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.

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?
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• 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…