research-article

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Understanding Cultural and Religious Values Relating to Awareness of Women’s Intimate Health among Arab Muslims

Authors:

Latifa Al-Naimi,

Mirela AlistarAuthors Info & Claims

CHI '24: Proceedings of the 2024 CHI Conference on Human Factors in Computing Systems

Article No.: 690, Pages 1 - 18

https://doi.org/10.1145/3613904.3642207

Published: 11 May 2024 Publication History

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Abstract

Women’s intimate health is a historically stigmatized topic in many cultures. Arab and Muslim values such as privacy and modesty can influence the extent to which members of these communities seek information or help regarding their intimate health. However, Eurocentric approaches to design and research for these groups only yield resistance due to their challenging of core values. We explore prior work in women’s health in HCI and cultural models to design for an underrepresented group in HCI research. Through interviews conducted with 16 participants who identified as Arab Muslims, we investigated attitudes, cultural and religious values, and backgrounds relating to awareness of women’s intimate health issues. Our thematic analysis identified shared experiences in learning about women’s intimate health and ways in which Arab culture and Islam synchronize or diverge. We contribute cultural and religious elements to consider in research methodology and design for Arab and Muslim communities.

1 Introduction

Issues relating to women’s intimate health are a growing topic of concern for a variety of reasons, including underestimating women’s pain [28, 37, 93], lack of healthcare research involving women as participants [30, 69], and the stigmatization of women’s sexuality [11, 42, 58, 76]. It is known that ignorance or lack of knowledge in health matters can delay early detection of problems, thus increasing the risk of severe complications [18]. Despite that, modesty and shame are attributes that are often associated with discussing subjects considered to be taboo, such as women’s bodies or intimate healthcare [35, 62, 74, 99]. These attributes are ingrained in numerous global ideologies, whether cultural or religious [19, 70]. In this work, we focus on women’s intimate health at the intersection of two large populations: Arabs and Muslims.

Intimate health is an especially sensitive division of healthcare that is susceptible to neglect in the Arab and Muslim world, especially for unmarried woman [14, 47, 52, 111]. However, typical Western modes of awareness on intimate health may be deemed too inappropriate and clash with important Arab and Muslim values, such as modesty (hayaa’ in Arabic), which contributes to the aversion towards delving deeper into the awareness of women’s health issues [90]. Moreover, consideration for parental and sometimes patriarchal figures within the family holds a significant role in the lives of Arab and Muslim women [57]. This role can manifest in several ways, such as hospital procedures requiring permission from husbands or fathers for specific women’s health procedures [52, 63, 91]. Another manifestation is the shame or reticence felt in women’s own homes in disclosing intimate health concerns [74]. Thus, the strong interconnection between family members weighs heavily in life choices and decision-making, including in healthcare. In such communities, access to information or healthcare may vary. It is therefore essential to cater sensitive information to the cultures involved in a culturally-sensitive manner [74, 99].

Cross-cultural research and decolonization research address this issue by 1) understanding how cultural dimensions specific to certain cultures affect cognition and interaction [36, 80], and 2) adopting methodologies that allow for considering populations on the margins, or "periphery" [8, 9], respectively. Decolonization practices call for decolonizing spaces that have presumed Western outlooks to be the standard for ways of being and acting [29]. Specifically, decolonial theory posits that the effects of colonialism are embedded in the modern world–and by extension in computing spaces [8, 9]. Decolonization strategies are important in HCI and computing because they encourage researchers to challenge philosophies, methodologies, or platforms established in and for Western civilizations. Rather than depending on and building on research from the Global North, working to incorporate prevalent beliefs and practices in communities where secularism may be shunned could prove more impactful among users whose lives, technological, and digital interactions are influenced by cultural and religious factors. The work that has been done in HCI research for women in the Global South has been valuable in recognizing cultural differences and can contribute to decolonial discourse and prompt additional inquiries in cross-cultural research and design for cultures that have been underrepresented [74, 99, 100, 108]. For example, Sorcar et al. [99] recognized the importance of culturally sensitive interventions in developing a software application for educating adolescents about the human immunodeficiency virus (HIV). By embracing culturally embedded modesty surrounding intimate topics, the authors were able to disseminate a crucial teaching mechanism to schools in India. The latest HCI research in the Global South provides a guidepost for communities with culturally and religiously adjacent values, such as the Arab world. Motivated by similar goals towards inclusive design, we investigate the methodologies of decolonization in HCI and literature on cross-cultural design in researching and designing for Arab and Muslim values. While these efforts contribute significantly to HCI research and design in decolonization strategies, we believe there are uncovered dimensions specific to Arab Muslim communities.

In this study, we reflect and draw upon literature on women’s health in the Global South, decolonization research, and cross-cultural design to investigate pathways for research and design in Arab and Muslim communities. Specifically, within the context of intimate health for women, we aim to answer the following research questions:

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RQ1: What are some perceived similarities and distinctions between religious and cultural motivations, and what aspects of religion or culture can we lean into for the main goal of improving women’s intimate health and well-being?

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RQ2: What categories of technology, if any, would aid in the support of increasing knowledge about women’s intimate health?

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RQ3: How do family members’ beliefs influence Arab Muslim women’s openness to seeking knowledge and discussing intimate health?

We conducted one-to-one interviews with 16 self-identifying Arab Muslims about their experiences and attitudes about various topics in women’s intimate health. Following a thematic analysis, our findings highlighted three themes interweaving religion, culture, and women’s intimate health. These are: religious perspectives in life and on women’s intimate health (Section 4.1), noted distinctions between Arab culture and Islam and their effects on the learning process (Section 4.2), and strategies of learning through self-discovery (Section 4.3). We contribute novel perspectives on women’s intimate health from Arab Muslim communities. We use these findings to formulate the essential components of a culturally sensitive safe space for women’s health discourse: space and time, context, language, people, and tools. While these findings provide an understanding of the perspectives presented by our 16 participants, they are not intended to be generalized to the entirety of Arab or Muslim nations. Additionally, we discuss research and design implications from reflections on cultural and religious values and draw comparisons to cultural models from literature in cross-cultural design. Finally, we introduce the culturally relevant majlis metaphor (an Arabic word for a sitting room where people socialize) and extend it to suggest cultural and religious considerations for researching and designing, with and for Arab Muslims, regarding women’s intimate health. We channel decolonial thinking in the HCI space first by utilizing the shared experience and language of an Arab and Muslim researcher to attempt to understand cultural and religious nuances that have influenced and continue to influence women’s intimate health discourse. Additionally, we promote decolonial thinking by proposing research and design considerations that may be more appropriate for the selected demographic based on identified shared values.

2 Background and Related Work

In this section, we provide contextual information about Arab culture and Islam and research into Muslims’ attitudes about women’s intimate health. We then examine contemporary work in HCI and design for women’s health and sexuality. Finally, we reflect on decolonization in computing and cross-cultural design and recent research efforts for women’s health in various cultures in the Global South.

2.1 Arab culture, Islam, and views on women’s intimate health

There are approximately 1.8 billion Muslims in the world today [34], and 464 million Arabs [26], not including Arabs that have settled in non-Arab countries. Situated geographically in the Middle East and North Africa, the Arab World is connected mainly by language and religion. It is estimated that 93% of Arabs are Muslim [59] and 20% of Muslims are Arab [40]. While Arab cultures predate Islam, they are heavily influenced by Islamic values such as practicing modesty, maintaining privacy, and preserving social relationships [1, 3, 16]. The study in this work intersects two large populations: Arabs and Muslims; we thus recognize its limitations and acknowledge the differences in Islamic practice among all the Arab cultures and tribes.

In the context of women’s intimate health, while researchers have been calling for its destigmatization, Arab and Muslim values such as modesty are likely to impede the extent of that destigmatization. In research conducted in South Asian Muslim communities, researchers highlight purdah, a term that uses the metaphor of a physical covering (a veil) to symbolize modesty in actions and words [54, 66, 74, 88]. In Arabic, a comparable term is hijab [2, 43]. While in both cases, these terms typically refer to the physical covering of a woman’s body, it also extends to the practice of conducting oneself modestly in the public eye and social interactions [2, 49, 60]. While there are many varying interpretations about the correct application of hijab for Muslim women [20, 81, 85], hayaa’ (modesty) is mandated for all followers of Islam [78, 96, 101].

Little research has been conducted in evaluating Muslim perceptions and attitudes towards intimate healthcare for women, and even less so in evaluating those of Arab Muslims. Bajaj et al. [24] recognized the importance of studying Muslim women’s health practices during Ramadan, the month in which Muslims fast from food and water from dawn to sunset. They highlighted Muslim women’s practice of elective fasting during Ramadan when they are religiously exempt from doing so, such as when they are menstruating, pregnant, or breastfeeding. This practice can result in health problems, which authors use to call attention to the religious obligation of preserving health [24]. Furthermore, a study of the prevalence of female sexual dysfunction among married Iranian women revealed that almost 74% of women reported some sexual dysfunction, with arousal being the highest level of dysfunction [50]. This study also showed that the quality of life and mental health are affected by sexual dysfunction. Suggested reasons for this sexual dysfunction include lack of sufficient knowledge and skill [14], religion-influenced restriction when talking about sexual issues [19, 110], or lack of privacy in the home, leading to a diminished sex life [50]. Mustafa et al. [74] highlighted that in Islam, it is believed that the body is a responsibility to be taken care of. Furthermore, it is also believed that seeking knowledge is encouraged rather than repressed. However, the lived experience of practicing Muslims around the world has affected the practice of seeking knowledge concerning intimate health, likely due to cultural impact.

It is common for Arab Muslims to subscribe to culturally-inspired patriarchal values [57, 64, 72, 100]. In some countries, laws and procedures prevent women from seeking medical care for various intimate health concerns without the permission of the husband or the father [52, 63, 91]. Even without these barriers, women often face intrinsic obligations of adherence and maintaining respect towards the patriarchs in their lives (usually a father or husband) [91]. However, much of the current research on women’s health in Arab and Muslim communities does not sufficiently include findings from male participants. This gap has been recognized by Tuli et al. [109] and Kumar et al. [65] in the context of their studies in India, which dealt with sexual health literacy and menstrual health education. The researchers found that men watched for social signals to indicate the safety of discussing taboo topics with peers and that the taboos prevented them from having conversations with female friends or partners even though they would be more comfortable doing so. Furthermore, they found that the men had limited knowledge of appropriate vocabulary relating to sexual health. In light of findings from Tuli et al. [109] and Kumar et al. [65], we include and investigate men’s perspectives as indirect stakeholders when considering design for women’s intimate health.

Recognizing the significance of religion and spirituality in various communities, researchers in non-secular HCI have contributed perspectives and design considerations for communities in which religion, spirituality, or culture affect the way individuals interact with technology [56, 82, 89, 97]. In a study looking into practices for addressing domestic abuse in Saudi Arabia, Rabaan et al. [83] identified fundamental values among their interview participants, including religious piety and social cohesion, and emphasized their consideration in design. They found that participants tied religious piety to the ways they recognized or handled domestic abuse [83]. They also found that maintaining social cohesion within the family and the community was a priority to women, sometimes at the expense of their needs [83]. These values are also likely to appear in intimate health contexts, prompting our motivation to identify and demonstrate the pervasiveness of various cultural and religious values and practices among our participants. For example, women may avoid calling attention to intimate health concerns they may be facing to maintain an image of religious piety by practicing modesty [74] or to protect the family’s reputation. By relying primarily on secular design and research, users whose lives are shaped by religion or culture may be overlooked in the HCI and computing spaces. This omission is especially detrimental in technology relating to health, as it can limit access to valuable resources. We contribute to non-secular HCI discourse by uncovering deep-rooted cultural and religious values in our participants that may aid in designing technology for women’s intimate health.

2.2 HCI for women’s health: technology and design

As the stigma associated with women’s bodies, sexual health, and pleasure transcends culture, the HCI community has recognized the importance of conversations centering on women’s bodies [10, 11, 12, 62], intimate and maternal health [41, 64, 72], and sexual pleasure [27, 61]. In an effort to destigmatize women’s intimate health, HCI researchers in this space have adopted a variety of methodologies to improve knowledge and self-discovery, such as Research through Design [33, 102], soma design [55, 102, 103], and participatory design [45, 102, 107]. These methodologies served as strategies for involving participants in the design process to become more familiar with the intimate body to reduce the stigma. Almeida et al. [12] developed Labella, a combined physical (underwear) and digital (mobile phone) system to promote "looking" to learn about intimate body parts. Søndergaard et al. [102, 103] created Menarche Bits, a toolkit for facilitating design for menstruation-related scenarios. Woytuk et al. [33] designed Curious Cycles, a tangible toolkit aimed at interacting with and understanding one’s menstrual cycle, encouraging users to inspect bodily fluids throughout the cycle. These studies used tangible materials such as mirrors, droppers, heat pads, or underwear to allow participants to become more familiar with their intimate bodies through interactions and prompts. However, in more conservative cultures, such as many Arab Muslim cultures, these methods are not likely to be acceptable due to associations with cultural or religious values. There has not been sufficient research examining the reception of soma design or similar in HCI for conservative cultures. Still, healthcare professionals have highlighted that female Muslim patients had strong preferences for certain healthcare practices that were related to religious practice and beliefs, such as preserving modesty. For example, female Muslim patients tend to avoid unnecessary exposure to their bodies [86] and often request female practitioners to carry out examinations [95].

Most adjacent to our study is HCI research for women’s health in the Global South. Researchers in this field have recognized the higher threshold of "impropriety" or stigma associated with women’s intimate health. Mustafa et al. [74] interviewed Muslim women from three countries (Pakistan, Bangladesh, and Malaysia) to uncover religious influences in dealing with women’s intimate health issues. [106] Tuli et al. [107] recognized the importance of cultural context by designing together with women in India and thus identifying together what a "safe space" means to them for handling menstruation on the road. Tuli et al. [106] developed Menstrupedia, a digital platform for menstrual health education in India. These studies developed methodologies and systems more appropriate to users from India by channeling their value systems and lived experiences. Eastern cultures share some similarities in their value systems, such as the influence of family and society for achieving social cohesion [39, 83]. Recognizing the experiences and perspectives of people in the Global South provides a basis for conducting value-driven HCI and computing research in the Arab world by considering similar values while drawing new, unique conclusions for a different subset of communities within Eastern civilization. Religious interpretations affected by language, for example, may lead to diverging revelations when comparing South Asian Muslims to Arab Muslims.

We believe one underdeveloped avenue is exploring cross-cultural design for women’s intimate health, specifically for Arab Muslims in HCI. Conservative value systems in Arab and Muslim populations present unique challenges in that space, but Eurocentric methods or motivations are not likely to be accepted due to differing value systems. Aiming toward decolonization in HCI research and design, our work with Arab- and Muslim-identifying individuals aims to contribute to healthcare in HCI discourse in ways that may align more with conservative and collectivist communities.

2.3 Decolonization and cross-cultural design

Recently, HCI researchers have been studying and designing for users from non-Western civilizations. In the past few years, there have been several calls for the voicing of experiences and ideation workshops at HCI conferences, such as ACM’s Conference on Human Factors in Computing Systems. Endeavors in the form of workshops such as ArabCHI [5, 6], Asian CHI [92], and IslamicCHI [73] have drawn researchers from their respective communities to voice the need for design paradigms that consider and are more representative of alternative identities and cultures. One exceedingly relevant approach for tackling this issue in the modern era is decolonization, a process that involves dissociating from "colonial" schools of thought. Scholars of decolonization argue that the effects of colonialism still prevail today in the form of social orders and forms of knowledge, which have been steeped in Western or Eurocentric values [8, 9, 29]. Decolonial computing posits that computing, being a modern development, is inherently colonial in nature [9]. To strive towards decolonial computing and HCI would mean challenging the status quo of modernity perpetuated by Western ideology. At the core of this, as stated by Ali [9], is to "shift away from a universal perspective toward a "pluriversal" perspective". Decolonization in HCI is crucial because it contextualizes the experiences and histories of individuals and communities affected by colonial ideologies and Western universality [9]. Decolonization strategies are pertinent to our research goals toward designing computing systems for women’s intimate health education and intervention for Arab Muslim users, as this topic tends to be influenced by religious and cultural values [15, 74]. By involving potential users from underrepresented Arab Muslim communities in research meant for them, we aim to highlight these marginalized voices to create more effective solutions that do not ignore how culture and religion permeate their daily lives, including how they use technology.

Relatedly, cross-cultural design involves considering the variation in the interpretation and practice of people with different cultural values [80]. Cross-cultural design has developed from the works of prominent anthropologists and cross-cultural researchers, such as Hall [51], Hofstede [48] and Trompenaars [46], who have contributed frameworks for describing different cultures. Hall’s "cultural model" enables comparisons through various dimensions, such as context (high-context versus low-context), time (monochronic versus polychronic), and space (physical space between people) [51]. Hofstede defined six cultural dimensions differentiating cultures, including power distance (extent of acceptance of a power divide), individualism vs. collectivism, and uncertainty avoidance (tolerance for uncertainty) [53]. These cultural dimensions have been utilized in HCI and computing research and design for understanding cognition in searching and organizing tasks [80], analyzing the use of color and imagery across nations [7], and comparing interpersonal disclosures on social media [71].

While these cultural models provide a promising basis by which to categorize and understand cultural attributes, further research into their application and efficacy in the Arab World shows that these models may differ over time. One study by Almutairi [13] recognized the lack of range in Hofstede’s cultural dimensions [48] for Arab nations due to treating them as a homogenous group. The author disseminated a more targeted version of Hofstede’s quantified Values Survey Module (VSM) questionnaire across seven Arab countries. She found that some scores differed from when Hofstede conducted this survey in 1967. For example, Lebanon and other Arab nations scored lower on the power distance index than previously tested. A lower score means there is generally less expectation of a power hierarchy. The author speculates that this could be attributed to a significant increase in exposure to Western countries, leading to societal shifts [13]. Thus, care must be taken when considering cultural dimension scores as nations go through cultural shifts due to political or economic events. These results found by Arab researchers highlight the need for the involvement or leadership of researchers from the cultural groups that are being studied –as is recommended in decolonial thinking [105] and cross-cultural design [80].

Both cross-cultural design and decolonization methods contribute to HCI and computing research for populations on the margins. Cross-cultural design considers cultural differences in the design elements of computing systems [80], while decolonial computing advocates for methods and solutions with and from the margins [8]. Namely, decolonization work extends beyond cross-culturalism because it contextualizes history and values in designing for non-Western individuals [25]. In contrast, cross-culturalism may become a tool to propagate Western ideologies by translating them across cultures [25]. In our work, we endeavor to apply a decolonial lens to HCI for women’s health by engaging with religious and cultural considerations for the Arab Muslim communities. For example, to involve the participants in the study, we create a familiar setting leveraging the shared language and experiences of the primary investigator. We also reflect on cross-cultural research in computing when discussing design considerations for future women’s intimate health solutions intended for Arab Muslim users.

Women’s intimate health is an area that is restricted in terms of discussion, education, and care in many cultures. General aversion may not be culture-related. Nevertheless, motivations for aversion and strategies to circumvent aversion can be tied to cultural values. For example, privacy concerns arise in women’s households in Pakistan due to the common occurrence of a single shared mobile device [100]. Regarding social media engagement, Abokhodair found that privacy was a core value emphasized by Islam and that privacy includes what users are exposed to in social media and what they choose to share themselves [1]. While this was not centered on women’s health, it can be hypothesized that similar attitudes would exist with issues such as participating in community-based forums for women’s health. Aiming to discover the "taboo tipping point" of participants, Sorcar et al. [99] iterated through versions of cartoon-based HIV education by changing elements such as the degree of explicitness in imagery and the accent and gender of the physician character. By acknowledging cultural resistance, they were able to disseminate knowledge that would not be rejected for its offensiveness to cultural values.

Similarly, in this paper, we adopt strategies that enable us to identify the lines that Arab Muslim participants are uncomfortable crossing linguistically or thematically. Hence, we opted for the term women’s intimate health in English or simply women’s health when referencing in Arabic. Use of the term women’s intimate health stems from the work of Mustafa et al. [74] and is used to encompass the intimate health concerns of Muslim women, which are: menarche, marriage/childbearing, and menopause. Moreover, the term women’s intimate health offers us two advantages for our research: 1) it provides flexibility in discussing a myriad of health concerns and experiences relating to reproductive organs, and 2) it adds a layer of abstraction and implicitness that may be required when engaging with participants who are sensitive to the explicit nature of the language associated with sexual or reproductive issues.

3 Methods

As an Arab Muslim woman herself, the first author led the qualitative study with the recruited participants. The one-to-one interviews were conducted in both English and Arabic, as needed, to provide the most comfortable environment for the conversation. The study protocols have been reviewed and approved by the University of Colorado Boulder Institutional Review Board.

3.1 Participants

A total of 16 Arab Muslims (10 self-identified as female, 6 self-identified as male) participated in one-to-one semi-structured interviews. We included male participants in this study to provide their perspectives and thus aid in answering RQ3 about family members’ influence. As noted and discussed by other researchers in past work, male family members hold significant roles in the lives of Muslim women –roles that can impact their access to healthcare as well as their use of online resources [57, 63, 91]. We ceased recruiting participants once data saturation was reached [32]. That is, when our interim coding process revealed that no new codes emerged relating to religion, culture, backgrounds in women’s intimate health, or technology assistance.

All participants were adults who identified as Arab Muslims, aged 19 to 38. Participant demographics included first or second-generation immigrants to the United States, transnational students from Arab countries currently living in the United States but planning to return to their home countries, and Arab Muslims permanently residing in an Arab country. Participants were recruited through institutional channels, social media outreach, and personal acquaintance using purposive [79] and snowball sampling [77]. An overview of participant demographics, including gender identity, age, Arab identity, and marital status, is described in Table 1. However, it is important to note that while most participants identified as belonging to a specific Arabic nationality, several have acknowledged that living in other Arab countries has influenced their cultural identity.

Table 1:

Participants	Gender Identity	Age Range (#)	Arabic Nationality (#)	Marital Status (#)
FP1 - FP10	Female	18-24 (3), 25-30 (4), 31-40 (3)	Iraq (2), Jordan (1), Kuwait (2), Palestine (1), Qatar (2), Syria (2)	Married (2), Never married (8)
MP11 - MP16	Male	18-24 (2), 25-30 (3), 31-40 (1)	Egypt (1), Palestine (2), Qatar (2), Sudan (1)	Married (3) Never married (3)

Table 1: Demographic information about the study participants, as they self-identified. Participant labels 1 through 10 denote female participants, and labels 11 through 16 denote male participants based on self-disclosed gender identities. Other demographic information, such as age ranges, Arab identities, and marital status, are summarized by the number of participants (#).

3.2 Interview

Following previous bodies of work that have used interviews to uncover personal attitudes from cultural and religious demographics [74, 87, 100], we used interviews to understand the views of Arab Muslims regarding women’s intimate health. Identifying as an Arab Muslim woman, the first author conducted all the one-to-one semi-structured interviews with male and female participants. Interviews ran from 28 to 75 minutes and were administered online via Zoom video conferencing software, either in English, Arabic, or a combination of both, depending on participants’ preferences.

3.2.1 Procedure.

During interviews, the first author used two transcribing software to transcribe the English portions of interviews: Zoom’s embedded transcribing feature and Google Recorder transcribing. For interviews run in Arabic, the first author transcribed them manually. Participants were provided with an informed consent document detailing the purpose of the study, what data would be captured and in what form, who would have access to their data, and what would happen to the data collected. They were allowed to ask questions before signing the consent form. Additionally, at the beginning of the interview, the document’s key points were reiterated verbally, and consent was confirmed verbally.

During the interview, the first author asked participants questions in the following categories: 1) background information and Arab identity, 2) role and importance of culture and religion, 3) extent of knowledge and experience with various women’s intimate health issues, 4) role of culture/religion on women’s health, and 5) role of technology and digital or online tools in women’s health education. Examples of questions in these categories are in Table 2. Examples of women’s intimate health that were provided to participants were menstruation, sexual and reproductive health, pregnancy, and menopause. However, participants were encouraged to discuss anything about women’s health. For example, a few participants chose to talk about sexual pleasure. In Arabic, the word "intimate" is not typically used in the context of women’s health. Thus, for interviews conducted in Arabic, the interviewer used the term women’s health while providing the examples previously listed. Participants did not face difficulties in comprehension related to the terminology, but some did about the extent of their experience on the subject matter. Participants understood that women’s health referred to health associated with female reproductive organs.

Table 2:

Category	Example Questions
(1) Background and Arab Identity	Which Arab culture do you identify with the most? Can you talk to me about your schooling growing up?
(2) Culture and Religion	What does your Arab culture mean to you? In what ways does religion play a part in your life? And culture? Is there a distinction between culture and religion in your life?
(3) Experience With Women’s Health	What is your understanding of intimate health for women? How do you feel about discussing these topics for educational purposes?
(4) Culture, Religion, and Women’s Health	Does religion or culture influence your decision to seek information regarding women’s intimate health? In what ways? In your opinion, what does Islam teach about women’s intimate health?
(5) Technology and Women’s Health	Have you used technology to seek information? How have you used [it]? Have you used technology to find a community to ask questions or seek support?

Table 2: Samples of interview questions organized into five categories.

3.2.2 Strategies for sensitivities.

Due to the sensitive nature of women’s intimate health and concerns about causing discomfort, the research team had discussions to increase the chances of eliciting expansive responses. The interviewer performed several steps to build rapport with participants and facilitate sensitive conversation. First, the interviewer began with questions about their childhood and schooling, which led to practice with expansive answers. Also, the interviewer signaled the beginning of more sensitive questions (such as those about experiences with menstrual and sexual health), reminding participants that they were free to answer to the extent they were comfortable. When responses were brief, the interviewer probed for deeper answers until some resistance was sensed. For example, when one participant mentioned an incident involving discomfort towards oversharing of sexual experience through social media, the interviewer asked follow-up questions, such as: "Were they describing their first time?" and "What part of that made you uncomfortable?" Another productive tactic the interviewer adopted was sharing her personal experiences relating to women’s health, such as recounting the events of her menarche (first menstruation), which demonstrated a level of openness that participants were encouraged to mirror. When interviewing male participants, most structured interview questions remained consistent with interviews with female participants. However, we asked additional questions concerning their roles and experiences with women in their lives regarding women’s intimate health. Also, we observed slight discomfort in the form of hesitation or using indirect language from a few of our male participants. In our sample, this was true for younger participants (both male and female) rather than just the set of male participants. To alleviate any sensed discomfort, we employed the same strategies listed above.

3.3 Data Analysis

We included both men and women in data collection relating to women’s intimate health because of the unique perspectives from both sides relating to differences in cultural upbringing, formal education, and social circles. We analyzed interview transcripts using a hybrid inductive and deductive thematic analysis [31, 44]. The first author performed open coding on interview transcripts and then generated themes and sub-themes. This was subsequently reviewed by the second author. Coding was done iteratively throughout recruitment and interviewing. We used Nvivo [67] qualitative analysis software (version 14.23.0) to aid the coding process. Nvivo was used to become familiarized with the data via annotations, highlighting relevant quotes, creating codes, and query keywords. Codes from deductive thematic analysis were guided by findings from prior work [74] and the research questions and thus were anticipated in designing some of the interview questions. We formed sub-themes by 1) relevance to the research questions, 2) grouping codes with reoccurring keywords or contextual sentiments, and 3) combining or eliminating sub-themes for concise and constructive reporting. Table 3 lists examples of deductive and inductive codes and the sub-themes they were grouped into.

Table 3:

Deductive Codes	Inductive Codes	Sub-Theme
Islam encourages learning about the body	Search for Islamic rulings about women’s health	Islam and education
Religious shame in learning about sex	Missing scientific lens
	Learning about prohibition of sex in school
(None)	Ghusl after menstruation	Ritual cleansing
	Ghusl after sex act
	Women’s health affects acts of worship
Sharing with same gender	Sharing with non-judgmental people	Comfort in social settings
Sharing with partner	Sharing with non-Arabs
Sharing with family
Internet search (generic)	Online discussion forums	Supplementing knowledge online
	Educational Arabic Instagram pages
	Arab women’s forums
	Menstrual tracking applications

Table 3: Examples of inductive and deductive codes and their corresponding sub-themes.

3.4 Limitations

Discussions surrounding decolonization in HCI cannot occur without acknowledging those who have been underrepresented in the context of this study. Firstly, the recruited participants were all cisgender Arab Muslims. While these demographics were not specifically targeted, gender non-conformity is still suppressed in most parts of the Arab and Muslim world [113]. Secondly, while our participants come from different Arab backgrounds, most came from urban settings with high technology literacy. Arab Muslims from rural settings or low-income households may express values different from what we have discovered. Finally, people with accessibility issues with menstrual products were not present or reflected in this study, and their experiences with menstruation may again highlight different values. All of these groups of people also belong to the "periphery" described in decolonization research.

3.5 Positionality and Reflexivity Statement

We acknowledge that our backgrounds and experiences may influence the nature of reporting. The first author is a Qatari Muslim who identifies as a cisgender, heterosexual woman who is fluent in English and Arabic. The first author was raised in Qatar and has spent over 25 years there. Qatar is one of six countries known locally as "Al-Khaleej" or "the Gulf" countries. These countries share common cultural characteristics, such as food, attire, and religious practice. The first author acknowledges that the characteristics shared by Khaleeji countries may and often do differ significantly from other Arab countries. These differences may affect interpretations and practice of religious scripture. Islamic education was embedded throughout the entirety of the first author’s schooling. While a practicing Muslim herself, the first author also has an extended family of different faiths. Her goals include supporting minority and societally marginalized communities through HCI and exploring the potential for incorporating religious faith and improving equality. The second author has a strong religious background and was raised in a family that focused on building communities among underserved populations. The combination of our differing backgrounds has allowed us to continuously check in with suggested approaches, language, and effective reporting. We have attempted to commit to the scientific method while preserving empathy for recruited participants.

4 Findings

In our thematic analysis of 16 interviews with Arab Muslims, we generated three predominant themes from the coding process and sub-themes within these groupings. The first theme encompasses religious perspectives in daily life and on women’s intimate health. The second theme relates to what Arab culture means to the participants and what values manifest as part of their cultural identity. The third theme concerns their journey of self-discovery about women’s intimate health issues and the elements that hindered or facilitated the process. Given the qualitative nature of our work, we acknowledge that Arabs, Muslims, and Arab Muslims cannot be considered a monolithic group due to differences in various cultural practices and religious interpretations. Rather, this work focuses on the perspectives of the 16 specific participants by highlighting commonly shared cultural and religious values and practices. We believe the reflections we present here are a necessary first step towards understanding cultural or religious factors that may influence the pursuit of designing and developing women’s health solutions.

4.1 Religious perspectives

4.1.1 Impact of Islam on life.

Most participants (14 out of 16) indicated that Islam was an essential part of their lives, primarily in the spiritual and metaphysical sense, but also in religious practices such as praying and fasting. There was a range of adherence to religious practices among participants, but most agree that religion was more significant in their lives in comparison to culture with regards to giving them a higher sense of purpose, a feeling of calmness for having a higher power watch over them, and a guidepost for how to treat people and live in harmony with others. Perhaps the most comprehensive sentiment that encapsulates those felt by multiple others was that of Female Participant 10 (FP10):

"It (Islam) helps frame how to deal with the world. It’s a good guideline. If you don’t know what to do, you can fall back on what feels right within the context of Islam. How to behave with people like you feel like there is some hope in the future, even if life is not great now, maybe this will actually get you some rewards in the afterlife." –FP10

Degrees of Islamic practice varied across participants. Adherence to religious practice is difficult to quantify, but 10 out of the 16 participants said they prioritize maintaining regular Islamic practices such as daily prayers, fasting during Ramadan, or wearing the hijab. A few participants stated that they do not regularly observe established practices or wish to improve their observation of such practices. Female Participant 4 (FP4), a university student, says,

"I plan my schedule around prayer times so I don’t miss them. Even during the school year, when I’m taking classes, I try to at least have a gap. Even if it’s like 10 minutes or 15 minutes, I’d go to the library or somewhere else to pray and then go to my next class." –FP4

Regardless of adherence to teachings or compulsory practices, most participants hold Islam in high regard in daily life and beliefs. As seen in subsequent sub-themes, the connection to Islamic values reappears for many participants in the context of women’s intimate health education.

4.1.2 Ritual cleansing (ghusl).

Participants’ Islamic perspectives on women’s intimate health centered solely on teachings mentioned in the Quran or Sunnah (the practices of the Prophet Mohammed). Hygiene and cleanliness were the most reoccurring themes both male and female participants brought up when asked if they knew of any Islamic teachings on intimate health. Hygiene was viewed as an obligatory act of worship that involved physically cleaning with running water and had a ritualistic series of steps. In Islamic scripture, the ritual of cleansing intimate parts, ghusl, is performed at the end of a menstrual cycle for women or after a sexual act for both men and women [84]. Ghusl is necessary to reach a state of purity to carry out other acts of worship, such as prayer. Another Islamic teaching that participants mentioned is that menstruating women should not pray or fast during Ramadan. Refraining from praying and fasting is considered an act of worship during this time. This teaching has been well-established for both male and female participants in their Islamic education of women’s health.

"I know during the period, you’re not allowed to pray. And you’re not allowed to have any sexual interaction. And then after you finish, you have to wash up; you have to clean everything. And then you’re back to, you can pray, you can have whatever you want." –MP11

In addition to Quranic passages, Muslims believe in and follow Sunnah and Hadith to varying degrees. Sunnah refers to a body of the practices of the Prophet Muhammad and can serve as a clarification for some Quranic verses [21]. For example, praying five times daily is an established obligation in the Quran. However, the sequence of steps in prayer is determined in Sunnah, based on how Prophet Muhammad performed them. Similarly, Hadiths refer to accounts of Prophet Muhammad’s sayings and customs [22]. Participant 6 reflected on the prevalence of menstruation and sexual intercourse in sources other than the Quran:

"Religion doesn’t really talk a lot about menopause and pregnancy, per se, but you can find a lot of Hadith and Sunnah about periods because having your period and having a sexual relationship affects other parts of Islam, like your prayer, your fasting, and all of these. So you have to refer to them in order to know, like, are you doing it right? Are you doing it wrong?" –FP6

Although most study participants became aware of menstruation and sexual intercourse through Islamic teachings, we learned that participants who attended school in Arab countries have varying degrees of religious influence in their education in the form of regular or semi-regular Islamic Studies classes. Female Participant 4 spoke of her experience learning directly from passages in the Quran about the complete ablution, ghusl, during one of her classes:

"In middle school, I remember we worked out the concept of ghusl (ritual cleansing), washing up after you get your period. And then they also discuss the ghusl that you get after having sex. But we were all kids who were a little confused at that part, but we all were taught about the ghusl." –FP4

Thus, exposure to some aspects of women’s intimate health has been rooted in the significant Islamic values of cleanliness and purity. So, at a minimum, participants have learned about religious contexts relating to women’s health if they had attended schools emphasizing Islamic education.

4.1.3 Sex and self-pleasure.

All participants noted that the topic of sex and sexual health is the least comfortable to bring up in conversation in comparison to other topics encompassed by women’s health, such as menstruation and menopause. Participants older in age (27+) were noticeably more open and at ease when asked about their experience and feelings about being exposed to discussions of sex and sexual health. Participant 8 talked about her experience visiting a gynecologist for the first time:

"I remember the first time I went (to a gynecologist). They asked me if I was married or not. Because they assume that no one has premarital sex in the Arab world. So they ask women if they’re married or not. Later on, I sort of became more aware of that sentence because I became more active. More sexually active. I just wanted to make sure everything was okay, and I didn’t want to lie to anybody. So I made sure the doctors weren’t Arab doctors or Muslim doctors so I can openly say, hey, that’s a strange question to ask." –FP8

While commonly a taboo topic, premarital sex is forbidden in Islam, with varying degrees of punishment in countries where Islamic law (Sharia) is the predominant ruling law of the land [94]. This was largely recognized by participants from an early age, though typically not in explicit terms. For example, Participant 7 described her exposure to lecture series in school by a female daa’iyah (preacher) discouraging improper relationships with boys and men:

"I remember more than one of the lectures was about how you are supposed to behave as a girl. How if you let a man near you even speak to you, people will think that you’re a whore. How people will think you’re shameless. People will suspect things and people’s suspicions are the most dangerous thing for you as a woman. And they would talk about the dangers of talking to men. I remember very clearly, this being said more than once: if a man doesn’t come through the door, he’s not welcome. If he’s not brave enough to meet your parents and be a potential husband then he’s not welcome. If he comes through your window he is like a sly fox." –FP7

A number of participants described a strong sense of religious guilt when researching some aspects of women’s intimate health, such as when Participant 8 attempted to learn about sex online:

"I always tied religion to it. Like I’m not going to look at that, haram (it’s forbidden), I’m not going to see that. But I see a little bit and I stop myself. And I’m like ’astaghfurullah’ (I seek forgiveness from Allah) and I pray to wash my sins away, that sort of thing." –FP8

Although not part of the interview, self-pleasure was brought up by five participants (3 female, 2 male); the female participants mentioned it in conjunction with severe religious guilt, mentioning feelings of being a "bad Muslim" or practicing excessive showering (to achieve ghusl).

"I later found out from my friends that, apparently, they did have that kind of sex education for guys. They did tell them you’ll experience urges or pleasures, or he’ll experience something such as wet dreams. No one tells these things to girls because they don’t expect women to have urges or women to grow up to want or desire pleasure because pleasure is never a conversation... There was this attachment to the concept of virginity that was very intense. There’s the shame that comes with feeling pleasure. Desire, even doing things such as masturbation, felt very shameful. That was specifically not okay for the longest time. –FP7"

Perspectives on self-pleasure were only discussed in detail by two female participants, who emphasized both feelings of guilt and lack of knowledge, even in religious contexts.

4.1.4 Islam and education.

Participants were asked two questions relating to the influence of Islam on women’s intimate health education: 1) if Islam has influenced past education, and 2) if it would influence their decision now. To address the first question, most participants stated that maintaining a state of purity through ghusl was the most notable religious contribution. They also mentioned the strict prohibition of sex before marriage and religious shame associated with self-pleasure, hence influencing their exposure to any material relating to sexual education. However, most of the participants stated that religion does not currently influence their decision to seek information about women’s intimate health; for example, they are sometimes curious about Islamic rulings on intimate health issues, such as surrogacy or different sex acts. Female Participant 8 (FP8) felt strongly that Islam does not prohibit knowledge acquisition regarding intimate health:

"Islam doesn’t say don’t teach your daughters about it. Islam doesn’t say don’t introduce your daughters to the concept of protection or teach them how to wear their pads. There’s no such thing as shutting off all that information." –FP8

Male Participant 14 (MP14) suggested that Islam is not against seeking knowledge in that area but feels that the way that Islamically influenced education relating to intimate health has been implemented requires improvement. He felt that scientific details were glossed over or ignored in favor of religious commandments regarding intimate health, even though Islam does not discourage it. Overall, participants’ beliefs of Islamic views have overwhelmingly indicated that Islam does not discourage curiosity regarding women’s intimate health, nor does it prevent followers from seeking knowledge or disseminating information.

4.2 Influence of Arab culture

When asked if participants felt that there was a difference between their Arab culture and Islam, with the exception of one participant, they all felt certain that there was a distinction. However, they also acknowledged that there were common values that the two agreed on, such as family bonds, generosity, attending to social obligations, and avoiding premarital sex. The role of culture in participants’ lives fluctuates across individuals. In comparison with the influence of Islam, Arab culture and identity were mostly deemed by participants as less influential. Yet, it is important to note that the line separating religion and culture was difficult for participants to define. One participant remarks that Arab culture and Islam are the same; one informs the other and so they are inevitably interwoven in most aspects. Female Participant 3 (FP3) compared the two from her perspective:

"The distinction is that religion comes from a religious text that’s very defined in the Quran. In Islam, your actions are very calculated. Everything is very clear and transparent. It’s very black and white in terms of the moral code. Whereas culture is really transient, it’s very fluid and it’s based on our way of telling stories. It’s very oral." –FP3

Participants’ answers about what defines "Arab culture" in their views varied greatly. Firstly, common characteristics were mentioned, such as Arabic language, food, art, poetry, and music. Other characteristics of Arab culture were highlighted that are closely linked to Islamic values, such as hospitality, generosity, strictness, cleanliness, maintaining a pleasant appearance, and maintaining family bonds. Participants have acknowledged that their Arab culture forms their identity, that that is unavoidable, but they are also selective about what parts of culture matter to them and which they choose to implement.

The next few sub-themes determined from participant responses highlight significant cultural traits and practices that have influenced participants’ education about women’s intimate health.

4.2.1 Privacy.

Within the confines of care for public representation lies care for maintaining privacy. Intimate health is generally considered a private matter; thus, participants considered it a delicate issue with appropriate contexts. The first dimension of privacy concerns respect for the inner workings of family life. For example, sharing intimate details about one’s sex life is viewed negatively. Female Participant 3 (FP3) observed:

"Sex is associated with family life, and family life is very private, so it’s something that I just have to respect. I don’t want to be the odd person on the table talking about it." –FP3

One participant suggested that this tendency can be detrimental to the woman:

"Your friend could be suffering with her partner sexually, and you would not know because she’s not able to talk about it because these are like family secrets." –FP5

In the vein of maintaining public decency, the sharing of private information relating to women’s intimate health has also been viewed as potentially harming one’s public image. One notable example mentioned by Participant 9 was her encounter with an Arab Muslim couple on social media who were relaying their experience with their first sexual experience. The participant recognized that the purpose of this story was to relay information, destigmatize sex, and combat sexual myths, yet the story made her uncomfortable. When urged by the interviewer to expand on this feeling and the reasons behind it, she responded:

"Any (online) platform now is public. It doesn’t really matter what you use because, at the end of the day, she’s a hijabi woman. She’s representing most of hijabis. Putting it out there. She talked a lot about detailed stuff that she she had gone through. And I feel like a lot of people would benefit from that, but I do think that a lot of people would be like, "That’s a bit inappropriate." I think if she would have had a private group on Instagram that is only for girls, it would have made more sense instead of showing it to the public." –FP9

Female Participant 9 (FP9) also indicated that if the content had been more scientific and factual than personal, she would have been more receptive.

The following male participant statement provides insight into two potential dimensions for privacy and comfort relating to conversations about women’s intimate health: 1) privacy of intimate health, and 2) discomfort discussing with a different gender:

"In our country, in the culture. It (women’s intimate health) is not really something that is comfortably opened up, or they (men) would accept to hear it or listen to it from a woman. Heck, some of them have issues hearing a female doctor telling a man and his wife, "Have you had sex in the last three weeks?" Obviously, you can answer her, but they would have issues doing so." –MP14

This observation bridges privacy with comfort, which will be discussed next in terms of what forms a comfortable setting for Arab Muslim participants.

4.2.2 Comfort in social settings.

There were multiple dimensions to the notion of comfort from a cultural perspective. In order of frequency of appearance in participant responses, these were: 1) not feeling judged, 2) being in an educational or professional context, and 3) being in the presence of people of their gender (e.g., all women gathering). The most prominent descriptor for creating a comfortable environment for conversing about women’s intimate health was the feeling of not being judged. Participants stated that, aside from "feeling" that the other person was more accepting, they were more likely to feel comfortable in a social setting with those deemed as peers, such as those close in age. Multiple female participants highlighted that being in the presence of other women was crucial to feeling a sense of comfort when discussing any issues relating to women’s intimate health.

"I think it would depend on the social setting –if you feel like people won’t be offended. I don’t think people should be offended, but if I think that people might be offended, I would speak to the person –If I had the questions, I mean– I would speak in private. But if I feel like people are like-minded and they won’t be offended by any of the questions, I would gladly participate and ask." –FP6

"There’s some kind of strength in having girls around. You can talk about period stuff out loud. With the girls. The girls, not the teachers. The teachers made us feel bad about talking about stuff like that. But amongst us –I remember a girl got her period in grade 6. She didn’t tell her teacher, she came to us, and another girl had a pad, and we all went into the bathroom." –FP8

Participants were also asked specifically how they felt about discussing women’s intimate health for educational purposes. They all said they had no moral issues with that context. Additionally, younger participants (under 24) emphasized that the purpose of discussing women’s intimate health affects the level of comfort in a social setting. For example, seeking advice or educating are more acceptable than sharing stories about sexual encounters.

"Some people are very comfortable talking about it. My roommate would totally be detailed and I’m like, ’I don’t want to hear this. But because it was more normal for her to grow up in a house where her mom discussed this stuff with her. Sometimes I’m like, I don’t want to hear this. I feel like it’s just too graphic." –FP4

Three of the participants stated that they sometimes felt the need to turn to non-Arab or non-Muslim friends and doctors to discuss issues with sexual health because they were perceived to be less judgmental. Participant 8 opted for non-Arab gynecologists whenever she could due to concerns of being judged, as seen previously in section 4.1.3. When asked if they had people in their lives they felt comfortable talking to about women’s intimate health, Participant 3 (FP3) responded:

"My friends in New York City. Everyone else here in [edited: Arab country] does not want to converse about it. They don’t wanna know about health issues. They can’t even say yeast infection comfortably." –FP3

With regards to sharing in the presence of male family members, several female participants described a slight shift in what they felt they were acceptable to bring up at home in the presence of male family members. Most of them went through a phase of not being able to be vocal about when they were menstruating, such as hiding when they were not fasting during Ramadan, even when they were exempt by religious scripture. Participant 4 (FP4) recounted her first time asking her father to buy her sanitary pads as being "a little awkward, but fine". In contrast, Female Participant 1 (FP1) emphasized a clear divide between transparency with her father versus her brothers:

"The idea of even buying the menstrual pads is off-topic. It’s outrageous. Yeah, my dad would never buy that stuff. He finds it weird and embarrassing. My brothers buy them for me. I taught them to not feel weird about it." –FP1

In our sample, this was a unique experience. However, it highlights the potential for genuine unease and awkwardness emanating from the patriarchal figures in women’s lives, which could deter women from disclosing intimate health concerns when necessary.

4.2.3 Appropriate timelines and shifting responsibility.

Participants reported that religion and culture do not actively influence their decision to seek information regarding women’s intimate health if they are curious about it. However, most acknowledge that it has influenced their journey towards knowledge-seeking, especially in terms of education in adolescence. With regards to sexual health, the assumption from Arab Muslim parents is that knowledge will not be needed until marriage due to the Islamic ruling prohibiting premarital sex.

"It was not mentioned because I think that it’s not expected of you to do it out of marriage. So I feel like maybe if I were married or about to get married, then this topic might be introduced by my mother or aunts or family members." –FP2

For Participant 11 (MP11), that timeline was earlier than an approaching marriage. This was influenced by the fact that he would be leaving to travel alone for the first time. His reflection denotes the problem with waiting indefinitely to relay pertinent information about sexual health and how to practice safe sex:

"In the Arab region, most of the time they go to Arabic schools, Arabic schools, Arabic schools, and then when they turn 18 or it’s time for university, they fly somewhere and face reality, and then they don’t know what to do." –MP11

The responsibility of educating adolescents about the menstrual cycle or sexual health was often delegated by participants’ parents to their schools or friends. This was the case for the majority of participants, especially with regard to sexual health. Even in the case of menstrual cycles, limited knowledge was provided by the mothers of participants in most cases. They were instead deferred to a school-sanctioned assembly about the science behind menstruation, along with demonstrations of how to apply a pad. In contrast, one participant highlighted a flaw in that strategy, as his mother was employed as a school administrator where he attended school:

"My mom was actually part of the administration at school when I went to seventh grade, and that’s when they introduced the science subjects separately, like biology, chemistry, and physics. So when we went to get our books before the school year started and she saw the biology book and she saw the chapter about sexual reproduction. She went to the administration the next day and made them take all the books back and rip those pages out." –MP12

While MP12’s experience may be considered an uncommon occurrence, it indicates that there is a need for more than one source of education (schools) to consolidate knowledge reliably.

4.3 Self-discovery towards women’s intimate health literacy

Prompted by interview questions, participants embarked on storytelling journeys to describe their first experiences with menstruation or the first time they learned about sex. They told stories about their interactions with other people in their lives, including embarrassing, funny, or shocking moments.

Curiosity was mentioned explicitly multiple times by several participants, but curiosity levels were also inferred by the interviewer. Male and female participants who spoke of high curiosity at an early age demonstrated a much deeper understanding and awareness of women’s health issues, including disorders that are less known in the Arab world, such as endometriosis and polycystic ovary syndrome (PCOS). Most participant’s comprehensive knowledge of women’s health was driven largely by personal curiosity. Curiosity drove participants to use multiple online resources to fill in gaps, despite cultural influences potentially holding them back.

"Culture has made it a bit difficult or made me feel shy to reach out and ask about these questions, but they have not affected my decision. My curiosity goes beyond these two factors." –FP2

Three participants described curiosity relating to Islamic rulings on various intimate health issues, such as the desire of Female Participant 6 to determine whether spotting during ovulation affects the obligation to pray. This underlines the importance and prevalence of religion in their lives.

Curiosity about menopause was very low for all participants, as none of them were going through it themselves. The extent of knowledge about menopause was very limited across the board. The men knew less than the women. The women’s exposure to it was through their moms, often through throwaway comments about hot flashes or mood swings.

4.3.1 Supplementing knowledge online.

We learned that most participants seek knowledge about women’s intimate health using digital means such as: 1) top search results on Google, 2) medical websites such as WebMD/Healthline, 3) forums, 4) websites containing Islamic rulings, 5) Arab social media gynecologist, 6) menstrual or pregnancy tracking apps (e.g., Flo). Having easy access to online content enabled participants to search quickly and privately for concepts they were not familiar with. As noted by Participant 3, she had also valued forums or discussion board websites for what was perceived as a more realistic and well-rounded view of experiences with women’s intimate health. This was echoed by Participant 4:

"I do look at Quora sometimes. Just to feel the personal connection. Sometimes that’s why I don’t like Google searches. Whatever it is, it could be the smallest thing and it’ll just show you another disease. You know, it’s just concerning. So then when you look at a lot of other people having that, you’re like, ’that’s probably not a disease’, you know? It’s comforting." –FP4

While some participants indicated that they had gained positive experiences with reading perspectives on online forums, they never participated or asked questions themselves.

One male participant noted a unique experience fueled by his curiosity, where as a teenager, he attempted to access Arab women’s forums in order to learn about women’s intimate health:

"I was still going through Arab women’s forms. And through these forums, a lot of them expressed that they were having issues with their moms asking them to steam their vaginas and their mom asking them to put perfume there. In these Arab women forums, they (make) you consent that you are a woman. And then, when you get to a certain section of the forum, it’s for married women. And there you have to consent again that you’re a woman that is married." –MP14

A few participants talked about using specific websites to find Islamic rulings on various aspects of women’s health, such as what religious practices should be if one is spotting rather than menstruating.

"Sometimes you want to know things about intimate health in an Islamic way. Like, ovulation is considered in Islam istihadha. So sometimes people, instead of having their period, they’re going to have spotting during their ovulation. Reading about it from an Islamic way makes you realize that –oh, it might be similar to a period, but it’s different because you can pray. Because for us, our reference is Quran and Sunnah, But we’re not as educated as religious people, imams, or Islamic scholars. So the only way to access them is through public forums or things like that." –FP6

Only 3 of the 16 participants were exposed to the Arab social media accounts, but they had very positive feelings about the presence of someone who was disseminating important knowledge in Arabic.

"There’s also ’this is mother being’ (@thisismotherbeing). I love her very much. She’s an Egyptian, she’s a mother, and she’s a sexual health specialist, and she started this collective of having a very honest, open conversation about sex. So she’s sort of approaching in a very professional way... So she has episodes. She used to be very directed at women, but she also started kind of moving also towards men’s sexual health. So sort of normalizing talking about things that we don’t usually talk about such as erectile dysfunction, such as anxiety when it comes to sex such as like the connection between the mind and the body when it comes to intimacy." –FP7

Social media content about women’s intimate health in Arabic is not popular yet, but for those slightly older interviewed participants (27+), they were lauded.

Finally, there were varying degrees of use of menstrual tracking apps among female participants. Several used the tracking features in the apps as well as the information panels to learn about women’s health. A few did not actively use menstrual tracking apps as they have regular periods and did not see a need for it. One participant (FP3) notably chose not to use any digital menstrual tracking features due to concerns about companies having intimate knowledge:

"I tried it once on an iPhone. When I first got the iPhone, then I freaked out because I felt the phone knew more about my intimate health than I did. So I disabled that option." –FP3

Overall, participants utilized various technologies for women’s intimate health, depending on context and personal preference.

5 Discussion

Our findings from interviews with Arab Muslims yielded a wide range of insights into attitudes and perceptions about religion and culture and how they played a role in their education of women’s intimate health. Our findings also highlighted individual qualities and actions that aided in knowledge acquisition. In the following sections, we propose considerations for research and design for women’s intimate health in HCI while addressing our initial research questions. First, we reflect on our findings and use them to define what a culturally sensitive safe space means for Arab Muslims in the context of women’s intimate health. We then provide recommendations for design and future strategies toward decolonization based on that safe space.

5.1 Components of a culturally-sensitive safe space

Research in the pursuit to destigmatize intimate health and create period- and sex-positive ecologies is vital but cannot be applied in blanket contexts for Arab Muslims. Our participants have illustrated that both religious and cultural values are embedded in daily interactions and perceptions and have shaped them throughout their childhood and into adulthood. Therefore, these values should not be ignored in researching or designing a socio-technical system. Our findings revealed that certain conditions must be met for those who identify as Arab and Muslim to feel comfortable in such a vulnerable and sensitive setting. Here, we categorize them into five components that create a safe space for knowledge acquisition. In no particular order, these are: space and time, context, language, people, and tools. These components can be used as a guideline for conducting research in Arab or Muslim communities.

5.1.1 Space and Time.

Participants in this study have stated and suggested that there are appropriate times to discuss certain topics. For example, speaking of personal experiences about sexual health was deemed inappropriate and uncomfortable in a public setting. Online, or in the presence of many strangers, was not the best time to relay this information. This suggests that Arab Muslims may resist information if relayed at the wrong time. Time was also a factor that was reflected in participants’ parents’ decisions to delay teaching menstruation and sexual health or by deciding that the best time for their children to learn about it would have been in school rather than at home. Overall, there were no explicit religious or cultural indicators for when the right "time" for learning about women’s intimate health would be. However, one common belief indicated by participants’ learning journeys was that education about sexual health did not need to happen until they were likely to encounter it (i.e., marriage). We also observed a disconnect between the parents and teachers of the participants during their school years when it came to expectations of who was responsible for teaching about menstruation or sexual reproduction. The appropriate "space" was not clearly defined, according to participants. For example, a few of the female participants’ mothers did not sufficiently educate them early enough about expectations for menstruation, instead assuming schools would handle it or they would learn from somewhere else. This is in line with the work of Tuli et al. [108], who found a similar difference in the expectations of responsibility for educating about menstruation. Since there is no clear expectation for the responsibility of education, stakeholders from all potential groups (e.g., school, home, clinic) should be involved in researching and designing for women’s intimate health education [108].

5.1.2 Context.

Situational or conversational contexts affected whether participants felt comfortable discussing women’s intimate health. This component relates to the context for broaching the topic of women’s intimate health. For example, is the conversational context educational? Is the situational context in an office or some other official setting? Based on our findings, the answers to these questions will likely influence how much participants would be willing to participate in conversations about women’s intimate health. It was imperative for the interviewer to establish the study’s goals early on and to use professional language to convey the educational intent. Our recommendation for this component in creating a safe space would be to emphasize educational purposes and potential benefits early in any attempts to involve Arab Muslim participants in research or design. From an Islamic perspective, Mustafa et al. [74] suggest emphasizing the body as an Amaanah (a loan), thus elevating the importance of taking care of it. This was not a critical theme that appeared in our findings, but caring for others and acquiring knowledge was, especially in relation to learning about menstruation. Thus, combining our participants’ feelings about empathy and the importance of seeking knowledge with the fact that the majority valued Islam, the concept of Amaanah may still hold value when designing for Arab Muslims.

5.1.3 Language.

This component relates to the language that should be used to create a safe space to learn about women’s intimate health. Most of the language associated with women’s intimate health brought up by participants was in relation to the Quranic text, thus emphasizing the role that religion plays in intimate health language. Outside of this context, knowledge about intimate body parts in Arabic appeared limited. This is most likely tied to the fact that much of the exposure to women’s intimate health has been through Western media, including television and social media. In HCI, future work could involve designing socio-technical systems using scientific Arabic terminology and testing responses regarding knowledge acquisition and subjective measures.

One goal of this study was to test the term we chose to use, women’s intimate health. Participants were asked what they thought that term meant before offering any explanations. Many assumed that the term was describing solely sexual intimacy. For future studies, we may simplify it to "women’s health". This is also in keeping with Hall and Hall’s [51] definition of high-context cultures, which Arab nations tend to be. In high-context cultures, people are more likely to be indirect; implicit meaning is embedded in the language, and people are expected to understand it within the given context. The first author believes that this option may translate better in Arabic. Language is a useful tool to utilize in studies incorporating cultural values, but it has limitations. One potential avenue to explore would be to follow in the footsteps of Sorcar et al. [99] in determining thresholds of acceptance for Arabic terms and phrases relating to women’s intimate health.

5.1.4 People.

This component relates to perceptions of the "other" person in a conversation. Most participants related being comfortable discussing women’s intimate health with how comfortable they perceived the other person to be. The general sentiment is that they would wait to see if openness to sensitive conversations was observed. This aligns with Tuli et al. [109], whose participants watched for social signals to indicate an openness to discuss sexual health. While this is difficult to pinpoint as a cultural practice, our participants appeared to demonstrate a constant state of assumptions. They would likely put the onus on the other person to indicate acceptance. This could be linked to an Arab value highlighted by participants: public presentation (or representing oneself in a positive light). This quality also stems from Islamic values from the Sunnah (the Prophet Muhammad’s established practices). Maintaining a pleasant appearance is important in Islam and begins with personal hygiene but extends to pleasant behavior such as showing respect and using kind words [4, 38, 68].

This component also concerns gender dynamics. Participants emphasized notable preferences for when and how they chose to discuss women’s intimate health. This manifested in finding comfort in girls-only environments at school, anxiety surrounding informing fathers of menstruation needs and picking female healthcare practitioners. Finding reassurance and solidarity in women-only spaces was also a strategy adopted by Pakistani women in [17, 75, 112]. However, our findings also showed that, in the context of sexual education, female participants were far more selective about sharing or inquiring –even amongst female peers. In this case, participants reported examples of using discussion board websites to seek reassurance in knowing about women’s intimate health concerns or conducting private online inquiries on their personal devices. This is similar to findings in [75], in which participants were very resistant toward sharing aspects of marital life with family and friends for fear of loss of respect and other societal repercussions. For this reason, researchers in this field have highlighted the importance of facilitating "connectedness" [75] while implementing strategies to protect anonymity [104, 112].

Finally, this component is also related to people in the family and how interactions occur with them in mind. For example, similarly to [74], participants in this study also reported hiding eating during Ramadan or not sharing menstrual concerns in the presence of male family members, especially in earlier years. However, in contrast to the findings of Mustafa et al. [74], most participants noted that, in hindsight, it would have been accepted by the father or brother, even if there was slight discomfort at first. It appeared that the perception of indecency was greater than the reality of it. The male participants in this study confirm this. When asked about the extent of conversations about menstruation and their feelings about it in their household, the male participants stated that while conversations weren’t extensive, they were open to and accepting of the topic of menstruation being broached. This may be a difference in the implementation or role of culture between South Asian Muslims and Arab Muslims. While responses from the male participants in our study did not indicate cause for concern for embarrassment or shame related to bringing awareness to women’s health issues, several female participants reported feeling anxious before sharing necessary information about their intimate health. Taking it further, Participant 1 taught her brothers to be more accepting of sharing about menstruation or other women’s health concerns. Thus, even though the beliefs of male family members may not hinder women’s intimate health discourse, female participants often had to undergo the emotional labor of facilitating that discussion from adolescence.

5.1.5 Tools.

The lack of formal settings for education on women’s health led to participants conducting their own research via the Internet. Furthermore, women’s intimate health was deemed a sensitive subject matter that should not be broached in all situations. Accessing information while maintaining privacy via personal devices appears to have been the most common and comfortable way to get information. Whether that information was through medical websites on Google, information menstrual tracking apps, or educational YouTube videos, knowing specific vocabulary is necessary to further knowledge on women’s intimate health. Privacy may be a culturally-embedded value [1], but it is also Islamically influenced. Muslims are taught to respect the privacy of others, for example, by discouraging revealing another person’s sins or discouraging entering another’s property without consent [38]. By extension, Muslims value their own privacy in many facets of life.

5.2 Designing for women’s intimate health among Arab-Muslims

Thambinathan and Kinsella [105] recommend embracing "other(ed) ways of knowing" as a decolonization methodology. To that end, we propose an Arabic metaphor for the components of the culturally-sensitive safe space we have defined above. These components align fittingly with the Arabic majlis. In literal terms, a majlis is a sitting room where people gather and socialize [23]. The majlis holds great cultural significance in creating space for regular or semi-regular social gatherings. We conceptualize the analogy of a safe space as an Arabic majlis in an effort to present reflections in a setting familiar to Arab researchers. Different contexts exist for how a majlis is held. For example, attending a formal family majlis that includes elderly relatives will likely involve different language and behaviors than one involving friends. A majlis with extended family typically involves polite conversation and drinking tea, while a majlis with friends might include inside jokes and card games. In all cases, the majlis is typically in a dedicated room or a room that has been repurposed for the event. As such, the parallel we draw with the majlis and the safe space is that –just like a majlis– safe spaces can take different forms in different situations, and they are not necessarily wrong simply because there are certain social limitations. The metaphor of a majlis does this by positing that in Arab cultures, all majalis (plural) have their place, and all are valued for different reasons.

In a digital space, the components of a majlis should mimic the characteristics of a physical majlis. For example, mechanics to ensure women-only spaces should be in place to the extent possible. Another property to consider is the creation of appropriate "contexts" for desired online spaces. This may mean providing distinct spaces for educational or professional content and casual experience-sharing content. Care should be taken in educational spaces due to the implications of several Arab countries falling at the short-term orientation end of Hofstede’s dimensions [13]. Cultures with short-term orientation tend to value stability and tradition rather than long-term growth. For the goal of educating women on intimate health, this may come into play for some Arab cultures with short-term orientation, in that drastic change of knowledge dissemination methods may not be accepted. Designing a fitting digital space may benefit from using the power distance dimension to combat this. Most Arab countries scored higher on the power distance index [13], indicating an acceptance of disparity in status. Prior work comparing Saudi Arabia, China, and Australia found that websites in Saudi Arabia were more inclined to contain images of leaders, and they relate this to the high power distance index [7]. Creating a digital tool or space for educational purposes may benefit from some endorsement or support from legitimate healthcare entities. However, this would only apply to circulating knowledge about women’s health rather than facilitating a support network. For the latter case, local entities may add to fears of discovery and losing anonymity. Also, in the case of support networks, typical social media features such as the ability to view people’s interactions should be discouraged, or the user should have some control over what is displayed.

Creating culturally familiar environments and enlisting the voices of non-Western people serve toward decolonial methodologies in HCI. Another methodology utilized is participatory design [98], which involves the intended users in the design process. For designing for Arab Muslims, this is an opportunity for further investigation into the intersection of religion, culture, and women’s intimate health.

Future research involving Arab Muslims must prioritize privacy [83]. Manifesting in different ways, privacy is a core value for Arab Muslims, especially in sensitive settings like women’s intimate health. Abokhodair et al. [1] emphasize that privacy is not confined to the individual but is also communal. Towards decolonization methodology in HCI research, prioritizing privacy for populations that highly value it is essential in establishing trust. This can be reaffirmed at multiple stages in a study by reminding participants that no personal information will be linked to them. Reminders help establish trust. In our study, this was reflected in a few participants who wanted to double-check that the recording would only be listened to by the first author. Future work for this area of research may proceed in several avenues. First, based on follow-up communication with our participants (outside of the procedural interview), we learned that many of them had taken measures to protect their anonymity, such as deleting search history or using virtual private networks (VPNs). Subsequent studies may delve into the mechanics of device and browser affordances that Arab Muslim users employ and their reasons for doing so. Another potential avenue to explore is the efficacy of soma design for women’s intimate health for Arab Muslim participants in a cross-cultural study comparing them to participants from a Western culture. In doing so, thresholds of acceptability for tangible props could be determined (within respectable reason).

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References

[1]

Norah Abokhodair, Sofiane Abbar, Sarah Vieweg, and Yelena Mejova. 2016. Privacy and twitter in qatar: traditional values in the digital world. In Proceedings of the 8th ACM Conference on Web Science. ACM, Hannover Germany, 66–77. https://doi.org/10.1145/2908131.2908146

Abstract

1 Introduction

2 Background and Related Work

2.1 Arab culture, Islam, and views on women’s intimate health

2.2 HCI for women’s health: technology and design

2.3 Decolonization and cross-cultural design

3 Methods

3.1 Participants

3.2 Interview

3.2.1 Procedure.

3.2.2 Strategies for sensitivities.

3.3 Data Analysis

3.4 Limitations

3.5 Positionality and Reflexivity Statement

4 Findings

4.1 Religious perspectives

4.1.1 Impact of Islam on life.

4.1.2 Ritual cleansing (ghusl).

4.1.3 Sex and self-pleasure.

4.1.4 Islam and education.

4.2 Influence of Arab culture

4.2.1 Privacy.

4.2.2 Comfort in social settings.

4.2.3 Appropriate timelines and shifting responsibility.

4.3 Self-discovery towards women’s intimate health literacy

4.3.1 Supplementing knowledge online.

5 Discussion

5.1 Components of a culturally-sensitive safe space

5.1.1 Space and Time.

5.1.2 Context.

5.1.3 Language.

5.1.4 People.

5.1.5 Tools.

5.2 Designing for women’s intimate health among Arab-Muslims

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