I asked the angels if they thought exposure to Europe, and its sexual culture, accounted for Tunisia’s substantial rate of premarital sexual activity. “That’s the song of the religious people,” Guedouar scoffed. “They always say the same thing. Me, I think it’s more because the age of marriage has grown. Women, they are more educated than before. She goes to university, she finishes her studies at twenty-four years old. She has to work. So she’s marrying at thirty years old. She has the right to a sexual life [before marriage].”
For all their feistiness, the angels were skeptical of a wholesale change in the current sexual landscape. “The generation that is liberated, that’s the minority, not the majority. It’s not the same in the north or the south; it’s not the mentality. It’s not going to change everywhere. It will change in certain families, in certain types of people,” one of the angels observed. “The women are becoming more and more open, but the men are not changing.” Guedouar nodded her head in agreement. “He’s still at the prehistoric stage.”
THREE MONTHS’ NOTICE
If male evolution is taking too long, women in Tunisia have alternatives. Theirs is the only country in the Arab region to provide abortion (ighad) on request, meaning that a woman eighteen years or older, married or single, can have her pregnancy terminated, up to the end of the first trimester, on a variety of grounds, spousal consent not required. Tunisia started down this road more than four decades ago, when it first legalized abortion under limited conditions as part of Bourguiba’s wide-ranging plans for national development.34
Two generations later, the fruits of this approach were clear during my tour of a youth clinic in Bardo, a suburb of Tunis. As the condom angels attest, Tunisian authorities have taken a comparatively bold approach to the delicate matter of providing sexual and reproductive health services to young, mainly single people—an approach many hope will survive any attempts by Islamic conservatives to retrench. Since 2000, the National Office of Family and Population (ONFP), the government’s department on reproductive matters, has set up centers across the country to help young people steer a smoother course through the early years of their sexual life.
The day I visited, the clinic was buzzing with clients, mostly young women in their twenties. One group was clustered around a television, watching a video on breast cancer; others were in and out of consulting rooms, meeting with gynecologists or midwives or psychologists for advice and care on everything from acne to diet to contraception, all free at the point of delivery. This diversification beyond straight reproductive and sexual health makes more than just good clinical sense, especially for centers in rural areas, where young women are under closer surveillance and need some cover to explain away a visit that might be noticed by friends or family. Even in the capital, the Bardo youth center is discreetly tucked behind the main clinic, which caters to married women, with a separate entrance.
Youth-focused clinics are springing up in Egypt and a number of other countries in the Arab region—often on rocky ground.35 Although they face many of the same social and cultural obstacles, Tunisia’s public clinics are unique in one key respect: the abortion wing. The facility I toured was spotless; a gynecologist and two nurses in surgical greens were finishing up a procedure in the small operating theater, and in a couple of darkened rooms to the side, I saw the blanketed forms of three or four women. The wing has a capacity for nine, but it’s rarely full, I was told; surgical abortions are rare these days, in part because women are turning up for terminations much earlier. And the procedure itself has become safer thanks to the introduction of “medical abortion,” which uses a combination of synthetic hormones rather than mechanical means. It’s not just that medical abortion has replaced surgical procedures in Tunisia; the overall abortion rate has fallen dramatically since the late 1970s, confounding fears that widespread availability would lead to an abortion free-for-all, particularly among unmarried women. The number of abortions in Tunisia’s public health system has fallen from twenty thousand a year in the late 1970s to an estimated fifteen thousand today, although the eligible population has grown by almost a third in that time. Unmarried clients are thought to account for roughly 15 percent of procedures, according to some estimates.36
Despite Tunisia’s successful track record with legal abortion, there is trouble brewing, says Selma Hajri, a Tunis-based gynecologist and a leading researcher on abortion trends in her country. “There is not a big pushback against abortion, not yet, [but] there might be. We can’t stop [abortion]; it is in the practice and it’s a law. But you can make it more difficult,” she explained. “For example, in the hospitals and family planning clinics, all women have access to abortion. But only to eight weeks [of pregnancy]. After that, you have to go to the hospital. And at that point, there is a stricter control. If a woman is single, they ask for her papers. The welcome is more difficult; barriers go up.”
Hajri is typical of many educated women I met in Tunis—so stylishly dressed and perfectly accessorized and speaking such flawless French that I sometimes lost my bearings in conversation and forgot that I was in Tunis, not Paris. She’s clear on where these new objections are coming from. “This is linked to the impact of religion. Midwives, even doctors, no longer want to be implicated in abortion. They are fine on contraception, but not on abortion. They think it is haram.”
On the subject of abortion, Islam offers a certain degree of flexibility. While the Qur’an warns believers against infanticide—particularly the killing of baby girls, which was a custom in pre-Islamic Arabia—it doesn’t touch on abortion per se.37 The cornerstone of Muslim thinking on the issue comes from verses in the Qur’an on the origins of human life and the timing of “ensoulment” of the fetus.38 All schools of Islamic jurisprudence forbid abortion after 120 days of pregnancy, except if a mother’s life is in danger; before then, however, positions vary not only between schools but within them as well, from the strictest stance, which prohibits abortion altogether, to the most liberal of positions, which allows it on a wide range of grounds.39 Today, however, there is plenty of fire and brimstone from local religious leaders, particularly with the rise in recent decades of Islamism, which condemns abortion outright. The upshot is that many women are firmly convinced that abortion is haram no matter what.
Hajri gets a lot of visitors from sub-Saharan Africa eager to learn from Tunisia, but delegations from other parts of the Arab region have been rare. “We tried to bring people from Arab countries,” she remarked. “They also say, ‘It is very good, it is very interesting, but we couldn’t bring this experience to our countries. We don’t have the law; we don’t have the structure.’ It’s like visiting something completely new. They always have this feeling, Tunisia, it’s not a real Arabic country, it’s not a real Muslim country.” While Tunisia has proved an inspiration to countries across the region on the political front in the “Arab Awakening,” its laws and policies on gender and reproductive rights, the product of a particular history, have been harder to emulate. But the ascendance of Tunisia’s Islamic conservatives has brought the country a little closer to its more religiously inclined neighbors, who now might be more willing to take a look at its experiences—good news if Tunisia’s progressive policies and practices continue. Hajri readily acknowledges the difficulty of taking her country’s show on the road. “One of the most important things is the will of the power, the government,” she said. “If there is no real will, if they didn’t want to bring to women the choice of abortion, it would be very difficult to make it happen.”
For women across the Arab world, that will cannot come too soon. In Egypt, almost every married woman I know—and several of my unmarried friends—has had at least one abortion. What this means in terms of national numbers is a matter of speculation, since there are few official statistics. One calculation from the mid-1990s put the number of induced abortions in Egypt at 15 percent of pregnancies, roughly on par with rates in Western Europe.40 Such numbers are hard to come by because abortion is
against the law in Egypt, although legal wiggle room allows it in limited cases of “necessity”—notably, where a woman’s life is in danger. And the penalties, on paper at any rate, are stiff: imprisonment for the patient and practitioner.41
This means, at the very least, that thousands of Egyptian women, and their doctors, are breaking the law every year; how they go about it depends on their social standing. Wealthy women can pay a private gynecologist around EGP 3,000 (USD 500) for a safe procedure, usually dilatation and curettage, or D and C, a tidy medical term for scraping out the uterus. Medical abortion, as we saw in Tunisia, is slowly gaining ground; although not quite as profitable for practitioners as surgery, it does have the advantage of plausible deniability, since the drugs needed for the procedure are used in other treatments as well and, in any case, can be procured without a prescription. For the less fortunate, there are doctors who will do a tandiif (cleaning) for around EGP 200. It is an unsurprisingly unpleasant experience: of dubious hygiene, offering inadequate pain relief, and perfunctory treatment mainly by male practitioners who, at best, just want to push patients out the door as quickly as possible or, at worst, refuse to treat unmarried women or actively condemn their morals while taking their money all the same; blackmail and sexual harassment can also be part of the service.
Meanwhile, poor women rely mainly on do-it-yourself techniques, including drinking boiled onion tea or soft drinks mixed with black pepper, or inserting the stem of a mulukhiyya, a tall weed whose leaves are commonly used to make soup, into the uterus—an organic version of the proverbial coat hanger. Some of these traditional approaches are being replaced by higher-tech versions. So instead of using a plant stalk, a woman who suspects she’s pregnant might go to a clinic and get an IUD, which will stop implantation of the fertilized egg. And rather than taking an herbal concoction, women can improvise by swallowing a couple of packs of contraceptive pills to induce bleeding—a homemade attempt at emergency contraception that is, in fact, available in Egypt but little used by women or medical practitioners there. Much more grisly is the prick-and-stick approach, in which the woman is knocked out with an injection and then hit about the back and abdomen until she starts to abort. In many cases, these rough-and-ready approaches—either at private clinics or DIY—are not expected to finish the job. Rather they are meant to induce bleeding, which means a woman can then turn up at a public hospital and legitimately seek attention for a “spontaneous” miscarriage or hemorrhage.42
While the law makes getting an abortion a complicated and costly process, it doesn’t appear to do much to deter either women or practitioners. It’s only when a patient dies, or some other scandal erupts, that authorities step in; otherwise, a conspiracy of silence keeps the clandestine abortion business ticking along. It wasn’t always like this. Egypt’s current law dates from the late 1930s, but when my grandmother was a young married woman in the 1940s, abortion was an open part of life. The daya, traditional midwife, would come to my family’s apartment, in a lower-middle-class part of Cairo, where there would be coffee and gossip as on any other social occasion; my father, then a young boy, remembers being sent outdoors to play, returning to find the daya throwing out an aborted fetus with the other remains of the day.
This laissez-faire approach to abortion reflected a long tradition in Egypt. Like everything else to do with sex, abortion wasn’t something you shouted about, but you didn’t go to great lengths to hide it either; hence the extensive advice on abortion in the books of Arabic erotica through the ages.43 Today, abortion is a trickier affair. Single women, in particular, are caught in a double bind: the taboo of premarital sex not only makes abortion, already a secretive matter, even more furtive for them but, as we’ve seen, also increases their likelihood of having to resort to it in the first place, because of inadequate contraception. And as research shows, the burden of religious guilt weighs heavily on many.44
Most countries in the Arab region have more or less the same position as Egypt when it comes to abortion: technical illegality, tacit practice under most circumstances. All countries in the region permit abortion when a mother’s life is endangered. Half a dozen, including Saudi Arabia, allow it in the case of a threat to a woman’s physical health; Algeria adds the risk to mental health. Kuwait and Qatar also consider fetal impairment adequate grounds. Legislation in many of these countries is based on that of former colonial occupiers and so tends to reflect Western attitudes of the day rather than local tradition.45 But whereas the United Kingdom, France, and Italy liberalized their abortion laws in the 1960s and ’70s, legislative changes have been far less dramatic in most Arab states. The result is that 80 percent of the region’s women live in countries where abortion is restricted in one way or another.46 Every so often, police swoop down and arrest abortionists, and religious figures inveigh against the practice, then it’s back to business as usual.
If, as in Egypt, women manage to get the job done anyway, does it really matter whether abortion is largely against the law? Of course it does, say health experts and reproductive rights advocates. Aside from arguments on the right to bodily autonomy, there is plenty of practical fallout from criminalizing abortion, safety being one of the main casualties. The burden of unsafe abortion hits poor women hard; according to some estimates, up to 10 percent of maternal deaths in Egypt are due to abortion, both natural and induced.47 And then there is the cost to the health service of mopping up after so many crude terminations. This is not a uniquely Egyptian situation: across the Middle East and North Africa, the World Health Organization estimates, there are around 1.7 million unsafe abortions performed a year.48
Given that so many women are running so many risks, why is there so little public debate about abortion in Egypt and neighboring countries? The heavy hand of patriarchy, strengthened by the rise in recent years of Islamic fundamentalism, hardly encourages free and frank discussion of women’s sexuality. Many women’s organizations in the region have yet to engage on questions of sexual and reproductive rights, abortion among them, in part because they are busy fighting other battles and in part because of the “patriarchal bargain” some of them strike, trading off gains in certain areas for concessions in others, like sexuality.49 And then there is the vested interest of a powerful medical profession reluctant to lose a steady source of income from a clandestine, and therefore lucrative, practice.
If Egypt is to change its laws on abortion as part of a broader platform of political and social reform, one country marking that trail is Morocco. The law on the books allows only for terminations in the case of danger to a woman’s health or life and requires a husband’s consent or, failing that, approval from a provincial medical authority. As in Egypt, the penalties for infractions can be severe. And as in Egypt, illegal abortions are commonplace—at least six hundred a day, according to some sources.50
One man out to change all that is Chafik Chraibi. As head of gynecology and obstetrics at a major maternity hospital in Rabat, he’s seen enough complications from botched abortions to last a lifetime. “You cannot imagine how many women are doing abortions,” he told me. “Here, every day, every day, I receive women, married or not, they are four to five months pregnant, they have ruptured their uterus, they are in a mess and they don’t know what to do. Yet they don’t want to admit it. But we know … they took something.”
In 2007, Chraibi decided to shift course, from mopping up to leading the charge. He is president and founder of AMLAC, the Moroccan Association for the Fight Against Clandestine Abortion. Its name speaks volumes about how social change happens in the Arab region. “It would be shocking [for society] if I said the name of the association was for the liberalization of abortion,” says Chraibi. “Maybe [in] the future generation, not mine.”
Today’s goal is already ambitious: a “softening” of Morocco’s laws on abortion to allow terminations up to eight or ten weeks in certain cases: rape, incest, minors, fetal malformation, for women with psychiatric disturbances or caught in “dramatic�
�� social situations (a housemaid seduced in her employer’s family and thrown out on the street, for example). But Chraibi is also advocating for sexual education in schools and easier access to contraception, not only out of principle—this will reduce the need for abortion in the first place—but also out of pragmatism: it makes the association more socially acceptable if it’s seen as promoting prevention rather than just abortion.
Chraibi’s group isn’t the only one pushing for change; Morocco has an active civil society and several organizations with an interest in these issues. But it’s Chraibi who has become the identifiable face of this particular battle—and the man journalists at home and abroad call when they want to talk abortion. It’s easy to see why. Chraibi is charming, confident, and urbane, with a dramatic voice and a lively manner. This is not a man who takes life lying down. When we met, he was juggling a uterine cancer surgery, staff meetings, a briefing for politicians, and a couple of media interviews with the local press and French and Italian TV.
Chraibi has been touring the country to raise awareness and stir public support. As far as he’s concerned, the main obstacle to change isn’t religion but politics. “Every month, I go to one or two towns in Morocco where I am invited by an association [of] doctors, women, etc. There are always two or three people who speak: a religious leader, a lawyer—the local magistrate—and me. I start, I pose the problem, and then we discuss. The religious guy is always flexible. He says until forty days, the fetus doesn’t have a soul so abortion is authorized in the case of need. He distinguishes between forty days and four months in the case of necessity. The majority of religious leaders are in the same direction. But the lawyer, the local magistrate, he only talks about the law. Religion is a lot more supple than the law.”
Unlike many others in the region, Morocco has been able to galvanize a public debate around abortion. This is, in part, because its greater freedoms of expression and civil society not only push such issues forward but also create a climate in which research on sexuality is at least possible; this research, in turn, generates facts and figures, however rough, on the scale of the problem, which allow for more informed argument. Thanks to Chraibi and others, there is visible progress on abortion: the more liberal-minded media, which loves to talk about sex in any case, is largely on board; major religious figures agree; there have been debates in Parliament, and national conferences, and a former government minister has gone on record supporting legal reform as advocated by Chraibi and his allies.
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