Local brands of sildenafil available in Egypt, including: Viagra, Virecta, Erec, Kemagra, Vigorama, Vigoran, Phragra, and Vigorex. Photo by Lisa Wynn

First, Americans might think of erectile dysfunction drugs (EDDs) as somewhat shameful (think about mocking attitudes towards Bob Dole’s decision to do Viagra ads), but they have a more positive connotation in Egypt. Two reasons:

1. As I’ve written elsewhere, in Egypt these drugs seem to be associated as much with the promise of exuberant, excessive sexuality rather than a shameful lack of erection. Maybe it would be more accurate to call them erection enhancement drugs rather than erectile dysfunction drugs.
2. Even though both EDDs and ECPs can be equally used in normative and non-normative sexual relationships, EDDs are seen by some as being less morally suspect. As my colleague, Dr Hosam Moustafa pointed out to me in an e-mail exchange,

“When we talk about marriage, which is the only state that makes sexual relations halal [religiously acceptable], we ask: What are the original aims of sexual relations? Answer: pleasure and getting kids. This what all humans have deep in their minds, whatever cultural background they come from. About the two drugs, how do they related with these two aims of sexual relations? Answer: erectile dysfunction drugs are associated with both positive sides of a sexual relation, i.e. both giving pleasure and ensuring having kids. EC and all contraceptives are associated with a negative outcome of sexual relations, i.e. not having kids.”

A pharmacy door in Cairo with ads for Cialis (top) and Viagra (bottom) on the front door. Photo by Hosam Moustafa.

Second: EDDs have a historical association with the black market / gift economy. When Viagra was first introduced and before lots of generic varieties were available, it was hard to get and expensive (it still is the most expensive brand on the market). People smuggled it into the country. It was given as gifts from one man to another. It is even used to grease the wheels of bureaucracy, being offered as a small bribe. Relationships with physicians are cultivated in order to access drugs that are hard to get. Even though sildenafil is now widely available in a range of prices, other drugs said to produce the same effect (Cialis and Tramadol are two such examples) still circulate semi-illicitly, in the category of a commodity that is thought to require both connections and expertise to obtain, and this is part of their appeal: they’re more than just commodities, they have a special aura.

So in asking why don’t ECPs have the same aura and circulate amongst women in the same way, maybe it’s partly because they’ve never been part of the black market. Packs of contraceptive pills, the kind you could cut up to equal a dose of emergency contraception, are government subsidized, widely available, and really cheap.

This sign at a Cairo restaurant stall advertises “Viagra soup.” The starred text on the bottom left reads, “For adults only.” Photo by Hosam Moustafa.

Finally: there are key continuities between modern pharmaceutical products for erectile dysfunction drugs and more “traditional” treatments, so the appeal of drugs like Viagra and Cialis is partly that they tie in with pre-existing ideas about how you can ingest certain substance to increase your virility. I’ve already written about Viagra sandwiches, and there’s also Viagra soup, dates, and who knows what else? This takes the notoriety of a global pharmaceutical product and maps it out over pre-existing notions about the virility-enhancing power of seafood. Using drug brand names to label food is not just a phenomenon in popular (shabi, as they say in Egypt) restaurants, either; a famous restaurant in an expensive mall in Alexandria offers the same soup (but wouldn't let us photograph their menu!).It's not just seafood that has this reputation. In the picture below is a wall of oils at a local apothecary, or <em>attar, which includes gargeer seeds or oil (that’s arugula to North Americans, rocket to Australians), about which there is a popular saying, “If women knew what gargeer could do for their men, they would grow it under the bed” (rhyming gargeer, arugula, with sareer, bed).

Salad = virility! It’s not exactly the American imagination of how food is gendered.

(Above) Apothecary wall with herbs, spices, and oils, including, on top, gargeer (rocket/arugula) oil. Photo by Hosam Moustafa.

Also I can’t resist including a picture of Cow Jam from the same pharmacy. A kind of vitamin supplement, the product contains neither cows nor jam. Photo by Hosam Moustafa.

But I put “traditional” in problematizing quotations above because it’s not like there’s a clear line between “traditional” remedies for erectile dysfunction and modern pharmaceutical products. Below is a picture of several products that Dr Moustafa and I bought in Cairo apothecaries. It’s not just oils and herbs. There are mysterious packaged products imported from all over the place, as well as local, “traditional” products. In the latter category, in the bottom right hand corner you can see shards of a resin — sold by the gram and very expensive — that is dissolved in hot water and then applied to the penis. It has a strong numbing effect and is supposed to make it possible for a man to perform longer.

Apothecary products purchased in Cairo. Photo: Lisa Wynn.

In the former category, notice on the right the package of Lina Sex, a gum which is supposed to increase the female libido, and which claims to be manufactured by “Astra zencesa group pharmaceuticals.” (As Dr Hosam Moustafa explains it, “All these drugs for women are used to treat decreased libido of women. It’s a main complaint here from most men that their women have decreased libido which I can explain as a kind ofself defense from men — I mean trying to say ‘the problem is not only me, my wife also has troubles’.”) The boxes with a crocodile and rhinoceros on them are made by the same local Egyptian company.

The delightfully mysterious “Flower Jel” claims to be “Made in U.S.A.” and reads on the back of the package,

“For the Past Si years, Ben Huczek Has Suffered From impotered and, despitence and, despoint the cause fortuntcly, Ben of the First Britis men to take FLOWER JEL after being referred to aconsultant urolgist who w conducting clinical conducting clinical Trials of the sex pill.”

Somewhat less delightfully mysterious is “Germany Black widows Powder Fever (Ms. special Super Night)”, which seems to be marketing itself as a date rape drug, because it says on the side of the box:

“Powdery white, tasteless, can quickly dissolve in various beverages without being found, after a few minutes after drinking, quick wins, after taking Chunxindangyang, fast exciting, noodles dinner, shortness of breath, hot air, eager to head shot, body heat, impatient with the rest of your love, this time of women, warm and flowing.”

Germany Black widows Powder Fever. Photo by Lisa Wynn

Incidentally, despite the claims on the side of the box, the contents are a clump of brown sludge with a powerful odor (and hence, I presume, taste, but I haven’t tried it).

The point is that when you go to apothecaries to find “traditional” remedies, what you find is a range of products that circulate transnationally (lots have Chinese characters on them but claim to be manufactured in Germany, Japan, or the US because of the prestige associated with products from these countries), that make reference to international pharmaceutical companies and clinical trials and German pornography, and that borrow on globally circulating (and ancient) notions of what constitutes an aphrodisiac (such as the Egyptian product with the rhinoceros picture on the box, even though rhinoceroses disappeared from Egypt during the Pharaonic era). Even local remedies and herbal formulations are now taught in the Khedr El-Attar apothecary training school, mimicking modern university education formats.

— L.L. Wynn and Hosam Moustafa

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.

I promised that the next post would be about emergency contraception in Egypt, but I couldn’t resist first writing about EC more generally and describing debates about EC in the U.S.

From rape treatment to mainstream contraception

For more than four decades, medical researchers have known that there are methods you can use after sex to prevent – not terminate – pregnancy. Emergency contraception (EC) was first researched in the 1960s by physician-researchers trying to find a way to prevent pregnancies in survivors of sexual assault. They experimented in giving rape survivors high doses of regular oral contraceptive pills (OCPs). Later it was established that inserting a copper-bearing IUD after sex was even more effective at reducing pregnancy risk.

Remember that this was during the pre-Roe v. Wade era so there were political reasons for looking for a way of preventing pregnancy, rather than expecting to be able to resort to abortion, for women who got pregnant after sexual assault. But of course there are also enduring religious and public health reasons for wanting to find ways to prevent pregnancy, rather than end it with abortion.

Increasingly, knowledge about this contraceptive technique filtered out to a wider public and in the 1970s through the 1990s, there was an underground movement of women and doctors spreading the word about do-it-yourself emergency contraception. You just take several pills from a regular pack of birth control pills within 5 days after sex.

(There’s a website run by Princeton University’s Office of Population Research that tells you exactly how many pills to take depending on what brand of Pill you’ve got, and as far as I can tell, this website was actually the first health information website on the Internet.)

Even though this form of contraception has been known for decades, it’s only in the past ten years or so that emergency contraceptive pills (ECPs) have become more widely known and marketed as a contraceptive option for all women, not just rape survivors. There’s been a global movement to introduce “dedicated products” worldwide and to lobby for them to be made available without prescription. (A “dedicated product” is when emergency contraceptive pills are packaged and marketed specifically for that purpose. Activists have long argued that this is an important improvement on the DIY culture of cutting up packets of pills because it increases awareness of EC and lends the method popular legitimacy.)

EC is an intrinsically liminal technology

I spent 5 years or so following debates over EC in the U.S., before I decided to look at EC in Egypt. I think there are three curious properties of EC and EC users that make this a particularly interesting technology to study.

1. To paraphrase Victor Turner, EC is “betwixt and between.” Classified as a contraceptive, but used after sex, it is often confused with medication (aka medical) abortion. The hormonal version consists of higher doses of the same drugs used in regular daily oral contraceptive pills. Another version of EC that has been tested (but is little used outside of China) is mifepristone, the same drug that is used to induce early abortions (also known as RU486 or the “French abortion pill”), but at a much smaller dose than what is required to terminate a pregnancy.

These properties contribute to EC being imagined as simultaneously more than a contraceptive and less than an abortion. This makes EC particularly fertile ground for debate and contestation. During U.S. debates, there were a lot of attempts by opponents to classify the method as an abortifacient, not contraception, even though medical authorities define it as a contraceptive.

1. Another reason why this technology is ambiguous is because its mechanism of action – the way it works inside the body to prevent pregnancy – is hidden from view and essentially unknown. Scientists postulate that that EC may work through three mechanisms: inhibiting or delaying ovulation, preventing fertilization by altering the tubal transport of sperm or egg, or preventing the implantation of a fertilized egg in the uterus. It’s the last possible mechanism of action that is fiercely contested, because even though medical authorities define pregnancy as beginning with implantation, some religious interpretations define the beginning of life at fertilization.

But basically no one knows for sure. You can prove a post-fertilization effect of EC either way, because there is no clinical evidence in humans that can either prove or disprove whether EC actually might have a post-fertilization effect. Why? Basically because you can’t figure this out without cutting up women. There are studies in the monkey and the rat (that show no post-fertilization effect), but the extent to which these can be extrapolated from to describe what’s going on in human reproductive tracts is unknown. So the chance that EC has a post-fertilization effect can only be statistically modeled and indirectly inferred. It is this peculiar characteristic of EC that further lends itself to imagination about the inner workings of a woman’s reproductive tract when the medication is taken.

You can see this in the public hearing the FDA held when considering whether to make ECPs available over the counter or not. First, consider the testimony of Carole Ben Maimon, the CEO of Barr Pharmaceuticals:

“Plan B works like other progestin-only oral contraceptives and prevents ovulation. Plan B is an oral contraceptive, not an abortion pill. The direct evidence is highly in favor of the fact that the primary mechanism of action, if not the sole mechanism of action, is prevention of ovulation.”

She was clearly at pains to make the point. NOT AN ABORTIFACIENT. In contrast, here’s what Judie Brown, the president of American Life League, said in her testimony:

“Emergency contraception, first of all, is not contraception. So-called emergency contraception can by definition abort a child before that child implants. A human being beings at conception, not implantation. …If a human zygote cannot implant, he or she will die. This means that the pills act to prevent pregnancy by aborting a child…”

1. The third characteristic of this technology to consider here is that we don’t know much about EC users. There are structural reasons why there are very few qualitative, in-depth studies of the characteristics of users of EC. With many medical technologies, access to the technology is mediated through a specific point of entry into medical bureaucracies, and researchers can take advantage of this to study users of the technology. So if, say, you want to study people using in vitro fertilization (IVF), you stake out an IVF clinic and find a cooperative doctor that will let you talk to her/his patients. But with EC, there’s no one easily identified point of access. Some women go to their doctor to get it, but it’s not like there are doctors who specialize in EC like there are with IVF. You can get it from your family physician or from your gynaecologist. Some women get it straight from a pharmacist. Other women borrow a friend’s pack of pills and cut it up.

That’s part of the reason why it’s hard to find people who are using it. The other is that use is relatively rare. An individual woman’s need for EC is predicated on non-consensual sex or a contraceptive accident, so it’s unpredictable. Many women have never used EC. There have been a few large scale demographic studies of user populations, but very little qualitative description of the sexual and contraceptive experiences of individual users.

The result has been a great deal of speculation about the characteristics-and morals-of women who use (or need) EC and the men they had sex with. The debates about making EC available over-the-counter revolve around the imaginations of users: who is using it, who they’re having sex with, and why they need EC. Basically, in the FDA debates over EC, 2 poles of sexual behavior were theorized:

1. An exploitative male sexual predator, either a teen playboy who will use access to ECPs to convince women to engage in unprotected sex, or an adult sexual molester who will administer the pills to his victims to cover up his crimes. In this imagination of EC use, women are cast in the role of weak sexual gatekeeper whose ability to say no will fall apart in the face of new technologies.

Consider, for example, the testimony at the FDA hearings from Robert Marshall, a state legislator from Virginia. He said:

“One name that should be on this NDA [New Drug Application] is Hugh Hefner. Playboys, adolescent adult males are going to be the primary beneficiaries of this.”

Or Susan Crockett, a pro-life Bush-appointed representative on the FDA advisory board reviewing the EC application:

“Making ECs available would be a welcome tool for adult sexual predators who molest family members, children of friends or students. They could keep a stash in their bedroom drawer or their pocket to give their victims after committing each rape.”

1. The other archetype of EC user advanced at those FDA hearings was the image of a responsible, condom-using woman in a committed relationship with an equally responsible man. Eight members of the National Organization of Women (NOW) spoke at the FDA public hearing describing their own personal experiences using EC after consensual sex. In those accounts, 6 described a contraceptive failure, and 6 described the women being in a committed sexual relationship.

Btw, Kimala Price has a great piece in Anthropology News discussing these archetypes and mythologies of EC users.

In considering the kinds of sexual encounters that are portrayed as typical in this debate, it’s also interesting to consider what portrayals of sex are absent. First, there’s no mention of non-heterosexual, non-penetrative sex, but we’ll bracket that off since this is a debate about contraception. Also absent is any depiction of:

● Consensual sex under the influence of alcohol, or
● getting “caught up in the heat of the moment” – i.e. no contraceptive used in the first place.

Much of the testimony from the NOW representatives described needing EC after a condom broke, but what about people who have sex without a condom in the first place? Don’t they have the same right to contraception as women who use condoms?

Incidentally, research strongly supports the idea that neither of the two poles of hypothetical sexuality portrayed in this debate are the face of “typical” American sexuality or, especially, of unintended pregnancy. A lot of people have consensual, unprotected sex, and these are the people who are overwhelmingly those who end up with unintended pregnancies.

But note that also absent in these two polar versions of the archetypical EC user is the possibility that women might be the exploiters, rather than men. The highly gendered portrayal of sexual encounters in the anti-EC position is revealed if we try a little thought exercise: can we imagine an alternative scenario in which the roles are switched? Imagine an older woman, figuratively hopping with STDs, who is trying to seduce a younger man into having sex without a barrier contraceptive by whispering into his ear, “Don’t worry, baby, you won’t be stuck paying child support payments for the next 20 years – I’ll take Plan B tomorrow morning.”

So that’s what EC debate has looked like in the US. What about elsewhere?
Debates over EC have taken strikingly different forms in the different countries in which it has been introduced, shaped by the social, cultural, religious, and political contexts. For example, in Latin America and Catholic-dominated countries, debate has often centred on EC’s mechanism of action and the moral status of a just-fertilized egg. In contrast, in most of the Muslim world, mechanism of action has not been a key issue, in part because of Islam’s very different religious interpretations of when life begins.

Now that I’ve set the stage by describing what EC is and why it’s such fertile ground (no pun intended) for societies to debate sexuality morality and when life begins, in the next posting I’ll talk about emergency contraception in the Arab world and in Egypt.

—
In this post I’ve summarized work I’ve done with several colleagues: Angel Foster of Ibis Reproductive Health, who is both a medical anthropologist and a physician; James Trussell, the director of the Office of Population Research at Princeton University; and Joanna Erdman, a legal scholar who is the co-director of the International Reproductive and Sexual Health Law Programme in the Faculty of Law at the University of Toronto.

Further reading:

1. Wynn LL, Trussell J. The social life of emergency contraception in the United States: disciplining pharmaceutical use, disciplining women’s sexuality, and constructing zygotic bodies. Medical Anthropology Quarterly 2006;20:297-320.

2. Wynn LL, Trussell J. Images of American sexuality in debates over nonprescription access to emergency contraceptive pills. Obstetrics & Gynecology 2006;108:1272-1276.

3. Wynn LL, Erdman JN, Foster AM, Trussell J. Harm reduction or women’s rights? Debating access to emergency contraceptive pills in Canada and the United States. Studies in Family Planning. December 2007; 38(4):253-267.

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…