Contents*

• Part 1: Greek Cyprus 279

• Demographics and a Brief Historical Perspective 279

1. Basic Sexological Premises 280
2. Religious, Ethnic, and Gender Factors Affecting Sexuality 280
3. Knowledge and Education about Sexuality 287
4. Autoerotic Behaviors and Patterns 288
5. Interpersonal Heterosexual Behaviors 289
6. Homoerotic, Homosexual, and Bisexual Behaviors 292
7. Gender Diversity and Transgender Issues 296
8. Significant Unconventional Sexual Behaviors 296
9. Contraception, Abortion, and Population Planning 298
10. Sexually Transmitted Diseases and HIV/AIDS 300
11. Sexual Dysfunctions, Counseling, and Therapies 305
12. Sex Research and Advanced Professional Education 307
13. References and Suggested Readings 307

• Part 2: Turkish Cyprus 308

• Demographics and a Brief Historical Perspective 308

1. Basic Sexological Premises 309
2. Religious, Ethnic, and Gender Factors Affecting Sexuality 311
3. Knowledge and Education about Sexuality 311
4. Autoerotic Behaviors and Patterns 312
5. Interpersonal Heterosexual Behaviors 312
6. Homoerotic, Homosexual, and Bisexual Behaviors 313
7. Gender Diversity and Transgender Issues 314
8. Significant Unconventional Sexual Behaviors 314
9. Contraception, Abortion, and Population Planning 315
10. Sexually Transmitted Diseases and HIV/AIDS 315
11. Sexual Dysfunctions, Counseling, and Therapies 316
12. Sex Research and Advanced Professional Education 318
13. References and Suggested Readings 319

*A Note for Researchers:  The numbers included in the section titles in the Contents above refer to the page numbers in the print edition of the CCIES. For the convenience of researchers, an Adobe Acrobat (PDF) file of this chapter is available for download above (click the PDF icon), which reflects the actual pagination of the book. This will allow scholarly writers to cite actual page numbers in the printed book for quoted material, as well as its availability on the Web and the URL if desired. See also How to Use This Encyclopedia.

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Demographics and a Brief Historical Perspective

ROBERT T. FRANCOEUR

A. Demographics

Cyprus, the third-largest island in the Mediterranean Sea, lies in the Middle East off the eastern shore of the Greek Islands, the southern coast of Turkey, and the western shore of Syria, with Lebanon, Syria, and Israel to the southeast. Measuring 141 miles by 60 miles (227 km by 97 km) wide, the island’s total land area is 3,570 square miles (9,250 km²), a little more than half the size of the state of Connecticut. The island is divided between Greek and Turkish regions, with 2,275 square miles (5,895 km²) comprising the Republic of Cyprus and 1,295 square miles (3,355 km²) in the Turkish Republic of Northern Cyprus. Two mountain ranges cross the island from east to west, separated by a wide, fertile plain.

In July 2002, Cyprus had an estimated population of 767,314, of which Turkish Cyprus had about 200,000. (All data are from The World Factbook 2002 (CIA 2002) unless otherwise stated.)

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***Note: The Greek authors welcomed the opportunity to prepare this chapter on Cyprus because very little has been published on Cypriot sexuality in the international literature. This has been because of the lack of adequate funding and professionals to conduct methodologically sound research on the island, a lack of a coordinating body, the difficulties involved in collecting data given a conservative and sexually inhibited society, the suppressive influence of the Orthodox Church on human sexuality, and other factors. We have collected, analyzed, and integrated whatever information we could find, including statistical data, the results of professional experience and clinical work, and anecdotal reflections from professionals in fields related to sexology.

B. A Brief Historical Perspective

Recent excavations on the island of Cyprus have yielded evidence of human society at least 10,000 years old. The Mycenean (Greek) culture flourished in the second millennium B.C.E. After Phoenicians colonized the island in the 10th century B.C.E., Cyprus remained a major entre-pôt for trade in the eastern Mediterranean. Annexed by Rome in 58 B.C.E., Cyprus later became part of the Byzantine Empire until the English King Richard I (Lion-Heart) established a crusader state there in 1191 C.E. The Lusignan dynasty ruled until 1489, when Venice annexed the island. In 1571, Cyprus became part of the Ottoman Empire.

In 1878, the Congress of Berlin placed Cyprus under British administration. After annexing the island in 1914, Great Britain made it a British colony in 1925. Between 1945 and 1948, the British used the island as a detention area for “illegal” Jewish immigrants trying to reach Palestine.

After 1947, the Greek Cypriot community expanded its longstanding agitation for union (enosis) with Greece, a policy strongly opposed by the Turkish Cypriot community. After violence in 1954 and 1955, Cyprus gained full independence under a 1960 agreement that forbade either enosis or partition and included guarantees of the rights of both Greeks and Turks. Efforts by the president, Archbishop Makarios, to alter the Constitution in favor of the Greek majority led to more violence in 1964.

A Greek Junta-inspired military coup against Makarios in 1974 led to Turkey’s invasion of Cyprus and the de facto partition of the island and declaration of the northern 40% of the island as the Turkish Federated State of Cyprus. Some 200,000 Greek Cypriots were expelled from the Turkish area to the Republic, while many Turks fled the Republic for safety in the north. The Republic has experienced a return of political stability and economic prosperity, with agriculture, light manufacturing, and tourism leading the way. The economy in the Turkish sector has been generally stagnant, as the international community refused to recognize the 1983 declaration of independence by the Turkish Republic of Northern Cyprus. Tensions have eased since the United Nations-sponsored Greek-Turkish talks on Cypriot unity, even though little progress has been achieved thus far.

1. Basic Sexological Premises, and
2. Religious, Ethnic, and Gender Factors Affecting Sexuality

NICOS PERISTIANIS*

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*Note: This combined section on gender roles, marriage, family, and ethnic and religious factors was written by Nicos Peristianis, president of the Association of Cypriot Sociologists, based upon his research and that of his colleagues.

A. Character of Gender Roles

Ethnographic and anthropological accounts of Cyprus (Peristiany 1974, Markides et al. 1978) stress the importance of the nuclear family as the paramount institution of Cypriot society, so much so that “an individual exists only as a member of a family,” and the self cannot be conceived independently from its familial roles. This is in marked contrast to Western “solitary” conceptions of the self (Mavratsas 1992). The family has acquired such significance, because it was, and still is to a large degree, the primary social, economic, and moral unit of Cypriot society.

The Traditional Cypriot Family and Gender Roles

The economy of Cyprus maintained its predominantly agrarian character well into the 20th century (Christodoulou 1992). The perennially heavy financial demands of conquerors and the especially hostile ecological factors—the strategic resources of water and land were always in limited supply, and diseases frequently destroyed crops—led to competition being a keystone aspect of life, and reliance on the family group being vital for survival. Economic activities were conducted by the entire household for the improvement of their common position, thus enhancing family solidarity and the strong distinctions between “insiders” and “outsiders.”

In his survey of rural life in the late 1920s, Surridge, a British colonial officer, noted an internal division of labor within the family, with men being responsible for heavy agricultural work and women (aided by the older children) for the lighter work in the fields, as well as housework. Usually one of the girls would stay behind to look after younger children and help with some housework (Surridge 1930). At the same time, much as in Greece and elsewhere in the Mediterranean, there was a “moral division of labor inside the family,” revolving around the cultural codes, or values, of “honor and shame” (Campbell 1983, Schneider 1971).

Honor (timi) refers to the value or worth of an individual—but since the individual exists as a “member of a family,” whatever worth one earns for oneself automatically “spills over” to the family. Correspondingly, shame (ntropi) refers to a loss of honor, esteem, or worth, which brings humiliation, “staining” the individual and family.

It is important to appreciate the salience of these codes on the lives of individuals in traditional Cypriot society. Peter Berger has argued convincingly that contrary to modern societies’ emphasis on “dignity,” which implies a notion of the self devoid of institutional attachments and roles, more traditional societies put an emphasis on “honor,” which “implies that identity is essentially, or at least importantly, linked to an individual’s institutional roles.” In fact, an individual in a “world of honor” “discovers his true identity in his roles.” “To turn away from the roles is to turn away from himself” (Berger et al. 1973). What, then, were the roles through which individual Cypriot men and women discovered their true identities or selves?

The traditional role of the man in Cyprus was that of representing the family to the outside world. As head of the family, he engaged in all tasks necessary to protect and sustain the family. He was the main income earner who made decisions regarding production by obtaining knowledge about environmental conditions, resources, and markets. After work, he would spend time in the coffeehouse (kafeneion), where information was exchanged and contacts made, as well as views shared on political and village affairs. The highest value for man was “love of honor” (philotimo), that is, self-respect and self-assertive courage, which amounted to assertive masculinity, in all areas of social life, to protect the honor of the family.

The traditional role of the woman was to be responsible for the family inside the home. Her tasks revolved around three sets of duties: first, the duty of being a good mother, hence the tasks of nurturing and caring for the children; second, the duty of being a good housekeeper, responsible for cleaning the house, cooking, shopping, and looking after domestic animals; and finally, the duty of being a good wife, by being obedient, respectful, and submissive to her husband.

The separation of the sexes in traditional society, especially rural areas, was quite strict, even though it has lessened with modernization. A woman would keep away from public areas, which were the domain of men. Women would never enter coffeehouses or athletic clubs; similarly, they would rarely be seen passing through the central square of the village, where most male-dominated coffeehouses were concentrated. In churches, women would occupy the rear and upstairs sections, the front part being reserved for men only. Women could attain more freedom to circulate among men only when they were not considered sexually risk-bearing, i.e., young girls before puberty and elderly, no-longer-sexually attractive women (well past menopause). In these cases, women could walk in the streets more freely, pass through the central square, and converse with men. But in no case could women enter and contaminate in church the holy of holies where the altar is housed.

Women’s avoidance of public spaces related to their need to avoid sexual shame. In fact, shame-avoidance was the principal value governing all female behavior in traditional society. In his classic study of a Cypriot highland village in the 1950s, Peristiany (1965) noted that a “woman’s foremost duty to self and family is to safeguard herself against all critical allusions to her sexual modesty. In dress, looks, attitudes, and speech, a woman in the presence of men should be virginal as a maiden and matronly as a wife.” A woman who behaves in conformity to the “code” regulating the behavior of her sex (femininity and passive modesty), is said to be an honorable woman (timia gynaika), whereas the one who doesn’t is without honor (atime), or, what amounts to the same thing, without shame—shameless (adiantrope). Again, honor and shame, respectively, are not restricted to the woman, but “spill over” to her family. Thus, for instance, in the case of an unmarried woman, shame taints directly the father and brothers, “who did not protect or avenge her honor.” After marriage, these responsibilities pass to the woman’s husband.

Whether father, brother, or husband, men bear the responsibility of caring for the women of the family. Indeed, this will be their conformity hallmark that regulates the behavior of their sex (“manliness and assertion of masculinity”). In both cases of non-conformity to the code of honor (“an unmanly man” or “an immodest woman”), the perpetrators are guilty not of breaking an externally given rule, but of betraying their very nature, their physis—because it is considered in the nature of men and women to act in those ways (Peristiany 1974).

Gender roles are taught throughout the socialization process. A study of the lowland village of Lysi in the early 1970s provides an account of the different patterns of socialization for the two sexes (Markides et al. 1978). From a very early age, in their games, boys try to imitate their father’s behavior and girls their mother’s. Until the age of 6, children are free to play in the streets and visit neighbors’ and relatives’ homes. But after this age, girls begin to spend most of their time at home, playing with their sisters or other friends, but also learning how to clean, cook, sew, and so on. As they grow older, they may be allowed to visit relatives or friends, once they have secured their mother’s consent. No such limitations apply for boys, who continue to be free to wander around and play in the streets, and to visit the kafeneion or other clubs and public places. Boys are encouraged to develop their masculinity as expressed through “physical courage, toughness, competitiveness, aggressiveness, and defending one’s honor,” whereas girls are taught to cultivate their femininity as expressed through “gentleness, expressiveness, responsiveness, tenderness and modesty” (Balswick 1973). The most important virtues that girls must learn are, again, those related to modesty and shame-avoidance. A girl must demonstrate that she is a virgin not only in the flesh, but also in spirit. She should avoid not only physical, but also social contact with men, because this could be associated with sexual desire. This entails accepting a number of social prohibitions, such as never to talk to a man in the street, unless he is a close relative; not to fraternize with men, and “when a man looks at her she should avert her eyes and blush; she should not laugh in front of men and if she does so, she must bring her hand in front of her mouth” (Markides et al. 1978).

If this behavior is maintained, her good name and family honor are preserved, which adds to her value as a future bride. Throughout socialization in the family and community, a girl learns to set marriage as the paramount goal of her life, since it allows her to become a wife and a mother. A woman who remains unmarried is destined to remain at the social and cultural periphery of the village, for she is not offered any role to play within the mainstream of society. Her destiny will, in fact, be to care for the elderly parents and the children of married sisters and brothers, and to engage in church-related activities.

Marriage and the creation of a family are also very important for young men, for it is only through them that they will be considered full and mature members of society with equal rights and responsibilities. A man reaches manhood only when he marries. Until then, he is still a kopellin, a “lad,” which means he cannot hold any responsible position within the power hierarchy of the village.

Social Change, Modernization, and Gender Roles

The roots of Cyprus’s modernization can be traced back to the beginnings of British colonialism. Prior to British control, Cyprus had been subject to Ottoman rule for approximately 300 years, during which time the land was owned by the State; the peasants had the right to use the land in exchange for the appropriate taxes. British colonialism introduced a connection between individual production and the right to private property. Peasants could now own the land they cultivated; but they could also lose it! Indeed, for various reasons, such as bad agricultural years and overspending on their children’s dowry, many peasants found themselves in heavy debt to insurers, to whom they had resorted for borrowing money, and to whom many eventually lost their land because they could not repay their mortgage.

Such destitute peasants sought employment in other sectors of the economy, namely the mines and small industries that started developing in the urban centers early on in the 20th century. After World War II, when Britain was forced to abandon her bases in the Middle East and to grant independence to India, Cyprus acquired enhanced strategic value. In response, the British constructed two large military bases on the island, at Episkopi and Dhekelia, with the resulting construction industry providing new employment opportunities. Furthermore, the increased needs of the British military and administrative personnel provided further jobs and new commercial possibilities.

During the 1950s, the final decade of British rule in Cyprus, the average annual rate of growth of the economy reached 12%, an indicator of the progress that was being achieved. Urbanization had also grown dramatically: Whereas at the beginning of British rule, the urban population was only 17%, by the time they left, it amounted to 36%. As Attalides (1981) showed in his study of social change and urbanization in Cyprus, the majority of the people who migrated to the towns were those who had no land of their own and no work, mostly unmarried men and women. Another major reason for migration was the decision to attend high school. This was because of the recognition that education provided a way out of the villages and hard toil in the fields, into “a better life” in the towns and employment possibilities in the newly created white-collar jobs.

Gradually, the urban centers became the foci of the economy as well as of social and cultural life. This, along with the emergence of a sizable urban middle class, led to a restructuring of power relations—a shift of power from the village to the city. As a result of these modernizing processes, the family underwent considerable change. Functions earlier performed by the family were gradually taken over by other institutions, even though not to the extent and with the consequences this had in the West. Thus, even though in many cases the family stopped being a production unit (as in the case of destitute peasants joining the working force in the mines or industry), in many other cases, money earned from work in the towns found its way back to the villages to help the family pay off debts and maintain its land and unity. In yet other cases, family businesses were set up in towns, so the family kept its production role in a new context (Argyrou 1996).

It is also interesting to note that, whereas in many other developing societies, urbanization led to a break-up of extended family systems into the nuclear system, in Cyprus there was somewhat of a reversal in the process. We have noted how rural Cypriot society was characterized by a nuclear family system; urbanization, in its early stages at least, had an expanding effect, since kin members were added to the nuclear core (usually younger relatives looking for a job in town). Thus, it does not seem that modernization and urbanization negatively affected family cohesiveness and strength (Attalides 1981).

There were, however, gradual changes in gender roles within the family. Two of the most important factors leading to these changes have been education and employment. Education became an important mechanism of social mobility, advancing both the status of peasants to that of white-collar workers and improving the status of women (Persianis 1998). The first primary schools were established by the Orthodox Church toward the end of Ottoman rule. Very few girls attended these schools because women’s destiny was to marry and have a family at an early age. Besides, because there were only male teachers at the time, parents were unwilling to allow their daughters to stay in school beyond the age of 8 or 9. For the same reasons, this absence was even more pronounced in the case of the few secondary schools, which were concentrated in the towns. The first girls to attend schools came from the wealthier (bourgeois) class, which valued the cultural benefits of education, expecting their girls to be taught how to be “refined ladies,” but also to remain “modest and quiet.” It is from the 1920s onwards, the period in which we start having increasing rates of urbanization and industrialization, that we have sizable increases in student numbers, including girls. Most of these new students were children of the wealthier rural and, primarily, urban classes. The motives, henceforth, became mainly economic, because education was now considered instrumental in securing a job in the towns, in commercial shops, trading firms, banks, and similar work. Such motives were further strengthened in subsequent periods, when the economy grew at a faster pace, providing more and more opportunities for work. This was true after World War II, but especially after independence in 1960, when the service sector opened up. Cypriots thought service jobs to be more appropriate for women, since they more closely resembled their traditional roles.

The 1974 Turkish invasion brought destruction of biblical proportions to the Greek Cypriots. Almost 40% of the land came under Turkish control; a full third of the population became refugees and had to flee to the south for survival. Most of these ended up in refugee camps at the outskirts of the larger towns, creating a large new wave of “forced” urbanization. Women from such refugee families, especially of rural and working-class background, provided cheap labor for light manufacturing industries, mostly in shoes and clothing, which found unexpected opportunities for growth during this period. Furthermore, the expanded welfare and other state services, which tried to cater to the new needs, provided new opportunities for middle-class women, both refugee and non-refugee alike. The final pull was provided with the economic recovery and unprecedented boost, the “economic miracle,” in the early 1980s, which created numerous new jobs in tourism and the wider service sector.

Throughout this period, women’s employment increased by leaps and bounds, as did schooling for girls. By 1995, women’s employment was 38.6% of the total, as compared to 35.17% in 1985. In both primary and secondary education, the ratio of girls was equal to that of boys, with some marginal differences at the tertiary level, where more boys than girls study outside Cyprus, whereas more girls than boys study at tertiary institutions in Cyprus.

All these changes have obviously transformed the Cypriot family and gender roles within it, although continuity with past patterns remains strong. Mothers, especially of the younger generations, are not only “allowed,” but “expected” to work. Recent research by Papapetrou and Pendedeka in 1998 shows that family members believe the mother to be sensitive, permissive, and flexible toward children’s demands. She is over-protective and worries a lot about her children, spending time in discussion with them, certainly more so than the father, which may explain why she demonstrates more empathy and understanding toward the children. This is seen to be related to the fact that she carries the care of the household and family, spends many hours at home, and thus has more opportunities to see each family member separately. This, it is speculated, may also provide her with the opportunity to “administer” or “rule,” to know “what” and “when” something must take place. Such powers, however, are not tantamount to the role of “leader,” which is reserved for the father. She is expected to work, but she is also expected to ungrudgingly interrupt her career to raise children. After all, woman’s working role is seen as a secondary one, important for supplementing the family’s income and not as the main breadwinner.

The father is the one considered to be really responsible for the economic well-being of the family. He is still considered to be the leader of the team and his opinions are “determinative” when it comes to “serious” matters, or matters which have an impact upon the whole family. He does very little in the house, his activity being mostly limited to heavy jobs (such as construction or repair-work) upon mother’s requests. Usually, he does not spend much time at home, but prefers the coffee shop, a hobby, or a second job; when he stays at home, he usually watches television, especially news reports. He is thus seen as austere, strongly opinionated, and distant. Often he is “unexpressive,” since man’s socialization into masculinity (competitiveness, toughness, aggressiveness, physical courage, and defending one’s honor) teaches him that expressiveness toward his wife and children is a “feminine” characteristic.

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

The traditional social and moral order has been sanctioned by the Cypriot Orthodox Church. The family is considered to be a divine institution, relations between its members being comparable to the relations between God, Mary, and the Christ Child. Icons were traditionally kept in a specific holder (ikonostasi) of every home, with an oil-lamp constantly burning, symbolizing the divine protection of the institutions of marriage and family.

During the marital ceremony, considered to be one of the seven “Divine Mysteries” or Sacraments through which God’s grace is bestowed to humans, St. Paul’s Epistle to the Ephesians is read to the newlyweds, reminding them that, in their relationship, the wife must fear her husband and be submissive to him at all times, whereas the husband must love the woman, as Christ loved the Church. Obedience, respect, and submission to husband are moral imperatives that highlight the patriarchal nature of traditional Cypriot society.

Modernization of all spheres of Cypriot life and secularization of the religious sphere have certainly brought about important changes. The 1960 Constitution of the Republic of Cyprus enshrines modern democratic ideals, including equality of men and women before the law. It also specifically prohibits any “direct or indirect discrimination against any person on the ground of his [sic] community, race, religion, language, sex, political or other convictions, national or social descent, birth, color, wealth, social class or any ground whatsoever . . .” (Article 28).

Nevertheless, as has been pointed out by Stavrou (1998), the patriarchal “logic” lurks behind some of the provisions of the supreme legal document of the country. For instance, in determining the ethnic community to which a citizen should “belong,” after marrying someone from the opposite community (i.e., a Greek Cypriot marrying a Turkish Cypriot or vice-versa), the Constitution clarifies that: “A married woman shall belong to the community to which her husband belongs.” Similarly, in the case of children under the age of 21 who are not married, a child “shall belong to the community to which his or her father belongs . . .” (Article 2: Par. 7).

This patriarchal logic pervades other sociolegal institutions and respective provisions or regulations. Thus, if an alien man marries a Cypriot woman, he does not automatically acquire Cypriot citizenship, unless he fulfills almost all the conditions that any other alien must fulfill in order to acquire citizenship. If, however, an alien woman is married to a Cypriot man, she thereby acquires his residence as well as his domicile.

While there are often no specific laws determining discriminatory social practices, traditional norms and values may produce such outcomes. For instance, there is no legal provision that regulates the name the parties in a marriage should assume. “The practice, however, as has been customary throughout much of the European Christian world, is that upon marriage a woman takes her husband’s family name. Also, the children take their father’s family name except in the case of illegitimate children, who take the name of the father of their mother” (Stavrou 1998).

In many other instances, the laws may provide for equality and prohibit discrimination, but traditional institutions and practices may still prevail. A most glaring case is that of divorce, traditionally governed by Church law, which entails different divorce provisions for husband and wife. Two reasons that may be invoked only by the husband as against his wife are: First, that the wife was found not to be a virgin on the night of the wedding, which has to be reported to the local Bishop the next day; second, that the wife spent the night with persons unrelated to her (unless she could not find a relative’s house to stay for the night, after being ousted from the home by her husband).

The Constitution perpetuated these unequal provisions by declaring marriage and divorce matters as the domain of the Church. It was much later, when Civil Marriage Law 95/89 amended the relevant article of the Constitution, to allow free choice of civil weddings for Greek Cypriots, and to place matters such as divorce, judicial separation, and family relations under the governance of special family courts. The Church of Cyprus reacted strongly against these legal changes and exerts all kinds of pressure in order to retain control of the institution of marriage. Until today, the Church insists that civil weddings are illegitimate and refuses to offer perpetrators the services of baptism and other holy sacraments. These pressures by the Church, but also (and perhaps most importantly), the weight of long-adhered-to traditions, explain why the vast majority of Cypriots (more than 70%) still choose religious, instead of civil weddings. Indeed, civil marriages between Cypriots account for only 3.6% of total marriages.

A similar situation prevails with divorce. The procedures for securing divorce through the Church are not only long and laborious, but they are also much more exacting and discriminatory against women. Nevertheless, because of the Church’s pressures and the special weight of adhered-to traditions, most Greek Cypriots prefer to put up with the difficulties of Church divorce instead of resorting to civil divorce. They are afraid of getting themselves entangled into a web of socially difficult or embarrassing situations. For instance, should one wish to remarry in church after a civil divorce, one may find oneself accused of attempting bigamy!

Interestingly, on the issue of abortion, women’s span of control or available choices seems to be much greater than in many other countries, even of the developed West. This seems to have to do as much with historical circumstance as with current social realities. Up to the early 1970s, the Criminal Code completely prohibited the practice and provided severe penalties for perpetrators. Developments related to the 1974 Turkish invasion drastically changed the situation when many Greek Cypriot women became pregnant after being raped by Turkish soldiers during the hostilities. Obviously, Greek Cypriot society was not ready to accept the offspring of the “barbarians” into its midst. Many Greek Cypriot men found it difficult enough to accept the raped women themselves, who were violated or “shamed” publicly. Even though the women resisted this violation of their bodies, the public consequences of the rape indirectly brought shame on their families, and especially on their men. As a consequence, the relevant law was radically amended to allow medical intervention for the termination of unwanted pregnancy in such cases. In addition, a provision was made for pregnancy to be terminated if two doctors advised that the life of an expectant mother would be in danger should pregnancy be allowed to continue, or in cases in which a newborn baby would face the risk of serious physical or mental disability.

These loopholes in the law effectively opened wide the doors for abortions under almost any pretext. Although hard data are not available, there are many indications that a large number of abortions are carried out in modern-day Cyprus. This may appear strange for a society that is still quite conservative on a number of other counts. Even stranger is the fact that there hardly appears to be much anti-abortion talk from any quarters, let alone an anti-abortion movement. Finally, the Church, though in theory opposed to all forms of abortion, seems in practice to be only paying lip service to a cause it does not really care to fight for. One suspects that the main reason for this is that the Church cares mostly to control not the private decisions, but the public behavior and choices of Greek Cypriots, since it is the latter which serves as an index of its power.

Obviously, the historical circumstances, outlined earlier on, explain to some extent why abortions were initially “legalized,” and why, consequently, once the legal prohibition was removed, the door was opened for abortions for all kinds of reasons. But why did the phenomenon grow to much larger proportions? It seems that social change and new realities in contemporary Cyprus account for the remaining part of the answer. Indeed, in recent decades there have been fast-paced and drastic socioeconomic changes, which seem to have eroded traditional values and norms without allowing the time for new norms to develop—the phenomenon of “cultural lag.” This is evident in the area of sexual relationships. Many young people are experimenting with sex in their relationships, something that contemporary “open” or “liberated” Cypriot society seems to “allow.” Yet the relationships of these young people with their parents (and teachers) do not seem to be so liberated as to allow for straight talk about sex and contraception—thus the many unwanted pregnancies and the use of abortion as an alternative to contraception!

Besides the young, many older people have problems with their marriage; hence the increasing rates of divorce. Both young and older couples also seem to be resorting to relationships outside marriage, which may again lead to unwanted pregnancies and abortions.

To the above must be added the fact that Cypriot males, and sometimes their women partners, seem to think that male contraceptives will somehow render lovemaking “less natural” and enjoyable. Thus, contraception ends up being the sole responsibility of women. And if she has not taken the necessary precautions, they end up with unwanted pregnancies and abortions.

The ease of abortions may be an important explanatory factor for the fact that children born out of wedlock are rarely found in Cyprus. To this, of course, we must add the prevailing conservative traditional values, which view unmarried mothers as immoral, since they are seen to be flagrantly violating the sexual code and carrying the “shame of dishonor.” Because stigma is a certain outcome for childbearing outside wedlock, and because abortions are so easy to arrange, it is no wonder that illegitimate births are almost nonexistent.

Cyprus has, in fact, introduced legislation (Law 243/90) to bring itself in line with the provisions of the relevant European Convention. An interesting example, which highlights all the above issues, concerned a case in the mid 1990s of an unmarried woman working in the Church-run broadcasting station (Logos). When she decided to go against convention and not hide the fact that she was pregnant, she was soon fired, as she was seen to be a case of embarrassment for her employer and a bad moral example for all. The fired woman sued the station and managed to win the case and be awarded compensation (Fileleftheros, 9 May 1995).

Another recent law, which aims to protect women from the abuse of traditional norms, relates to the Prevention of Violence in the Family and the Protection of Victims of Violence (47(I)/94). Such a law was of absolute necessity in Cyprus, where many men consider it their legitimate right to uphold their power as husbands and/or fathers in the family through any means possible, including violence, whether it be physical or psychological violence against the wife and children, or sexual violence against the wife.

The Sociolegal Status of Men and Women in Work/Employment

For many years, women in the labor force suffered various forms of discrimination as regards inequality in pay for similar work done, conditions of work, type of employment, and opportunities for advancement. Gradually, as a result of a number of factors, such as pressures from women’s organizations and the trade unions, and political pressures emanating from the signing by the Cypriot government of various international treaties, the situation has substantially improved, at least as far as legal provisions are concerned. This has not, however, substantially improved the situation for all women, nor has such legal improvements dramatically improved the life of women.

A good example is that of social insurance legislation, enacted since independence, which provides for a marriage grant payable to working women when they marry, as well as a maternity grant and allowance, the former paid to a woman giving birth, the latter paid during a maternity leave of up to 12 weeks. Unfortunately, the plan does not cover self-employed women or unpaid family workers in agriculture, who comprise approximately a third of the total number of economically active women. Furthermore, it does not cover thousands of women involved with unpaid housework, as this is not considered “proper” work. This means that a great number of Cypriot women, particularly older women, have to remain in a state of complete dependence on their husbands. Social insurance legislation has been modified appropriately, after ratification of the International Labor Organization Convention 100, and the Equal Remuneration Law (158/89), to provide for equal pay for men and women for work of equal value. This has decreased the gap between male and female wages, although it has certainly not closed it, since equal remuneration is practiced only by the government and a few large corporations, mainly banks, but certainly not by the private sector at large. Among the laws that seek to improve the legal position of women in employment is the “termination of employment” law (24/87), under which sex, pregnancy, or maternity can never constitute reasons for the termination of employment. Again, however, evidence shows that many employers tend to ignore the law, and that in such cases few women proceed to take legal measures against the perpetrators (Varnavidon & Roussou 1995).

Another interesting example, which illustrates how small an effect changes in laws can have on actual social practices, is the abolition of the pre-independence law (180), which prohibited the employment of women during the night. For many years following abolition of this law, social resistance to the idea of women working outside their homes during the night has been such that few women still dare to do so. The result has been an intense shortage of women working in jobs for which night duties are essential, such as nursing and paramedical occupations. For this reason, private clinics have been given permission to employ women from foreign countries. Also, Cypriot women employed in the Cypriot Police Force and the National Guard, as well as those working in the thriving tourist industry, are exempt from night duties.

Lastly, we should underline the fact that in 1985 the Cyprus government ratified the United Nations Convention (34/180) on the Elimination of All Forms of Discrimination Against Women (Law 78/85). This symbolized Cyprus’s commitment to eliminate all forms of discrimination against women in all spheres of life, be it education, politics, employment, family, or public life.

In summary, two major comments could be made about legislative change and its impact on Cypriot society. To begin with, most ratifications of international conventions and relevant laws were passed in the recent decades, after independence in 1960, but mostly after 1974. This suggests that, until recent times, concerns about equality and the protection of the rights of various underprivileged groups in society, including women and children, were not a primary issue, because traditional Cypriot society was based on conservative norms, values, and morals. Cypriot life revolves around the central social institution of the patriarchal family, with the father enjoying controlling power over the behavior of the other members of the family, especially women, as the preordained “order of things,” legitimated by religion.

Modernization and socioeconomic change have contributed to an “opening-up” of society and the gradual espousal of more liberal values and norms. Thus, the introduction of the various laws outlined above. Yet, it seems that Cyprus is going through a period of transition, in which new values coexist with traditional ones. This, as well as the efforts of traditional male and clerical power holders to cling to their powers, seems to explain the persistence of inequality between the sexes and generations.

Women themselves have been slow to organize and push for their rights. Traditionally, the main domain of women’s participation in public life has been that of voluntary institutions, especially charitable organizations. This is true especially for upper- and middle-class women, the roots of the phenomenon dating back to the formative stages of the bourgeois class in Cyprus and its ideals of keeping women away from the world of production, as “queens” in the private realm of the family, into which men would retreat after work. Women’s involvement with charitable institutions was accepted and encouraged, because, in dealing with these, they could expend similar “feminine” services as the ones expended within the families themselves, namely care, love, and affection (Peristianis 1998). Voluntary organizations, and especially charitable ones, seem to have increased in numbers after the Turkish invasion of 1974, with the appearance of new social groups in need of support (Antoniou 1992). Interestingly enough, the leadership of most of these organizations is composed of men, with the exception of a handful of organizations, such as the Cyprus Red Cross and the Association for the Prevention of Violence in the Family.

Women from the working classes had a more prominent role in the trade unions, which started organizing early on in the 20th century. The oldest such union, PEO (Pancyprian Federation of Labor), is controlled by AKEL, the communist party of Cyprus. SEK (Federation of Cypriot Workers) is controlled by DISI, the right-wing party, and DEOK (Democratic Workers Federation of Cyprus), is controlled by the socialist party, EDEK. There are also strong autonomous unions representing government employees (PASIDI) and bank employees (ETIK).

In the labor history of Cyprus, women have fought alongside men for basic labor rights, such as social insurance, improvements in wages, and shorter working hours (Pyrgou 1993). However, trade unions do not appear to have actively pursued women’s rights for equality in the labor market. In fact, trade unions have accepted pay discrimination against women in labor agreements with respective employers (House 1987). It is interesting that the first law (in 1961), which provided for equal pay for women in the public sector, was enacted, not after trade union pressure, but as a result of a private prosecution by a woman employee who sued the Republic of Cyprus for not upholding the Constitutional Law’s provision for equal treatment of the sexes.

Cypriot women have never gone on strike in pursuit of their specific rights as women. One possible reason for this may be the fact that, whereas all unions have departments dealing with women’s matters, policymaking of these departments is directed by men (Antoniou 1992). Overall, although women constitute more than a third of the total trade-union membership, they seem to exert little influence of their own.

A contributing factor is obviously the control of all general unions by the political parties, who are, once again, male-dominated, and whose primary objectives have to do with furthering their political ambitions. Even more surprising is the fact that women’s organizations themselves seem to be controlled or strongly affiliated with political parties. Thus POGO (Pancyprian Organization of Women) is controlled by the communist party; Equal Rights and Equal Responsibilities is controlled by the right-wing party. The Socialist Feminist Movement and the Women’s Organization of the Democratic Party are even more forthright in declaring their affiliation in their own names.

For decades now, the primary focus of concern for the political parties has been the ethnic conflict between Greek and Turkish Cypriots, “the Cyprus Problem.” This has overshadowed all other issues, including those concerning women, equality of the sexes, and gender relations. Even though the higher officers of these women’s organizations have the opportunity to participate in the decision-making processes of the political parties, their voices are seldom strong enough to make a real impact, as the leading teams are always male-dominated. This becomes even more obvious in times of elections, as women candidates seldom, if ever, make it on parties’ lists. Because of prejudices and stereotypes, hardly any women who do make it onto ballots manage to attract enough votes to enter the House. In 1999, there were only three women members out of a total of 53 members. Women seem to do somewhat better in local government, where they appear to be increasing their numbers yearly. Of course, these posts hold negligible political power, so women’s gains in this area do not amount to a serious improvement in their status or impact.

C. General Concepts and Constructs of Sexuality and Love

In traditional Cypriot society, marriages were arranged by parents and had nothing or little to do with the personal preferences of the young people involved. Often a young man coming of wedding age would suggest to his parents a particular girl of his fancy (usually a girl he found attractive in external appearance but had little knowledge of—since girls were expected to practice “male-avoidance,” in order to protect their reputation and honor). If the parents approved of their son’s choice, they would proceed to sound out the parents of the girl, usually through the services of a mediator/matchmaker. If the parents disapproved of the choice, their objections usually prevailed, as they were supposed to “know best” because they were “older and more experienced.” Obviously, the girl’s opinion was rarely asked for and her freedom of choice was much more restricted than the young man’s.

The paramount criteria for parents’ preferences had to do with considerations of their family’s best social and economic interests—thus, they had to be satisfied with the economic well-being of the girl’s family, the status of her family in the social hierarchy of the village, as well as the moral reputation/standing of the girl and her family in the village. Obviously, a good choice for marriage would enhance both the material resources as well as the status of their family in the village community. Parents would give a “dowry” to the young couple as a material aid to help the newlyweds make a good start in their married life. The bride’s family would usually contribute the house plus furniture, kitchen utensils, household linen, and similar items. The bridegroom’s side would provide some land and animals. Attalides (1981) notes that marriage settlements imply a bargaining process of matching the assets brought to the new household by the respective partners. Moreover, the practice of giving equal inheritance to all children means that parents must be aware so that what they give to one child at the time of marriage does not jeopardize the share of any remaining children. “In this situation, it is understandable that control of premarital sexuality should be extremely strict for girls.” Thus, if a girl acquires a “bad reputation,” the bargaining power of a potential husband is enormously increased, allowing him the chance to make “virtually extortionate demands for a property settlement, thus incapacitating the domestic group from provision for further children” (Attalides 1981). Of course, property considerations were only one set of reasons for the adherence to a strict moral code of behavior for women, but they were surely an important set.

The above constitutes one more set of reasons why families had to always be vigilant of the reputation of their women. Young women had to maintain their chastity until their wedding day. If a woman’s sexual purity was questioned, she risked her chance of ever marrying. Virginity was a necessary condition of a woman’s moral integrity and the principal prerequisite for marriage. It should be remembered that virginity did not entail only the “physical purity of a girl,” i.e., an “intact hymen,” but implied that “the girl should avoid any social contact with men that is automatically associated with sexual desire” (Markides et al. 1978).

So important was the value of female purity that during wedding celebrations, the visual display of the bloodstained sheets, proving the bride’s virginity, had central importance. It has been noted (Argyrou 1996) that the virginity rite “expressed female subjugation but also the wider subjugation of younger people of both sexes to their elders and in particular their parents,” for the rite symbolized in a “tangible and indisputable way” that the parents had been managing and controlling the family well. Argyrou (1996) demonstrates how changes to the rite, leading to its disappearance, reflect changes in the power relations between the older and younger generations, as well as between the sexes. The first set of changes became visible in the 1940s, when new employment opportunities were created, giving young men the opportunity to move to the towns for jobs. The sons of wealthier parents moved to towns in order to obtain secondary education. Eventually, with mass education, this became true for all classes and for both sexes. Youngsters were now exposed to new ideas and values through books, magazines, and newspapers. Overall, opportunities for economic independence and education decreased the dependence of the young on their parents and eroded the latter’s authority and powers of control, as children could be more knowledgeable or competent than their parents in some areas.

Other developments also contributed to the changing nature of power relationships between generations. For instance, a young man moving to a town often found it practical to stay with his in-laws, so that his fiancée and mother-in-law could look after him and he could also save money to contribute to the costs of building a house. This practicality made vigilant observation of the engaged youngsters difficult for the parents. It also meant that parents themselves chose to avoid the embarrassment of asking for evidence of a bride’s virginity, whereas the couple itself increasingly considered the matter their private affair rather than a public spectacle. By the late 1960s and 1970s, “the practice of having fiancees move in with their in-laws became generalized” and “engaged youngsters were sleeping together with the parents knowledge and implicit consent.” Loizos (1975) notes that, in fact, by the 1960s, “youngsters had acquired power to veto their parents’ choice of marriage partner.” Balswick (1973) points out that by this time, young people considered “romantic love” to be of primary importance, and this development was responsible for the challenging of parentally arranged marriages. The concept of romantic love was related to changing sexual standards. For if love was felt to be a prerequisite for marriage, then only the young people themselves could determine the existence of love, and this entailed a certain amount of familiarity with members of the opposite sex. Thus “dating” started becoming common.

Such developments cannot be taken to imply that youngsters have now been liberated from traditional values and that virginity and female chastity are no longer important to men. In fact, as Argyrou (1996) reminds us, what has changed has mostly to do with the “timing of sexual access to the bride.” Furthermore, the traditional “double standards,” requiring a woman to be a virgin until she marries but not so the man, are still prevalent in Cypriot society. Similarly, although some expected that modernization and romantic love would lead to the demise of the dowry system (Balswick 1973), the practice seems to be going strong with some minor changes. Nowadays, the bride’s parents are still the ones who contribute to the house and most other items needed for setting up the new household. The groom’s parents are expected to have invested considerably in their son’s education, which will have led, or hopefully will lead in the future, to very good employment.

After 1974, with the displacement and impoverishment of a third of the population, who lost all their wealth and became refugees so they could not give any dowry to their children, the tradition suffered a setback. However, traditional values and expectations were so strong that the state was pushed to donate land or money to all unmarried daughters of refugee families as a form of dowry for establishing their own households in the free south. Besides, the economic recovery and boom after the 1980s has enabled Cypriots to continue with the practice (Stavrou 1992). Some analysts point out that the willingness of Cypriot parents “for deferred gratification” in order to invest in their children’s dowry, may actually itself be one of the main reasons for the continued success of Cyprus’s economy (Balswick 1973, Mavratsas 1992). The above realities may account for an interesting paradox, revealed by social surveys. On the one hand, young Cypriots claim that love is what is important in marriage and that the giving of a dowry is an outdated practice that they do not believe in. On the other hand, they say that parents should “help” with a house and in other ways so the young couple can make a start in life (Intercollege 1996). This seems to vindicate Argyrou’s (1996) position that we are looking at developments in sexual mores and related practices, which are the result of “a struggle in which children won a dominated freedom and parents retained partial control through compromise.”

D. Religious Beliefs Affecting Sexuality

In Cypriot society, the religious attitudes and beliefs of the Greek Orthodox Church exercise a strong influence on the sexual attitudes and behavior of the people. Some insight into this factor can be gained from the responses of Greek Orthodox priests to a semi-structured questionnaire regarding seven sexual topics: a) adultery, b) premarital sex, c) masturbation, d) abortion, e) contraception, f) homosexuality, and g) coital abstention. There were 130 (23.2%) responses from the total of 560 questionnaires distributed to all priests on the island, followed up with face-to-face interviews of 27 of the priests (Georgiou 1990).

On the issue of premarital sex, the priests were asked for their pastoral response to the following “situation”:

A young, engaged Christian couple who has been cohabiting for three years is very much in love, but they cannot marry immediately as they have a number of difficulties. As they do not want to have sexual intercourse before the marriage ceremony, but are involved in heavy petting, they approach a priest for advice. (Georgiou 1990)

For their pastoral advice, the priests chose the following:

A thematic analysis was performed using subjective responses based on 14 mutually exclusive general categories. The responses were: The couple:

Face-to-face interviews with the 27 priests revealed what appeared to be a confused attitude toward premarital sex. They offered a variety of legalistic definitions of premarital sex, which dichotomized sexual acts into “acceptable” or “not acceptable.” Some, for example, drew the line of “acceptability” at light kissing between a couple engaged to be married. Others drew the line at a light caress, rejecting all other sexual expressions as either unacceptable or sinful, and so on and so forth. There was also no consensus as to why premarital sex was a sin. The majority said that it was a sin because the Orthodox Church said so. None of the priests, however, could refer to any specific writings of the Orthodox Church to validate their claim. (See other responses from this survey of priests on homosexuality in Section 6B, on contraception in Section 9A, and on abortion in Section 9B.)

3. Knowledge and Education about Sexuality

A. Government Policies and Programs

There are no specific government policies and programs for sex education. There are no formal sex education programs taught in schools beyond the biology lessons, which cover subjects such as the anatomy and physiology of the reproductive organs, fertilization, twins and genetics, sexually transmitted diseases, changes during puberty, and birthing. These lessons are normally taught by biology teachers, and it is left to their discretion to answer specific questions that may be raised in class. These lessons are taught from the age of 15 upwards.

B. Informal Sources of Sexual Knowledge

There is an element of informal sex education from organizations such as the Family Planning Organization, but this only covers specific groups of people, such as married women seeking gynecological or family planning assistance, soldiers doing their National Guard service, and other minority groups. There is also some teaching in hospitals and schools, but limited staff does not allow for further expansion.

When the main author arrived on Cyprus from the United Kingdom in 1983, there were no explicit sexual articles published in the Cypriot media for fear of reprisals. I wrote my first article on Cypriot male sexuality during this period, but found it impossible to find an editor willing to publish it in their newspaper, as it contained words such as “penis” and “vagina.” There seemed to be an inherent fear of publishing sexual articles of any nature, as the editors believed that there would be a volcanic eruption from the Church and the conservative people of Cyprus. They could not have been further from the truth! When a brave editor of a relatively small, radical right-wing newspaper decided to publish the article, there was applause from many sectors of society; one of the long-lasting, but superfluous taboos had been broken! Cypriots were thirsting to learn more about sexuality. After the newspaper editor’s initial enthusiasm, I proposed a weekly column, which would allow people to write in their problems anonymously and receive replies in the newspaper. He agreed, and the first sexual column in the history of Cyprus was launched in 1984 in the newspaper Alitheia (The Truth). The sales of this particular small newspaper increased dramatically in just over a year!

The degree of sexual ignorance from the questions being received was apparent: “Can I get pregnant by swallowing sperm?” “What is the clitoris?” and many, many other questions touching on topics such as anal sex, transvestitism, telephone sex, and sexual problems. At least a dozen letters were received every day. The columns gave people from all age groups and all walks of life an opportunity to write their questions or problems about sexuality, and get a response published in the media for all to read. The weekly column in the popular magazine To Periodiko, which ran from 1984 to 1994, reached a peak audience in excess of 30,000 people weekly. More than 1,000 articles covering all aspects of sexuality were published during this period. This, along with a weekly radio program titled Human Sexuality, broadcast live every Saturday at lunch time by the author, covered a wide variety of sexual topics and provided a large part of the informal sex education of the population. After a few years, other newspapers began to publish articles, usually translated from foreign magazines. Beginning in September 1999, this editor completed a series of six television programs on human sexuality for EF-EM, a local TV station in Larnaca. (See Section 10, Sexually Transmitted Diseases, for survey data on the knowledge of adolescents regarding STDs.)

In the Knowledge, Attitudes, Beliefs, and Practices (KABP) Survey on AIDS (Georgiou & Veresies 1990, 1991; see also Sections 5B, Interpersonal Heterosexual Behaviors, Adolescents, 6A, Homoerotic, Homosexual, and Bisexual Behaviors, Children and Adolescents, and 10A, Sexually Transmitted Diseases and HIV/AIDS), 3,176 15- to 18-year-old schoolchildren gave us additional insights into their sources of sexuality information. The respondents reported receiving their first sexual information from five main sources: books and periodicals (24.1%), newspapers and magazines (15.4%), friends (12.0%), videos (12.3%), and television (12.2%). It is not clear from the questionnaire, however, who is actually providing this information in the sources mentioned. Sex differences showed that the boys were more likely to obtain their information from videos (9% vs. 3.3%), probably commercial pornography, while the girls were more likely to obtain their information from books and periodicals (14.7% vs. 9.4%) and mother (4.4% vs. 0.6%). It appears that newspapers and magazines are read equally by both. Subsequent sources of additional sexual information included: television (13.2%), schoolteachers (12.3%), and medical personnel (11.7%). The same-sex differences as those noted above emerged, with the exception of books and periodicals, which are again read equally by both sexes.

When asked, “Where would you prefer to get information about human sexual behavior? (Circle only your first choice),” the great majority of respondents preferred to obtain their information from books and periodicals (24.1%), followed by newspapers and magazines (15.4%), friends (12.6%), videos (12.3%), and television (12.2%). All the other responses were below the 5% level.

It should be noted here that there are no known sex education videos circulating in Cyprus, apart from the commercial pornographic videos that are freely available for rental in most video shops, certainly before the clamp-down on piracy came about. It therefore appears that 12.3% of the respondents are obtaining their information from pornographic videos. When asked to name their second preferred source of sexual information, students listed books and periodicals (16.1%), newspapers and magazines (14.2%), television (13.7%), videos (12.7%), and friends (11.4%). The remaining responses were below the 5% level. Sex differences showed that more males than females would prefer the radio as an important second source of sexual information (108 males vs. 46 females), newspapers and magazines (105 males vs. 70 females), television (224 males vs. 194 females), and videos (111 males vs. 38 females). More females than males would prefer sources such as books and journals (153 females vs. 137 males), mother (191 females vs. 56 males), and doctors and nurses (226 females vs. 143 males).

The survey gave no information regarding the specific books, videos, and magazines that students used, or how accurate the sex information was. Moreover, it is not clear how the students interpreted the question, “From where do you get information about human sexuality?” in a country where human sexuality courses have never been taught formally at school. Under the circumstances, the concept of “human sexuality” may be a difficult one for teenagers to interpret.

4. Autoerotic Behaviors and Patterns

A. Children and Adolescents

The only data available on child and adolescent autoerotic behavior comes from retrospective histories taken with a clinical sample of 840 patients whom the main author saw in clinical practice between 1993 and 1996. While male masturbation in this sample is far more prevalent than female masturbation (85% vs. 15%), approximately 50% of masturbating females felt guilty about this behavior compared with 48% of males.

It appears that parents also have fears of the female losing her virginity if she is allowed to “play about down there!” Virginity is related to the “honor” (timi) of the family, and this is very carefully guarded. Males, on the other hand, are often encouraged and “cajoled” to continue, if they are caught fondling their genitals in infancy, as this is seen as a normal part of growing up. Given that the females get rather negative messages when caught masturbating, and indeed may be chastised for this behavior, then it is perhaps not a surprise to find that only 15% of the females in this sample masturbated.

Still, it may be a little surprising that such a large number of Cypriot girls begin masturbating at such a young age, before age 10. One of the factors is certainly the early growth spurt that females have in relation to boys, but there are probably other explanations also. Most males learn how to masturbate from their friends (77%) compared to only 26.5% of females. The majority of girls, however, learn to masturbate by themselves, through experimentation or accident (54%), compared to fewer boys (21%) that learn in this way. Again, more girls (19%) learn to masturbate from the media, books, magazines, and the like, compared to about 2% of boys. It appears that girls tend not to talk as openly as boys do with their peers about masturbating, and therefore, this is not the source of their information. Girls, it appears, prefer to find their sexual information from books and magazines, and self-experiment in the privacy of their own home.

The main author’s clinical experience has shown that there is a widely reported incidence of childhood masturbation from infancy to nursery-school age. These cases are often reported by parents and are accepted by parents and caretakers if the child is male, and it is often joked about: “He’s as potent as his father. Look, he’s started young.” If the child is female, such behavior is often frowned upon, with punishment as a consequence if it continues. Over the last decade, I have had a number of parents coming to the clinic to discuss the “normality” of their young infant daughter’s masturbatory behavior, sometimes in horror that their little “innocent” should be capable of such “disgusting” actions! I have yet to see a parent come to discuss their son’s masturbatory behavior!

B. Adults

There are no data available for adult masturbation, but from anecdotal evidence in clinical practice I would say that adult masturbation in a stable relationship is quite rare for both sexes. There are the few occasions when masturbation is reported by a married man who has problems approaching his wife sexually because of marital discord, but this occurred in less than 1% of the clinical population. I believe that the Cypriot male views masturbation more as a “child’s thing,” and not the sort of thing that a “man” does, unless compelled to do so by circumstances.

Women, on the other hand, will often refuse to masturbate even when the husband is in therapy, believing that coitus is the “proper thing.” They prefer not to become part of the therapy until it reaches a stage where coitus is allowed. It follows from this that the treatment of anorgasmia using the traditional European or American treatment protocols is doomed to failure in Cyprus, as masturbating to orgasm is the essence of this therapy. (In Cyprus, one has to be a very creative sex therapist to succeed!)

5. Interpersonal Heterosexual Behaviors

A. Children

No data have been gathered to date regarding children’s sexuality or sexual rehearsal play in Cyprus.

B. Adolescents

The only systematic survey that has been conducted to date in Cyprus regarding adolescent sexuality involves a sample of 3,176 (1,528 male and 1,643 female) Cypriot lyceum students conducted by Georgiou and Veresies in 1990 and 1991. The Knowledge, Attitudes, Beliefs, and Practices (KABP) Survey was organized and completed along the lines of work carried out by the World Health Organization (WHO), the Global Programme on AIDS, the Social and Behavioral Research Unit (SBR), the Cyprus National AIDS Committee, the Ministry of Health, and the Ministry of Education in Cyprus. The whole project was headed by the main author of this chapter as the WHO Principal Investigator.

Even though the premise of the research was to look at the knowledge, attitudes, beliefs, and practices of Cypriot adolescents toward HIV infection and AIDS, many of the 177 questions in the survey touched on other aspects of human sexuality. There were two questionnaires, one for high school adolescents and another for head teachers. A multistage random-cluster sampling strategy was used to obtain data for the survey, using 27 schools—20 (79.2% of the sample) in urban areas and 7 (20.8%) in rural ones. The 177-question survey was answered anonymously, and covered the following areas: sociodemographics, sources of information on AIDS, knowledge of AIDS, attitudes and beliefs about AIDS, attitudes toward people with AIDS, knowledge of sexually transmitted diseases (STDs), leisure-time activities, perceived norms in certain health-related behavior, drinking and drug abuse, attitudes about condom use, and sexual behavior.

Adolescent Attitudes and Behavior

Previous Heterosexual Experiences. Students were asked to respond to a series of questions about individual behaviors ranging from hugging to anal sex. Even though hugging, deep kissing, and petting are not considered sexual activities through which HIV is transmitted, they are often enough preliminary steps toward sexual intercourse. Therefore, the percentage of young people engaging in them indicates when these steps toward more-advanced sexual activity are first taken (see Table 1).

Three quarters of the adolescents (76.7%) surveyed have experienced hugging at least once. Of these, the majority were boys (1,340 boys vs. 1,075 girls). One in six (15%) of the boys and one third (32%) of the girls were “sexually inexperienced,” not having engaged even in petting. About half of the students have experienced deep open-mouth kissing and some sort of petting above the waist. Again, the majority of these were boys (963 boys vs. 439 girls). About one third have petted below the waist (850 boys vs. 289 girls) and a further one third have slept together without sexual intercourse (628 boys vs. 242 girls). Sexual intercourse was attempted by approximately one quarter (18.6%) of the students (550 boys vs. 97 girls), which means that about 94% of the girls and two thirds (66%) of the boys were technically still virgins, even though they may have had other sexual experiences.

Judging from the figures for sex differences, it appears that the boys are not having sexual intercourse with the indigenous females. This raises the question of who their sexual partners are. Is it mostly with prostitutes, either local girls or imported “artists,” or is it with tourist girls? This data does not answer these questions, but they are definitely worth further investigation because of the implications for HIV transmission.

A further 25% of the respondents reported experiencing oral sex at least once (563 boys vs. 103 girls).

There is no doubt that the most dangerous sexual activity in terms of contracting HIV is receptive anal sexual intercourse. Masters, Johnson, and Kolodny (1988) point out that the risk from a single episode of anal intercourse with an infected partner is considerably higher than with other sexual activities—probably on the order of one in 50 to 100. Just over 15% of the respondents reported experiencing anal or rectal sex. Of these, the majority were boys (424 boys vs. 41 girls). It would certainly be worth investigating further whether the boys had homosexual or heterosexual anal intercourse, whether they had used a condom, and whether they were the receptors or the penetrators. It is also not clear why there should be so many boys participating in anal intercourse. If a large majority of girls were involved, this would be understandable, given the patriarchal attitudes that prevail in Cyprus regarding the preservation of a girl’s (“technical”) virginity. Perhaps the males are using anal sex as a means of birth control.

Among the 19.4% of respondents reporting having had vaginal intercourse, 11.7% (296 males and 75 females) reported having had one or two sexual partners, 4% (123 boys and 5 girls) between three and six partners, and 3.7% (115 boys and 4 girls) admitted to seven or more partners.

Of those who reported vaginal intercourse, the most frequent age of first intercourse was 14 to 16 years old, 14.4% (see Table 2). Girls showed a marked increase in sexual intercourse starting at age 15, whereas for boys, a marked increase was noted after age 13. The figures for the 11- and 12-year-olds appear to be rather high on first impression and need to be examined further (see also Table 6.)

Table 3 shows the most common reasons given for having a first coital experience. Eleven males and only two females reported being raped; from anecdotal clinical evidence, male adolescent rape is uncommon in Cyprus.

Contraceptive and Prophylactic Condom Use. Knowledge and use of condoms is another important area of adolescent sexual behavior, with 2,298 (72.4%; 1,378 boys vs. 915 girls) admitting they had seen a condom, and 65.6% (1,312 boys vs. 771 girls) saying they knew how to use them. Of the roughly one-in-four teens who had had sex, 6.7% (168 boys and 45 girls) had never used a condom, 7.0% (193 boys and 7 girls) had used a condom sometimes, 3.6% (108 boys and 7 girls) most times, and 3.9% (110 boys and 15 girls) always.

These findings have dire implications for HIV and other STD transmission. Only one in five students who had had sexual intercourse at least once had always used condoms. Three out of four were unprotected sometimes or all of the time. Moreover, it is not clear from the question whether the condom was used correctly or not, whether it was placed on the penis before any type of intromission, or whether it was placed on the penis just before ejaculation for purely contraceptive purposes. It is also not clear whether the condom was used for other sexual practices, such as anal and oral sex, which are also high-risk behaviors. These issues can be incorporated into any safe-sex and health education program.

Kinds and Duration of Relationships. The disparity between a much higher incidence of sexual intercourse for Cypriot males and a much lower incidence for females raises the question about who the females are that these young men are having sex with. Questions were asked regarding the age of the sexual partner, the duration of the relationship, and the demographic identity of sexual partners. Given the very high influx of tourists every year—for the past six or seven years, tourists have outnumbered the indigenous Cypriots—questions were asked that differentiated between the kinds of sexual partners Cypriot men and women have. Table 4 analyses the responses to these questions.

It appears that there are a large number of longstanding relationships with indigenous Cypriots. A total of 434 students (13.7%) said that they had a longstanding relationship with someone their own age. Of these, there were many more boys than girls (346 boys vs. 88 girls). A further 146 (4.6%) admitted to having sexual intercourse with a Cypriot partner their own age whom they had recently met. Again, the majority of these were males (126 males vs. 20 females).

Another category of partner preference that has implications for HIV transmission are the large number of students who had sexual intercourse with tourists their own age whom they had recently met. The overwhelming majority of these were boys (236 boys vs. 13 girls). Another equally potentially high-risk behavior was with tourists their own age whom they had known a while, even though it is not clear how long a term is indicated by “a while.” Of these, again the majority were males (181 males vs. 14 females). To the list of potentially high-risk partners could be added the students who had coitus with older tourists whom they had just met (120 males vs. 12 females), and the older tourists whom they had known for some time (77 males vs. 15 females). Further, potentially high-risk partners would include Cypriot prostitutes (212 males vs. 4 females) and foreign prostitutes (133 males vs. 7 females). It is not clear why there are a small number of females in the prostitute categories, as it is unlikely that they frequented a male prostitute. Perhaps they misinterpreted the question to mean that they themselves were paid for having sexual intercourse—there have been such known cases in Cyprus among the student population.

Cohabitation. In response to the question, “Have you ever lived with a man or a woman as a regular sexual partner without being married?” 148 (4.7%; 134 boys and 14 girls) said that they had cohabited with a sexual partner before marriage.

Teen Pregnancy. A total of 73 boys said that they had made their partners pregnant, and a further 11 girls admitted to being made pregnant by their boyfriends.

Age of Marriage. Table 5 summarizes the results of the question, “At what age would you like to marry?”

C. Adults

The following data were obtained from a clinical population of 840 clients of varying ages and educational backgrounds (see Section 12, Sexual Dysfunctions, Counseling, and Therapies, for details on sample and methodology).

Virginity

It is clear that far fewer males (9.4%) than females (69%) are virgins when they become engaged or marry. “Family honor” is at stake because of the prevailing belief that a nonvirgin or “soiled” bride should be considered a second-rate citizen in no way equal in social and ethical standing to a virgin bride. Indeed, many brides-to-be have been accused of not being a virgin by their fiancés on the first night. This often results in both families getting involved, taking the female by force to be examined by a gynecologist, and deciding whether the couple should stay together based upon the doctor’s diagnosis. Needless to say, such affairs are extremely degrading for the female involved. Even if the couple decides to stay together, there is no guarantee their relationship will stabilize and survive. In my clinical practice, I have encountered many cases of males who believe that virgin females should bleed like a chicken with it’s head chopped off! The males expect to see much blood on the sheets, and if this does not happen—which inevitably it does not—then the accusations will begin, and the horrid saga begins. (See also comments on premarital sex under Sociolegal Status of Males and Females, Children and Adults, in Section 1A.)

Nonvirgins before marriage who have slept with a partner before making a firm commitment to marriage will often visit a gynecologist and ask for a hymenorrhaphy or hymen-repair operation. This is one way of “fooling” the potential husband and avoid being ridiculed and belittled by the “expert” spouse who thinks that he has the ability to differentiate between a virgin and nonvirgin with his penis on the first night. My national live radio program at Radio Proto (1991 to 1992) and my advice column in the best-selling national magazine To Periodiko received many questions about hymen-repair operations. Gynecologists I spoke with admitted performing at least two or three such operations a week, for a total of thousands annually on the island.

Tables 6, 7, and 8 summarize some responses from the author’s clinical population of 840 adults. There appears to be quite a range in the frequency of sex, with a fairly even spread between the sexes (Table 8). About two thirds of the sample have sex more than twice weekly, with the remaining third less than once weekly. Remember that this is a clinical sample that has come for sex therapy for some sexual dysfunction or other, which inevitably adversely affects the frequency of lovemaking. This picture may not be so representative of the general Cypriot population. My guess is that, given our Mediterranean temperament, we Cypriots are generally more hot-blooded than this!

There is a clearly significant difference between the sexes regarding the number of sexual partners in their lifetime (see Table 9). Two thirds of the women tended to stick with only one partner mostly, compared to about 7% of males, while very few women have more than two to three partners compared to males (8% of females vs. 73% of males). Whether this reflects the difference between the sexes or the inhibitions and taboos that exist in the Cypriot culture is not clear; the editor’s guess is that the taboo placed upon female “promiscuity” by family and society is certainly a hindrance to moving from one partner to the other. Certainly, females that are likely to have multiple partners that are known in society will be labeled with very nasty names, such as “used,” “prostitute,” “ethically free,” and others. These females tend to have difficulties finding a marriage partner, particularly if their behavior is well known. Usually, when a marriage is about to take place, both sets of parents will begin conducting an informal “character” assessment by asking various individuals in the close community of the prenuptials for a character reference. If the girl has a “bad name” in this community, then this will be reported to the potential bridegroom’s parents who will strongly advise their son not to proceed, and will continue to stand as an obstacle until their son “sees sense”! These societal norms and taboos are enough for young girls not to consciously want to repeat one mistake twice or more.

About one third of males and one fifth of females had never experienced giving or receiving cunnilingus (see Table 10). A very small percentage of males tend to dislike giving cunnilingus (7%), whereas a much larger number of females dislike the act (21%), which could be for a variety of reasons. The most common reason cited by women in this sample was the partner’s inexperience, his ignorance about the clitoris, and his or her belief that the vagina is the most stimulating and sensitive of areas. Also cited were the inhibitions of females who feel that they are dirty “down there,” or that coitus is the only “acceptable” form of sex.

Not surprisingly, very few males do not enjoy being fellated—these being in the older age groups, which tend  to be a lot more conservative in their sexual behaviors. About a fifth of the women in this clinical sample did not like giving fellatio to their partners, again probably related to taboos and inhibitions rife within the Cypriot community. Over a third of the men and a quarter of the women had never experienced this sexual behavior, but again these tend to be in the older age groups above 50 years old in the lower working social classes. Certainly, one third of the women thoroughly enjoyed it, as did well over half of the men (see Table 11).

A majority of the men and women who reported experimenting with anal sex appear divided about equally between those who tried it once or twice and those who were a bit more persistent, trying it three to six times before deciding not to continue with this sexual outlet (see Table 12). A third of the women and 44% of the men who tried anal sex appear to have incorporated this outlet into their sex lifestyle on a perhaps more regular basis, despite the disapproval of this behavior by the Greek Orthodox Church and despite it generally being considered a “no-no” by most couples. Perhaps one of the reasons for its fairly widespread occurrence among both sexes is the availability and popularity of pornography. Additional questioning of this clinical population revealed that it is mostly the male who will “subtly coerce” his partner into trying it, mostly for the sake of experimentation, after viewing anal sex on a pornographic video. In many cases, the reaction of the wife will determine the frequency of anal sex thereafter.

Unfortunately, there has been no epidemiological study of the sexual behavior of Cypriots. This small clinical sample is the only data available at present and it is limited by focusing on details of sexual functioning among a group of people who at some point in their lives developed a sexual dysfunction. In my opinion, this does not necessarily mean that the sexual histories and behaviors of these particular people differ from those without sexual dysfunctions, as this sample of people were also likely “normal”—without dysfunction—at some point before they decided to seek sex therapy. Their dysfunctions did not exist all their lives. The ideal, of course, is to have a methodologically sound, longitudinal epidemiological study with a substantial random sample of subjects. The lack of funds at present has made this very difficult to impossible.

Divorce, Extramarital Sex, Single Mothers, and Domestic Violence

See comments under Sociolegal Status of Males and Females, Children and Adults, in Section 1A.

6. Homoerotic, Homosexual, and Bisexual Behaviors

A. Children and Adolescents

Previous Homoerotic or Homosexual Experiences

Many adolescents have some kind of sexual interaction with same-sex peers. This fairly common behavior, particularly among young adolescent males, might best be referred to as “homoerotic” rather than “homosexual.” Sorenson (1973) found that about 9% of young people in the United States had one or more sexuoerotic experiences with someone of their own sex between the ages of 13 to 19. The likelihood of homoerotic activities in adolescence is significantly greater among those who have had same-sex experiences prior to adolescence. Indeed, most adolescents have their first homoerotic experience with another adolescent.

In the Knowledge, Attitudes, Beliefs, and Practices (KABP) Survey (Georgiou & Veresies 1990, 1991), about 34% of the respondents reported having hugged someone of the same sex at least once. Of these students, the majority were girls (722 girls vs. 354 boys). A further 7.9% had kissed passionately and a further 5.3% had petted above the waist—of these the majority were males. Table 13 summarizes the frequency of various sexual activities with a same-sex partner.

The majority of students who reported experiencing same-sex anal intercourse were males (141 males vs. 9 females). It is not clear, however, how these 9 females could be involved in homosexual anal intercourse, unless it was taken to mean anal penetration by a homosexual boy or with a dildo, but the likelihood of this is probably very small. These results are probably because of a misunderstanding of the question, or ignorance regarding anal sex.

When asked, “With how many people of the same sex have you had oral or anal sex?” 88.7% reported never experiencing oral or anal sex with a same-sex partner. An additional 4.3% had attempted homosexual oral or anal sex with between one to two partners (119 males vs. 18 females), and 1.2% had with three to six partners.

It appears that the majority had their first homosexual experiences when they were between the ages of 13 to 16 (see Table 14). During these ages, 5.5% of the respondents reported having their first homosexual experience. There may be a latent period for homosexual experiences at the age of 12, but this cannot be confirmed by the data. It has been shown by Kinsey and his co-researchers that the age of puberty is related to the age of the initial sexual experiences, including homosexual ones. It is not clear from the data, however, when Cypriot boys reach puberty, even though it might be presumed that it is younger than 11 years old for some boys.

B. Adults

A Few Statistics

The author’s clinical sample of 840 patients cited earlier gives us some idea of homosexual and bisexual behavioral practices in a group of men and women seeking help with some sexual problem or dysfunction. A second bias in this data is the gender balance, with 597 males to 243 females.

The respondents were asked during history taking if they had ever been approached sexually by another person of the same sex. This opening question was chosen as much less threatening than asking whether the client had actual same-sex experiences. If the response was “yes,” then they were asked simply, “What happened?” Of the total number of responses, 12.4% of the sample admitted to some type of sexual contact to orgasm with a same-sex partner; 11.6% were male and 0.8% female.

In order to avoid polarizing the population into “homosexual versus heterosexual,” the following clinical data were collected using the seven-point rating scale of heterosexual-homosexual attraction/behavior devised by Alfred Kinsey (1953).

It seems clear from the data that the majority of people who admitted to some type of homosexual contact or experience were Kinsey 1 or 2 (13.1%), with very few, 1.7%, in Kinsey 5 and 6. This indicates the transitory experiences of these people with a same-sex partner. Indeed, all of the male experiences, with the exception of 18 cases discussed below, were age 18 to 20, the age when all Cypriot males are required to do their National Guard training as a soldier in an army camp for 26 months. It was during this period in the National Guard that most of these experiences occurred. Most of these young soldiers would be “picked up” by homosexuals “cruising” the scene and taken to their army camp. The deal would be struck in the car, and most of the time they were offered a small sum of money ranging from ten to 15 dollars (US) in exchange for “services,” which meant the homosexual fellating the soldier, or the soldier penetrating the homosexual anally, but not the reverse. With most soldiers, this activity was a one-time experience; with a few, it was repeated two or three times.

The five exceptions that had not had these types of army experiences had encountered homosexuals while studying abroad, and they behaved in a similar fashion to what has been mentioned above. The other 18 males had a specifically homosexual orientation, and their homosexual experiences were more varied and more frequent. These homosexuals had voluntarily entered same-gender relationships, and their interest in opposite-sex partners was very limited. The women were mostly patients who had come to specifically discuss their sexual orientation, and they were involved with a single partner with whom they had fallen in love. All were married at the time.

Homosexual Life in Cyprus

ALECOS MODINOS*

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*Note: The following perspective on homosexuality in Cyprus was provided by Alecos Modinos, B.Arch., A.R.I.B.A., president of the Gay Liberation Movement of Cyprus, and a chartered architect.

For centuries, this island, which is now an independent country only 100 miles (160 km) from the coast of Lebanon, was a model of social and familial conservatism. Family ties were close, the patriarchal concept was entrenched, and strict social mores were enforced by both Church and tradition. The pattern of life, while not unduly exciting, was extremely stable nevertheless.

Abruptly, in just a few short weeks 25 years ago, the pattern of centuries was destroyed when Turkey invaded and occupied almost 40% of the country. A great percentage of the population lost their homes and jobs, and fled to the southern half of the country before the advancing armies. Thousands were killed or injured and another 200,000 became refugees.

In those short weeks, the entire social fabric of Cyprus was destabilized. Family ties were abruptly loosened or disappeared altogether in the chaos that followed, and even now, 25 years later, there are still over 1,600 missing persons as a result of the invasion. In a small island-state of less than 700,000 people, the effects of the invasion and continuing occupation were profound.

In May 1989, the following headline appeared on the front cover of a popular national magazine and in daily newspapers: “Homosexual Accuses Cyprus to the Council of Europe for Violation of His Human Rights.” The article clearly demonstrated how many journalists were not only prejudiced, but knew very little about the subject. Cyprus is one of the few member countries of the Council of Europe that until very recently had not abolished its anti-homosexual laws. The existing criminal law, CAP 154, articles 171-174, considers homosexual acts a criminal offense punishable by 5 to 14 years’ imprisonment. This law was influenced by the British Colonial occupation of the island between 1878 and 1960, and was incorporated in our legislation in 1929 in accordance with the British “Criminal Law Amended Act of 1885,” a good reflection of the Victorian period! In Britain, the 1885 anti-gay law was abolished with the “Sexual Offenses Acts of 1967,” but this had no effect in Cyprus, which by then was an independent state. Cyprus thus was left with an outdated colonial law that Britain had abolished 32 years ago. Homosexuality between women is not a criminal offense, but is completely ignored by the law as if it does not exist at all.

The first discussion on homosexuality was organized by the Pancyprian Mental Health Association in the fall of 1979. In the spring of 1982, a two-day seminar was organized by the same association on the same subject. About 500 persons attended; the great majority were women, and the absence of men was obvious! As a result of the second seminar, five gay men began working together. Five years later, after many difficult and laborious efforts, 16 gay men and a lesbian founded the Gay Liberation Movement of Cyprus on December 10, 1987. As of January 2000, less than half-a-dozen persons have come out of their closet, while the remaining hundreds of gay men and women members of the Gay Liberation Movement still remain in the closet for fear of reprisals.

From 1989 onwards, with great caution, two radio stations arranged live interviews with a gay man who answered questions from listeners calling in. Between 1991 and 1992, in a regular weekly radio program titled Human Sexuality presented by the main author of this chapter, homosexuality was included as a topic on three separate occasions. After this initial exposure on live radio, homosexuality was more openly discussed on a few other private radio and television stations.

On December 6, 1990, the European Commission decided unanimously, with 15 Commissioners, in the case Modinos vs. Cyprus, that Cyprus was violating the human rights of homosexual people. The case went to the European Court, as the Government was reluctant to reform the law. Following a hearing on October 26, 1992, the European Court decided eight to one on April 23, 1993, that Cyprus was violating the human rights of homosexual persons, and ruled that the antiquated anti-homosexual law of 1885 must be abolished. The sole dissenting vote was cast by the judge from Cyprus.

The Greek Orthodox Church bitterly opposed this law reform and was supported by the majority of the members of Parliament. However, after a lot of pressure from the European Council of Ministers over a period of five years, a week before the third ultimatum given to the Government was to expire, the Cypriot Parliament very reluctantly reformed the law in May 1998.

The new law, made to the satisfaction of the Church and the majority of the opposing Members of Parliament, was found unacceptable by Amnesty International, the human rights organizations of the island, practically all the Pancyprian scientific organizations including the Family Planning Organization, the Gay Liberation Movement, and, on September 17, 1998, by the European Commission. The amended law, which the Cypriot government submitted in early 1999 to the European Council of Ministers, was rejected because it was full of discriminations. The Cypriot government planned to rewrite the law and submit it again in 2000.

The Cyprus government was obliged to revise the 1999 law in May 2000 because of the discriminations that were not accepted by the European Council of Ministers. During the voting procedure in Cyprus, 27 of the 40 Cypriot Members of Parliament walked out, and as the Cypriot media wrote, “it was not for purposes of micturation [urination]!” Of the remaining 13, two were against the law with the remaining 11 passing the amended law. The main points in the amended law included:

Homosexuality is still a subject very few Cypriots talk about, despite the great publicity through the media since 1989. Cypriots in general are sympathetic and sensitive people who oppose any violations to human rights. There is, therefore, no organized movement against homosexual persons at present. General attitudes toward gays are slowly changing in a positive way because of the European Court’s decision and the great publicity given by the media to the gay law reform. However, parents are very unhappy and bitterly disappointed if they have a lesbian daughter or a gay son. Given the slow progress toward liberalization, there still exists a lot of prejudice and discrimination from all walks of life against lesbians and gay men, and this is why the vast majority still remain in the closet.

Besides the clinical data gathered by the main author, there are some anecdotal data regarding homosexual behavior gathered from members who attended the weekly meetings of the Gay Liberation Movement, but this is not in a presentable format that would make any scientific sense. There is clearly a need for further research on this important topic of human sexuality, but the lack of funding makes this difficult.

The difficulties that homosexual and lesbian Cypriots encounter stem from the great social stigma associated with the limits on open homosexuality in the small Cypriot society, the legal system, which still considers gays criminals, and the powerful Orthodox Church, which considers homosexual relationships “the gravest of sins.”

Most Cypriot homosexuals conceal their identity behind the curtain of wedlock; it is estimated that about 80% of homosexual males are married with families. Marriage makes them feel accepted and secure in a patriarchal, very family-oriented society. Homosexual activities outside marriage are usually conducted with other married homosexuals, or indeed, married “heterosexuals” who are willing to “service” the gay partner with anal penetration without this being reciprocated. Other willing partners include tourists who frequent the island; there is a huge choice, given that Cyprus welcomes about 1.5 million tourists annually!

Because Cyprus did not have its own university until recently, a record number of young Cypriots study abroad. Away from home, they are free to join gay groups, become gay activists, take part in gay parades, and thoroughly enjoy a very active gay life, including one-night stands—a way of life forbidden to them at home. Some even develop long-term relationships. After finishing their studies, many settle down abroad. Those who return home have the same predicament that practically all gay people have in Cyprus. Very few of them remain free at home and travel abroad for holidays and business trips; the great majority will get married, have children, and lead a double life.

There are no organized gay bars or clubs on the island. However, there are a couple of bars/pubs in the main towns, usually owned by gay persons, that are known meeting places with a mixed clientele. Beaches, parks, and “cottages” in the main towns are listed in all European gay guides, but are best avoided because many people frequenting these places, especially during the summer months, land in trouble with plainclothes young policemen acting as “provocateurs.” Cyprus’s many exercise gymnasiums are another popular meeting place. Good cinemas and theatrical productions, recitals and concerts, as well as ballet performances from visiting companies, attract a number of gay men. Often, they socialize with other gay friends over coffee, sometimes for dinner, and most of the time with mixed groups of friends without anybody knowing, perhaps not even suspecting, they are gay.

The great majority of adult gay men and women who remain single and tire of one-night stands want to eventually settle down in a permanent relationship. Such relationships are much easier to achieve between women than men and are, thus, more numerous. The majority of adult lesbians have a lasting relationship. Cypriot men grow up to be strong and to conceal their emotions, and they find it very difficult to be tender and loving toward another man. The Gay Liberation Movement and specialists trained abroad, enlightened with the latest scientific discoveries concerning human sexuality, have assisted many gay persons who seek counseling, with the result that we now have over 30 male couples who have been living together for six to ten years in the main towns. Very few of these couples have talked this over with their family. For the great majority, there is unspoken understanding and silent acceptance, a practice terribly common between all who have a gay son or a lesbian in their families.

Lesbians are discriminated against both as women and as lesbians. Practically all get married and have children; very few of them will dare or manage to have a special friendship with another woman. In the past, they were active members of feminist organizations or women’s groups, without letting anybody know of their homosexual inclinations. Unavoidably, special friendships were formed and, as a result, suspicion and prejudice made all such women’s groups slowly disappear. Some lesbian couples in the main towns live together, but most live with their families or in separate flats, even though they have been together for several years. This provides them with good cover for family, friends, and colleagues alike.

The younger generation of lesbians today are somewhat more rebellious and daring. They refuse to get married, even to socialize with other young men as a cover-up, especially if they are economically independent. They usually live on their own, not with their families. They socialize with small groups of five or six other lesbians of the same age on the look-out for a partner. They usually form relationships lasting only a few months. Sometimes, they may meet the right person and settle down to a more permanent relationship, but many of these will have relationships on the side for quite a while before making a final commitment to one person.

Single lesbians, especially those who have given up hope of finding a permanent friend, avoid the company of straight men and often meet and socialize with gay young men who share the same interests. The necessity to socialize with the opposite sex brought many homosexual men and women together, thanks to the Gay Liberation Movement, which helped to disperse the myths and stop the prejudices that existed between them.

Recently, although they still dare not come out in the open, the women of very wealthy families who have studied abroad live their lives and form friendships with other women. They ignore the drawing-room gossip about them, much as that hurts and makes them and their families miserable. They often put up a fight with their own families, who may accept their sexual orientation, but they are concerned about what the other people say.

Practically all Cypriot gay men take holidays abroad, even those who can hardly afford it. They travel alone or with friends. They are out to enjoy themselves and have as many sexual relationships as possible, trying to make up for that which is forbidden for them at home. Greece is very popular, with the gay bars of Athens, the saunas, and the gay beaches of Myconos and other Aegean islands coming first. Amsterdam, Paris, London, and other European cities are always resorts for those who can afford them.

Homosexual men are not accepted or retained in the army if their homosexuality is discovered. Except for half a dozen or so cases, all members of the Gay Liberation Movement have served their national service and have excelled in the posts they were assigned by their officers.

Apart from occasional parties at Christmas and special occasions, where about 50 gay men and some lesbians are invited, there are few gay private parties. The first one was in December 1990 to celebrate the unanimous decision of the European Committee, when the 15 Commissioners condemned Cyprus for violating the human rights of homosexual people. The second took place in April 1993 to celebrate the European Court’s decision against the Government for the same reason, and since then, two more to raise money for people with AIDS. About 350 gays attended these huge parties that were considered a great success by all who attended.

Cyprus is a divided country, proud to be a member of the Council of Europe and trying hard to become a member of the European Union. To achieve this, a first necessary step is the equality of all citizens in the eyes of the law. But this is a minimum demand. What must be achieved is true equality in the minds of all people in everyday life. To achieve this, we still have a long way to go!

In the main author’s 1990 survey of Greek Orthodox priests (mentioned in Section 1/2B, Religious Beliefs Affecting Sexuality), the priests were asked for their pastoral response to a second situation involving an 18-year-old boy who is having a sexual relationship with another boy, and finding it rewarding and fulfilling. He has heard from someone that it is wrong, and approaches a priest for guidance and advice. The responses chosen by the 130 priests responding to the questionnaire were:

The subjective responses given by the 27 priests interviewed face-to-face were analyzed using a thematic analysis consisting of 16 general categories, some of which are included below:

The face-to-face interviews elicited more attitudes from the Cypriot priests that were similar to the survey responses cited above. There was a belief that all homosexuals are really promiscuous heterosexuals who choose same-sex partners for fun, as their passions have overrun them, and that this was definitely the work of the devil. The focus appears to be on the homosexual act, as opposed to the homosexual person. This was further reinforced by the belief that the homosexual person was seen to be the person who accepts being penetrated. This “true” homosexual was referred to by many of the priests interviewed as the passive partner, whereas the active penetrative partner was not seen as being homosexual by many priests. This appears to be congruent with St. Chrysostomos’s belief of gender expectations, or men behaving inappropriately like women.

7. Gender Diversity and Transgender Issues

There is no information available on this topic. There are certainly a few transsexuals and transvestites living on the island, as they appeared in media interviews seven or eight years ago, but little is really known about their situation. The main author has also seen a couple of transvestites and one transsexual in clinical practice, mostly seeking advice regarding sex-change procedures and relationship problems.

8. Significant Unconventional Sexual Behaviors

NATHANIEL PAPAGEORGIOU*

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*Note: The editor is grateful to Nathaniel Papageorgiou, Chief Superintendent in the Criminal Investigation Department (CID) of the Ministry of Justice and Public Order, for providing parts of this section on sexual crimes.

A. Coercive Sex

Sexual Abuse of Children and Incest

Because Cyprus is a close-knit community, it is difficult to conceal sexual abuse and incest with children. The police statistics cover only a minor portion of what happens within families. For example, there has only been one case of incest reported between 1995 and 1997. In the same period, 15 cases of sexual assault on a minor between ages 13 and 16 years old were reported, with 5 cases of assault on a minor younger than 13 years of age. From a sample of 840 patient interviews (see Section 12, Sexual Dysfunctions, Counseling, and Therapies, for details), 3.6% or 29 females and one male reported sexual encounters with relatives. These encounters were with a cousin (1.8%), uncle or grandfather (1.3%), father (0.4%), and brother (0.1%). This rather small sample of the general population indicates that the problem of incest is far larger than what is reflected in police statistics. It seems reasonable to assume that most such cases are “hushed-up” by the families and by the authorities to avoid shame for the family and having to face all the consequences thereafter. If such incestuous practices were known, the family would be stigmatized, and the chances of the female victim finding an appropriate partner for life would be severely affected.

Rape and Marital Rape

Of the 25 cases of rape reported to the police between 1995 and 1997, all involved tourist women visiting the island. Some of the rapes were perpetrated by Cypriot males “on-the prowl,” while many others have been by foreigners living on or visiting the island. Most of the female victims were from Scandinavian countries, with a few from Europe. There is no doubt that there have been more such cases that were not reported for various reasons.

Perhaps the most common sexual assault is that perpetrated by husbands on their wives. The author has encounter many such cases, including sexual coercion and abuse. If these cases are reported to the police, they are usually covered up and do not go to the courts for fear of shaming the family and destroying its honor. Many times, the police and family members persuade the wife to keep this within the family and not to press charges. Even cases that are reported are often “struck-off” the record after intervention by family members concerned about the probable effect on family ties and honor. (See comments at the end of Sociolegal Status of Males and Females, Children and Adults, in Section 1A.)

Sexual Harassment

Sexual harassment is perhaps the most commonly occurring crime in the workplace and by Cypriot men harassing tourist women. Sexual harassment in the workplace has been a frequent topic of discussion by the local media, as this was a way of life here in Cyprus. In the workplace, it involves male supervisors using their position and power against women, or women who want to improve their work status or to obtain a promotion. This type of behavior still occurs, but not on the scale that it was once practiced.

A study involving sexual harassment was conducted in 1997 by the Research and Development Center of Intercollege, a large private college in Cyprus, using 1,500 questionnaires that were distributed anonymously to both men and women. About 85% of the sample felt that sexual harassment was a serious social problem in Cyprus. About 40% of the sample actually knew first-hand of people who had been victims of sexual harassment; most of these took place in nightclubs (cabarets) with strippers (96%), with foreign home workers (73%), in hotels (64%), in factories (38%), in shops and offices (28%), and at schools and colleges (17%).

B. Prostitution

There has not been any systematic study conducted on the rather large population of prostitutes in Cyprus. Apart from the local indigenous prostitutes, there is a growing group of foreign artists who have been specially imported by cabaret and nightclub owners for “entertainment” in their clubs. These girls, from the Philippines, Russia, Bulgaria, and India, are given work-permits and visas by the Cypriot government to work as dancers in these clubs. It is estimated that there are over 1,000 foreign girls working on the island, plus an unknown number of Cypriot women. The latter are probably dwindling because of the growing number of foreign imports who are favored by the Cypriot males who frequent such clubs. These foreign girls are not officially registered to work as prostitutes, but it is often recognized by the authorities that this happens. These girls are monitored for sexually transmitted diseases on a regular basis by the authorities.

In the last few years, there have been cases where the owners of these clubs have been convicted of coercing these women to have sex with customers against their will. These cases are usually reported because of some dispute over pay for services rendered between the women and their boss. Most of these cabarets are frequented by Cypriot businessmen in groups who are out for a laugh and a bit of fun with their friends; most are married.

C. Pornography and Erotica

Pornography and all types of erotica are freely available in Cyprus to those who want it. Before the ban on video piracy which the government implemented about two years ago, there were literally hundreds of video shops where anyone of reasonable age could go and ask for a porno tape “behind-the-counter.” These tapes cover the whole gamut of sexual behavior, from straight heterosexual sex, to anal and oral sex, homosexuality, bestiality, sadomasochism, fisting, and all the other sexual behaviors in between. Cypriots can rent their usual thrillers or soap movies on a regular basis, and while in the video shop, pick up a porno movie to watch while the children are in bed. Many of these tapes were subsequently copied and are still circulating in many households in Cyprus, often entertaining the children as well, who happen to find their hidden location while the parents are at work.

There were large groups of Cypriots who, out of sheer curiosity and fascination, were requesting harder and harder varieties of porn that consisted of acrotomophilia, anaclitism, anolingus, bestiality, bondage, coprophilia, fisting, klismaphilia, and much more. This surfaced about 12 years ago when the author had the opportunity to interview one of the main suppliers of pornographic material on the island. He mentioned that the more “perverse” or “deviant” the sex he could obtain on video, the greater his business!

D. Sexual Crimes

[Update 2003: To the police and the public, sexual assaults, and especially sexual assaults against young children, are a major social concern. In Cyprus, sex crimes are not reported frequently. This is because of the conservativeness and closeness of the society in Cyprus. It is believed that the police statistics cover only a minor portion of sex crimes, especially of crimes that are committed in the family, for example crimes of incest and of partner violence.

[Even though changes in the social structure are taking place in Cyprus, it is still considered a shame to a family that experiences a rape case. Many families decide to either “hide” this crime, or to take no legal action, and bring the offender to justice, in order to avoid publicity of the case, and therefore shame. Because of the close-knit community in Cyprus, many people always avoid the possibility of getting stigmatized. This is the case especially for rape cases where the honor of the family is at stake. Therefore, it is assumed that the phenomenon of sex crimes might be larger than what the statistics show.

[There seems to be an increase in the rape rates since 1997. To be more specific, in 2001, 18 cases were reported involving rape cases, compared to 10 that were reported in 1997. In the year 2000, there were 12 rape cases reported and in the year 2001, 18. Out of these 30 cases, only 2 were committed by the partner of the victim.

[The majority of the other types of sex crimes showed a decrease since 1997. Comparing the statistical information of 1997 to the statistical information of the year 2001, there was a decrease in the following categories of sex crimes:

• Seduction of a female under the age of 16
• Procuring
• Indecent assault against a female
• Indecent offense

It should be noted that these types of sex crimes all showed a major decrease in the past four years.

[No cases were reported to the police for the following sex-crime categories in the year 2001:

• Seduction of a female between the ages of 13-16
• Pimping
• Solicitation

[The categories that showed relevant increases and decreases between the years 1997 and 2001 were, indecent offense and indecent offense exposure. These two categories have some commonalities between them. The category of indecent offense was the most prevalent of the others throughout the years 1997-2001. For example, in 1997, there were 101 cases of sex crimes reported, 24 of which were indecent offenses. Again, for the year 2001, there were 80 cases of sex crimes reported, 31 of which were indecent offenses. It should be noted that there has been an overall decrease in the cases concerning sex crimes by 20.8% (21 cases) between the year 1997 and 2001.

[Sex-crime cases where the perpetrator is a member of the family or the partner of the victim are rarely reported. For example, in the year 1997, there were only 8 such cases reported, and all of them were indecent assault against a female, while in the year 2001, there was only one case reported where a member of the victim’s family was the perpetrator, and this was a rape case. This shows how the family in Cyprus in the 21st century is still afraid to bring a case of such nature in the court of law, or even report it to the police. This emphasizes how the “honor in the family” cliché discourages victims in Cyprus from reporting incest cases, or even rape cases to police, and thus not bringing the perpetrators before justice.

[Even though Cyprus is a small country, and it is not expected to have large numbers of sexual crimes, we believe that there is a dark figure to this category of crimes. In fact, until quite recently, the number of sexual crimes committed each year was negligible (see Table 15). (End of update by G. J. Georgiou and L. Papantoniou)]

9. Contraception, Abortion, and Population Planning

FAMILY PLANNING ASSOCIATION OF CYPRUS*

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*Note: The editor is grateful for information supplied for this section by the staff at the Family Planning Association of Cyprus.

[Update 2003: Mission: The Cyprus Family Planning Association promotes the development of a society where all people can enjoy the basic human right to make free and informed choices in their sexual, emotional, and reproductive lives:

[Aims:

“Youth Center”: The activities will be carried out in all parts of Cyprus where youth can potentially be reached.

[Summary: The “Youth Center” project aims towards the provision of counseling, informational, and educational services, in the field of Sexual and Reproductive Health, to youth living in Cyprus. In-person counseling will be provided and, at the same time, a hotline will be established so that young people can have access to the psychological support they might need. Young volunteers, members of the “Youth for Youth” group, will receive comprehensive training in order to become able to run the center. Furthermore, youth will be able to obtain information regarding issues in S&R Health through a website. Concurrently, a massive distribution of relevant informational material will take place throughout the project.

[Objectives: The Cyprus Family Planning Association has assumed a leading role in the provision of services in the field of Sexual and Reproductive Health over the past three decades. Issues such as unwanted pregnancy, teen pregnancy, sexually transmitted infections, and abortion have surfaced as major social problems, especially among youth, in the past few years in Cyprus. Unfortunately, the increasing magnitude of these problems has not yet been measured scientifically. Expert observations, however, allow for great concern.

[Based on its ongoing effort to target young people, educate them, and provide them with psychological support and information in regards to Sexual and Reproductive Health, the CFPA strongly believes that the creation of a program such as the “Youth Center” will establish a more direct contact, strengthening its existing relationship with youth so that the above services are provided in the most effective way possible. Furthermore, sex education is not currently fully provided by the educational system in Cyprus. The Youth Center project aims to attempt to fill this gap through peer education, a tested and rewarding method of approaching youth. Young men and women, who live in rural areas, do not have easy access to free family planning services. Also, young people who live in tourist areas are more prone to exhibit risky sexual behavior, and therefore may become more exposed to sexually transmitted infections. CFPA will try to approach these youth and provide them with the services, the information, and the attitude needed to sustain a healthy sexuality.

[Aim of the Project: The main goal of the “Youth Center” project is to satisfy the unmet needs of young men and women throughout Cyprus with regards to their Sexual and Reproductive Health. (End of update by G. J. Georgiou and L. Papantoniou)]

A. Contraception

In the main author’s clinical sample, 33% reported using the condom and 21% used coitus interruptus. The IUD ranked third at 7.3%, followed by 6.7% for the contraceptive pill. Very few Cypriot women use the diaphragm, cervical cap, or contraceptive foam—only 0.1% for each. Cypriot women tend to have concerns about placing objects in their vagina, not necessarily because they may injure themselves, but because there is a repulsion to placing items in the vagina. This seems to be a cultural attitude reported in the sexual histories taken by the author. “Touching” the vulva seems to be out-of-bounds for most Cypriot women, and this is reflected in the relatively low frequency of women who masturbate. The IUD is slightly more acceptable because this is placed by the gynecologist and does not entail self-insertion. One in five survey subjects reported using no contraceptive, and 3.8% reported sterility. (See Section 5B, Interpersonal Heterosexual Behaviors, Adolescents.)

In the 1990 survey of priests conducted by the main author, the priests were presented with a case for pastoral counseling involving:

a Christian couple with five children. The husband is 35 years old and the wife 30. Only the husband is working and earning a small income, which provides the essentials for the family. Under the circumstances, the couple has decided to use artificial contraceptives (that do not allow fertilization to take place), and go to a priest to discuss the matter. (Georgiou 1990)

The priests responded as follows:

Older (over 65) and less-educated priests (junior school with additional training in the Theological School of the Cypriot Archbishopric) tended to be more against the use of contraception than the younger, more-educated priests (p = 0.0002).

The thematic analysis of the subjective responses included 17 mutually exclusive general categories, some of which are presented below:

B. Abortion

Perhaps the fact that over half of the main author’s sample do not use adequate contraception should lead us to the conclusion that many Cypriots have abortions or have numerous children. The latter is not the case, and epidemiological statistics for abortion are unavailable. Using the same clinical sample of 840 patients (see Section 12, Sexual Dysfunctions, Counseling, and Therapies), 21.5% said they had had an abortion. Examining the statistics from an unpublished Cyprus Family Planning Association study, 20% of the total sample of 496 women reported having at least one abortion during the years 1995 to 1997, with 19% having at least one from 1985 to 1987. Interestingly, in the 1980s, 25% of these women were single, 18% were engaged, and 19% were married, whereas in the 1990s, only 3% were single, with more married women (27%) having abortions than before. It is certainly difficult to be certain about precise figures, but a figure of approximately 20% of the female population during any one year would be a fair estimate of the incidence of abortion. In the same study, about 7% of women had two abortions between the years 1995 to 1997, compared to 11% of women who had two between 1985 and 1987. (See also Section 1A, Sociolegal Status of Males and Females, Children and Adults.)

It is known that there are about 10,000 births per year, and it has been estimated that there are probably 12,000 to 13,000 abortions yearly. It appears that many Cypriots use abortion as a method of contraception after all else fails. The majority of gynecologists on the island will freely give abortion upon demand, because of a loop-hole in the law amended after the 1974 invasion of Cyprus by the Turks, allowing abortions for women who had been raped by Turkish troops or based on medical grounds with the permission of two medical doctors. This law still exists and allows gynecologists to practice abortion upon demand. There are only two gynecologists on the island whom the author knows that do not perform abortions for ethical and religious reasons.

In the main author’s 1990 survey, Greek Orthodox priests were presented with the following situation involving abortion:

A Christian woman is pregnant with her fourth child, even though her doctor warned her not to have another child as she would be endangering her health. Presently three doctors have told her that if she continues the pregnancy there is a chance that she would die. She has been advised, therefore, to have an abortion. As she is a woman who believes in God, she approaches a priest for advice. (Georgiou 1990)

The responses selected by the priests were as follows:

An additional 3.1% of the total sample of 130 priests avoided the question.

A thematic analysis of the subjective and “something else” responses produced 14 mutually exclusive general categories, some of which are examined below:

C. Population Programs

The total population of Cyprus was estimated at 746,100 at the end of 1997, compared with 741,000 in 1996, having increased by 0.7%. In 1997, the number of births in the Government-controlled areas (the Greek Cypriot side) declined from 9,638 in 1996 to 9,275 in 1997, giving a crude birthrate of 14.2 per 1,000 in 1997 compared to 14.9 in 1996. Both the number of births and the crude birthrate have followed a declining trend in recent years. The total fertility rate (TFR), which describes reproductive behavior unaffected by changes in the age of the population, is 2.3, slightly above replacement level but declining.

Cyprus has one of the lowest rates of extramarital births in Europe, and fertility is almost exclusively marital fertility. In 1997, only 146 children were born out of wedlock constituting a mere 1.6% of the total number of births. The mean age of women at the birth of their first child was 25.8 years old, while the mean age at birth irrespective of the older child was 28 years old in 1997. Women in rural areas tend to start younger, compared to urban areas: 24.8 years and 26.3 years, respectively.

At the Special Session of the United Nations on Population and Development in New York, June 30 to July 2, 1999, the Cyprus Delegation reported that:

Cyprus is undergoing demographic changes worth mentioning. Fertility is falling below replacement level and shows no sign of recovery. Concurrently, mortality is on the decline and currently is at 7.9 deaths per 1000 population. Also, infant mortality is 8.0 per 1000 live births, while maternal mortality is practically zero. Moreover, life expectancy is 75 years for males and 80 years for females. These are indications that Cyprus is going through a period of nearly stagnant population growth, 1.0% per year in the last five years, a phenomenon of population aging. Although, aging does not mean an old population, still my Government is worried about the problems that come in its way and in particular the social and economic implications.

Indeed, the government certainly wants to increase the declining population of 600,000 Cypriots on the island, and is giving incentives to this effect. All parents who have four or more children, so-called “multi-sibling” families, receive monetary and social incentives. For example, each child is entitled to a child benefit allowance of about $60.00 per child per month, and mothers receive a “mother’s allowance.” Also, all health expenses are paid by the government, as well as subsidies on school fees, books, entrance to museums, theatres, low-interest loans for building or repair of existing home, reduction in months spent doing National Service, tax incentives, and others. There is even discussion in Parliament at present to offer a duty-free car of choice, which is a huge incentive for most families, as car duties can exceed 100% of the value of the car.

In Cyprus, reproductive health is integrated into the primary health care system, and is provided free of charge by public sector institutions and at affordable rates by the private sector. The total expenditure dedicated to health purposes, from all sources, is on the order of 6% of GDP, or 16% of all public expenditure. This compares very favorably with most developed countries.
            In Cyprus family planning issues are entrusted to specialist doctors in the private sector, but more so to an NGO subsidized mainly by Government. The services provided are not confined within the narrow meaning of population control but also include access to information relating to sexual and reproductive rights, sexual education, including health issues, reproductive choice and gender equality; it also provides counseling on sexual relations and more recently on the prevention of HIV/AIDS. (United Nations Cyprus Delegation, June 30-July 2, 1999)

Some information regarding the work of the Cyprus Family Planning Association (CFPA) is provided in a recent unpublished study. The data were obtained retrospectively by examining 495 patient records of visits to the CFPA between 1985 and 1997. Most of the women visiting the CFPA were married between the ages of 21 and 41. The most commonly requested services were for birth control and cytology tests. The four major services that women requested were Pap tests, IUD insertions, breast examinations, and prescriptions for the contraceptive pill.

10. Sexually Transmitted Diseases and HIV/AIDS

A. Sexually Transmitted Diseases

There are no systematic surveys that have been conducted regarding sexually transmitted diseases, as most of the population with STDs saw private practitioners who do not need to report these statistics. There are, however, some official statistics, which are based mainly on the monthly returns from the dermatology clinics of the four Government general hospitals. Although rare, certain cases may be reported by gynecologists, urologists, and possibly general practitioners in the private sector. The diseases recorded are those that are considered notifiable and reported to the World Health Organization (see Table 16). The sharp increase in AIDS cases in 1997 is because of the adoption of a new case definition by the United States Centers for Disease Control in 1993. A workshop on epidemic preparedness was held in November 1999, during which the list of notifiable diseases was revised to include other STDs such as chlamydia.

From the KABP Survey on AIDS of 3,176 schoolchildren examining their knowledge, attitudes, beliefs, and practices related to AIDS, there were a few questions regarding STDs that would be worthy of note (Georgiou & Veresies 1990, 1991).

Twelve questions were designed to tap respondents’ knowledge about syphilis, gonorrhea, chlamydia, and genital herpes:

Overall, it appears that Cypriot school adolescents are relatively ignorant regarding STDs compared to their American, Canadian, and English counterparts. This relative ignorance, probably related to the fact that there is no formal sex or health education in schools, needs to be addressed.

Asked more specific questions regarding STDs, the great majority of students were “uncertain.” Overall, it appears that less than 20 to 25% of the students have correct knowledge regarding ways of transmission, therapy, prevention, and asymptomatic status of STDs. Perhaps the most striking finding is the fact that only about 25% of the students were aware that condoms can protect against gonorrhea. The overwhelming majority (63.1%) were uncertain about the prophylactic use of condoms. There was also high uncertainty regarding syphilis transmission from an asymptomatic person (57.8%), and whether a person who has caught syphilis once can catch it again (64.3% uncertain, with 15% incorrect). It is clear that these issues need to be urgently addressed in any program on human sexuality.

B. HIV/AIDS

LAURA PAPANTONIOU

[Update 2003: Note: The following data for HIV/AIDS was abstracted by the Editor from the Ministry of Health, National AIDS Programme (NAP) December 2002 report prepared and provided to the Editor by Laura Papantoniou, M.D., National AIDS Programme Manager. Elements of Dr. Papantoniou’s summary in the 2001 volume 4 of this Encyclopedia have been incorporated into this summary.

[Dimensions of the Epidemic

[Our current knowledge of the HIV/AIDS epidemic in Cyprus is based on epidemiological surveillance, which covers the period between the first reported AIDS case in 1986 and the end of December 2002. From 1986 on, this surveillance has included both cases of AIDS and cases of asymptomatic HIV infection. There has been an upward trend in the number of new cases of HIV infection diagnosed in each year until 1994, followed by a slight decrease until 1998. A small increase observed between 1999 and 2002 was mainly because of cases among foreign people and cases of clinical AIDS among repatriated Cypriots, who returned to Cyprus to continue their treatment that had been initiated abroad and was interrupted, mainly because of interruption of the supply of free drugs.

[Mean age at diagnosis is rather advanced in Cyprus compared to most other countries, being 34.2 years. A proportion of 73.5% of seropositives were aged between 20 and 40 years at the time of diagnosis, and this is in concordance with the fact that the main mode of transmission is sexual intercourse.

[Monthly epidemiological reporting is based on data collected from the sources shown in Table 17. Table 18 shows the numbers of new cases of HIV infection by year. Since the beginning of the surveillance in 1986, 140 seropositives were AIDS patients at the moment of diagnosis or subsequently developed AIDS. Of those people, 52 subsequently died of AIDS.

[Preparing Phase Two Response

[When the strategic plan covering the period 1995-1999 ended, a workshop took place in October 2001 to prepare the next five-year plan, under the guidance of a WHO expert. The Phase Two plan, in its initial stage, is being designed to address the main groups that were identified by the workshop participants as being at risk for HIV infection: drug abusers, youth, and men who have sex with men.

[The evaluation and follow up of the 1995-1999 Programme was based on systematic epidemiological surveillance and on sentinel surveillance in selected populations. Behavioral studies have been initiated among selected sections of the population. A Study on the Knowledge, Attitudes and Behaviour Regarding AIDS, Sex and Sexually Transmitted Diseases, Among the Adult Population of the Limassol Town and Rural Areas was carried out in 2001. Preliminary results from this study are described below. Further statistical and sociological analysis of the results is planned. This is considered to be a pilot study that will serve for the carrying out of a nationwide study that will cover the remaining areas of the government-controlled part of Cyprus.

[Despite the low HIV prevalence in Cyprus at present, the potential for increase in the number of new cases is visible, particularly among persons with risky sexual behavior and among people who are making use of illegal drugs. The study was undertaken in order to obtain quantifiable data on the individual and public risk in Cyprus of becoming infected with HIV and other sexually transmitted diseases and on various ethical an social aspects related to HIV infection.

[This study is of the cluster type, based on WHO methodologies, regarding the sampling of communities and of individuals within these communities. The sampling frame used was the list of cumulative totals of the population of the communities included in the 1992 census, which at the time was the most recent census that has been conducted. The sample selected consisted of 505 individuals—243 men and 262 women.

[Eligible for participation were Cypriots and other permanent residents (over 3 months in Limassol District) aged 18 to 50 years. Foreign workers on contract, foreign students, and Cypriots who live permanently abroad were excluded but are eligible for a different study design that will probably be planned in the future.

[Out of 767 households visited, 601 households were eligible for participation to the study. There were 96 refusals and 505 participations, giving a participation rate of 84%. Results of the study are summarized below:

[Survey Results: Knowledge. Cypriots who participated in the Study on the Knowledge, Attitudes and Behaviour Regarding AIDS, Sex and Sexually Transmitted Diseases proved to be quite knowledgeable about the modes of infection with HIV, except in the case of perinatal transmission, which 20% of respondents failed to identify correctly. Ways by which HIV is not transmitted are less well recognized, with misconceptions ranging from a low 13.5% of those believing that eating with an HIV-infected person can expose one to the risk of infection with HIV, to a high 66% of those believing there is risk of acquiring HIV infection during the act of donating blood. The percentage of people who believe that insects can transmit HIV is 46.4%.

[When different ways of protecting oneself from HIV are considered individually, knowledge may be rated as medium to high, ranging from 63% for abstinence from sex, to 93.7% for avoidance of common use of needles. Correct condom use is correctly identified as protective against HIV infection by 93% of the respondents.

[Avoiding people who are HIV-positive and using the contraceptive pill (by women) are still considered by 27% and 23%, respectively, as ways of protecting oneself from HIV infection.

[Naming correctly at least two ways of protecting oneself from HIV is used for the estimation of Prevention Indicator a. The level of 90% specified for Prevention Indicator a (P.I.a) is not reached, since the highest percentage for naming correctly two ways of protection is 82%, represented by the combination of “avoiding common use of needles” and “correct condom use.”

[Knowledge on the general features of HIV infection is medium to low. As many as 65% of respondents did not know that an HIV infected person can have a negative test for HIV, whereas 26% did not know that it is possible to be infected with HIV but have no external signs of it. A proportion of 83% did, however, recognize that the presence of another sexually transmitted disease increases the risk of HIV infection.

[Survey Results: Attitudes. Relatively low proportions of respondents consider that using a condom is a man’s responsibility (53%) or a woman’s responsibility (56%). (The possibility that the questions may have been misinterpreted should be explored and relevant corrections made before using the questionnaire in future surveys). Eighty-seven percent of respondents (86.4% of men and 87.5% of women) stated that they could get a condom any time they need it. People who believe they can protect themselves from HIV by avoiding risky sexual behavior represent 91% of the respondents. A proportion of 17.3% of respondents believe that a woman who carries a condom in her bag is loose, whereas 34.9% believe that a woman and 14.3% that a man should guard their virginity until marriage.

[It is believed by 85.1% of respondents that alcohol can lead to risky sexual behavior and by 81.3% that the intravenous-drug-related risk for HIV is high in Cyprus. Risk of getting AIDS from foreigners is believed by 83.8% to be increasing in Cyprus. The corresponding figure regarding Cypriots is 60.2% of respondents. As many as 77% of respondents (79% of men and 52% of women) consider that it is acceptable to donate blood so as to have a test for HIV at the same time.

[Positive attitudes towards people with HIV are noted on the whole. However, 6.2% believe that HIV-infected people got what they deserved and 5% believe that they should be isolated away from society. A proportion of 68% (72% of men and 65% of women) stated they could be friends with an HIV-infected person and 91% believe that free care for HIV should be provided by the State.

[Participants were asked to adopt (or reject by not marking) various statements about a) people with multiple sexual relationships, b) morality, and c) factors which control sexual behavior. Further analysis is needed, for better validation of the answers to this type of questions.

[Survey Results: Behavior. Data on the behavior of the participants identified various sexual activities and provide limited information on the use of drugs and alcohol. The main findings are as follows:

[Five out of six, 86.5%, of respondents stated that they had had sex (defined as penetrative sexual intercourse in the questionnaire). The proportion of people having had sex increases with age, whereas respective proportions for men and women are 92.1% and 81.4%, presumably because of the earlier onset of sexual activity in men. Mean age of onset of sexual activity is: 17 years for men with a range of 12 to 29 and 20 years for women with a range of 13 to 36. Moreover, 13% of men started sexual activity before the age of 15 and 50% between 15 and 17; 2.5% of women started sexual activity before the age of 15 and 30% between 15 and 17.On average, both men and women tended to have had sex for the first time with an older person than themselves.

[Forty-three percent of people out of those who stated that they had had sex, reported having had sex with a person other than their steady sexual partner at some time in their lives (respective proportions for men and women are 67.8% and 17.3%). (The question does not define what is meant by “steady sexual partner” and does not ask whether the intercourse with a non-steady partner took place while the respondent was in a steady, free relationship or in wedlock. In future surveys, inclusion of these clarifications will be considered).

[Among the people who answered that at some time they had had sex with a person other than their steady partner, 63.5% stated that they used a condom in the last sexual intercourse with a non-regular partner. Reasons cited for not using a condom during the last sexual contact with a non-regular partner include the partner’s refusal (5%), not having thought to use one (22%), being dizzy from alcohol drinking (10%), and the belief that it decreases pleasure (58%). (The question did not include options for the participants to state whether they were “embarrassed to buy one” or “embarrassed to ask partner to use one,” and this should be included in the questionnaire for future use). Of those having had sex with a non-steady partner, 48.3% stated that they always used a condom with the non-steady partner, 33.8% stated they used one sometimes, and 17.9% stated they never used one.

[The proportion of people reporting use of intravenous drugs at some time in their life is 1.7% for all categories. For the 18-to-20 age-group category, this proportion is 4.3%. One in 40 respondents, 2.4%, reported having had a sexual partner who was a drug addict at some time in their lives. It is interesting to note that 11.3% of respondents—17.5% of men and 4.9% of women, as well as 25.9% of people aged 18 to 20 years—reported having been led at some time in their life to unchecked sexual behavior because of alcohol consumption. These figures are close to figures obtained from studies on drug use conducted in Cyprus among school youth.

[The mean number of lifetime sexual partners is 14 for men, with a range of 1 to over 100 (the latter reported by four people), and 2.5 for women, with a range of 1 to 20 (also one woman at 45). Some overreporting of sexual activity in men and some underreporting in women is to be expected, because of prevailing social norms and taboos. It is believed, however, that differences in mean number of sexual partners in men and women do exist and that men would tend to have sexual contacts with people not meeting the inclusion criteria to the study, such as foreign bar girls or visitors. This issue would have to be clarified in future research.

[It is interesting to note that the interviewers reported that on some occasions men tended to brag about their sexual achievements, leading presumably to an exaggeration in their recorded answers. Most of these cases concerned men who visit nightclubs and bars on a regular basis. On the other hand, some women seemed shocked that it was even considered possible that they engage in such activities. (It is specified that interviewers were asked to record on separate sheets of paper or to report verbally to us any interesting reactions and situations encountered in the households, and this has led to the collection of very interesting comments regarding the reactions of the participants. This information will have to be evaluated in the course of future study of the survey results. It is, also, reminded that, because of the methods used in data collection, identification of respondents and linkage of information to known individuals are quite impossible).

[Six percent (6.3%) of men and 3.8% of women stated that they had had sex with a person who was of the same gender as themselves at some time in their lives. These figures are very interesting, since the forbidden nature of the subject did not allow for much optimism as to the level of response to the question. It is very encouraging to have obtained even this level of response, though this figure should be considered a clear underestimate of the true level of homosexuality. It is noted, however, that it is comparable to some of the results obtained by Kinsley in his famous study, Sexual Behavior in the Human Male, conducted in 1948 in the USA on 12,000 males, at a time when acceptance of homosexuality was probably at similar levels as it is currently in our country. This issue is being examined in cooperation with the Gay Liberation Movement of Cyprus, for a more in-depth evaluation, in light of statistical and sociological information from the extensive international research.

[Six percent (6.3%) of respondents (5.7% of men and 7.0% of women) stated that they had at some time been forced to have sex. The question does not specify whether the event took place within or outside the family. It is interesting to note that in a recent study conducted by the Advisory Committee for the Prevention and Handling of Violence in the Family, 11% of respondents had admitted having been victims of violence in their family, but it is not specified which proportion had suffered sexual violence. Further evaluation is needed.

[It is very important to note the early onset of sexual activity and the large number of sexual partners reported by relatively large proportions of the respondents, and this information should be taken very seriously into consideration in the preparation of future preventive strategies against AIDS and other sexually transmitted diseases. All this information will have to be reexamined and evaluated, in cooperation with the authorities dealing with the study and management of the drug problem in Cyprus.

[Costs and Financing of Treatment and Care

[Estimated Costs. Care for HIV-infected persons and people seeking support from the National AIDS Programme includes free medical care (antiretroviral treatment and treatment for opportunistic infections and neoplasms), nursing care, laboratory support for the diagnosis of cases and the monitoring of treatment based on WHO guidelines, and counseling for HIV-infected individuals and their families and for people undergoing examination for HIV. These services are offered free of charge to all citizens of the Republic and for a fee to people who are not citizens of the Republic.

[Table 19 shows the cost of delivering antiretroviral treatment to patients from 1995 to 2002. The cost of other components of HIV/AIDS care include:

[Financing HIV/AIDS Care

[Future Requirements

[Main concerns at present are linked to risky sexual behavior, which has been the basic driving force of the epidemic until now, since over 90% of cases have been infected through sexual intercourse, and to the increasing use of illicit drugs, which has a potential for a sudden increase of new cases of HIV infection.

[Health Education. Based on the international experience that knowledge does not necessarily lead to behavior change, a new orientation is now being promoted, with the development of peer education projects in schools. Despite the fact that the first attempts were highly encouraging and successful, peer education has not yet been applied on a routine basis in schools because of a shortage of staff and time constraints. Most other health education activities are also focusing on the area of behavior change in youth and other sections of the population. Such activities are information kiosks, special events, lectures, messages and programs using mass media, youth meetings, and others.

[It should be noted that health education is facilitated by the fact that sex issues and the subject of condom use may be easily addressed in Cyprus because of the high level of knowledge and sensitization among the population. Opposition from certain society leaders, mainly the Church, is hampering full implementation of effective health education. New material is being constantly developed, such as brochures, booklets, posters, TV spots, videos, and various advertising items (key rings, T-shirts, etc.) as a necessary complement to these activities.

[Health education focuses mainly on sexual behavior, but all other important issues, i.e., compassion and avoidance of discrimination, safe blood donation, dangers of drugs and other habit-forming substances, and the hazards of perinatal transmission, are addressed as well.

[Based on the country situation and the recommendations from WHO/UNAIDS, the immediate requirements for the National AIDS Programme may be defined as follows:

[Conclusions

[In the light of the above epidemiological and general information, it is evident that the HIV/AIDS situation in Cyprus is comparable to that in other Western countries. Based on current epidemiological evidence, health education activities are focused mainly on prevention of transmission of HIV through sexual intercourse, with the main emphasis on abstinence, delayed sex, mutual faithfulness, and the correct use of condoms. Peer education in schools and in youth NGOs is being promoted, though at present, it has only been implemented on a pilot basis. Program evaluation is planned according to WHO guidelines and constitutes an integral part of the NAP, but has not been implemented to a satisfactory degree to date. (End of update by L. Papantoniou)]

[Update 2002: UNAIDS Epidemiological Assessment: This combined epidemiological assessment is for both the Turkish Republic of Northern Cyprus (TRNC) and the (Greek) Republic of Cyprus.

[HIV seroprevalence among blood donors has been reported below 0.01% in Cyprus since 1989. There was no evidence for HIV infection among pregnant women that were tested from 1998 until 2001, with the exception of one HIV case detected among 4,019 pregnant women in 1992 and one case detected among 2,422 pregnant women in 2001. HIV seroprevalence among bar girls remains below 1%. No infection has been detected among sex workers over the years. HIV prevalence among injecting drug users is reported to be between 0.1% and 0.3% between 1993 and 1999. Of clients of voluntary counseling and testing, 0.4% and 0.8% were found to be HIV-positive in 1999 and 2000, respectively.

[The estimated number of adults and children living with HIV/AIDS on January 1, 2002, were:

[No estimate is available for the number of adults and children who died of AIDS during 2001.

[No estimate is available for the number of Cypriot children who had lost one or both parents to AIDS and were under age 15 at the end of 2001. (End of update by the Editors)]

11. Sexual Dysfunctions, Counseling, and Therapies

A. The General Situation

There is scant information on sexual dysfunctions and therapies in Cyprus, mainly because of the lack of qualified, professional therapists who can systematically collect such data. As of 1999, the main author was still the only professionally qualified sexologist with doctoral training on the island. There were a few psychologists who attempted sex therapy using psychoanalytic techniques with very poor results. There were also a number of medically qualified dermatologists, STD specialists, and urologists who advertised as “sexologist,” but are not qualified in any form of sex therapy and have no specific training in this field. Their treatments included mostly drugs and papaverine and prostaglandin penile injections for both erectile problems and premature ejaculation, regardless of etiology. In 1999, Viagra was granted an import license, and no doubt this will be used widely. The situation is quite sad really, as many patients fall victim to costly medical treatments without seeing any benefit.

Unfortunately, at present, Cypriot law does not regulate the training, certification, or licensing of sex counselors or therapists. Anyone can advertise freely on their signs whatever they wish, on the condition that they do not use the adjective “specialist.” So “dermatologist-sexologist” is a legal sign, but “dermatologist-specialist sexologist” would be illegal if the individual does not have qualifications and clinical training in sexology. Few Cypriots are aware of this distinction and its inevitable consequences for the delivery of effective healthcare in this specialized area.

[Update 2003: The medical profession is quite determined to protect their self-interests and will not allow any other profession, even qualified clinical sexologists with doctoral degrees, to practice sex therapy on the island. The law regarding medical practice written in the 1960s and amended in 1979 clearly states that no one can diagnose or treat without being a qualified medical practitioner. The editor and author of this work has been arrested once and taken to court a second time based upon charges brought against him by the president of the Cyprus Medical Association. The charge was practicing medicine without being a qualified medical practitioner. On both accounts, the case was thrown out and nothing further was heard, but the Medical Association is far from happy with this situation. There are frequent “witch hunts” and publications in the local media about ‘apparent sexologists’ exploiting the public, and being called charlatans along with other ‘titles.’ This anachronistic legislation will be tested in a court of law in order to bring it in line with European standards. (End of update by G. J. Georgiou)]

B. Some Limited Observations

The Population and Its Problems

The following observations have been culled from 840 clinical cases of Cypriots with sexual dysfunctions who sought treatment at the editor’s Natural Therapy Centre in Larnaca between 1993 and 1996. Some additional insights came from a survey of sexual knowledge, attitudes, beliefs, and practices of 3,176 schoolchildren aged 14 to 18 years old conducted under the auspices of the World Health Organization (Georgiou et al. 1990), a study of the sexual attitudes of Greek Orthodox priests (Georgiou 1990), a 1995 book on the treatment of premature ejaculation by the editor, and Homosexuality, a book written in 1982 by the Pancyprian Society of Psychic Health after a seminar on homosexuality.

A quarter of the editor’s clinical population were age 18 to 25, 40% between ages 26 and 35, 21% from age 36 to 45, 9% ages 46 to 55, 4% between the ages of 56 to 65, and the remaining 1% 66 and older. One percent of the sample had not completed elementary school, 12% had attended junior high school but not graduated, 12% had attended school to age 15, 40% had completed high school, and about 20% were university graduates. Two thirds of the subjects were married, 12% engaged, 2% separated, 1.5% divorced, 1% widowed, and 18% single. Some of the 840 attending were partnered, but individual histories were taken, and are presented here as such. The sample is quite representative of the spread of occupations on the island, and covers professionals (13%), technical—plumbers, electricians, and so on (9%), business people (20%), clerical (12%), civil servants (10%), housewife (6%), agricultural (11%), unskilled (9%), students (3%), unemployed (1.5%), waiters and hotel workers (5%), and others (4%). All clients completed a sexual-history questionnaire covering 75 topics or questions modeled on Wardell Pomeroy et al.’s Taking a Sex History (1982).

In terms of the whole sample of 840 patients, the most common problem was secondary erectile dysfunction (30%), with an additional 2% primary erectile dysfunction. Other male dysfunctions included premature ejaculation (24%), retarded ejaculation (2%), and male sexual desire disorder (5%). Secondary inhibited orgasm (7%) was the most common female complaint, with an additional 3% presenting with primary inhibited orgasm—the total of female inhibited orgasm: 11%. Other female dysfunctions included vaginismus/coital phobia (11%) and female sexual desire disorder (6.5%). One percent presented with problem paraphilias, mostly “flashing.”

Premature Ejaculation

Males suffering from premature ejaculation commonly postpone treatment for years, waiting until the stress and anxiety of the chronic situation makes the problem a lot worse and their marriage is threatened. Only 15% of premature ejaculators seek help within three years of onset. Thirty-seven percent wait four to ten years, 31% wait 11 to 20 years, and 4% wait more than 20 years. In comparison, men with erectile dysfunction are much quicker to seek help, probably because their problem directly threatens their male ego. Ninety-two percent of impotent men sought help within three years of onset, 4% within four to ten years, and 4% in 11 to 20 years. A strong majority of premature ejaculators recall ejaculating quickly from their early masturbatory experiences.

This appears to support Helen Singer Kaplan’s (1983) theory of the ejaculatory reflex being conditioned to ejaculate early from the initial sexual experiences. Very few of the males recalled otherwise. Most of the males who came for treatment for premature ejaculation had the problem for many years, on average about ten years, but only decided to seek help when additional stress factors had exacerbated the problems to such a degree that many were ejaculating before intromission. Certainly the majority where finishing in 10 to 20 seconds, to the woman’s growing frustration. At this point, additional coercion from the wife resulted in the men seeking help.

Erectile Problems

Many cases of erectile problems began with an extramarital partner, and not with the wife or major partner. This may be because of the tremendous performance anxiety that is again related to the huge Mediterranean masculine ego to “conquer” the woman and show her that one is a “man.” I have also thought that it may have been because of the anxiety related to the prickling of consciences, but having spoken at length to many of these men, this does not appear to be the case. Indeed, many of them had come to me not so much to improve their relationship with their wives, but to help them “get it up” so that they could “prove” their manhood with their girlfriends. Many actually expressed satisfaction in the wish to “do it just once” with the girlfriend, and that would be enough! The shame, disappointment, anguish, and bruised ego was very apparent in many of these men. The vast majority of them had no sexual or relationship problems with the spouse—their motivation in pursuing an extramarital partner was purely to satisfy their ego, and not much else.

In addition to these psychological problems, I have found causes related to dietary stresses and abuses, smoking, nutritional deficiencies, subclinical hormonal imbalances, subclinical hypothyroidism, reactive hypoglycemia, toxic metal status, systemic toxemia, and others. These causes I would consider as “organic,” but not in the traditional classical medical view of organic. There may not be any obvious pathology that can be measured on blood tests, Doppler, or morphological changes, but there is a continuum of health and disease, with a lot of gray areas in between. Many of these men have malfunctioning organs and tissues, which inevitably will affect penile functioning, unless one holds the view that the penis has its own will and personality and is totally independent of other bodily functions. Cognitive-behavioral sex theory is often quite effective in treating an erectile problem that is strictly psychogenic in etiology, but compound a psychological factor with smoking two packs of cigarettes a day, eating fast foods full of empty calories and fats, working a 12- to 18-hour day, drinking alcohol regularly to “destress,” being anxious and insecure about the future, and so on, as many Cypriot males do, and it is obvious that something more than traditional cognitive-behavioral sex therapy may be indicated, including nutritional and homeopathic remedies.

Vaginismus

A clinical incidence of 11% for vaginal spasms in Cypriot women is much higher that reported in other countries, where the reported incidence ranges between 1 and 4%. The origin of this difference, I believe, lies in the cultural dynamics, and specifically the sexual messages that both sexes receive while growing up in Cyprus. The male child gets messages based around: “You are a male, so it is normal, acceptable, and a sign of your manhood to pursue and conquer females sexually,” whereas the woman gets a very different message: “You are a female and must remain a virgin, as this has direct links with your honor and that of your family—be careful as males are cunning and are only after one thing.” Sixty-nine percent of the women in this clinical sample were virgins until they married, compared to only 9% of the men. The women had limited premarital experiences, and their sexual knowledge was obtained mainly from friends and media—with all the misconstrued ideas and prejudices that are inevitable from such sources, mixed with a high level of anxiety and neuroticism. A large majority of the vaginismic women reported dwelling on the fear of coitus, starting when some friend or cousin shared her initial “painful” sexual experiences, saying that the pain was unbearable, and that they had hemorrhaged. Without exception, these women had high scores on the Spielberger Trait Anxiety Inventory (SPAI), averaging at least one or more standard deviations above the mean for their age group.

Dysorgasmia

There appears to be a problem with the statistics for dysorgasmia, which one would expect to be higher than the 10% reported in this limited clinical sample, particularly when 24% of the males have a chronic problem with premature ejaculation. Again, the answer may lie in cultural values and conditioning. Cypriot women are very reluctant to discuss their sexual lives with a complete stranger, even when that person is a competent professional in the sex field. Also, Cypriot women have been taught not to consider or make a fuss about the quality of their sexual pleasure, given that their male is performing like an epividoras (stud). Cypriot women tend to lament in silence, perhaps until things in the marriage get to such a point where frustrations can no longer be tethered. Other causes may include physical and mental fatigue from coping with home, work, and many children, an insensitive husband who is tender only in bed, limited sexual foreplay because of ignorance and inhibitions, marital discord, and certain “naturopathic” organic causes. Similarly, I believe the incidence of female sexual desire disorder, a scant 6.5% in my clinical sample, is not indicative of the actual incidence of female inhibited sexual desire in the general population. Cypriot women are not taught to expect much from their sexual relations, and so they suffer in silence. We simply do not see these people in clinical practice.

Male Coital Phobia

A recent development in this limited clinical sample has been a three- to fourfold increase over the past two or three years (compared with five years ago) in the incidence of males seeking help with unconsummated relationships owing to their own coital fears. I have no explanation for this fascinating phenomenon, which is certainly worthy of being researched.

The main author’s clinical experience with over 10,000 patients in the last 16 years in Cyprus suggests that the treatment of sexual problems in both sexes is getting more and more difficult. Modern Cypriots are more stressed and anxious, more concerned about finances, apprehensive about the future, concerned about personal safety, have less time for relaxation and leisure activities, are more affluent with all the consequences of bad eating and drinking leading to poor health, and more.

12. Sex Research and Advanced Professional Education

Certainly there is much research that needs to be done in the field of human sexuality on the island of Cyprus. Lack of funding for such research has left the island literally virginal territory for sexology.

The tertiary educational establishments on the island, and there are many, do not even have a single course geared to human sexuality. Perhaps the administrators and educators see it as unnecessary, or fear that it would take up additional space on a busy curriculum. Perhaps it is the inhibitions of the governing bodies to include such topics in the curriculum. Whatever the case, these topics do not exist, neither in the private institutions that award undergraduate and postgraduate degrees from external universities, nor in the one and only newly opened University of Cyprus. It goes without saying that there are no sexological journals and periodicals published in Cyprus, or indeed any national and regional sexological organizations. It is difficult to set these up with only one member!

Certainly the talent for research exists on the island. We have the second highest rate of university graduates per population ratio in the world, as well as the technology and infrastructure. We also have keen researchers who would love to participate in ongoing research. If someone will fund, research will progress.

References and Suggested Readings

Demographics and a Brief Historical Perspective

ROBERT T. FRANCOEUR

A. Demographics

In July 2002, Turkish Cyprus had an estimated population of 200,000 out of an estimated total Cypriot population of 767,000. All data are from the authors, and pertain to the Turkish Republic. Readers are invited to compare these figures with those in Part 1, Greek Cyprus, of this chapter.

B. A Brief Historical and Cultural Perspective

Cyprus occupies a very important strategic position in the triangle of Asia, Africa, and Europe. Because of this strategic significance, several countries occupied the island of Cyprus during its history. Among these countries, the most important ones were the Phoenicians in the 10th century B.C.E., the Romans in 58 B.C.E., and the Ottomans, who were there for 300 years starting in the 16th century. After the division of the Roman Empire, the island became part of the Byzantine Empire. Cyprus was ruled by Britain during the Christian Crusades to the Holy Land. Later, the Lusignans and Venetians came to Cyprus.

In 1571, the island was occupied by the Ottoman Empire and ruled by them until 1878 when it was leased to Britain at the Berlin Congress during the Crimean War. In 1914, Britain annexed the island when the Ottomans participated in World War I on the side of the Germans. At the Lausanne conference in 1925, Cyprus became a British Colony and remained so until 1960 when independence was declared and a bi-communal Republic of Cyprus was established.

During the British administration, Cyprus was the scene of disturbances as a result of Greek Cypriots’ campaigning and efforts for Enosis (the aspiration to unite the island with Greece). The Turkish community strongly opposed the union of the island with Greece. The first major uprising was in 1931 when the Greek Cypriots set fire to the Government House. The second move came in 1955 when again the Greek Cypriots launched the Eoka terrorist attacks.

The colonial government cooperated with the Turkish Cypriots and tried to suppress the Greek violence. The reason why the Turkish Cypriots cooperated with the British was because the only aim of the Greek Cypriots was the union with another country, Greece, not the independence of all the Cypriots.

The Republic of Cyprus had a short life of just over three years. In 1963, the island again became the scene of intercommunal strife, and the regime collapsed. On March 5, 1964, the United Nations (UN) Security Council recognized the Greek Cypriot faction of the government as the official government of the Republic of Cyprus. This UN resolution contributed to the continuation of intercommunal conflict resulting in ten thousands of Turkish Cypriots abandoning their villages and homes in the big cities and living as refugees in restrictive enclaves in the north.

In 1974, the Greek Junta joined hands with the fanatical Greek Cypriot elements and annexed the island to Greece (until the Junta was replaced by a democratic government). Because of this, Turkey exercised her right of intervention under the 1960 agreements and intervened in July 1974. Since then, the two communities have been living separately in two regions, the Turkish Cypriots in the north of the island and the Greek Cypriots in the south. The intercommunal talks for solving the Cyprus issue have not produced any positive results. However, the recent decision of the European Union (EU) to accept Cyprus as a member has perhaps created an opportunity for ending the division of the island. In May 2003, the borders between the north and south were opened, signaling a new attempt at reunification.

1. Basic Sexological Premises

A. Traditional Turkish Cypriot Family Life and Gender Roles

Since the beginning of the 20th century, Turkish and Greek people of Cyprus have engaged in agriculture and animal husbandry. In the cities, Turks opted to become civil servants, whereas the Greeks engaged in trade alongside with employment in government services.

As in other Mediterranean countries, Turkish Cypriot women traditionally occupied themselves with work at home while the male population undertook the role of the breadwinner. But, in time, these sorts of activities could not secure a prosperous life. It was difficult to have sufficient income and maintain a decent life for the family because of the lack of irrigation water and technical insufficiencies obstructing productivity, especially in the northern rural areas. This shortcoming affected the social life of the family. In due course, in order to obtain a better income, people had to move from villages to the big cities.

In the traditional Turkish community, the man was the head of the family. He was responsible for the protection of the family’s honor and dignity and for ensuring a better life for all. The activities at home did not concern him very much. He spent most of his free time at coffee shops and clubs, which were only visited by men.

Women in the traditional Turkish family were responsible for all the work inside the home, looking after the children, cooking, washing, tending the domestic animals, and meeting the husband’s various needs. Above all, she had to be honest and dignified and protect the family honor in every respect. Women and grownup girls normally stayed at home and did not frequent places visited by men, but visited other women friends in their homes. In mosques, women occupied specially prepared areas where men could not see them. Sexual relations between husband and wife were strictly secret, even kissing each other was not disclosed to third parties. Only very young girls and mature women could freely go around, as they were not considered to be sexually at risk. Women and grownup girls were fully familiar with the traditional sexual evasion. They knew how to dress, talk, and behave in public places where men were in the majority, without losing their honor and dignity.

Under the traditional Turkish Cypriot gender roles, girls and boys up to the age of 6 could easily play together in the streets. After this age, the parents dictated the conventional conditions to their children. Boys were given more freedom in their activities, while girls were told to be modest and not get involved in any disgraceful activity. They were told that they had to learn traditional behavior in their social life. If a girl was seen talking to a boy who was not her relative, this could have been interpreted as reflecting a sexual desire. The advice of the mothers and fathers to their daughter was that, when a boy looked and/or smiled at her, she should not smile or look back. She should close her mouth with her hand (if she had the urge to smile) and divert her glance elsewhere. A girl who obeyed the traditional rules, honored her family and had a better chance of a good marriage.

In the traditional Turkish Cypriot society, the roles of young girls and boys were very strict. Nowadays, these strict rules have changed, and the relations between the genders have become easier and more modern.

B. Social Changes and Modernization

The influence of the British colonial administration and the increase of technical facilities around the world have forced Turkish Cypriots to move to the cities. Some members of the family, usually the main breadwinner and the young boys, try to find job in the cities. In 1950s, the Turkish Cypriots’ preference was to get a job either in the British sovereign areas, or to find employment in the mining industry or the civil service. These were good sources of income.

The modernization in the Turkish Cypriot community started after the end of World War II. During this time, the people in the cities had a better source of income and a better social and cultural life. This alone led to the relocation of people from rural areas into the cities. This, in turn, led to increased education and, as a result of increased education, the philosophy of sexual strictness changed and became much more flexible.

Since 1960, important changes have taken place in the family structure. In the Turkish community, employment in the civil service became the most secure area of livelihood for both the male and the female. The significance given to education also increased. In the 1950s, kindergarten education was officially introduced (although there had been private kindergarten facilities long before that). During the late 1960s, the number of boys and girls in both elementary and secondary education was almost equal. However, after 1974, because of the influx of the population from Turkey to the northern part of the island, the number of boys in schools increased, as the Anatolian people traditionally give priority to the education of boys rather than girls.

In 2001, Dr. Ahmet Cavit carried out a research study on the communal structure of the Turkish Cypriots, including the immigrants from various parts of Turkey. According to this research (census of December 15, 1996), the total number of the population in Northern Cyprus was 200,857. Of these, 146,450 were citizens of the Turkish Republic of Northern Cyprus (TRNC), 30,702 were citizens of Turkey, and 5,425 were citizens of other nations.

This study indicates that the immigrants from Turkey also take part in the political life of Northern Cyprus. In the 1998 general elections, four out of 50 Members of Parliament were of mainland Turkish origin. According the statistics of the Research and Statistic Department of TRNC, 1,108 marriages took place in 1998. One third of these marriages were among the immigrants. Most of the married Turkish Cypriot couples had secondary or higher education levels. TRNC recorded 2,433 births during 1998. A breakdown of this figure indicates that the majority of the Turkish Cypriots preferred private clinics, whereas the immigrants frequented government hospitals because of their low economic position.

Because the immigrants give priority to the education of boys, their daughters rarely have secondary education, as their parents prefer to see them married and having children instead of carrying on to higher education. According to this study, Turkish Cypriots prefer government services, whereas immigrants find employment as manual workers and waiters.

Another important aspect is the increase of women in employment. A 1998 study revealed that 20 out of 100 women were employed outside the home. In 2001, this increased to 28%. Looking at the role of woman in modern life, the mother is still seen as more loving and tolerant than the father and often communicates better with the children. She devotes more time to the family, looks after the children, runs the house, and sometimes contributes to the family budget by working outside the house as well. The man is the breadwinner, head of the family, and has the final say in family affairs. Husbands rarely get involved with domestic affairs and spend most of their spare time at coffee shops or clubs. This is especially true in rural areas. As in most parts of the world, women and men in cities are successfully trying to achieve a sense of equality of the sexes.

C. Sociolegal Status of Males and Females

Secularization has been an important factor in the life of the Turkish community since the early 1920s, when Kemal Atatürk introduced modern life and secularization in the Republic of Turkey, as well as introducing the right of women to vote. During the last 20 years of the British colonial administration, the family life inherited from the Ottomans underwent important changes. The 1960 Cyprus agreements also contributed to the modernization. Article 28 of the 1960 Cyprus Constitution provides for equality of the male and the female.

In the Turkish Republic of Northern Cyprus, if a foreign individual marries a Turkish Cypriot, he or she becomes a citizen after the lapse of one year from the date of the marriage. Marriage and divorce in the Turkish community is performed under the Turkish family law. It has no connection whatsoever with religious rules.

In Northern Cyprus, abortion is not legally allowed except under very special circumstances. However, it is common knowledge that abortions are possible in private clinics.

D. Legal Status of Men and Women at Work

In Northern Cyprus, it is not a common practice in the private sector for men and women to receive equal pay even when they perform the same duties. Despite agreements between trade unions and employers to ensure equality for men and women, discrimination still exists. It is different at the civil services. Equality does exist there, and men and women have equal payment and equal chances for promotion. Another reality in the Turkish Cypriot community at the moment is that a large number of labor forces from mainland Turkey accept employment at very low wages, thus increasing the wage gap between the male and female by forcing the female to accept employment at still lower wages. According to Cavit’s study, most of these workers are illegal immigrants.

Women in Northern Cyprus do not fight for their rights. The main reason for this is the fact that senior posts and political offices are mainly occupied by men. So far, women’s efforts and desires to get a better place in the political arena have not produced any positive results. The existence of only four women MPs out of 50 in the Parliament is a proof of this.

E. General Concepts and Constructs of Sexuality and Love

Traditional marriages in the Turkish Cypriot community were performed on the basis of Görücü evliligi, arranged marriages. The candidate bridegroom and his family visited the bride-to-be and her family to see the chosen woman (sometimes for the first time) and eventually ask for the hand of the woman in marriage. The decision of the youngsters was not of great importance in this system, although most families did at least ask their opinion. The choice of the elders was the decisive factor. Sometimes, a boy requested his parents to go and ask for the hand of the girl whom he had seen and liked physically without knowing her personality and/or educational level. It was always the boys who asked for the hand of the girls, never the other way around.

Usually, the family of the bride was chosen first, because the boy’s parents wished for a bride from that particular family. The main criteria for the man’s family in these marriages were the social and financial status of the woman’s family. It had to be of the same background, rank, and social standing to theirs and occupy a position of respectability in the community.

If the impressions of both of the families were positive, then the marriage was agreed upon and the couple got engaged, usually during a ceremony including family and friends. The couple was seldom allowed to be alone together. Typically, a member of the family, this could even be a child, was sent along with them as a chaperon. The period of engagement was kept as short as possible. The families wanted to have the marriage ceremony as quick as possible. Traditionally, the engagement ceremony was paid for by the bride’s family, and the wedding ceremony by the bridegroom’s family.

This tradition is still mostly true, although recently, more and more families are sharing the cost, as weddings are getting more and more expensive. The woman was supposed to bring her dowry into the marriage, including all the furniture for the new house, and the man was supposed to supply the house in which they were to live in. At present, this, too, can vary, and there is no set rule, especially in the cities.

It is still customary for the bridegroom to give a piece of precious jewelry to the bride on their wedding day. This stems from the time when the bridegroom was only allowed to see his bride after the wedding ceremony was over. This present was called the yüz görümlügü (to see the face), as it was presented after the bridegroom had lifted the bride’s veil, thus seeing her face for the first time.

Until the 1950s, marriages in the Turkish Cypriot community were performed on a religious level by a Hodja, a man of religion. After the enactment of the family law during the last years of the British colonial administration, these became civil marriages and were performed by marriage officers. All marriages performed prior to the enactment of the law were considered as performed under the law.

Until the 1950s, the woman’s family was very strict with the virginity of their daughters. The girl was not allowed to have sexual relations before her marriage, not even during the engagement period. The men, on the other hand, were encouraged to “gather some experience” before their marriage. The day after the wedding, the bridegroom’s family was anxious to see the red blood spot on the sheet, proving the virginity of the bride. This was mostly true in the rural areas and rarely in the cities. However, after the 1970s, this tradition was also widely abandoned, and the virginity of the bride was not the first prerequisite for the continuation of the marriage. But even today, an intact hymen is interpreted as belonging to an “untouched” woman.

After the 1960s, men and women preferred marriages based on mutual love and respect, preferring to choose their partners themselves, but hoping for approval by their parents. Families tolerated the decision of their children without imposing traditional rigid conditions. At present, dating and flirting has increased in the Turkish community. This has been made easier for most by the increased number of men and women studying and working together. Some go as far as to say that flirting is a must prior to marriage. There is even a modern version of arranged marriages, where the families choose the partner but agree to let the man and woman go out dating before they make up their minds. The engagement period can also take as long as it is necessary for the couple to make up their minds. Despite these developments and changes, there are still many people, especially in the rural areas, who believe that virginity is essential in the community. The enlightened youth, though, is starting to believe in the equality of the sexes, including their sex lives before marriage.

A difference is seen in the marriage understanding of the Turks who came to Northern Cyprus from Turkey after 1974. They are more conservative and prefer marriages among themselves, especially between relatives.

2. Religious, Ethnic, and Gender Factors Affecting Sexuality

Religion does not have any direct effect on sexuality in the Turkish Cypriot community. Though adultery, abortion, premarital sex, and homosexuality are a sin in Islam, most people are not influenced by this. During the holy month of Ramadan, sex, flirting, touching each other, kissing, and so on, is not permissible in the fasting time from dawn to sunset every day. In 1990, a respected Hodja offered the following advice to young people: “Get acquainted with each other prior to engagement. Afterwards, only get engaged if it is your own decision. It is not a sin for young people to get to know and talk with each other beforehand. Get married only if there are not any problems during the engagement period.”

3. Knowledge and Education about Sexuality

This section was prepared from a study by Nuri Gökşn, M.D., Chief Medical Officer of the Turkish Hospital in Famagusta.

A. Government Policies and Programs

In the TRNC, there is no sexual education in schools. The only information about sex given at schools is during biology lessons on an insufficient level. Teachers try to teach the students only the anatomic structure of the genital organs.

B. Sexual Knowledge in the Turkish Community

To ascertain the level of sexual knowledge among the Turkish community, a three-stage study was carried out. These studies were undertaken at the encouragement of the late Prof. Dr. Alpay Kelâmi, who was a Turkish Cypriot andrologist/urologist working at the Free University of Berlin, Germany. The first stage was carried out among the 4- to 12-year-old age group by K. Bolayır and N. Cahit in 1990. The second stage was carried out among the 14- to 18-year-old and 18- to 24-year-old age groups by K. Bolayır, N. Gökşn, and E. Emekçi, in 1991. The third stage was carried out among the age group over 30 years of age by K. Bolayır and S. Özyigit in 1992.

In the 1990s, sexuality was not taken up in the media very much. Sexual words, such as “penis” or “in the vagina,” could not be written in the newspapers. Teachers were reluctant to give sex education to the children in schools, because they themselves had insufficient knowledge on sexual issues. During the above studies, the schoolchildren made interesting comments when questioned on the subject of biology lessons. They said teachers avoided any reference to genital organs and sometimes boys were sent out of the classroom while a female teacher talked to the girls only, thus compelling the boys to ask the girls questions as to what the lesson was all about afterwards.

This study revealed that children are not immensely affected by traditions and taboos. Unfortunately, however, as time goes on, communal pressure will affect these children. During this study, in a TV discussion in 1990 with A. Kelâmi, Telaloglu, and Bolayır, the priority was given to the sex education of the parents and schoolteachers.

In 1991, in the first part of the second stage of this study, 980 schoolchildren 14 to 18 years old were questioned:

The second part of the second stage of the study surveyed 1,000 18 to 24 year olds in 1991, including the following questions:

A 1998 study of 800 persons in the age group over age 30 produced the following results:

Between 1990 and 1998, we examined the level of sexual knowledge in the Turkish Cypriot community. We tried to ascertain how and from where people got their sexual information. The answers given by 6 to 70 years olds reveal that the level of sexual knowledge in the community is very low.

It is a very important finding that 95% of youngsters do not discuss sexual issues with their parents and 98% of boys and girls also do not discuss sexuality with their teachers. Where do these boys and girls get their sexual knowledge? Young people of marriageable age learn about sex from friends, magazines, porno films and similar publications, and the media. In the past, males used to get their sexual experiences in brothels. Nowadays, nightclubs and pubs have replaced these places.

Porno films can be easily bought in Northern Cyprus. From Bolayır’s clinical experience, the following are some of the main complaints of people watching porno films in the Turkish Cypriot community.

4. Autoerotic Behaviors and Patterns

A. Children and Adolescents

In a 1990 study among 980 young people, it was established that 95% of boys and 13% of girls masturbate. Girls in the Turkish Cypriot community are sexually under greater pressure and control than boys. Therefore, girls who feel guilty masturbate in secrecy and under very secure conditions as if doing something wrong. It appears that parents are always inclined to take great care to prevent their daughters from masturbating, and have a fear that they might lose their virginity if they are allowed to do so. Hence, we see that statistical data for girls are very limited. No clear-cut results have been obtained in these studies regarding the age at which girls and boys start masturbating. Generally, the girls are taught to be shy, which is probably another reason why they could not admit to masturbating. However, it can be said that many girls start masturbating at about the age of 11 years and boys at about age 13 years. As adolescents grow older, masturbation becomes more frequent, especially among boys. Our clinical experience has shown that parents accept masturbation if the child is male. In a sense, the parents are proud of their son’s masturbatory behavior, saying their boy is a real man, like his father. Sometimes, parents refuse to discuss the normality of their daughter’s masturbation. These parents never accept their daughter’s masturbation and punish her as a consequence if she continues.

B. Adults

There is no available data about adult masturbation in the Turkish Cypriot community. It is thought to be very rare in both sexes, but it is practiced by a number of married men who have problems approaching their wives because of marital conflict. Turkish Cypriot women say that they do not masturbate when their husbands are abroad or in therapy.

5. Interpersonal Heterosexual Behaviors

A. Children

No study on the sexual rehearsal play among children has been made in the Turkish Cypriot community.

B. Adolescents

There are no puberty rituals as such in the Turkish Cypriot tradition, but the start of menstruation for the girls and circumcision for the boys are both celebrated as milestones. When the female child starts menstruating, the mother is told. She in turn tells the father, the sisters and brothers, the grandparents, and the aunts and uncles. A great fuss and excitement surround the child, with everyone kissing and congratulating her on becoming a woman. The girl is usually embarrassed by all this commotion around her.

Every young boy knows that one day, he is going to be circumcised and “become a man.” Traditionally, boys are circumcised between the ages of 5 and 7 years. Parents usually like to have the boys circumcised before they start elementary school. In the past, circumcisions were performed without any anesthetic by men called sünnetci, non-medical men specializing in circumcisions. The child was held firmly by two male family members (other than the father) while the sünnetci performed the operation. As soon as the child opened his mouth to cry out, a little piece of lokum (“Turkish delight candy”) was put into his mouth and the whole procedure was over in minutes. Although these sünnetci still exist in rural areas, nowadays circumcisions are performed under anesthesia by urologists in hospitals. On the day of the circumcision, the boys are dressed in special costumes and hats. Depending on the family, they may then be taken around the village or the city on horses with accompanying traditional Davul and Zurna music drums and a kind of clarinet. The children and adults of the family, sometimes in cars and blowing their horns, follow this happy procession. On the eve of the circumcision, a party is given, and all the guests bring presents or give money to the circumcised boy. The boys continue to wear their long white shirts for about a week until they can wear trousers again.

No clear-cut studies have been carried out in the Turkish Cypriot community on sexual behaviors among adolescents. However, Bolayır’s (1991) study of 230 adolescents (age 16 years.) revealed that 80% of the boys and 30% of the girls had experienced hugging, kissing, petting, and sexual intercourse. Boys and girls of this age consider themselves to be mature. Boys try to prove themselves by endeavoring to influence girls. On the other hand, girls are under the influence of physical and psychological changes and want to be loved. At this period, the young do not possess sufficient sexual knowledge, but they put on a brave face and attempt to think and act strongly.

In a 1998 study by Bolayır among 210 adolescents, it was established that 68% of the boys and girls in the 16- to 18-year-old age group had no sexual intercourse, 20% had only one such experience, and 10% more than one. Ninety percent of these youths knew what a condom was and 48% had used and knew how to use a condom properly. To avoid pregnancy, some boys and girls preferred anal sex. However, there is no available data about the extent of this practice.

The male adolescent’s main sexual experience is with women working in nightclubs, pubs, and other entertainment places. These interactions are with payment, and the duration is short. The women in the nightclubs are commonly known as “Natasha.” It is an interesting fact that 50% of the men who have paid for sexual relationships with “Natasha” are married and are mostly fathers. In the community, sexual relationships between Turkish Cypriot men and women and tourists are at a very low level.

C. Adults

The study made in 1992 among 800 people of marriageable age revealed that virginity was an important phenomenon in the Turkish Cypriot community. According to our clinical findings, 11% of men and 77% of women were found to be virgins when first engaged or married. In the Turkish Cypriot community, one of the reasons for ending an engagement or marriage is when a bride is found not to be a virgin on the first night of her marriage or during her engagement. Sometimes, members of both families insist on a medical examination prior to marriage to prove the virginity of the girl, forcing the girl concerned to be examined by a gynecologist. This is an unfair, unacceptable, and disgraceful position for the girl. Several families have a hymnography operation—hymen reconstruction—performed on their daughters before marriage. As a result of this, the girl is compelled to have to resort to a deceitful marriage and build her life on unsound foundations. Nowadays, virginity has lost its importance in the cities, but unfortunately not in the rural areas or with the very conservative families.

This study also showed that 3% of the girls and 15% of the boys had their first sexual intercourse before the age of 16, and 75% of these males had their first sexual intercourse before marriage with prostitutes. Nine out of 10 Turkish women had their first sexual intercourse either with their fiancée or husband. It is expected that this rate has increased in recent years and, therefore, new research is necessary.

In the Turkish Cypriot community, 98% of married women and men do not have extramarital sexual relationships during the first years of their marriage. But in this male-dominant community, after a short lapse of time, and probably trying to prove their superiority over their wives, most men do not keep up this good record. The majority of the men who visited nightclubs to have sex insisted that they went there under the influence of alcohol and on the insistence of their friends. Some even infected their wives with sexually transmitted diseases from these extramarital sexual relationships.

In the Turkish Cypriot community, it is acceptable for men to easily and openly speak to their friends about their extramarital activities. They can also unreservedly speak with their doctor, telling him or her how and from whom they got the disease. However, this is not the case with women. Women who have extramarital affairs will possibly be labeled as prostitutes, whereas men are often considered as brave for acting in this way and are easily forgiven in the public eye. This is the traditional mentality of the community. In Northern Cyprus, 75% of the women tend to stick to only one partner in their life, but that is not true of the men, 75% of whom have one or more extramarital relationships.

Our clinical experience shows that 4 out of 10 men and 7 out of 10 women do not like oral sex. Three out of 10 women do not know what a clitoris is or what a clitoral orgasm is. They claim that the vagina is the only source of sexual pleasure. These findings show the level of sexual knowledge of the women in the community.

Another clinical finding is that in the younger generation, 70% of men and 30% of young women enjoy anal sex. Young Turkish Cypriots who are interested in and watch porno films often prefer anal sex.

In a close-knit small community such as Northern Cyprus, confidential information is not easily disclosed, so more funds are required to carry out detailed research.

6. Homoerotic, Homosexual, and Bisexual Behaviors

A. Adolescents and Adults

To establish the ratio of homosexuality in a community of 200,000, it is essential to make a very detailed study. Traditional community principles and family pressure make this sort of study all the more difficult.

In a study made in 1992, clinical samples indicated that there were 16 homosexual cases, 14 boys and 2 girls. The average age was between 19 and 23 years. Eight of these boys were exposed during their military service. These homosexuals coerced their peers to have sex with them in return for money or valuable gifts. As soon as these cases were exposed, the army immediately discharged the involved homosexuals for misconduct.

Our studies show that these male homosexuals not only enjoy anal sex, but also all other sorts of activities, such as deep kissing, hugging, nipple stimulation, nongenital touching, oral-genital kissing, and hand-genital stimulation. Male homosexual orgasm is more commonly achieved by fellatio or mutual masturbation. Briefly, it can be said that not all male homosexuals necessarily engage in anal intercourse. It could also be ascertained that female homosexuals insert different phallus-like objects into their vagina during sex.

Looking at the reports of the Kinsey Institute, it is seen that the differences between homosexual and heterosexual findings are about the same. “The major difference between homosexual and heterosexual sex activities is that homosexuals cannot engage in penile-vaginal intercourse with a member of the same sex.”

People in Northern Cyprus dislike talking about homosexuality. However, according to widespread belief among the Turkish Cypriots, this is not so among the Greek Cypriot community. Prior to 1974, parents even advised their children to always keep this in their minds in their relationships with the Greek Cypriots.

In the Turkish Cypriot community, it is a great disgrace to be a homosexual, which makes it very difficult to find out the exact number of homosexuals in the community. It is also very difficult for the homosexuals to seek any rights in the community. They have no clubs or places of assembly of their own. Parents never approve of their children’s being gay or lesbian.

Homosexuals in the Turkish community escape from the community by either immigrating to other countries, or staying and struggling to have a place in the community. Those who flee aspire to have a better and easier life and enjoy homosexuality somewhere else. Those who stay and wish to have a place in the community, opt to marry someone from the opposite sex and carry on his or her homosexual activities in secret.

In 1986, when we started to examine the level of sexual knowledge in public schools, we encountered several problems from the Ministry of Education. It was indeed not easy to get permission to conduct this study, simply because the officials of the Ministry were of the opinion that such a study would provoke homosexual feelings among the students. In fact, this is not true. In our opinion, and also according to the Kinsey Institute, homosexuality is not an abnormality, nor an illness or a disorder.

Today, in the Turkish Cypriot community laws inherited from the British colonial administration are still in force on sexuality. Since 1974, the Turkish and Greek communities are living apart in Cyprus as a result of events started by Greek Cypriots in 1963. Negotiations are continuing, and there is hope for a peaceful solution. The Greek side has already enacted the relevant law legalizing homosexuality. The Turkish community has so far not done so. Nevertheless, homosexuality is legal in the European Union, which both communities are trying to join.

7. Gender Diversity and Transgender Issues

In Northern Cyprus, there are very few transsexuals. In 1996, five people, three women and two men, who were anxious to change their sex, were interviewed. Although they all wanted to have a surgical operation immediately, they all believed that if they stayed in Cyprus, they could be ousted from the community. All claimed that they could reach their goals easier abroad in developed, large countries.

8. Significant Unconventional Sexual Behaviors

A. Coercive Sexual Behaviors

Sexual Abuse of Children and Incest

In small communities like the Turkish Cypriot community, any attempt of child sexual abuse can easily be uncovered and can have widespread repercussions. Such events are also given great coverage in the press.

According to the reports of the Criminal Department, only three incest cases occurred during 1995-1996 in Northern Cyprus. On the other hand, there were 12 cases of child sexual abuse. In fact, these figures are probably incorrect. In order to avoid scandals and disgrace, and to protect the family honor, events among relatives are not reported to the police.

Rape and Marital Rape

According to police reports, cases of rape have increased in the Turkish Cypriot community after the arrival of immigrants from Turkey. These reports claim that the numbers of such cases are 12. However, the opinion is that these do not reflect the real situation, as raped women are afraid of a bad reputation in the community and, therefore, prefer to remain silent.

Marital rape is even more common than anticipated, because violence in the family has always existed in both communities in Cyprus. Some cases of marital rape consist of attempts by men to have anal sex with their wives against their will. In most cases, men usually act only in accordance with their egocentric feelings and desires, and do not take into consideration the psychological feelings of their wives. Sometimes, men go to such extents, that woman have no other choice but to complain to the police. However, both the police and the members of the family do their best to avoid going to court. The main reason for this is the fear that during the trial period, family honor will be harmed, and the families of both the husband and the wife will be disgraced considerably.

Irrespective of the belief that the number of such cases may have decreased during recent years, it is essential to continue investigating these cases in the Turkish Cypriot community.

Sexual Harassment

In the Turkish Cypriot community, sexual harassment of women by men generally occurs at the place of work. The offer of promotion priority and higher payment is used as an excuse to sexually harass and violate the woman employee. Additional dangers await women subjected to this sort of sexual harassment. Other male employees might consider the woman as easy prey, risking the honor of the woman and her family.

In 1994, there was a report in the local press about the sexual harassment of a woman at her workplace. Following this publication, a questionnaire was sent to about 200 female employees in various workplaces. Three out of four women surveyed replied that sexual harassment was rather widespread in the Turkish Cypriot community. Women working as cleaners in private homes and belly dancers were also possible targets. Sexual harassment in schools and in government offices is less common.

B. Prostitution

Although prostitution is illegal, it was common knowledge that, until recent years, prostitution was practiced in certain houses. However, nowadays, there are no local prostitutes, because girls known as “Natasha” from countries like Russia, Ukraine, Moldavia, Romania, and Thailand are in abundance operating as prostitutes, usually controlled and forced by the nightclub owners. These girls claim that they only get 25% of the money received from the customers in return for sexual intercourse, with the rest of the money being kept by the bosses.

C. Pornography

See survey results at the end of Section 3B, Knowledge and Education about Sexuality, Sexual Knowledge in the Turkish Community.

D. Sexual Crimes

The incidence of sexual crimes in the Turkish Cypriot community is very low. This number is so low that it is not worth dwelling on it. Kidnapping of children has not taken place during the last five years. According to police reports, there were 6 cases of rape in 1997, 5 in 1998, and 7 in 1999. Seduction, indecent assaults against women, and indecent offenses were also found to be very rare.

9. Contraception, Abortion, and Population Planning

A. Contraception

To avoid pregnancy, males have learned to use condoms, and the females hormonal contraceptive pills and intrauterine devices (IUD). In extramarital sexual relationships, the males prefer to use condoms, as this is a precaution against sexually transmitted diseases and AIDS as well.

In the Turkish Cypriot community, the question as to which one of the couple is mostly responsible for the prevention of pregnancy during their marriage is very important. Is it the woman or the man? In fact, the best method for couples that do not wish to have children is for the man to have a vasectomy operation. This is the simplest and safest method (Kelâmi et al.). If the couple change their mind and wish to have children again at a later stage, the man can easily have a vasectomy-reversal (vasovasectomy) operation.

In a study carried out in 1996 among 100 couples, it was ascertained that only 2% have had vasectomies and 8% had tubal ligation. The same study showed that 15% of men used condoms and 20% had coitus interruptus, 35% of women used pills and 15% used the IUD. Five percent of the couples took no precaution. In these cases, tests revealed sterility in either the man or woman.

In contrast, most of the immigrant families from Turkey in the Turkish Cypriot community, take no precautions against pregnancy, so many of their families have between 5 to 10 children. However, when questioned about the number of children and their socioeconomic problems, their common reply was: “No problem, God will give the livelihood of the children.”

B. Abortion

Abortion is the only way to end undesired pregnancies. As stated previously, abortion is illegal except in very exceptional circumstances. However, it is quite possible to get an abortion in the private clinics in Northern Cyprus, despite the fact that this is considered a sin and crime in Islam. In a study carried out in 1999 by Bolayır and Gökşn among 300 women, it was determined that 21% of the women had had one abortion, 15% had had two, and 5% had had three or more abortions. There are no doctors in Northern Cyprus who will not perform abortions for ethical reasons.

C. Population Programs

The total population of Cyprus is about one million. There has been no steady increase of the population of Northern Cyprus during the last 50 years. The reasons for this are the political problems and intercommunal conflict. These compelled a large number of Turkish Cypriots to emigrate from the island. However, after the Turkish intervention in 1974 and the agreement to relocate the Greek Cypriots from the North to the South and Turkish Cypriots from the South to the North, there has been a sudden increase in the population in the Turkish community. This is because of the arrival of immigrants from Turkey. In 1974, the Turkish Cypriot population was about 120,000; in 1999, it was 200,000.

In Northern Cyprus, there is no official department of the government to direct family planning. This is done by specialist doctors. People, too, have learned to keep a balance consistent with their socioeconomic condition. However, tax exemptions for children encourage people to have more than one child. Parents with more than one child also enjoy subsidies in school fees and facilities in hospitals.

10. Sexually Transmitted Diseases and HIV/AIDS

A. Sexually Transmitted Diseases

In Northern Cyprus, people suffering from STD generally prefer treatment by private medical practitioners because they want to keep this a secret. Although it is a legal obligation to report such cases to the Ministry of Health, in general, medical practitioners, urologists, gynecologists, and dermatologists refrain from doing so. Therefore, there are no reliable records on STD in Northern Cyprus, except for AIDS, which is normally reported. The only available data is from our own clinical samples, results learned from our researchers, and from official statistical information given out monthly.

As stated earlier, the study carried out among 100 young people in 1990 confirmed that they had insufficient knowledge on sexually transmitted diseases. Faced with this finding, we were requested by schoolteachers to give talks to the students on all matters related with sex. Up to now, we are doing this task periodically. In the course of these conferences, it was discovered that AIDS was the main topic of interest. For instance, 98% of the participants did not know that the papilloma virus causes warts in the genital region. Another virus, the herpes genitalis, enters the body and remains there for the rest of one’s life and causes painful sores on the skin of the genital organs that may reappear from time to time for many years. Also, chlamydia and gonorrhea, if not treated, lead to scarring in the channels of the genital organs. These scars might cause infertility in females and urethral stricture in men, as well as facilitate entrance of the HIV virus into the body.

In Northern Cyprus, men who have sexual intercourse with girls in nightclubs do not know whether the girls are drug users or recipients of blood transfusions, but they should at least know that they are risking exposure to HIV and/or some other STD.

During the period of 1996 to 1998, the number of cases officially reported are shown in Table 20. According to our clinical experience, Turkish Cypriot schoolchildren are anxious to learn more about STDs. But the question is, from whom are they going to receive this information? Although the young have learned to use condoms, the majority do not know how and/or what type of condoms to use. Neither do they know the exact benefits of using a condom. It is obvious that sex education should be a must in every school. The question is how to introduce this information into the school curricula and train teachers to present the information.

B. HIV/AIDS

AIDS is a frightful disease in Northern Cyprus as it is in the whole world, particularly because a person with this deadly infection is seldom aware of the infection and continues to have sex, thus transmitting the disease to others. Throughout the world, as well as in Northern Cyprus, there are thousands of undiagnosed individuals with HIV, as this infectious disease takes a long time to manifest itself. Thousands of tourists from various countries of the world visit Northern Cyprus every year, and certainly some of these have sexual intercourse with Turkish Cypriots. Even if only a fraction of these are unknowingly HIV seropositive, their partners can easily be infected.

The only way to find out whether one has AIDS is to have a blood test. The ELISA test (enzyme-linked immunabsorbant assay) is generally performed in the Burhan Nalbantoglu State Hospital, but there is no way to require Turkish Cypriots suffering from other sexual transmitted diseases and drug users to have the ELISA test. Such a requirement for arriving tourists is beyond any practicality. However, the application of the ELISA test in Northern Cyprus started in 1986. According to Dr. Tansel Dikengil, the head of the Microbiology Department of the State Hospital, 180,000 people are annually subjected to the ELISA test. This test is applied to every patient undergoing an operation, to newly married couples, and those who apply to become citizens. The test is also obligatory for individuals who are known to have had sexual intercourse with an HIV-seropositive partner. Under an agreement between the Ministries of Health of Northern Cyprus and Turkey, Refik Saydam health institute in Ankara also confirms the result of the tests that are found to be HIV seropositive in Northern Cyprus. The Ministry of Health of the TRNC (Turkish Republic of Northern Cyprus) reports these results to WHO at the end of each month. The results of the HIV-seropositive tests between the years 1987-1999 are shown in Table 21. The most recent number of seropositive persons in the TRNC is 87. Of these, 27 were Turkish Cypriots and 60 were foreigners; 70 were men and 17 women. The average age was 31.8 years. Out of the total 87 cases, 40 were heterosexuals and 47 were homosexuals. Three cases were the result of blood transfusions and five were drugs users.

In Northern Cyprus, of the 15 total cases of AIDS, 12 were male and 3 female. These patients received treatment in medical centers in Ankara and Istanbul. Three patients died in Northern Cyprus. The foreign patients, 80% of whom came from Moldavia, Russia, Ukraine, and the Far East, were sent to their countries at their request. In 1996, Gökşn carried out a test on 2,000 soldiers between the ages of 19 and 23 yrs. No cases of HIV seropositivity were found as a result of these tests. The ratio of 0.1% HIV in Northern Cyprus is rather low compared to other countries.

Treatment, Prevention Programs, and Government Policies

In Northern Cyprus, the Ministry of Health educates the public on AIDS throughout the year, but especially on the first of December, which is worldwide “AIDS Day.” Lectures, television and radio panels and interviews, and other activities are organized. The public is continuously reminded that the most important preventive measure for AIDS is the use of condoms. Brochures, leaflets, posters, key rings, and T-shirts are used in the anti-AIDS campaign to stress the fact that risky sexual intercourse without using condoms is the main factor of the AIDS infection, not forgetting blood transfusions and the hazards of prenatal transmission.

Cooperation with the World Health Organization and UNAIDS is an important issue in Northern Cyprus. The main criterion is the prevention rather than the cure of AIDS. The media plays an important role in all anti-AIDS campaigns. However, the difficulty is educating the homosexuals, drug users, and those frequenting prostitutes. It is emphasized that abstinence from sex and the correct use of condoms are very significant in preventing the spread of the disease among the community.

[Update 2002: UNAIDS Epidemiological Assessment: This combined epidemiological assessment is for both the Turkish Republic of Northern Cyprus (TRNC) and the (Greek) Republic of Cyprus.

[HIV seroprevalence among blood donors has been reported below 0.01% in Cyprus since 1989. There was no evidence for HIV infection among pregnant women that were tested from 1998 until 2001, with the exception of one HIV case detected among 4,019 pregnant women in 1992 and one case detected among 2,422 pregnant women in 2001. HIV seroprevalence among bar girls remains below 1%. No infection has been detected among sex workers over the years. HIV prevalence among injecting drug users is reported to be between 0.1% and 0.3% between 1993 and 1999. Of clients of voluntary counseling and testing, 0.4% and 0.8% were found to be HIV-positive in 1999 and 2000, respectively.

[The estimated number of adults and children living with HIV/AIDS on January 1, 2002, were:

[No estimate is available for the number of adults and children who died of AIDS during 2001.

[No estimate is available for the number of Cypriot children who had lost one or both parents to AIDS and were under age 15 at the end of 2001. (End of update by the Editors)]

11. Sexual Dysfunctions, Counseling, and Therapies

A. The General Situation in Northern Cyprus

During the 1980s the main author and his colleagues carried out a series of research surveys in the Turkish Cypriot community with the support of the late Prof. Dr. Alpay Kelâmi. The results of these studies indicated that the level of sexual knowledge was inadequate and that there were no qualified professionals to treat the individuals suffering from sexual dysfunction. People were mostly ignorant as to which physician was knowledgeable or involved in treating sexual dysfunction of either men or women. Most were inclined to visit general practitioners. In 2003, Cypriots who seek professional help with a sexual problem are limited to a few general medical practitioners, andrologists, and gynecologists who have expanded their interest and expertise to include some professional training in sexual counseling and therapy.

In the traditional mentality of the people in Northern Cyprus, the sexual organs were to be concealed at all times, The sexual organs were considered taboo, prohibited areas of the body that were not exposed or discussed, even with a spouse or physician. When it came to a disease or functional disorder of the sexual organs, nothing is disclosed to close family members. Even visits to the physicians are avoided, with the belief that the disorder may be temporary and might cure itself. If the situation continues for a longer time, the advice of the same-sex elders in the family or close friends of the same sex might be sought. A visit to a doctor is only considered when nothing else works. Sometimes, the treatment is made more difficult through the waste of precious time. If, however, the ailment were in any other part of the body, friends and family would be extensively asked for advice and the doctor visited immediately.

Understandably, the few pioneering physicians who have decided to address sexual issues in Northern Cyprus have come from the well-established fields of urology and gynecology, and the new field of andrology, the diagnosis and treatment of the dysfunction, function, and disease of the male genital organs.

In the field of andrology in general, and contributions to the sexual health of the people of Cyprus in particular, it is a great pleasure to stress the services of the late Prof. Alpay Kelâmi. Turkish and Greek Cypriot urologists attended courses on andrology and urology at the Free University of Berlin organized by Kelâmi. He also played a leading role in organizing numerous International uroandrological symposia in Northern Cyprus. Distinguished doctors, all authorities in their fields, from all over the world attended these international symposia and presented papers and had discussions on relevant subjects. Several Turkish Cypriot doctors, and doctors from Turkey and other countries had the opportunity to exchange views with the participating foreign specialists. Unfortunately, however, the Greek Cypriot authorities did not allow Greek Cypriot doctors to attend these symposia because of political reasons. Prof. Kelâmi also participated in TV and radio interviews after each symposium in Northern Cyprus between the years of 1980-1992 and enlightened the public on sexual issues. His innovative “Art and Andrology” exhibitions during the symposia were additional means of bringing the medical sexual issues to the attention of the lay public.

Having acknowledged the many contributions of the late Professor Alpay Kelâmi to the sexuality education of physicians and to the sexual health of Turkish Cypriots, because he was a urologist/andrologist, his focus in sexuality was on the male, and the treatment of women was more restricted to their procreative role.

B. Diagnosis and Treatment of Sexual Dysfunctions

The first author of this chapter on Turkish Cyprus is a physician specializing in uroandrology with some 20 years experience in treating sexual dysfunctions. An associate professor of urology, he has presented papers on andrology, sexual therapy, and rehabilitation at three-dozen professional meetings and has organized several international conferences on urology and andrology. The observations offered here are based on the main author’s clinical practice.

Diagnosis and Treatment of Erectile Dysfunction

For many years, the cause of male impotence was believed to be solely psychological in origin. Even today, some physicians believe that the majority of cases of male impotence have some psychological origin. This is not correct. In fact, more than 80% are primarily of physiological origin, although many of these patients are affected psychologically later on.

In the past decade, clinical research in erectile dysfunction has demonstrated that penile erection is a vascular and neurological phenomenon. In our clinical experience, when we evaluate a male patient suffering from impotence, we consider that erection appears to be the result of three hemodynamic stages, the proper clinical evaluation and management of which requires an understanding in anatomic and physiologic aspects of these prerequisite events.

An impotent patient in Northern Cyprus is evaluated by a sensitive medical interview. The initial evaluation is based on doctor-patient communication during history taking together with the husband and wife/partner. Unfortunately, however, in Northern Cyprus, the visit of the husband to the doctor together with his wife/partner is an important problem. The Turkish Cypriot community is a small and conservative unit. The traditional mentality is that discussing sexual matters in the presence of a doctor will damage the family dignity. In fact, women are reluctant to discuss these matters with any person. Women in general shoulder so many responsibilities in the family that probably sexual affairs are ignored. In the traditional mentality, the women even refrain from discussing sexual matters with their husbands. So, many women over the age of 50 years never like to visit doctors to discuss sexual issues. However, in recent years, couples are beginning to visit doctors jointly to discuss their problems. This is a good omen for the future.

In taking the sexual history of the patient, Turkish Cypriots use a different sexual terminology than physicians, creating a communications problem that needs to be addressed and resolved. Questions are especially directed to verify the existence of an erectile problem, because sometimes patients describe impotence as lack of libido, or retarded or premature ejaculation. By the end of the interview, the physician should be aware of the patient’s problem. History taking leads to identifying psychological and physiological factors that may affect erectile performance. Most cases involve both physiological and psychogenic erectile dysfunctions. These findings are confirmed by intracavernal injection tests and analyses of blood, urine, and hormones.

One common disease that causes erectile dysfunction in men is diabetes. In the Turkish Cypriot community, when looking at the patients who suffer from physiological erectile dysfunction, the following symptoms are seen; gradual loss of erectile ability, change of rigidity of the erection, and diminished morning erections. In contrast, if the suggestive diagnosis is primarily of psychological origin, predisposed individuals may be affected and the long-lasting rigid erections, as well as morning erections, may diminish and disappear for a long time. Our clinical experience has shown that, as in other communities, purely psychologically impotent men are very rare. Looking at the ages, we see that most of the impotent patients of psychological origin are under age 40 while patients with physiological impotence are over age 40.

When looking at the options of treating patients with erectile dysfunction, it can be seen that many advances have occurred, such as penile prostheses or the “miracle drug” sildenafil (Viagra). Patients with erectile dysfunction in Northern Cyprus received either nonsurgical or surgical treatments. Among the alternatives to surgical treatment for impotent patients are: intracavernous injections, vacuum devices, hormonal injections, behavioral sex therapy, and sildenafil (Viagra). If all these treatments fail to remedy the erectile dysfunction, then the patient is advised to have surgical treatment. In Northern Cyprus, we apply venous and arterial surgery for vasculogenic impotence or use penile prostheses in these patients. The majority of the impotent patients who received penile prosthesis in our clinic were diabetic.

Since 1980, 640 males were treated in our clinic for erectile dysfunction: 70% of these were cases of impotence, 17% of premature ejaculation, 7% of honeymoon impotence, 4% of sexual desire disorder, and 2% with retarded ejaculation.

Honeymoon Impotence

This is normally seen in male patients with anxiety and a lack of sexual experience and knowledge. According to our clinical experiences, the custom in the conservative community of expecting a spot of blood on the sheet on the wedding night, plus the expectations of the family members of the bridegroom, can easily cause him increased anxiety and prevent him from having an erection. A few more unsuccessful attempts may lead the young groom to believe he is permanently impotent. An andrologist can easily diagnose this “honeymoon impotence” and the treatment of such cases is very easy in modern medicine. Between 1999 and 2001, 13 cases of honeymoon impotence were treated in our clinic. As all cases were found to be because of psychological impotence, the treatment results were very satisfactory.

Early Ejaculation

According to our clinical experience, the patients who suffer from early or “premature” ejaculation have a good erection initially, but the duration of the erection changes from between 10 to 15 seconds up to 2 or 3 minutes. These patients do not like to receive early treatment, as they believe that this problem threatens their male ego. They prefer to continue to suffer from this situation rather than visit a physician. However, upon increased coercion from their wives, they eventually seek medical advice from an andrologist or sexologist. In these cases, men always visit their doctor on their own. It has to be stressed that sex therapy is very effective with this disorder.

Drugs Affecting Sexual Function

According to our clinical experience, there are diseases that affect erectile dysfunction, such as diabetes, vascular diseases, hypercholesterolemia, alcoholism, heavy smoking, depression, and hypertension. Some of the pharmaceuticals used in the treatment of these diseases may affect erection. They may also affect sexual desire (libido) and ejaculation. Although there are numerous publications, both epidemiological and anecdotal, on the adverse effects of these drugs, many physicians are still not aware of these negative side effects.

Dysorgasmia and Anorgasmia

Very few cases of male dysorgasmia have sought help in our clinic, Those who do are usually men over the age 40.

As noted earlier, women do not like to discuss their sexual problems with strangers, with family members, or with a specialist doctor competent in the field of sex. The majority of these women are unhappy and complain about their lack of sexual satisfaction, despite the insistence of their husbands to make love to them regularly. According to Özyigit, most sexual complaints from the females involved inhibited orgasm, vaginismus (vaginal spasms), and coital phobia, most cases of which can be traced back to negative sexual learning, misinformation, religious inhibitions and prohibitions, or lack of sexual knowledge.

Dysorgasmia among women is more frequent in a long-term marriage. This is believed to be because of the heavy burden of the women, housework, childcare, and the need to work outside the house, as well as contribute to the family budget. Men’s insistence on making love whenever they desire, without taking into consideration the feelings of the women, and their failure to include enough foreplay prior to sexual intercourse, are among the reasons for women’s dysorgasmia. In Northern Cyprus, the main cause that diminishes sexual desire for women is the lack of quality in the sexual foreplay. Many Turkish women are deprived of enjoying orgasm, but yet prefer to suffer in silence instead of speaking out. In brief, women avoid revealing or discussing their dysorgasmia or anorgasmia problem, and so suffer without relief.

Sex Therapy

It is common knowledge that one of the most effective behavioral therapies for erectile dysfunction, the sensate focus exercises, is designed to reduce the performance anxiety that is interfering with erectile dysfunction. This requires the cooperation of both of the sexual partners. In Northern Cyprus, behavioral sex therapy is applied to all patients with erectile dysfunction as the initial choice of treatment. Between 1990 and 1994, 90 patients were evaluated, and those diagnosed with erectile dysfunction of psychogenic origin showed a good response to sex therapy.

In 12 out of 20 cases of early ejaculation, a combination of sex therapy and the sildenafil drug produced a very good response. Seventy percent of the patients who did not respond to sex therapy alone, received another type of combination therapy. This included intracavernous injections, vacuum therapy, the sildenafil drug, and sex therapy. According to investigations, these patients’ disorder had physiological origins, and most had significant performance anxiety as well. In our cases, very few received sex therapy together with the intracavernous injection.

C. Certification and Advanced Education

In many developed countries, in both Europe and North America, as well as both the Greek and Turkish communities of Cyprus, licensed physicians, psychologists, and psychiatrists can offer sexual diagnosis, counseling. and therapy as part of their healthcare expertise. In many countries, including both Cypriot communities, there is no further regulation, certification, licensing, or required training for sex educators, counselors, or therapists as such, apart from the standard licensing or certification of traditional healthcare professionals. If a political solution is found to the separation of Cyprus’ two communities, and the island becomes a member of the European Union, these issues will then hopefully be solved.

12. Sex Research and Advanced Professional Education

Despite the research that has been done in Northern Cyprus since 1980 on sexual matters, we believe that further research is necessary.

Political, social, and economic problems prevailing in Cyprus for the last 50 years have had adverse effects on sexuality. These problems have caused several interfamily discords between the older and young generation. The research studies that we carried out in the Turkish Cypriot community have shown that sexual knowledge is insufficient. The young make use of foreign publications, magazines, journals, and TV programs. Because these publications are produced outside of Northern Cyprus, they address their own communities and do not generally meet the requirements of the Turkish Cypriot community. There is a definite need for periodic publications on sexuality produced within the Northern Cyprus community and similar material addressing the Greek Cyprus community. On the other hand, widespread intersectional research and surveys on sexuality have to be made in order to have reliable information for future planning. There is also need for a clear need for family, relationship, and sex counseling.

However, the prevailing political structure in Cyprus has so far prevented cooperation between the two communities. There is need for cooperation in the fields of dangerous diseases, such as AIDS and so on. Laws have to be enacted by both communities on patient’s rights in keeping with the WHO requirements. Nongovernmental organizations in both the North and South have to cooperate and work more closely in every field of health. And finally, universities in Northern Cyprus have to contribute more towards sexual education.

References and Suggested Readings