Ayman Assi on sexual health care: “Public health is at stake”

President and co-founder of the NGO Marsa, Associate Professor at the Faculty of Medicine of Saint-Joseph University, Ayman Assi tries to change the Lebanese mentality regarding access to sexual health care. Let's see how the NGO Marsa implements on the field this essential work to change Lebanese mentalities.

ayman assi marsa david hury bytheeast
Ayman Assi, president of the NGO Marsa: "Things are changing, albeit slowly. We may not see the change in our lifetime, but the wheels of change are rolling. In any case, Lebanese people will be better despite all the conservatisms." © ByTheEast
ByTheEast: How was the NGO Marsa born?

Ayman Assi: In the early 2000s, following the results of a study on Lebanese doctors which shed light on the fact that the majority of them did not know how to treat Sexually Transmitted Infections (STIs). To make matters worse, they did not even approach the subject with their patients irrespective of whether they could diagnose the particular infection. STIs were a closed book. They did not talk about it leave alone delve into the intricacies of a patient’s case. It was terrifying scenario. In fact, the subject was a taboo for Lebanese doctors.

Even today, in advanced cases, Lebanese doctors lack the know-how and the expertise to diagnose and treat these infections. Public health is at stake.

As the saying goes, necessity is the mother of invention: in 2011, Marsa was created in collaboration with a handful of doctors to mitigate the entire gamut of issues related to STIs. There is an urgent need to have a dialogue between doctors and patients on sexual health.

BTE: How is your team made up?

Assi: From the very onset, we wanted to create an atmosphere that nurtures and promotes an open communication between patients and doctors and everyone in our team has been sensitized and trained in this regard and make patients feel comfortable about the subject.

To this end, we have taken utmost pains to eliminate any form of judgment and have promoted openness and guaranteed anonymity; through these essential steps we have been able to mitigate strong headwinds in this very sensitive subject.

Step by step, we have had success in gaining the trust of our beneficiaries. Our team consists of part-time doctors, psychologists as well as a group of sexual health educators that we have trained internally to host and interview patients. We also use volunteers for outside operations, like outreach including distribution of condoms on the streets.

“Marsa’s center is located in Badaro; it benefits heterosexuals as well as homosexuals and transsexuals even though the latter groups are considered as ‘non-compliant’ by Lebanese society.”

BTE: Who is the main audience for Marsa?

Assi: Just about everyone! Since the creation of Marsa, our NGO, we have targeted the general public so that it can gain free and wide access to our healthcare.

We opened our first center (in the Clemenceau neighborhood, Beirut) so that all sexually active people can have access to sexual health care, without judgment and in complete confidentiality.

Today, this center located in Badaro, provides benefits to people from all walks of life, irrespective of nationalities and social classes; it benefits heterosexuals as well as homosexuals and transsexuals even though the latter groups are considered as “non-compliant” by Lebanese society. Today, it is mainly young people, mostly in the age group of 20-40 years, who come to see us. We also have younger patients as well as older ones, up to the age of sixty. Men and women with varied levels of education visit us regularly.

BTE: How to communicate about sexual health in Lebanon?

Assi: At first Marsa began through word of mouth. We have organized several campaigns in the streets to distribute flyers and condoms; we have conducted face to face meetings with people at varied locations such as in the streets, in bars, or even music festivals. Our clinic dedicated to sexual health is open to all. Interestingly, after each of our outings, phone calls from potential patients have peaked.

BTE: How do you finance your operations?

Assi: We started Marsa with funding from the World Health Organization (WHO). Subsequently we applied for grants from international NGOs, on a project to project basis. Back in 2014, we received the prestigious Red Ribbon Award delivered by UNAIDS, the program funded by the United Nations. On the local scene, we also have some sponsors to support our cause.

BTE: In many fields in Lebanon (blood donation, etc.), NGOs and civil society often take the place of a state that does not fulfill its functions. For example, there is not, as in Europe, a Planned Parenthood program where women can ask for going on the pill…

Assi: Actually, this question was one of the primary reasons for the creation of Marsa! We realized that sexually active and unmarried women do not go to a gynecologist! They know in advance that they will be judged by the gynecologist, as well as by the secretary, and by the other women in the waiting room… In short, what would an unmarried woman do with a gynecologist?

“As an NGO, we are not here to incite people towards sexuality neither are we promoting promiscuous relations. We offer a medical service to patients. “

BTE: As you say, Lebanese state is a failing state. What relationship do you have with the authorities and ministries?

Assi: On excellent terms in fact – especially because we are helping them. We work with the Ministry of Health, the Ministry of Social Affairs, and other government entities. As an NGO, we offer medical care services that is not at odds with the Lebanese State. We are not here to incite people towards sexuality neither are we promoting promiscuous relations. We offer a medical service to patients. The real problem is that all Lebanese laws that punish sexual acts in general are totally at odds with good care and access to the health rights of the affected population. We are mitigating health concerns of Lebanese citizens who live in a society trapped by its taboos.

BTE: What does Marsa offer concretely to its beneficiaries?

Assi: We have four main services:

  • Anonymous and free screening for STIs (HIV, Hepatitis B, Hepatitis C and syphilis): this service, provided by sexual health educators, is always overbooked because of the need;
  • Medical consultations with doctors;
  • Psychosocial support sessions;
  • Awareness raising through outreach, prevention and education at schools, universities and youth clubs and organizations.

When a patient arrives at Marsa’s, he/she receives a number and then everything that follows is anonymous. We are extremely careful and attentive to the level of knowledge required for getting the protection against STIs as well as means to cap their transmission. We have extensive information on these subjects. At times we have patients who have never even heard of a condom, or who do not know how HIV is transmitted. We educate and take care of them from the ground up.

BTE: Where does this problem of the lack of information in Lebanese society come from? School, parents, traditions?

Assi: There is a total vacuum in terms of education on sexual health in Lebanese curriculum. This is applicable to not just schools but at the university levels as well.

To make matters worse, this scenario is also applicable at the academic curriculum of health professionals, including doctors, nurses, midwives, in Lebanon. There is not a word that caters to sexual health.

We have suggested for a new curriculum on the subject to universities… now interns come to train in Marsa. While earlier there was very little information on this topic in the country, we are taking steps to shed more light on the topic. Earlier, 60% of our beneficiaries had unreliable sources, such as pornographic materials or hearsay from friends, for their sexual health. We are making a difference.

One of our projects in collaboration with other national NGOs involved partnering with the Ministry of Education to create modules on sexual education to place them in the framework of civic education courses that will be taught in several schools. Unfortunately, this has yet to be applied. However, there are some schools that have come forward and asked us for guidance for sensitizing sessions on sexual health at secondary classes.

More progress on the subject will come once Lebanese society sheds its reservations on the topic.

BTE: Can you work in all Lebanese regions?

Assi: We have only one center in Lebanon, located in Beirut. To access our services, patients have to go there physically. Our awareness campaigns are more flexible in terms of reach and we have the capability to project them everywhere, including in the Beqaa Valley, in Tripoli (North), in different neighborhoods of Beirut, as well as in South-Lebanon.

For the distribution of flyers, we do not limit ourselves to Beirut, although we do it outside as well, but the reach is limited. We can’t go to Tripoli to distribute condoms randomly in the streets unless a specific organization or university or school asked us. We can go to Jbeil or Jounieh, but not to Saida or Tyre. Having said that, we meet the same level of reluctance in the Christian community as well as in the Muslim community. Even in Jbeil or Beirut, bar owners sometimes refuse to let us distribute condoms inside their institutions; it’s very random.

“As everywhere in the MENA region, we are seeing in Lebanon an increase in new HIV infections.”

BTE: What is the picture of sexual infections in Lebanon in 2019?

Assi: As everywhere in the MENA region, we are seeing an increase in new HIV infections. In some key populations who come to see us at Marsa, this can be up to 5.5% of people. Downstream, the Ministry of Health offers the treatments, so they are free for patients. In Lebanon as elsewhere, we respect the guidelines of UNAIDS: any infected person must take the drug, anyone not knowing his status should be tested.

In some populations, more than 45% of our beneficiaries carry the Human Papilloma Virus (HPV) without even being aware that they are carriers. There are hundreds of different versions of these viruses, including some of them that are carcinogen ones (cervix, prostate…). It is important to remember that many of these medical conditions can be effectively treated and in fact they can be prevented as well since there is a vaccine against these viruses recommended by the WHO.

Among the widespread STIs in Lebanon include chlamydia and gonorrhea – very contagious urinary infections. Again, these can be cured so long as you take the necessary antibiotics. These STIs affect nearly up to 25% of the population who come to see us. It is therefore imperative to detect them and treat them timely before they become a nasty and expensive medical affair. We are talking now about super Gonorrhea which is resistant to the available antibiotics.

BTE: But is there an improvement in the situation? Do Lebanese people talk more freely?

Assi: I believe that young people are increasingly more open to all of these topics, especially those who have a certain level of education; they are more aware on such issues, including on their basic human rights, etc. They are now much better informed to counter the narrative and arguments of people who harbor the old mindset or people with a closed mind.

I believe, everything depends on the entourage. For example, if a young Lebanese from a closed environment, joins a university where there is a real mix of people, he/she is likely to see his mentality evolve and change throughout his formative years of study. In contrast, a young Lebanese who joins a university where there is no such social and cultural mixture, his/her lack of exposure is likely to keep his knowledge and spirit caged.

BTE: On March 30, a military court acquitted four soldiers accused of “unnatural relations”. Is this a real step forward for Lebanese society?

Assi: All I can say is that any punitive law on matters of sexuality – sex before marriage, women’s rights from A to Z, sexuality in general… – can limit access to health care for the concerned persons. My only concern is that anyone and everyone should have the right to access healthcare, including sexual health.

The problem with punitive Lebanese laws is that everything is done in secret; Lebanese society is very quick to stigmatize these people.

Our true fight lies here.

“From primary school there should be reforms that essentially confronts the parents, who are often conservative and who will impose their mindset.”

BTE: Young Lebanese men often have biased relationships with women, for many reasons. Should we educate them first, on “how to treat well a member of the opposite sex”?

Assi: You have hit the nail right in the head. This is one of the root causes for this mess in the state of sexual healthcare. Right from an early age, from primary school there should be reforms that essentially confronts the parents, who are often conservative and who will impose their mindset and dictate their ways of thinking to school principals, saying that they do not want their children to have an open-mind; they do not want a different narrative to the one told at home.

BTE: Could it change?

Assi: Things are changing, albeit slowly. We may not see the change in our lifetime, but the wheels of change are rolling. In any case, Lebanese people will be better despite all the conservatisms. The world is changing, globalization has made the world into a village. People are traveling and seeing what is happening elsewhere. As long as Lebanese society remains a mixture of conservatives and progressives, there is hope.

Marsa’s 2018 accomplishments

  • 2044 blood testings and counseling sessions
  • 616 medical consultations
  • 700 psychological support sessions
  • 8500 free condoms distributed
  • 560 young participants to awareness sessions
  • 3 sexual health courses at USJ, Balamand and LAU

Useful infos

  • Phone/Fax: +961 1 380515
  • Beirut center address: Badaro (next to Tayouneh), Traboulsy Street, Karim Bechara Building, 2nd Floor
  • Web: www.marsa.me