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28 juin 2009 7 28 /06 /juin /2009 13:31

SEXUAL BEHAVIORS AND PRACTICES IN MOROCCO[1] (I)

HOMOSEXUALITY

 

Prof. Dr. Abdessamad Dialmy

University Mohamed V Rabat

 

 

The social-anthropological studies that describe sexual behaviors and practices are qualitative in their big majority. In fact, only four studies[2] have tried to assess quantitatively sexual behaviors and practices, but their sample is not representative. Neither political power nor religious forces are favorable to assess Moroccan sexuality. The quantitative assessment of "illegal" and "anomalous" sexual behaviors and practices could be an official recognition of their existence and their importance, which is an inconceivable thing within the logic of a state that essentially governs in the name of a scholar and fundamentalist Islam attached to what must be. These qualitative studies say one essential thing: sexual behaviors and practices are characterized by an uncontrolled opening[3] that could be described in terms of anarchy[4].  Of course such statement disturbs an Islamic state, which is unable to demonstrate the opposite. Finally, the last weapon is to declare the results of qualitative studies not representative.

 

I- Homosexuality

 

Sexual socialization makes itself through rituals that construct a dominant masculine heterosexuality. Homosexuality remains this non-definitional troubling in-between. 

The socialization of the boy is centered on the glorification of his penis. Thus the circumcision, as a rite of passage[5], is a fundamental act in the construction of the masculine identity: through it, the boy is delivered from the prepuce, excluded of the female world and acquires virility[6]. Consequently, the female world becomes an object of sexual desire. So circumcision is the founding moment of heterosexuality. The main anxiety of parents is to have a homosexual boy[7]. To be heterosexual is to be sexually correct.  

At his first marriage, the groom is ritually called sultan (king), which is a way to say that "the groom becomes a man when becoming the male par excellence, the king (...). He symbolically becomes the king from the beginning of ceremonies and he remains king until their completion, until the wife's blood is spilled (...). The king makes the groom reach the adult age, and the groom makes penetrate the king in his private domain, in what determines his identity, the first conjugal sexual act”[8]. To be a man is to be a king, and to be a king is to be a man. To be a man-sultan means to be virile, it means to dominate the wife, it means first to be married. Therefore, the male (rajal) is the harsh man, as opposed to the lenient man (rouijel)[9]. The man is the master who must sexually initiate the wife and control later on the sexuality of his female offspring  (the preservation of virginity).  

This hierarchical relationship of sexes is currently in transition in the sense that the traditional dichotomy between two hierarchical sexual identities is put into crisis by the evolution of Moroccan society, and more precisely by the evolution of the sexuality and reproduction. Female sexuality now dares to affirm itself[10] outside the institution of marriage. It is a sexuality that is de-institutionalizing and that is beginning to claim the right to auto-determination and independence.  

But masculine identity as power is still there, insufficiently shaken by the breakthroughs of the Moroccan woman in the domains of education and employment. Besides, the socioeconomic crisis (induced by the structural adjustment policy since 1983) compels the common Moroccan male to regress toward the traditional shapes of masculine domination. The principle of sex equity is the first victim of this crisis in spite of all efforts made by the civil society and state feminism[11] in order to dissociate between equality of sexes and economic expansion. A tradition that affirms itself in the name of Islam, supported by scholars and fundamentalists, becomes an ideological shelter that allows the rejection of all hopes for sex equity in spite of the fact that social-sexual evolution goes slowly in this sense.    

A study entitled "Masculine Identity and Reproductive Health in Morocco" revealed that, for the common Moroccan man, bi-sexuality remains illness, deviance and vice[12]. It is above all a depreciation of the man, a man who is bi-sexual is said to be feminine. Bi-sexuality relegates the man to a patriarchal lower rank. Youngsters, the most concerned with their sexual identity because of their socioeconomic vulnerability, feel this depreciation even further when their sexual behaviors are homosexual.  

In Morocco, the most tolerant social attitude explains masculine homosexuality by an excess of feminine hormones[13]. Implicitly, this "popular-scientific" explanation of homosexuality reduces it to the so-called passive homosexuality. The penetrated homosexual is the only one considered homosexual. Indeed the excess of female hormones is interpreted in terms of anomaly and illness. But even when recognized as a prisoner of his hormones, the homosexual is not considered as a victim, the forgivable victim of a hormonal destiny independent of his will. While being irresponsible, the penetrated homosexual is accused of immorality and inspires disgust[14].  

Is male homosexuality compatible with masculine identity? Five answers[15] have been provided to this question. The first consists in establishing a mechanical synonymy between maleness and masculinity. In other terms, having a penis is sufficient to be male. The second consists in reducing homosexuality to receptive homosexuality. Only the one that is penetrated is said homosexual and stop being a man. The third answer consists in de-masculinizing all homosexual actors. If the receptive homosexual is de-masculinized because he is penetrated, the penetrating homosexual is also de-masculinized because of his abandonment of work, honor and dignity, values that are still associated to masculinity. The fourth answer consists to dice-sexualize all homosexual actors. Homosexuals are not considered as women or as men. Not being a man, the sodomite is not even a woman; this is due to a newborn respect expressed to the woman's consideration. The fifth answer consists in dehumanizing the homosexual actor. The homosexual stops being a human being to become an animal, he stops being human as well as religious because of a homosexual activity. Heterosexuality as an Islamic principle is definitional of the human being. 

These distinctions that synthesize attitudes of the common Moroccan allows to distinguish two sexual meanings of masculinity: a biological sense according to which the male is a man with respect to his anatomy, and a social-religious sense where the man is exclusively heterosexual. Social-religiously correct masculinity is heterosexual. One notices that masculinity is first of all sexually defined by the biologic sex, and then by the sexual behavior. To be a man means to be a heterosexual male. Consequently, there is no masculinity outside this orientation, no homosexuality in the man's definition. Homosexuality is the mistake that excludes the man from the field of masculinity. 

Girls are discreet and allusive concerning this topic. For them, homosexuality is not considered a less dangerous substitute (no risk of defloration or pregnancy in comparison with the heterosexual intercourse), but above all as an immoral behavior, a perversion[16]. The attitude toward homosexuality is negative: 90% refuse the masculine homosexuality while 87,2% refuse the female one[17]. The perception of homosexuality as an anomaly is expressed by its current Arabic translation, choudoud, which literally means perversion. Masculine homosexuality is not translated through the word liwat and lesbianism is not translated by the word sihaq in spite of the existence of these two terms in Arabic. Words liwat and sihaq are more descriptive, with less perverse connotation.

For boys, the homosexual intercourse is assumed only in so far as it is a means to prove a double virility. The active homosexual (louat) makes love to women and men without defining himself a bi-sexual person. For this reason, the Moroccan boy reports his first homosexual relationship gladly only if he had the active role, the penetrating role. No one speaks about his first homosexual experience in which his partner has penetrated him[18]. Indeed, the situation of the hassass (who likes to be penetrated by taste) and the zamel (the homosexual male prostitute) the two figures of “passive” homosexuality is different. Their sexual practices are not assumed because of socially depreciated[19]. But the hassass is more depreciated because he likes to be penetrated. The zamel is more considered as worker, a prostitute. Consequently, sex work becomes for some homosexuals a stratagem to live their homosexuality in a less dangerous way.

One recognizes homosexuality like a recurrent social phenomenon, which begins to be described in terms of market[20]: youngsters sell their bodies because they are not able to sell something else, without a concern about satisfying any kind of bio-psychological need. Here homosexuality is prostitution, sexual work. It is not recognized as hormonal destiny and/or interior need. This economic interpretation of homosexuality in terms of prostitution is a way to justify it or even to excuse it. Within this logic, youngsters would not have another solution to earn their living[21]. 

In some cases, masculine homosexuality is a surrogate. It is the sexual act that takes place between two males because of the lack of a female sexual partner. This homosexuality does not answer an interior psychological need; it does not reflect a recognized and assumed homosexual identity. It is essentially pragmatic. It is expressed through two major shapes: the rape of the minor by the adult[22] and the adult homosexuality in jail[23].



[1] Extracted from my paper entitled « Sexuality and Sexual Health in Morocco », in "Challenges in Sexual and Reproductive Health: Technical Consultation on Sexual Health, OMS, Genève 2002.

[2] I refer here to A. Dialmy's books La femme et la sexualité au Maroc (Casablanca, Editions Maghrébines, 1985, in Arabic) and Logement, sexualité et Islam (Casablanca, Eddif, 1995) and to Naamane-Guessouss's book Au delà de toute pudeur (Eddif, 1987). I refer also to Dialmy's study Identité masculine et santé reproductive au Maroc, MERC/Ford Foundation, 2000.

[3] A. Dialmy : “Vers le libéralisme sexuel”, Al Asas, n° 20, 1980. This article was published again as a chapter under the tittle of "Jeunesse et sexualité à Casablanca" in my book Sexualité et discours au Maroc, Casablanca, Afrique-Orient, 1998, pp. 51-63.

[4] A. Dialmy : Sexualité et Politique au Maroc, FNUAP, 2001, inédit p. 27-28.

[5] A.V Gennep : Les rites de passage, Paris, Emile Noury, 1909.

[6] C. Bonnet: “Réflexions sur l'influence du milieu familial traditionnel sur la structuration de la personnalité au Maroc”, Revue de Neuro-Psychiatrie Infantile, n° 10-11, 1970.

[7] A. Belarbi: Enfance au quotidien, Casablanca, Le Fennec, 1991, pp. 111-113.

[8] Elaine Combs-Schilling: “La légitimation rituelle du pouvoir au Maroc ”, in Femmes, culture et société au Maghreb, Casablanca, Afrique-Orient, 1996, pp. 76-85.

[9] This distinction between hard man and soft man is taken from Elisabeth Badinter in XY, De l’identité masculine, Paris, Odile Jacob, 1992.

[10] The magazine Femmes du Maroc deals regularly with feminine sexual themes. See A. Dialmy : “Les champs de l’éducation sexuelle au Maroc : les acquis et les besoins ”, in Santé de reproduction au Maroc : facteurs démographiques et socio-culturels, Rabat, Ministry of Plan and Economic Prevision, CERED, 1998, p. 289.

[11] A. Dialmy: “La transition démocratique: du mouvement féministe au féminisme d’Etat ”, Al Ittihad Al Ichtiraki, 15 April 1998 (in Arabic) and published again in my book Toward an Islamic sexual democracy, Fès, Infoprint, 2000, pp. 55-58 (in Arabic).

[12] A. Dialmy : Identité masculine et santé reproductive au Maroc, op. cit. p. 72-74.

[13] Ibid. pp. 72-74.

[14] Ibid. pp. 72-74

[15] Ibid. pp. 74-78.

[16]A. Dialmy : Jeunesse, Sida et Islam au Maroc, Casablanca, Eddif, 2000, pp. 75-76.

[17] A. Dialmy : Logement, sexualité et Islam, Casablanca, Eddif, 1995, p. 229.

[18] A. Dialmy : Jeunesse, Sida et Islam au Maroc, op. cit. p. 78.

[19] S. Davis : Asolescence in a Moroccan town, Rutgers University, New  Brunswick, NJ, 1989.

[20] A. Dialmy : Identité masculine et santé reproductive au Maroc, op. cit. p; 74; and Sexualité et Politique au Maroc, op. cit. p. 32-39.

[21] L. Imane : Prévention de proximité auprès des prostitués masculins au Maroc, Casablanca, ALCS, inédit.

[22] A. Dialmy : Jeunesse, Sida et islam au Maroc, op. cit. p. 90.

[23] M. Jamal : L’homosexualité dans la prison marocaine, memory of master in sociology, 1995, (under direction of Pr. Dialmy). See also, A. Dialmy : Jeunesse, Sida et islam au Maroc, op.cit. p. 90.

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28 juin 2009 7 28 /06 /juin /2009 13:28

SEXUAL BEHAVIORS AND PRACTICES IN MOROCCO (II)

HETEROSEXUALITY

 

Prof. Dr. Abdessamad Dialmy

University Mohamed V Rabat

 

 

II- Heterosexual  Behaviors

 

The induced sexual need by the non-structured policies of the state is so intense that it leads youngsters and adults to zoophily, continual harassment and wild, multiple relationships. 

 

II-1 Zoophily 

 

Zoophily is very recognized especially by rural boys, those that have spend their childhood in the countryside. Donkeys, sheep and poultry were the object of their first sexual experiences[1]. Animals are chosen for their warmth, lubricity or tightness[2].

 

II-2 Harassment  

 

Coeducation in the urban public space is not profoundly accepted nor assimilated. It is lived through the pattern of sexual harassment (dragnet). Within this space, the freedom of the male does not end where begins that of the female. Public space is a space of systematic dragnet, on foot, by car, in the bus, wherever, whenever [3].  

“Dragnet" as the main mode of dating makes of the youngster’s sexuality an occasional, unsteady and fast sexuality. “Dragnet" leads to shorten the period between the first meeting and the sexual act[4].  

 

II-3 Multi-partner relationships 

 

Rare are youngsters that recognize one partner only. For the majority, the multi-partner relationships seem to be the norm. However, one can distinguish between a successive multi-partner relationship that is change of the partner and a simultaneous multi-partner relation that consists in having several partners at the same time[5]. This second type of relationship is more frequently invoked. It is presented as having a "pure" fiancée and several dirty "occasional" sexual partners. This form of multi-partner relations saves morality, on the one hand, and satisfies security compulsion on the other hand, reassuring an ego that is culturally submissive to the virility imperative, which is perceived as multi-partner relationships. To be virile or die, that is the dilemma. For Moslems, the connection between virility and multi-partner relationships takes root in the prophetic model. 

 

III- Heterosexual Practices 

 

The practices described below mainly concern the sexual activity of teenagers and youngsters. 

 

III-1 Masturbation 

 

Among boys, masturbation begins long before puberty, starting from the age of eight[6]. It takes place without ejaculation. Collective masturbation is also a game, "the challenge to determine who can make it longer than others"[7]. 

Girls speak with difficulty of their masturbation. They speak more about rubbing themselves against objects such as the cushion, the pillow or the table[8].

The factors that arouse the desire for masturbation are varied enough. The two main sources are seeing sex movies and the narrowness of the parental lodging. Indeed, many boys felt a strong sexual arousal when they either saw or heard their parents making love[9]. This factor is invoked again and again. 

 

III-2 The brushstroke  

 

It is a common expression by Moroccan youngsters to say that the penis operates like a brush between the big lips of the vagina or between the girl's thighs, penetration often being refused and feared. In this case, girls and boys are together convinced of the value of virginity as non-defloration[10].  

Girls find in the brushstroke a means that allows them to pass with success the test of “the good premarital sexual behavior,” sexual pleasure without defloration. By refusing the temptation of penetration, girls feel a kind of pride[11], and forget the shame and guilt that are socially associated with all kinds of premarital sexual activity.  

 

III-3 Heterosexual sodomy 

 

Among boys, heterosexual sodomy is very appreciated by boys. But numerous are girls who refuse sodomy. The main reason of the refusal is originated in the social and religious vision of “the sexually correct" according to which sodomy is condemned. But girls often have to let themselves sodomized[12]. Sodomy is here a surrogate to vaginal penetration.  It is a substitute that allows the young boy to ejaculate inside, in an inside. Some girls recognize to have experienced it and express remorse and disgust in general[13]. 

In the conjugal setting, some wives see sodomy as a practice unworthy of a married woman. In few cases married women admit practicing and enjoying sodomy[14].  

 

III-4 Oral sexuality 

 

The oral intercourse constitutes another palliative for defloration. The girl's refusal to let herself be penetrated gives the boys the opportunity to put pressure on their female partners to get a fellatio[15]. Therefore, in general, the fellatio is a practice of substitution associated to premarital sexuality or in some cases to an extra-conjugal activity[16]. But within the conjugal framework itself, the normalization of oral sexuality is admitted among a category of youngsters who have a high level of education. However, the fellatio seems to be more frequent than cunnilingus. This bigger frequency of fellatio expresses the sexual selfishness of the dominant male[17].  

 

IV- Female Sexual Satisfaction  

 

As a result of rapid increase in female literacy and the spread of TV since the 1970s, young women have more access to the themes of romantic love and sexual consumption[18]. In the same way, the expansion of video shops in the 1980s encouraged the consumption of pornographic movies that play a pedagogic role in the erotic domain[19]. The discovery of sexual pleasure by Moroccan women is there, incontestable. It ensues a growing importance of sexual understanding in the maintenance of the couple. 

 

IV-1 Premarital 

 

By the late 1970s the first survey on sexuality in Morocco by Dialmy[20] revealed that only 8,7% adopt the Islamic prohibition of premarital intercourse (2,2% among boys and 18,3% among girls). Moreover, this premarital intercourse does not presuppose a marriage project and is practiced for itself, for pleasure (67,7% among men and 45% among women). According to this study, virginity must be preserved until marriage for only 9% of girls and could be consumed just after engagements for 40%. The premarital sexuality is satisfying for 90% among men and 75% of women.

In the 1980s, according to Naamne-Guessouss, "the majority of young girls (65,3%) have had one intercourse at least"[21].

During the 1990s, young women show more sexual emancipation as it appeared through Dialmy's studies, "Jeunesse, Sida et Islam au Maroc" and "Sexualité et politique au Maroc"[22]. For the "new" young woman, a lover or a potential husband is appreciated for both his sexual and economic potency. Hence sex relationships become subdued to the groping, to the principle of the test and the mistake. They are becoming unsteady and utilitarian. Some unmarried young women consult for frigidity[23]. In general, the young woman doesn't want to hear about premarital sexual abstinence.

 

IV-2 Conjugal

 

According to S. Naamane-Guesouss, women divide in three categories with respect to this issue: the first category is represented by educated young women aged less than 35 years for whom sex is shared pleasure; a second category of educated women aged 35 years for whom sex is the opportunity to give pleasure to the husband in exchange of his affection, a third category of illiterate women aged over 35 years for whom sex is a chore and a suffering [24].

In my "Sexualité et Politique au Maroc"[25], I argued that the above female positions two major opinions are confronted here. The first believes that the conjugal couple is based dialogue and sexual understanding, the second thinks sexual modernization of the conjugal couple concerns a statistical minority mostly related to urban areas[26]. 

For the first opinion, wives manage to live sexuality as pleasure, not as a chore. In intellectual middle classes the wife has begun to discuss sexual matters with her husband in terms of right thanks to her economic contribution to the household. In the high social spheres, the wife is open to all sexual practices. In sum, there is undoubtedly a discovery of sexual pleasure by the married woman. More and more, and sometimes without the knowledge of the husband, some married women consult female gynecologists for questions of pleasure. According to a psychiatrist interviewed in Fez, the majority of men can only follow and find more and more normal that the conjugal partner participates actively in coitus. Female pleasure is more and more normalized. Husbands bring pornographic cassettes to their wives for inspiration and imitation. Some married men consult a psychiatrist because they need to know whether oral or sodomite intercourse are normal practices. 

For the second opinion, this normalization of the wife's sexual involvement would only touch the middle and high classes. In the other layers of society, there is a lot of dissatisfaction, a lot of hesitation and a lot of silence within the couple. But sexual misunderstanding with the husband is not the only cause of female adultery. In some cases, the wife cheats on her husband for money without being really poor. She does it in order to be able to satisfy her intensive need to consume more and better[27].  

 

Conclusion

 

In conclusion, let’s recall that sexual behaviors and practices described above were also related in two Moroccan newspapers, Al Ahath al Maghribiya (in Arabic) and L'Opinion (in french). "From heart to heart" and "Beyond taboos" are respectively the two files through which personal sexual stories are exposed twice a week since more than 2 years. In doing so, these newspapers created a public discussion about sexuality between story's writer, reader and sexologist[28] or psychologist and are contributing to undermine the taboo of sexuality in Morocco.

 



[1] A. Dialmy : Jeunesse, Sida et Islam au Maroc, op. cit. pp. 74-75.

[2] A. Serhane : L'amour circoncis, Casablanca, Eddif, 1996, p. 156.

[3] A. Dialmy : Logement, sexualité et Islam, op. cit, pp. 65-66.

[4] A. Dialmy : Jeunesse, Sida et Islam, op. cit, pp. 100-104.

[5] Ibid. p. 104-110.

[6] Ibid. p. 72.

[7] Ibid. p. 72.

[8] Ibid. p. 73.

[9] Ibid. p. 73.

[10] Ibid. p. 85.

[11] Ibid. p. 86.

[12] Ibid. p. 88.

[13] Ibid. p. 89.

[14] Ibid. p. 89.

[15] Ibid. p. 87.

[16] A. Khatibi: Blessure du nom propre, Paris, Denoël, 1974, p. 50.

[17] A. Dialmy: Jeunesse, Sida et Islam au Maroc, op. cit. p. 88.

[18] E. Evers Rosander: Women in Borderland: Managing Muslim identity Where Morocco meets Spain, Stockholm Social Studies in Social Anthropology, Stockholm, 1991.

[19] A. Dialmy: Jeunesse, Sida et Islam au Maroc, op. cit. p. 143.

[20] A. Dialmy: La femme et la sexualité au Maroc, op. cit., pp. 133-134.

[21] S. Naamane Guessous : Au delà de toute pudeur, op. cit. p. 44.

[22] A. Dialmy: Sexualité et Politique au Maroc, op. cit, p. 18.

[23] Ibid. p. 19.

[24] S. Naamane Guessous: Au delà de toute pudeur, op. cit. pp. 205-208.

[25] A. Dialmy: Sexualité et Politique au Maroc, op. cit, pp. 20-23.

[26] Nadia Arrif: “Condition sexuelle de la femme rurale: cas de l'Unnayn”, Portraits de femmes, Casablanca, Le Fennec, 1987.

[27] A. Dialmy: Sexualité et Politique au Maroc, op. cit, pp. 20-23.

[28] The sexologist A. Harakat was the consultant of L'Opinion newspaper regarding "Au-delà des tabous" file. This sexologist recently gathered some letters and his responses that occur between May 1999 and June 2000 in a book which took the title of the file, "Au-delà des tabous. Réflexions sur la sexualité au Maroc", Casablanca, Editions Axions Communication, without date.

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25 juin 2009 4 25 /06 /juin /2009 12:08

SEXUALITY IN SOCIAL SCIENCES IN MOROCCO[1] (I)

 

Prof. Dr. Abdessamad Dialmy

                                                                                                                                           University Mohamed V Rabat

 

In the 1960s, the Malthusian imperative imposed on Morocco by international operators was at the origin of some research on sexuality through some studies on marriage (the minimum age of the first marriage, choice of the spouse…etc.) and family (type and size). It is through this institutional dimension that sexuality has been established as an object of knowledge and action in order to control national demographic explosion.

Parallel to this Islamized Malthusianism, a practical tolerance of sexual liberalism could be observed in spite of the existence of repressive laws, which forbid all shapes of non-marital relation. The explosion of premarital sexuality due to the crisis of employment and marriage is demonstrated by the fact that the percentage of bachelors with AIDS is continuously increasing[2]. Between 1986 and 1997, 20% of persons living with HIV are bachelors. In June 2001, this percentage reached 39%. Henceforth, bachelors are more infected than married people (36%). The practical and non assumed sexual liberalism has, in my sense, filled out a compensatory function in the sense that individuals, politically crushed during the 1960s and the 1970s, "realize" themselves sexually without touching to the established order. Sexual liberalism is observable in the impunity of the urban sexual harassment, in the free sale of contraceptives, in the explosion of premarital sexuality, in the rise of male and female prostitution. Indeed, the field of sexuality knows a fast evolution characterized by the emergence of anarchical sexual behaviors and practices theoretically condemned in an Islamic society.

In a context of economical precariousness, these anarchical sexual behaviors are not informed nor chosen, they are undergone in a way and a fortiori the HIV risk increases. The expansion of sexual work is the indicator par excellence of the vulnerability of youngsters to this risk. The STD constitutes a national curse; there are 400 000 new cases every year according to evaluations of the ministry of health. Therefore, associated to STD and AIDS threat, sexuality began since the end of the 1980s to be perceived in terms of risk and, therefore, classified among public health problems. Programs are elaborated in the aim of promoting sexual health, especially understood as prevention against STD-AIDS. But already the development of family planning, a prior necessity of development, has made sexuality shift from the private domain to the public one and from the individual level to the collective one. The HIV risk does perpetuate and strengthen this perspective.  

Through contraception, premarital relationships, sexual work, and STD-HIV risk, Moroccan sexuality has joined the universal and the global. It also begins to conceive itself in terms of sexual rights: right to sexual information, right to choice, right to sexual pleasure, right to protection and care. But the founding secularism at the heart of sexual health is said to be inadmissible in the name of an Islam that refuses to recognize sexuality as such, but always associates it with marriage in the Islamic term/institution of nikah. Sexual specificity is thus affirmed in the name of Islam.  

Therefore Moroccan sexuality is a social/cultural construction that oscillates between the specificity of tradition and the universality of modernity. This oscillation is both the indication of an ideological and theoretical contradiction, and a permanent source of tension. But this contradiction is solved in daily life, at the levels of social praxis and among professionals of sexual health. It is this movement of pendulum, characteristic of Moroccan sexuality, oscillating between the specific and the universal, between the ideological contradiction and practical programs that I would like to describe in this paper. 

Within this framework, this paper tries to answer the following question: What is the status of sexuality and sexual health in the practice of social sciences in Morocco?  

From a bibliography[3] that covers the notions of family, woman and sexuality (from 1912 to 1996), the hypothesis of the progressive disclosure of the object "sexuality" emerged. In other words, the object family and the object woman veiled successively sexuality as object of research. And it is above all because of the emergence of AIDS that sexuality currently shifts toward a kind of epistemological autonomy in the sense that it has began to be studied without being eclipsed by family or woman and without being cautioned by the “morality” of family or woman objects.

At the quantitative level, the pure sexual themes occupy a minor status with respect to the objects of family and woman as the following two figures demonstrate: 

 

Figure 1: Distribution of Writings on Family-Women-Sexuality 

 

         Period

 

Theme

Colonization

 

1912-1955

 

%

Independence

 

1956-1975

 

%

Neo-national

 

1976-1996

 

%

Family

 

41,2

31,3

15,6

Woman

 

41,0

47,3

58,4

Sexuality

 

17,8

21,4

25,0

Total

100

100

100

 


 

Figure 2: Distribution of Writings on Sexuality 

                                                              

            Period

 

Theme

1912-1955

 

%

1956-1975

 

%

1976-1996

 

%

Behavior

 

1,6

1,9

7,5

Body, virginity

 

3,2

1,9

3,5

Prostitution

 

3,2

0,0

2,5

Fertility

 

9,8

17,6

4,5

STD-AIDS

 

0,0

0,0

7,0

Total

17,8

21,4

25,0

 

 

As one can notice through these two figures, sexual themes have recently acquired a relative statistical importance. But most importantly, one can notice that the object sexuality has been landed mainly through the demographic perspective (fertility and contraception) from 1912 to 1975. It is only in the third period that the demographic prism relatively fades away so that notions of sexual behavior and risky sexuality attract more attention.   Indeed, concentrating attention on the family meant studying sexuality only through its institutional demonstrations. Variables of social studies of family overlook behaviors and sexual practices outside marriage.  

 

1- Women as a challenge

 

Women studies are having the absolute majority during the two last periods, after-independence (1956-1975) and neo-national (1976-1996). These studies are mainly focused on themes related to development like the veil, education, employment, the use of contraceptives and virginity. Consequently, the object woman was a stage in the progressive discovery of sexuality as "object" by social studies through the mediation of body that was here fundamental.

The emergence of the object "woman" is indeed correlated to the public production of the female body in a society that had to break with one of its ideological foundations, the public eclipse of body. Education and employment particularly raise the question of the veil while the increase of contraceptive use reinforces in the same sense the appearance of female body as non-mechanically devoted to pregnancies. The veil is in fact the socio-religious mechanism that served to eclipse female body in the traditional urban public space[4]. And it was quite normal that, after independence, Moroccan society faces the issue of the veil when facing the question of female education and employment. The construction of modern Morocco in the name of the development ideology could not be effectively carried out in social setting divided in two hierarchical worlds, one public and male and the other domestic and female. National power anxious to insert the woman as actress in the process of development waged a battle against the veil and the seclusion of women. In this sense, already in 1952 Allal el Fassi wrote that "the veiled woman is not less exposed than the unveiled one to the danger of prostitution"[5]. He went further by accusing the separation of sexes to be responsible for homosexual practices[6]. In doing so, Al Fassi was certainly under the impact of Egyptian reformists (like Mohammed Abdou) or Egyptian feminists like Hoda Chaaraoui. But there was also the impact of the western[7] family model on the Moroccan family. Consequently, after independence, the veil was not recognized as a sign of resistance to colonization. The battle of the veil is highly symbolic because it translated the historical necessity of the emergence of woman as a productive body in the productive space. The liberation from the veil was a kind of liberation from submission, from the patriarchal image of the homemaker. It was the first step toward the emergence of woman as a body-subject that can say no while giving the impression to offer itself. This body-subject can invest public space without hiding body and beauty. This public unveiling of female body, reinforced by progressively extended contraceptive use, allowed first to define body less and less as "a trunk of pregnancies" according to D. Chraïbi's expression[8] and more and more as an erotic pleasure instrument[9]. Indeed, the recurrent theme of virginity indicates the will of female body to act as an actor of premarital sexual pleasure that is critical of patriarchy and its Islamic justification[10].

This public production of the female body began by the battle against the veil and is continuing through the battle against virginity. Indeed Bouhdiba[11] tends to say that Arab-feminism had two main stages, the first one is the liberation from the veil between the two world wars while the second is the conquest of the right to flirt and sex (critique of chastity and virginity. In the 1970s the female circumcision[12] was as an emerging topic in Egyptian feminism). But according to J. Berque[13], the Moroccan reformist Allal al Fassi addressed to the town council of Fez in 1927 a petition through which he asked for the prohibition of exposing the bride's linen during the wedding night. This petition suggests the idea that Moroccan reformism is precocious and adopted a proto-feminist critique of the taboo of virginity since the 1920s.

Of course, the veil and virginity are two main themes directly related to the body and sexuality, which raises the general question of compatibility between women’s liberation (modernity) and Islam[14]. For current Moroccan feminism that is expressed essentially through female associations[15], there is no contradiction between women’s liberation and Islam. For this elitist movement of the Moroccan female intelligentsia, women’s liberation and integration into development can be achieved with Islam and not against it. In other words, Moroccan feminism never claims secularism. For fundamentalists, some feminist claims are unacceptable. For them, present Moslem woman has first to be veiled without refusing modernity. Due to massive access to academic education, the fundamentalist veiled woman is both involved in the conquest of the positive western knowledge and in the Islamic ethics[16]. This ethics is the setting in which the western knowledge must be made use of, it is also the setting that draws divine borders for female behavior in society. Consequently the fundamentalist veil[17] is the symbol through which woman is both Muslim and modern in a mixed public space without arousing the danger of chaos (fitna) induced by the seductive powers of women. According to some fundamentalists students of al Adl wa al Ihssane interviewed at Fez university[18], the traditional veil means effectively woman’s exclusion, but the "true" Islamic veil "protects" woman to be perceived as a desirable public body. This "new" veil does not prevent woman to participate in production, knowledge and power and guarantees her free circulation in the public zones of the urban space. In this case, the public space does not turn into a place of excitation and sexual harassment. Hence the necessity to create the concept of veiled feminism[19] to understand the internal logic of fundamentalist feminism. Far from defining itself anti-feminist, the fundamentalist veil claim fills a feminist function in the sense that it symbolizes the woman's refusal to be assimilated to a sexual and seductive body-object. The moralization of relations between sexes is obtained thanks to the veil and thanks to a bodily discipline. But let's signal here the gap that exists between the ideal and reality: Twelve percent of veiled young girls are favorable to premarital sexuality[20]. Furthermore, a veiled gynecologist asserts that veiled young girls have intercourse and consult for sexual pleasure issue[21].

Besides this gap, Islamic feminism also collapses in the claims of the Moroccan feminist associations concerning seven major points related to family status and to sexual and reproductive health. These points were presented in the Project of National Plan of Woman Integration in Development [22] (1999) as non-secular claims and as possible Islamic options. They are : the increase of the legal age of marriage to eighteen years for girls, the suppression of the matrimonial tutor, the suppression of polygamy, the transformation of repudiation into divorce, the allotment of conjugal wealth after divorce between spouses, the installation of condom distributors, the protection of abortion outside marriage. The Islamic refusal[23] of these points shows the limits of an Islamic feminism in Morocco and the resistance of the juridical Islam to the sexual and reproductive rights. It also points out its unhistorical definition of Islamic sexuality and family. Perhaps Dialmy's essay entitled "Toward an Islamic sexual democracy"[24] is the only work that demonstrates that the necessity to protect premarital sexuality against STD/VIH risk is not incompatible with the intentions of Islamic law and with the spirit of Islam. Especially in "Sexual health and Ijtihad" chapter, Dialmy argues that Ijtihad with both the available sacred texts and beyond the texts is necessary to protect sexual health as a central dimension of public health. Since premarital abstinence is unrealistic, it is less dangerous to use a condom. Having premarital sex with a condom or having it without a condom is illicit but having premarital sex with a condom is less harmful.

The religious resistance to the seven main feminist Moroccan claims showed that there is no difference between official Islam (ministry of Islamic affairs/Oulema) and Islamic fundamentalism as far as women and sexuality are concerned. A non-formal Islamic forehead constituted itself to struggle against gender liberation summarized in these seven points. For this front, these seven points have already received a definitive negative Islamic answer that consists in a double dependency: sexuality is dependent on marriage and woman is dependent on man. This double dependency is supposed to be an Invariable according to the juridical dominant Islam. Mystic Islam[25], which shows the possibility of an Islam defined as a possible theory of sexual rights and egalitarian family, is both excluded by Moslem scholars and fundamentalists. However, let's note that a more egalitarian Islam is applied in Iran with reference to Shiit juridical schools. Ayatollah Khomeïni introduced a new family law that could be considered among the most advanced in the Middle East, "without deviating from any of the major conventional assumptions of Islamic law"[26]. Under this new law, three major conquests : 1) "the first wife has the right of divorce should the husband take a second wife without her consent", 2) "the wealth accumulated during the marriage is divided equally between the couple in the event of divorce, 3) housework wages must now be paid upon divorce or on the woman's demand"[27]. On the other hand Ayatollah Khomeini allowed marriage of enjoyment[28] which brings an answer to the problem of sexuality in an Islamic community where youngsters, for lack of means, get married late.



[1] Extracted from my paper entitled « Sexuality and Sexual Health in Morocco », in "Challenges in Sexual and Reproductive Health: Technical Consultation on Sexual Health, OMS, Genève 2002.

[2] Analyse épidémiologique des cas cumulés de SIDA-Maladie enregistrés au 30 juin 2001, Ministry of Public Health, DELM/DMT, Service of STD-AIDS (Title/hp/k).

[3] A. Dialmy : “Le champ Famille-Femme-Sexualité. Les voiles de la sexualité ”, in Les Sciences Humaines et Sociales au Maroc, Universitary Institute of Scientific Research, Rabat, 1998.

[4] G. Tillion : Le harem et les cousins, Paris, Seuil, 1965, M. Chebel : Le corps dans la tradtion au Maghreb, Paris, PUF, 1984.

[5] Allal el Fassi : "L'auto-critique", Rabat, 1979, 4th edition, p. 272 (in Arabic).

[6] Ibid. p. 272.

[7] D. Masson : “Les influences européennes sur la famille indigène au Maroc”, Entretiens sur les pays de civilisation arabe, n° 7-10, 1937.

[8] D. Chraïbli : Le passé simple, Paris, Seuil, 1954.

[9] A. Bellarbi : “Soins corporels féminins : entretien ou séduction?”, in Corps au féminin, Casablanca, Le Fennec, 1991.

[10] N. Bradley : “Le scandale de la virginité”, Lamalif, n° 25, 1968; F. Mernissi : "Virginité et patriarcat", Lamalif, n° 107, July 1979; S. Naamane Guessous : Au-delà de toute pudeur, Casablanca, Soden 1987.

[11] A. Bouhdiba : La sexualité en Islam, Paris, PUF, 1975, p. 286.

[12] The absence of excision in Moroccan society removes to Moroccan feminism an important means that could have joined it more strongly to Egyptian feminism. Among the cultural reasons justifying excision, the desire of some Arabian and African societies to pull up the girl's sexual desire and, later the one of the married woman. In this setting, one pretends that an excised girl can resist the desire better and can support married better once her husband's prolonged absence. The feminist critique of excision indicates a woman's claiming of which one recognizes the body as desiring body. Indeed, the Egyptian feminism, pioneer and symbol of the Arabian feminism, first attacked female circumcision during years 1970-1980 as amputation and mayhem and considered it like a harmful cultural practice. In "Women and Neurosis" (1977), N. Saadawi accuses excision to be a source of psychic disruptions affecting the sexual desire and the orgasmic faculty. On such study basis, the African feminists and Arabic succeeded in 1990 in making adopt the term of Female Genital Mutilation (FGM). This term was adopted in a conference of the Inter-African Coalition (IAC) co-sponsored by the World Health Organization. See N. Wassef and A. Mansur : Investigating Masculinities and Female Genital Mutilation in Egypt, NCPD/FGM Task Force, Cairo, 1999.

[13] J. Berque : "Ca et là dans les débuts du réformisme religieux au Maghreb", in Etudes d'orientalisme dédiées à la mémoire de Lévi-Provençal, Paris, Maisonneuve et Larose, 1962, T. II, p. 484.

[14] Z. Daoud : Féminisme et politique au Maghreb, Casablanca, Eddif, 1993.

[15] A. Dialmy : Féminisme, islamisme et soufisme, Paris, Publisud, 1997, pp. 131-182.

[16] Dale F. Eickelman : “ Mass higher education and the religious imagination in contemporary Arab societies ”, American Ethnologist, 19, 4, 1996; Christiansen C. Caroe and L. Kofoed Rasmussen: “The Muslim Woman- A Battlefield ”, in Contrasts and Solutions in the Middle East, Ole Hoiris and Sefa Martin Yurukel (edited by), Aarhus University Press (Denmark), 1997.

[17] H. Taarji : Les voilées de l'Islam, Paris, Balland, 1990.

[18] A Dialmy: “L’université marocaine et le féminisme ”, in Mouvements féministes: origines et orientations, Faculty of Arts and Human Sciences of Fez, Fez, 2000.

[19] Ibid. p. 56.

[20] A. Dialmy : Logement, sexualité et Islam, Eddif, Casablanca, 1995, p. 183.

[21] A. Dialmy : Sexualité et politique au Maroc, UNFPA, 2001, p. 18.

[22] Project of National Plan of Women Integration in Development, Secretary of State in charge of Social Protection, Family and Childhood, 1999.

[23] The refusal was both expressed by Ministry of Religious Affairs, Oulema, fundamentalists and some political parties. This refusal expressed itself essentially in the Casablanca walk held march 12, 2000.

[24] A. Dialmy: Toward an Islamic sexual democracy, Fez, Info-Print, 2000 (in Arabic). Let's signal that fundamentalists stopped the book impression and only 400 copies could be impressed and sought.

[25] A. Dialmy : Féminisme soufi, Casablanca, Afrique-Orient, 1991; Leila Ahmed (ed) : Women and Gender in Islam, New Haven, Yale University Press, 1992.

[26] Homa Hoodfar : "Population Policy and Gender equity in Iran", in C. M. Obermeyer (ed) : Family, Gender and Population in the Middle East, The American University in Cairo Press, 1995, p. 123.

[27] Ibid. p. 124.

[28] "Opinion of Imam al Khomeini", in S. Wardani : "The marriage of enjoyment is licit among Sunnit", Cairo, Medbouli Library, 1997, pp. 133-136 (in Arabic).

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25 juin 2009 4 25 /06 /juin /2009 12:01

SEXUALITY IN SOCIAL SCIENCES IN MOROCCO (II)

 

                                                                                        Prof. Dr. Abdessamad Dialmy

                                                                                                                       University Mohamed V Rabat

 

 

2- Toward sexuality as object of research

 

The shift of interest of the social sciences toward sexual behaviors and sexual practices is especially characteristic of the third period (1976-1996) thanks to the threat of AIDS and explosion of STD. The threat of AIDS and explosion of STD indicate a big sexual "opening" among bachelors. Because of the crisis of unemployment and marriage, non-conjugal intercourse characterizes present Moroccan sexuality. Henceforth, in the domain of sex, people admit having sex wherever, whenever, with whomever and with whatever means available[1]. Traditional notions of hshuma and aïb (shame) are loosing their weight in the social regulation of sexuality, especially female sexuality[2]. Indeed, sexuality outside marriage doesn't mean only the extension of prostitution, but also the emergence of an in love and erotic sexuality that is neither marriage nor prostitution, of a dice-institutionalized sexuality. This sexual activity outside both marriage and prostitution tends to be accepted practically by a society that continuous to refuse its normalization at the level of principles and laws[3].  Consequently, the analysis of sexual change must abandon notions of opening and modernization in order to substitute them with the notion of anarchy. This notion shows the extent to which the evolution of the Moroccan sexuality is unfit to be analyzed in terms of strategy and management. The Moroccan sexual anarchy would be located in the midway between formal and non-formal policies. It is politically non-planned even though one agrees to say that the power exploited sexuality to dice-politicize masses and youngsters and to "resolve" employment crisis. Four sectors constitute the field of practical policies[4] that are progressively setting up, although one cannot speak about the existence of a lucid and transparent sexual policy. These policies are : 1) the promotion of a tolerant judicial practice ( society gives less and less importance to sexual offenses, the big frequency of these offenses makes impossible their incrimination in their totality, hence the discriminatory application of the law), 2) the promotion of a sexually permissive culture (definition of virginity only as non defloration, definition of sexual activity as leisure), 3) the promotion of a sexually exciting information, 4) the promotion of contraceptives, of preventive techniques and of sexual counseling.

The fourth non-formal medico-sanitary policy aims objectively to liberate sexuality from all fears and to transform it into a means of pleasure. This major shift is widely spread by some feminine magazines that appeared in the 1990s such as Femmes du Maroc. This magazine devotes a regular section to sex education, which transmits a very practical sexual information to its readers. Sexual impotence[5], sexual obsession[6], lack of desire[7], inhibition of senses[8], climax of sexual pleasure[9], first sexual experience for men[10], premature ejaculation[11], caresses after love[12], Viagra[13].  These are some of the themes that Femmes du Maroc has dealt with through both a scientific and a permissive perspective. In these "files", Moroccan sexologists and andrologists are interviewed. For Femmes du Maroc, sexual education is not only the techniques to use within the institution of marriage, but also sexual liberal values seeking to free individuals in a liberated sexuality. However, this liberal definition of sexual education doesn't lead Femmes du Maroc to claim a change of penal code in order to dice-incriminate premarital sexuality when free and chosen [14].

If the notion of sex education is mechanically accepted by the liberal tendency (here illustrated by Femmes du Maroc for example), it is subject to a controversy as to its content, its ethical, its targets, its agents, its methods, its vehicular language and its media support. Let's recall that the Moroccan Islamic State’s reaction was unfavorable to chapters 4 and 7 of the program of action of the ICPD. For Moroccan officials, all notions relating to sexuality and sexual health must be dealt with in conformity with two principles believed to be immutable in an Islamic law also conceived at as indisputable, the legal inequality of sexes and the subordination of sex to the marriage. No right to sexual activity outside marriage is recognized.

Consequently, protection of sexuality outside marriage raises a legal problem because of the legal rejection of the use of condom outside marriage[15]. Among public physicians themselves[16], a trend asks to Islamize sexual health and sexual education and to reduce them to theoretical knowledge of sexual anatomy and physiology, early marriage, faithfulness to the partner, avoidance of STD and perversions (like homosexuality)[17]. In other words, sexual health and sexual education have to be both technical and Islamic. They must not transmit some values as the right to sexual pleasure outside marriage or outside heterosexuality. For this reason, fundamentalists among public professionals of health propose to medicalize the notion of sexual education and to name it sanitary education in order to avoid all "risks of cultural imperialism".

For health decision-makers, there is a kind of official silence on sexual pleasure in itself. For those people, the most important thing is that sexual activity should not lead to a high rate of fertility or STD/HIV. If all social actors agree with the aim of non elevated fertility, they have no consensus concerning the way to prevent STD/AIDS. For fundamentalists, there are only two ways to resolve this problem, abstinence and marital faithfulness, while liberals propose the use of condoms and conceive faithfulness outside marriage. To "conciliate" between liberals and fundamentalists, public health decision-makers propose abstinence, faithfulness and condom. Moreover, they maintain the notion of sexual education and consider it as a strategic goal in their recent "Plan National Stratégique de Lutte contre le SIDA"[18]. But conscious of the importance of religious leaders in shaping popular opinion, the Plan of the ministry of health associates the ministry of religious affairs as a partner in the elaboration of the programs of sex education[19]. For the ministry of health, the most important is not to adhere to the secular ethics of sex education that is at the heart of the declaration of human and sexual rights but only to achieve a lower STD/AIDS rate. In doing so, the ministry of health seems to ignore that the recognition of the right to sex is a major condition to individual and collective sexual health. Such ethics is not only not assumed by public decision-makers of public sexual health who are concerned with reaching a "religious" agreement on public sexual health programs. There is also a lack of a fundamental secular conviction[20] among the majority of public physicians because of their conception of medicine as a set of techniques that do not carry universal human values. This reduction of medicine to a technique leads some physicians to claim its moralization in the sense of its Islamization[21]. A sexuality that is supposed to be definitively regulated by Islam has also to be regulated by an Islamized medicine.

The emergence of infertility clinicians, sexologists and andrologists in the private sector[22], is also exploited by fundamentalists and used to reinforce their Islamic definition of sexual and reproductive health and sexual education. For them, these new disciplines are mainly supposed to solve the conflicts that could emerge from infertility and help some men to manage erectile dysfunction in the setting of marriage because procreation and sexual pleasure are two high aims of Islamic marriage. But impotence and infertility issues keep private because their "managers" are mostly private professionals and remain enclosed in a reductive definition of sexual health like a technical struggle against individual illnesses, individual handicaps and individual dysfunctions.




[1] A. Dialmy : Sexualité et Politique au Maroc, op. cit., p. 17.

[2] D. Dwyer : Images and self images : male and female in Morocco, Columbia University Press, New York, 1986.

[3] A. Dialmy : Sexualité et Politique au Maroc, op. cit., pp. 81-83.

[4] Ibid.

[5] N° 16, March 1997, pp. 48-51.

[6] N° 17, April 1997, pp. 38-41.

[7] N° 18, may 1997, pp. 54-56.

[8] N° 21, September 1997, pp. 52-53.

[9] N° 26, February 1998, pp. 54-56.

[10] N° 27, March 1998, pp. 52-53.

[11] N° 28, April 1998, pp. 62-63.

[12] N° 29, May 1998, pp. 62-63.

[13] N° 30, June 1998, pp. 72-73.

[14] See the analysis of our interview with the editor in chief of Femmes du Maroc in our study Sexualité et islam au Maroc, op. cit, pp. 82-83.

[15] A. Dialmy : Jeunesse, Sida et Islam au Maroc, Casablanca, Eddif, 2000, pp. 207-210.

[16] A. Dialmy : La prise en charge éducative des patients MST dans la santé publique, Ministry of Public Health/ European Union, 1997, pp. 39-46.

[17] Ibid. p. 39.

[18] Plan National Stratégique de Lutte contre le SIDA, Ministry of Health, presented by Morocco to the General Assembly of United-Nations on HIV/AIDS (New York 25-27 June 201), pp. 18, 21.

[19] Ibid. p. 22.

[20] A. Dialmy : La prise en charge éducative des patients MST…, op. cit. pp. 39, 40 et 45.

[21] Ibid.

[22] The Société Marocaine d'Andrologie et de Sexologie was founded at 1993.

Repost 0
21 juin 2009 7 21 /06 /juin /2009 21:37

SOME SEXUAL ISSUES AND PROBLEMS

IN MOROCCO[1] (I)

 

                                                                                                   Prof. Dr. Abdessamad Dialmy

                                                                                         University Mohamed V Rabat 

 

Feminine premarital sexuality, single mothers, sexual work, infertility, erectile dysfunction and sexual-spatial dysfunction are some issues and problems that theoretically transform the sexuality in a public health question due to the size and to the social and economic repercussions of these phenomena. Both the medical and the social dimensions of these phenomena illustrate the obvious impact of sexuality on socioeconomic development. Nevertheless, feminine premarital sexuality, single mothers, sexual work are not targeted by the public health policy which is exclusively focused on birth control. This policy orientation is illustrated by the existence of National Program of Family Planning.

 

1- Premarital Feminine Sexuality   

 

Moroccan social traditions make of the girl's precocious marriage a main element in the sexual and procreative strategy inspired by a patriarchal reading of Islam.

 

1-2 Woman's middle age at the first marriage

 

According to the patriarchal Islamic paradigm, the precocious marriage has several advantages. It is a mouth of less to feed and a way to avoid the risk of the premarital defloration, that is to say the risk of dishonor. The rate of single woman is lower than the one of single men; the masculine celibacy is, in fact more tolerated socially. Less than 1% of women remain bachelors at the end of their reproductive life[2].    

Figure 1: Matrimonial statute according to the sex 

 

Statute

 

Sex

 

Bachelor

Married

Widowed

Divorced

Indeterminate

 

Men

 

44,1

54,2

1,0

0,6

0,1

Women

 

39,0

53,8

5,5

1,6

0,0

 

 

Nevertheless, urbanization and schooling, though still incomplete, are gradually undermining the patriarchal paradigm of precocious marriage. Indeed, a tendency towards delayed marriages has been illustrated by the different socio-demographic investigations since years 1960. According to the last National Investigation on the Health of the Mother and the child (ENSME, PAPchild 1999), the percentage of women that got married before reaching 26 years fell besides currently of 863 for one thousand among women aged of 25-29 years. In the same way, this proportion fell further among the married women at the age of 20 years, of 638 for one thousand among cohorts of women currently aged of 45-49 years to 273 for one thousand among those of the cohort of 20-24 year women. The decrease of marriage among teenagers is faster and more outstanding. The investigation has revealed that marriage age varies according to different generations of women : Marriage at the age of 18 concerns 45% of women between 45 and 49,19% among those who are between  25-29, and only 16% for those aged between 20 and 24 years. The rate of those who got married early than15 is only 8,4%. 

The recession of marriage is confirmed by the female average age at the first marriage:  

 

Figure 2: Evolution of the female middle age at the first marriage

 

Year

 

1960

1987

1994

1997

Average Age

17,3

23,4

25,8

26,4

 

During 1996-97, the average age of the urban woman at the first marriage is 27,8 years (against 24,7 years in rural areas). Between 1994 and 1997, the rate of bachelor women increased: Out of 10 women reaching approximately 30 years, 4 are single. They prefer celibacy to polygamy. This latter is, indeed, decreasing. The proportion of women living in polygamous unions regressed from 5,1% in 1992 to 3,6% in 1996-97. Polygamy is particularly decreasing among at the educated women.  

One of the main consequences of the rise of the female average age at the first marriage is the emergence of premarital sexuality. The social status of this sexuality is, however, problematic.  

 

1-3 Between Dismissal and Acceptance

 

Legally, sex is prohibited for boys and girls before marriage. Yet, traditional standards are much unfavorable to girls. Girls are more submitted to familial and social coercion in the strict connection between sexuality and marriage. The usually, the family’s males lead this coercion. Furthermore, these males manhood is evaluated according to the extent of their control over sex prohibition and coercion on "their " women[3].

The sexually unsteady girl is said to be a "flirt". Moreover, she is considered like a prostitute even though she doesn't accumulate partners to accumulate money. She is said to be a prostitute because of the immorality of her conduct. Sometimes the family, unable to face the accusing gaze of others, changes the district. The girl's bad sexuality "offends the masculine pride of the family's men, it reduces these men to powerless males"[4].  

Yet, in the name of realism, men are adopting feminist attitudes to sex[5]. For these men, the premarital feminine sexuality is conceived in terms of rights or a fact that has to be admitted.  The girl who makes love in "a reasonable and respectable" manner is considered to be as virtuous as the one who does not make love. Sexual stability out marriage undermines social condemnation. It is, therefore possible to affirm that love has started to be more valued than virginity.

 

1-4 Virginity and artificial hymen 

 

Dialmy asserts that it is necessary to distinguish between koranic virginity and consensual virginity[6]. The first means that the girl doesn't have any sexual experience, while the second defines virginity as no defloration of the hymen. However, more and more young women are questioning the principle of virginity. Gynecologists attest the existence of numerous girls who are deflowered and not embarrassed at all not to be virgin[7], although opportunities of marriage decrease for these girls usually of modest social origin. These girls may opt for sexual work or for an artificial virginity. Indeed for the low classes and rural surroundings, consensual virginity is not a simple "bodily detail"; it is the only "capital ". In these surroundings, one even has to provide a certificate of virginity at the time of festivities of the marriage.

According to the Femmes du Maroc director, the repairing of the hymen would be the most frequent surgical "operation"[8]. It is a flourishing medical trade in the region Casablanca-Rabat, "between 500 and 600 $US the operation". Some generalist physicians would exercise the operation for derisory prices[9], 50/60 $US, but the suture doesn't hold and the husband realizes the subterfuge. For feminists, physicians who exercise the repairing of the hymen adhere objectively to a false notion of honor and, therefore, reinforce the patriarchal system[10]. Do they believe in this system indeed? Do they make the repairing to avoid the scandal to the girl, or do they do it for humanitarian reasons? Do they make it for merely financial interests?  

 

2- Single mothers 

 

The 1996 Casablanca and Rabat survey[11] on the lived conditions of single-mothers in Morocco shows that 68% of the mothers who abandon their children are aged between 15 and 24, they are all illiterate. Although they live in urban area, they originally come from rural area. They are usually either domestic or factory workers. 

Even though if the main concern of Islam is the child's legitimacy, the scholastic logic of the Moslem jurists' methodology prohibits them from legitimizing a posteriori the filiation: for them, the recognition of a natural child's legal filiation implies the legitimization of what it stands for, that is fornication. The jurists (foqaha) are, therefore, much more concerned with the punishment of fornication and its fruits rather than proving a natural filiation. For them, the central issue is the punishment of fornication within the rules of the Shari'a (Islamic Law) through the application of penalties (flogging or bet to death). As a determinant of the purity of lineage as well as the circulation of possessions, sex cannot be exercised outside the institution of marriage that precisely regulates lineage and possessions. Therefore, the natural child must remain a natural child so as not to sow the confusion of lineage and possessions[12]. 

As an extension of the Moslem law, the Personal Statute Code (Moudawwana) stipulates expressly (art. 38, al. 2) that the filiation outside marriage doesn't create any tie of relationship vis-à-vis of the biologic father and doesn't have any impact on the filiation. In other words, neither the Moslem law nor the Personal Statute Code do recognize to the natural child the right to institute a judicial suit in view to prove a filiation. The absence of such a possibility is in flagrant contradiction with the arrangements of the Convention of the child's Rights that recognize to the child the right to have a family, a name and an identity. This big hiatus increases the number of children victims and endorses the marginal status of the single-mother whose already precarious social situation is furthermore worsened by having to come up against numerous legal difficulties.  

In fact, the civil status is granted to the abandoned child according to two modes: the father is either identified as "unknown" or substituted by a cross where the father's name must be written down on the register of the civil status[13]. The natural child right to have a fictional patronymic name is ferociously refused by the Moslem jurist. On the other hand, a circular of the ministry of the interior allows the mother to give her own family name to her natural "child", but this possibility is conditioned by the single mother's paternal family males consent. With the absence of this consent, the child remains without a family name, and undergoes all the negative psychological and social consequences of an existence without name, that is to say without identity.

The stigma of the natural child starts right after his arrival to the world: single-mothers give birth to their children in separate rooms of the married women. After the childbirth, the personnel of health notify the case to the judicial police. Thus, the sanitary and judicial machine gets in march to exclude, even before the birth, the natural child and to transform into an abandoned child[14].  

The phenomenon of single mothers shows that the contraceptive education doesn't target this social category of socially modest girls. Certainly the contraceptive official message targets the married women in age of reproduction, the schooled girls usually benefit from an education on population that explains them the cycle of reproduction and that sensitizes them to the contraception use. Such an education is not developed enough by an informal education addressed to the non-schooled and dice-schooled girls.



[1] Extracted from my paper entitled « Sexuality and Sexual Health in Morocco », in "Challenges in Sexual and Reproductive Health: Technical Consultation on Sexual Health, OMS, Genève 2002.

[2] Azelmat, Ayad et Housni: Enquête de Panel sur la Population et la Santé (ENPS-II) 1995, Ministry of Health/Macro International Inc, Calverton, 1996.

[3] A. Dialmy: Identité masculine et santé reproductive au Maroc, MERC/Ford Foundation, 2000., p. 112.

[4] Ibid. p. 117.

[5] Ibid. p. 113-114.

[6] A. Dialmy: Jeunesse, Sida et Islam au Maroc, Casablanca, Eddif, 2000., p. 86 et 220.

[7] A. Dialmy: Sexualité et politique au Maroc, Rabat, FNUAP, 2000, pp. 17, 18, 35.

[8] Ibid. p. 43.

[9] Ibid. p. 43.

[10] Ibid. p. 44.

[11] Les filles-mères dans la réalité marocaine, AMSED, 1996

[12] Analyse de la situation des enfants au Maroc, UNICEF/Royaume du Maroc, 2001, p. 177.

[13] Ibid. p. 177.

[14] Ibid. p. 178.

Repost 0
21 juin 2009 7 21 /06 /juin /2009 21:31

SOME SEXUAL ISSUES AND PROBLEMS

IN MOROCCO[1] (II)

 

                                                                                                    Prof. Dr. Abdessamad Dialmy

                                                                                                     University Mohamed V Rabat 

 

3- Sex-economy 

 

The development of sexuality has an economic impact no less important. As an implication of the social and the economical crisis (provoked by the structural Adjustment Plan since 1983), sex becomes a means to earn money and to live up to the increasing mode of consumption. The impoverishment of families forces numerous girls and boys, young women and men to sell their bodies in a market more and more organized within non-formal networks. Sexual work is a non-formal answer to unemployment and to poverty[2]. It concerns women, men and children. Moroccan economy so much functioning through sex that one is able to speak of a "prostitution economy". With the absence of a sustainable development policy, sexual work represents a solution or a relief from problems of unemployment. It is creating a kind of dynamic consumption in certain regions and sectors (tourism), it serves to attract some foreign investors, to seduce… Tolerance for prostitution is the only option left for a realistic economic policy.  

 

3-1 Sexual work of adults   

 

Sex marketing is correlated to the poverty of women and the impoverishment of families[3]. Very often, prostitution is the consequence of a necessity to survive and to fund other's survival (a family). It remains the most accessible means to face unemployment and precariousness. Barons of prostitution constitute unorganized networks[4].  

 Sex is growing into a business, a market, and an economically profitable activity that allows several social categories to survive. Girls (from 14 years), repudiated women, students, graduate unemployed persons, homosexuals, female workers in factories are the concerned social categories by this phenomenon. Even victims of a STD, family's mother continues to work, covering up her infection to the customer not to lose him. Other mothers prostitute occasionally, at the time of the school return to be able to buy supplies for their children or at the time of the Big Feast to buy the ritual sheep[5]. 

The masculine prostitution[6] is both heterosexual and homosexual. Henceforth, women pay men, a phenomenon that has started to be socially visible. Women who resort to the sexual services of men are not solely foreigners[7]. As for homosexuals, everybody recognizes that their number is increasing. Lawyers represent homosexual’s decrees in front of both the police and the court.  

Sometimes, sexual work also responds to a need of luxury and consumption. Basically, the girl goes with men because she needs to satisfy some elementary needs like a lipstick, a perfume, a birthday gift... Every partner offers her a gift of this kind. Later, this develops into professionalism. For girls coming from the middle classes, prostitution is not a means to make money, but a means to be able to consume more and better, to have apparently a luxurious life[8]. Some women already financially independent use sex to enjoy more financial comfort. To curl the end of month and get better dressed, secretaries, whose salaries are lower than the SMIG, submit themselves easily to several men without identifying themselves as of prostitutes

The correlation sex/money received a very strong thrust thanks to the male Arab Gulf tourism[9]. In other cases, sex serves to attract the foreign investors, to seduce them. As a "whorehouse " Morocco attracts customers thanks to the sexual offer. More than this, prostitutes are being exported to other countries[10].  

 

3-2 Sexual work of children  

 

According to Najat Mjid, the president of the Bayti association, 60% of children of the street of Casablanca recognize having been victims of sexual violence done by older children, evening guards and drunkards. Yet, it is difficult here to set a rigorous limit between rape and prostitution in the sense that wherever the child of street offers himself sexually he is able to spend the night in a garage, to get a cigarette, drugs or a piece of bread. 

In Marrakech[11], Peter Kandela says that visitors and tourists are offered sexual services of around 9 years children. The national price varies between 1 and 35 $US while for tourists (European or Arabian of the Gulf), it can reach until 170 $US. The visitor-tourist chooses the child, takes him to the hotel, prepares him (cleans him), feeds him, enjoys sex with him and then abandons him. Children having got used to this money refuse to come back to their families (according to Bayti association). Since homosexuality is illegal, this prostitution is rather clandestine. Kandela affirms that 48% of Moroccan children of the streets are exploited sexually next to food or a shelter-place.  

Children are completely unconscious of the HIV risk. According to Kandela, the judicial instruction files concerning the minor prostitutes do no mention the use of the condom.  

 

3-3 Values destruction and political guaranty 

 

The transformation of sex in economic activity is more and more done with a social consent, that is to say with the approval of the community and the family. With the absence of adequate development policies, some poor families leave their children to tourists' prostitution. Sometimes, children (including the males) are even encouraged overtly by their families[12]. Male honor, then, stays quiet. Thus, in certain regions, villages people even demonstrated against the police raids aiming prostitutes, putting forward that "it makes people live" and it is an engine of the local trade[13].  

Everybody agrees that the administrative authorities are conscious of the  economic role of prostitution in certain disinherited regions. The disappearance of prostitution in these regions would produce a real crisis there, and the political decision-maker has to compose and be tolerant[14]. With respect to security, prostitution would be a factor that delays a potential social explosion. There is complaisance and complicity on behalf of the public authorities to the extent that prostitution is becoming an aspect of the tolerated sexual liberalization. This policy of tolerance that consists of pretending not to see (prostitution) is interrupted by campaigns that serve several ends at the same time : to put pressure on actors of the field, to remind that authorities can outrage, to prove to the fundamentalists that the state does fight against the debauchery. In fact, neither sexual work nor sexual liberalization are fundamentally accepted, they both constitute an improvised, an unconscious and an informal choice to face poverty and fundamentalism: "prostitution rather than poverty" and " prostitution rather than the veil " would be the tacit slogans of the administration[15].  

The state is accused by the Moroccan elite (politicians, intellectuals, technocrats) of being responsible in the sense that it doesn't provide the minimum supplies for the repudiated woman to survive and to raise her children.  The State is said to be responsible when it allows girls without any qualification to emigrate (this implies exporting prostitutes, reducing unemployment rate and making money). It is finally accused of granting easiness to pimps and lobbies working in sex business[16]. 

             

4- Infertility

 

Infertility is statistically a minor phenomena in Moroccan society and is essentially treated in the private sector, which might be considered as a "luxury" reserved to a small minority, to an elite. The rare centers of fertility at Casablanca and Rabat recognize effectively that their services, techniques of medically assisted procreation in particular, are accessible to a very small and rich minority while Moroccan demographic studies reveal that infertility is more connected with a low socioeconomic status[17]. The infertile individuals are in their majority rural, less educated and socially more excluded by infertility itself[18]. However, definitive infertility (sterility) rate is in general very weak[19], 2,8% on 1987 and 2,1% on 1995.

 

5- Erectile dysfunction 

 

According to Pfizer, one million of people in Morocco would endure erection’s troubles. But Pfizer doesn't say how it managed to have this number, especially as "consultations for erectile dysfunction motive remain rare and difficult. Facing a physician, the impotent Moroccan man doesn't manage to say his impotence, he waits for the physician who either guesses or discovers it"[20]. Moroccan Society of Andrology and Sexology doesn't give any quantitative estimation. Studies on the question are very rare. In 1999, an epidemiological survey entitled "Prevalence of the erection dysfunction in Morocco"[21] has been achieved by the following physicians: Qadri, Berrada, Tahiri and Nejjari of the statistical department in Casablanca. The composed sample of 655 men over 25 years was selected only in Casablanca. According to this survey, 53,6 % of men endure erection trouble. And more age is older, the more the erection dysfunction includes a larger number of people:

 

 

 

 

 

 

 

              Figure 3: Age and erectile dysfunction 

 

Age category

% of men with erection dysfunction

 

25-34 years

34,6

35-40

48,5

41-50

58,9

51-60

80,6

61-70

92,5

 

Otherwise, the survey establishes strong interrelationships between the erection dysfunction and some pathology:  

 

- Diabetes: 94,1%, p = 0,02,  

- Cardiovascular pathology: 90,0%, p = 0,01%  

- Arterial hypertension: 82,0%, p = 0,05  

- Depression: 76,5%, p=0,0002,  

- Prostate’s surgery: 75,0%, p = 0,0002. 

 

The survey recommends the consideration of erectile dysfunction a problem of public health in the sense that this unrest is in clear increase and has an important impact on the stability of the families (conjugal life). What are the foundations of this survey 's assertions? Let's recall that Viagra rate of sale in Morocco since May 1998 doesn't create "crazies" as in Egypt. Maybe such a claim is a way to make Viagra benefit form a medico-social cover. The recommendation to consider erectile dysfunction like a public health problem is likely to be an act that aims at legitimizing taking in charge of Viagra by social security. This hypothesis is heuristic especially as the erectile dysfunction is still a question mainly treated by the private health sector. This sector guarantees further confidentiality and anonymity, which is essential within a under-developed society where sexological consultation still be a "social risk"[22]. Indeed, impotent men[23] are not really taken in charge by the public sector of health especially because of socio-cultural reasons (lack of privacy first) but also because of lack of andrologists and sexologists in this sector[24]. There is no public hospital specialized in sexual problems like the one in Cairo. The majority of men with impotence problem consult andrologists or sex therapists after having their addresses in the yellow pages of the directory or after having read articles in the press[25]. This means, on the other hand, that these consultants are educated and belong to solvent social classes.

The existence of some sociological reasons to erectile dysfunction may also explain the recommendation to consider it as a public health problem. Among these reasons, the overcrowding of lodgings, the cohabitation of adults and the absence of bedrooms. Moreover, sexual dissatisfaction is due to bad conditions of lodging, which could be one of the psycho-sociological factors that constitute the fundamentalist personality[26].

 

6- Sexual-spatial dysfunction 

 

When thinking of sexuality in terms of pleasure and well-being, it means exercising it in positive spatial conditions that enable a complete satisfaction. Shared lodging with neighbors or with parents is susceptible to become an erectile dysfunction factor, and consequently of a marital pathology[27]. Indeed, the conjugal couple sometimes doesn't find an adequate place necessary for an intimate sexual relationship since the domestic lodging is overcrowded. On the other hand, the non-recognition of sexuality outside marriage as a human right also leads to the transformation of space into an obstacle to the satisfaction of the " illegal" sexuality. 

 

6-1 Places of the premarital sexuality 

 

The illegal sexuality of youngsters endures a major problem. One of these problems is the place. In fact, very few boys can invite their girl friends to the parents' house, which is considered as a sacred place. As a way of tinkering[28]: one makes love in a car, in toilets, in the stairwell, on the terrace, in the forest... These places are not safe and youngsters constantly run the risk to be surprised in the act of fornication by the police or by hooligans, or simply by people. The spatial-sexual tinkering means a fast and an unsatisfactory sexual act in an inconvenient place. 

 

6-2 Conjugal sexuality and domestic lodging 

 

In contrast, conjugal sexuality seems to benefit from the conjugal domicile in general, although the bedroom is not systematically present. For example, in Fez 25% of the households don't have a bedroom[29]. In Casablanca, among people arrested by the police in hotels while having 'illegal' sex are married couples who do not have adequate space for making love.  

Indeed, the number of people living in household[30] developed from 4,79 in 1960 to 5,81 in 1994. Small households (1 to 3 people) represent 20,1%, middle households (4 to 6 people) 40,8%, large households (7 to 10 people) 27,4% and  very large households (10 and more) 11,7%. This evolution is paradoxical in the sense that it contradicts with the logic of urbanization. It implies to specify the Durkheim’s law of contraction of the family, and to distinguish between nuclear family and small size family. Suburban families, while being nuclear in the sense that they are constituted of only one conjugal core, are not small size families. Not only the total rate of fertility didn't decrease to the same rhythm as in the other districts of the city, but one attends the cohabitation of adults more and more that increase the households size. The rural exodus, the crisis of the lodging and of the employment, the decrease of the spending power drive to a forced return to the cohabitation of adults, that is to say to the overcrowding of the already tiny lodgings. Indeed, "between 1982 and 1998, the level of urban households promiscuity became more articulated, the average number of people living in the same room shifted from 2,1 to 2,6"[31]. More seriously, "the 20% of the most underprivileged population live in average lodgings of an occupied room by 3,4 people"[32]. These rates of the room occupation represent a critical doorstep. A lot of households don't arrange an autonomous, distinct and freestanding bedroom.  

The examination of rooms evening dwelling enables to distinguish between 5 modes of sleeping[33]:  

 

- Individual mode (a person by room/or a conjugal couple in a room); 

- Territorial mode (parents in a room, boys in a room and girls in a third

room); 

- Bipolar raw mode: parents and a child at a low age in a room and all others in the second room; 

- Bipolar clear mode: parents in a room and all others in the other room; 

- Collective mode: everybody in a unique room.  

 

Therefore, the fact of living in only one room makes the child share the intimacy of parents, which predispose the child to aggression and delinquency, to incest, to precocious sexual relations, to prostitution, to doubt and to lack of confidence in him/herself. In some cases, to avoid the small lodgings, promiscuity and the irritation that follow, children prefer to remain in the street, and the parents are happy not to see their child coming back in the evening. These children are exposed to develop into children of streets[34].

 

Conclusion

Feminine premarital sexuality is due to the elevation of the middle age at the first marriage. The social statute of this premarital feminine sexuality is problematic and oscillated between acceptance and dismissal. It leads to distinguish between two meanings of virginity, Koranic and consensual. Sometimes, the consensual one makes physicians repair hymen to "prove" no defloration. This surgical operation reinforces the patriarchal system. In some cases premarital feminine sexuality is the origin of the phenomena of single mother who are and her child non-recognized at all and not benefits any right.

The opening of sexuality would also have an economic function no less important. Facing the social and economical crisis (provoked by the structural Adjustment Plan since 1983), the sex becomes a tool to earn money to live and to increase consumption. The impoverishment of families obliges numerous individuals from the two sexes to sell themselves on a market more and more organized in non-formal networks. The sexual work is a non-formal answer to unemployment and to poverty. It both concerns women, men and children. Morocco would use the sex intensively to the point that one is able to speak of a "prostitution economy".

 

 



[1] Extracted from my paper entitled « Sexuality and Sexual Health in Morocco », in "Challenges in Sexual and Reproductive Health: Technical Consultation on Sexual Health, OMS, Genève 2002.

[2] A. Dialmy: Sexualité et politique au Maroc, op. cit. p. 37.

[3] Ibid. p. 37.

[4] Ibid. p. 33.

[5] According to many interviews with some mothers in the newspaper Al Ahdath al Maghribiya.

[6] L. Imane: “La prostitution masculine au Maroc", Kalima, n° 24, March 1989.

[7] A. Dialmy: Sexualité et politique au Maroc, op. cit. p. 33.

[8] Ibid. p. 35.

[9] Ibid. p. 36.

[10] See some articles in the newspaper Al Ahdath al Maghribiya on this topic.

[11] Peter Kandela : “The prostitution of children in Marrakech and the spread of Aids ”, The Lancet,  Volume 356, n° 9264, 9 December 2000.

[12] A. Dialmy: Sexualité et Politique au Maroc, op. cit. p. 37.

[13] Ibid. p. 37.

[14] Ibid. p. 38.

[15] Ibid. p. 39.

[16] Ibid. p. 39.

[17] "Niveaux, variations et déterminants de l'infécondité au Maroc", in Santé de reproduction au Maroc: facteurs démographiques et socioculturels", Rabat, CERED, pp. 184-187.

[18] J. Join : “Invocations pour l'enfantement”, Hespéris, 1953; P. Lalu : “Le mythe de l'enfant endormi, occasion d'examen gynécologique”, Maroc Médical; J. Mathieu et R. Manneville : Les accoucheuses musulmanes traditionnelles de Casablanca, Paris, Imprimerie Administrative Centrale, 1952; P. Pascon : “Population et développement”, BESM, n° 104-105, 1967; R. Bourquia: Femmes et fécondité au Maroc, Casablanca, Afrique-Orient, 1996.

[19] "Niveaux, variations et déterminants de l'infécondité au Maroc", op. cit. p. 192.

[20] According to an endocrinologist at Fez interviewed by A. Dialmy in Sexualité et Politique au Maroc, op. cit. p. 50.

[21] No published.

[22] A. Harakat: Troubles érectiles et consultation sexologique, in Espérance médicale, March 2001, T. 8, n° 70, p. 118.

[23] According to Pfizer, a million of people in Morocco would endure erection’s troubles. This evaluation is extracted from an unpublished study titled "Prevalence of the erection dysfunction in Morocco", Casablanca.

[24] A. Harakat : "Troubles érectiles et consultation sexologique", op. cit. p. 119.

[25] Ibid. p. 118.

[26] A. Dialmy: Logement, sexualité et Islam, Casablanca, Eddif, 1995.

[27] A. Harakat: "Troubles érectiles et consultation sexologique", op. cit. p. 119.

[28] A. Dialmy: Jeunesse, Sida et Islam au Maroc, op. cit. p. 103-104.

[29] A. Dialmy: Logement, Sexualite et Islam, op. cit., p. 140. 

[30] RGPH 1960, RGPH 1971, Caractéristiques socio-économiques de la population (Direction of Statistics 1982), Les caractéristiques socio-économiques et démographiques de la population (DS, 1994), Enquête Nationale sur la Famille, DS, 1995.

[31] Enquête nationale sur les niveaux de vie des ménages 1998 /1999, Rabat, CERED, p. 16.

[32] Ibid. p. 16.

[33] A. Dialmy: Logement, sexualité et Islam, op. cit, p. 144-145.

[34] Analyse de la situation des enfants au Maroc, op. cit. p. 170. 

Repost 0
18 juin 2009 4 18 /06 /juin /2009 18:08

FAMILY PLANNING AND CONTRACEPTIVES IN MOROCCO (I) [1]

 

Prof. Dr. Abdessamad DIALMY

University Mohamed V Rabat

 

Since the 1960, sexuality has been transformed in public health issue through programs of family planning that aim to reduce fertility rate. 35 years after, the impact of contraception birth control proved to be more important than the other factors (mainly the elevation of the woman's average age at the first marriage). The contraception indicator appraised to 0,56 in 1979-80 and to 0,82 in 1995 indicates that contraception use contributed to the decrease of the fertility rate to of 18% in 1979-80 and 44% in 1995 "[2].

In fact, Family Planning has been adopted by the economic and the social planning since 1968 and was granted the status of a national priority[3] in the 1973-1977 five years plan (plan quinquennial). 

 

1- Attitudes toward Family Planning

 

Since King Hassan II's official declaration that stated the "choice" to adopt Family Planning (FP) as a national policy, there has been no research that has dealt with the senior national executives, physicians or community leaders (both civic and religious). All the social studies have dealt with the attitude of women, and only in some rare cases with the husband attitude[4]. The following questions were not asked to the relevant actors: is population an issue in Morocco? Does FP have an adequate answer to population issue? Consequently we don't really know what the practitioners really think about the relevancy of FP and to what extent they are for or against it? These two questions are still without any answer. In sum, we can conclude that the FP policy was in its beginnings a mechanical execution of a preeminent politically made decision. Political power had to produce a religious legitimacy to this policy. In this sense, Mekki Naciri, since the middle of the 1960s, argued for the FP Islamic legitimacy while appraising that Islam licit the interrupted coitus. He also thought that the prophetic saying "gets married yourselves and multiply yourselves I'll be proud of you…" is not an incitement to maximal procreation[5]. Maybe the unique negative attitude towards FP in the 1960s was expressed and defended by Allal al Fassi and his political party, Istiqlal.  They both defined FP like "an imperialistic action against religious principles"[6].

Surveys on Knowledge, Attitudes and Practices, in 1966 in cities[7] and in 1967 in the countryside[8], indicate that 61% among women accept the idea of the contraception. Yet, 87% among them don't use any modern contraceptive. 52% of men accept the idea of contraception. Yet, 92% don't practically worry and believe that it is women's thing.

 

2- Insitutionalization and orientations

 

What are the major national program stages of family planning in Morocco? Through some documents from the Direction of the Population of the Ministry of the Public Health, we can expose these stages in the following way. The beginning is the 1965 royal memorandum that displays the impact of the fast demographic growth on economic and social development in the Kingdom of Morocco and the HassanII's signature of the Declaration of chiefs of state on the population. Since then, the programs of FP have functioned through the structures of the Ministry of the Public Health along with the Supreme Commission on the Population in Morocco.  In the 1970s, the Division of the Population in the ministry of health together and the Family Planning Moroccan Association (AMPF) were instituted. AMPF's task consists of sensitizing the population and of offering birth control services. Households visits experience to sensitize people to PF took place during 1977. The 1980's were also rich years for the FP: the involvement of female and male nurses in the FP services, the creation of the National Center training on the Techniques of the Human Reproduction in Rabat and the regional centers for FP services and IUD installation (Intro-uterine Device). But the most important action happened in 1988 with the beginning of social marketing programs, partnership between ministry of health and USAID to involve the medical and the pharmaceutical private sectors in the sensitization operation and in the contraceptive technique sale with adequate prices. During the 1990s, the generalization of the training on IUD techniques for no medical employees was finalized. Some new techniques were introduced like Norplant technique (1993) and injections (1994). In 1993, the ministry of health implemented a public strategy of Information/Education/Communication.

Underlying the 1988 cut would complete this historical account[9]. Indeed, from 1967 to 1988, resistance to the FP emerged, especially in the rural area. According to advanced explanations, rural resistance would be a reaction due to the under-information of the target population. But it seems that information, in spite of its importance, is not able alone to create planned demographic behaviors in radical contradiction with procreative patterns anchored in the dominant collective psyche[10]. Anyway, the social resistance to FP drove to the adoption of a new plan of orientation[11] in 1988. The five big objectives of this plan were privatization, modernization, de-feminization, ruralization and advertisement of mass. 

 

3- Contraceptives: between public grant and purchase

 

The family planning policy proposes programs of action that consist of offering services and contraceptives: consultation, grant and pose of products. Yet, the 1988 plan's orientation indicates that the sanitary authorities were tempting contraception users to acquire contraceptives so that the public sector doesn't finance all the FP. The purpose of this orientation was also the development of FP towards responding the user's need. The exemption from payment of the contraception, owed to the international assistance (Ford Foundation, World Bank, USAID...) do not leave to the user neither the choice of the contraceptive technique nor the possibility to express the need of the contraception. The public authorities insistence on this kind of FP leads society to realize that the FP is above all a public need. Marketing consists, therefore, in treating society like a market and to deal with the user of the contraception like a consumer, which implies bringing the user to buy, to express the need of the FP, and to select a specific technique.  Even with regard to the weakness of the spending power of the population, the social programs had to continue. The 1988 plan orientation foresaw that the private sector could only cover 30% of expenses of the FP program. The Moroccan Program of Social Marketing of the FP Al Hilal passed this prevision: "in 1992, 37% of provision was assured by the private sector and this part increased slightly in 1995 reaching 38%[12]. This program is a successful example of the partnership between the ministry of health and the private pharmaceutical sector that targets couples with weak income.

Thus the FP program became widespread thanks to the continuous execution at the national level of the strategy of the Visit at Home of Systematic Incentive and thanks to the implication of the private sector. "Today, services of FP are available by various channels for the whole of the population"[13]. Of course, the public sector remains the privileged sector of provision in contraceptive methods. 60% of women addressed themselves to public centers of health and clinics, the others addressed themselves to the private sector, nearly exclusively to pharmacies. "The public sector covers 55% of methods requiring a regular provision (pill, condoms and injectables) and 84% of clinic methods (IUD, horn ligature)[14]. In urban area, female acceptors get a stock to equal part close to the two sectors, while three quarters of rural women make it close to the public sector. To say the public sector for the urban woman half and for the three rural woman quarter, it say the exemption from payment. In other terms, the success of programs of the FP is financed mainly by the state thanks to the international help. These data are summarized in the next figure.

 

Figure 5: Source of provision in modern contraceptive methods[15]

           

Year

Source

ENPS-II 1992

%

Panel 1995

%

Evolution

%

Dipensary/Health center

42

46

+4

Pharmacy

31

33

+2

Mobile team

11

5

-6

Hospital/Maternity

10

11

+1

AMPF

3

1

-2

Other private

3

4

+1

 

The contraceptive practice is characterized in general by the under utilization of IUD. Indeed, among contraception users, only 8% chose the IUD in 1992 whereas 68% chose the pill. The IUD is rejected in general for four main reasons: incompatibility with the arduous physical work, rumors, opposition of the husband, problems of access and of follow-up process[16].


 

The contraception use by method is as following:

 

Figure 6: Use contraception by method[17]

 

Year/Source

 

Methods

ENPS-II 1992

%

Panel 1995

%

Evolution

Pills

68

64

-4

IUD

8

9

+1

Feminine sterilization

7

8

+1

Condom

2

3

+1

Other modern methods

1

1

0

Traditional methods

14

16

+2

Prevalence rate

42

50

+8

 

In general, an increasing positive attitude towards contraception is observed, but it seems that traditional populations "resort to modern contraception in order to stop childbearing when they have reached a desired number of children, rather than to space births or reduce their fertility"[18].


 



[1] Extracted from my paper entitled « Sexuality and Sexual Health in Morocco », in "Challenges in Sexual and Reproductive Health: Technical Consultation on Sexual Health, OMS, Genève 2002.

 

[2] M. Amghari: "Fécondité: niveaux, tendances et déterminants", in Population et développement au Maroc, op. cit., p. 32.

[3] Fécondité, Infécondité et nouvelles tendances démographiques au Maroc, Rabat, Direction of Statistics, CERD, 1993, p. 33.

[4] A. Akhchichene: Les hommes et la planification familiale au Maroc, Rabat, Ministry of Health, 1998, unpublished; A. Dialmy: Identité masculine et santé reproductive au Maroc, MERC/Ford Foundation, 2000.

[5] Mekki Naciri: "Aperçus sur la planification familiale dans la législation islamique", communication to Séminaire National sur la planification familiale, Ministry of Public Health, Rabat, October 1966.

[6] See that in Hassan al Alaoui: La planification familiale au Maroc, Rabat, Ere Nouvelle, 1979, p. 46.

[7] “Enquête d'opinion sur la planification familiale au Maroc, 1966”, BESM, 104-105, 1967.

[8] M. Martenson: “La planification familiale au Maroc”, BESM, n° 112-113, 1969.

[9]"Politiques de l'éducation sexuelle au Maroc", in Santé de reproduction: facteurs démographiques et socioculturels, Ministère de la Prévision Economique et du Plan, Centre d’Etudes et de Recherches Démographiques, Rabat, 1998, p. 205

[10] A. Dialmy: Femme et sexualité au Maroc, Casablanca, Editions Maghrébines, 1985,  p. 110 ‘en arabe).

[11] Plan d’orientation pour le développement économique et social 1988-1992. Rapport de la commission santé, nutrition et planification familiale, MSP, 1987.

[12] "Programme Al Hilal", Caducée (Casablanca), n° 38, undated, p. 24.

[13] Enquête Nationale sur la santé de la mère et de l'enfant (ENSEME) 1997, Ministry of Health/ PAPchild, 1999, p.165.

[14] Ibid. p. 180.

[15] Enquête Panel, SEIS/Ministère de la Santé, 1995.

[16] La dynamique du programme de planification familiale du Maroc 1992-1997, Ministry of Public Health/The Evaluation Project, 1998, pp. 32-33.

[17] Enquête Panel, SEIS/Ministère de la Santé, 1995.

[18] C. Varea et al: "Determinants of contraceptive use in Morocco : stopping behavior in traditional populations", Journal of Biosociological Sciences, 1996, 28, pp. 1-13.

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18 juin 2009 4 18 /06 /juin /2009 18:05

FAMILY PLANNING AND CONTRACEPTIVES IN MOROCCO (II)

 

Prof. Dr. Abdessamad DIALMY

University Mohamed V Rabat

 

4- Contraceptive prevalence 

 

Since the beginning of family planning in 1966, woman has constituted the main target of programs. Men are aimed through some messages in order to push them to accept and to facilitate the women's use of contraceptives. Generally, men reject contraceptives for themselves. The male acceptance rate of continence, withdrawal, condom, and vasectomy is weak because the male “defines contraceptive practice as a female thing, as "the business of women”[1]. The masculine involvement in contraception is weak; it is neither a lifestyle nor a conjugal policy[2]. When it is not a medical indication, the contraceptive alternation[3], that is to say the contraception use in turns by the conjugal couple, is  perceived such as a gift that the husband makes to his wife. The contraceptive alternation is never defined as woman's right.

 Woman remains, therefore, the main agent of the contraceptive practice. Her knowledge and her contraceptive method practice have positively evolved with time. Thus, in relation to the investigation of 1995 Panel, PAPChild (1997) records a clear improvement of the contraceptive method knowledge among women in age of procreation (15-49 years). The best known methods are by order of importance: the pill (100%), the DIU (95%), the horn ligature (92%), the injectables (83%), the condom (81%). The least known methods are the Norplant (57%), the vaginal methods (as the diaphragm, the moss and frost (21%)), and the masculine sterilization (6%). More than nine women out of ten (94%) mentioned a traditional method such as : the maternal nursing (88%), the periodic continence (78%) and the shrinking (70%). 

Concerning the modern contraception, 78% of women brides already used it, against 71% in 1995 and 63% in 1992. The pill comes on top with 75% against 68% in 1995. At the time of the investigation, 58,4% of women aged between 15 and 49 years declared that they use a contraceptive method, including 3,2% of women that use the prolonged maternal nursing. This means that the rate of modern methods use is 48,8%. 

Otherwise, the new generations tend to delay the first pregnancy. Indeed, among women without children, the first utilization shifted from 4,2% for women born in the 1950 years to 45,8% for women born in the 1980 's. In 1996-97, 13% of women without children resort to the contraception. The use of the contraception after the first child shifted from 33% for women born around 1950 to 60% for women born around 1976.  

Globally, the rate of the contraceptive use didn't stop increasing. 

 

Figure 7: Evolution of the contraceptive prevalence rate  

 

Year

1980

1992

1995

1997

Contraceptive prevalence rate

19,4

41,5

50,3

55,3

 

In 1996-97, the rate of contraceptive prevalence reaches the most elevated level in: 

- the age group 35-39 years with 66% 

- the urban area with 65,8% against 51,7% in rural area. 

- the category of women having the secondary or superior level in education: 72,1%. 

The proportion of women in situation of unsatisfied need in family planning, that is to say women who want to stop pregnancies or to space them but failed to do so, knew a meaningful decrease[4]. The rate of this category of women shifted  from 22% in 1987 to 20% in 1992 to 16% in 1995. The satisfied demand concerning family planning is in progression[5], it increased from 59% in 1987 to 77% in 1995. However, these measures remain imprecise because they are exclusively based on women's declaration. Men's needs and women's needs are not always the same within the marital couple, that is to say the husband's opinion is an important factor in the evaluation of unsatisfied needs of contraception[6].

 

5- Decrease of the total fertility rate

The positive interrelationship between the elevation of education level and the elevation of the contraceptive prevalence implies that, for the educated woman, having a child doesn't have the social and the economic value that it has for the illiterate woman. For the illiterate and dependent mothers, a child is a factor of valorization and stabilization. For these mothers, it is important to have enough children, - boys especially- for old age[7]. The status of family assistant usually reserved for rural woman does not enable her neither income nor autonomy. Besides, in the countryside, the child is a source of wealth rather than of expense: since 6-7 years, the child is able to work in the fields, chores of water and wood,  trade, and the handicraft. In this rural context, contraception is for woman a means to fall in value socially[8].

This rural specificity explains a weaker decrease of the total fertility rate (TFR) in comparison with the urban area. If at the national level the TFR in 1997 is 3,1 child by woman, the gap between urban and rural areas is still meaningful: 4,1 in rural area and 2,3 in urban area. In the countryside, motherhood and work in the fields are not incompatible. On the contrary, having a lot of children is for the rural mother a means to unload her an important part of the daily labor. It is therefore with urbanization that one moves towards a weaker TFR. A further weaker TFR is also achieved through education. Indeed, for the category of women who have a superior educational level, the TFR is 1,6 children per woman, that is to say a weaker TFR than the replacement rates[9]!  

In spite of the relative rural resistance, the decrease of the TFR is perceptible on the longitudinal plan, which testifies the success of family planning programs. Between 1962 and 1997, the TFR recorded a remarkable decrease of 20%, between 1962 and 1980 and 56% between 1962 and 1997 (PAPChild). 

Figure 8: Evolution of the TFR

 

Year

1962

1980

1997

TFR

7,0

5,6

3,1

 

Moroccan TFR decreased to lower than a half in 35 years. The decrease of fertility rates has reached all ages, without exception. Besides, the precocious fertility is relatively weak: the teenager mother's percentage lowered. It shifted form 8,5% in 1982 to 4,5% in 1995. In accordance with this, the rate of fertility to 15-19 years is only 35°/°° (PAPChild).  

To conclude, the evolution towards a nuclear type of family (owed to the urbanization, to schooling, to the elevation of the average age of the first marriage and to the contraceptive prevalence) leads to the decrease of fertility. The role of the contraceptive prevalence is even more important. Indeed, more than half of the reduction of the fertility is owed to the contraceptive method utilization. This utilization, while meeting understandable some resistance, could seriously reach the rural, the illiterate and the poor woman. Even if the rates of schooling (of girls) and of education (of adult women) have not increased, and although the response to family planning services is not always guarantied[10], the demographic transition is taking over thanks to programs of family planning that Morocco has put in practice since 1966. 

 

6- Toward integration of FP in reproductive health programs

 

The emergence of the reproductive health notion is currently leading to a shift form the FP traditional worries such as acceptance rate, the use prevalence and the unsatisfied contraceptives needs.  "Reproductive tract infections are associated with infertility, cervical cancer, adverse outcomes of pregnancy, and HIV transmission. These infections also have socioeconomic costs related to their treatment and to their impact on functioning and status… It is clear that disease conditions that are contraindicated by methods of contraception should be of concern to a family planning policy"[11]. The reproductive health implies that FP would not succeed without taking into consideration the women's health as a whole, particularly reproductive morbidity and the STD-HIV. Moreover, the reproductive health paradigm needs to work on the quality of cares, respect of human rights [12] as well as the involvement of men[13].

Part of the PAPChild investigation (ENSEME 1997) is the examination of reproductive morbidity. This includes the diagnosis of the treated illnesses[14] among bachelor women during their reproduction age (15-49 years). It also raises the question of the perception of [the suggestive] symptoms of reproductive morbidity  such as prolapse, urinary incontinence, vaginal losses, urinary tract infection and troubles of menstrual cycle. Infertility is perceived as the most morbid symptom. Such an attitude is very common in a patriarchal society that constructs fertility as a major determinant of woman's social integration. The investigation was also interested in the gynecological morbidity that comes with pregnancy and post partum. The socio-cultural perception of a symptom as morbid is important in the sense that it determines the condition of searching for care.

This investigation revealed that for women reproductive morbidity means[15], infertility (18,6%), troubles of the cycle (13,5%), genital prolapse (12,9%), urinary infection (12,9%), vaginal losses (10,3%), and urinary incontinence (5,4%). Accordingly, 13,5% of women declared more a symptom of reproductive morbidity. Sterility is the symptom induces most of to the consultation, 75,6% of infertile women consulted a physician. Troubles of the cycle symptoms were a reason of less consultation. Concerning other symptoms considered by women as morbid 50% among women don't consult mainly because of the expensive consultations. The majority of women who consult are educated and urban, that is to say financially solvent or have a medical insurance. For other women, apart sterility, these morbid symptoms do not constitute a problem, they need no consultation. It is important to point out that the consultation is not always medical. " 26,7% of people have recourse to the traditional healer and the herbalist because of the problem of barrenness" [16].

PAPChild/ENSEME 1997 has also taken the pathologies bound to pregnancy, childbirth and post partum into consideration. These pathologies are bound to the weak rate of the antenatal consultation[17], to the predominance of the childbirth at home (in rural areas especially) and to the weakness of the postnatal follow-up with regard to both the mother that the newborn [18]. But "the insufficiency of the surveillance of the childbirth by medical structures as well as the existence of some unjustified practices such as the forceps can be to the origin of rips some of are serious, especially the vaginal rip or fistulas vesico-vaginal, which is a real major "handicap [19]. Consequently the quality of cares becomes a major worry. The Dialmy's study entitled "The socio-cultural management of the obstetric complication in Morocco" showed that the inaccessibility to health services is mainly due first to : the bad quality of health care services and second to some cultural factors such as male resistance to the hetero-consultation[20]. Indeed, the husband refuses in some cases that his wife be examined and treated by a male nursing.

From these observations, an integration of the STD/AIDS services to the services of primary health cares and programs of maternal and child health proves to be necessary. But the different programs of maternal and child health[21], namely the "Program of Surveillance of Pregnancy and the Childbirth" and the "Integrated Hold in charge of the child's illnesses" (PCIME) don't mention the STD-AIDS explicitly. Maybe it is due to the fact that programs of the health ministry need a better integration and coordination. Indeed, sometimes, the action of the ministry of health is compromised by the fact that different ministry administrations are working on the same issues with the same objectives. Thus, diseases are objects of specific programs within the Direction of Epidemiology and Struggle against diseases and are also the object of other programs within the Direction of Population[22]. For instance, the program of pregnancy surveillance childbirth is one of the programs that are shared between these two main administrations.

However, according to "Strategic National Plan for the struggle against AIDS"[23], this integration is in progress. Concerning STD taking in charge, there was a training of 3800 general physicians and 4500 nurses working in cells of maternal and child health and family planning, in primary health care institutions, in emergency services as well as among the dermatologists and gynecologists. Within the domain of follow-up and epidemiological surveillance, a system of epidemiological surveillance of the STD-HIV has been effectively institutionalized. This system allows the examination of HIV infection tendencies among pregnant women in order to warn the vertical transmission mother-fetus. Let's recall that the sero-prevalence rate among the pregnant women is 0,15% in 2000 (Source: Ministry of Health).

However, it is necessary to point out that the expenses of the ministry of health in maternal and child health (MCH) concerning the primary health cares (27,2 millions of $US)[24] are distinguished from the relative expenses of the STD-AIDS. In other words, the expenses concerning the STD-AIDS don't go to the financing of the MCH. For the STD-AIDS, the ministry of health spent 54 millions DHS in 1998-1999 while the Moroccan Association of Struggle against the AIDS (ALCS) spent 4,6 millions of DHS[25]. To what extent could we consider this separation of budgets an obstacle against the complete integration of STD programs in primary health cares?

 

 



[1] A. Dialmy: Identité masculine et santé reproductive au Maroc, op. cit. p. 142.

[2] Ibid. p. 143.

[3] Ibid. 144.

[4] Santé de reproduction au Maroc…, op. cit., p. 66.

[5] Ibid. p. 66.

[6] A. Zguiouar : Planification familiale au Maroc: besoins non satisfaits et intention d'utiliser, Université de Montréal, 1995.

[7] Analyse de la situation des enfants au Maroc, op. cit. p. 41.

[8] Ibid. p. 41.

[9] Ibid. p. 41.

[10] F. Navez Bouchanine et Al : Etude des pratiques sociales et de l'acceptabilité des services de santé materno-infantile et de planification familiale, Ministère de la santé publique/FNUAP, 1994.

[11] H. Zurayk, N. Younis, H. Khattab : "Rethinking Family Planning Policy in Light of Reproductive Health Research", in C. M. Obermeyer (ed): Family, Gender, and Population in the Middle East, Cairo, The American University in Cairo Press, 1995, p. 249.

[12] J. Jacobson: Family, Gender and Population Policy: Views from the Middle East, The Population Council, New York, 1994, p. 18.

[13] A. Dialmy: "The husband use of male contraceptives in the couple is not adopted as contraceptive alternation, as private conjugal policy. Its only a help that husband brings to his wife in order to permit her to take rest", in Identité masculine et santé reproductive au Maroc, op. cit. p. 143-144.

[14] ENSEME/PAPchild, op.cit. pp. 116-119.

[15] Ibid. p. 120.

[16] Ibid. p. 124.

[17] Only 3,8% of the rural women benefited the antenatal consultation at the time of pregnancies recorded during the last 3 years preceding the PAPchild survey, against 22,4% in urban area.

[18] The postnatal cares only touch 12,3% of parturients at the national level. They only touch 50% of the rural women that give birth in supervised middle (against 86% in the urban). The absence of complication, the nonexistence of the service and the cost generated are the main factors that drive to the weakness of the postnatal consultation rate (PAPchild).

[19] PAPchild, op. cit., p. 96.

[20] A. Dialmy: La gestion socioculturelle de la complication obstétricale dans les régions Fès-Boulemane et Taza-Al Hocéima-Taounate, Ministère de la Santé/Direction de la Population/USAID, Fès, Imprinego, 2001.

[21] National Program of immunization, Program of Struggle against the Illness Diarrheic, National Program of Prevention and Control of the Diabetes…

[22] Analyse de la situation des enfants au Maroc, op. cit. p. 81.

[23] Plan National Stratégique de Lutte contre le SIDA, op. cit. p. 4.

[24] Z. E. El Idrissi M. Driss et al: "Analyse des dépenses de santé maternelle et infantile à travers les comptes nationaux de la santé: Cas du Maroc", Symposium International sur les Comptes nationaux de la Santé, York, Angleterre, 20-21 june 2001.

[25] Z. E. El Idrissi M. Driss : "Analyse de la Réponse face au VIH-SIDA, adéquation du financement", Atelier de Consensus National sur les Stratégies de Lutte contre les MST-SIDA pour 2002-2004, Rabat, 7-9 June 2001.

Repost 0
12 juin 2009 5 12 /06 /juin /2009 12:16

HIV, AIDS and THE PUBLIC HEALTH SECTOR IN MOROCCO (3)

 

                                                                                                                Prof. Dr. Abdessamad Dialmy

University of Rabat, Morocco



III- Management of STIs and AIDS patients

 

This third section will deal with the syndromic approach in the management of STIs before moving to the access to care and psychosocial support for AIDS patients.

 

III-1 Management of STIs

 

First, one should state that the statistics on STIs were absent before 1991. This year, 50 567 STIs cases were registered. This number reached 307 040 in 2000 and 600 000 in 2004. Thus, the statistics of STIs are a result of the impact of HIV-AIDS epidemic on the policies of the ministry of health. Because STIs are the bed of AIDS, the knowledge of their prevalence in order to prevent and treat them belongs to the adoption of the second-generation surveillance.

All types of STIs exist with a majority of leucorrhees and uretrites. Women infected by STIs other than AIDS are more numerous than men and their proportion is increasing: 63% in 1991 and 79.5% in 1994.

How are STIs combated by DELM/PNLS? These institutions launched the syndromic approach since 1997 to avoid an expensive etiological diagnosis as well as any risk of a wrong clinical diagnosis. This approach avoids laboratory analyses, which are expensive, and avoids the risk of the sick not coming back after a first clinical diagnosis or after been asked to do some biological analyses. This approach means that the patient has to be immediately and freely treated of all-important causes of the syndrome. The treatment is supported by education (counseling, condom, and information for the partner…). Syndrome approach could be summarized in four stages: clinical history, clinical exam, administration of a treatment and education (condom…). In principle, this approach permits primary health care services to take STIs in charge.

According to a declaration of the ministry of health (ONUSIDA 2001), the implementation of syndromic approach since 2000 embraced all regions of the country, especially in terms of supplying specific medicines. This statement is not realistic in the sense that medicines are still unavailable in public structures according to several testimonies sourced through informal interviews. But it also means that before 2000, STIs were not completely taken in charge. This situation is due to three factors:

1) the cultural resistance of population to seek care for STIs.

2) the insufficiency of the sanitary structure and the unacceptability of care in the public sector.

3) the insufficiency of the medical insurance and the financial inaccessibility of the private sector

 

As an indicator of fornication for an extensively illiterate population, STIs constitute an extreme taboo issue to the point that the sick rarely bothers to even try to take care of himself/herself. Because of shame, there is sometimes auto-medication either by the use of plants or by the consumption of medicines that drags in the house or at a friend's. About 50% of STI carriers use auto-medication (Jrondi 1998: 298) encouraged by sellers in the pharmacies (Ministry of Health 1887: 11). In a lot of cases, sellers in pharmacies deliver medicines to the sick without medical prescription. In this way, the sick make savings and avoid the embarrassment of being examined by a physician. In spite of several and varied resistance toward consulting a physician, the general belief claims that modern medicine alone can treat STIs efficiently. But according to a nurse, seeking medical care starts only when the illness has worsened (Dialmy and Manhart 1997: 86).

In the case of minors, its more difficult. Indeed, according to the Moroccan legislation, minors cannot benefit from care or medical treatment without the downstream of their parents or legal tutors. Health professionals are obliged, except in a case of emergency, to procure parental consent. No medial act on a minor is therefore legally foreseeable without the knowledge and consent of the parents. In the case of minors, the medical power and the medical secret fade away when facing the parental authority. In practice, and in the interest of minors, several nurses accept to take them in charge and to respect of their privacy, but they risk being pursued if a problem results. Evidently, the downstream of the parents poses more problems in the case of the STIs. One could not imagine easily a teenager telling his/her parents that he/she has a STI. The communication on sexuality between parents and their progeny is traditionally unconceivable, especially between the father and his progeny. It would be necessary to think, therefore, how to review the law in order to allow nurses to take minors in charge without the consent of parents in the case where a health problem concerns their sexuality.

On the other hand, insufficient services are a major obstacle for treating STIs. Sanitary condition in the remote rural areas and the expensive medicine are often evoked by the population (Dialmy and Manhart 1997: 118-119). In spite of efforts undertaken to improve sanitation in rural areas, 31% of the rural population live further than 10 km from the nearest health care centers and 47% spend in the minimum about one hour to reach them (CERED 1999). The physical inaccessibility of the different health structures contributes to their weak utilization by the population. Thus, in 1999, the rate of medical consultation in public health centers didn't go beyond 0.4 contacts per capita and per year, while the rate of bed occupation did not exceed 56%. The weak recourse to public health services (CERED 1998), notably in rural areas (49% against 68.4% in urban), can also be explained by the cultural resistance to dispensed cares. It starts with a poor welcome (a long wait and neglect) and continues with the speed of the exam, the absence of discretion and privacy, the absence of communication and the prevalence of corruption (Dialmy and Manhart 1997: 126-130). In certain cases, women refuse to be examined by a male physician and men by a female physician. The nurses themselves recognize that conditions of welcome and care are depressing (Dialmy 1997: 14). Consequently, according to a study on the quality of managing STIs in the public sector, only 2% of the patients received correct information about their disease whereas 84.5% affirmed that the physician didn't give them any explanation on the cause. Only 13.9% of male patients and 2% of female patients were adequately treated (Ministry of Health 1997).

The absence of medical insurance has, of course, a negative impact on access to medical care. Indeed, access to medicine is still quite difficult for different social strata even though the cost of medical care in Morocco is about 30% cheaper than in the European countries. The average rate of medicine consumption doesn't exceed 18 $US per capita[1] and per year (against 36 $US in Algeria, 280 $US in France and 400 $US in Japan). Results of a survey (UNICEF 1997) show that the provisions of medicines in health centers did not provide more than 15% of what the population needs. The availability of medicines is only $0.40 per capita and per year whereas the registered credits to the title of the budgetary exercise 1997-98 foresees an equivalent endowment per capita to $1,30 DHS. The average varies between $0.23 and $0.85.

In spite

 

of the weakness of the patients’ spending power, the population bought 65% of prescribed medicines. This indicates the interest of the population in medical care on the one hand, and on the other hand, its strong disposition to contribute to its financing. In fact, medical care expenses supported by households constitute 55% of the covered medical expenses. Moreover, medicines occupy the first position (65%) in the global medical consumption of households.

 

III-2 Access to care for HIV-AIDS patients   

 

In 2001, only 100 infected people benefited form the trio-therapy. 70 benefited from the budget allocated to this effect by the ministry of health (400 000 $US) and the support of the International Therapeutic Solidarity Fund (270 000 $US). 30 others benefited from the social security of the trio-therapy. The cost of trio-therapy was at this period 650 $USS per person per month and 7 800 $USS per year. 140 people requiring a trio-therapy were excluded from it.

Since February 2003, patients requiring ARV have access to it thanks to the grant of the Global Fund. The initial prescription and the ulterior modifications of the treatment with ARV are made at the level of the poles of excellence[2]. As for to the centers of reference[3], they assure medical follow-up (visits, numeration of the CD4 and measure of the viral load, opportunist infection treatment) and regular provision of patients with ARV. For instance, the center of reference of Marrakech began to play a more important role in managing people living with HIV in the region. The number of people who are followed up there continues to grow, from 11 patients in 2003 to 71 in 2004. In this way, the rate of patient displacements, often expensive and laborious, to the pole of excellence of Casablanca has been appreciably decreased.

Before 2003, the trio-therapy cost more than $600 per patient per month. Thanks to negotiations led by laboratories, it only costs $100 per patient per month. However, after the signing by Morocco of the free exchange agreement with the United States, perspectives changed. This agreement forbids the importation and manufacture of the generic drug, implying more payment for the ARV. The consequence is the impossibility to perpetuate the generalization of the ARV. On January 13, 2005, Moroccan Parliament endorsed the legal project n° 28-04 approving the principle of adoption of the free trade agreement between Morocco and the United States. The text collected 55 voices for and a voice against, emanating from the GSU (Unified Socialist Left) as well as 23 abstentions of the PJD (the fundamentalist political party). President Bush described the free exchange agreement between Morocco and the United States in March 2, 2005 in a message addressed to the American Congress: “This agreement contains the protective degree of high intellectual property, ever gotten in a free exchange agreement with a developing country”. The American Congress adopted the agreement on July 21, 2005.

The American government is anxious to sign this kind of agreement in order to be able to set up its own policy in the international management of AIDS. For the year 2004, the American Congress granted President Bush only $2,4 billions to be dedicated to the Presidential emergency plan against AIDS. This money won't be given to the Global Fund.  It will be employed in the bilateral programs of USA in order to help countries that accept programs of struggle against AIDS conceived and elaborated by the American government. These programs impose to use medicines which are produced by American laboratories. Therefore, the free exchange agreement with Morocco is a defense of the American pharmaceutical industry. Besides, the American policy insists on a prevention based on abstinence and fidelity and not on the promotion of condoms. In the same way, it doesn't foresee programs of intended risk reduction among sexual workers and IDUs. In one word, it seems to be a very conservative policy. Also, the American government doubted the efficiency and security of the ARV, notably combinations of stationary doses (3 ARV in 1) having been yet pre-qualified by the WHO and MSF[4]. However these combinations are less coercive for patients and therefore perfectly adapted to patients in poor countries, thanks to the simplicity of their utilization.

 

 

III-3 Psychosocial management of persons living with HIV

 

The psychosocial management of persons living with HIV is mainly assured by NGOs. For instance, ALCS especially provides help to people living with HIV. It grants emergency financial support to poor patients by taking over transportation and feeding expenses. Its volunteers assure daily services for infectious diseases in Ibn Rochd hospital in Casablanca. These volunteers listen and respond to the needs of hospitalized people. The reception of non-hospitalized persons is assured while a legal and administrative aid is granted to Moroccan migrants in Europe. At the level of medical treatment, ALCS provides 80% of other medicines, besides the anti-retroviral, that are necessary for the treatment of opportunist infections that complicate AIDS. Among other activities of ALCS are: sponsorship of medicines, documentation, animation of conferences, free distribution of condoms, bus Info, the telephonic permanence, and informative seminars. ALCS also provides a therapeutic accompaniment at the hospital Ibn Rochd of Casablanca where a team of volunteers are available three times per week to help and to counsel patients involved benefiting a trio-therapy, to take their medicines correctly, despite daily constraints, and to manage the secondary effects of it.

All these activities show that “the only NGO working on all aspects of the AIDS epidemic in Morocco is ACLS” (Schuette 2003). This positive image of ALCS came out in an exploratory investigation with people living with HIV (Cakir 2003). The investigation, which we directed, took place at the Ibn Rochd hospital in Casablanca; in the zone of the ALCS in Tangier, and in the zone of OPALS-Maroc at Rabat.

 

Indeed, patients discern from services in Casablanca and Rabat a preservation of anonymity and confidentiality. “The only place where I can communicate is in the service at Casablanca” affirms a sick. Another patient testifies in favor of OPALS at Rabat: “OPALS  is always there and I can go there when I want to tell them of the small details of my life. I always find someone to whom I can talk”.

People living with HIV and more especially women accord a primordial importance to the existence of these associations. The zones of the associations constitute the only place where they can express themselves freely without fear of dismissal. Finally, the associations’ personnel, by their advice, their capacity to listen, and their psychological support represents for these isolated people an inestimable source of comfort.

 

 

Conclusion

 

HIV and AIDS are not faces of a visible social identity. The stigmatization, the discrimination and the exclusion of HIV victims result in their invisibility. No movement or group claims public expression for HIV+ or AIDS patients. Even though there is a popular distinction between “good sick” (victims of blood transfusion for example) and back sick”, HIV and AIDS remain correlated to prostitutes, IDUs and homosexuals (bad sick) in the Moroccan daily thought. Even though “the interpretations of the AIDS proceed from an opposition between “endogenous risks” and “exogenous risks” (Paicheler and Quemin 1994), AIDS is still perceived as God's punishment on the personal mistake and the unhealthy life style (endogenous risks), that is to say sexual perversions. Certainly, HIV is invested in the explanation of the pathology but it is coated in a global understanding of the disease as cruelty and as God’s intervention toward social regulation.

This social representation of AIDS is implicitly adopted by health policy makers and Moroccan associations when they continue to use the epidemiological category of “at-risk groups”. This notion is founded on moral and religious presuppositions. Indeed, it assumes the social perceptions that make AIDS a divine punishment, the punishment that God inflicts on the deviant and risky groups. One of the first tasks that imposes itself on policymakers in Morocco is how to replace this moralizing notion of “at-risk groups” with the notion of “risky practices”. This one avoids the paradigm of deviance and makes people aware that HIV risk concerns the day-to-day life of everybody. This notion refers to the individual with the aim of making him/her responsible without stigmatizing any particular group. 

Otherwise, the Moroccan conception for prevention never tries to fight for the legalization of non-marital sexuality, homosexuality and the use of the drug on the grounds of human rights and individual freedoms. It works in the setting of the established religious values. However it is demonstrated that the criminalization of these practices is a serious obstacle to the success of preventive measures. In one word, sexual disempowerment (Herdt 1997) of individuals effects the spread of HIV/AIDS. So, one can wonder if the Moroccan management of HIV favors the transformation of social norms.

In what measures can associations precede institutions in this direction to modify representations and the relative attitudes toward non-marital sexuality, homosexuality and use of drug? In what measure can the associative action lead to the legal recognition of these practices in order to better protect those at risk of HIV? Because one can objectively suppose that the promotion of the condom alone is insufficient to modify the traditional representations of sexuality. But first are the NGOS conscious of this strategic stake; the secularization of sexuality as the best way for its protection? Currently, one must note that the dependence of NGOs on the state and political parties explains that the secular option is muzzled as public opinion. In other terms, the existence of associations in Morocco is not a veritable proof of the existence of a civil society. A real civil society is necessarily secular. It is the society in which the man is freed of religious tutelage. It is the society of the adult citizen that chooses his/her religion freely (or his no-religion) without that the state intervenes in this choice.

It is necessary to conclude therefore that the Moroccan institutional and associative fight against AIDS is currently at the technical stage. At the level of prevention, it is about simple IEC action that does not attack the ideological foundations of the state and the society. For this reason, one can wonder on the real impact of this IEC action on behavioral change of the population. But the transition to curative measures, thanks to the Global Fund, risks bringing the social representation of HIV/AIDS in the paradigm of chronicity and to make (people or government?) forget that the best prevention resides in the socioeconomic invulnerability of the individual, in his/her responsibility and in his/her liberty of choice. The new notion of chronicity can reduce AIDS to a question of access to care. Consequently, the risk is to forget that the real stake is to build a health system that fairly allows access to care for all the sick, but which also act in the direction of the modernization of the Moroccan daily thought and its development.

 

June, 2005

 

Références

 

ALCS (2003). « Prostitution de rue au Maroc ». Sida-Solidarité, n° 11, September-November 2003.

 

ALCS (2004). « Silence, la police dépiste ». Sida-Solidarité, n° 12, July/September 2004.

 

Al Ouazzani A. (1987). La question urbaine au Maroc. Rabat : Faculté de Droit (Service des Thèses).

 

Cakir Emmanuelle (2003). La prise en charge sociale et les problèmes de stigmatisation des personnes vivant avec le VIH-SIDA au Maroc. Nancy Université Henri Poincaré (co-direction A. Dialmy/Université de Fès).

 

CERED (1998). Demande de soins de santé dans les provinces cibles du programme BAJ- 1998. Rabat :  Direction of Statistics.

 

CERED (1999). Enquête nationale sur les niveaux de vie des ménages 1998 /1999. Rabat, Direction of Statistics.

 

Chajai Atiqua  (2002). “Morocco From the “Plauge” to Silence?” in  Prevention of AIDS Through Mass Media Among Mediterranean Youth.  Edt. Centro Studi – Gruppo Abele.

 

Dialmy A and Manhart L (1997) Les MST au Maroc. Construction sociale et comportement thérapeutique. Rabat : Imprimerie Temara, 1997.

 

Dialmy A (1997). La prise en charge éducative des patients MST dans la santé publique. Ministry of Health/European Union.

 

Dialmy A (2000). Jeunesse, Sida et Islam au Maroc. Casablanca : Eddif

 

Dialmy A (2001). "Anthropologie des MST-SIDA au Maroc : existe-t-il une politique de santé sexuelle?" dans Systèmes et politiques de santé, De la santé publique à l'anthropologie, Paris : Karthala, pp. 301-328.

 

Dialmy A (2002). « Sexuality and Sexual Health in Morocco”, in Challenges in Sexual and Reproductive Health: Technical Consultation on Sexual Health, World Health Organization, Geneva, 2002.

 

Dialmy A (2003). « L’usage du préservatif au Maroc », in L’approche culturelle de la prévention et du traitement du VIH/SIDA (Colloque Régional UNESCO/ONUSIDA Fès 2001), Etudes et Rapports, Série Spéciale, n° 13, Division des Politiques Culturelles, UNESCO 2003, pp. 50-59, Web french version only : http://unesdoc.unesco.org/images/0013/001303/130320f.pdf

 

Herdt, Gilbert (1997).  “Sexual Cultures and Population Movement: Implications for AIDS/STDs”, in Gilbert Herdt Ed., Sexual Cultures and Migration in the Era of AIDS: Anthropological and Demographical Perspectives. Oxford : Claredon Press.

 

Imane L (1994). Prévention de proximité auprès des prostitués masculins au Maroc, Casablanca : ALCS (non published).

 

InfoSida Maroc, n° 4, Casablanca, 31 march 1993.

 

Jenkins C, Robalino DA (2003). HIV/AIDS in the Middle East and North Africa: The Costs of Inaction. Washington : World Bank.

 

Jrondi S(1998) : "Les maladies sexuellement transmissibles, sexualité et relations entre les sexes", in Population et Développement au Maroc. Rabat : CERED,

 

Ministère de l’Education Nationale (1993). L'éducation féminine Casablanca : Dar Ettaqafa, 1993 (in Arabic)

 

Ministère de la Santé (1997). Evaluation de la qualité de la prise en charge des cas de MST. IP6 et IP7. Rapport Préliminaire", Rabat: DELM/AIDSCAP.

 

Ministère de la Santé (2001a). Analyse épidémiologique des cas cumulés de SIDA-Maladie enregistrés au 30 juin 2001. Rabat : DELM/DMT, Service of STD-AIDS.

 

Ministère de la Santé (2001b). Plan National Stratégique de Lutte contre le SIDA, Ministry of Health, presented by Morocco to the General Assembly of United-Nations on HIV/AIDS (New York 25-27 June 2001).

 

Ministère de la Santé (2004). Appui à la mise en œuvre du plan stratégique national de lutte contre le SIDA 2002 – 2004, 1er  Rapport Annuel, Mars 2003-Mars 200.

 

Ministère de la Santé (2005). Appui à la mise en œuvre du plan stratégique national de lutte contre le SIDA 2002 – 2004, 2ème Rapport Annuel, Avril 2004- Mars 2005.

 

Paicheler G et Quemin A (1994). « Une intolérance difficile : rumeurs sur le sida ». Sciences Sociales et Santé, n° 4, pp. 41-72.

 

ONUSIDA (2001). Regional Workshop on Socio-cultural Approach in prevention of HIV-AIDS, ONUSIDA/WHO/UNESCO/FNUAP, Fez, June 2001.

 

Schuette Asta (2003). “The Fight Against AIDS in Morocco: Examining Cultural and Official Attitudes”. Rabat : Centre d’Etudes Interculturelles.

 

Spira A et Bajos N (1992). Les comportements sexuels en France. Paris : La Documentation Française.

 

Spencer B (1992). « Jeunes hétérosexuels : les obstacles culturels au safer sex », Transcriptase, 8, 1992, 35-37.

 

Thiaudière Claude (2002). Sociologie du sida. Paris : La Découverte.

 

UNFPA (1997). Rapport d'analyse du programme et d'élaboration de la stratégie, Casablanca : Editions Le Fennec.

 

UNICEF (1997). Amélioration de l'offre de soins en milieu rural. Etude dans les provinces de Boulemane, Sidi Kacem et Mohammedia. Rabat : Direction des Hôpitaux et des Soins Ambulatoires.

 

World bank (2002). World Development Indicators Database (SIMA).

 

 



[1] This level of consumption didn't change since 1995 according to acts of Journée de l'Association Marocaine de l'Industrie Pharmaceutique, Casablanca, 29 juin 2000.

[2] The North excellence pole is constituted by the service of Medicine A in the Ibn Sina hospital at Rabat. It covers the North zone of the country. The South excellence pole is constituted by the service of the Infectious Diseases of the hospital Ibn Rochd at Casablanca. It covers the South zone of the country. These two poles of excellence work in cooperation with regional reference centers.

[3] The Centers of reference are situated in the Regional Hospitable Centers and in the military teaching hospital Mohammed V at Rabat. They have referent physicians for the management of HIV/AIDS. In the South region, these centers are represented by the regional hospitals of Agadir, Safi, Marrakech, El Jadida, Beni-Mellal et Laâyoune. In the North region, they are represented by the regional hospitals of Tangier, Tetuan, Fez, Meknes, Oujda et Kenitra.

[4] MSF : Médecins Sans Frontières.

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12 juin 2009 5 12 /06 /juin /2009 12:11

HIV, AIDS and THE PUBLIC HEALTH SECTOR IN MOROCCO (2)

 

                                                                                                                Prof. Dr. Abdessamad Dialmy

University of Rabat, Morocco

I-4 Financing and performances

 

In order to achieve these projects, funds received from the Global Fund for the 1st year (March 2003-March 2004) of the first phase (2003-2005) was $2 271 408, 00 (Ministère de la Santé 2004). Actual expenses amounted to $1 355 258, 08. The committed but not yet remitted funds are $702 741, 44 (up to May 10, 2004). These expenses concern the social communication campaign ($391 888, 89), the bio-medical equipment and reagents ($310 852, 56), and condoms ($58 000, 00). Funds saved on the ARV and condoms totaled $208 685, 00: ARV ($118 701, 67) and condoms ($89 983, 33).

For the whole of the first phase comprising two years, March 2003 to April 2005, the grant of the World Fund rose to $3 909 772, 00. Of this sum, $3 289 060, 14 have been used effectively. The used sum was distributed between the DELM/PNLS ($2 062 243) and the six under beneficiaries: ALCS ($458 126), OPALS ($259 250), AMSED ($301 591), LM-LMST ($65 050) , AMJCS ($36 900), Secretariat of State for Youth ($106 900).

The performances of the first phase can be divided in four sections (Ministère de la santé 2005 : 42).

At the level of the prevention of the HIV infection among vulnerable groups:

- 400 peer educators have been recruited concerning HIV prevention close to the vulnerable groups (410 were foreseen). But there has been no evaluation of their functioning or effectiveness.

- 3748 sex workers and female workers received an education from the peers concerning HIV-AIDS (3400 were foreseen).

- The percentage of sexual workers that acknowledge using condoms with their last client has not been measured although this has been foreseen. Yet a survey on the street prostitution has been achieved by the ALCS in 2003 in the setting of the first phase. This survey showed that a percentage of 37% of sexual workers use the condom systematically. However, the objective of the PSN regarding this topic during the first phase is to bring 50% of the sexual workers to use condom systematically. One could suppose that this study is not mentioned by the PNLS because its performance is unsuccessful. But it is also possible that not mentioning the result of this study means that the study is not perceived by the PNLS as representative and objective. 

At the level of implementation of a program of social communication targeted on youngsters and women:

- 1563 educators were recruited concerning HIV prevention close to youngsters and women (foreseen: 1969).

- 332 600 young girls of 15 to 24 years age category and women sensitized for the prevention of the HIV (300 400 foreseen).

- 61 500 young girls of 15 to 24 years and women educated for the prevention of the HIV (84 800 foreseen).

- the percentage of youngsters of 15 to 24 years that know how to prevent the HIV has not been measured. It would be measured in June 2005 (according to the report).

- 5 142 000 condoms have been distributed at the level of intervention regions (foreseen 4 000 000).

At the level of the promotion of the counseling and the voluntary HIV test:

- 37 centers of counseling and HIV testing are henceforth functional (foreseen 35).

- 1 3 067 people were counseled and tested for HIV anonymously and confidentially (11 200 foreseen).

At the level of the tri-therapy treatment:

- 1 489 AIDS patients receives an association of ARV (foreseen 1500)

- 45% of people having an advanced HIV infection receive an association of ARV (foreseen 37%).

In general, these official results are positive. They led the Global Fund to grant a second slice for the 2nd phase. The approval of the 2nd slice confirms the recognition by the Global Fund of the expanded efforts for the implementation of the program. These efforts continue to make Morocco a model for MENA region. This recognition resulted in the choice of Morocco as host country of the 8th board meeting of Global Fund to hold at Marrakech from December 12-16 2005.

 

 

II- Prevention

 

This second session will present some aspects of the IEC national campaigns but will especially analyze the popular reticence and resistance toward HIV test and the use of condom. It will conclude by a brief overview on the structural vulnerability in Morocco.

 

II-1 IEC activities

 

During the period 1991-1994, the following didactic materials were produced (InfoSida 1993): 

- AIDS Posters                                               26.000 

- AIDS Info-Bulletin                                       30 000 

- Stop AIDS Auto-tights                                 10 000 

- Stop AIDS Adhesive                        40 000 

- Big Public AIDS Leaflets                              369 000 

- STD Leaflets                                               167 000 

- AIDS Pins                                                    5 000 

- AIDS Short sleeve shirts                               10 000 

- Blood transfusion Leaflets                             220 000 

- AIDS Game                                                 10 000 

- Streamers                                                     15 

- Leaflets for travelers                          20 000 

- TV Spotlight                                                 1 

- Song on AIDS in schools                             1 

- Press Book                                                  250 

  

 While television is the first information medium, these data show that only one TV Spotlight was produced on AIDS between 1991 and 1994. Unfortunately, this television spots, which was sponsored by the Ministry of Health in 1993 depicting two men playing dice, lead some people to believe, “playing dice could cause AIDS” (Chajai 2002 : 91). Coming second is the radio. Newspapers and magazines reached only 10.1% while posters reached fewer women (2.9%). According to some nurses (Dialmy 1997), STOP AIDS poster is not well understood by people. People who do not read believe that it is about cars and about campaigns against accidents. So in a society where the illiteracy rate is still high, direct contact is more effective. For this reason, a lot of nurses were sent as mobile teams to popular markets, to gather people thanks to public crier in the countryside and shanty towns. Bars and mosques were also targeted as adequate places to transmit oral preventive messages. But the dominant perspective of the nurses suggests the use of audio-visual media. Some nurses assert that with or without the belief in Islam, sex workers, STIs and HIV exist, so it is necessary to talk about them and about condom both on TV and radio.

On the other hand, education aiming at the prevention of STIs-HIV in the school manual Feminine Education is shy and contains some mistakes. To mention only an example, one affirms that STIs can be transmitted sexually, either by pollution, that is to say the common use of toilets or using unclean napkins without making clear what is transferable by pollution. The manual concludes with the following recommendation: "that the person infected by AIDS should hurry in seeking medication because the more it is done quickly, the more the chances of recovery are bigger" (Ministère de l’Education Nationale 1993: 11)! In fact, this manual has little impact and is unable to change the schooled youngsters' representations of STIs-HIV. These representations remain close to the commonsensical dominant social representations (Dialmy et Manhart 1997: 47-67), that is to say, distant enough from the biomedical knowledge. A spontaneous epidemiology and a plain etiology still make of the STIs-HIV-AIDS a social construction made at a time of scientific elementary scraps, of judgments of values, of explanations being a matter for a pre-modern medicine and magic-religious beliefs. The spontaneous epidemiology develops xenophobia, social discrimination and misogyny while the plain etiology implies four spheres of factors in the explanation of the STIs-AIDS, the cold, the debauchery, the occult, and body proximity (Dialmy 2001).  

The social construction of STIs-AIDS in Morocco reflects also the dominant social misogyny. Spontaneously, the Moroccan profane man tends to affirm that women are more likely to be infected by HIV-AIDS than men. The unconscious symbolic association established between women's cold and dirt lead to considerations of women as more vulnerable and as the source of all STDs. There is one shortcoming in the extensively patriarchal social constructions: the Moroccan man occults the sexual relationship power in which women are often victims of the sero-positivity (or of the disease) of men.

To fight those social representations, the ministry of Health launched in June 2004 a national social communication campaign on struggle against AIDS and used various media to reach a very large audience. This campaign utilizes the TV, radio, press and posters. It is financed by the program of support of the Global Fund. On February 3, 2005, the third phase of this campaign began and aims especially to fight against the stigmatization and the discrimination of people living with HIV. In order to meet that objective, four posters have been made as well as televised and radio spotlights in Arabic, the Moroccan national language, and in the different Berber dialects.

The question that arises here is this: how can we measure the impact of this social communication campaign on the social representations of HIV/AIDS described above? The answer to this question requires a specific and independent investigation.

 

II-2 Reticence vis-à-vis HIV Testing

 

The first Center of Information and Anonymous Free Testing (CIDAG) was set up by the ALCS in 1992 in partnership with the Ministry of Health. According to the ALCS and the OPALS, the CIDAGs train today a big number of consultants who are permitted to know their serological statute anonymously and freely and to absolutely respect ethical rules. The CIDAGS also orient the HIV+ people toward suitable medical services.

These CIDAGs exist today in the cities of Agadir, Azrou, Beni Mellal, Casablanca, El Kelaa, Essouira, Fez, Guelmim, Khenifra, Marrakech, Meknes, Oulad Teima, Rabat, Settat, Tangier, Taroudant, Taza and Tetouan. Because the existing CIDAGs do not cover all the national territory, mobile CIDAG of the ALCS furrowed all the country during the 2003 summer campaign. Those mobile CDAGs achieved 807 HIV tests in three months. Other mobile CIDAGs occurred in February 2005 at Layoune (with 101 HIV tests), in Tiznit in April 2005 (with 146 HIV tests), in the region Sous Massa Draa (with 508 HIV tests), at Meknes (with 400 HIV tests).

These numbers, as well as those showed in the setting of the performances of the support program of Global Fund, must not conceal the reticence of the Moroccan population toward the HIV test. An indirect evidence is that the majority of the 453 seropositive people participated in the Service of the Infectious Diseases of the Ibn Rochd hospital in 2003 learned about their serological statute at random, either at the time of a medical visit or at the time of donating blood. According to a social worker of the ALCS, the 20 000 seropositive people are unaware of their statute or did not dare to take the test. The seropositivity is therefore often unconscious, unknown, what clears on a brutal passage in the state of illness. Reasons to this situation are numerous. First of all, CDAG are often not known, or if they are, they are sometimes far from the people and, therefore, geographically inaccessible. Then, for those that did not transgress norms, the HIV risk is not perceived. They do not feel concerned, perceiving themselves as normal individuals. There is also the desire for ignorance, to delay most possibly the moment of the conscious entrance in precarious state of HIV+. Finally, in a society where each still lives under the (mortal) look of others, it is difficult to keep confidentiality. To take the test means taking the risk of being stigmatized, marginalized, and excluded. The belated HIV test, when it is not the consequence of a total ignorance (of HIV infection and its transmission modes), is a way to win time against social death.

Another fact surrounding the HIV test is consent. People arrested for prostitution or homosexuality are submitted to forced and involuntary HIV test during their detention. These practices, which seem to be on the increase, are carried out by the police, with the complicity of some physicians of the Ministry of Health (ALCS 2004). Such HIV tests are done at the police station. Sources from the regional hospital of Tetuan affirmed to the ALCS that a physician and a male nurse have been called to the police station where they were asked to administer HIV tests on homosexuals arrested at Tetuan. This practice is completely illegal: no HIV test can be done without the knowledge of the individual and without his/her consent, as stipulated in the instructions of the Ministry of Health. In these instructions confidentiality is also mentioned as an inalienable right of the individual.

This fact shows how “the struggle against AIDS, disease transmissible through blood and sexual contacts, re-tie surreptitiously with social hygiene, associated with the sanitary police and the moralization of mores” (Thiaudière: 2002: 4). In fact, has the struggle against AIDS in Morocco ever overlap with social hygiene, the sanitary police and the moralization of mores? When “incidents” occur, associations like ALCS and OPALS-Maroc promote the citizen and defend the individual liberties, including those of homosexuals and prostitutes. But the conflict between the NGOs, the Ministry of Health and the police has never occurred : on the one hand, the nursing implied in this affair acted without the downstream of the Ministry of Health and its agreement, on the other hand, the NGOs ever claimed the right to homosexuality or prostitution.

 

 

II-3 Resistance to the Use of Condom

 

The condom is precisely an object of multidimensional resistance. Associated with sexual activity outside marriage, a supposedly immoral, dirty, and dangerous activity, the condom inherits all the negative features of this "bad sexuality". Consequently, we find the condom trebly condemned by popular opinion, by the jurist (traditional), and to some extent by the health system itself (Dialmy 2003). 

For the popular opinion, extensively dominated by a patriarchal perspective, the condom is rejected because it hinders an easy and fast excitation and because it risks compromising the man in his virility. It may also prevent a complete enjoyment. The condom is also rejected because it is expensive and compromising at the time of its purchase (being tied to bad sexuality). Individuals accuse the condom of being fragile and permeable and sow doubts and distrust in couple (both conjugal and non-conjugal). The condom is often unavailable at the time of an unforeseen and circumstantial intercourse. Also, in many cases, in spite of the consciousness of risk, the condom is not used just to prove one’s courage, for example. 

Among female sex workers, the majority acknowledges not being able to impose the condom on the customer for fear of losing him (Dialmy 2000). They prefer to ignore the probability that the customer could be sick or that they themselves may be sick. For them, the use of the condom serves first to protect the customer. Meanwhile, they consider themselves as already dead. Their soul is dead, they say. The customer's power and supremacy shows that “masculine domination” finds here a privileged field to express itself completely and also to ruin the woman's personality completely. This relation of domination between the customer and the female sexual worker shows how “the possibility to protect an individual is limited ... when there exists a big imbalance in the relationship” (Spencer 1992: 35-37).  Female sex workers, admitting their own lack of control, “conduct” themselves with an almost mystical abandonment into God’s hands. Resigned and fatalistic, they are convinced that whatever happens to them and what can still happen to them depends on external social or supernatural strengths. Female sex worker does not have any “internal orientation of control” (Spira and Bajos 1992) and consequently cannot adopt any preventive measures. This attitude refers to a specific religiosity made of total passivity in front of the divine will. But for the sexual worker, this fatalistic attitude is beneficial. It makes her not to feel guilty, which in some sense is relaxing.

Some quantitative data, achieved by the ALCS after an investigation on street prostitution (n = 315), confirm the non-systematic and non-general utilization of the condom. “If 99% of female sex workers know the condom, only 37.6% of them reported using it with all customers. 57.9% reported that they accept intercourse without condom if the condom is not available at the moment of the intercourse. For 80.1%, the condom is perceived as a factor that makes the client move away” (ALCS 2003).

Another factor that were discouraging the use of condom among female sex workers is the police behavior as it is reported by Schuette : “up until a few years ago, if a police officer discovered a teenage girl with a condom in her purse she could be fined and apprehended. The police assume that the girl is a prostitute, based solely upon her possession of a condom.  The Moroccan AIDS NGO ACLS organized two or three seminars for judges, lawyers and police on prostitution to begin addressing cultural issues such as the possession of a condom.  ACLS director (Amina Chajai) reports that the situation has improved since these seminars (Schuette 2003).  

Coming to the Moslem jurist (Dialmy 2000), sexual activity outside marriage is religiously illicit and it is unconceivable to think about its protection from the risks of infection by the use of condom. Recommending protection through the condom implies encouraging sex outside marriage institution. The jurists refuse here to use ijtihad, that is, the creation of new and adapted laws in the AIDS context. The sanitary protection of the non-institutional sexuality is not conceived[1]. According to these traditional jurists, the real protection consists of the mutual conjugal fidelity and in premarital abstinence. Consequently, protection of sexuality outside marriage raises a legal problem because of the legal rejection of the use of condom outside marriage (Dialmy 2000: 207-210).

At the level of physicians and practitioners, the attitude towards prevention is ambiguous. Nurses are divided over non-discrimination, negative discrimination, and positive discrimination (Dialmy 1997: 52). Those who are for non-discrimination mean that there is difference between the STI patients and other patients. These nurses say that they do not have the right to judge a patient of immorality. On the other hand, the nurses that express a negative discrimination do not hesitate to condemn the immorality of the infected individual, her/his unconsciousness and her/his ignorance. For these, the STIs that should be avoidable are sought-after through a risky and illegal sexual behavior. Their condemnation is sometimes expressed in the name of Islam, with sex-related diseases being a kind of punishment for fornication. Other nurses consider the STI patients as an object of mercy and express a positive discrimination. Thus, they hold that STI patients should be a priority and require an educative management. For the majority of the nurses, STIs consultation is an ideal moment to immediately transmit the educational and preventive message. For them, it is necessary to exploit the fear of the sick and his/her disarray, his/her incentive to spread messages of prevention and education (sanitary and sexual). During the treatment, these nursing-counselors recommend in principle abstinence, faithfulness or the use of condom. However, nurses prioritize these instructions: the advice of the condom comes after the one of morality. Worse, the advice for the condom use is offered only in 9% of medical consultations (Ministère de la Santé 1997: 11). One notes, therefore, that recommending the use of the condom and change in sexual behavior implies two contradictory instructions: to counsel on condoms is associated with secularism and a civil sexuality while to counsel on moralization is associated with re-islamisation.

This practical ambiguousness comes from the medico-sanitary official vision. This one recommends (and distribute) the condom as a protective tool against STD-HIV but it (implicitly) recommends it as a vulgar instrument to use in a vulgar sexual relationship to escape a vulgar disease. For the health system, the condom is a necessary evil. It is a necessary bad thing for avoiding risks of a bad sexuality. The condom is said to be used for preventive ends without the adherence to the secular morals that is its main component and, which founded it (Dialmy 1997). For this secular morality, the condom is part of a permissive sex education process that recognizes the right to sexual activity for members of the two sexes even outside marriage. In recommending the condom for saving public sexual health, one indirectly recognizes the individual right to sexual health and to sexuality. However the public health system, confined by political and religious considerations, cannot assume this secular founding morals of the condom. It is, therefore, satisfied with adopting the condom as a technique devoid of sense and culture. Indeed, it can only recommend it as a tool without values because it is in a weak position in relation to the religious power. The sexual health policy is supposed to be “islamically correct” whatever the political orientation of the ministry of health and of the government.  In Morocco, any political force could be non Moslem. Let's recall here that the Moroccan Islamic State’s reaction was unfavorable to chapters 4 and 7 of the program of action of the ICPD[2] at Cairo in 1994. For Moroccan officials, all notions relating to sexuality and sexual health must be dealt with in conformity with a principle believed to be immutable in the Islamic law (the Shari’a which is also conceived as indisputable), the subordination of sex to marriage and to the heterosexuality. No right to sexual activity outside heterosexual marriage is islamically recognized. Consequently, there is an official silence on sexual pleasure in itself. For the health decision-makers, the most important function of the condom is to maintain a low prevalence of HIV infection. In doing so, the ministry of health seems to ignore that the recognition of the right to sex is a major condition to individual and collective sexual health. Such ethics is not assumed by public decision-makers of public sexual health who are mainly concerned with reaching a "religious" agreement on public sexual health programs. This goal is not difficult to achieve given the lack of a fundamental secular conviction  among the majority of public decision-makers and of physicians in the public sector (Dialmy 2002). Those in nursing define medicine as a set of techniques that do not carry universal human values. This reduction of medicine to a technique leads some physicians to claim its moralization in the sense of its Islamization. Consequently, a sexuality that is supposed to be correctly regulated by Islam has also to be treated by an Islamized medicine and public health.

As one sees it, the adopted logic of prevention does not refer to an individual judged free and responsible to himself, but to a subject of God (or of the King, the commander of believers) who must remain Moslem and must respect the Moslem sexual morals.

 

II-4 A necessary struggle against structural vulnerability

 

“Where overall social and economic conditions are poor, there is a greater chance of HIV spreading” (Jenkins and Robalino 2003: 42). That is the case in Morocco where the poverty level is increasing, developing to 19% in 1998/1999. The World Bank estimates that 10 million Moroccans live below the threshold of poverty. According to the national figures, Morocco had 5.3 million poor people between 1992 and 1999. In effect, out of five Moroccans one is poor. Poverty is more common among women, children (most of whom are engaged in trading or are living in street), the illiterate and the rural inhabitants. Rural Moroccans are worse off, representing 60% of all the poor. “This situation resulted in high levels of internal migration, with increasing numbers of young men and women searching for jobs in urban areas. While the national unemployment rate is 22 percent, the rate is 35.5 percent among youths 15 to 24 years old” (Jenkins and Robalino 2003: 43).

Measures of larger social and economic factors, such as the Human Development Index, literacy rates by gender, unemployment, expenditures on health and, as a measure of women’s health, maternal mortality, give an indication of the relative state of development in a country. In Morocco, the Human Development Index is 126. Some indicators of Development are as follows: Male literacy  (62 %), Female literacy (34 %), Unemployment (22%), GDP spent on health (3,6%), Maternal mortality (230)[3], Urban (52%). These structural factors, besides a poor and dysfunctional health care system (inadequate STIs treatment) increase overall vulnerability in Morocco.

These structural factors lead to a practical tolerance of sexual liberalism that could be observed in spite of the existence of repressive laws, which forbid all shapes of non-marital relation. Sexual liberalism is observable in the impunity of urban sexual harassment and in the rise of male and female prostitution. Indeed, the field of sexuality knows a fast evolution characterized by the emergence of anarchical sexual behaviors and practices. In a context of economical precariousness, these anarchical sexual behaviors are not informed nor chosen, they are undergone in a way that increases the HIV risk.



[1] But in societies where Islam isn’t the state religion like in the countries of Europe, Moslem jurists consent to legitimize the use of condom to preserve public health. It provides proof that it is possible to create new laws ( ijtihad ) even where laws and texts exist already. That is to say that the question becomes political when Islam is the main source of legitimization of the political power.

[2] ICPD : International Conference on Population and Development.

[3] 227 according to the last declarations of the Moroccan Ministry of Health in 2004.

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