New Reproductive Health Technologies in Egypt

Thanks to Kerim and Savage Minds for inviting me to contribute. I thought I’d write something about a new research project I’ve recently started on new and emerging reproductive health technologies in Egypt. This project looks at Egyptian interpretations of four technologies: emergency contraception, medication abortion, hymenoplasty, and erectile dysfunction drugs.

Some interesting paradoxes to contemplate:

  • Why are there at least a dozen local brands of sildenafil available from Egyptian pharmacies, and “Viagra sandwiches” or “Viagra soup” is on the menu at almost every restaurant that specializes in seafood, but there is only one brand of emergency contraceptive pill in Egypt, which is sold by an NGO because it’s not considered commercially viable enough for the mainstream pharmaceutical companies to bother with it?

The tap in the bathroom of the apartment where I stay when I’m doing research in Egypt. My roommate and I have often wondered where these came from. Was it a marketing campaign by Pfizer during the era when they weren’t allowed to engage in direct-to-consumer advertising for their product? Or did some sink manufacturer just think it would be cool to put Viagra on the handles?

  • A number of studies show that induced abortion (as opposed to “spontaneous abortion” aka miscarriages) is quite common in Egypt; one carefully designed study showed that there are probably as many per capita abortions in Egypt (where abortion is prohibited unless two doctors certify that it’s necessary to protect the health of the mother) as there are abortions in the United States (where it is constitutionally protected but often restricted). Misoprostol, a medication used to treat ulcers, can be used very effectively to induce early abortion, and it’s readily available without prescription from pharmacies in Egypt. Yet preliminary research suggests that its abortifacient properties are virtually unknown to Egyptians. It’s super cheap, and a lot safer than illegal surgical abortions. Women could induce abortions themselves for a few dollars, but instead they risk their future fertility, their health and their lives having unsafe abortions, or they pay huge sums of money to have illegal surgical abortions performed by qualified doctors outside of regular office hours. Why?
  • A recent fatwa (a ruling of Islamic jurisprudence) by a leading Egyptian jurist holds that, under certain circumstances, it’s OK for a woman to have surgery to repair her hymen before getting married, to hide the evidence of premarital sex. This fatwa is somewhat controversial, but the person who pronounced the fatwa is no rogue; he’s a highly respected cleric. So if one Islamic authority says it’s OK, why is hymenoplasty not taught in Egyptian medical schools, and why do physicians get nervous or angry when you ask them about it?

I think these are really interesting questions. I’m especially interested in the links between religion and medicine: Like how does the interpretation of a technology by Islamic jurists influence whether something appears on the medical curricula? And when experts in Islamic jurisprudence are asked to provide a ruling on a new technology that they know nothing about, how do they educate themselves about that technology in order to be able to make a ruling about its permissibility in Islam? Who do they go to for answers? Do they go online (like I do)? Do they consult local doctors? International experts?

Beyond the scope of expertise, it’s important to consider what people actually do, sexually and contraceptively, and what extent they are influenced by expert opinion. What about people whose sexual and reproductive lives defy religious codes and cultural norms? What about Christian Egyptians? How do they use these technologies, and do they care about formal religious opinions about these technologies? What about unmarried women who are sexually active? What do they think about expert opinion, how do they navigate fatawa (plural of fatwa) and medical bureaucracies to prevent a pregnancy, or terminate one, or hide evidence that they aren’t virgins when they marry? Things like emergency contraception, medical abortion, and hymenoplasty are technologies that can be used to disguise evidence of non-normative sexuality, and the stakes are particularly high for women, as it is primarily women who bear the consequences of extramarital sex in Egypt – as elsewhere in the world.

But I’m still struggling with the why of this research. Why is this important to study? I was at a dinner party a few months ago with some physicists and I was talking to Professor Ewa Goldys who asked me about my research. Ewa is a big grant-getter in the Physics Department at Macquarie. She listened politely while I talked all about these titillating topics – sex and drugs and abortion and fatwas – and then she said, “But why does this matter? Why is the research important?” I was like, “Because it’s interesting. Duh!”

Unfortunately I have to provide a better answer than “it’s interesting” to get a grant for this research (right now I have a small grant from my university but I’m angling for a big national research grant). So I’ve been thinking about how to frame this as Really Important Research. Maybe someone can help me? Obviously there’s a public health case to be made about women’s health, fertility, and morbidity. And yes, the subject matter is inherently interesting, because it’s fundamentally a story about sex, science, and religion.

But what’s theoretically interesting about this? Yes, religion and medicine mutually influence each other, but that’s hardly a cutting edge insight for medical anthropology. I can say that the project hasn’t been much done before. There’s no work on EC in Egypt, very little written about erectile dysfunction drugs, and not much on hymenoplasty. There have been some fantastic anthropological studies of reproductive health technologies (RHTs) surrounding normative sexualities in Egypt, like Marcia Inhorn’s work on IVF for married couples, but very little work on RHTs that are popularly associated with non-normative sexualities, i.e. for people having extramarital sex. But just saying that “I’m writing about something new” doesn’t get you grant funding.

This is an ongoing project, so any suggestions or criticism are most welcome. You don’t have to know much at all about Islamic jurisprudence or reproductive health medicine to have anything interesting to say about the topic, because the technologies I’m researching are all over the news in the U.S. and elsewhere, and I’m particularly interested in comparative perspectives. Is anyone out there looking at these technologies in other parts of the world?

Next post my Egyptian colleague Dr Hosam Moustafa will join me and we’ll write more about emergency contraception, aka the “morning after pill,” in Egypt. Then we’ll cover erectile dysfunction drugs, medication abortion, and hymen reconstruction surgery. Stay tuned…

12 thoughts on “New Reproductive Health Technologies in Egypt

  1. I’m really looking forward to the rest of your posts. I know nothing about anthropology and academia, but I love reading the various anthropology blogs, and I hope you get your grant.

  2. When Morgan finished a draft of Systems of Consanguinity and Affinity he got a chorus of “So what?”s. As someone fascinated with kinship that story always makes me feel a little better when people give me blank stares. How it makes you feel in regards to your own research depends a lot on your opinion of Morgan, I suppose.

    Have you approached many MPHs, demographers, or epidemiologists about your research? It would be interesting to know if what they see as interesting about your work matches up with what anthropologists see as interesting about it.

    While perhaps not enough to hang a major research project upon, I find your example of abortion via use of Misoprostol vs. surgical procedure interesting. It strikes me as an interesting case study of “What shapes individuals’ decisions to access medical care?” Russ Bernard uses the wonderful term educational model of social change to refer to what he (rightly, I believe) sees as one of our most misguided common sense beliefs, that if we impart enlightening knowledge to people they will then go on to utilize it to improve their lives. Is it altogether clear that even if Egyptian women knew about Misoprostol that they would prefer it to illegal surgical procedures?

  3. I found really interesting this research, in that I’m carrying on a reaserch among Egyptian women in Italy focussing the practice of khitn, the female circumcision. So I’m interested in the way representations and practices concerning sexuality, reproductive health, intertwining with religious representations and interpretations, are currently developing in Egypt. I would really interested in exchaging informations, thank you for the interesting posts, I’m waiting for reading the next!

  4. LL — this work is very important. The problem of expert knowledge(s) is crucial in all contemporary societies and your triangulation of expert between the ‘religious,’ the ‘medical,’ and the ‘scientific,’ I think defines a complex field in which to explore the relevant issues. I am irked that someone would ask you a question leading you to question the importance of this research. I note that Professor Goldys’s bio points to commercial applications of her research. Is this what *she* meant by important? That at ‘Phase 0 phase’ of your research you should be thinking of commercial applications? But even here, you are covered, as big pharma will no doubt be interested in what you find out!

  5. This is indeed very interesting. But you seem to have laid out (questions to be addressed by) multiple projects. Most interesting to me are the questions of how individuals – especially women, especially Muslim women – choose reproductive technologies such as birth control or abortion methods. As MTBradley asks, “[Even] if Egyptian women knew about Misoprostol [would they] prefer it to illegal surgical procedures?” Such questions have both anthropological interest and potential impact on public health.

    No doubt equally interesting are the questions you raise in the post about how religious practitioners interact with medical practitioners, and how they gather the information necessary to make legal / religious decisions.

    Questions of gender, as well as class, religious identity, etc. are suggested by the observation that Sildenafil, as well as the commodified word ‘Viagra’ are in wide circulation while emergency contraception is not considered commercially viable. These questions seem generalizable – or at least comparable – to similar questions surrounding gender and capital elsewhere in the world.

    But that looks like at least three projects to me. And all I know about RHT in Egypt is what I read in the blogs.

  6. Thanks everyone for your enthusiasm and for thinking that this doesn’t need more justification than I’ve already offered to sound like a worthwhile research project.

    Strong, yes there certainly is a lot of pressure right now on universities in Australia to come up with commercial applications of research; it’s a larger part of a neoliberalization of education in Australia that reconceptualizes students as clients and industry, rather than government, as potential “partners” i.e. funders (and beneficiaries) of research. As in, “I met with the clients today, and they didn’t like the grade I gave them…”

    MTBradley, I LOVE your story about Morgan. And as for interdisciplinary partnerships, yes actually I collaborate regularly with a French epidemiologist and American public health types/demographers and physicians. (My postdoc was in a demography/public health department where I was the only anthropologist.) They seem quite enthusiastic about this type of research because they often deal with quantitative data but don’t have the qualitative research to fill out the numbers and make them speak. But then I have encountered other demographers who find the qualitative approach verging on irrelevant because it’s not generalizable.

    Chad, you’ve raised some good points, many thanks for your feedback — I’ll address the EC / sildenafil comparison soon! And yes, it’s a big project, and I have contemplated cutting down this project to look at just one technology, but I can’t resist how interesting it is to make comparisons between technologies. I’ve got material to compare male and female technologies, surgical procedures and pharmaceutical products, more or less “respectable” technologies and one that is considered wholly dubious. I’ll be at it for years I expect.

  7. Re: Viagra faucets.
    It’s unlikely this is actually related to Pfizer pharmaceutical product marketing. More likely, Viagra is also a brand name manufacturer of plumbing equipment, as in Kohler toilets. Just coincidence. Pfizer trademarks only extend to drugs and things a consumer public could confuse Pfizer products.
    Viagra may have Sanskrit roots in strength/tiger/vitality.
    Or it could Latinate, like the way. Both would make sense for copper plumbing or piping of water.

  8. Simon, fascinating suggestion, I’ll have to do some more investigating, thanks!

    And Kerim, speaking of spam, you know as my colleague Hosam Moustafa and I have been talking back and forth about this topic via e-mail, we discovered that any time we wrote e-mails to each other with “Viagra” in the text, they never arrived. We now have to write about “V***** and “C****s.”

  9. Neat project! I think MTBradley’s inclination to ask *if* Egyptian women would use miso if awareness of its qualities were better disseminated is a good one. This kind of question helps one step back and consider how Egyptian women define and weigh things like ‘cost,’ ‘risk,’ ‘efficacy,’ and ‘safety’ in their decisions for pregnancy termination. The early history of misoprostol in Brazil suggests how central these questions might be for your investigations. In the mid-80s in Brazil, a battle raged over the meaning of cost, safety and efficacy miso offered (or didn’t offer) women and society, ultimately resulting in federal restrictions on access, sale and production of miso, which pushed it to the black market. So what are the Egyptian womens’ perceptions of the benefits, drawbacks, and effects of misoprostol v. surgical abortion? These perceptions can begin to unpack why miso hasn’t been seized more popularly.

    On the topic of risk: for a comparative project, Elise Andaya has done fascinating research in Cuba on calculating risk in abortion. I look forward to your findings!

  10. Neat project! I think MTBradley’s inclination to ask if Egyptian women would use miso if awareness of its qualities were better disseminated is a good one.

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