4.1. Defining the MENA region

The geographical area of interest is the MENA region, which, according to UNICEF, includes 20 countries [14]. In the first phase of the review, there were two inclusion criteria: the official language and religion as articulated in each country’s constitution. The focus is on those countries in which Arabic is solely the official language (thereby excluding Iran and Djibouti), and in which Islam is the official state religion (thereby excluding Lebanon, Sudan, and Syria) [15–17]. Language and religion are crucial in establishing cultural linkages and similarities among the remaining 15 countries, namely, Algeria, Bahrain, Egypt, Iraq, Jordan, Kuwait, Libya, Morocco, Oman, Qatar, Saudi Arabia, Palestine, Tunisia, The United Arab Emirates (UAE), and Yemen.

The commonality of a language is a key factor in understanding and conveying the truth about a culture [18], and Arabic is the language in which the holy Quran is written. Similarly, religion is an ancient human institution that has an undeniable impact on individuals and societies [19]. The establishment of Islam as the official religion of a nation in its constitution acknowledges the significant role played by religion and demonstrates both its cultural and political importance for the countries of focus in this study [20]. It has been asserted that, in many parts of the world, Islam has been a force for homogenizing and harmonizing societies on cultural and moral levels, and establishing standardized central beliefs and values [20,21].

4.2. Burden of HPV in the MENA region

Several investigations have identified particular geographic areas linked to HPV-induced cancers and the prevalence of the infection itself. Nonetheless, the countries in the MENA region were neither highly represented nor covered by many of those studies, leading to a shortage in data vis-à-vis the burden of HPV and related cancers in this region [22]. Assessment of HPV prevalence is difficult because screening is uncommon and there are insufficient regular national cancer registries [5]. For example, in Bahrain, Libya, Oman, Palestine, and Qatar, no studies were conducted to detect the presence of high-risk HPVs in human cervical cancers. By contrast, very limited studies explore its prevalence in Algeria, Egypt, Jordan, Kuwait, Morocco, Tunisia, and the UAE (Table 1 ) [7,22].

The prevalence of HPV in preinvasive cervical lesions ranges from 50% to 100% in North Africa (Algeria, Egypt, Libya, Morocco, and Tunisia), from 32% to 66% in the Middle East (Jordan and Palestine), and from 37% to 67% in the UAE; for the case of benign genital warts, the prevalence was 84.4% to 87.5% for Tunisia [7].

The prevalence of HPV in the MENA countries presents a public health issue, even though studies have shown that it is low and that cancers induced by HPV present low rates in the general population of these countries [7]. However, this issue might escalate and become a public health threat if not tackled promptly. It has been noted that the majority of women in the region do not have access to the preventive services such as the Pap test, which allows for the early detection of cell abnormalities, or to preventive vaccines against the high-risk HPV types [22]. Adopting HPV vaccinations would be a feasible intervention because most countries in the region have already established efficacious vaccination delivery programs [7].

4.3. HPV in the cultural context

Countries in the MENA region are conservative regarding sexual behaviors compared with the West, because they have more traditional religious and social norms [5]. Indeed, Islam shapes people’s practices and habits, including sexual and reproductive health and imposes that sex be carried out within the context of marriage [6]. Cases of STIs in the region are thought to be higher than reported, leading to a false belief that STIs are rare there [7].

This region has the second youngest population in the world, with 90 million people aged 15–24 [6]. Despite reports that the age of sexual debut is highly correlated with the incidence of HPV globally, there are insufficient data about sexual debut in the region because the topic is perceived as a taboo; however, the sexual debut age is estimated to be between 19 and 23 [7,23]. Compared with precedent evaluation, the percentage of youth who are engaged in premarital sexual activities is increasing [6]. It has also been reported that the age of marriage is delayed for both sexes and the number of people getting married at a young age is declining [6]. All those factors offer evidence that standard sociosexual behaviors are drastically changing in the MENA region, particularly among the younger generation, which may, in the long term, increase STDs’ transmission and incidence, particularly of HPV and related diseases [6,7].

Mental and physical health are affected by religion, which plays a protective role in hindering the occurrence of diseases [24]. Similarly, the perception and understanding of diseases and the acceptance or refusal of certain treatment techniques or preventive measures is significantly impacted by religion [25]. In the case of HPV preventive measures, it has been asserted that conservative cultural and religious views may constitute barriers to their acceptance. For instance, qualitative studies have shown that among parents’ principal concerns are discussing sexual activity with their children, and the perception that a consent to vaccinate is a tacit encouragement to become sexually active [26]. Studies conducted in Britain have shown that acceptance of the vaccine was less likely among adolescents who are practicing Muslims. Ethnic differences in HPV vaccine acceptability were gauged in a British study, which revealed that sex-related concerns such as premarital sexual activity were the reason given by 20% of Muslim Pakistani mothers compared with 2% of the white British ones for declining vaccination [13,27].

5.1. Islam and sexual behavior in the Holy Quran

What is the Holy Quran?

The Holy Quran is the primary book of Islam, the third Abrahamic religion [28]. Muslims consider it to be a sacred text and the ultimate message of God to the entire human race revealed in the year 610 CE over a period of 23 years to the Prophet Muhammad through the angel Gabriel [29,30]. The Quran is not primarily a book of rules, but instead it serves as guidance, stimulation to the minds and souls, and a proof of God’s marvels. It is composed of 114 surahs, which are equivalent to chapters.

5.2. Sexuality in the Quran

The practice of sexual relations across cultures and societies occurs within a framework that is often subject to strict interpretations and regulations [29,31]. From a Quranic perspective, sex is regarded as a holy activity and a human need that should be satisfied in a lawful and appropriate manner with legitimate partners [31]. The concept of pair (zawj) is central to life and procreation [29] as the following Quranic text states: “Glory to Allah Who created in pairs all things that the earth produces as well as their own (human) kind and (other) things of which they have no knowledge” (Quran, Surah 36, Verse 36) [32]. Abstaining from all sort of sexual intercourse outside of the legitimate (halal) frame for both sexes reflects purity and high morals, whereas any unlawful (haram) practices (zina) are sins, which deserve punishment during life on earth and after death [31] (Table 2) [31,32]. In the Quran, around 27 verses are dedicated to the denunciation of the unlawful sexual relation [29].

5.3. Islam and sexual behavior in the Hadith

What is the Hadith?

The Hadith is a collection of sayings, actions, and permissions of the Prophet Muhammad as reported by reliable witnesses [33]. This collection is considered to set an example and illustrate the ideal behavior for all people [29].

5.4. Sexuality in the Hadith

Many sources of Hadith demonstrated that sexual desire is a natural need and the sole decent and encouraged way to satisfy it is through a lawful relationship such as marriage [31,34], whereas illegitimate sexual practices are considered a great sin that deserves punishment [31,34] (Table 3) [34–37].

5.5. Islam and sexual behavior in the literature

The scholar Rizvi, whose work emphasizes on interfaith and peace advocacy, has argued that being a Muslim requires the acceptance of the limitation of the individual’s personal freedom because God has rights on us that should be respected and never transgressed. However, to handle sexual needs and impulses, he described what it is called “lawful temporary ways,” which consisted of whether to temporarily abstain or temporarily get married. The latter is called mut’a (pleasure) [37]. He also described the varied ways in which tensions between religion and sexuality have been expressed by the social systems and the conflict and the difference between the fundamentals of the Islamic teaching on sexuality and the new concept of sexual freedom in Muslim societies [37]. In this context, the Tunisian human rights advocate and sociologist Bouhdiba describes that the perception of the role model symbolized by the Prophet Muhammad and his teachings from Hadith to Sunna has deteriorated through history, and even became considered as primeval. As time goes by, the number of Muslims who abandon that model is increasing [29].

The Egyptian feminist writer Nawal El Saadawi declared that freedom is a key factor for both sexes in all facets of life [38]. However, she argues that freedom at the economic and social levels did not grow and blossom simultaneously with the sexual level, which might have induced distortions within societies including the Arab society [38]. Lately, a noticeable shift has been observed in youths’ sexual behavior, where the occurrence of unofficial sexual practices, whether extramarital or premarital, has dramatically increased [31]. For example, there is zawaj al-misyar (marriage in transit), characterized by restricted matrimonial rights (housing, financial, support, etc.), and which is endorsed by couple of muftis in Saudi Arabia [31]. In Egypt, it is common to witness the phenomenon of zawaj‘urfi (customary marriage), which is a union that is not reported to the official authorities and where women have very limited rights [31]. Nonetheless, several Muslim societies are in denial and reluctant to face the reality of this phenomenon, which is attributable to the fact that people tend not to admit or disclose their sins and that it is culturally and religiously recommended not to reveal others’ sins [31].

Muslim societies are experiencing deep changes vis-à-vis gender relations as well as sexual life; the ancient model is no longer applied as it used to be on different paramount facets [31]. It is an era characterized by tension, perplexity, doubt, and confusion induced by veering sexual codes and norms and the questioning of the religious ethics [39]. This drastic behavioral change in Muslim societies, including those in the MENA region, might in the long-term increase HPV incidence and its related diseases [6,7].