Waris Qidwai  ( Family Medicine Division, Department of Community Health Sciences, The Aga Khan University, Karachi. )

Back-ground: There is a shortage of scientific data on the subject of sexuality from Pakistan. We decided to document misconceptions among Pakistani young men, regarding masturbation and nocturnal emissions and to make a case for sex education in the country.
Objective: To study the knowledge, attitude and practice of Pakistani young men as regards masturbation and nocturnal emissions and to see any associations with demographic factors like age, marital status, occupation, level of education and socio economic status.
Method: A questionnaire was developed, based on the objectives of the study. It was administered to 188 men between the ages 18-30 years, who presented to the outpatient department of the Aga Khan University Hospital. There was double entry of the data from questionnaires and the demographic form into the computer program, using the Fox Pro for windows and the SPSS for windows.
Results: We found a high prevalence of misconceptions and guilt associated with both these acts. Eighty percent of the respondents had masturbated while a 94% had experienced nocturnal emissions. 31.4% and 62.8% of the respondents reported association of physical illness and weakness with masturbation. Responses were 14.9% and 42.6% for nocturnal emissions. Association of guilt with masturbation and nocturnal emissions was 68.6% and 32% respectively.
We also studied the association of demographic variables with these prevalence figures, in order to point out areas for future studies and interventions.
Conclusion: We have documented the misconceptions regarding masturbation and nocturnal emissions among Pakistani young men and have made a case for sex education of our youth (JPMA 49:251, 1999).

There is a shortage of recently collected scientific data on the subject of sexuality from Pakistan and other developing countries. Available data testifies to the fact that misconceptions regarding sexuality are prevalent in the society, resulting in psychosexual problems.
In the nineteenth century, the campaign against masturbation became a medical mania. It reached its apogee under John Harvey Kellogg, M.D., who invented corn flakes and other cereals and nut foods as meat substitutes to reduce all carnal desire, and hence masturbation. The stigma on masturbation remains¹.
A study conducted more then one and a half decades back, among male university students in Pakistan, found that 73.45% had masturbated, while 69?49% thought that it to be a harmful act. A 37% of the students thought nocturnal emissions to be harmful².
In a study conducted on 1000 consecutive patients with sexual disorders attending the psychosexual clinic at All India Institute of Medical Sciences, males were included between the ages of 21-30 years. It was found that premature ejaculation (77.6%) and nocturnal emissions (71.3%) were most frequent problems followed by feeling of guilt about masturbation among 33.4%. Another 19.5% patients reported excessive worry about nocturnal emissions³.
In a survey carried out in Kuala Lumpur, Malaysia, among 1200 adolescents aged between 15-21 years, it was found that almost half of those who indulged in masturbation were worried by the act⁴.
Anxiety arising from masturbatory guilt plays a major role in the production of frigidity and impotence. Reduction of this anxiety through greater community awareness of the normality of masturbation is therefore a fertile area for the principles of preventive medicine to be applied⁵.
In a survey carried out in China, among 1091 grade five and six students, 17.8% had masturbated while 59.7% had fear or guilty feelings. More then half the students thought that wet dreams require treatment while two thirds had heard about them before their first experience⁶.
In a recent study conducted in China, the common encountered adolescent health problems include nocturnal emissions and masturbation⁷.
In another study carried out in China, among 445 senior high school students, 47.9% of boys did not have previous knowledge about puberty, majority of them were puzzled and disgusted at its onset. Another 18% reported masturbation while a substantial. 64% of boys wanted sex education⁸.
A survey conducted in Bombay, concerning knowledge and attitudes relating to human sexuality among 22-44 years of age female teachers from eight colleges showed the knowledge of normal male and female anatomy was inadequate, the majority of them had received no formal sex education but accepted the idea of imparting it to their children⁹.
According to an unpublished survey carried out in Sri-Lanka, involving 200 males aged 16-24 years, showed that 33% of the respondents felt that nocturnal emissions harm the body. Masturbation was thought to lead to problems such as impotence, premature ejaculation and body weakness. The need for sex education is again emphasized.
In Malaysia, men of Indian origin considered masturbation to be bad while those of Chinese origin were more tolerant towards the issue¹⁰.
In a study carried out in Beijing, 4366 middle school students were interviewed. The results showed that the knowledge relating to masturbation and nocturnal emissions was very limited¹¹.
After realizing the need for a study to document the prevailing misconceptions among Pakistani young men, regarding masturbation and premature ejaculation, we decided to scientifically collect data on these issues and make a case for sex education in the country.

A self-administered questionnaire was developed, keeping in mind, the objectives of the study. Based on the extensive literature search and the experience of colleagues. a series of questions were developed to enquire about prevalence of misconceptions about masturbation and nocturnal emissions.
The questionnaire was developed in English and Urdu languages and was administered in either language according to the convenience of the respondents.
A form was developed for the demographic profile of the patients, and was filled out by the respondents. It included the parameters of age, marital status, level of education and socio-economic status.
The questionnaire was administered to males between the ages of 18 to 30 years, visiting the General Practitioners at the out-patients department of The Aga Khan University, Karachi, Pakistan with any complaint or as an attendant. The objectives of the study were explained to them and a consent form was signed if they agreed to participate. Men were selected by convenience sampling. The investigator was present during the questionnaire administration to answer any questions for clarification. Sex education was imparted after the questionnaire was filled out.
A sample size of 188 was selected which had a 95% confidence level. The study was conducted between October 1995 and July 1996.
There was double entry of the date obtained from questionnaires and the demographic form into the computer program, using the Fox Pro for windows and the SPSS for windows.

The data was analyzed by tabulation, to see the prevalence of the different misconceptions. Associations between the misconceptions and various demographic parameters were noted.
Eighty percent of the respondents had masturbated in their past lives, while 40% were currently involved in the practice. The practice of masturbation was higher in those less than 25 years of age (42.7%) ill comparison to those above this age (36.5%). A 3 1 .4% of the respondents thought that masturbation can caused physical illness (Table 1).

This idea was more prevalent among laborers (55.6%), in comparison to students (15.4%). A 62.8% thought that masturbation cause physical weakness (Table 1). Again this misconception was more prevalent among laborers (77.8%) than among students.
A 22.3% of the respondents considered, masturbation to be a cause for impotence (Table 1), while 32% were not clear (p<0.05). This misconception was more prevalent among laborers (50%), than among students (7.7%), and was more prevalent among the middle and low income groups (51.3%), than among the higher income groups (10.7%). A 10.6% of the respondent considered masturbation to be a cause for infertility while another 40% were not clear (p<0.05).
A significant 68.6% of the respondents associated a feeling of guilt with the practice of masturbation (Table 1). This was more so in laborer (89%), in comparison to students (44%), and among middle and low income groups (78%), in comparison to the high income groups (47%) (p<0.001)
A 94% of the respondents had experienced nocturnal emissions. A 14.9% of the respondents thought it produced physical illness (Table 2), while another 20.7% were unsure about the correct answer. Physical illness was considered to be caused by nocturnal emissions more in the middle and lower socio-economic groups (p<0.05).
A 42.6% considered nocturnal emissions to be a cause for physical weakness. A 32% of the respondents associated a feeling of guilt with nocturnal emissions (Table 2). This guilt was much higher among the labourer (67%) then among students (28%).
About 30% of the respondents thought that nocturnal emissions caused dark halos around the eyes, which is considered to be a sign of ill health in the society (Table 2).

This misconception was higher among labourers (57%) than among the students (26%).
About 11% of the respondents thought nocturnal emissions to be a cause for impotency. (Table 2). Again this misconception was higher among the labourers (33%) than among the students (10%). The findings of our study are compared with those from others, in Table 3.

The last study on misconceptions regarding masturbation and nocturnal emissions in Pakistan was done in 1981¹. It seems that either no remedial measures have been taken following this study or that measures taken have had no impact, because our study has found these problems exist to the same extent even today. Because of unknown reasons, the problems arising from misconceptions regarding these important issue have been ignored. Table 3 compares findings of our study to those of other studies in the region. The Verma study³, conducted in a sex therapy clinic found much less guilt associated with masturbation than with nocturnal emissions. The Zulkifi study⁴, conducted in Malaysia on adolescents found substantial guilt associated with masturbation. The Hsu-Hy study⁶, found a low incidence of masturbation but substantial guilt associated with masturbation.
The prevalence figures of masturbation and the associated guilt found by Ahmed² are similar to those found in our study. This serves as a validation of the data gathered by us and gives reason to believe that the rest of the data is also likely to be correct. There is a difference in the two study populations.
Analysis of our data, provides useful information about the possible associations of various demographic factors with misconceptions. This data is not conclusive since this was a prevalence study but does provide directions for future studies and possible intervention areas.
Misconceptions are more prevalent in laborers than in students. This could be because of a lower literacy rate and socio-economic deprivations amongst them in Pakistan. This is the group of men exploited more often by quacks and untrained sex therapists.
It is unfortunate that a significant number of our young men continue to suffer from such misconceptions, corrections of which can relieve these economically productive people from considerable unwarranted anxiety.
Sex education of our youth is perhaps the answer to these problems. A survey conducted in Bombay, India among female college teachers of 22-44 years age supported the idea of sex education for their children⁹. The issue of imparting sex education to youth is a very sensitive issue and a careful approach is required. It could be imported at the school or the college level or family practitioners could be involved because of their respect in society.
It is hoped that this study will be thought provoking on the important issue of imparting sex education to youth and would be followed by further studies and interventions.

I wish to thank Dr. Rukhsana W. Zuberi, Associate Professor, Community Health Sciences, The Aga Khan University, for her guidance in carrying out the study.

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