In Egypt, where no national survey has been conducted on sexually transmitted infections (STIs) other than HIV in over ten years, a stigma regarding the use of protection and contraception methods remains among the younger generations. This stigma, a result of social and religious censure that comes with any sexual act falling outside the bounds of marriage, is damaging to the health of young Egyptians.
According to UNFPA (United Nations Population Fund in Egypt), less than one percent of the population is estimated to be HIV-positive, which means Egypt is a low-HIV-prevalence country. However with high risk behavior, such as having sex without protection, the risk of contracting HIV rises to an alarming five percent.
“Risky behavior with limited or no condom use is an issue with regards to HIV and other STIs,” says Ziad Rifai, the UNFPA Representative in Egypt. “However, the focus of interventions is correctly on Most at Risk Populations (MARPs), as the prevalence of HIV is much higher than in the general population.”
The World Health Organization’s definition of MARPs includes “men who have sex with men, female sex workers and their clients, and injecting drug users” because it is these individuals who engage in high risk behaviors that include “unprotected sex (particularly anal sex), sex with multiple partners, or the use of the same piercing or injecting equipment.”
According to Rifai, focusing on MARPs is strategic in a country with such a low prevalence of HIV in the general population, limited resources, and many urgent health issues. “However, the overall use of condoms among the general population or among MARPs is very limited, even if its use is for family planning purposes,” says Rifai.
Ahmed, 29, who is unmarried and sexually active, explains that he buys condoms from a pharmacy away from his house. “Although I don’t know the pharmacist downstairs myself, and I’m sure he doesn’t know my family, I always buy condoms from a pharmacy closer to my girlfriend’s house,” he says. His girlfriend, an American, is the one who requested this method of contraception, he says.
“I didn’t learn anywhere at all the value of using condoms,” he says. “There are no sexual education courses that I’ve ever encountered. I always thought that women had to take pills to avoid pregnancy, and the only sexually transmitted disease I’ve heard of is HIV.”
“Socio-cultural factors do play a significant role in contraceptive use,” Ziad Rifai says. “Part of the reason that condom use may be low is that there’s a stigma attached to it, but without definitive evidence we can’t assume we know the reasons for low condom utilization rates (1 percent) and how to address this.”
Last October, the Egyptian government decided to scrap all content in the secondary school curriculum relating to sex education, reproductive health and sexually transmitted diseases. Anything pertaining to reproductive health is no longer part of the school curriculum, and any pages containing drawings of male and female genitalia, as well as the entire lesson on sexually transmitted diseases, were removed entirely from school books.
Ahmed, however, does not see this as a significant change. “They taught us the scientific parts of the lesson and explained the way children are made, but never bothered to explain anything further or help us to understand the benefits of sex for reasons other than reproduction.”
The shame of buying condoms haunts Ahmed every time he heads a pharmacy. “I think that the pharmacists are going to judge me for being sexually active while not married,” he says. “I see them looking at my hand for a wedding ring when I pull out that condom box and produce the money for it.”
“I do notice if they are not wearing a wedding ring,” says Mohsen Ahmed, 33, the owner of a pharmacy in the Dokki district in Cairo, “but I don’t judge anyone. My job is to provide them with the medical care they need, and if they need condoms, I’ll sell them condoms.”
The pharmacy, on a busy main street in Cairo, has a condom stand in one of its corners, where the customer can simply pull out the type of condoms they want and ask for the price at the counter.
“Like most pharmacies that sell condoms, I leave that stand visible for everyone to see, and if my customer needs condoms, he can just take the box without bothering to ask,” Ahmed adds.
Ahmed, however, has never been in a situation where he needed to explain to his customers which type of contraception method is better for them. “While customers prefer to talk to me about all kinds of over-the-counter medicine they buy, picking the right contraception method for them is a subject that they would rather explore themselves.”
“Of course I wouldn’t be able to talk to the pharmacist about my sexual needs and what kind of method I need for contraception,” explains a sexually active Egyptian woman in her mid-thirties who preferred to remain anonymous. “I don’t buy condoms myself, and I go through hell to buy birth control pills here in Egypt. Sometimes I ask my foreign friends or my fiancé to buy them for me.”
Although she tries to keep safe and doesn’t engage in sexual activity with multiple partners, the young woman explains that once before she got pregnant. “I wish I was able to go to the pharmacy myself and buy whatever I need without fear,” she says.
“Contraceptive use is deemed the woman’s role but in many cases the men are the decision makers,” Rifai says. “Gender also plays a role in that there are correlations between the number of children a women bears and her education and economic status [a higher education correlates with a lower number of children]. Also, gender issues generally stand in the way of a woman’s ability to negotiate safe sex.”
In Islam, the main religion in Egypt, premarital sex is considered a punishable sin. While Egyptian law does not follow religious jurisprudence exclusively, such practices remain punishable by law and are considered socially unacceptable.
“The Ministry of Health supports birth control pills and subsidizes their costs, because they care about family planning and considering it a top priority now,” says Dr. Rafik Mohamed, 28, a pharmacist who is sitting in his small pharmacy in Manial. He says a lot of women now are not as shy as they used to be six years ago in asking for birth control pills or injections. “They come here on time every month for the injection and they ask me to write down the next month’s appointment,” he explains.
“To address Egypt’s population issues, one must look beyond offering family planning services,” Rifai explains. “The inception of the Ministry of Family and Population is part of the efforts of Egypt’s government to not only improve access to and the availability of quality family planning services but to also look at the population in a more holistic manner that involves youth, gender, education and human rights issues.”
Mohamed, however, does not think that the new generation is shy about inquiring about contraception. “I think older people are shyer than the current generation in asking for these methods [of contraception],” he says. “The younger generation comes here with a better understanding of sexuality and intimacy and know how to protect themselves from pregnancies or STDs.”
Mohamed says he does not judge those asking for contraception. “I think that the shame they feel is not connected to the way pharmacists are acting, but comes from years of the way society connects sex with shame and sinfulness.”
“It’s my duty as a pharmacist to give them the right and the safest method,” he adds.
While the big pharmacy franchises such as Ezaby and Saif are the best at easily providing contraception methods here in Egypt, some pharmacies are not as welcoming.
“We don’t sell condoms here,” an old pharmacist sitting behind his counter in a Downtown pharmacy says. “Go buy your condoms elsewhere.”
The man refused to answer Al-Masry Al-Youm’s questions, because “contraception is against Islamic understandings of sex. It’s a sin to meddle in how many children God wants us to have.”
Religious extremists disapprove of contraception use generally, even in the sexual relationship between a man and wife, and say that God provides fathers and families with the necessary income to cover their children’s needs. Some moderate Islamic scholars, however, disagree.
Meanwhile a 36-year-old homosexual man, who calls himself “Maher” to preserve his anonymity, explained to Al-Masry Al-Youm that he believes that asking for condoms in a pharmacy poses a higher risk than the possibility of attracting STIs. “I feel that, because of many elements, including the fact that I’m still not married yet, the risk of people finding out about my secret life as an Egyptian homosexual is higher than the risks of getting HIV.”
Maher knows that he belongs to one of the Most at Risk Populations and that his choices might increase his chances of becoming infected, but he is “scared to death of what might happen [if people found out].”
“In this case, I prefer my privacy to my health,” he says.