Now in the last post on the topic, I mentioned that EC website that Princeton runs, http://ec.princeton.edu. There’s an NGO in Cambridge, MA called Ibis Reproductive Health that got a grant to make EC information and educational materials available in Arabic. A significant chunk of that grant was dedicated to creating an Arabic language version of the EC website. At Ibis, Angel Foster led this project and I took on the job of putting up the Arabic text that she created (with translator Aida Rouhana) online.
These days it’s not that hard to do websites in Arabic, but six years ago, it was a real puzzle. I couldn’t find any Arabic language plug-ins for DreamWeaver or FrontPage, so as I cut and pasted the Arabic text into the HTML programs, it wouldn’t display the Arabic properly, so it was really hard to do the links on specific words. The Arabic phrase for emergency contraception, which looks like this in Arabic:
منع الحمل الطارئ
looks like this in HTML code:
منع الحمل الطارئ
So I just had to muck around, highlighting different phrases, counting off letters or doing searches for strings of HTML code like that above, putting in links and then seeing where the links showed up in the Arabic texts, and then shifting the links around accordingly. It was a stupidly slow process. There was probably a better way to do it, but I wasn’t able to figure it out, so I slogged through the slow way.
Translation vs adaptation
I’m getting off the topic. Angel had decided that we couldn’t simply translate the existing website into Arabic. It had to be adapted to fit the social and cultural context of the Arabic speaking world and meet users’ needs. So, for example, she decided to include specific questions in the FAQs section on the interpretation and acceptability of EC in Orthodox Christianity and in Islamic jurisprudence. We hunted around for any fatwas on EC, both in published compendia of fatawa as well as in online databases, but we couldn’t find any. In fact, in the past 5 years, I have only found 1 fatwa on EC in an one of the many online fatwa databases.
That’s where interest in this Egypt research project came from. What did it mean that there were no fatwas on EC? Either it meant that EC wasn’t on anyone’s radar screen and was so totally unknown that nobody was asking about its status in Islam – hard to believe since there were dedicated products available in several Middle Eastern countries (including Yemen, Egypt, Tunisia, and Lebanon) – OR it meant that EC was just wholly uncontroversial and subsumed under jurisprudential discussions about pre-coital hormonal contraceptives.
Well I thought that was a really interesting possibility, considering how in the U.S., as I previously described, EC’s status as a contraceptive vs. abortifacient has been contested, and debate often hinges on the mechanism of action.
Angel and I developed a working hypothesis, which we published in a little paper for Harvard Health Policy Review along with colleagues James Trussell and Aida Rouhana: that debate over EC in the Arab world was likely to hinge around the social and moral contexts of the sex that precedes EC use, rather than focusing on mechanism of action. We hypothesized this partly based on existing debates in Islamic jurisprudence about contraception, but also based on interpretations of abortion in Islamic law, where the acceptability of abortion is partly considered in light of when life begins. (Also considered is the relative value of the mother’s life versus the life of a fetus: in contrast to some extreme Christian interpretations, in Islamic law the woman’s life is always considered more valuable than the fetus’s life, because the woman is already embedded within existing kinship networks of sociality and obligation, whereas the fetus is not.)
In most of the interpretations of the four Sunni schools of Islamic jurisprudence, ensoulment, the joining of the soul with the developing fetus, is not believed to occur right at the moment of fertilization or implantation. Some jurists think ensoulment occurs at 40 days, while others opine that it does not occur until 4 months, the time when the pregnant woman can usually start to feel the movements on the fetus inside her. This, we speculated, would predict a lack of debate about EC’s mechanism of action in the Muslim world.
By the way, I’ve repeatedly submitted questions to several online fatwa websites, requesting a fatwa on EC. Nobody has ever responded! Next year we plan to submit a request directly to Dar al-Ifta in Egypt (the main body for issuing fatawa in Egypt) to get a formal ruling. But my colleague, Dr Hosam Moustafa, has carefully searched the Dar al-Ifta archives and not found a single existing ruling.
Egyptian archetypes of EC users
I’ve described the archetypes of EC users that appeared in US debates. What archetypes are there in Egypt? First, I should note that there really hasn’t been much public debate about the topic. A dedicated product is available in Egypt and since most non-narcotic pharmaceutical products are, in practice, available from pharmacists without prescription, there was no situation where Egyptians publicly debated the appropriateness of EC being available without the mediation of a physician, as there was in the U.S. and many other countries.
Nevertheless, there seems to be a widespread assumption that emergency contraception will be used by women who are engaging in illicit, premarital sex. In short, EC has “the reputation of being used by teenagers and prostitutes,” as one informant put it. Why? As the same informant said,
“Pregnancy? Is this emergency? It is just a normal result. When will it be an emergency? When it is really negative with the sexual relation. This happens only when the sexual relation is not an accepted one, I mean haram [i.e. forbidden, illicit].”
The assumption is also that people who are having sex within a proper marital relationship will be able to plan their contraceptive use properly, so there won’t be accidents and emergencies – and if they accidentally get pregnant, well then that’s a gift from God, not a disaster.
The advertising used to promote Contraplan II (the dedicated brand of EC available in Egypt) works hard to dispel this association between EC use and illicit sex. The promotional materials published in major Egyptian newspapers in the last year suggests a list of likely EC users:
- People who are regularly using contraceptives but they missed a dose, a condom tore, or they had a problem with their IUD;
- People who had sexual intercourse without protection and the husband and wife don’t currently want to get pregnant;
- The husband suddenly returns from travel or from work abroad and there was no time to get started on a regular contraceptive method before they had sex; and finally,
- In case of rape.
The language makes it clear that most users will be married couples, with the rare exception of sexual assault.
But the marketing strategy of the company belies this portrait of the respectable married EC user. The radio ads promoting the product aired on Nogoom FM (“Stars FM”), a radio station that is directed towards teens and young adults – who are not likely to be married. The strategy seems to be to publicly put a respectable face on EC use, but to simultaneously make sure that info circulates amongst the community where need for EC is most acute: unmarried people who have sex.
OK that’s enough info on EC in Egypt. Next up, Viagra soup – but I’ll come back to EC in a later post when I write about our methods and the different kinds of info that a team of a female American anthropologist and a male Egyptian small-town physician are able to get…
References:
Foster A, Wynn L, Rouhana A, Polis C, Trussell J. Disseminating on-line reproductive health information in Arabic: Results from a survey of users of an emergency contraception website. CyberOrient: Online journal of the virtual Middle East. April 2006
Wynn L, Foster A, Rouhana A, Trussell J. The politics of emergency contraception in the Arab world: Reflections on Western assumptions and the potential influence of religious and social factors. Harvard Health Policy Review. Spring 2005; 6(1):38-47.
Foster A, Wynn L, Rouhana A, Polis C, Trussell J. Reproductive health, the Arab world and the internet: usage patterns of an Arabic-language emergency contraception website. Contraception. Spring 2005; 72;130-137.
This was a very interesting entry, and an interesting choice to contrast with America, not one most people I know think to use.
Definite food for thought here. Thanks!
Thanks, Cobalt. Yes, the comparison between Egypt and the US on this matter is interesting because most Westerners’ assumption is that Egypt would be much more conservative when it comes to women’s reproductive rights. But in fact, it’s the U.S. that’s more conservative when it comes to EC, partly because of different ideas about when life begins, and partly because the U.S. regulatory system is much stricter. We’ve encountered NGOs where they assume that they shouldn’t try to introduce ECPs in the Arab world because they won’t be locally acceptable. Why not? Because, they reason, if they’re controversial in places like the US and Catholic-dominated countries in South America, then they’ll be even more controversial in the Middle East. But the assumption doesn’t hold, because different places are conservative in different ways.
I am really excited by this research! As a future medical anthropologist hoping to study in Egypt this sounds so intriguing. One aspect I’m sure you’ve looked into but I thought I’d mention is the effect of globalization on women’s reproductive choices. This also brings in the pathologization of pregnancy in the West and how those views influence how we approach medical “problems” elsewhere in the globe. The fact that we term Plan B “emergency contraception” just enforces the idea that pregnancy is a condition that needs to be treated instead of a natural part of life. The visibility and stigmatization of women who use EC in America would be interesting to compare to the reactions in Egypt.
The population problem in Egypt also should play a part in contraceptive use and abortions. In a country whose population has doubled in twenty years sparks the debate of the government encouraging family planning to reduce poverty and overcrowding.
I can’t wait to read more!
Hey Kathleen, thanks! Yes, globalization and women’s reproductive choice, pathologization of pregnancy, absolutely. The pathologization of pregnancy in particular comes from economic models of public health costs: being pregnant is always associated with more morbidity than not being pregnant, and that costs money. But that model is tied to particular imaginations of economic systems. On pathologization of pregnancy and how that comes into conflict with local meanings of pregnancy, and on the “population problem” in general, I’m sure you’ve seen Kamran Asdar Ali’s excellent book, Planning the Family in Egypt.
On the “emergency” in emergency contraception: there’s an interesting history to that name. For a while, there were some pharmaceutical companies that tried to develop and market in several Asian countries a postcoital hormonal contraceptive to be used by women who were part of the migrant labor economy — either they or their husbands were migrant laborers, so they saw their partners rarely (and sometimes unexpectedly) and didn’t want to take a daily contraceptive pill. The effort fizzled out when it became apparent that it just wasn’t very effective. Using high doses of hormones after sex does reduce the risk of pregnancy significantly, but it’s still one of the least effective contraceptives you can use. So the “emergency” was borne out of activist efforts to get people to think about it as a last choice contraceptive, not one that should be relied on even irregularly as a first-choice contraceptive (also b/c it does nothing to prevent disease transmission).
For a while, activists were marketing it as the “morning after pill,” but then they decided to shift to calling it emergency contraception, for 2 reasons: 1) as mifepristone (RU486) started to become known, they wanted to distinguish it from an abortion pill and emphasize that it was a contraceptive (meanwhile, anti-EC activists insist on calling it the “morning after pill” for this very reason, because they contest its status as a contraceptive), and 2) activists worried that the “morning after” part was giving people the wrong idea: that it should be used a day after sex, when in fact it can be used up to 5 days after sex, but the sooner it is taken after sex, the more effective it is. Still, we know just from studying Google searches that “morning after pill” is much more widely known than the term “emergency contraception.”