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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.

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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. 

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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.

Repost 0
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.

Repost 0
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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11 juin 2009 4 11 /06 /juin /2009 11:18

HIV, AIDS and THE PUBLIC HEALTH SECTOR IN MOROCCO (1)

 

                                                                                                                 Prof. Dr. Abdessamad Dialmy

University of Rabat, Morocco

 

 

Abstract

 

This paper deals with the AIDS epidemic in Morocco, the institutional response to that epidemic and its limits. It divides in three sections.

The first section tries to describe the AIDS epidemic in Morocco (evolution and distribution) and to expose the responses to this epidemic while presenting institutions and NGOs that manage it, their plans and programs, their financing and their performances. The official data indicate a low prevalence (less than 1%) but the impact of HIV on the development of the health sector, both institutional and associative, is remarkable. A good cooperation exists between institutions and thematic NGOs in the management of the epidemic. This cooperation was a critical factor in its acceptance by the Global Fund of the Morocco’s proposition for supporting the implementation of the National Strategic Plan. 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.

The second section deals with the question of the prevention through three indicators, the IEC campaigns, HIV testing and the use of condoms. It presents some aspects of the IEC national campaigns and especially analyzes the popular reticence and resistance toward HIV test and the use of condom. It concludes by a brief overview on the structural vulnerability in Morocco. The question that arises in this section is how can we measure the impact of the social communication campaigns on the social representations of HIV/AIDS, on the attitude toward HIV test and toward the use of condom. The condom is still an object of multidimensional resistance. It is not only condemned by popular opinion and traditional jurist, but also to some extent by the official health system itself.

The third section treats the question of the management of Sexually Transmitted Infections’ patients and people living with HIV. This question has a double dimension, the first is the access to care and medicines; the second is the psychosocial accompaniment of patients. STIs are not completely taken in charge. This situation is due to three factors: the cultural resistance of population to seek care for STIs, the insufficiency of the sanitary structure and the unacceptability of care in the public sector, the insufficiency of the medical insurance and the financial inaccessibility of the private sector. Regarding AIDS patients requiring trio-therapy, they have access to it since February 2003 thanks to the grant of the Global Fund. 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. As for the psychosocial management of persons living with HIV, it is mainly assured by NGOs. The zones of the NGOs constitute the only place where HIV+ and AIDS patients express themselves freely without fear of dismissal.

The paper concludes by some recommendations. The main one is that 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. This struggle is necessary because of the sexual disempowerment of individuals effects the spread of HIV/AIDS. Finally, one could fear that the transition to curative measures, thanks to the Global Fund, risks bringing the social representation of HIV/AIDS in the paradigm of chronicity. The result could be a neglect of the prevention and its definition mainly as the socioeconomic invulnerability of the individual, as his/her responsibility and as his/her liberty of choice.

 

 

Keywords : cares, communication, HIV-AIDS, institution, management, medicines, NGOs, prevention, program, vulnerability.

 

Introduction

 

In Morocco, HIV and AIDS constitute a national curse that impact the health sector, which begins to develop and organize itself  within institutions and programs that aim to promote sexual health, especially understood as prevention and treatment of HIV/AIDS. But as Information, Education and Communication (IEC) with HIV risky groups like prostitutes and homosexuals cannot be an official and public objective of the public policy in a Moslem country, the involvement of civil society became necessary and unavoidable. Indeed, from the beginning of the epidemic, some national NGOs were created to help in managing the HIV/AIDS epidemic and especially in dealing with the non recognized risky groups. The impact of HIV-AIDS is clear: at least, it led to the creation of new policies and programs within the current health institutions but it also showed the limits of those institutions, the necessity to involve other arms of government, and to create new thematic NGOs.

The definition of a public sexual health policy in Morocco, a young democracy with an old Islamic tradition that opens up progressively on human rights, is not a comfortable task. This health policy, necessarily multi-sectorial, resembles the Moroccan politics and oscillates between modernity and tradition, freedom and repression, God’s rights and human rights. Indeed, the set up of the policy tries to combine between persuasion through IEC and the defense of individual liberties on one hand, with the repression of non marital sexuality, prostitution, homosexuality, forced HIV test of at-risk groups on the other hand.

In the political unconscious, a correlation is established between AIDS epidemic and the so-called risky or vulnerable groups and between these groups and the poor milieu. Even epidemiological data do not systematically support this correlation. Without the intervention of NGOs, the correlation AIDS/poor milieu, besides the fragility of the young democratic experience, would lead to a repressive and coercive management of the epidemic. The collective action of NGOs is the main channel through which the paradigm of citizenship and human rights of the sick is heard. Further, those NGOs at least participate in the elaboration of the public sexual health policy. It is thanks to their pressure that AIDS became, in spite of its weak prevalence, one of the priorities of the Ministry of Health. Some public tasks are reserved for them: preventive advertisement, HIV testing, counseling through the national listening telephonic line, research funding, distribution of medicines and condoms. Thus, “the public powers consecrated the status occupied by the movement for struggle against AIDS in the implementation of a struggle policy against the epidemic” (Thiaudière 2002: 39).

This paper divides in three sections. The first tries to describe the AIDS epidemic in Morocco (evolution and distribution) and to expose the responses to this epidemic while presenting institutions and NGOs that manage it, their plans and programs, their financings and their performances. The second section deals with the question of the prevention through three indicators, the IEC campaigns, HIV testing, the use of condoms to conclude on the necessity to fight the structural vulnerability. The third section treats the question of the management of Sexually Transmitted Infections’ (STI) patients and people living with HIV. This question has a double dimension, the first is the access to care and medicines; the second is the psychosocial accompaniment.

 

I-AIDS Epidemic, Institutions, NGOs, and Programs  
 
What is the AIDS prevalence in Morocco? How did the epidemic evolve? Which groups are most affected? How was AIDS institutionally managed from the beginning of the epidemic? What is the identity of the thematic NGOs and what role have they played in the management of AIDS epidemic? These are the questions that will be addressed in this section.
 
I-1 A Low Prevalence

 

What is the epidemiological situation of AIDS in Morocco? The answer to this question cannot be completely exact because the quantification of the epidemic is difficult for two reasons: the first is the insufficiency of the anonymous and free HIV test centers and the second is the immoral (illegal), and therefore difficult to quantify, character of some modes of transmission. For instance, the homosexual mode leads to a differential and more serious social condemnation[1]. These two reasons mean that HIV and AIDS cases are not all diagnosed. However, the ministry of health (Ministry of Health 2001a) states that from 1986 (when the diagnosis of the first case of AIDS in Morocco was made) until 30 June 2001, 879 accumulated cases of AIDS were counted. These cases are mainly correlated with males (65%), 20-39 aged (44%), bachelors (39%), urban (88.5%) and heterosexuals (68%).

A year and half later, 234 cases were recorded bringing the number to 1113 by December 31, 2002. Six months later, there were 1237 AIDS cases, making it an increase of 16.7%, a striking development when compared with the rate of the spread in 2002. The transmission mode predominating stays the sexual transmission in 82% of cases (73% heterosexual and 9% homosexual). In 2003, the prevalence is 0.09% for STD patients, 0.12% for pregnant women, 0.5% for patients with tuberculosis, and 0.02% for blood donors.

In June 2004, the number of cases reached 1442, out of which 62% were males. 84% of these cases were concentrated in the cities. The age distribution was as the follows: 2% for those under 15 years, 25% for those between 15 and 29 years, 44% for those 30 to 39, and 12% for those 40 to 49 years. 75% of the patients were heterosexuals, 5% were homosexuals, 4% were bisexuals, 1% was contaminated through blood transfusion, 2% from intravenous drug injection, and 3% were perinatal cases (mother-child transmission). Six months later, being December 2004, 1587 of accumulated cases were recorded.

In 2004, the system of surveillance was extended to embrace sexual workers and prisoners. The prevalence is 2.27% among sexual workers and 0.83% among prisoners. 0.13% were pregnant women and 0.23% were STD patients.

The first years of testing (1986-1990) found most positive results among foreigners, returning citizens, or those infected through blood or blood products. Now the patterns are shifting and a rising proportion of cases are resulting from sexual transmission, especially through heterosexual contacts. The rate of infection among women exploded veritably, increasing from 8% in 1988 to 38% in 2001. Transmission among Intra-venous Drug Users (UDIs) is more common at Tangier while homosexuality remains the transmission mode dominating at Marrakech.

At the level of HIV+, the last official data suggests that their number oscillates between 15 000 and 30 000 people.

These data indicate a low prevalence. Indeed, “the AIDS epidemic has yet to impact Morocco in the same manner that AIDS has devastated neighboring sub-Saharan countries” (Schuette 2003). Does this low prevalence of AIDS explain itself by supposedly Moroccan immunological and constitutional specificity? Does it refer to the hypothesis that male circumcision is a factor of reduction of the HIV infection[2]? Does it refer only to a under-declaration, especially in the private sector? Indeed, most the declared cases are by physicians of the public sector and very few physicians of the liberal sector declare their patients. What is paradoxical in a country where more of the half of the population seek medical cares in the liberal sector. In addition to these hypotheses, the difficulty of access to taking a HIV test because of its non-availability in all regions explains certainly the under-diagnosis. Besides, only the AIDS cases are obliged to be declared. The declaration of seropositivity is not obligatory.

The weakness of AIDS prevalence in Morocco is definitely amazing because factors of HIV propagation are very present and varied enough. These factors are mainly reflected in: the wide prevalence of STIs, the growing sex work industry, drug use, sexual exploitation, the paucity of the use of prophylactics, multi-partnership, homosexuality, precarious economic conditions, periodical return of Moroccan workers (in Europe), wild urbanization, international exchange and tourism (largely sexual), subordinate feminine condition.

Furthermore, the low prevalence can be ascribed to either the lack of official recognition of the real numbers for national considerations (the national honour) or to religious considerations (the denial of the existence of AIDS in Moslem Morocco) or to economic considerations (not to scare off the tourist).  But, some Moroccan medical authorities affirm that the official low prevalence is true. They relate the low spread of the pandemic to the distinction between two types of HIV: one that spreads essentially through sexual relations and another that spreads through blood, especially among IDUs. These medical authorities hold that the type of virus that has spread in Morocco is the type that passes through blood, the fact that explains the low prevalence of infection because the consumption of drugs by syringes is a phenomenon that has not yet reached a level of spread that allows it to become the major mode of transmission.

Despite the low prevalence, Morocco belongs to the second level which “consists of those countries with a gradually growing accumulation of infections and at least some high-risk groups identified” (Jenkins and Robalino 2003: 19). Thus, despite the low prevalence (less than 1%), the impact of HIV on the development of the health sector, institutional and associative, is remarkable.

 

I-2 Institutions and NGOS

 

Between 1987 and 1988 the Ministry of Health created an AIDS program under the Direction of Epidemiology and the Struggle against Diseases (DELM). In 1986, a setting up of a management cell and constitution of a technical committee of struggle against STIs-AIDS was established.

In 1991 a working group was created, including Ministry of Health, USAID, WHO and ACLS (the sole Moroccan thematic NGO at this period).  The group operates under the name: Programme National de Lutte contre le SIDA (PNLS). In this context, some important measures were taken such as: the agreement to sponsor medical costs, the exploitation of blood grants to exercise the serological testing, the setting up of a system of STIs-AIDS notification, the financial support to infected people, the production of information media, and the organization of information campaigns. Another objective of the PNLS was to take free charge of patients and to provide information (on IEC policy), with a focus on more vulnerable populations such as soldiers, migrated workers, prisoners, hotel employees, and drug addicts. 

Between 1991 and 1994, integrated programs of STIs and AIDS were promoted. These programs aimed at the institutionalization of a system of epidemiological STIs-AIDS surveillance. Inaugurating these integrated programs would seem to suggest that surveillance in Morocco has evolved into second-generation surveillance, which precisely includes STIs surveillance and behavioral surveillance. Earlier surveillance recommendations were for serology only. Behavioral surveillance of at-risk groups, constituting the second aspect of the second generation surveillance, seems to be more difficult to launch officially. So this aspect of surveillance will be delegated to national NGOs like ALCS[3] and OPALS-Maroc[4].

Moroccan Association of Struggle Against AIDS (ALCS) is the first thematic NGO founded in 1988 when only 30 AIDS cases were recorded. It was recognized as a public utility in 1993. It has initiated some laudable efforts aimed at bringing the attention of Moroccan populations to the problem of AIDS through radio, the press, and through conferences. It undertook a sensitization campaign that targeted secondary school students and produced audio and visual cassettes with messages on AIDS to female prostitutes (UNFPA 1997: 32). The ALCS aims, in particular, targets not recognized by the public authorities such as prostitutes and homosexuals. In 1990, it had enlightenment projects addressed to homosexuals in Casablanca and Rabat (Imane 1994 : 1). But, the absence of a gay community that assumes itself and that is self coordinating made the task more difficult. Consequently, ALCS dealt mainly with male prostitutes because those are the most visible exhibition of homosexuality in Morocco.  For that reason, Morocco appears to be the first country in the region to have developed HIV prevention programs for male sex workers. Also, in the 1990s, ALCS created centers for anonymous free testing in Agadir, Casablanca, Meknes, Rabat and Tangier. By mid June 2005, ALCS had established 16 stations in the national territory.

OPALS-Maroc is another important thematic NGO. It was created in 1994 with the mission of contributing to the improvement of the access to care for vulnerable persons. It has 14 stations (Tetouan, Tangier, Fez, Marrakech, Casablanca, Settat, El Kalaa, Taza, Beni Mellal, Azrou, Essaouira, Khenifra, Agadir, Laayoune). Its national bureau is based at Rabat. In partnership with the ministry of health, Opal-Morocco created 14 Centers of Ambulatory Treatment (CTA) in 14 cities. The CTA has a light structure that offers a whole range of services like consultation, counseling, HIV testing and prevention, treatment of STIs, management of people living with HIV, psychosocial support, treatment of opportunistic diseases, and the accompaniment of patients to hospitals.

The involvement of the civil society is crucial. Indeed, it is thanks to the work of various associations that the struggle against AIDS is one of the priorities of the Ministry of Health. However, those associations do not constitute a philanthropic movement because of the fact that being infected with HIV, stigmatized as a deviant, do not predispose infection with HIV to be an object of charity. Therefore, it is necessary to define these associations first as mediators between the institution (Ministry of HealthDELM/PNLS) and patients, then as of under-administrators of the HIV epidemic, thanks to their implication in the prevention and cares. Their main stake is to be recognized by the institution as the spokesperson of victims of HIV. Thus, there is no confrontation between NGOs and sanitary and political authorities in the measure where associations respect the red lines drawn by these authorities: the defense of people living with HIV does not lead the NGOs to the defense of premarital sexuality, prostitution and homosexuality.

These NGOs are solely thematic in the sense that they are concerned with the AIDS theme in general. No NGO constitutes itself by addressing the needs of infected people of a precise type, example, the transfused, or drug users, or homosexuals, or prostitutes. No NGO is specialized in the management of a precise group of HIV+ or AIDS patients. So they do not defend or represent a particular stigmatized group concerned with HIV-AIDS; for instance, sex workers, MSM (Men having Sex with Men), or UDIs. Each of the NGOs tends to represent the maximum number of seropositive and sick persons. The Moroccan NGOs in the struggle against AIDS differ between them only by the degree of their dynamism. Consequently, the strength of the NGOs comes from the fact that they have not been founded by people living with HIV. These people are absent from the social scene and from the political field: they are invisible.

The strength of these thematic NGOs is also determined by their proximity to the political power. Indeed, the Moroccan NGOs are generally “tools of integration, through the elitization of new strengths of change, in the circuits of the state" (Al Ouazzani 1987). In other words, the association provides another way of doing politics; that is, another way of gaining a pseudo-political status and influence thanks to the struggle against AIDS. The advantage of this strategy is that “normal” and healthy people can be involved in the struggle against AIDS. Further, a part of the elite can be involved and is effectively involved. This fact also explains why there is a remarkable cooperation between DELM/PNLS and civil society. 

 

I-3 PSN, Global Fund, Moroccan Committee of Coordination

 

In 2001, a Strategic National Plan of Struggle Against AIDS (PSN) was adopted (Ministry of Health 2001b). This plan is based on two major axes which are the prevention of HIV and the treatment of STIs  patients and Persons living with HIV (at all the phases).

The set up of this plan necessitated a co-ordination between the health department, other governmental departments, UN agencies, and NGOs. Initially, all these institutions worked together in setting up the thematic group ONUSIDA. Later, in February 2002, the Moroccan Coordination Committee (CCM) was created from the thematic group ONUSIDA for the purpose of fulfilling the requirements of the Global Fund. Morocco’s proposition for supporting the implementation of the National Strategic Plan (PSN) was the only one approved in the MENA region in June 2002. The acceptance of the Moroccan proposition is the result of a good dialogue between the PNLS, NGOs and other ministries in the struggle against AIDS. The acceptance of the national proposal means also the institutional strengthening of CCM.

The initial composition of the CCM was constituted from a hard core represented by the thematic group ONUSIDA that has been functioning actively since 1999. This thematic group includes representatives of the PNLS, thematic NGOs, the UN system and other international partners. Since the signing of the proposition of the support program for the struggle against AIDS, the CCM has been widened in order to incorporate new partners from the private sector and some governmental departments like education, youth, and Islamic affairs.

The CCM is composed of 7 beneficiary members of the Global Fund. The Ministry of Health (DELM/PNLS) is the main beneficiary. ALCS AMJCS[5], AMSED[6], LM-LMST[7], OPALS-Maroc and the Secretariat of state for Youth are the under-beneficiaries. Among the other ministerial departments represented in the CCM[8] was the Ministry of National Education. This led to the creation of several health clubs in schools that give also some notions of sexual education. The incorporation of the Ministry of the Islamic Affairs is fundamental in islamically legitimizing all PSN actions, especially the promotion of the condom. Let's recall here the critics of some fundamentalist who are against the promotion of the condom by the Ministry of Health and who accuse ALCS to be a Zionist organization.

A unit to manage the program of support of the World Fund was created to serve as the secretariat of the CCM. This unit guarantees the diffusion of information among members of the CCM for follow-ups and for the implementation of the program. It also prepares the quarterly meetings of the CCM, elaborates on minutes and ascertains their diffusion by different means of communication (email, fax, and postal mail).

In order to deepen some domains, under-committees emanated from the CCM during quarterly meetings. These under-committees meet according to needs and periods for several times per month. They present a synthesis of their reflections for validation at the time of the CCM’s meetings. The 3 under-committees constituted up to now are:

- “Under-committee on information, education and communication”: This under-committee deals with the validation of the educational support, which is produced during the setting up of the support program. Its main task for 2004 was the follow-up of the implementation of the national campaign on social communication.

- “Under-committee of follow-up and evaluation”: Its main task is the implementation of the plan and the follow-up of different associated activities. This committee works at present on the production of an adequate system of information. The goal is to produce reliable and qualitative data for the appreciation of indicators of the program while adopting the information on the Countries Ripostes for Information System (CRIS) of the ONUSIDA. The setting up of a system of supervision of the field activities was also among the terms of reference of this work group for 2004.

- “Under-committee of taking charge”: This under-committee deals with the planning of needs in medicines, the setting up of strategies for distribution and management of stocks, and the coordination of the different services under its control.

The support of the Global Fund to the setting up of PSN aims to contribute to the control of the HIV/AIDS infection in its two main components: the prevention of the HIV infection and the reduction of the impact of the HIV/AIDS on infected people and their family. The general objectives of the program are:

 

1) the reduction of the vulnerability of groups more exposed to HIV/AIDS in the important intervention regions.

 

2) the implementation of a social communication program to the profit of youngsters and women.

 

3) the diagnosis and the control of people living with the HIV.

 

The first two objectives are concerned with the setting up of the first component of the support program, while the third objective works on reducing the impact on people living with HIV.

The first component has three subdivisions: supporting projects for the reduction of vulnerability to HIV, supporting the implementation of a social communication program, supporting the reinforcement of counseling and voluntary HIV test.

Support for projects on reduction of vulnerability is confided exclusively to the ALCS. These projects touch risky and vulnerable groups, that is to say sex workers, men having sex with men, and female workers of the agro-food sector. Support for the implementation of a social communication program is entrusted to multiple actors. The ministry of health is charged with the national campaign of social communication and the access to condoms. The LM-LMST is charged with producing a theater piece on AIDS. The sensitization campaign in youth clubs in rural areas is entrusted to the Secretariat of State for Youth. Women and illiterate girls are the concern of the AMSED. The AMJCS keeps its specialty, that is to say the mobile kiosks of information. Finally, the reduction of vulnerability in women and girls as well as HIV/AIDS’ education through the computer are confided to OPALS Maroc.

The support for the reinforcement of the counseling and of the voluntary HIV test is also sub-divided into three tasks :

 

1) the equipment of counseling centers and HIV test, confided to the ALCS, OPALS and the LM-LMST

 

2) the mobile unit of prevention and diagnosis of HIV, confided to ALCS

 

3) the equipment of the provincial laboratories of the Health Ministry for the realization of diagnosis tests, confided to the National Institute of Hygiene (INH).

 

The second component, the reduction of the impact on people living with the HIV, is subdivided in two major actions: access to the Anti-Retro-Viral medicines (ARV) and biological follow-up of patients.



[1] Thus, there exists a discriminative distinction between good and bad sicknesses. The first are represented by the accidentally contaminated people as hemophiliacs, transfused and newborns. These are considered as innocent victims and are treated with less contempt. The second, that owe their status to their deviant conducts (homosexuality, drug use, prostitution) are strongly condemned and rejected. In the same way, HIV+ women are stigmatized more violently than men because they are accused of having illegal sex, something not permitted to women in under patriarchal logic, which is still extensively dominant.

[2] « How to explain the reduction of the HIV transmission bound to the circumcision? For the momznt, the different hypotheses notably imply a thickening (keratinization ") of the acorn’s skin at the circumcised man, that would give back it less permeable to the HIV, and the fact that the foreskin, deleted by the circumcision, rich in cells called " Langerhans ", that possesses many receptors for the HIV. But, nothing is yet sure », Le Monde, September 5, 2005.               

(http://www.lemonde.fr/web/article/0,1-0@2-3244,36-685842@51-628865,0.html).

[3] ALCS : Association Marocaine de Lutte contre le Sida.

[4] OPALS-Maroc : Organisation Panafricaine de Lutte contre le Sida.

[5] AMJCS : Association Marocaine des Jeunes contre le Sida.

[6] AMSED : Association Marocaine de Solidarité et de Développement.

[7] LM-LMST : Ligue Marocaine de Lutte contre les Maladies Sexuellement Transmissibles.

[8] Other members are : 1) Other associations: Association Marocaine de la Planification Familiale, Croissant Rouge Marocain, 2) Organisms of Private Sector :  Conseil National de l’Ordre des Médecins , Confédération Générale des Entreprises Marocaines, Association Marocaine des Industries Pharmaceutiques, 3) UN Agencies : WHO, UNPD, UNFPA, UNICEF, ONUSIDA, UNFEM, FAO, 4) Bilateral and Multilateral : Belgium, Deuschland , European Union.

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8 juin 2009 1 08 /06 /juin /2009 18:03

نشرت جريدة المساء المغربية (عدد 843، 6-7 يونيو 2009) فتوى تجيز شرعا العادة السرية ووطء الجماد بالنسبة لغير المتزوجين، وصاحب هذه الفتوى هو الفقيه عبد الباري الزمزمي. وهذا نص الفتوى:

 

" نعم يمكن استعمال بعض هذه الوسائل والأدوات من طرف المرأة كما الرجل، ممن تعذر عليهم الزواج، ويعتبر ذلك خيرا لهم من اللجوء إلى الزنا، أي يمكن استعمال تلك الأدوات تماما كما هو اللجوء إلى العادة السرية في انتظار فرصة الزواج، وهو يعتبر خيرا من الإقدام على خطوة الزنا، واليوم توجد في بعض الدول امرأة بلاستيكية بالنسبة للرجل مثلا وأعضاء تناسلية ذكورية يمكن استغلالها من طرف المرأة، لكن فقط في حالة تعذر الزواج...".

 

ليس غرضي في هذه الورقة مناقشة شرعية هذه "الفتوى"، فالفقهاء المالكية حرموا ذلك.  لكن يبدو أن الزمزمي استند في ذلك على الحنابلة الدين سمحوا بالعادة السرية تجنبا للوقوع في الزنا (انظر في هذا الصدد "كشف القناع" و"غاية المنتهى"). وسار الحنفية في نفس الاتجاه تقريبا حين اعتبروا أنها ضرر أخف من الزنا. ما أود قوله شيء آخر ألخصه في نقط ثلاثة.

أولاها أن العادة السرية ووطء الجماد شكلان من أشكال الشذوذ الجنسي. فالشذوذ الجنسي يعني الالتقاء الجنسي الذي لا يمكن أن يؤدي إلى الإخصاب، وهو ما يقع في العادة السرية/الاستمناء (التقاء الفرج الذكري أو الأنثوي مع اليد) أو في وطء الجماد (مثل مجامعة الأصنام، أو مجامعة المرأة البلاستيكية أو الرجل البلاستيكي). وهو ما يقع أيضا عند التقاء الفرج الذكري بإست ذكر.

ثانيها أن إباحة الاستمناء ووطء الجماد تعني أن الفقيه المفتي المذكور أعلاه يتصور الفعل الجنسي كغريزة فردية حيوانية، أحادية الجانب، خالية من كل مشاعر، ولا تحتاج إلى علاقة إنسانية لكي يتم إشباعها بشكل مرض. القول بالاستمناء يعني تعريف الجنس كقذف وإنزال لا غير من أجل القضاء على توتر حيواني.

ثالثها أن الفقيه ينصح الشباب غير المتزوج بتفضيل الشذوذ الجنسي على العلاقة الجنسية السوية بين المرأة والرجل، باعتبار هذه الأخيرة زنا عند انعدام وجود الرابطة الزوجية. السؤال المغيب من طرف الفقيه المفتي هو علة تحريم الزنا. وهو السؤال الذي لا بد من مواجهته.

يذهب الفقهاء إلى أن تحريم الزنا جاء للعلل التالية:

1) "موافقة هذا التحريم للفطرة التي فطر الله الناس عليها، من الغَيْرة على العِرْض". بهذا الصدد، يبين الدرس الأنتربو-السوسيولوجي أن الغيرة على العرض من المفاهيم الأبيسية التي تبرر السيطرة الذكورية وامتلاك الرجال للنساء. اليوم، من الضروري الاعتراف بأن المرأة مواطنة حرة، لا هي متاع للناس، ولا هي متاع لأبيها أو لأخيها أو لزوجها. ومن حقها (كما من حق الرجل) أن تقيم العلاقة الجنسية التي تختارها بحرية قبل الزواج. ويعني الاعتراف بكرامة المرأة أن يعترف لها المجتمع بهذا الحق، وأن ترفع وصاية الرجل عن جنسانيتها.

2) تحريم الزنا يقوم على ضرورة المحافظة على الأسرة. إذا قامت علاقة جنسية مع الغير أثناء الزواج، فمعنى ذلك أن الزواج ليس مُرْضيِا على الصعيدين الجنسي والعاطفي. وهنا لا يكمن الحل في التحريم، وإنما في علاج العلاقة الزوجية أو في الطلاق. لا داعي للمحافظة على أسرة غير مرضية بالإكراه والقمع، خصوصا وأن الشرع يعطي الزوج الحق في أن يتزوج من أخريات (وكان له أيضا الحق، ولا يزال، شرعا، في امتلاك الجواري). من هنا يظهر أن تحريم الزنا آلية في صالح الرجل بالأساس، باعتباره أبا، أخا أو زوجا. واضح أن المرأة غير المتزوجة كانت معرضة للزنا أكثر من الرجل غير المتزوج، إذ كان من حق هذا الأخير أن يمتلك خليلة جارية بشكل شرعي يشبع فيها كل رغباته الجنسية. فالرجل ليس في حاجة إلى زنا مثلما هي المرأة، ومن ثم تشديد تحريم الزنا.

3) تحريم الزنا يحد من انتشار الأمراض الجنسية. ليست العلاقات غير الزوجية هي التي تسبب الأمراض القابلة للانتشار جنسيا. ما يسبب تلك الأمراض هو سوء الظروف الصحية العامة وانعدام التربية الجنسية وضعف الوعي الصحي وتعذر الاستفادة من الخدمات الصحية.

4) "الزنا من أسباب انتشار جرائم القتل وكثرتها، فقد يقتل الزوج زوجته وعشيقها، وقد يقتل الزاني زوج معشوقته أو من ينازعه عليها". صحيح أن الزنا يؤدي إلى القتل في بعض الأحيان، لكن الإحصائيات تبين أن نسبة جرائم القتل الناتجة عن الزنا نسبة ضعيفة جدا. وتبين هذه "العلة" أن الزنا المجرم عمليا هو زنا المرأة (البنت، الأخت، الزوجة). وتشكل الغيرة على العرض السبب الرئيسي في وقوع جريمة القتل الناتجة عن زنا المرأة. وكما أسلفت القول سابقا، علينا أن نعي أن مفهوم الغيرة على العرض من آليات السيطرة الرجالية على المرأة في إطاري القبيلة والعائلة الممتدة، وأنه آن الأوان لتجاوزه باسم حقوق المرأة وباسم المساواة بين المرأة والرجل. 

5) يكمن السبب الرئيسي في تحريم الزنا في منع وقوع الحمل قبل الزواج وفي منع وقوع اختلاط الأنساب بالنسبة للمتزوجين. ونفهم منطق ووجاهة هذه العلة في فترة تاريخية امتدت إلى الخمسينيات من القرن العشرين عجز خلالها الإنسان عن التحكم في خصوبته بشكل مضمون. يظل هذا السبب قائما بالنسبة للمرأة المتزوجة التي تريد الإنجاب، فزناها يمكن بالفعل أن "يدخل ما ليس من صلب الزوج في أسرته وعائلته، فيشارك أفراد الأسرة في الميراث وهو ليس منهم، ويعاملهم معاملة المحارم وهو ليس محرماً لهم". لكن هذا السبب لا يصمد بالنسبة لزنا غير المحصن. اليوم، بفضل وسائل منع حمل طبية فعالة في متناول الجميع، بإمكان شاب وشابة غير متزوجين أن يقيما علاقة جنسية عاطفية متراضية دون خطر حمل غير مرغوب فيه ودون خطر الإصابة بأي مرض.  

إن تهافت العلل الكامنة وراء تحريم الزنا يوجب سقوط تحريم الزنا. ذلك أن"الحكم يدور مع علته وجودا وعدما" وأنه "لا ينكر تغير الأحكام بتغير الأزمان" و"مراعاة الأزمنة والأمكنة والعوائد". كل ذلك يبين أن فقيه اليوم، إذا أردنا الاحتفاظ به كمساهم في وضع القانون، عليه ألا يتصرف في النص انطلاقا من عمومية اللفظ وإنما من خصوصية السبب. فحين يواجه نصا غير ملائم لمتطلبات الصحة الجنسية (وهي الحق في الرفاه الجنسي بغض النظر عن الحالة العائلية)، عليه أن يعمل خصوصية السبب وأن يفتي بجواز العلاقات الجنسية قبل الزوجية نظرا لأنها لم تعد تهدد لا صفاء الأنساب ولا عرضا مرتبطا ببنى اجتماعية (القبيلة والعائلة الممتدة) في طريق الانقراض والتجاوز. إن التشبث بتحريم زنا غير المحصن تشبث بعقلية أبيسية تفقد تدريجيا أسسها الاقتصادية والاجتماعية والإيديولوجية.

ختاما، يجب اعتبار إجازة الاستمناء ووطء الجماد من طرف الزمزمي اجترارا للمذهب الحنبلي الذي انحدرت منه وهابية متشددة. من مزايا هذا الاجترار أنه يذكر أن الإسلام يعترف بضرورة النشاط الجنسي قبل الزواج، ومن ثم بمشروعيته. لكن أن نجعل من الشذوذ الجنسي الحل الجنسي الوحيد لإشباع الرغبة الجنسية قبل الزواج حل لا يخلو من مخاطر على الصحة النفسية وعلى التوازن الاجتماعي، مع العلم أن متوسط سن الزواج الأول ارتفع بشكل ملحوظ. بتعبير آخر، هل نريد للشباب المسلم أن يمارس العادة السرية ما بين سن البلوغ وسن الزواج، أي لفترة تدوم 18 سنة تقريبا؟

 

د. عبد الصمد الديالمي

الرباط، 8 يونيو 2009

 

  

 

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6 juin 2009 6 06 /06 /juin /2009 12:23

 

I conducted the interview with Dr. Abdessamad Dialmy, in the presence of my friend Maria Ezzaouini, a note taker on Monday 11/ 05/ 2009. I made a huge mistake with technology. After 10 minutes of recording, I realized that the Dictaphone was not recording anything. So I had to re-conduct the interview. I was very embarrassed and less confident. Fortunately the interviewee was very understanding and accepted to be re-interviewed. Therefore, I had to restructure and modify the questions to avoid redundancy and boredom. This experience taught me to be more careful the next time.

Nezha Belkachla, Association Démocratique des Femmes du Maroc.
 

 

R: So good morning Si Abdessamad. I’m sorry for the inconvenience. I didn’t record you from the beginning, I have to admit it. That was something stupid from my part, but I would like to ask you again to introduce yourself, and I’m very very sorry.

 

A.D: No problem. I’m professor Abdessamad Dialmy. I’m a sociologist I teached at Fez university for 30 years, now I’m teaching in the university of Rabat, two faculties. I deal with some sensitive themes like sexuality, Islamism, Aids. I published a lot of articles and books in Arabic, French and English. I participated to many collogues and international conferences and I realized a lot of research and expertises for some Moroccan institutions and for international organizations.

 

R: Ok. So…Eh…well… I think that what actually pushed me to interview you is your interest in the domain of prostitution, of sex tourism and of migration of women towards other countries for sexual exploitation, and that’s very interesting for me and for the research because we also want to know the opinions and the experiences of experts and experienced people in Morocco, not only the participants themselves, but rather we want to approach the problem from a different angle, from an angle, perhaps a perception of a researcher; and that’s why I’m here with you, let’s say. Eh…I’m actually conducting this research as a member of ADFM (Association démocratique des femmes du Maroc), and my name is Nezha Belkachla, and I want to conduct this as my first experience with social research; and that I’m supposed to do this research for the Collective of Research and Training for Development-Action, that… in which, I mean, I participated in Beirut, twice, and my third time will be in July when I’m gonna present my research in front of a jury, and so I was interested actually to know how you’re approaching the phenomenon, and my first question to you will be what is your definition of sex tourism? When…you know… when you talk about sex tourism, apart from what we review in the literature, what is your own definition?

 

A.D: le tourisme sexuel, c’est quand une personne du Nord voyage dans un pays du Sud, principalement pour avoir des expériences sexuelles avec d’autres personnes étrangères, étranges, dans leur pays, dans leur environnement. Pourquoi cela ? Pour  plusieurs raisons. Peut être faut-il évoquer d’abord, en premier lieu, des raisons économiques. Quand c’est commercial, quand c’est un rapport sexuel tarifé, il est moins cher au Sud.. Pour un touriste en provenance des Etats-Unis, d’Europe ou bien des riches pays Arabes du Golfe, consommer du sexe en Thaïlande, au Maroc, c’est moins cher, c’est beaucoup moins cher. Il y a cette raison qui est importante, n’est ce pas ? Qu’il faut rappeler, qu’il faut souligner, n’est ce pas ? Et puis il ya aussi une autre raison qui me semble importante… Qui dit sexe, sexualité dit érotisme,  recherche du plaisir, or le plaisir érotique est plus grand quand il est exotique, quand le partenaire est étrange, étranger, différent, cela change, cela excite le désir… c’est consommer un corps autre, un corps différent. Bon voilà au moins deux  raisons qui me semblent importantes et qui expliqueraient pourquoi certains hommes et femmes du nord et des pays riches vont ailleurs vers les pays du sud pour y faire du tourisme sexuel… Donc c’est moins cher quand c’est tarifé, mais aussi parce qu’on marie érotisme et exotisme.

 

R: OK. When we were talking, I mean, a few minutes ago and there’s something, the stuff that was not recorded because of my mistake… Eh you talked about certain aspects of prostitution or of sex tourism in which the customer, not the customer but the, you know, the women that offers herself to that customer… she can do it not particularly for money, but she can do it because she wants to explore a certain difference or perhaps… yah… how can you call this prostitution? Because… I don’t know…I mean…can we… I mean… call person a prostitute between quotes, a worker in sex, when she’s not doing it for money, she’s not selling her body?

 

A.D: Oui là, il faut quand même faire une déconnexion entre tourisme sexuel et prostitution. Ce n’est pas tout le temps lié. Le touriste sexuel ne rencontre pas que les prostitués… Il peut rencontrer les prostitués plus facilement peut être, mais il peut aussi chercher à avoir des relations sexuelles avec des non-prostitué (e) s. Et là il y a aussi une demande interne, chez les autochtones, et chez les hommes, et chez les femmes. Hommes et femmes Marocains par exemple rechercheraient à avoir des rapports sexuels avec le touriste pour des raisons non-commerciales, non-monétaires. L’autre est d’abord un autre. Il est différent, et pour l’autochtone, c’est également de exotisme, un exotisme inversé… Par exemple pour une marocaine, faire l’amour avec un italien ou avec un français, ça la change aussi, et puis faire l’amour avec un européen ou un américain, c’est une autre manière de faire l’amour. L’Européen ou l’Américain, on suppose qu’ils sont plus attentifs au plaisir de la femme ; ils seraient plus soucieux de ses orgasmes, si je puis dire. Par contre, le stéréotype veut que l’homme marocain, et arabe en général, ne se soucie pas du plaisir de la femme. Qu’il s’en soucie moins ou très peu…  Il y a cet aspect des choses aussi… Le touriste serait donc intéressant pour ça aussi… La touriste présente également des avantages, elle aurait moins de blocages, moins de résistances, moins de honte, moins de sentiment de culpabilité… Tout est sexuellement possible avec le touriste.  En plus de cette liberté sexuelle, le/la touriste, paie pas sous forme directe, pas sous forme de salaire, il peut faire des cadeaux, il peut inviter à un voyage, à un dîner; il représente aussi une possibilité d’avoir un visa, de partir ailleurs… Et puis les relations avec le/la touriste peuvent être romantiques et amoureuses et peuvent conduire plus loin, déboucher parfois sur un mariage… Comme on peut rencontrer un/une touriste juste pour passer une nuit d’amour agréable, sans lendemain. En un mot, le tourisme sexuel n’est pas tout le temps corrélé à l’argent, il n’est pas tout le temps corrélé à la prostitution… Mais il reste que l’achat des services sexuels chez les autochtones reste la principale caractéristique qui définit le tourisme sexuel.  Avec le/la touriste, l’autochtone d’un pays musulman arrive à dépasser beaucoup de tabous… par exemple, on se permet plus de choses avec le/la touriste qu’avec un partenaire marocain… on suppose que l’autre,  Européen ou Nord américain,  est plus ouvert… Des positions sexuelles non courantes entre partenaires Marocains sont acceptées, de même pour certaines pratiques sexuelles comme l’amour en groupe, les rapports anaux ou sadomasochistes. Ce sont là des comportements et des pratiques qui ne sont pas encore vraiment admis et intégrés dans la sexualité intra-marocaine, choses que l’on peut vivre et expérimenter avec l’étranger.

 

R: Ok… eh…So now that will lead us perhaps to talk about those workers in sex… when they actually practice sex. Are they… do they have some kind of contract with the nets? … are there any nets? … So do they have any contract with those nets to work only with tourists or they can practice prostitution in general?

 

A.D: En général, un travailleur ou une travailleuse sexuelle ne cible pas spécialement les touristes. Les travailleurs sexuels ne font pas en principe de distinction entre les clients, que le client soit solvable, qu’il paie, c’est le plus important. Mais il est évident que les clients nord- américains, européens  et Arabes du Golfe paient plus et mieux. C’est cela qui pousse à leur donner la priorité, à les préférer. Par définition, il est difficile de dire que les prostituées se réservent à certaines catégorie de clients, basées sur la l’ethnie ou la nationalité… C’est l’argent qui fait ici la différence.

 

R: OK. And when you were talking, I mean, in your article…Eh…there’s an article in which you talked about prostitution that I’ve read lately, and you said that there are many reasons that push women, for example, to go to prostitution,… not only for money, OK…but there are other things like… you know… something that they had in their childhood, for example, That I want to explain more to me.

 

A.D: il y a une théorie générale qui affirme que les prostituées ont été violentées et violées durant l’enfance, mais pour parler en toute franchise, il n’y a aucune marocaine ou sur le Maroc qui infirme ou confirme cette théorie. Cela reste une hypothèse à vérifier dans le contexte marocain.  Il faudrait interroger les prostitués marocaines et marocains pour voir si effectivement il y a eu violence sexuelle subie durant l’enfance. Cela étant, il faut signaler qu’au Maroc, il y a des enfants qui se prostituent avec les touristes. Même si cela la pédophilie prostitutionnelle est plus sévèrement punie par la loi, les touristes se permettent ces abus dans les pays du Sud. Tant que cela ne débouche pas sur un scandale public, les autorités ferment les yeux.  Les familles elles-mêmes sont complices, eu égard à la pauvreté, à la misère. Ces familles sont prêtes à tout.  Quand la fille issue d’un milieu pauvre est déflorée, il ne lui reste plus rien comme autre capital. Du coup, elle perd tout espoir de trouver un mari, elle est dévalorisée et s’auto-dévalorise. Elle tombe alors facilement dans la prostitution parce qu’elle n’a plus rien à perdre. Par contre, une jeune fille ayant d’autres capitaux comme le diplôme, le salaire, la bonne famille, ne risque pas vraiment de tomber mécaniquement dans la prostitution à la suite d’une défloration. Et puis n’oublions pas le facteur politique dans les pays où il y a le tourisme sexuel, là, les administrations sont complices… Le travail sexuel avec les touristes permet de faire rentrer des devises, de « résoudre » le chômage des jeunes. Ça permet à ceux-ci de se prendre en charge, voire de prendre une famille en charge. L’Etat se désengage et laisse les jeunes libres de gagner leur vie de cette manière. En un mot, L’Etat laisse faire parce que ça l’arrange aussi… Malgré les lois, malgré la répression judiciaire qui est ponctuelle et ciblée, les familles en profitent, les hôtels en profitent, les taxis en profitent, les boites de nuit en profitent, certaines régions, certaines villes en profitent. Tout cela fait que l’administration est obligée de fermer les yeux. Elle en profite aussi. Certaines administrations en profitent car elles-mêmes gèrent indirectement le champ prostitutionnel et y prélèvent des « impôts ». Pour résumer, le tourisme sexuel exploite principalement la vulnérabilité économique des pays du Sud, en de certains facteurs culturels. Le facteur politique réside dans le réalisme de l’Etat. Mais il faut reconnaître également que les Etats sont parfois eux-mêmes dépassées. La prostitution que consomme le touriste sexuel relève parfois du crime organisé par des réseaux transnationaux.  La traite et le trafic des femmes et des enfants sont les moyens les plus empruntés par ces maffias pour alimenter le marché de la prostitution. Femmes et enfants sont parfois achetés, parfois enlevés  puis introduits de force dans le circuit prostitutionnel. Aussi les Etats sont-ils appelés à lutter, à avoir des stratégies nationales pour contrecarrer la traite des femmes et des enfants. Certains fonctionnaires sont corrompus et s’impliquent pour faire échouer les stratégies nationales. Cependant, il y a des états et des pays, comme la Thaïlande, qui organisent officiellement et publiquement le tourisme sexuel. Au Maroc, on ne peut pas dire que l’Etat organise et accepte le tourisme sexuel. En pratique, il y a un laisser aller, un laisser faire, ce qui fait que le tourisme sexuel est plus au moins toléré, plus au moins accepté. Par exemple, quand il y a arrestation d’une prostitué marocaine avec un touriste européen ou arabe, seule la prostituée est poursuivie par la justice même la loi impose d’incriminer le client également. Celui-ci est seulement refoulé… Donc deux poids deux mesures, et cela encourage de manière implicite mais objective les touristes sexuels.

 

R: Ok… So…Eh… now…I think… Eh…sex tourism has always existed… you know since the 30s and the 40s…why this focus now and what has made it increase?

 

A. D: Je ne pense pas qu’il ait existé de manière aussi structurelle, non c’est quelque chose qui a vraiment émergé à partir des années 1980 suite aux politiques de l’ajustement structurel. L’Etat n’est plus là pour assurer l’emploi, la santé, l’éducation, le logement. Les gens sont livrés à eux même, les gens sont lâchés dans un marché néolibéral qui englobe le sexe aussi…Le sexe devient à son tour une marchandise dans les pays du Sud. Les corps des femmes et des enfants du Sud sont consommés sur place par le touriste ou exportés au Nord. Le tourisme sexuel participe davantage de la victoire de l’économie néolibérale, d’un rapport de force inégal entre le Nord et le Sud.

 

R: Eh… we were talking about… Eh… now we can talk about the workers in sex, and so… I mean… according to your experience as a researcher. Eh…this position as a worker in sex…Eh…we know that…Eh… they’re doing it for money, as you stated before, and for other reasons; but does it make a difference? How does it make a difference in their social and economic status? I mean concretely…Do they have higher ranks socially or economically?

 

A.D: Oui dans la mesure où ça se fait d’une manière plus discrète, dans des endroits qui sont plus luxueux, plus secrets, plus réservés; et puis les familles sont parfois complices, les familles savent… cela rappelle la distinction entre une prostitution de rue (condamnée, pourchassée, méprisée, emprisonnée, maltraitée), une prostitution de classes moyennes visibles dans certaines discothèques, dans des cafés, avec un statut et une image meilleurs… et une prostitution de luxe, invisible, secrète, avec des circuits spéciaux. Je pense que le touriste sexuel Européen profite principalement de la prostitution « moyenne » tandis que le touriste du Golfe Arabe est plutôt le moteur et le promoteur d’une prostitution de haut standing. Et c’est pour cela que les prostitués qui vont avec les touristes sont moins inquiétées. Ça se fait de façon plus discrète, avec des partenaires plus côtés si je puis dire… et du coup cela  retentit positivement sur leur image. La famille serait là plus acceptante, eu égard justement à cette différence de statut… plus le client est élevé, plus cela améliore l’image du travailleur sexuel.

 

R: And how do you think they feel about their status? How do they feel about this?

 

A.D: Bon, là il y’aurait à mon avis moins de culpabilité, moins de honte… quand la famille est complice, quand ça rapporte plus, quand ça se fait de manière discrète, quand c’est fait de manière choisie, il y a un sentiment de culpabilité qui est moindre, il y a moins de honte, et cela donne une image de soi qui n’est pas très mauvaise finalement. C’est quand la famille ne sait pas, quand elle condamne, quand elle est dure, quand elle réprime, quand la personne elle-même est s’auto-humilie que l’image de soi est négative.  C’est la prostituée de rue qui arrive à peine à se nourrir qui se sent le plus mal. Et pourtant, c’est elle qui endure le plus, c’est elle qui n’a vraiment pas d’autre choix. Surtout quand elle a un ou deux enfants à nourrir, à élever, seule. Plus on s’élève dans la hiérarchie sociale, plus il y a le choix, plus l’image de soi de la prostituée est positive. Les prostituées high standing s’habillent bien, vont au restaurant, achètent tout le monde, cela influence leur vécu, positivé, elles auraient même un sentiment de pouvoir. De plus en plus, des jeunes filles marocaines préfèrent avoir un tel mode de vie, c'est-à-dire sortir avec plusieurs partenaires étrangers ou bien placés, profiter de la vie, avoir de l’argent, elles préfèrent tout cela au fait d’être mariée avec un marocain fauché ou qui arrive à peine à vivre et à les faire vivre.

 

R: OK, and… I mean just from your experience…Eh…as a researcher…I mean how do some of these participants feel…I mean when they are with customers, you know? I mean do they that they are humiliated…that they’re respected? How do the customers treat them?  

 

A.D; Cela dépend des clients. Il y a des clients qui sont compréhensifs, qui comprennent pourquoi la jeune femme ou le jeune homme a recours à la prostitution… Là le rapport peut être respectueux…c’est justement le cas du touriste sexuel. Pour celui-ci, pour l’Européen surtout, la prostituée est une travailleuse qui vend des services sexuels. Elle n’est pas perçue comme débauchée ou perverse, et cela réduit  la dépréciation et le mépris. Quand cette conscience citoyenne n’est pas là, c’est bien sûr c’est le mépris, la violence, l’insulte verbale. Donc, on ne peut pas généraliser… Le client traite la prostituée en fonction de son propre niveau socio-économique et intellectuel. Plus ce niveau est élevé, plus il y a de compréhension.

 

R: And when you started talking about sex tourism and linking it with the project that was actually designed by the government to promote tourism in Morocco, so what is the link between this project and the escalation of sex tourism in Morocco?

 

A.D: C’est ce qu’on a dit effectivement tout à l’heure. Bien sûr il y a mondialisation et libéralisation. C'est-à-dire qu’on on fait du tourisme une activité principale dans l’économie du pays. Qui dit encouragement du tourisme dit encouragement des loisirs et des plaisirs, aussi faut-il produire une main d’œuvre sexuelle qui va accompagner la demande touristique. Le tourisme, c’est des loisirs, c’est du service, c’est de l’accueil, c’est du sauna, du massage, c’est de la sexualité directe. Sun, sand, sea and sex, les quatre s, c’est connu, et tout ce qui va avec. Le touriste qui vient pour les monuments, il va trouver les monuments, le touriste qui vient pour la religion, il va trouver de la religion dans les santuaires ou les moussems (festivals), et le touriste qui vient pour le sexe doit trouver une offre sexuelle à sa disposition, à la disposition de son pouvoir d’achat.

 

R: Eh…And when we were talking about categories of people that work in sex, and you talked about kids, you talked about women, you talked about young girls. You said that there are no actually studies that can show sometimes the amount of people or the number of people that work in sex. Can you just tell us perhaps what category of people is more recruited, for example, kids, young girls, women, certain ages?

 

A.D: Ce sont surtout les jeunes filles. Elles constituent à mon sens la partie statistiquement la plus importante de la main d’œuvre sexuelle. Il y a également des enfants des deux sexes. Et une partie constituée de jeunes hommes, pour des services hétérosexuels et/ou homosexuels à l’adresse des touristes, selon la demande. L’âge varierait grosse modo entre 15-16 ans et 30 ans. La majorité des travailleurs sexuels, hommes et femmes, sont recrutées principalement dans les milieux défavorisés… je dis principalement parce que le facteur économique est déterminant. Les travailleurs sexuels potentiels sont des personnes économiquement vulnérables, appartenant à des familles elles même vulnérables.

 

So…Eh…so how can girls and women…I think that we talked about their financial problems a few minutes ago…Eh… I want to talk now about their experiences in general. You talked about their social status, their economic change…how they make them feel, but their experiences in general…Have any of the participants talked about this? I mean about how they feel in their experiences?

 

A.D: De manière générale, c’est la honte, c’est le sentiment de culpabilité, mais comme je l’ai dit tout à l’heure, de plus en plus, il y en a qui vous disent que c’est un mode de vie préférable à un mode de vie petit-bourgeois, établi, dans le cadre d’un mariage misérable, dans une famille misérable… Donc, grosso modo, eu égard à la religion, eu égard à la loi et aux traditions, c’est le stigma, c’est  la honte, mais de plus en plus, de nouvelles valeurs qui émergent, basées sur l’argent, la réussite, ou tout simplement la légitime défense contre des conditions sociales pénibles, impossibles. La prostituée se défend en vous disant qu’elle n’a pas d’autres choix, que la société et l’Etat sont responsables de sa misère, et finit par devenir accusatrice. Se définissant comme victime d’un ordre sexuel injuste, elle se pose tour à tour comme objet de pitié et comme juge accusateur. Elle ne se sent plus débauchée ou coupable, elle se sent de plus en plus comme victime d’un système social et économique.

 

R: OK. In case the state wants to integrate them or maybe NGOs, in your opinion, will they be able to change, I mean to go and do other jobs, or there are some workers that stick to their job and say it’s more rewarding for them?

 

A.D: Encore faut-il que l’Etat le veuille…Est-ce que l’Etat le veut vraiment? Le peut-il ? Quand on a le projet de recevoir 10 millions de touristes, parmi ces 10 millions, il y aura sûrement des touristes sexuels… Il faut donc répondre à la demande sexuelle des touristes sexuels …et du coup on peut se demander si vraiment on a l’intention stratégique d’éradiquer la prostitution. Il me semble que la réponse à cette question ni pas un oui automatique…Il y a le besoin d’une manœuvre sexuelle pour faire marcher le champ du tourisme, pour le faire mieux marcher. D’un autre côté, l’Etat lui-même et les associations féministes adoptent la définition de la prostitution comme une forme de violence, comme la forme extrême de la violence que subit l’être humain, et notamment la femme et l’enfant. En d’autres termes, la prostitution ne serait jamais un choix libre dans un marché libre. Pour lutter contre la prostitution comme réponse « facile » à la vulnérabilité, il y a un travail de sensibilisation et de rééducation à mener, en attendant l’habilitation et l’empowerment de la femme.  Si vous n’offrez pas d’alternative crédible et durable. , la prostituée restera prostituée malgré le travail de sensibilisation. Ce défi, celui de sortir les prostituées de la vulnérabilité, personne ne peut le relever aujourd’hui… Les maffias du crime organisé exploitent cette impuissance, impuissance due à un partage mondial inégal des richesses. Pour cette raison, la prostitution est aujourd’hui un des visages de la mondialisation. Et le tourisme sexuel participe de cette mondialisation du sexe, de ce marché mondial du sexe qui rapporte des milliards de dollars, pas aux travailleurs sexuels eux-mêmes. Sans être pessimiste, je me demande si c’est un marché que l’on peut maintenant détruire, voire seulement réguler. Quand ils ne sont pas complices, les Etats sont de plus en plus impuissants devant le crime transnational organisé. Le Maroc est impliqué dans ce réseau international… En 2008, le Ministère marocain de l’intérieur affirme avoir démantelé 228 réseaux internationaux de trafic et de traite des femmes. La coopération internationale au niveau des polices des frontières et d’Interpol se fait pour lutter contre le trafic, contre la traite. On doit entreprendre une action préventive de sensibilisation auprès des femmes, auprès des enfants, auprès des familles, les avertir, leur dire que ce n’est pas un bon chemin, que ce n’est pas le bon chemin. Mais ce n’est pas suffisant… tant qu’il y a vulnérabilité économique, il y aura vulnérabilité à l’appel du marché prostitutionnel. Plus une jeune fille est vulnérable économiquement, plus elle risque de répondre à cet appel, avec ou sans la complicité de sa famille.

 

R: But for the moment, is there any pressure from the part of the Civil Society on the government itself, I mean concerning to be strict about the laws or perhaps think about other projects of laws that can help combat the phenomenon?

 

A.D: Il y eu en 2007 une action de la « Ligue Démocratique des Droits des Femmes » (LDDF) qui justement a appelé à lutter contre la prostitution qu’elle définit comme  une forme de violence. Puis récemment, une réunion panarabe s’est tenue à Rabat pour endiguer le fléau de la traite des femmes. C’est un début, c’est encore balbutiant. Moi je reste réaliste, je ne pense pas qu’on puisse résister à la mondialisation de la prostitution. C’est un champ informel et clandestin qui échappe au contrôle total de la puissance publique. Les 228 réseaux internationaux œuvrant à partir de Maroc qui ont été démantelés ne constituent à coup sûr que la partie apparente de l’iceberg. Vous savez, la plupart des prostituées qui œuvrent maintenant dans les pays du Nord, à Amsterdam, à Paris… sont de moins en moins des autochtones… ce sont des femmes de l’ex-empire soviétique, des femmes africaines, des femmes Arabes… 80% des prostitués en Hollande sont d’origine étrangère. Il en est de même du marché sexuel dans les pays arabes du Golfe.

 

R: So what is the position of the law? When, for example, they display such networks?

 

A.D: La loi est claire. La loi pénalise : elle pénalise la prostituée elle-même, elle pénalise le client, elle pénalise le proxénète, elle pénalise les lieux où il y a prostitution. La loi est claire, la loi est contre. Il faudrait la durcir, chose qui ne semble pas être urgente pour les autorités. Il faut donc au moins l’appliquer de manière stricte, contre les clients étrangers, les touristes sexuels, et pénaliser aussi les fonctionnaires qui concourent à la violation de la loi…

 

R: OK Maybe my last point of interest would be in case we had actually an international network or an international movement to combat this phenomenon, what would be, in your opinion, the strategy that could be rewarding…I mean that could help combat this phenomenon?

 

A.D: La stratégie, c’est le partage équitable des richesses. Pour commencer, il faut commencer par lutter contre la vulnérabilité économique du Sud. Il faut commencer par lutter contre la vulnérabilité économique des femmes du Sud, des familles du sud. Tant que le sud est vulnérable, tant qu’il vulnérabilisé par une mondialisation sauvage, néolibérale, les femmes du Sud, les enfants du Sud seront toujours une proie facile pour les réseaux internationaux et nationaux, L’enjeu est d’assurer une vie décente aux femmes et aux enfants du Sud. C’est un facteur capital. Tant que cela n’est pas réalisé, il y aura toujours le risque de les faire recrutés par un réseau prostitutionnel.

 

R: OK, anything to add? I mean something else I didn’t ask you about and that you wanted to say, I mean?

 

A.D: Bon, pour le moment, je ne vois rien d’autre à ajouter… (un rire)

 

R: OK, (un rire). OK, would you like to publish, I mean any I want to publish from what you said? And because I would like to show you perhaps the last product after the transcription, and if you think that I said something which is not appropriate or maybe I wasn’t that faithful to what you said please let me know…Well thank you so much, Dr. Dialmy Abdessamad, and I’m really very grateful to you…and…I…I would like to apologize for any inconvenience again.

 

A.D: Vous n’avez pas à vous excuser. C’était parfait. C’était bien. C’est vrai, j’aimerai relire la transcription. Comme ça je pourrais ajouter des choses,…

 

R : Très bien

 

A.D : OK ? J’allais vous demander ça d’ailleurs, OK ?

 

R : Non, je vais le faire (un rire). Bon merci beaucoup.

 

A.D : ça fera un texte plus cohérent…

 

R : Très bien

 

A .D : Parfois à l’oral, on ne contrôle pas ce qu’on dit. On n’est pas tellement bien…mais à l’écrit on peut retranscrire… rajouter des choses.

 

R : Très bien. Merci beaucoup

 

A.D : C’est moi qui voudrais vous remercier.

 

 

 

 

 

 

 

 

 

 

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18 mai 2009 1 18 /05 /mai /2009 01:10

الدكتور عبد الصمد الديالمي، عالم اجتماع، الرباط، المغرب

 في نقد التطرف الجنسي

رد على الريسوني  ومن معه

 

قبل ثلاثة أيام، طلب مني صحافي من مجلة "نيشان" رأيي في ما كتبه الريسوني عن "مقالتي" "معركة جنسية بين الشباب المتفجر وفقهاء القانون في المغرب". لم أفهم سؤاله لأنه لم يكن لي علم بما كتبه الريسوني ولأني لم أنشر قط مقالة بهذا العنوان. فطلبت منه مهلة للتقصي قبل الجواب.

بعد البحث في شبكة الأنترنيت، اكتشفت أن المقال الذي انتقده الريسوني سبق لي فعلا أن نشرته أول مرة في جريدة "الأحداث المغربية" يوم 19 يناير 2007 تحت عنوان "المعركة الجنسية الراهنة أو إرادة العلمنة" الصامتة". ثم نشرته مرة ثانية بشكل مقتضب على موقع "الأوان"، وهو موقع "رابطة العقلانيين العرب"، تحت عنوان "في الانتقال الجنسي"، وذلك يوم 24 أبريل 2008. ونشرته مرة ثالثة تحت عنوان "الانتقال الجنسي أو إرادة العلمنة الصامتة" في كتابي الأخير "سوسيولوجيا الجنسانية العربية" (بيروت، دار الطليعة، 2009).

وعلمت من خلال الريسوني أن بعض المواقع الإلكترونية الأخرى، من بينها مواقع مثلية، تلقفت المقال ونشرته بعد أن غيرت عنوانه الذي أصبح "معركة جنسية بين الشباب المتفجر وفقهاء القانون في المغرب". تم ذلك دون علمي ودون مشاورتي. لا أدري هل لتلك المواقع الحق في ذلك، خصوصا وأني أرفض رفضا قاطعا عنوانه الجديد، المخطئ والمستفز، والذي أثار نقاشا مجانيا لا دخل لي فيه. على كل حال، فهمت أن الريسوني والإسلامويين قرؤوا مقالي في المواقع المثلية، مما زاد من رفضهم له. وكما هو منتظر من فقيه إسلاموي، خلت التعليقات من اللياقة ولأدب ومن كل بعد علمي أو فكري، ووظفت كعادتها أسلحتها المعهودة من شخصنة واستفزاز وتبخيس وتجريح واتهام وترهيب. ورغم أني اقتنعت منذ سنة 2000 بأن النقاش العلمي الموضوعي مع الإسلامويين نقاش شبه مستحيل، فليسمح لي السيد الريسوني بتنويره بالملاحظات السريعة التالية.

يجب التمييز في مقالي بين ثلاث مقاربات:

- في المقاربة الأولى، قمت بوصف أبعاد ما أسميته بالانفجار الجنسي في المغرب انطلاقا من تلخيص لأعمالي الميدانية التي استمرت أكثر من خمس وثلاثين سنة، وهي أعمال عالم اجتماع مغربي متخصص في تشخيص الظاهرة الجنسية. وبإجماع المنتقدين الآخرين للمقال، كان الوصف موضوعيا رغم توصياته.

- في المقاربة الثانية، صغت مفهوم "الانتقال الجنسي" كنظرية تفسر الانفجار الجنسي الحاصل في المغرب، وهي صياغة أصيلة غير مسبوقة. ورفضت النظرية الإسلاموية التي تنظر إليه كخلل وكتفكك. فعلت ذلك بصفتي عالم اجتماع لا يقف عند البحث الميداني بل يحاول بكل تواضع الارتقاء إلى المفهوم وإلى التنظير.

- في المقاربة الثالثة، ارتأيت أنه من الضروري تكييف بعض القوانين الجاري بها العمل (في موضوع الجنس) مع تطور السلوكات والقيم الجنسية المغربية الجديدة، والتي تسير في اتجاه قيم الحداثة والمساواة. فالقوانين المعمول بها في كل مجتمع موضوع صراع ومساومة بين القوى الاجتماعية المحافظة والتقدمية، وتتغير حسب الأزمنة والأمكنة، وحسب المصالح. وسؤالي في هذا الصدد هو التالي: ما جدوى قوانين يخرقها الكثير من المغاربة يوميا؟ هل يتم خرقها لأنها غير واقعية؟ أم لأنها لا تستجيب للحاجيات الجديدة للمغربي الجديد؟

في هذا المقاربة الثالثة، كتبت بصفتي مثقفا ملتزما بحقوق الإنسان كامتداد للإسلام وكتجسيد حداثي له، وهذه أطروحتي التي فصلت فيها القول في أعمال أخرى. وكتبت بصفتي مواطنا مغربيا وليس لأنني مواطن فرنسي يشعر بطمأنينة بفضل ذلك، رغم أني مدين لفرنسا مدى الحياة بإنقاذي من تهديدات الإسلامويين في صنعاء سنة 1999. أفكر وأكتب في هذا الاتجاه منذ أن بدأت التدريس سنة 1971، أي 16 سنة قبل الحصول على الجنسية الفرنسية. إنني أفعل ذلك باسم مبدأ، مبدأ المساواة الجنسية بين كل الفاعلين الجنسيين. وهي المساواة التي أتمنى أن تتحقق يوما في القوانين المغربية، لأنها مبدأ إسلام حداثي استراتيجي.

إن ردة فعل الفقيه أحمد الريسوني أمر طبيعي لأن جهازه المفاهيمي محدد ومحدود بضيق الإيديولوجيا الإسلاموية التي لا تسمح له بتصور منطق أشياء كثيرة، من بينها مثلا القدرة على التمييز بين علاقة جنسية قبل زوجية متراضية بين شاب وشابة عازبين من جهة وبين السرقة أو الرشوة من جهة أخرى. لا شك في أن السرقة والرشوة مرفوضتان بالإجماع من طرف الأديان ومن طرف الأخلاق الوضعية المدنية. أما العلاقة الجنسية قبل الزوجية المتراضية، فالأخلاق المدنية ترى فيها أحد حقوق الإنسان الأساسية وأحد تجليات الحريات الفردية، وترى فيها علاقة نبيلة خالية من كل عنف ومن كل نفاق. وهذا أفق يتعذر على الريسوني تصوره، فبالأحرى تقبله. في نفس السياق، أصبح مفهوم الشذوذ نفسه لا ينسحب سوى على العلاقة الجنسية العنيفة أو العلاقة الجنسية بين الطفل والراشد. أما العلاقة الجنسية المتراضية بين راشدين، سواء كانا من جنس مختلف أو من نفس الجنس، فأصبحت في المنتظم الدولي علاقة سوية وشرعية في ذاتها وبذاتها. طبعا، من حق الفرد الذي له قراءة محافظة للدين أن يرفض شرعية تلك العلاقات وألا يمارسها في حياته الشخصية الخاصة، لكن ليس من حقه أن يفرض رفضه على الآخرين. فالقانون يحمي حق ممارسي تلك العلاقات وحق رافضيها في آن واحد لأنها علاقات تخص الحياة الحميمية الخاصة لكل مواطن ومواطنة.

 ومن الأشياء الأخرى التي لا يعرفها الريسوني أيضا أنه لا تناقض بين علمنة القوانين من جهة وبين الإسلام والإيمان من جهة أخرى. من أمثلة العلمنة في القانون المغربي ما يلي:

 

- منع الاسترقاق وامتلاك الرجل لعدد غير محدود من الجواري الحسان لأغراض جنسية.

-عدم العمل بقطع يد السارق والسارقة.

-عدم جلد الزاني غير المحصن وعدم الاحتفاظ بهذه المصطلحات.

- عدم رجم الزاني غير المحصن وعدم الاحتفاظ بهذه المصطلحات.

-عدم قتل فاعل ما فعله قوم لوط (عليه السلام) وعدم الاحتفاظ بهذا المصطلح.

-عدم الاحتفاظ بمقولة النكاح.

- عدم الاحتفاظ بطاعة الزوجة للزوج.

- التسوية بين الزوجين في رعاية الأسرة.

- إثبات الأبوة أثناء الخطوبة بوسائل علمية حديثة وشرعنتها.

- عدم تجريم تغيير العقيدة وعدم الاحتفاظ بمقولة الردة.

- ضمان الحرية الدينية دستوريا.

 

من الممكن اعتبار هذه القوانين ثمرة اجتهاد رغم وجود النص، ومن الممكن أيضا اعتبارها علمنة جزئية. فهي علمنة لمعاملات، علمنة لا تتنافى لا مع إسلام المغاربة ولا مع دستورية الإسلام (كدين دولة) ولا مع مؤسسة إمارة المؤمنين (المستنيرة).  من هنا، يتبين كيف أن الإسلام لا يتنافى مع علمنة القوانين الجنسية والأسرية. إنه الشيء الذي بات أمرا ينبغي تفسيره وتبسيطه إلى كل المغاربة حتى تنتهي القوى الرجعية من استغلال الإسلام سياسيا في اتجاه رجعي. من هنا بدأ إصلاح (حقل) الدين. ومن هنا ينبغي أن يستمر. إن التوافق بين الإسلام والعلمنة القانونية أمر بديهي وضرورة تاريخية حتمية. أما الإسلامويون"، فيتجنبون تلك البداهة وتلك الضرورة ويتعمدون تعريف العلمانية كإلحاد من أجل الاستيلاء على السلطة السياسية باسم الإسلام وإقامة دولة ديكتاتورية باسم الإسلام. إن الإسلام الحق براء من ذلك. في هذا الصدد، ليرجع الريسوني إلى مقالتي "نحو إسلام علماني"، المنشورة سنة 1998 (في جريدة "الأحداث المغربية")، والتي أعيد نشرها في كتابي "نحو ديمقراطية جنسية إسلامية" (سنة 2000) لكي يتسع صدره وأفقه الفكري.

وأختم هذا الرد بالقول بأن العلمانية تشكل الإطار الوحيد الذي يتأكد بفضله الكل من أن إسلام المواطن تدين صادق غير مكره، تدين لوجه الله (وحده)... كما يجب...  إسلام في صالح مواطَنة حقة لا تميز بين خلائق الله... إسلام التسامح الذي أنشد إليه...

 

د. عبد الصمد الديالمي

الرباط، في 21 مارس 2009

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