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

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…