first and second money can be paid to the woman, or to her father for holding. Any “second” money, in case of the early death of the man, is paid before the money in the estate is apportioned to other heirs; or any other money he may have borrowed or was holding for his wife is paid first, as the money was hers, fit ajulain, in life or death. The contract once signed is a legal document and is blessed in the mosque and then registered with the Courts.

The amount of the dowry paid in 1994 at the time of the engagement varied from BD400 to more than BD2000 according to the Statistical Abstract 1994. Distribution of dowries paid by non-Bahrianis are shown and also tracked in terms of amount and geographical distribution in the country (Statistical Abstract 1994: Table 3.53).

The current generation may use the woman’s dowry to buy furnishings for the home, rather than having it held by the father or put into her separate bank account. This arrangement depends upon the couple and their relationship. The man’s family may also be required to pay for an expensive hotel wedding reception. This depends on the families involved and the contract arrangements. Women report that they were told by their mothers from the time they were young, “never give your money to your husband.” If their money is loaned to the husband, it is generally done legally with a contract.

The financial straits of some young men and their families make it difficult for these men to marry. During the last few years, several benevolent social organizations, including the various Islamic Associations, have arranged group weddings once a year, so some or all of the costs of the dowry and weddings are alleviated. These costs can be prohibitive for the young men and prevent them from marrying (“Mass Wedding,” 1996). A description of a traditional Sunni wedding ceremony is given by Al-Khalfan (1993), and a Shi’ite ceremony is described by Hansen (1967).

After the engagement, which is equivalent legally to a Western marriage, the woman may move into the man’s father’s house. Ideally women do not become pregnant during this engagement time and should wait until after the public wedding ceremony. The engagement is usually less than one year, and longer engagements are discouraged. If the woman does become pregnant, the family then decides if a family or public wedding will take place.

During the “engagement” period, some couples decide unilaterally or mutually that they are not compatible and they will divorce. According to the Statistical Abstract 1994, 28 percent of the Bahraini divorces were before there was any sexual union, 16.5 percent for non-Bahraini divorces (Statistical Abstract 1994: Table 3.74). In the 1994 report, 19 percent of the marriages lasted longer than one year (Statistical Abstract 1994: Table 3.77). Once the Court grants a divorce, a delay of three months is required (Al’ Idda) to ensure the women is not pregnant, then the divorce is finalized. Islam discourages divorce and teaches reconciliation is better.

A man can say the word talaq three times in his home to divorce his wife, then the couple has two options. They can see a religious man, a sheik, for his opinion, or attend a court. In both situations, the conditions surrounding the statement will be assessed, i.e., was talaq said in a calm manner or was the man under stress? Was the woman in a state of purity (tuhr)? If under stress, then the courts will consider talaq as said once. If said in a calm manner, then the legal divorce proceeding will go forward with review of the provisions in the marriage contract. The specific laws pertaining to divorce and inheritance are governed by Sharia law. The Shi’ite follow the Ja’afari, and the Sunni the Maliki rite.

Women can obtain a divorce for certain prescribed reasons: the man disappears or is absent; the man is impotent; if the marriage causes the wife mental or physical illness, e.g., man is a homosexual, wife battering, or adultery; non-support by the man; or if a special condition clause was included in the contract as a condition for marriage (Ramzani, 1985). In July 1996, a landmark divorce case was publicized in Bahrain’s newspapers. A women was able to divorce her husband who had AIDS, as she said she was at risk for contracting it through sexual contact.

Marriage and divorce rates are tracked by the Central Statistics Organization. The general divorce rate is 1.7/100 population, and the general marriage rate is 7.5 (Statistical Abstract 1994: Table 3.45). The trend is one divorce for approximately every 4 to 4.5 marriages. Eighty percent of the marriages and 85 percent of the divorces were among Bahraini couples (Statistical Abstract 1994: Table 3.44). Bahrainis in 1994 also married Asians, other Arabs, other Gulf Arabs, Europeans, and Americans. The divorces followed the same general distribution (Statistical Abstract 1994: Table 3.44). Among Bahraini couples, 91 percent were married for the first time, while among expatriate couples, only 56 percent of the men were married for the first time. The age range of women marrying showed 1.6 percent were 19 years or younger, however this age range accounted for 8.9 percent of the divorces in 1994 (Statistical Abstract 1994: Table 3.43). Trends show young divorced men and women frequently remarry (Statistical Abstract 1994: Table 3.56).

If a woman was proven barren before the divorce, or if she wishes to keep her children and not have to give them to her mother or her ex-husband, then the woman may choose not to remarry, in which case, she will continue to live in her parent’s house. Her family will continue to protect her and, now that she is divorced, she needs more protection from men who may assume she is “more easy” in her ways.

Ideally, a man informs his wife if he wishes to take another wife. However this is not always practiced. The woman may be told afterwards. She may discover the other marriage or marriages in a sudden way, e.g., during the Government census when the Government census taker is trying to determine which wife he is talking to; some find the other wife and husband in a new house she paid for, or in some cases, the wife may never know. There are Bahraini men who have families in Egypt, India, Philippines, or elsewhere, of which their Bahraini families are unaware. In some cases, the family only finds out when the man dies and the various wives make inheritance claims on the estate.

A man’s marriage of another wife is generally not a valid claim for divorce, as a man may legally have up to four wives at one time. Most women do not want to share their husband and their family usually supports them (Taki, 1974). The possibility of polygamy makes wives anxious, especially if they are barren or fail to produce male children. Women voice their feelings of insecurity in a serious or joking manner, as they do not know if their husband already has another wife or if he plans to do so. He can also say to them, “if you do not do this, I will look for another.” There is a greater risk for older women, as there is always the threat that the husband could take a younger wife. The latter is one concern which reportedly makes women keep menopause a secret, as they do not want their spouses to know of it out of fear that he may take a younger wife.

Women make great efforts to keep their husbands satisfied and traditionally this included placing packs of rock salt in their vagina after delivery (A. Mohammed, 1978; Rajab, 1978). The purpose of the salt crystals was to reduce the size of the vagina after delivery to normal or less than normal size so the man will feel more pleasure (Dickson, 1915; Hansen, 1967:108). The use of rock salt and its effects has been documented since the early twentieth century by the doctors at the American Mission Hospital in their annual reports, and in Kuwait and Saudi Arabia (Dickson, 1915) and Oman (Doorenbos, 1976). The main result was rock salt atresia of the cervix, so that in subsequent deliveries the cervix was so tough, it had to be cut to allow delivery. Another effect of the salt packs was unexplained elevation of the patients’ temperature after delivery and suspected sepsis. Records show in 1938 that the first MRCOG consultant attended delivery of eighty-four patients and seventy-nine had rock salt atresia. The Ministry of Health took a proactive approach to this problem and registered, trained, and supervised all the traditional midwives. By the late 1970s this practice “was nearly died out” (Rajab, 1979:7). However cases are still seen, even as recently as 1996 in the Maternity Hospitals. In the latter case, an elevated temperature was noted and upon examination it was found the woman had inserted a vaginal pack of rock salt. Herbal passaries known as mamool were also used to tighten the vagina, drain lochia, and promote involution of the uterus (Al-Darazi, 1984:37-38). Some women used a combination of salt crystals, herbal pessaries, and antiseptic solutions. Vaginal douches of datol, a strong disinfectant, are still commonly used after childbirth. Regarding resumption of sexual relations after delivery, the wife usually stays with her mother for the first forty day after delivery and may have also stayed with her mother for one month prior to delivery (Curds, 1977:47).

Serial monogamy is seen in Bahrain, and some women are divorced and remarried three or more times during their lifetime, and men marry more often. As women become older, their chances for remarriage lessen. There are no reports outlining the common causes of divorce, although in the one study conducted on coping mechanisms of Bahraini couples, marital sexual satisfaction was an issue raised by 25 percent of the husbands (Kahtanie, 1992). The Islamic rules of inheritance work against remarrying or polygamy, and the sons generally oppose remarriage which might engender other children, thereby affecting other inheritors (Taki, 1974).

Extramarital Relationships

There is a type of marriage referred to in the Koran as al Mut’a, or temporary marriage. At the time of the Prophet, this practice was allowed for the soldiers who spent many years away from their homes. If the woman the soldier kept became pregnant, then she was to become a full legal wife. The Prophet himself later stopped this practice, and Umar bin Khatab, shortly after the Prophet’s time again instructed men to stop these type of alliances, as women should be taken as legal wives only.

This practice of temporary marriage has continued only among the Shi’ite. One example is described as seen in Sar Village by Hansen (1967:127). In this particular marriage, the girl did not leave her village to live with her husband in A A’li. Currently, the term Al Mut’a has taken on a new meaning. Men who are having an affair may use this term to describe their current relationship, however, there is no legal basis for this type of relationship today (Al-Faruq, 1988:6).

The extent to which Bahraini and expatriates are involved in extramarital affairs is not known. Anecdotal stories are passed around when an incident occurs, e.g., a Bahraini store owner was called to testify to the police about the good behavior of his Bahraini worker. The worker had severely beaten an Indian neighbor who was found to have been sleeping with the man’s wife. Incidentally, this woman was “covered” whenever she appeared in public.

The Changing Nature of Bahrainian Marriage and Household

Three major changes have occurred in Bahrain which are driving forces for change in Bahraini families and family relationships. Household structures have changed from mainly extended families (Allah) of twenty to thirty members living under one roof, to variable forms including traditional extended households with several generations of family members to nuclear family households (no Arabic word to describe this) located in one of the new cities, e.g., Isa Town, Hamad Town, or a flat. Another major change in all types of households since the 1970s has been the introduction of Asian maids. These maids clean the house, cook, and depending on the family, assume a little or a lot of influence in child rearing practices. However, these maids are economically, and in terms of power, “the lowest of the low” (Al-Sharyan, 1987:350). Their presence has helped the wife to go out and work outside the home, as child rearing is done with the help of the maid. Formerly, the presence of a grandmother would have been the only means allowing a woman to work outside. A third change was the introduction of private automobiles in the 1950s. The automobiles allowed family members to take tours together, and men took their families to beaches and oases. More activities could be planned together as a family (Taki, 1974). These three factors have contributed to the breakdown of the extended family and increased prevalence of conjugal families.

Some women reportedly are very frustrated in their marriages. They are working at a job, running the house, may be making more than their husbands, and are not shown any interest or appreciation by their husbands. Some state that the husband’s attitude is “I take your money and you do what I tell you.” The men may be out every night visiting traditional coffee houses smoking shisha, playing chess or dominoes. They may be out drinking in hotel bars or restaurants. The men receive many invitations for lunch and the tendency is for them to take every opportunity to be out of the house. The men spend little time with the children and some have the attitude, “have them and wait until they grow up.” Women get frustrated if their husbands are lazy. Traditionally, men and women lived separate lives in Bahrain and their social networks were segregated (Taki, 1974). The frustrations expressed by some women reflect the continuing trend of separate lives maintained by some husbands while their wives are expecting more from a marriage. Information on these divergent lifestyles and expectations would be helpful to in crease public awareness, and to teach couples how to resolve these different expectations from a marriage in order to control the number of divorces.

Children and the elderly are suffering the consequences of divorce. The woman returns to her family with the children depending on their age, or the children go to the father and most likely a stepmother for their upbringing. If the woman remarries, her parents or the husband definitely have custody of the children. After marital breakups, society suffers a greater burden in terms of juvenile delinquency due to unsupervised children (Al-Falaij, 1991), an increase of malnutrition and infant mortality (Al-Naser, 1993), and abandonments of the elderly in Government hospitals.

Sexuality and the Physically Disabled and Older Persons

The physically disabled can marry in Bahrain and whether they do depends on their family and the extent of their problems. There are institutes for the blind (Noor Institute for the Blind), deaf (AlFarisi Rehabilitation Center for the Deaf), and handicapped (National Bank of Bahrain Rehabilitation Home for Handicapped Children) in Bahrain where they receive special training. Bahrain has long been the recognized leader in the Gulf for the training of the handicapped, and for providing them with education and employment opportunities.

If the man is affected with a handicap, the family may find him a bride locally, or more likely abroad, in India. The chance of a handicapped woman marrying depends on the effort made by the family on her behalf, and the presence of a maid to help her. Male informants stated that a handicapped woman would have difficulty marrying because of her limitations in organizing the house. People with mobility handicaps due to polio, birth injuries, or later trauma injuries do marry, but this depends on the injury. Again, if there is difficulty finding a spouse, families will find a wife for their son in India, while the daughter may remain at home her entire life.

Those who are mentally retarded generally do not marry, but there is no law prohibiting marriage. A case was cited where a family employed the son in the business and found him a wife. Male informants queried why anyone would want to marry a retarded woman, as she could not organize the home?

The elderly in Bahrain comprised 5.5 percent of the population according to the 1991 census. The elderly are defined as older than 60 years of age. The elderly remarry, but it is more likely the men will remarry. Marriage statistics for 1994 show that the oldest age for marriages was 40 to 44 for women and 50 plus for men. However, it should be noted that age is a relative matter. All births were not recorded in the past, so many 40- to 80-years-old do not know their exact age. Also, people adjust their birth dates, i.e., men have reported that they added years at the beginning of their working life so they could get Government employment at an earlier age. Others drop years, especially when in their 40s, by changing all their legal documents after saying a mistake was made earlier. Also when people are asked their age, many just underestimate it, e.g., one man said he was 45 when asked by a hospital surveyor. The surveyor reported she looked at him and thought to herself 60 to 65 minimum. The man saw her pausing and said, “50 to 55, whatever you like.” The official Government retirement age is 55 for women and 60 for men. There has been no study on the relationship of changing of birth data in the official records and work benefits and entitlements. The life expectancy at birth in 1995 in Bahrain is 74.2 years for women and 69.9 years for men (76 and 71 respectively according to the 1996 World Almanac), both figures being higher than the average for other Arab states, 64.1 and 61.5 years respectively (Baby, 1996b).

Regardless of the recorded age, the physical condition of the middle-aged or elderly affects their sexual ability. Among the elderly in Bahrain, long-term complications of diabetes, hypertension, and cardiovascular diseases can result in male impotence. Since the 1980s, penile prostheses have been available to treat men who are known to have organic causes of their impotence (Amin, E., 1984). This procedure is available in public hospitals and with greater confidentiality in private hospitals.

Incidence of Anal Sex, Fellatio, and Cunnilingus

There are no enforced legal restrictions in Bahrain regarding the practice of oral sex or anal sex. Informants reported that according to Islam, oral sex is allowed. The rationale is mutually satisfying sexual positions including oral sex are considered normal. Some women say they are reluctant to participate in oral sex, although Bahraini and Western women participate to keep their husbands satisfied.

Anal sex is considered abnormal activity and associated more with homosexual activity of which it is considered a possible precursor, so it is forbidden (haraam). Reportedly, if a man even asks his wife to perform anal sex, she has the right to file for divorce. Anal sex is practiced, however, and while the woman may not agree, the husband in some cases is threatening by saying “if you don’t, I will go elsewhere.” Also women do not file for divorce. Occasionally women discuss this activity with friends or doctors because of the discomfort they experience and the need for creams or suppositories to soothe small rectal tears. Some women find out about their brother’s anal sex activities indirectly when they complain about discomfort and an inability to sit down. One informant reported that a friend’s brother, who was engaging in anal sex for money, told his sister that he had no money and the man paid him BD50.

6. Homerotic, Homosexual, and Ambisexual Behavior

A. Children and adolescents

There have been no studies or even articles published in English regarding these topics. In a few rare publicized cases involving a rape and/or a murder, it was revealed, for example, that an adolescent male was involved in a long-term homosexual relationship with an older expatriate male, or that a young boy was a victim of a homosexual rape by one man or a gang of boys. There are no statistics available on these topics since 1956.

B. Adults

Objective data are not available regarding adult behaviors relating to homoerotic, homosexual, or ambisexual behaviors. Very few male homosexuals openly admit their homosexuality and most get married to keep up appearances. Since homosexuality is haraam and abhorred according to Islam, most relationships are discrete in order to protect the family name or a spouse. Male informants report that there are now some Bahraini gay men who openly reveal that they are gay, and who state they have no intention of marrying, but this may be fewer than 5 percent of the gay men in the population. Anecdotal stories are related by informants; however, no one could contribute any information on specific behaviors, such as roles or courtship patterns. Islam prohibits homosexual or lesbian relationships, so most couples do not openly admit their relationships, and there is no way to legalize these relationships in Bahrain.

There is a homosexual community comprised of expatriates who are more open about their sexual orientation, e.g., Filipinos and Thais, who are unlike the Bahrainis who are very careful to hide their sexual proclivities. There was an incident in the early 1990s when twenty to thirty Filipino homosexuals were deported by the Government. Despite this, the Filipino gay community now flourishes as before.

Patterns in sexual outlets for homosexual men have not been studied. Filipinos report male drivers (Arabs or Asians) put their hands on the knee of the passenger, and the Filipino has to indicate his preference. Filipino men and others working in barber shops approach their customers by offering to massage them. Such approaches are reported by many men including Bahrainis and expatriates. Men report having to shop around for a barbershop where they feel comfortable and “don’t have any problems.” Women report friends and families warn other families where they should take their sons to have their hair cut and where not to leave their sons alone. Some parties in the desert reportedly are another venue which men use to meet potential contacts.

Women, as they are kept under more careful watch of their parents, meet other women in school, at friends’ houses, weddings, or parties. Women are free to meet at any time, as they are always encouraged to socialize with other women. Only one informant personally knew a lesbian who had told him that she and her friends meet at school or the university, and that lesbians usually marry and have children while continuing their female relationships. This woman said there were a large number of Bahraini lesbians in the community.

The prevalence of lesbian relationships in Bahrain is not known. Male and female informants all mentioned they knew about Bahraini lesbians. Female relationships are considered “safe” by parents, so the women meet easily and often. Like the gay men, lesbians are frequently married and have children. Expatriate lesbians are more open about their sexual proclivities and these women dress in a style that is immediately identifiable by their countrymen, e.g., Filipina “T-birds,” or Scandinavian lesbians among others. The incidence of female-to-female STD or HIV infections has not been reported.

Ambisexual (bisexual) adults usually marry in Bahrain and each spouse may have a lover on the side (lesbian, gay, or heterosexual). Only anecdotal stories are available regarding this topic, and there are no data on the prevalence of hidden bisexuality in Bahrain.

A question is frequently raised by expatriates regarding homosexual activity in the country. Are the men truly homosexuals, bisexuals, or heterosexuals? What role does opportunity for sexual release play in their behavior? A story was related about an incident in a hotel. Several Saudis gave money to the male Asian hotel clerk and told the clerk to find them some women. The clerk took the money. The men called down to the desk several times to find out where the women were. During the last call when the clerk said no women were available, the men said, “You come up then.”

7. Gender Conflicted Persons

A. Transvestites, Transgenderists, and Transsexuals

Male transvestites or benaty (males dressing as females) are seen occasionally in public, e.g., attending a public festival, while in the hospital, or shopping. Informants report that this is “much more common in Kuwait.” People are tolerant, mainly ignore them, and do not talk about them. A few comment on the behaviors seen, e.g., “high voice,” “make-up,” or “using a fan,” but do not relate to the nature of the person. Bahrain men dressed as women have been reported as providing the entertainment at exclusive parties where expatriates are rarely invited. One female British author reported attending such a party as her introduction to the country a few years ago. It is not known what proportion of these male transvestites are homosexuals, bisexuals, or heterosexuals.

In some situations, men have been known to dress as women for other reasons, mainly in order to breach security, e.g., to get into a dormitory to visit a friend, to get into a female prison to visit someone, and to hide from the police. The latter practice has caused some problems, and now female security guards are being used in Government agencies, as only a woman can touch or search a woman. One Filipino passed as a female maid for a couple of years before being caught by his employer.

Cross-dressing by males is not considered an act of juvenile delinquency in other parts of the world; however in Bahrain, Saudi Arabia, and the rest of the Gulf region, which has strict religious based norms, cross-dressing is seen as a clear instance of alienation from traditional values (Al-Falaij, 1991). One study showed 4 percent of Saudi male juvenile delinquents were cross-dressing (Al-Ghamdi, 1986). While there are no published data for Bahrain on cross-dressing, 12.4 percent of male juvenile delinquents and 16 percent of female delinquents in one study in Bahrain were accused of moral delinquency (Buzaboon, 1986:151).

Women in the Gulf have a long practice of wearing the sirwal chemise-long full pants with long loose overshirts seen among all Pakistanis (males and females) and some Indians. This fashionable ‘Punjabi-style’ outfit is worn by men and women alike in Bahrain by many nationalities and is also fashionable in the West. The only differences between men’s and women’s styles are the type of material, style of buttons, and decoration. Loose pant suits are another preferred style of dress for women to preserve modesty. Women are frequently seen wearing loose pants in the whole Gulf region. There is no association between a woman wearing slacks and being lesbian among Gulf countries. There are lesbian Filipinas known as “T-birds” who dress like a man and who flatten their breasts. They purposely are trying to look like a man. There have been Scandinavians who have pointed out lesbians from their own country. They report, “See how they wear a shirt and pants like that. Only lesbians dress like this at home, so we can identity them easily.”

The incidence of transgenderists has not been studied at all. None of the informants reported knowing any Bahraini who said, “I am this gender but trapped in this body.” Westerners and Filipinos report knowing of people making such comments in their home countries.

Voluntary sex-change operations for completely gendered adults to the opposite sex are not done in Bahrain and they are illegal. This view is supported by the Koran and the Prophet’s teachings (Al Herbish et al., 1996). If there is confusion regarding the sex organs of a child at birth, then investigations will be conducted to determine sex assignment of the person. Sex-change protocols followed for newborns are similar to those published in Saudi Arabia (Taha and Magbol, 1995). If the sex organs are predominantly those of a male, the male sex will be assigned; likewise if those of a female, the female sex is assigned. Unfortunately some problems are not apparent until the time of puberty (Abdul Jabbar, 1980; Farsi, et al., 1990). A study in Saudi Arabia on intersex disorders detected in puberty or later reported that all genetic males, known as females, accepted sex reassignment as males. Females incorrectly known as males did not readily accept sex reassignment, as culturally the male sex is preferred (Taha and Magbol, 1995; Al-Herbish et al., 1996). The nature and incidence of some cases in Bahrain have been reported by S. Al-Arrayed (1996).

The man’s chances for remarriage are limited mainly by his financial resources and his ability to pay the marriage contract divorce settlement, and if he can afford the dowry for a new wife. Poor men unable to provide well for their families have been known to marry four wives, as there are currently no regulations regarding minimal income; however this is now being recommended (Ahdeya Ahmed, 1996). In other Gulf countries, men are being encouraged to take a second wife in order to reduce the numbers of unmarried local women. The U.A.E. Government extends soft loans to finance taking a second wife, and men already having foreign wives are now eligible.

B. Specially Gendered Persons

The kaneeth (xanith) is a specially gendered person reported historically in the Gulf (Wikan, 1982) and still seen today. The prevalence of these male transvestites/homosexuals is not known. None of our informants have personally known such individuals, however many reported they have heard others talk about this topic. Some informants described people they have known and/or their families. One Bahraini informant reported that “the person they knew like this was Omani and he lived in our neighborhood and he was the best cook.” Another reported, “There is a man who is married, and he has children, but he is also like this.” Others said, “This was more common in the past.” Following up on this comment, a long-time expatriate resident mentioned “that soon after independence and after the British left, all the Omani men were sent back home in dhows from Manama. People went to the sea front to see the dhows cast off. These men had worked as maids, (there were no female maids then), as singers in bands at women’s parties, and were eunuchs.” These Omani men sound like the description of the third gender kaneeth described by Wikan in Oman in the 1970s (Wikan, 1982).

When asked about the term kaneeth, Bahrani informants did not agree that the kaneeth is a third gender. The term in Arabic means a male or female homosexual. Bahrainis said some marry and have children, so are bisexuals according to the English definition. Kaneeths in Bahrain would not necessarily show feminine manners, or dress in a more feminine style, unlike those reported in Oman, but would wear a thobe or Western-style men’s clothing.

8. Significant Unconventional Sexual Behavior

A. Coercive Behaviors and Neglect

Child Physical Abuse and Neglect

The incidence of child abuse has not been studied or reported in the medical literature in Bahrain. Articles published in Bahrain have alerted physicians to note and report suspected cases (Al-Ansari, 1992; Molloy et al., 1993). Two hospital informants noted knowing of only two cases of child abuse in the past eleven years in Bahrain, and in one case the mother was mentally disturbed, while in the second case the child was handicapped. Similar abuse of handicapped children is also mentioned in Saudi Arabia (Al-Eissa, et al., 1991). Two articles on childhood trauma in the Gulf (Bahrain and Saudi Arabia) did not mention if any of the cases were due to child abuse (E. Amin, 1979; Al-Otham and Sadat Ali, 1994). Nonaccidental burning of children is another type of abuse which may exist in Bahrain and which requires a team approach to detection and treatment (Saeed, 1992). Child abuse does exist in Kuwait, and is reported in increasing frequency (Al-Rashied, 1988), and in Saudi Arabia (Al-Essa, et al., 1991; and Qureshi, 1992). A case of Munchausen Syndrome by proxy has been reported in Saudi Arabia (Al-Mugeiren et al., 1990) and doctors in Bahrain have been alerted to note such cases (Molloy, et al., 1993).

School teachers have also been educated regarding child abuse and are to report suspected cases of child abuse to the social worker. One study was conducted regarding teacher awareness of symptoms (Ali, 1996). Since schooling is not compulsory, or may be conducted at home with home study, teachers cannot know of the full extent of this problem. According to the Koran, children are to be treasured, and strict discipline and physical means of discipline are not commonly used. From ages 1 to 7, parents are exhorted to love and care for their children, and from 7 years onward to be as a friend to guide their child.

The extent of abuse to which children are subjected from the many maids employed in the country likewise is not known. However, Al-Rashied in 1988 noted in Kuwait that child abuse has been noted more often after increased reliance on baby sitters. Individuals report knowing of suspected abuse cases in Bahrain, and when they were confirmed, the maids were deported. In one example, a Filipina brought to work for a family was found using physical means to control the children and scaring them so much their personalities changed, which is how the parents first became aware of the problem. Another South Asian maid absconded, and was later caught working as a prostitute. The parents then wondered if she had been entertaining men in the home, as the children had reported previously that the maid used to lock them in their rooms when the parents were away.

Many of the cases of child abuse are not physical abuse or battered child syndrome, but neglect, or cases of failure to thrive. Bahraini doctors have been alerted to note these cases (Al-Ansari and Al-Ansari 1983). One expatriate, for example, reported thefts from her vegetable garden. The culprit was eventually caught and it was a young boy who was hungry. Investigation of the case showed there were four wives and forty children in the family and an unemployed head of the family. The expatriate dropped all charges. Social workers have reported finding neglected handicapped children who were being kept in boxes in the home so these children had severe contractures. In these cases, the mothers had many other children to care for. Side effects of medical procedures are sometimes not noted by parents among their large number of children until the damage is irreversible. Young children are sometimes left in cars overnight and they die in the extreme heat as their absence in the house was not noted. A study on the impact of family size on morbidity showed crowding, poor sanitation practices, low education, and poor personal hygiene resulted in more family visits to health centers (Nasib et al., 1 983).

The Bahrain Government has an effective means of helping abused children once identified. All reported cases of abuse and neglect are investigated and social workers and community health care nurses follow up each case, even daily, if it is felt this is needed. Even though all government health care services are free to all residents, utilization of psychiatric services for children by parents is low. In 1981 and 1982, the last published data, only. 016 percent of children were referred for psychiatric help, while it is estimated 5 to 20 percent of children could benefit from the services. Boys outnumbered girls in conduct disorders, while girls had more reactive and neurotic disorders (AlAnsari and Al-Ansari, 1980). The possible underlying causes of childhood psychiatric problems were not discussed in the article.

Charity from the Government, the Red Crescent, or other family members may not be meeting all the physical needs of some families. Other agencies and social organizations provide needy families family aid (Jameyat Al-Islah, Jameyat Al-Islamiya, Jamiyat Al-Tarbiat Al-Islamiya, Sunduq Al-Infaq Al-Khairi, and Al-Eslah Society’s Welfare Committee). Only official begging is sanctioned in the country, i.e. women mainly are licensed and have a permit to visit shop owners to solicit charity and usually only during the month of Ramadan. However beggars (men and women) can be seen in many parts of the capital city on a regular basis.

Child Sexual Abuse

The worldwide current awareness of family sexual abuse started in the 1980s (Patten, 1991). The incidence of child sexual abuse in Bahrain has not been documented in any published reference. Hospitals keep their own statistics which are not officially reported. In contrast to rarely seen cases of battered child syndrome, several cases of sexual abuse are seen every week by hospital medical personnel, nurses, and social workers according to informants. The number of children seen by private doctors and in private hospitals is also not reported. A team of doctors and a psychologist are now addressing this issue, and perhaps data on prevalence and trends will be available in the future. The lasting impact on the children involved and their families, and the relationship of sexual abuse to dysfunctional families to broken homes due to other social factors, such as high unemployment, have not been studied or reported.

Sexual abuse is detected in various ways, including the wife catching the father and daughter. In some cases, bleeding in the genital or rectal area may be the first sign seen by parents or reported by the child; a skin rash or symptom of a sexually transmitted disease (STD) may be the first sign. Babies of six to eight months, toddlers, preadolescent, and adolescent children are the victims. In some cases the abuse is from a male relative (father, uncle, or brother), or outsider, or gang of boys who may be sexually abusing the male or female child in question. Cases are reported of maids playing with and sexually abusing male or female children. None of the reported cases are as extreme as the male mutilation seen in Saudi Arabia by a mentally disturbed mother (Hegazi, 1990). Incest and sexual abuse cases reportedly occur among Bahraini and non-Bahrainis, including South Asians expatriates. Health care personnel state Pakistanis are more frequently involved, however there are no clear data on trends.

The extent and frequency of police involvement in sexual abuse cases varies. If an outsider or group of boys is involved, and a male child was abused, then the police may be called. If a female child was abused and a male relative was involved, e.g. the father, then the police are not called. In these latter cases, the female child may more often be taken to a private doctor, or to no doctor. In the last ten years, there have been two publicized cases of young girls raped by expatriate men. One was a 5-year-old child playing outside her house. Neighbors and family members caught the expatriate Asian man and severely beat him. The second case involved an Asian school guard who raped a young preadolescent female student.


Pedophilia has not been studied, however pedophilia regarding young boys is talked about and is not a new practice. During the late 1980s, there was a man reportedly raping young boys in the Muharraq area. The case was discussed opening by worried parents, but the outcome of this situation was not publicized. Bahraini pedophiles paying boys for sex both in Bahrain and abroad are known, and such cases are discussed openly by older members of the local community. Groups of older boys are sometimes involved in rapes of young boys, however this data are not reported. Pedophilia in Saudi Arabia, in contrast, is considered a major crime, and those caught are sometimes beheaded, depending on the extenuating circumstances such as alcohol use and kidnapping.

Rape: Acquaintance, Date, Marital, and Stranger Rape

The prevalence of rape is not reported. Isolated cases are known to occur, and a few have been reported in the print media, usually no more than one case in a year. Those reported in the media generally involved expatriates and sometimes Bahrainis. One case of homosexual rape of a young village boy by an older village boy resulted in the child’s murder. Stranger rape does occur, e.g. one Asian woman (a maid), took a taxi ride late at night and was raped by the driver. She also contracted a severe case of genital herpes from this incident. The frequency of rape in Bahrain, in comparison to cities of 500,000 to 600,000 people, would provide valuable comparative data. Many Bahraini families possibly do not reports rapes due to the shame involved, and Asian women are reluctant to report also, so accurate figures are difficult to obtain, but underreporting of rape is the situation in all countries around the world. Marital rape has not been studied.

B. Sexual harassment

Sexual harassment has not been studied in Bahrain in the work place, nor in social situations. According to the Sura Al Noor, unrelated men and women ideally should talk about essential things only. Women government workers have been known to call and harass a male coworker over the telephone while at work, but this is very rare. Likewise the occasional male coworker has been known to harass a female coworker at work or in social situations. These incidents are reported as very rare, however the real prevalence is not known, as Asian females in particular are reluctant to report any problems or to cause trouble for fear of loosing their jobs. Bahraini females are also reluctant to report such cases due to the lack of witnesses and the shame of making the problem publicly known. There was one publicized case of telephone harassment, which continued after a Bahraini woman married. The harassment resulted in a murder plot, after which the man’s body was discovered in the desert. The husband was jailed for life and the woman for a shorter term.

Women report that off-color jokes may be told in their presence when they are a member of a group. The men will “look out of the corner of their eye” to see if they were overheard. The women say they have been schooled not to respond in any way, or to indicate that they heard what was said.

Touching between men and women in public, such as holding hands, is seen occasionally, however at work it is limited to an occasional handshake. An unrelated man should not touch a woman according to Islam. Some women refuse to shake hands even in professional situations, or some wear gloves, or a glove on the right hand. This practice can be seen on the television during graduations and other public ceremonies when an official shakes everyone’s hand.

Body language has been studied among the Arabs for many years and social distance is reportedly closer than seen in some Western countries. Men talking to men, and women talking to women may be standing within six to ten inches of each other. In Bahrain, however, this social distance appears to be extended between members of the same sex to twelve to eighteen inches so expatriates do not have the same “close” feelings as when talking to some Mediterranean nationalities. Among males and females, this talking distance is usually further apart at two to three feet. Very rare exceptions to this rule occur when someone is agitated and they may poke with a finger at an expatriate person’s arm while making a point and usually without realizing what they are doing. Occasionally, a powerful man may put their hand on a woman’s back, but this is rare and the expatriates say they feel uncomfortable. Among the various expatriate groups in Bahrain, this social distance varies depending on the age (hand holding seen among male or female teenagers) or the nationality. Hugging when meeting a person is more common among the Filipinos, while casual kissing is seen among all groups, including Bahrainis, at the airport upon departure or arrival. Hand holding among men is a common sight among grown men. Bahrainis, South Asians, and Filipinos are seen holding hands on the streets. The practice is also seen among some women, but it is less common.

Kissing between men is a common practice and is seen in the media, in public, and at work. Kissing on the cheek, forehead, and shoulder is a sign of respect, and among friends a sign of welcome. Kissing between women is also seen frequently in public and at work as a sign of respect, and of greeting, especially if the women have not seen each other recently or some one is returning from a trip.

C. Prostitution

Prostitution has existed in Bahrain for many years and the British Agency Annual Reports include data on this topic. There was an increase in prostitution reported between 1926 and 1937 in the British reports. A number of foreigners earning good pay came to Bahrain from Persia, Iraq, and India without their families, and this caused an increase in prostitution which is a matter of supply and demand.

The history of prostitution in Bahrain since World War I has been discussed in various sources. Designated brothel areas were established (Rumaihi, 1976:193). There was formerly a section of west Manama, between Naim and the Police Fort, known as “Gubla” and an area in Muharraq known as “Al Grandol.” There were brothels in these areas with female prostitutes, and the male prostitutes were almost as numerous as women. A February 8, 1937, court decree ordered that prostitutes should live and work only in these two designated places. Prostitutes living or working elsewhere would be deported. The court ruling also ordered the deportation of those “highly professional” prostitutes. The female prostitutes were predominantly from Persia, Iraq, and Oman, with Persians commanding the highest prices, then Iraqis and Omanis respectively. The female prostitutes were all known as “Daughters of the Wind” according to Belgrave (1960); Bahraini informants report they were known as “Daughters of Love.”

The male prostitutes were chiefly Omani boys (Belgrave, 1960). All the Omani men did not live in this area, as some also lived with families who could afford their services. Later, there were Bahraini women who were the children of former slaves also working in these areas, while Belgrave notes the presence of foreign women “who had become Bahrain subjects by the simple expedient of marrying Bahrainis” (1960). Among these various groups of women, some were divorced, more commonly they were poor, and a few married women did it for the money or even pleasure. The brothels themselves were attended by men of all socioeconomic classes and ethnic groups.

Bahrainis now in their early forties or older all reported a range of knowledge regarding this topic and the location of the districts. Some knew of such a former “Red Light” district, but they were not sure where it was exactly. Some said they used to visit it with their parents while on business trips, for example, to collect rent. Others reported they visited the area because it was where “all the action was.” One informant said he collected bottles and cans for recycling and used the money to visit the ladies. Another informant reported she was very young, but she remembered seeing a man with a young boy. When she asked her mother why the man had the young boy, her mother answered “he is married to him.”

The term Grandal is still used in another context by elderly people to describe or comment on an individual whose behavior is “loose” according to preferred standards. Such a woman is called a Grandal, or it is said she is acting like a Grandal. Older people listening understand the connotations of the term. The areas designated for prostitutes started to decline in the early 1970s, and prostitution activities became more dispersed throughout the country with the opening of hotels. Still, women reportedly can still be seen standing in doorways in the old Gubla area in Manama.

Various reasons are given for the decline of this area in town and the recent changes seen in prostitution patterns. First, in the early 1970s, there were major political and economic changes seen in Oman. The current Sultan deposed his father and began investing millions of rivals in major infrastructure improvements in the country. There was an improvement in job opportunities, so many Omanis returned home. Second, the local, economic development of the 1970s due to the boom in oil prices resulted in the building of many new apartment blocks so there were flats (apartments) available in many parts of the city. Also the British military wanted flats and villas in which to live, so there was a building boom, and then Bahrainis moved into these dwellings also (Taki, 1974). People could have more privacy away from their families. Third, the economic boom of the 1970s also meant people had more disposable income and could afford extras like paying for a small flat or small villa. Fourth, the economic boom of the 1970s resulted in an increase of expatriate laborers between 20 and 50 years of age, including those from the Philippines and Sri Lanka. These two groups, all informants state, are highly involved in prostitution in Bahrain. Some Filipinas are paid a monthly salary or gifts of sometimes up to BD400 (US$1,000) or more by their male friend. Because of the low opinion of Filipinas in general, women with families and even elderly women over 60 report being approached directly or indirectly for prostitution (money is brushed on their arm or flashed so they can see it). Finally, after Bahrain gained full independence from the United Kingdom in 1971, U.K. residents were granted special visa privileges, i.e., no visa was required for the first three months of entry. Many U.K. residents came to Bahrain and the United Arab Emirates in the Gulf looking for jobs and employment opportunities. Some of the British women found jobs, others sponsors, and others travel between Bahrain and the United Arab Emirates and are seen frequenting the hotels working as prostitutes. This visa law was changed in 1996, and a visa is now required for U.K. residents due to reciprocal changes instituted by the European Union.

After the opening of the Saudi Causeway in late 1986, local women experienced many problems while they were walking on the streets, in shopping malls, or attending parties in hotels. The Causeway also led to an increase in the number of incidents reported by women who said they or their friends were approached by Saudis. Western women with their children reported being approached in shopping malls by Saudi men and being offered money for their services. Bahraini women, because of the problems, began avoiding hotels even for wedding parties on Wednesdays, Thursdays, and Fridays to prevent such situations from occurring. Women working in public areas in Government buildings are given hotel phone numbers by Saudis, and many have requested job changes to less public areas as a consequence. These situations were predicted by Wilsher in 1982, and reflect an expansion of the prostitution activities described by Faroughy (1951:20) who stated that “prostitution forbidden in Saudi Arabia has greatly increased under the complacent eyes of the authorities and Bahrein has become a kind of ‘pleasure island.’“

Solicitation for prostitution is quite open. Expatriate men report being approached by women in hotels and shopping malls. One first-time consultant visitor from the U.S.A. in 1989 was invited to look at a photo album of women by a taxi driver, taking him from the airport to his business appointment. The visitor reported being absolutely amazed to see this in a strict religious country. A Filipino man attending a hotel disco with a group of friends approached a Western woman and asked for a dance and was told “you cannot afford me.”

The nationality of female prostitutes has changed through the 1980s and 1990s. During the 1980s, Filipinas could be seen going off with men they picked up, even while in family pizza restaurants. Sri Lankans were available on certain streets in various areas of Manama. Also there continues to be a main street in Adliya commonly referred to as the “meat market” where Filipinas walk about at night. New nationalities of prostitutes have been seen during the 1990s. Since the breakdown of Communism, Russians began traveling freely to the Gulf. Many came to Bahrain and the United Arab Emirates for shopping, and there was a billion dollars in Russian trade for the United Arab Emirates during 1995 alone. Some of the women also came to sell small items, while others came as prostitutes. Russian women were available in some of the expensive hotel restaurants frequented by Saudis, outside two- and three-star hotels and other restaurants frequented by other tourists. Many of them advertised their services for BD20 ($53) dollars by holding up two fingers. One informant asked to see the C.P.R. (Central Population Registry) residence cards of Russian women outside an expensive restaurant. They had current C.P.R. cards and their profession was listed as “business.” By the summer of 1996, Bosnian female prostitutes were reportedly working out of one of the mid-size hotels. These women usually asked for the equivalent of BD25-50 or a gift such as a watch if money was not available. Adolescent Ethiopian prostitutes have been seen on the Exhibition Road area with pagers.

Prostitution is not illegal in Bahrain, and it must be mentioned that solicitation for prostitution is not as blatant in Bahrain as that seen in Abu Dhabi where women constantly walk up to men standing alone on the street, or while waiting for transport.

D. Pornography and Erotica

All pornographic materials are strictly prohibited by law and are confiscated by customs officials if detected. Most, if not all, expatriates coming to Bahrain are told that three items are strictly prohibited, i.e., pornography, items on the Israeli boycott list or made in Israel, and cultured pearls. The latter two classes of items are seen, however. Cultured pearls are not to be sold in Bahrain, but are worn, and the boycott list has changed since the Gulf War.

Pornography is available in Bahrain, e.g., magazines, as they are not picked up by security upon arrival as easily as metal items (by the metal detector), or drugs (by drug sniffing dogs) or computer diskettes containing pornography. All videos are viewed by customs agents at the airport upon arrival; others are retained and can be picked up later in Manama at the censorship office. Blue videos are still smuggled in, as well as items on the Israeli boycott list; these reportedly are “not that difficult to find.” Arrests of individuals holding blue movies or computer diskettes containing pornography, and those caught selling them are sometimes publicized in the newspapers as a deterrent. Relatives and roommates may turn in the sellers or users to the police. Names of the culprits may be publicized in the press or withheld.

E. Sex-Related Murders, Suicide, Self-Mutilation, and Sex with Animals

Murders in Bahrain have been very rare for the first nine decades of the twentieth century. The British advisor reported in the Bahrain Government Annual Reports Volume II 1937-1941 that “usually about one or two murders are dealt with by police during the year.” This general trend continued until the 1990s.

The early reports also mentioned that “occasional murders may take place which are not detected, especially women and newly born children.” These women were put to death by their relations because “they had dishonored the family. Killing a woman for this reason was considered by many Arabs to be justified” (Belgrave, 1960:100). Belgrave notes that he knew of cases where an unmarried girl was “put away” because she was pregnant, but he knew of no cases of a wife being killed because she was unfaithful. One case was related in the late 1980s of an expatriate Arab man and his brothers who managed to forcibly take the man’s wife to their home country. They informed the wife’s Western doctor they were going to have the woman and the child killed for bringing shame on the family. No action could be taken as there was no crime in Bahrain. This practice has been stopped in Bahrain for decades.

Currently, it is reported that the majority of pregnant, unmarried Bahraini women are sent abroad for abortions or practice self-induced abortion to avoid bringing shame on themselves and their family. Others may check into a maternity hospital, sometimes under a false name, and leave the child behind in the hospital.

Prostitutes in the former brothel areas were sometimes murdered by jealous lovers according to Belgrave (1960:103). More recently, during the last ten years, there were two sex-related murders involving Filipinas. The media reported one was murdered at work reportedly by a Pakistani lover, while the other body was found in a dumpster near a hotel.

Sex-related murders between individuals who are or were lovers have been reported, but they are very rare. During the last ten years, there were several publicized heterosexual cases in the media, e.g., a Filipino couple (the man murdered the woman, and then killed himself), and a South Asian woman was killed by her lover. There have been a couple of homosexual-related murders, for example, one village man killed his lover and buried him in the yard. And in another case, a younger Bahraini male (late teens) killed his elderly British lover.

Suicide due to shame about sexual matters is rare, but does occur. An Indian woman whose child was found to be HIV-positive confessed that she was involved with a Pakistani male. After an investigation, it was determined he had slept with a Filipina, who had been involved with a Saudi. The Indian woman committed suicide soon after the investigation, and her family (husband and son) were deported as they were HIV-positive.

Successful suicides versus parasuicides appear to be more common among Asians in Bahrain, particularly Indian males and females. Firearms, except for antiques, cannot be legally held by the general public in Bahrain, so serious suicide attempts are made by means of hanging, electrocution, drinking of kerosene or self-immolation, slitting of wrists to cause arterial bleeding, and drug overdose. Investigations published in the press show that the men are usually depressed over their financial situation or illegal residency status, while the women are having work difficulties (termination or warning letters), or family difficulties in India or locally. Some Indian women are trapped in abusive marriages to Bahrainis and have no place to seek assistance. Other precipitating factors may include sexual abuse by the husband’s male relatives and other family situations.

One research study on suicide has been published to date (Metery et al., 1986). In 1981, the police suicide register showed 150 people attempted suicide mainly by ingesting drugs for a rate of 0.04 percent. Religious values (suicide is a mortal sin in Islam) and social stigma possibly contributed to the low rate (Metery et al., 1986). This study showed more women, generally unmarried in their twenties, attempted suicide, and 60 percent had attended their local health centers within the previous six months complaining of somatic symptoms such as headache and body aches. This study did not indicate the number of Bahrainis or non-Bahrainis listed in the suicide register. A growing pattern of self-induced drug overdoses is reported among Saudi women (Malik, et al., 1996), Kuwaiti (Emura et al., 1988), and Qatari women (El-Islam, 1974). The precipitating event(s) leading to suicide need to be studied.

Parasuicide survivors (impulsive attempts) are brought to health care facilities. A six-month audit of Medical Department admissions between late 1995 and early 1996 in one general hospital showed 1.08 percent of the admissions were parasuicide attempts, with a ratio of 4.5 females to males, the same ratio of Bahrainis to non-Bahrainis, and the same ratio of impulsive situations versus psychiatric histories. Causes of impulsive attempts included exam failures, problems at work, fight with a family member, recent divorce, recent parental death in the family, and marital arrangements.

One case of self-mutilation by a Thai male who became depressed, reportedly when his girlfriend left, was reported in the press. Urological surgeons in the large government hospital performed successful surgery in this case. Attempts of this nature are extremely rare (one case in ten years).

Another deliberate self-harm (DSH) practice known as “jumping syndrome” appears to be common in the Gulf States, and is seen increasing in prevalence in Qatar (El-Islam, 1974), Saudi Arabia (Mahgoub, 1990), and Kuwait (Suleiman, et al., 1986). Predominantly Asians, and mainly females with an average age of 29 years, are jumping off buildings in an attempt to kill themselves. Studies show that many have died, while others have had extensive fractures and required long-term hospitalization for an average of fifty-six days, which places a cost burden on the Gulf States free health services. The proportion of unsuccessful attempts resulting in minor injuries is not known. The females jumping in most cases had no history of previous psychological illness. Sexual and physical abuse are the most important factors which push females to deliberate self-harm (DSH). Some of the jumping syndrome survivors alleged that this was the reason, however sexual abuse was not proven (Sadat-Ali, et al., 1995:189). Reportedly this is the method of choice for suicide in Kuwait due to the non-availability of drugs (Suleiman, et al., 1986). Cases of jumping syndrome have not been reported in the media in Bahrain, however medical personnel have been alerted to this trend.

There have been no studies conducted regarding Bahrainis having sex with animals, and there are no local anecdotal stories discussed regarding this topic. An archaeology text by Bushiri (1992) discusses seals found in Bahrain and Kuwait from the Dilmun period which show intercourse between a man and a bull, which the man performed from behind the bull while holding the rear of the bull.

9. Contraception, Abortion, and Population Planning

A. Contraceptives

Attitudes regarding contraception vary from couples who accept all children as the will of God and who make no effort to prevent pregnancy, to those who plan, space, and limit their families. In the former situation, many women report it is the husband who feels more strongly about this issue and who refuses to use contraception. In some cases, the women want more children and the husband refuses, e.g., the woman may be the second or third wife and the husband has many children, including sons, from a previous marriage(s), so he may then have a vasectomy after only two children from the last wife. The wife may then feel cheated and express regrets. Other families quote the Koran’s injunction to be able to provide for their children well, so they use various forms of birth control (condoms, IUDs, or pills) to space their children. Spacing varies from one to three or even fifteen years. Women say, “My husband told me I can get pregnant again after three years,” and men have said, “On my salary, I can only afford to have this number, so we needed to space our children.” Among the college-educated, some boldly say “Two is enough.” One Government publication reported that 50 percent of Bahraini families are using some form of contraception and another report states that 54 percent of married women are using contraception (Ahmed, A.A., 1995:15). The local birth rate of 2.91 percent is still one of the highest in the world. There are other factors motivating high pregnancy rates, including certain segments of society who are having children simply to outnumber other segments of society for potential political gains.

A group of Bahraini intellectuals from several specialties organized the Bahraini Family Planning Association (B.F.P.A.) in 1975. Bahrain has the only F.P.A. in the Gulf and is one of fifteen in the Arab region with their regional headquarters in Tunis. There are 165 country associations in the world with their main office in London. There are approximately 200 active members in Bahrain promoting the association’s work. A survey was conducted by the association in 1983 to test the attitude and knowledge of the population regarding contraception. This initial survey showed promising results, and the association has been active ever since. The association has facilitated other research by providing data, contacts, or support to researchers, and several theses have been completed (Al-Darazi, 1984,1986; Al-Gaseer, 1990). The B.F.P.A. contributed U.S. $10,000 towards the costs of the 1996 National Family Health Survey of 5,000 randomly selected Bahrain families, including 26,000 individuals. The survey was sponsored by the Gulf Cooperation Council Ministers of Health and the U.N.D.P. The questionnaire included items relating to reproduction and sexual health. The report with analysis is expected in 1997.

The funding for the B.F.P.A. organization comes in part from funds redistributed by the B.F.P.A. Central Committee to countries around the world. The local president is on the B.F.P.A. Board, the Central Committee, and the Budget Committee. Other funds come from donations by local individuals, various institutions, and the Government, i.e., Ministry of Labor and Social Affairs. Contraceptive aids are given by the B.F.P.A. to the Ministry of Health for distribution to families in the Primary Health Clinics, Salmaniya Medical Center, or the Maternity Hospitals. The B.F.P.A. also accepts gifts of clothes and other items, which are distributed to needy families. Annual reports are prepared at the local, regional, and federation levels describing activities of the association.

The activities of the B.F.P.A. are geared toward increasing public awareness of the types of contraceptives available for family planning. There is no local opposition; however, an occasional non-Bahraini will raise opposition to their work. The association provides lectures to representatives of local groups who then go back and talk with members of their respective group. The B.F.P.A. has videos, cassette tapes, and pamphlets, as well as a library at their association headquarters in Gafool. The current five-year plan has four main goals which the group is trying to reach, i.e., youth awareness, promotion of counseling and family planning, empowerment, and development of volunteerism and fund raising.

Family planning nurses working in Maternal-Child Health indicate that there has been a trend toward increasing use of tubal ligations and vasectomies for birth control, even among village residents. B.F.P.A. and the staff nurses state that people are better educated about their options for birth control, have the desire to space children, and many want to limit children out of economic necessity, e.g., due to the recession and no jobs. Nurses praise the support of the Bahrain Family Planning Association and their assistance in providing free contraceptives, and at times clothing or goods to needy families.

Free contraceptive aids are available from the Government at all the Primary Health Centers and at the Government hospitals for all Bahrain’s residents. Free tubal ligations and vasectomies are likewise available and are being used increasingly by older couples as a means of birth control. Health education courses regarding contraception are presented at the Government Primary Health Care Centers and videotapes are also available. The 1993 Annual Report for Primary Health Care in Bahrain notes that “due to religious beliefs and traditional attitudes,” a total of 4,573 visits were made during 1992 for family planning services. Out of these visits, 2,917 women initiated a contraception method, and 263 received IUDs. A total of 8,660 women received family planning counseling sessions, which was 7.8 percent of females in the child-bearing age (Fouzi Amin, 1993). A study conducted in one Health Center in the United Arab Emirates included 908 women between 15 to 44, and 50 percent of them were using some means of contraception (Blankensee et al., 1995).

Many doctors discuss birth control options including sterilization with grand multigravida (more than eight to ten children) and high-risk patients (those with repeated Cesarean sections and other complications) at the time of delivery. Doctors document when the patient refuses to have a procedure, or has signed a sterilization permit. After delivery, the doctors indicate if the patient has requested some form of birth control and what choice was made. The doctors’ personal beliefs play a factor in whether birth control options such as a tubal ligation are even mentioned. Some couples, after making their own choice, may be told by a doctor that their choice to have a tubal ligation is haraam (forbidden). More assertive and more educated couples will find another doctor, while others may be ashamed or afraid to discuss this matter with another doctor. There are no institutional ethical standards to guide physicians regarding this matter, or to suggest that they refer couples to another doctor who is willing to discuss such matters. If a woman is declared unfit, e.g., mentally retarded or unfit to be a mother, the family can request she be sterilized.

Condoms are sold openly in grocery stores and pharmacies. There are many private clinics in Bahrain, and three private hospitals, where birth control information and supplies are available for a fee.

Data on birth control practices of the various expatriate populations are not reported. Misconceptions regarding pregnancy abound, and some Indian girls are prohibited by teachers and parents from swimming in coed pools for fear they will get pregnant. The knowledge of Syrian, Jordanian, Palestinian, and Beluchi women has not been studied, and they are the expatriates having the largest families.

B. Teenage Pregnancies (Unmarried)

Although unmarried pregnancies occur, their incidence and prevalence among Bahrainis and non-Bahrainis, and teenagers specifically, are not known. A Bahraini girl/woman and her family will try to cover up such a scandalous incident. Male informants all knew of women “in trouble,” while female informants rarely knew of anyone.

Teenage pregnancies are not a major problem as seen in the West, because a girl’s behavior is strictly monitored by her parents. A girl, from the time she is ten to twelve, is kept close at home when not in school. Even if she attends the University, her parents know where she is and her daily schedule. Most girls are married after completion of Tawyehi or college, and some later even in their thirties; however until she is married, a girl is expected to live at home. A Kuwaiti researcher supports this perception that “illegitimate pregnancy is a problem of small dimension in Moslem societies” (Hathout, 1979). No objective data are available on this topic.

The children of unmarried women, in the early part of the twentieth century, were at times murdered with the girl by family members (Belgrave 1960:101-102). Other infants were abandoned on municipal rubbish dumps, Samadah, at the corners of streets, or placed outside the hospital (Belgrave, 1960:103). Some of these foundlings were looked after in the American Mission Orphanage. Others were cared for in the Government hospital, and very often foundlings were taken in by women who had no family. Another view was noted by Charles Belgrave who wrote that “for the children there was very little stigma in illegitimacy” (1960:103). He said he knew several young men “who were proud of belonging to important families, though on the wrong side of the blanket.”

Currently four to six abandoned children a year are referred to the Children’s Home. The number of expatriate women and maids becoming pregnant is not known, as many return to their homes to deliver. Rare cases are reported in the media, e.g., an expatriate maid delivered a child which died and the body was buried in the garden, and later a child in the family uncovered the body while playing. In this case, the expatriate woman was deported. Other newspaper reports note court cases where, for example, a young boy found a dead baby wrapped in a cloth outside the home, and he told his mother who alerted the Police Station.

C. Abortion

Abortions are provided in Bahrain only under strict religious regulations, i.e., a person cannot decide to have an abortion because of lack of birth control or an unwanted birth or rape. Abortions for these reasons are illegal. One study was conducted in Kuwait on “unwantedness,” so it is a phenomenon seen in the Gulf. In Kuwait, the women tried to induce abortion with medicines, violent exercise, or mechanical interference (Halliout, 1979). Objective data on this topic is not available for Bahrain.

A medically indicated abortion allowable by Sharia Law can be obtained in a government hospital, usually before three months, if the fetus has been found to be deformed, or with a congenital defect detected through ultrasound, amniocentesis, or other tests. Early abortions can also be performed if the pregnancy poses a threat to the life of the mother, and early deliveries are done if the woman has life-threatening conditions such as PET or placenta previa. The justification for these abortions is to save the woman’s life and to preserve the family, as she has other children to care for, and “she is the root of the family while the fetus is the branch which is sacrificed to save the root” (Hathout, 1979). In the case of the fetus with a defect, the rationale for abortion reportedly is to prevent suffering.

The attitude to abortion, especially in the case of an unmarried pregnancy, varies from liberal, “Why didn’t she have an abortion when she was outside the country?” to very conservative, “She had an abortion outside and this needs to be reported to the religious police.” Some informants report that the majority of unmarried Bahraini women have abortions outside the country due to the shame (ayeb) of an illegitimate birth. Illegal abortions do occur in Bahrain. Informants reported, “She drank some liquid and had an abortion.” Others report, “She was told to take seven to eight birth control pills for three days, but it did not work.” Nurses report this latter method is seen and is effective. Some individuals try other self-induced methods which are more dangerous, including dilatation of the cervix, and insertion of items into the uterus. A Filipina abortionist was caught operating in Bahrain in 1995 after a Saudi client became septic due to the abortion and during interrogation revealed the abortionist to the police. All the considerable money the abortionist had in her bank account was confiscated by the Bahrain Government and she was deported.

D. Population Policy

The population growth of Bahrain is 2.9 percent, which is one of the highest in the world. The effect of this high population growth, and its effect on the country’s growth and development, has been discussed in many reports and in the media. There is currently no government policy to educate people regarding the need to reduce population growth. All informants stated that there is no policy that women should be encouraged to use some means of birth control or to have a tubal ligation after so many children, e.g., four.

The Government has instituted a fee of BD100 (U.S.A. $265.00) for all expatriates who deliver in government facilities and who are non-entitled workers, or the spouses of non-entitled workers. This may be an indirect means of discouraging expatriate births, or a way of controlling their spacing. For many expatriates to pay BD100 a year out of a monthly salary of BD60-80 is a great burden. Likewise, the Government requires male workers to be making a minimal salary of BD250 before they can bring their families to Bahrain. Another means of controlling the number of expatriates and their burden on the health service is to deny residence visas for elderly relatives (over 65). Generally, work visas for government jobs are not given to expatriates over 60 to 65 years for men and 55 years for women.

Premarital counseling is encouraged by the Government and is provided free in the Primary Health Centers and government hospitals. In 1992, 545 couples received premarital counseling and among them, eighty-nine abnormal findings were detected (Fouzi Amin, 1993:27). Premarital counseling is being encouraged, but is not yet required among Bahrainis because of the high incidence of first cousin marriage (39 percent) and the high frequency of genes for blood disorders in the population, including sickle cell disease, G6PD deficiency, a variety of major and minor thalassemias (Nadkarni et al., 1991), as well as other congenital anomalies (Sheikha Al-Arrayed, 1996).

Other Arab countries, such as Egypt, have population control slogans such as “look around.” Other Islamic countries, such as Pakistan and Iran, have developed programs to educate people to limit their families to two or three children. Bahrain has no public policy to date. Approximately 0.1 percent of the recent Ministry of Health budget has been spent on family planning, while 0.2 percent has been spent on control of illegal drugs, and 0.3 percent on medical exams of newly hired expatriate workers (1991 Ministry of Health Report).

10. Sexually Transmitted Diseases (STDs)

A. Incidence, Patterns and Trends of STDs

Venereal diseases were reported by the first American missionaries who arrived in Bahrain in the late 1890s and early 1900s (Rajab, 1979). The missionary doctors were able to test for gonorrhea in the early 1900s and found it was a common disease. Venereal disease in 1914 ranked next to malaria (Patterson, 1914). A high proportion of the population was suffering from the ophthalmic form of gonorrhea which was rampant according to the Government of Bahrain Administrative Report for 1926-1937, and the Bahrain Government Annual Reports 1926-1960. Venereal infections ranked high, along with smallpox, malaria, dysentery, and trachoma.

Tracking of a second STD was started after a definite diagnosis for syphilis was possible by 1933-34 at the American Mission Hospital’s Laboratory (1933-34:9). During the 1940s, there were over a thousand cases treated annually, and by 1948, venereal infections had spread even more, and 200 patients were treated as inpatients and 1,200 as outpatients. At that time, the Government took certain stern measures against foreign women of loose character (Al-Khalifa, 1982). Venereal infections started coming down after the introduction of new medicines, and Bahrain was the pioneer for the whole region in developing an infrastructure to improve health care. In 1952, the Public Health Department (P.H.D.) was separated out as a distinct entity, and its statistics show that after 1965, venereal infection trends are greatly reduced from the 1940s (Al-Khalifa 1982:219). The P.H.D. laboratory is the preferred lab for testing blood samples of infectious diseases and all positive samples are sent to them for confirmation and follow-up of personal contacts.

The incidence of STDs has been studied mainly in relation to their effect on urinary tract infections and antibiotic drug resistance (Yousef et al., 1991), infertility, and impotence, rather than the epidemiology of their occurrence and relationship to various types of sexual activity.

The overall frequency of male urethritis and STDs in Bahrain is low, 108/100,000 (541/500,000) versus 1,600/100,000 in the USA, however the isolates of Nisseria gonorrhea found are often highly resistant or show diminished sensitivity to penicillin (Yousef et al., 1991:94). The number of gonorrhea cases peaked in 1980 to over 600 cases/year. The 1994 figures were the same as 1990 (379 to 380 cases/year). Gonococcal infections in 1994 ranked third after influenza and chicken pox. In contrast to Bahrain’s statistics, the first case of Nisseria gonorrhea in a pregnant Saudi woman was only reported in 1988 (Abdul Khaliq and Smith, 1988).

Syphilis cases reported to the P.H.D. in Bahrain have been increasing since 1990 from 37 to 104 cases in 1994 (Statistical Abstracts 1994). These rates (0.019 percent) are low in comparison to other parts of the Middle East and may reflect reporting inconsistencies or treatment outside Bahrain. A seven-year study conducted in Saudi Arabia on 90 percent of hospital births (Saudis and non-Saudis) showed an increase from 0.2 percent to 1.5 percent overall incidence of syphilis in 1986 (Abbas and Satwekar, 1989). This rate is high in comparison to European statistics, but lower than other Middle East and African data. Endemic syphilis is prevalent in the Middle East, and all cases of syphilis are treated as infectious until proven otherwise. Up to 20 percent of adult Bedouins in Saudi Arabia have been exposed to endemic syphilis bejel (Abbas and Satwekar, 1989). Secondary syphilis symptoms may be the first noted and treated. In Saudi Arabia, this has been reported by Basri and Smith (1991). In one case, the husband was being treated in a VD clinic but did not tell either of his wives, and one wife was never brought for treatment. In another case, a Somali bisexual had many sexual contracts, and in the third case the patient denied any extramarital contacts. A problem in Saudi Arabia which is difficult to overcome, is tracking of contacts. The first case of congenital syphilis was reported in Kuwait in 1987 (Hariri and Helin, 1987).

The seroprevalence of chlamydial infections was shown to be 44 percent of 100 pregnant women randomly screened in Bahrain. This suggests a high prevalence of chlamydial disease in the population, although some of the antibody-positive cases may be due to old ocular infections (Rajab et al., 1995). The USA average is 3 to 5 percent, and 15 to 20 percent in an STD clinic. In Saudi Arabia, the rates ranged from 10 percent of women seen in a gynecology clinic to 30.6 percent of men attending an STD clinic. Chlamydia overall accounted for 11 percent of all gynecological infections seen in one Saudi Arabian hospital (Qadri et al., 1993). Another study in a Saudi Arabian STD clinic showed 46 percent of males and 36 percent of female were affected, while 2 percent of men and none of the women attending a Primary Health Care clinic were affected (Qadri et al. 1993). Genital forms in Saudi Arabia were estimated at 38.4 percent and ocular forms at 61.6 percent. Chlamydial infections can be a cause of blindness, and is a familiar disease, especially where there is overcrowding, large numbers of children, lack of water, and poor hygiene. The prevalence of people with and without overt genital disease is higher in Saudi Arabia than in developed countries, but similar to rates seen in Bahrain. The role of chlamydia in female infertility due to blocked tubes was reported by Babag and Al-Mesbar (1993), who state that chlamydia is high in the Saudi Arabian population, but significantly higher in infertile women.

Hepatitis B is now classified as a sexually transmitted disease. The percentage of the Bahrain population affected is 2 percent (Mahnon and Fernandez, 1972). This incidence is higher in Saudi Arabia (14 percent) and 9 percent in Oman (Al-Dhahry et al., 1994). Saudi Arabia and Oman have high endemicity of hepatitis B, while Bahrain has more hepatitis C (4.7 percent) versus Saudi Arabia (0.2 to 5.0 percent) (Bakir, 1992). Currently, hepatitis C is not classified as an STD. A study on the risk of transmission of hepatitis B infection among family members in Bahrain showed a transmission rate of 26 percent (Parida and Effendi, 1994).

Human papiloma virus (HPV) is a sexually transmitted agent which has been shown to have a strong relationship with neoplasms of the female genitalia. One study showed the rate of infection among 25- to 35-year-old women in Bahrain to be 63 percent (Sunderaj, 1990).

B. Treatment for STDs

Treatment for STDs is provided free to all Bahrainis; however, due to the nature of the disease and its social implications, people generally attend private clinics, see consultants in the private hospitals, or even attend clinics outside Bahrain for treatment. There is a specialized private venereal disease clinic in the Gudaibiya area.

Prevention of spread of STDs through tracking of sexual contacts is a problem in the Middle East (Basri and Smith, 1991). Affliction with VD is seen as a sign of low morality, so patients vehemently deny any extramarital affairs. The men may not tell even their wives they are being treated. The men may have had casual sex (as seen in Saudi studies) while overseas, so their contacts are unknown and are lost. The Bahrain Public Health Department tries to determine all contacts. Other forms of prevention include vaccinating all newborns in Bahrain for hepatitis B according to WHO guidelines to prevent a burden later in the health care system. Other prevention efforts include public education lectures, programs in the media, and other methods. These programs do not include the incidence of these diseases in Bahrain nor their prevalence in the various ethnic groups, but mainly stress the need to make a general concerted effort to prevent them by good moral behavior.

One direct method for prevention of STDs has been tried in Bahrain, as in other Arab countries. During the late 1980s, the Jordanian Government started handing all single male travelers a card warning about the dangers of AIDS. Likewise in Kuwait, information pamphlets are distributed at the airport warning travelers about the dangers of sexual diseases outside the country. As many Arab men take single or male-only group vacations to the Far East and Europe, such prevention problems were instituted by several Arab countries. Traveling Bahrainis state that at the Bahraini Airport, pamphlets on STDs are likewise distributed, but men report this is not on a consistent or daily basis as in other countries. Another direct way of prevention, by prohibiting sex vacations, was in effect for awhile. Visas were required to travel to certain countries, e.g., Thailand. These restrictions have since been lifted.

There are Bahraini men who regularly travel to Thailand, Philippines, Hong Kong, or elsewhere for sex vacations. Some are unmarried, others married. Informants have reported that one single man was asked, “Aren’t you afraid of contracting some disease?” he responded by saying, “God’s will.” He could not be convinced of the unsafe nature of his activities. Another married man makes two trips a year. When he was asked about safe sex, he shrugged his shoulders. Another man, a well educated and highly paid professional, would make Asian trips and repeatedly return with ophthalmic infections and expected his doctor to cure him again. The incidence of these trips is not known, nor how many use “safe sex” during these encounters. There are Bahraini women having affairs in Bahrain, usually in hotels or flats, as well as abroad. The number who have contracted STDs due to an affair have not been studied or reported. The annual number of venereal cases published by the Government does not distinguish among Bahraini and non-Bahrainis, nor do they make any distinction among those who contracted the STD from their husband or wife, through a local affair, or an affair abroad. There are no statistics regarding how many are divorced or unmarried and living on their own versus individuals living in parental homes. All this information is needed to detect trends and to plan effective prevention programs.


A. Incidence, Patterns, and Trends

Doctors in Bahrain were first alerted in 1985 to the new disease called AIDS (flocks at mana ‘ah al mukta sabah), and lectures were given in 1989 and 1990. The first public reports on the occurrence of HIV in the population appeared in 1990. At that time, 95 percent of the HIV carriers reportedly were drug users, and 5 percent had received organs or blood outside the country (Fulafel, 1990). The latter group going to India have a risk of 1:12 of HIV seroconversion following transplantation in Bombay, based on figures from other Gulf countries (Al-Dhahry 1994:314).

HIV testing is done in government facilities. No consent is obtained from individuals before testing. Now all conscripts into the Bahrain military and civilian employees of the military are tested for HIV, HBV, HCV, sickle cell disease, G6PD deficiency, and other relevant factors depending on family history and country of origin. Staff are tested upon employment and during retroactive screening regimens. Patients attending the Shaikh Khalifa Bin Mohammed Al Khalifa Cardiac Center for any invasive procedure are all routinely checked for blood-borne viral diseases. Expatriates positive for HIV will not be treated at the Cardiac Center unless they have an emergency condition, and like all positive expatriates, will be sent to their home country immediately under Public Health Laws. Other hospital and clinic patients, excluding dialysis patients, are not routinely tested, and are checked based on the nature of their current signs and symptoms. If an HIV-positive result is returned, generally elective surgical procedures are canceled.

Expatriate workers recruited for all government health care facilities are tested, as well as maids, cooks, and beauticians who are processed through recruitment agencies and hired to work in Bahrain. Bahrain does not require an “AIDS-free certificate” for all expatriates, including wives and children, taking up residence before their arrival in the country, unlike Kuwait and Saudi Arabia, which require all expatriates taking up residence in the country to be HIV-free. The United Arab Emirates Health Department screens everyone in the country for HIV on a periodic basis as their expatriate work force comprises 70 percent of the population. Over 1,600 HIV-positive cases have been detected to date in the U.A.E., with the majority of cases detected among Asian expatriates who were deported.

HIV Incidence Among Newborns, Children, and Adults

HIV-positive status is seen among newborns in Bahrain. The incidence is not known, as women and babies are not being screened as done in 37 states in the USA, and elsewhere. The suspected rate of infection at the time of birth, or later from breast feeding is not known, nor the number of newborns who later revert to HIV-negative status, Children of various ages have been detected positive for HIV and have died from AIDS. The first AIDS death in Bahrain in the 1980s was a child infected through a blood transfusion given abroad. The known routes of HIV transmission have been vertical, mother to child, and from blood transfusions received abroad. Infections from sexual abuse have not been revealed to date if such data are known. The rate of horizontal transmission among family members is also not known. A few adolescent HIV and AIDS cases have been seen in health care facilities.

The incidence of HIV infections among adults has been reported by the Government. More men than women have tested HIV-positive. The proportion of Bahrainis versus expatriates is not clearly indicated in the Government data. In 1991, according to Ministry of Health figures, 0.09 percent out of 7,374 blood donors were positive and 0.01 percent of 8,173 reporting for their preemployment physical exam. The trends show an increasing number of reported cases each year for men and women. All expatriates who test positive for HIV are deported according to the Government’s Public Health rules (as are those with hepatitis B and C, tuberculosis, and leprosy). The potential drain of these expatriate individuals on health care funds, and the possibility of cross infection to others, are the rationale of the Government enforcement of deportation rules.

There are three main patterns of HIV infection seen among men. Intravenous drug users comprise the largest number. During the late 1980s, government media releases indicated IV drug use was the primary known source of HIV infection among men (Fulafel, 1990). Heterosexual, bisexual, or homosexual activities, including multiple sex partners in Bahrain or abroad, e.g., India, Thailand, Philippines, and Western countries, are the second source. Blood transfusions abroad, in countries where blood is not routinely tested, e.g., India, Philippines, remains a third route of infection.

There is a long history of hard drug use among men in Bahrain. Iranian opium was marketed between Iran, London, and Hong Kong by the British trading ships of the East India Company during the late nineteenth century and into the early twentieth century. Some opium was shipped to Bahrain via dhows. Opium was sold in herb shops in Manama called Abdareen shops. These sales continued during the 1920s and 1930s. There was widespread use among those of Persian descent, Beluchis, and Indians. People usually smoked opium, but as their tolerance developed, they began taking it orally. One man used to see his relative putting three to four pieces of opium in his mouth and drinking it with tea. Unlike the other groups, the Arabs only used opium for medicinal purposes to treat headache or stomach ache, and it was given in small quantities diluted in milk to put a child to sleep.

The use of opium later declined in the early 1940s when it was outlawed and became a controlled substance. Then new types of drugs, including IV drugs became prevalent. A study from 1980 to 1984 showed an annual increase in cases of drug involvement and narcotics dependence (Mattar, 1985). In 1991, the Bahrain courts heard 197 drug-related cases involving 433 drug users or traffickers of several nationalities.

Currently, drug use is strictly controlled and there are frequent arrests at the airport, mainly of expatriates who try to bring in heroin, opium, and hashish (marijuana). Other drug caches of heroin have been found at sea hanging on buoys. Occasionally, someone is caught, usually an expatriate trying to bring in drugs via the Saudi Causeway. In spite of controls at all ports of entry, supplies of drugs are readily available on the Island. School principals have openly told students what places to avoid, as they are known for drug sales. People report having relatives who are IV users of hard drugs. Money is given to them by family members to purchase drugs. Others may rob to support this habit. The Government newspapers every week contain information about court hearings for drug use, drugs confiscated at the airport, drug sales, or drug-related deaths - all among men. The incidence of these drug hauls is reported by the Ministry of the Interior. The incidence and prevalence of IV drug use among the population is not reported, but it is a major factor in HIV transmission in the country. Narcotics Anonymous has a local chapter, and reformed addicts attend, speak at local seminars, and give public lectures upon request. They talk about the twelve-step rehabilitation program and how it helped them, once they admitted they were addicted to drugs.

The extent of bisexual activities and the danger of HIV transmission due to these unsafe sex contacts has implications on the future health of the women to whom these men are married and their offspring. The frequency of interaction among homosexual and bisexual men is not known, however anecdotal stories show that Bahraini men have been known to have Western expatriate lovers in Saudi Arabia, and elsewhere, unknown to their Bahraini wives. Also, naive young women sometimes discuss their personal relations with coworkers, including their husbands’ practices during intercourse, e.g., “needing a cucumber in his rectum.”

The patterns of HIV infection among women in Bahrain differ from men. Their numbers are very low. The early cases in the 1980s were seen among women who contracted the virus during operations abroad, or from blood transfusions, e.g., from India. Their positive status many times was discovered when the patient attended a hospital for another procedure. More recently, women are being infected during heterosexual activities with their husbands or a lover; fortunately, these cases are rare to date. Transmission of HIV infection from a wife to her husband has occurred, but these cases are also rare.

Among health care workers, there have been no documented cases of HIV contracted through blood contact or sharp injuries. However, several cases and deaths due to hepatitis B and hepatitis C infections from patients are known in the community. The practice of deporting the HIV-positive expatriates, and deaths of some Bahrain patients from AIDS, has kept the known number of HIV cases in Bahrain below 200 for the last ten years. The published cases of AIDS are listed as 20 (Wahdan, 1995)

If there are data kept on the incidence of HIV among homosexuals, lesbians, and bisexual persons, they are not published, nor are they in the public domain.

B. Availability of Treatment, Prevention, and Government Policy

The Government of Bahrain provides free health care for all Bahrainis who are HIV carriers. Government workers must provide care for these individuals, and doctors are aware of all current treatments available abroad. All experimental medications are not available in the country; prophylactic antibiotics to prevent Pneumocystis carrini are available.

Regarding expatriates, the Government policy regarding HIV/AIDS includes the following:

1. Recruiting agencies need to test workers in certain service areas in their home countries, including maids, beauticians, cooks, and health care workers. In Saudi Arabia and Kuwait, all seeking residence, not just workers, are tested prior to arrival.

2. The above categories of workers are retested after arrival.

3. All expatriates found positive for HIV, HBV, or HCV are deported.

4. All expatriates who are later tested and found positive are deported.

5. There is no scheduled testing for all the inhabitants of the country. (Countrywide testing has been conducted in the UAE and Kuwait).

6. Local drug users who test positive are incarcerated if their behavior shows they are a risk to others, or upon the request of concerned family members.

Research regarding the topic of HIV is scanty. The Government conducted one study in the late 1980s regarding the population’s knowledge about AIDS. The majority reported it was “an expatriate problem.” Another study was conducted among military conscripts, and it showed the men knew about the disease, but some were unclear about transmission routes and prevention measures (Parida, 1992). A study conducted by medical students showed that only 5.9 percent of Bahrainis understood the modes of transmission for AIDS, and 32.2 percent believed it could be cured (Chand, n.d.). Obviously, more public health education is needed regarding the topic. A 1995 study on nurses’ knowledge about AIDS has not been reported to date. In 1995, the Government announced appointments to a National AIDS Committee.

The United Nations resident coordinator and UN Development Program (UNDP) resident representative, Dr. Faysal Abdul Gadir, has been outspoken regarding shying away from the AIDS threat:

Once again there is the problem of people not acknowledging that in fact it is a problem.... Forget for a minute the sociocultural view that it is impossible to contract it due to religious and social regulations. The reality is people are contracting the disease and we can’t close our eyes and say it is the problem of industrial and non-Moslem countries. We cannot say it is irrelevant to us. It will mean a drain on the budget as the State will have to take care of each patient until he dies. (Gadir, 1996)

Lectures are provided occasionally to the public on HIV and AIDS in the Government Health Centers and videos are also shown. The Ministry of Health has distributed booklets in Arabic about AIDS. Indirectly, the Government provides knowledge about AIDS though the choice of movies shown on government controlled television channels (Arabic and English). The WHO sponsored an AIDS-awareness day in 1995. Discoveries of the latest AIDS advances are sometimes published in the local government-controlled newspapers (Arabic and English). During the 1996 Ninth International AIDS Conference, daily updated information was printed in the local English-language newspaper.

Public education about the dangers of AIDS is not provided on a continuing basis. There are no active government media programs, such as the public service advertisements seen on the television in the UK, USA, or other countries. There are no large posters shown on hoardings (signboards), or at bus stops or public malls as seen in India, Hong Kong, and Botswana. There are no notices about safe sex, or clean needles on the doors of pubic toilet stalls, or at the airport like you see in Australia or Hong Kong. The overall health education budget for the Ministry of Health in 1991 was 0.1 percent of the total budget or U.S. $120,000.00 (BD 56,229,000) for education regarding all areas.

12. Sexual Dysfunctions, Counseling, and Therapies

A. Definition of Sexual Dysfunction

The definition of sexual dysfunction can be based on the patient’s perception and/or on underlying organic and psychological causes. There have been no reports published in the Bahrain medical journals on this topic, although various lectures on related topics have been presented.

B. Availability of Diagnosis and Treatment

The patients’ perception of sexual dysfunction needs to be assessed accurately by urologists and other health care professionals. In some cases, the individual who is normal may be comparing himself to what others say they are capable of performing, e.g., intercourse once a week versus three times a day (E. Amin, 1994). Many patients are reluctant to describe sexuality and sexual aspects of their marriage, as seen in the study among primary health care patients conducted by Kahtanie (1992). Once a psychological basis for sexual dysfunction is diagnosed, the patients are referred to the psychiatrist if they agree. Many patients in Bahrain and the Gulf do not seek psychiatric help until their difficulties become more prominent and continuous and interfere with their marital or social life (Al-Khani and Arafa, 1990). Acceptance of psychiatric referrals has increased dramatically during the last ten years, although education level and perception of any shame associated with psychiatry still inhibit individuals getting the help they may need. Bahrain provides free psychiatric service for anyone in the country, and the Psychiatric Hospital and outpatient clinics are well staffed with highly trained Arabic- and English-speaking Bahraini and expatriate male and female doctors.

Individuals with addictions whose behavior is erratic, including their sexual activities, can receive free psychiatric treatment and can attend addiction clinics or drug detoxification programs. There are also long standing, self-help groups, such as Alcoholics Anonymous (held at American Mission Hospital), and a new local chapter of Narcotics Anonymous (founded in 1996). There are known cases where addicted individuals having HIV continued to be irresponsible in their sexual behavior, and their families asked to have them placed in jail to control them in the interest of the public welfare and prevention of cross infection.

Organic causes of sexual dysfunction are varied and their incidence is rising. The incidence of congenital anomalies in Bahrain is 20 percent. This figure is based on the 80 percent of deliveries which are conducted in the Ministry of Health facilities (excluding the military and private hospitals, and home births). Anomalies of the genitourinary system rank second at 2.5/1,000 after musculoskeletal at 2.8/1,000 (Al-Arrayed, 1987). This rate is lower than 21.6/1,000 in Al-Ain and 12.9/1,000 in Abu Dhabi, and 6.6-8.5 /1,000 in Saudi Arabia (Topley and Dowda, 1995). The author notes that all malformations, based on international studies, may not be noted at birth (only 43 percent), or during the first six months (82 percent). Other problems are noted later, especially those of a sexual nature, which may be detected only during adolescence, or later after marriage.

Organic causes of sexual problems seen in Bahrain and the Gulf area include undescended testis, hypospadias (Al-Arrayed, 1987), webbed penis (Husa and Al-Samarrai, 1990), intersex disorders requiring gender reassignment such as Turner’s Syndrome, Kleinfelter’s Syndrome, and XX genotype females/phenotype males, and XY women (Al-Arrayed, 1996). Expert surgical help is available, as well as penile prosthesis implants. Endocrinologists can provide adjuvant hormonal therapy, as needed. Clinical psychologists or psychiatrists can provide counseling for individuals and/or their families on gender identification and possible social outcomes. In order to prevent the continual rise in occurrence of organic causes of sexual dysfunction among the young, doctors are recommending genetic counseling for individuals before marriage and after birth of an affected child. A genetic counseling group clinic has been established; however participation is voluntary. Screening on 515 couples in a Health Center showed that among them, 89 had abnormal findings detected (Fouzi Amin, 1993). A similar recommendation for genetic counseling was made in Kuwait (Telbi, 1988).

13. Research and Advanced Education

There are no institutes or programs for sexological research in the State of Bahrain. Nor are there any post-college or graduate-level programs for the advanced study of human sexuality, or any sexological journals or periodicals. Occasionally, a related article will be published in the two national medical journals:

Bahrain Medical Bulletin. Editorial Officer. Box 32159, State of Bahrain. Tel: 0973-265 258; Fax: 0973-277 036

Journal of the Bahrain Medical Society. Editorial Office. Box 26136. Manama, State of Bahrain. Tel: 0973-742 666 (5-10 pm local time); Fax: 0973-715 559

There are also no national or regional sexological organizations among the six Gulf Cooperation Council member states (Bahrain, Saudi Arabia, Kuwait, Qatar, United Arab Emirates, and Oman). There is a Bahrain Sociologists Society, which has published a series of monographs in Arabic. Bibliographies available on Bahrain include:

Ailan, Redhy Mustafa. 1996. Bibliography for Women in the State of Bahrain. (In Arabic). Bahrain: Information Center for Women and Children.

Badu, Balghis, and Mary Awad. 1995. Arab Women Bibliography: A Study Conducted in Eight Arab Countries. Center for Arab Women Training and Research, Tunisia. (Includes French and English titles for Bahrain, Egypt, Jordan, Kuwait, Lebanon, Morocco, Palestine, Yemen; database to be updated annually.)

Davis, Gordon A. 1993. Catalog of the Bahrain Historical and Archaeological Society Library. (English titles). Bahrain: Historical and Archaeological Society, P.O. Box 5087, Juffair, Bahrain.

Manzer, Bruce. 1996. BMED: An Index to Gulf Medical Journal Holdings in the Al Farsi Library (1979-1995). Bahrain: Ministry of Health, Al-Farsi Library, College of Health Science, P.O. Box 12, Sulmaniya, Bahrain.

Sarhan, Mansoor Mohammed. 1995. National Bibliography Vol. 1. Fakhrawi Book Shop Printing & Publishing, Translation, Bahrain: P.O. Box 1643, Manama, Bahrain.

Statistical Abstracts 1994. 1995. State of Bahrain, Central Statistics Organization, Directorate of Statistics.

Information is available in English and Arabic on related topics in the following libraries: Bahrain Family Planning Association Headquarters, Al-Qufool, Bahrain Tel: 0973-232233, 256622 Fax: 0973-276408

Al-Farsi Library, College of Health Sciences, P.O. Box 12, Ministry of Health, Al Sulmaniya, Bahrain. Tel: 0973 255555 ext. 5202 Fax: 0973 252569 Telex: 8511 HEALTH BN

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