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Partie III. Un quotidien (é)mouvant

Fear and Floating in Alexandria: The Economy, the Pound, and Women’s Sexual Health

A Small Size Case Study and an Online Application
Économie, livre égyptienne et santé sexuelle des femmes. Étude de cas restreinte et application en ligne
Ilka Eickhof
p. 193-216

Résumés

Cet article traite des répercussions économiques contemporaines sur la santé sexuelle des femmes en s’appuyant sur des études récentes et sur un petit travail de terrain ethnographique mené en Alexandrie. L’article se concentre sur la régulation de l’activité sexuelle présumée des femmes (avant mariage), un sujet en lien avec le défi économique du mariage en Égypte en général. Sur la base de cette étude de cas couplée avec un questionnaire en ligne diffusé dans le milieu social alexandrin, l’article décrit la situation avant et après la dévaluation de la livre égyptienne, et les répercussions que celle-ci a pu avoir sur la capacité des femmes à prendre des décisions relatives à leur santé sexuelle. Exposant les défis en termes de consultation ou de finances ainsi que la pression sociale et morale qui régit les choix des jeunes femmes, l’article revient sur une application média fictive pour illustrer une stratégie d’adaptation alternative face aux structures d’inégalité du genre dans la ville.

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Notes de la rédaction

Owing to the sensitivity of the topic, and in order to protect already available medical and psychological support structures, this article deliberately does not name women’s shelters, women’s groups, peer educational approaches, or supportive gynecologists or feminist organizations unless their profile is public and the author has permission to mention them. The political situation did not allow for interviews to be conducted with pharmacists (except on the basis of personal connections), and the online survey was disseminated via snowball sampling.

Notes de l’auteur

Photographs accompanying the explorative ethnography were taken by Hanaa Safwat, and the design of the application was developed by Valerie Arif.

Texte intégral

Introduction – Health and the Pound

1‘They come at night’, the young female pharmacist said with an impish smile on her face when we entered the pharmacy and asked for condoms. It was late morning, the sun was shining brightly, and the street was full of people in a shopping mood due to the upcoming Eid, the end of Ramadan in sight. The small room did not offer a spot that would have protected us from the gaze of others, but luckily the pharmacy was empty and the pharmacist was a young woman. The fact that there was a woman standing behind the counter made it immediately easier to ask for an item that seems to point at the customers’ immediate sexual activity, specifically in a society in which female sexuality is strictly regulated through dominant moral discourses and the associated regulatory expectations.

2The outline for this ethnographic article was formulated shortly after Egypt floated the Egyptian pound on November 3 in cooperation with the International Monetary Fund (IMF) in order to receive a large loan, a three-year extended arrangement for an amount equivalent to approximately US$ 12 billion, to support the government’s economic reform program. Since then, the pound has consistently plunged in value, with an inflation rate raising from 10.199 to 22.002 (data: IMF, see Farid 2017). The inflation rate refers to the increase of prices over time in relation to the purchase value of money: in other words, the pound’s loss in value versus the dollar increased from $ 8.8574 in September 2016 to $ 17.8823 in February 2017 (data: Central Bank of Egypt).

3The International Monetary Fund (IMF) hosts a promotional video on its website entitled “Egypt: A Chance for Change”. The representational repertoire of the images in the three-minute-long video is two-fold: the introductory orientalistic representation of Egypt (camels, pyramids, sunset, and the gentle sounds of the oud in the background), and generic images depicting the presumed structural problems of the Global South – overcrowded streets, traffic chaos, poverty, and large numbers of young people – which when taken all together offers a simplistic visual introduction of Egypt as an ‘object of development’ (Mitchell 2002: 210). The images are accompanied by an explanatory voice-over and direct remarks by Christine Lagarde, who has been the Managing Director of the International Monetary Fund since 2011. “The key objectives for the authorities under the program is to restore confidence in the Egyptian economy through monetary and exchange rate policy reform and strong fiscal consolidation to ensure public debt sustainability,” the male voice-over tells us (‘1 :14). “Far-reaching structural reforms are another key component of the program, for example reducing energy subsidies will help to free up resources for spending in priority areas such as health [...].” (‘1 :28). In this way, the IMF paints itself as an analyzing expert standing completely outside the country and its people, thereby overlooking its involvement in the very problems it describes (Mitchell 2002: 210, 211).

4However, the floating of the pound – which according to the IMF is a necessary step in order to introduce structural reforms – has had (and continues to have) a severely negative impact on health for various, partly intersecting, reasons. In general, wages increased by up to around 25 % in accordance with the changing economic situation, meaning that purchasing power depreciated for the same amount of work, especially for lower-income groups. This led to a need to work two to three jobs simultaneously in order to make a living, which in turn can lead to serious repercussions for psychological and physiological health (see Boktor 2015). By the end of the year 2016, major price rises and import issues led to a general scarcity of medication. A Twitter account (which is still active at the time of writing) was set up to enable informal searches for and swapping of medication without having to rely on the black market (https://twitter.com/​Twiter_pharmac) (Gaballa and Knecht 2016, Mahmoud 2017). The devaluation of the pound contributed to this situation (Sanchez 2016), in part because the exchange rate directly influenced the price of imported medication (with major suppliers like Pfizer and Novartis covering 40 % of the market), and despite its large pharmaceutical industry, Egypt relies on imported ingredients.

  • 1 Gynera, Yasmin and other contraceptive pills are imported by a private company, SoficoPharm, which, (...)

5The scarcity of medical products also affected pharmaceuticals linked to women’s sexual health choices, including contraceptives such as the pill, the morning after pill, and one of the available abortion pills, the most popular one being Misoprostol (Memo 2017). Al-Monitor, a media site that offers reporting and analysis from and about the Middle East reported in January 2017 that “popular types of imported contraceptive pills [like Gynera and Yasmin] were among the first to disappear from pharmacies and move to the black market”, raising allegations of illegal stockpiling by pharmaceutical companies because of the government-mandated price increase expected in February and July 2017 (Smekar 2017).1

6The factors that influence young women’s choices with regards to sexual health are linked to the country’s economic situation. Other intersecting components are background, financial means, demeanor, the advisory help on offer, access to information in general, and dominant social dynamics and moral standards. This contribution draws on a small ethnographic study conducted in Alexandria in July 2017. Alexandria remains understudied in comparison to Cairo, and although due to financial and timely limits this research is no more than a small sample, it is hoped that it will lead to wider studies in the area. The on-site research was carried out by two women (of 29 and 35 years of age, one European, one Egyptian), who visited 15 pharmacies in the downtown area of Alexandria, Egypt’s second-biggest city. The exploratory ethnographic small-scale study is accompanied by an informal qualitative questionnaire involving women from and residing in Alexandria (10 women between the age of 23 and 38. At the point of the questionnaire, 6 of them were married, 2 were divorced, and 2 were single). On the basis of the findings, the article introduces a fictitious media application presented as an alternative strategy that circumvents gendered structures of inequality in Alexandria (or any other city). The aim of the article is to give substance to the conclusions drawn from recent studies and women’s local experiences, and to translate these findings into a helpful tool which could improve women’s access to sexual health choices.

7This small-scale study is not meant to cater to the general ‘over-embodiment’ of both media and scholarly work when it comes to the (Western) representation of women in the Arab World (Ghannam 2013: 4). Ethnographies have questioned the ‘dis-embodiment’ of men, and have unsettled the dominant trope of domination and patriarchy in the Arab World and clarified matters of family, masculinity, care, masculine desire, family bonds, and patriarchy (see for instance Inhorn 2012, Ghannam 2013, Naguib 2015, Joseph 1983, 1993, Singerman 1995, Hoodfar 1997, Hoodfar and Hélie 2012, Kreil 2016), specifically with a focus on Cairo as the locus of government and political power. By discussing the availability of contraception after the floating of the pound and women’s accessibility to choice-making processes when it comes to sexual health, the aim of this research is to look at how the structures of capitalist economies are reinforcing contested patriarchic gender structures. I am mindful of the limitations of such a small-scale ethnography, and yet hopeful that more research will follow and that the media application might find its way into reality.

Figure 1. Alexandria train station

Figure 1. Alexandria train station

Hanaa Safwat, June 2017

Contraception and Emergency Contraception

8Emergency contraception (EC) in the form of the so-called morning-after pill was introduced to the Arab World between 2000 and 2005 (Wynn et al. 2005: 39) ; however, there is a lack of consensus among schools of Islamic jurisprudence with regard to rulings on abortion and the issue of ensoulment, the morally contested moment at which a soul enters the body (Wynn et al., 42). The interpretations with regard to EC are similar: although the mechanism of action may be debated, what matters are the circumstances, and these are not necessarily linked to religious justifications, but rather to the moral-traditional code of conduct. In Egypt, contraceptives and EC are available not only through private-sector agencies, but also in subsidized form through the state-run Egyptian Family Planning Association (EFPA), in collaboration with the Ministry of Health and the Ministry of Social Affairs (see UN report 2002). According to its website, the EFPA operates 112 permanent centers in the country, and has 55 associated facilities and one mobile clinic, and focuses on the provision of information, education and communication. In 1972, EFPA set up the Alexandria Training Centre for family planning professionals (see website efpa-eg.net/ar/home.php).

9For the past two years, Contraplan, the over-the-counter morning-after pill, was difficult to find. Although some pharmacies did have some imported packages (which are three times the price of locally produced ones), most would send the customers away empty-handed (informal conversations with the author, 2016, 2017). The shortage of locally produced products would force women (or their male friends) to ask around for further information on alternatives (for example, if someone from abroad might have brought EC with them), or to try a wide range of pharmacies, repeating the ordeal of exposing the customer – which in some cases might lead to avoiding the exposure at all, and to following up on the basis of unsafe decisions in terms of unwanted pregnancies.

10“Unsafe abortion is a major concern [...]. Given the reality of the failure of all forms of birth control, and since individuals do not use contraceptives correctly every time, abortion will remain a fundamental issue in reproductive health,” states a shadow letter submitted to the CEDAW committee (United Nations Convention on the Elimination of All Forms of Discrimination against Women, an international treaty to combat gender inequality) by the Egyptian Initiative for Personal Rights (EIPR) in collaboration with the US Center for Reproductive Rights (Berer 2009, quoted in Supplementary Information to CEDAW Committee). The letter heavily criticizes the status of women’s sexual and reproductive health and autonomy in Egypt, highlighting the Egyptian State’s role in it. Shadow letters and reports are alternative information provided by NGOs, which are usually part of treaty-monitoring bodies, in addition to the required governmental reports. In this letter, the stated areas of concern were specifically the prevalence of unsafe abortions, the lack of access to post-abortion care, and limited access to comprehensive family planning services and information, particularly for adolescents (Center for Reproductive Rights 2010). These social rules do play a huge role when it comes to general knowledge and the dissemination of it within communities: what is the difference between a contraceptive, a morning after pill, and an abortion pill, where is it available, and who can request these without further social repercussions or judgement ?

11A case study from 1998 on the economics of abortion safety in Egypt pointed out three levels of safety - ‘indigenous’ methods, biomedical methods at clandestine clinics, and biomedical abortions by a private gynecologist (Lanea et al., 1998). An informal abortion carried out by a physician in a clinic in Egypt currently costs between 20,000 EGP to 50,000 EGP, depending on the specific case (informal conversation with Gynecologist, IE 2017). Safety is expensive, and a lack of financial resources determines the choice. Although more and more women enter the job market and have an independent income (Singerman 2007), being able to come by a sum in this range is almost impossible for women from the lower social classes. It is difficult to find recent numbers in this area, but an older study using data collected between 1995 and 2000 recorded 2,542 maternal deaths due to unsafe abortions in Egypt; according to the author of the study this number accounts for at least 6 % of maternal deaths in the region (Hessini 2007: 76). Another even older study from 1998 quoted in the WHO report on Sexual and Reproductive Health published in 2006 revealed that almost 20 % of admissions to obstetrics and gynecology departments were for “treatment of an induced or reportedly spontaneous abortion” (Grimes et al. 2006: 6). Studies and estimates of maternal mortality due to unsafe abortions are often based on unreliable data, however, especially in countries in which abortions are illegal or limited to specific cases. In this regard, data is often of the poorest quality where abortion is the least safe (Gerdts 2013).

12It is a common misconception that EC is an abortifacient (a substance that induces an abortion), a factor that plays a huge role in influencing perceptions in a society in which although contraception might be accepted, abortion is constructed as being problematic, leading to wrongly used religious justifications for objecting to EC (see Weissberg et al. 2009). According to a study on awareness and use of emergency contraception (EC), methods among women at the family health-care centers in Alexandria, 75.5 % of the interlocutors (a cross-sectional study of 151 women, 57 % of whom were university graduates and 6.6 % illiterate) did not know about EC, and only 14.6 % stated that they had discussed it with a healthcare provider (El-Sabaa 2013). Furthermore, 51 % stated that EC was not legal in Egypt, and 72.8 % did not know whether or not it was available (El-Sabaa 2013: 169). Interestingly, the study also shows that 20.5 % had used EC and only 3.2 % found it difficult to obtain, but 96.8 % found the cost of the EC high (El-Sabaa 2013: 171). This might have to do with the fact that even before the floating of the pound, imported EC was fairly expensive in relation to average incomes, whereas now the locally produced EC costs 13 EGP (about 60 euro cents). In conclusion, the majority of the interviewees indicated that they believed that EC was unavailable or illegal, and that it could not be obtained from pharmacies without prescription. We can rely on the numbers from these exploratory studies as an approximate description of the real situation, but they nevertheless give us a direction in which to think and act. Apart from the restrictive abortion law, the studies show that the combination of a lack of knowledge and counseling with regard to women’s sexual and reproductive health issues are a primary concern.

  • 2 For an informative study on women’s rights in Arab societies within the family through the content (...)

13In Egypt, abortion is officially only allowed if two specialists certify that the pregnancy endangers the life of the pregnant woman. The Egyptian Penal Code of 1937 (sections 260-63) criminalized induced abortion without any clear legal provisions allowing for exceptions. Reasons such as preserving physical or mental health, rape, or economic justifications are not permitted. Egypt’s abortion law is therefore one of the most restrictive in the region, and there is a generally high level of social disapproval of abortions.2 In 1998, the Egyptian Grand Sheikh of al-Azhar, Muhammed Sayed Tantawi, issued a fatwa that recommended that unmarried women who had been raped should have access to an abortion, a statement that was restated in 2004 (Hessini 2007: 77). It does not, however, necessarily apply to women who are members of the Coptic or other non-Muslim communities. The impetus of the fatwa is of a social nature, and it is aimed at preserving “female marriageability” (Hessini 2007: 78).

Figure 2. Remains of the Leaning Tower of Azarita

Figure 2. Remains of the Leaning Tower of Azarita

Hanaa Safwat, June 2017

Marriage, Morality, and Sexuality

  • 3 The extremes of honor-shame-based regulations of morality reflecting the social intolerance of fema (...)

14The morality linked to women’s rights in regards to sexual health or other related fields is often paired with an intrinsic discussion on masculinity and claims of equality. Women’s rights and the ability to take independent decisions not only question the husband’s (or male guardian’s) authority (qiwama), but are also seen as a threat to the general stability of society because it is assumed that women will misuse their rights. Nadia Sonneveld’s examination of Egyptian cartoons depicting judicial khul’ in Egypt, the unilateral demand by a wife for a divorce, suggests a similar line of thought: the cartoons represent women with moustaches, flirting with other men, or wearing what is seen as a western style of tight, high-heeled outfit (Sonneveld 2006: 51). When taken together, they convey the message that women are becoming like men but are not able to handle it, and become westernized in the sense of immoral behavior. Depending on the social context, pre-marital sexual activity by women and women’s choices in terms of regulating it is similarly viewed and commented on as immoral western behavior. The careful balance between an assumed Europeanized moral code and local sociocultural regulations is visible in various social situations and dynamics, and is mostly observed and negotiated through the appearances of a woman being associated with her (and her family’s) propriety. Women are expected to abstain from any kind of sexual activity before marriage, and to preserve their virginity until then. The hymen, according to Abu-Odeh, becomes a three folded signifier of respectability and virtue: the actual hymen, the “hymenizing” of the body, and the public display of the body before a social audience (behavior) – which is the place where ideologies and moralities are negotiated and balanced (Abu-Odeh 2010: 917, 918). Honor- and shame-based heterosexuality and shame and shaming linked to an individual’s sense of morality and an imagined Western sexuality are common notions that determine interactions in social spaces, and often transgress class divisions in some forms (Newcomb 2006).3 Pharmacies in Alexandria will be presented as examples for negotiations within a social space such as this.

15In Egypt in general, however, delayed marriage has become the norm. The financial cost of marriage presents a challenge for young people, and results in a prolonged period of waiting that has been coined by Singerman as “waithood” (as opposed to adulthood) – remaining single (or engaging in informal marriages) for a long time in order to save money (Singerman 2007: 6). “Waithood” not only forces people to remain in a state of adolescence; it also challenges common notions of marriage and sexual norms.

16Linked to the notion of “waithood” is the topic of informal marriage (which is commonly denoted by the term ‘urfi), which also can take the form of a secret second marriage. While ideal roles of men and women in marriage are more or less determined by concepts of maintenance (the legal duty to support wife and children) and obedience (the legal duty to be obedient to the husband), informal marriages are challenging these traditional concepts (Sonneveld 2012: 80). People consider informal marriages for a variety of reasons : young people use it as a minimum Islamic standard for premarital sex ; women who wish to marry but do not want to lose their state pension or divorced women who are afraid to lose custody of their children in the event they remarry might favor it ; and there is the case of misyar marriages, which is a marriage in which the husband and wife do not live together because the woman wants to have a job and her freedom despite the need to acquire a social position through marriage (Sonneveld 2012 : 84, 94). The public debate on informal marriage deviates from the actual difference between formal and informal marriages: women’s financial contributions and high unemployment among men affect the general maintenance-obedience structure and go beyond informal marriage.

  • 4 For a different perspective on this topic, see also Wynn’s (2016) research on the practice of hymen (...)

17Informal marriage, which is generally viewed as worthy of moral condemnation in relation to young people and women’s sexual norms (Abaza 2001), can also be criticized from one particular angle: it does not serve to raise a family, what is seen as the main purpose of marriage (Sonneveld 2012: 84). According to Singerman, the media and government policymakers alike have begun to engage with the topic of premarital sex, dating, and morality, and although some voices are more sensational than others, this is a sign of recognition of societal change (Singerman 2007: 8-9). The fact that formal and informal marriages are being strongly discussed in the public debate hints at these slowly changing norms: In Sonneveld’s opinion (Sonneveld 2012: 98), “The mere fact that there are women who marry husbands with no intention of establishing a household or of raising a family, and who express a desire to become financially independent, is an indication that the norms of Egyptian marriage and the family unit have changed”. In a national study of patterns of marriage and family formation in Egypt in 2004 quoted by Singerman and Bahgat and Afifi, 13 percent of single young males (and 22 per cent of engaged young males), and 3.4 percent of single (or engaged) females ‘knew someone close’ who acknowledged sexual relationships outside marriage (Singerman 2007: 37, Bahgat and Afifi 2007: 75 et seq.). The researchers asked about a third person’s sexual activity in order to circumvent the shame of discussing the sensitive issue of their own personal sexuality. Surveys in this area have to be taken with a grain of salt, however; because of the sensitive nature of the topic, associated with the honor-shame discourse, most surveys may be underreported, and the unreported numbers may be quite high. According to a study also conducted in 2004, however, nearly 49 per cent of young people in Egypt agreed with the statement “More young couples are engaging in intimate/sexual relations before marriage,” (Bahgat and Afifi: 78).4

18Altogether, due to the economic circumstances and high unemployment, the current situation is that young men are often financially not able to marry and women often postpone marriage to pursue an education (Sonneveld 2012: 94). Gender structures as regards the notion of the maintenance-obedience relationship are slowly being challenged, and the dynamic that emerges from more and more women entering the labor market and higher education is challenging social public spaces and the gendered interaction within them, even though women must find a balance between visibility and propriety (Newcomb 2006). As a result of the financial burden of marriage and the intrinsically linked change in social space, young people are - slowly - challenging the familial ethos that ties sexual activity to marriage, thereby provoking the authorities and the state to respond. If one keeps these dynamics in mind, it can be seen that the price increases following the floating of the pound and the lack of products linked to sexual activity are only one of the barriers for young women wishing to make self-determined choices with regard to their sexual health. The intersecting socio-economic circumstances I have described above may have created a situation that is even more sensitive in relation to women’s sexual health and women’s claim for self-determined choices in this area.

Figure 3. El Togareya Coffee House

Figure 3. El Togareya Coffee House

Hanaa Safwat, June 2017

The Space of the Pharmacy

19According to Bourdieu, people’s position in society is differentiated by the distribution and volume of material, social, and cultural resources, and the respective composition of these capital units (Bourdieu 1984). By interpreting these resources and capital units, we see access to contraception and EC by women is regulated by intersecting variables such as their socio-economic status, age and habitus, and marital status, whether they live in a city, in a town, or the country, their education, their juridical and legal status, and the dominant morals. Gender ideologies are linked to space through certain habitual performances and practices that seem appropriate. The pharmacy in itself is a space that is regulated by gendered structures on various levels: those who work in the space and those who enter it, all of whom interact with each other within a gendered relationship, and construct gender identity and notions of masculinity and femininity – with all their ambiguities and the fluctuating social constituency of gender they entail due to variables such as age, class, appearance, and (interpretable signs of) religious belief. These variables partly play out in the social space of a pharmacy, where a woman’s access to contraception and EC depend on the assistance, knowledge, and willingness of the pharmacist(s), and where the public condemnation of authority over female sexual activity can be observed. “You might as well just tell them that you are about to have sex,” said one interlocutor in a conversation, asking whether or not she ever did or ever would buy condoms in a pharmacy in Alexandria. “Asking for condoms is somehow linked to the act itself, as if I would go out and right away go and have sex. […] I would never buy condoms or the morning-after pill.”

20Buying a contraceptive like a condom generally seems to be more difficult. The survey collected several reactions similar to the one stated above: “I might as well just go in and tell everyone that I am about to have sex, like, now!” or “I would never ever do that !” Another interlocutor, however, said that she enjoyed buying condoms in pharmacies, that she felt powerful when she did so with an entitled performance. She ventured out to neighborhoods far from where she lived, however. Two women mentioned that they would put on a wedding ring when buying contraceptives in pharmacies, one explaining that she thought it avoided hassle, and the other that it made her feel more entitled and less shy, even though she was not married. One interlocutor once bought condoms and had them delivered by the pharmacy, but then had to deal with an overly engaged delivery employee who refused to give change or to go and get it: “It felt a bit like a punishment but also I did not want to deal with the situation since I was in my house and it was already very awkward. I would not do this again or recommend it.”

21Despite the theoretical availability of contraceptives and EC, it is the purchase of these items, specifically by young women, that is regulated by the dominant socio-moral codifications, starting from obtaining knowledge about their availability up to the point of asking for them in the pharmacy. Despite the fact that contraceptives are legal and prescription-free in Egypt, and the morning-after pill is an over-the-counter emergency contraception that at a price of 13 EGP is financially accessible to most, customers may be confronted with strong social regulations that impeding the purchase, as well as a possible lack of knowledge and counseling. In one case in the field study, two elderly men barely took any notice of the interlocutor entering the pharmacy because they were deep in conversation. When she asked for condoms, one of these men handed her a small blue pack of an unknown brand, telling her in a fatherly manner that it was a present. When we inspected her purchases later that evening, we saw that the gifted condoms had passed their sell-by date. A slightly different experience took place in a larger pharmacy (which was not a branch, however). The interlocutor found herself faced with 6 male employees when she entered the pharmacy. After considering her next step, she approached one of the pharmacists and asked for condoms in a low voice, to which the employee responded with “what kind?” and then returned to the customer with a variety of Durex condoms. The interlocutor noticed that none of the other employees either glanced at her or seemed to care at all. Another small pharmacy in a side alley was occupied by a male and a female employee. The female pharmacist did not move an inch after answering in the affirmative to the question whether the pharmacy sold condoms, but just stood in front of the inquirer and waited. The interlocutor asked again, adding that she would like to buy some, and the pharmacist moved to the other side of the space and handed a small pack of condoms directly to the customer, without putting it into a bag.

Figure 4. Mosque on Salah Moustafa Street

Figure 4. Mosque on Salah Moustafa Street

Hanaa Safwat, June 2017

22EC was available in only one out of five pharmacies (in which the male pharmacist handed the locally produced EC over the counter without any hesitation). Three of the remaining four pharmacies informed the customer that the EC is unavailable, and in the last one, the female pharmacist pointed out a pharmacy where she thought the customer might find the product. In no case was counseling offered, and no one asked whether any advice was needed. One of the studies I have mentioned above on the awareness and use of emergency contraception (EC) methods among women also cites the low level of nurses’ knowledge of EC in the two Alexandrian family health centers, but no data were collected on this point because the focus of the study was on health care seekers, not providers (El-Sabaa 2013).

23Interactions in pharmacies are influenced by a number of intersecting matters: in spaces such as these, customers and employees alike embody the cultural system by regulating their physical presence accordingly, and by doing so reproducing the structure through the embodied sets of habitus (Bourdieu 1977). The pharmacist is acting on a dispositional habitus and reacting to the customer’s dispositional habitus, and both habitus are reproduced and are reproducing the social structure: the body embodies signifiers of social inequalities like movements, gestures, and usage, and therefore situates principles of practice below consciousness and language (Ghannam 2004: 46). This concept should be seen less as determining and more as a frame for agency and intentionality (Ghannam 2004: 47). Linked to the habitus is the ‘social gaze’ which could be documented during the ethnographic encounter. The social gaze has efficacy due to the fact that the receiver recognizes the perception, and it influences self-identification and embodiment (Bourdieu 1984). Within a (global) societal regulation of female sexuality based on honor and shame, simply entering the pharmacy can be already intimidating, depending on the purchase to be made. In this case, it was the larger chains that seemed more difficult during the research in Alexandria, despite the initial belief that these chains would offer a stronger sense of anonymity. Here, the interlocutor was confronted with several employees instead of just one pharmacist: the assistant in front of the counter who was not able to help and directed the customer to one of the pharmacists behind the counter, who then handed over a receipt that had to be given to the cashier. The cashier then handed the bill to another person (a woman) who took the purchase (the contraceptive pill) and, after examining it and the interlocutor in front of other customers, put it in a bag and handed it over the counter. The turnaround in smaller pharmacies seemed much easier and quicker, and despite the expected judgemental gaze, the interlocutors did not feel exposed in an uncomfortable situation for too long.

Figure 5. Mostafa Salah Street

Figure 5. Mostafa Salah Street

Hanaa Safwat, June 2017

24One of the most recent works on the topic of women encountering the pharmacy space in relation to sexual health is the pilot study “Women’s Access to Emergency Contraceptives in Egypt”, initiated and coordinated by Nana Abuelsoud, and led by Doaa Abdelaal (Abuelsoud 2017). Ethnographic research for the study was conducted in the Cairo neighborhood of Dokki, together with focus group discussions, in-depth interviews with pharmacists, and an anonymous online survey. The study’s aims is to examine pharmacists’ attitudes and service towards young women seeking to purchase EC. The conclusions of Abdel Hameed and El Damanhoury (2013) in relation to healthcare providers’ negative attitudes towards young women seeking clinics for sexual reproductive health services (Abuelsoud 2017: 5). The (ongoing) project aims to ensure the accessibility of contraceptive methods to women in Egypt by communicating its findings (for example, pharmacists with an especially biased attitude towards young female customers buying contraceptives (Abuelsoud 2017: 11)) and recommendations to policymakers, to guide women’s groups and feminist Civil Society Organizations, and to disseminate information in general. Another important finding is that pharmacists seem to be neither prepared nor willing to offer information and knowledge on the usage of contraception or EC (Abuelsoud 2017: 17).

25An interesting additional contribution on space and gendered sexual health in Egypt has been provided by Youssef Ramez Boktor, who conducted an in-depth study on the normalization of the use of Viagra (and other chemical enhancers), the exhausted body, and the general pressure to perform well (Boktor 2015). In his research, Boktor includes observations of consumption habits and how medicine is distributed, drawn from attending a pharmacy in a low/ to lower middle class neighborhood in Cairo. He describes the local pharmacy as “a place in which people negotiate their pain, disappointments, dreams, hopes, and above all their coping mechanisms”, mentioning the very particular relationship male customers have with their pharmacists (Boktor 2015: 2). Evidently, male sexual health issues are equally surrounded by (different kinds of) social, economic, and political pressure, often accompanied by silence and fear of talking about them.

26Where in this case (male) resident’s trust in the neighborhood pharmacist allows men to buy enhancers, it is the anonymity of a different neighborhood (and often a female pharmacist) that women seek when obtaining their choice of medical assistance. This is not to say that men are free from feelings of shyness or shame as regards their sexual health. Boktor describes how men enter the pharmacy in silence, ask for the pharmacist, and buy the enhancers without exchanging a single word: “The men-only code is developed enough that it can accomplish the whole process of selling and buying the enhancing pills” (Boktor 2015: 47). These dynamics of power are very much related to, and influenced by, not only gender, but also class, by social, cultural and monetary capital, and by a sense of entitlement.

Health, Knowledge and Accessibility

27The Reproductive Health Working Group (RHWG) is a network of researchers and practitioners from Arab countries and Turkey that has been active since 1989. It focuses on women’s reproductive health and well-being in an interdisciplinary manner, and addresses the links between gender, ideology, political economy, and health, and how cultural and material resources shape the options and decisions that people make regarding their health (Sholkamy, Ghannam 2004).

28This article and the fictitious media application, which is informed by the ethnographic research, the survey, and the available studies on the issue of women’s sexual health, focuses on the significance of these health choices, and emphasizes the fact that well-being is not just being in good health, but also implies “the security of being able to stay that way” (Sholkamy, Ghannam 2004: 2). The social and economic situation described above reproduces situations of precarity in terms of psychological and physiological welfare for women. The term ‘precarity’ refers here to a relational and shared condition of everyday life, and within it a specific distribution and hierarchization of precariousness in relation to inequality (Lorey 2015: 11,12). Differences in social and economic capital, age, religion, habitus, appearance, class, and disability discrimination influence and shape the specific experience. There are common interests underlying these specific social relationalities, however, which create different outcomes for women, and form the starting point for the application.

Figure 6. Appzakhana, location map

Figure 6. Appzakhana, location map

Valerie Arif

Figure 7. Appzakhana, List of Pharmacies and Clinics

Figure 7. Appzakhana, List of Pharmacies and Clinics

Valerie Arif

29The application allows searches by pharmacies and clinics, or by products and services. A 24-hour-a-day, seven-day-a-week helpline provides information for those who do not have access to the application, and offers advice on prescription medication, feminine hygiene, and family planning services. The basic feature of the application is a customer rating of pharmacies on the basis of intrusiveness, consultancy, the gender of the pharmacists, locality, and price, and it includes a comments section. The rating and comments system followed by customers for customers helps circumvent governmental and societal regulations on the ‘right’ conduct of life and women’s bodies. In short, the application seeks to separate decision-making processes and access to information from governmental or social regulation and is restricted through its customer-led verified information.

Figure 8. Appzakhana, Product Detail Pharmacy

Figure 8. Appzakhana, Product Detail Pharmacy

Valerie Arif

Figure 9. Appzakhana, Rating Example

Figure 9. Appzakhana, Rating Example

Valerie Arif

30The ‘Pharmacies & Clinics’ section of the application provides an overview of the products the pharmacy offers, brands, and pricing. Taking into account the intersecting variables of the general dire economic circumstances and the notion of ‘waithood’ and the slowly expanding prevailing social norms of pre-marital sexual activity or informal marriages, pharmacies may have an interest in investing in their customer relationships as regards sexual health-related products, and in forwarding updated information in this area. Previous research has shown that sales rise by about 25 per cent if expert help and advice is offered (see Angus.ai, realeyesit.com, or imotions.com). Here, sales figures and financial profit are used as (admittedly not unproblematic) bait for possibly offering solutions for women in precarious situations, notwithstanding their social status, personal means, religion, marital status, or any other variable.

Figure 10. Appzakhana, Search Example

Figure 10. Appzakhana, Search Example

Valerie Arif

Figure 11. Appzakhana, Search Detail

Figure 11. Appzakhana, Search Detail

Valerie Arif

31Needless to say, the application cannot solve the economic part of the problem. Even prices as low as 5-15 Egyptian pounds for contraceptives or EC remain unaffordable for some, and the application will not be accessible for everyone. With the help of the application, however, the issue of availability versus accessibility can be circumvented by some. Through this dynamic, the social media application subtly questions a dominant reality that has become normative - in this case a reality that states that contraception and EC are questionable and shameful, and therefore inaccessible.

32Education is one of the most significant class markers in Egypt, and social inequalities are reproduced within the system of public versus private (international) schools. Education in this sense also means knowing where to obtain information, claiming access to it, knowing how to ask for it, and being informed about possible choices. The information collected through the ethnographic research such as reactions encountered by the female customer, discussions, the availability of pharmaceuticals, or specific attitudes were integrated into the application. Nevertheless, neither the research nor the application is meant to draw conclusions over and above the indications experienced and the suggestions used in the application. Intersecting variables such as class, age, ethnicity, culture, marital status, gender identity and expression, health status or disability, income, language, neighborhood, or religion will have a powerful influence on the specific interaction.

Conclusion

33“One of the key guiding principles of the Egyptian program is to actually strengthen safety nets in order to protect the most vulnerable,” purrs the IMF video (1 :58). On June 29, 2017, fuel prices surged around 50 % in order to meet the terms of the IMF loan deal - a huge weight on the shoulders of those who live below the poverty line of approximately $ 54 per month (Farid 2017), and the poverty rate is rising, according to CAPMAS, the Central Agency for Public Mobilization and Statistics (27.8 % for 2015). This increase will come with further reductions in real income and wage stagnation, and so the vast majority of the population will be put under even more pressure, and will increasingly struggle to make ends meet. The principles of autonomy, non-maleficence, and beneficence all weigh in favor of the rights of a woman faced with the possibility of an unintended pregnancy to have unrestricted access to EC, as opposed to providers whose moral views are opposed to it. The politico-economic perspective on health is, as this article has sought to show, linked to the social conditions of the macro-level, and then becomes a part of the social space within which women engage and organize their social practices. This paper has deliberately moved away from an emphasize on Islam or a culturalizing view of the social space to one that is more interested in the complex local forces that shape bodies, identities, and decision-making processes.

34This small case study conducted in Alexandria focuses on an example of how an economic situation has an actual impact on the female body, in this case with regard to regulation of the autonomous decision-making processes of women’s sexual and reproductive health. The fictitious online application has been developed based on publications, a small-scale ethnographic research in Alexandria, and an informal survey. The solution-oriented application proposes an alternative course of action that circumvents the IMF’s official long-term goals, which, at least for the moment, have a severely adverse impact on women’s sexual health. Despite the possible support the application may offer in terms of undermining the concept of health as collectively defined privileges and attenuating inequalities in health due to economic and symbolic capital made available through class habitus, it is the pre-marital sexual activity of young women and the general authority over women’s sexuality and sexual health that remains the subject of debated and/or social condemnation, and therefore regulate the availability of contraception and EC.

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Annexe

Valerie Arif is an independent graphic designer from Egypt working on cultural and commercial projects. Her work has been showcased as part of the CairoNow : City Incomplete exhibition at Dubai Design Week 2016 and Beirut Design Week 2017 and was featured in the Weltformat DXB : Delusions & Errors exhibition at Dubai Design Week 2017. Arif’s projects include the ‘AUC_Lab Notes on Practice’ series featuring editions on Malak Helmy’s and Hassan Khan’s work respectively. She developed the extended brand identity for Mada Masr, and designed a metro map for Cairobserver, available for free in digitally and print.
www.behance.net/varif

Hanaa Safwat is a visual artist based in Cairo with a BA in fine arts from the Faculty of Fine Arts, Helwan University. She has exhibited her work in PhotoCairo 5 and Nile Sunset Annex, both in Cairo, in addition to her site specific work around the city and her performance work with No Point Perspective Dance Theatre Company. Written works have been published by Mada Masr and Ikhtyar Collective.

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Notes

1 Gynera, Yasmin and other contraceptive pills are imported by a private company, SoficoPharm, which, being the sole operator in the field, is not regulated by competition from other importing companies.

2 For an informative study on women’s rights in Arab societies within the family through the content of legislation, access to justice, and conduct of the judiciary, see Welchman (2007).

3 The extremes of honor-shame-based regulations of morality reflecting the social intolerance of female sexual behavior are honor killings; as reconstructed in many Arab Codes, they are being seen as a severe threat to men’s masculinity. For a detailed account see Abu-Odeh (2010).

4 For a different perspective on this topic, see also Wynn’s (2016) research on the practice of hymenoplasty in Egypt to disguise evidence of premarital sexual intercourse, in which the author examines the relationship between hymenoplasty and extra-marital and para-marital sexuality.

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Table des illustrations

Titre Figure 1. Alexandria train station
Crédits Hanaa Safwat, June 2017
URL http://journals.openedition.org/ema/docannexe/image/3847/img-1.jpg
Fichier image/jpeg, 2,5M
Titre Figure 2. Remains of the Leaning Tower of Azarita
Crédits Hanaa Safwat, June 2017
URL http://journals.openedition.org/ema/docannexe/image/3847/img-2.jpg
Fichier image/jpeg, 2,3M
Titre Figure 3. El Togareya Coffee House
Crédits Hanaa Safwat, June 2017
URL http://journals.openedition.org/ema/docannexe/image/3847/img-3.jpg
Fichier image/jpeg, 1,9M
Titre Figure 4. Mosque on Salah Moustafa Street
Crédits Hanaa Safwat, June 2017
URL http://journals.openedition.org/ema/docannexe/image/3847/img-4.jpg
Fichier image/jpeg, 2,1M
Titre Figure 5. Mostafa Salah Street
Crédits Hanaa Safwat, June 2017
URL http://journals.openedition.org/ema/docannexe/image/3847/img-5.jpg
Fichier image/jpeg, 1,9M
Titre Figure 6. Appzakhana, location map
Crédits Valerie Arif
URL http://journals.openedition.org/ema/docannexe/image/3847/img-6.jpg
Fichier image/jpeg, 968k
Titre Figure 7. Appzakhana, List of Pharmacies and Clinics
Crédits Valerie Arif
URL http://journals.openedition.org/ema/docannexe/image/3847/img-7.jpg
Fichier image/jpeg, 1004k
Titre Figure 8. Appzakhana, Product Detail Pharmacy
Crédits Valerie Arif
URL http://journals.openedition.org/ema/docannexe/image/3847/img-8.jpg
Fichier image/jpeg, 964k
Titre Figure 9. Appzakhana, Rating Example
Crédits Valerie Arif
URL http://journals.openedition.org/ema/docannexe/image/3847/img-9.jpg
Fichier image/jpeg, 976k
Titre Figure 10. Appzakhana, Search Example
Crédits Valerie Arif
URL http://journals.openedition.org/ema/docannexe/image/3847/img-10.jpg
Fichier image/jpeg, 980k
Titre Figure 11. Appzakhana, Search Detail
Crédits Valerie Arif
URL http://journals.openedition.org/ema/docannexe/image/3847/img-11.jpg
Fichier image/jpeg, 988k
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Pour citer cet article

Référence électronique

Ilka Eickhof, « Fear and Floating in Alexandria: The Economy, the Pound, and Women’s Sexual Health », Égypte/Monde arabe,Troisième série, 17 | 2018, mis en ligne le 28 février 2020, consulté le 18 mai 2021. URL : http://journals.openedition.org/ema/3847 ; DOI : https://doi.org/10.4000/ema.3847

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Auteur

Ilka Eickhof

Ilka Eickhof (MA Islamic Studies, Sociology, Modern History) teaches at the American University in Cairo, Sociology department. Before she was a research associate and lecturer at the Center for Middle Eastern and North African Studies at Freie University Berlin (2011-2014), and a PhD researcher and lecturer at the Netherlands-Flemish Institute in Cairo (2014-2017). Selected publications: Anti‐Muslim Racism in Germany. A Theoretical Approach (2010); My Friend, the Rebel. Structures and Dynamics of Cultural Foreign Funding in Cairo (2014); All that is Banned is Desired : ‘Rebel Documentaries’ and the Representation of Egyptian Revolutionaries (2016) ; Producing Inequality : Creative Economies in Cairo (2017).

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