Abortion in Post-revolutionary Tunisia: Politics, Medicine and Morality 9781789206913

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Abortion in Post-revolutionary Tunisia

Fertility, Reproduction and Sexuality General Editors: Soraya Tremayne, Founding Director, Fertility and Reproduction Studies Group and Research Associate, Institute of Social and Cultural Anthropology, University of Oxford. Marcia C. Inhorn, William K. Lanman, Jr. Professor of Anthropology and International Affairs, Yale University. Philip Kreager, Director, Fertility and Reproduction Studies Group, and Research Associate, Institute of Social and Cultural Anthropology and Institute of Human Sciences, University of Oxford Understanding the complex and multifaceted issue of human reproduction has been, and remains, of great interest both to academics and practitioners. This series includes studies by specialists in the field of social, cultural, medical, and biological anthropology, medical demography, psychology and development studies. Current debates and issues of global relevance on the changing dynamics of fertility, human reproduction and sexuality are addressed.

Recent volumes: Volume 46 Abortion in Post-revolutionary Tunisia: Politics, Medicine and Morality Irene Maffi Volume 45 Navigating Miscarriage: Social, Medical and Conceptual Perspectives Edited by Susie Kilshaw and Katie Borg

Volume 41 Elite Malay Polygamy: Wives, Wealth and Woes in Malaysia Miriam Koktvedgaard Zeitzen Volume 40 Being a Sperm Donor: Masculinity, Sexuality, and Biosociality in Denmark Sebastian Mohr

Volume 39 Volume 44 Global Fluids: The Cultural Politics Privileges of Birth: Constellations of of Reproductive Waste and Value Care, Myth and Race in South Africa Charlotte Kroløkke Jennifer J.M. Rogerson Volume 38 Volume 43 Reconceiving Muslim Men: Love Access to Assisted Reproductive and Marriage, Family and Care in Technologies: The Case of France Precarious Times and Belgium Edited by Marcia C. Inhorn and Nefissa Edited by Jennifer Merchant Naguib Volume 42 Making Bodies Kosher: The Politics of Reproduction among Haredi Jews in England Ben Kasstan

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ABORTION IN POST-REVOLUTIONARY TUNISIA Politics, Medicine and Morality

Irene Maffi

berghahn NEW YORK • OXFORD www.berghahnbooks.com

First published in 2020 by Berghahn Books www.berghahnbooks.com © 2020 Irene Maffi All rights reserved. Except for the quotation of short passages for the purposes of criticism and review, no part of this book may be reproduced in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system now known or to be invented, without written permission of the publisher. Library of Congress Cataloging-in-Publication Data Names: Maffi, Irene, author. Title: Abortion in post-revolutionary Tunisia : politics, medicine and morality / Irene Maffi. Other titles: Fertility, reproduction, and sexuality ; v. 46. Description: First edition. | New York : Berghahn Books, 2020. | Series: Fertility, reproduction and sexuality v. 46 | Includes bibliographical references and index. Identifiers: LCCN 2020003260 (print) | LCCN 2020003261 (ebook) | ISBN 9781789206906 (hardback) | ISBN 9781789206913 (ebook) Subjects: LCSH: Abortion--Tunisia--Public opinion. | Contraception--Tunisia--Public opinion. | Reproductive rights--Government policy--Tunisia. | Reproductive health services--Tunisia. | Public opinion--Tunisia. | Tunisia--Social conditions--1987Classification: LCC HQ767.5.T8 M34 2020 (print) | LCC HQ767.5.T8 (ebook) | DDC 362.19888009611--dc23 LC record available at https://lccn.loc.gov/2020003260 LC ebook record available at https://lccn.loc.gov/2020003261 British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library ISBN 978-1-78920-690-6 hardback ISBN 978-1-78920-691-3 ebook

To Ugo Fabietti with gratitude and unaltered affection

Contents

List of Figures and Tables viii Preface ix Acknowledgements xii Notes on Transliteration xiv Introduction. Situating Abortion: Islam, the Arab Countries and the Tunisian Exception

1

Chapter 1. Putting Abortion into Question: Debates, Actors and Stakes after the Revolution

29

Chapter 2. Female Bodies, Contraception and Reproductive Norms 62 Chapter 3. Reproductive Governance, Moral Regimes and Unwanted Pregnancies

95

Chapter 4. Imagining Early Pregnancy: Ontologies of the Foetus and the Moral Perception of Abortion

140

Conclusion 175 Glossary 178 References 181 Index 197

Figures and Tables

Figures 2.1. Image from a booklet used to explain the effects of hormonal contraception. 63 2.2. Evolution of contraceptive use by type. 82 3.1. First page of the Dossier santé Jeune/Ado. 113 4.1. Sonographic image used in ONFP clinics. 142

Tables 0.1. Number of abortions and maternal mortality due to unsafe abortion in the MENA region for the period 1995–2000. 5 0.2 Legal grounds for abortion in the Arab states. 7 2.1. Evolution of the total fertility rate in Tunisia. 72

Preface

O

n a warm afternoon in September in a café located in central Tunis, I have a meeting with Amel, an acquaintance who works in the sexual and reproductive health domain. Having arrived in the country only one month earlier, I am trying to meet healthcare providers who work in government reproductive and sexual health clinics and hospitals to find out whether it is easy to get permission to conduct participant observation in these settings and what procedures need to be followed. Amel first gives me the names and numbers of several doctors and midwives she knows well, then expresses her interest in the research I am planning. I have already told her that I would like to investigate the discourses and practices of healthcare providers in government sexual and reproductive health facilities, particularly in relation to abortion and contraception. I am interested in the possible transformations of medical and paramedical personnel’s attitudes and those of their patients after the revolution of 2011; Islamists have gained political and social consensus, and previously silenced conservative ideas about the role of women in society have emerged. Amel, sipping her tea, tells the story of a young woman – a relative of one of her friends – who had recently had an abortion in a government clinic. The young woman had phoned Amel asking for help, and Amel had sent her to a clinic whose director is a colleague and a friend. Although the young woman was well received and easily obtained a medical abortion, the story did not have the expected happy ending. Two weeks after the procedure, she went back to the clinic for the post-abortion appointment. It was Ramadhan, and the building was full of children waiting to be circumcised, as this procedure was offered free of charge. She entered from the clinic’s main door, and the nurse who received her in the hall asked loudly, so that everybody could hear it, whether she had come for an abortion. The young woman, very embarrassed, looked at the floor, trying to avoid being noticed.

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Preface

The nurse asked her to sit in the corridor with the other women who were waiting to be examined by the personnel. While children were playing and running in the clinic, the nurse announced that the staff would first receive the children and then would see the women at the end of the morning. After a while, the nurse came back to speak with the young woman and again told her loudly that if she had come for an abortion, she had to move to the section of the clinic for young people (because she was not married). At this point, all the women sitting next to her were aware that the young woman had come for abortion care and that she was unmarried. While she was walking out of the corridor to reach the section of the clinic for young people, the nurse asked her publicly whether she had inscribed her name in the register of unmarried women who got an abortion. The young woman, shocked and upset, walked out of the clinic crying and phoned Amel to tell her what had happened. The latter was outraged by the young woman’s story and called the director of the clinic, arguing that the nurse’s behaviour was inadmissible and that providers who do not treat their patients respectfully should work in the archive (fieldnotes, 21 September 2013). I believe that Amel told me this story to signify her interest in the research I was going to undertake and to express her perception of the evolution of sexual and reproductive healthcare facilities after the revolution. Her view was that the post-revolutionary period had witnessed the degradation of government healthcare services, and this perception was shared by several other interlocutors I had met over the previous weeks. Thus, I began my research with the idea that material conditions had significantly worsened; after the important ideological change that had happened in Tunisian society after 2011, healthcare providers offering sexual and reproductive services had begun to manifest new conservative and even stigmatising attitudes towards women seeking abortion care. Several activists in the domain of women’s rights I met at the beginning of my research depicted a very dark portrait of the government healthcare sector and of Tunisian society in general. They emphasised that poor women were the main victims of the disruption of Ben Ali’s rule, although after the revolution they discovered that in the interior regions of Tunisia (regions de l’intérieur) the conditions of the population were deplorable well before 2011. After I gained access to the clinics and the hospital where I conducted fieldwork, the situation appeared more complex and nuanced than the one the discourses of several of my interlocutors depicted. I realised that rather than bringing

Prefacexi

about a radical change in the attitudes of healthcare providers and users of government clinics, the revolution of 2011 had exposed existing practices and discourses as well as material constraints that were unknown during Ben Ali’s rule because the authoritarian regime proscribed its citizens’ free expression and strictly regulated their public conduct. In this book, I explore the continuities and transformations characterising the governance of the reproductive and sexual conduct of Tunisian women in the post-revolutionary period. How did and does the medical and social system set up by the postcolonial state in the second half of the twentieth century affect female citizens’ reproductive and sexual conduct? How does the revolution of 2011 and the establishment of a democratic government shape healthcare providers’ and women’s behaviour in this field? Did the appearance of multiple political forces and the success of the Islamist party Ennahdha change contraceptive and abortive practices? What are the sexual and reproductive health policies of the post-revolutionary state? Are they new or part of the previous regime? Taking contraceptive practices, especially abortion, as the entry point, I consider the ideas and behaviours of healthcare providers working in government reproductive and sexual health facilities and of their patients during the period between summer 2013 and summer 2014. I also examine the impact of the activities of militants volunteering in several Tunisian NGOs that target sexual and reproductive health. I hope to show that women’s sexual and reproductive conduct and the medical and social norms regulating them are significant if one wants to understand the nature of the political transformations Tunisia has gone through since 2011.

Acknowledgements

T

his book was made possible by the generosity and welcoming nature of the healthcare providers and female patients whom I met at Tunisian public clinics that focus on sexual and reproductive health. These individuals shared their time, thoughts, feelings and intimacy. Many healthcare providers provided me with material and scientific support. I would thus like to thank the president of the Office National de la Famille et de la Population; the physicians, midwives, nurses and other health workers at the clinics where I carried out my research; and the head of the Department of Obstetrics and Gynaecology at Hospital T. I am also indebted to the various Tunisian NGOs with whom I collaborated during my stay in the country: the Groupe Tawhida Ben Cheikh, the Association Tunisienne des Femmes Démocrates, the Association Tunisienne pour la Recherche sur le Développement, the Association Tunisienne de Santé Sexuelle et Reproductive, the Association Tunisienne des Sages-Femmes du Nord, the International Planned Parenthood Federation, and the United Nations Population Fund. My research has also benefitted from the invaluable help of Selma Hajri, Atf Gherissi, Emna Hassairi, Sana Ben Achour, Dorra and Amel Mahfoudh, and Mondher Kilani. At the Institut de Recherche sur le Maghreb Contemporain, Pierre-Noël Denieuil, Karima Dirèche and Imed Melliti donated their time and supported my research in every possible way. I also give many thanks to Hayet, Christiane and all the other personnel for their sympathy and kindness. My Tunisian friends have made my stay in the country one of the most pleasant times of my life, so I would like to thank Atf, Chiheb, Fayrouz, Jannet, Malika and their families. I also thank Anselmo, Lucia, Elisa, Enza, Nino, Serena and Vincenzo for their warmth and cordiality.

Acknowledgementsxiii

Many thanks go to my husband and children, who moved to Tunisia with me and spent a year there. During this time, we all learned to love this country thanks to our inexhaustible curiosity and enthusiasm. Johanna Mishtal very generously read some chapters of the book and provided constructive feedback. In addition, Soraya Tremayne and Marcia Inhorn provided invaluable encouragement and support. I thank Angel Foster for allowing me to read her very relevant and still unpublished PhD thesis on the history of reproductive and sexual health in Tunisia. I am grateful as well to Ibtissem Ben Dridi, Irene Capelli and Ayse Dayi, all of whom have contributed in many ways to this book. Finally, I am indebted to the Faculty of Social and Political Sciences and the Institute of Social Sciences at the University of Lausanne (Switzerland), to the Institut de Recherche sur le Maghreb Contemporain (Tunisia) and to the Christian Michelsen Institute of Bergen (Norway) for providing scientific and financial support.

Notes on Transliteration

A

ins (‘) are the only diacritics included in the transliterations of Arabic terms, personal names, place names and sources. Commonly accepted English forms are used for some personal and place names. Words in colloquial Tunisian Arabic are transliterated according to that pronunciation.

Introduction

Situating Abortion Islam, the Arab Countries and the Tunisian Exception

Abortion in Islam

T

he Quran does not contain any reference to abortion (ijhadh). Jurists and theologians have often referred to Surah 81 in which the Quran condemns wa’d, the pre-Islamic practice of burying female children alive, common among Arabian tribes, to justify their opposition to abortion (Bowen 1997: 163). Based on analogical reasoning (qyas), abortion – the suppression of the foetus – is equated with the killing of an already born child. The legal status of the foetus was an issue debated by jurists in the Middle Ages on the basis of the Quran, the Sunna and the hadiths (oral reports concerning the words and deeds of the prophet Muhammad). The foetus’ relationships with her parents, her extended family, her community and God were important matters that were discussed well before the medical developments of the twentieth century.1 Surah 23 of the Quran was (and still is) regarded as crucial: We created man of a quintessence of clay. Then we placed him as semen in a firm receptacle. Then we formed the semen into a bloodclot; then we formed the clot into a lump of flesh; then we formed out of that lump bones and clothed the bones with flesh; Then we made him another creation. So blessed the God the best Creator. (Quoted in Musallam 1983: 53–54)

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Abortion in Post-revolutionary Tunisia

This passage concerns the theory of foetal development that has been central to the Islamic theological and juridical debate on ­abortion. Foetal development is supposed to entail four phases – nutfa (semen), ‘alaqa (blood-like clot) and mudgha (lump of flesh) – before the ‘living being’ in the womb of a woman becomes a human being (insan), which is when the soul enters the foetus’ body (‘the inbreathing of the spirit’) (Katz 2003: 30). While the Quranic text does not provide any indication of the duration of each stage, a hadith specifies the following: ‘The Prophet said: Each of you is constituted in your mother’s womb for forty days as a nutfa, then it becomes a ‘alaqa for an equal period, then a mudgha for another equal period, then the angel is sent, and he breathes the soul into it’ (Musallam 1983: 54). The legal status of the foetus evolves over time; it is characterised by a gradual process of humanisation that starts with conception and ends with the spirit entering the foetus. In the Islamic tradition, together with ensoulment, the progressive development of the ‘recognizably human physical form’ is also given great importance (Katz 2003: 34). Muslim jurists refer particularly to Surah 23 and the cited hadith to justify their attitudes towards abortion. While abortion is never encouraged and generally prohibited, several Islamic legal traditions regard it as acceptable if it occurs before ensoulment and under specific conditions. The time of ensoulment varies according to the interpretations of the hadiths that describe foetal development. While the quote above indicates that ensoulment does not happen before 120 days, other hadiths ‘give forty days as the total of the four stages’ (Bowen 2003: 55). Hence, Islamic jurists consider abortion to be acceptable under specific circumstances, specifically before 120, 80 or 40 days after conception. The four legal schools of Sunni Islam – Hanafite, Shafiite, Malikite and Hanbalite – have divergent positions on abortion, and jurists can also express different opinions within each school (Bowen 2002, 2003; Katz 2003; Musallam 1983). The Maliki and Shafiite schools prohibit it altogether, whereas the Hanafis allow it before 120 days of conception even without what the juridical tradition regards as valid reasons. The other two schools locate themselves in an intermediate position. While the embryo is not already a human being before ensoulment, the ‘potentiality’ of becoming one cannot be ignored (Bowen 2003: 62). However, Islamic juridical traditions recognise several ‘valid reasons’ for abortion, such as to save the woman’s life,2 to preserve the woman’s health, to preserve the health of a nursing child, to preserve the woman’s beauty and to avoid the ‘hardship resulting

Introduction3

from excessive offspring’ (Katz 2003: 43). While it is beyond the scope of this chapter to go into the details of the Islamic discussions about abortion, it is necessary to emphasise their important theological, juridical, moral and social implications, as well as ‘their high level of tolerance for ambiguity and complexity which avoids absolutist simplifications of the intricate moral issues raised by fetal life’ (Katz 2003: 45). This flexibility and complexity is still present in the contemporary debate and has legitimised the adoption of different abortion laws by each Islamic country and even some changes in the regulations under different historical circumstances (Bowen 1997, Makhlouf Obermeyer 1994). For instance, Iran liberalised abortion in the years immediately before the Islamic Revolution (1979), then prohibited it altogether after Khomeini took power and again made it available after 1994 (Bowen 2003). Political, economic and demographic reasons have been at the origin of the changing Iranian reproductive policies, showing the plasticity of the religious discourse and the possibility of using it to justify very different laws. As emphasised by Carla Makhlouf Obermeyer, in Muslim countries as well as elsewhere, religion and morality are translated into politics in accordance with the political, social and economic interests of the group in power (1992, 1994). The complexity of positions on abortion in Arab-Islamic countries also emerges in the reverse perspective, where, although officially prohibited, pregnancy terminations are very common and performed by healthcare professionals in generally safe conditions (Fathallah 2011; Gruénais 2017). In Lebanon, Zeina Fathallah interviewed a number of midwives and obstetricians-gynaecologists who belong to different religious communities that regularly perform abortions and do not seem particularly worried by the state laws criminalising it or by religious prohibitions (Fathallah 2011). In Morocco in 2010, Professor Chraïbi, a well-known obstetrician-gynaecologist and the founder of the AMLAC (Moroccan Association Against Clandestine Abortion), declared during a debate broadcast by the Moroccan TV Médisat that 800 abortions were performed every day in his country, 600 of which were under medical supervision and 200 were outside medical settings (Gruénais 2017: 220). I will now turn to the actual regulations of abortion in the Arab countries that show several similarities as well as the differences existing between the law of the state and the religious discourses.

4

Abortion in Post-revolutionary Tunisia

Abortion in the Arab World During the 1960s when several Muslim states were starting birth control policies, some international meetings between religious leaders, health professionals and other actors were organised to discuss Islamic positions on family planning and biomedical technologies (Hessini 2007). In 1971, a conference bringing together Muslim scholars to discuss Islam and family planning was held in Rabat. Modern contraception was approved in accordance with the ‘right of families to look after themselves regarding procreation’ and the freedom to choose the number of children they want to have (Lapham 1977: 18). While reproductive biomedical technologies were generally accepted, as they were not considered to infringe upon Islamic precepts, sterilisation and abortion were not allowed due to conflicting opinions among religious leaders. At the Rabat conference, it was decided that abortion ‘is forbidden after the fourth month of gestation except for saving the life of the mother’, although some scholars stated that it should be forbidden ‘at any stage unless for extreme personal necessity to save the mother’s life’ (ibid.: 19). Among the Islamic countries of the MENA region, as already mentioned, Iran legalised abortion for social and economic reasons in 1976, and Turkey made it accessible on request in 19833 (Dabash and Roudi-Fahimi 2008, Lapham 1977). The only Arab country that decriminalised abortion after independence was Tunisia; in 1973 it became accessible to all categories of women without the husband’s consent and free of charge in family planning clinics. Recently, Bahrain has also made abortion available for social and economic reasons upon request (United Nations 2013). By the end of the 1980s, abortion laws in the Arab countries were still very restrictive, and only Egypt, Jordan, Algeria, Morocco and Tunisia authorised it ‘in the event of risk to the mother’s physical or mental health’ and ‘in the case of danger of a deformed or congenitally abnormal birth’ (Faour 1989: 259). The sanctions for health professionals who violate the law are severe, including imprisonment from six months to ten years and a fine and suspension from their professional activity. Women can also be punished with imprisonment and pecuniary sanctions (ibid.). Overall, except for Turkey and Tunisia, the official statistical data on induced abortion rates in the countries of the MENA region are almost non-existent because legally performed abortions are very limited and abortion ‘is largely a taboo subject’ (Tabutin and

Introduction5

Table 0.1  Number of abortions and maternal mortality due to unsafe abortion in the MENA region for the period 1995–2000. Country Algeria Bahrain Egypt Iran Iraq Jordan Kuwait Lebanon Libya Mauritania Morocco Oman Palestinian territories Qatar Saudi Arabia Sudan Syria Tunisia Turkey United Arab Emirates Yemen

Number of abortions 718,670 25,754 2,079,216 2,590,681 893,285 196,792 70,169 177,298 117,050 116,196 699,692 80,642 98,135 20,272 699,405 702,248 653,965 118,102 2,301,955 78,770 606,339

Deaths due to unsafe abortions 1,076 16 2,542 5,697 908 161 52 85 190 801 1,084 105 141 14 927 1,893 580 256 1,536 49 842

Source: Leila Hessini (2007) in the journal Reproductive Health Matters, used with permission.

Schoumaker 2005: 652). However, induced abortion is illegally practised in most Arab countries, and in 1992 the Damascus Conference on Unsafe Abortion and Sexual Health in the Arab World recognised that unsafe abortion is a major health problem in almost all Arab countries (Hessini 2007). Sex education, revision of abortion laws, provision of family planning services and programmes designed to take care of women with post-abortion complications and to change healthcare providers’ attitudes were discussed. Indeed, maternal mortality and morbidity related to unsafe abortions4 were and still are a major concern in the Arab countries where access to abortion is restricted. It must also be noted that, as mentioned above, illegal abortions are safely performed in the private sector in several Arab countries, even though they are only accessible to those women who can afford to pay for them, excluding large groups of the population (Bowen 1997). In Jordan, where I previously conducted fieldwork,

6

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I sometimes attended consultations in the private sector where a woman explicitly asked for abortion care and was referred to a practitioner who did perform pregnancy termination (Maffi 2012). This is also confirmed by the study of Lara Knudsen, who, however, stresses the fact that in the medical sector in Jordan ‘the cost of illegal abortion is exorbitant,’ and therefore ‘women who are unable to secure a doctor’s assistance may take certain medicines or insert traditional herbs into the vagina in an attempt to start bleeding’ (Knudsen 2006: 179). A report by the World Health Organization (WHO) estimates the number of unsafe abortions in ‘Western Asia’5 to be 830,000 each year, causing about 600 maternal deaths, and 900,000 in Northern Africa (Maghreb), causing 1,500 maternal deaths (WHO 2008: 2). In 1994, the United Nations International Conference on Population and Development (ICPD) held in Cairo ‘forged a global consensus on abortion’ (Dabash and Roudi-Fahimi 2008: 3). The Programme of Action of the International Conference of Population and Development established that abortion should ‘not be promoted as a contraceptive method’ but that it should be safe in the countries where it is not against the law; also, governments and nongovernmental organisations should ‘strengthen their commitment to women’s health, to deal with the health impact of unsafe abortion as a major public health concern’ (quoted in Dabash and RoudiFahimi 2008: 3). They should also ‘promptly’ offer post-abortion care, education, counselling and family planning services. Although the Cairo conference was a turning point because it focussed on the reproductive choice of individuals rather than families and female empowerment, as well as linked the issue of human rights to health and reproduction (Shalev 2000: 39), there was no recognition of a new international right to abortion (Bonnet and Guillaume 2004: 27). In 2013, all countries of Northern Africa (Algeria, Egypt, Libya, Morocco, Sudan and Tunisia) permitted abortion to save a woman’s life, but only Algeria, Morocco and Tunisia also authorised it to preserve a woman’s mental health (United Nations 2014).6 Algeria no longer permits abortion in the case of rape and incest – as was still the case in the 1990s – whereas Morocco amended the Penal Code in 2016, allowing female victims of rape and incest to terminate the pregnancy. Sudan and Tunisia also allow abortion in the case of rape and incest. Foetal impairment is a legal ground for abortion in Morocco (since 2016), Tunisia and Sudan. In the ‘West Asia’ region, in 2013, all Arab countries allowed abortion to save a woman’s life,

Introduction7

Table 0.2  Legal grounds for abortion in the Arab states. Risk to woman’s life Risk to mental health Foetal impairment Rape and incest Economic and social  reasons All grounds

All countries Algeria, Bahrain, Jordan, Kuwait, Qatar, United Arab Emirates Bahrain, Jordan, Kuwait, Morocco, Oman and Qatar Bahrain, Morocco, Tunisia, Sudan Bahrain, Tunisia Tunisia, Turkey

whereas only Jordan, Kuwait, Qatar and the United Arab Emirates (UAE) permitted it to preserve a woman’s mental health (United Nations 2013). Rape and incest are a legal ground for abortion only in Bahrain, whereas foetal impairment is a legal reason to terminate the pregnancy in Bahrain, Jordan, Kuwait, Oman and Qatar.

Islamic Fatwas, Women’s Rights and Abortion Since the early discussions on family planning and abortion in the 1960s, religious leaders have been involved in the debate, and Islamic juridical traditions have been used to legitimate the laws of the state in the domain of reproduction (Hessini 2007). However, state legislations do not systematically reflect religious opinions, which can sometimes be more liberal than the law. Several examples can illustrate the gap existing between religious fatwas and state laws on abortion. In 1998 in Egypt, the Grand Mufti – the supreme religious leader – argued that ‘rape victims should have access to abortions and to reconstructive hymen surgery to preserve female marriageability and virginity’ (Hessini 2007: 78). His opinion notwithstanding, the Egyptian state did not change the law, which does not allow abortion on these grounds. In the same year, the Algerian Islamic Supreme Council issued a fatwa allowing abortion for women who had been raped by religious extremists during the civil war (1990–1998), but it was never transformed into law. In other cases, religious opinions have contributed to the revision of a previously existing restrictive law, such as in Sudan and Saudi Arabia. In Sudan, abortion law was amended in 1991, shortly after the Islamists came to power, expanding the circumstances in which abortion can legally be performed (Tonnessen 2015). In

8

Abortion in Post-revolutionary Tunisia

Saudi Arabia, Islamic jurisprudence also allowed for the e­ xpansion of i­ndications in which an abortion can be performed (Hessini 2008). In other countries, religious opinions are more restrictive than the law, such as in Kuwait, where religious authorities do not consider rape as legitimate grounds for an abortion (Hessini 2007). Examining the abortion regulations in Arab countries, it is worth mentioning that existing restrictive laws mostly date back to colonial times, when pronatalist policies were enforced by British and French authorities.7 In the Arab countries where abortion has been partially decriminalised, it is usually not in the name of women’s rights but to save the life of the mother, to protect the honour of the family, to ensure the marriageability of a woman, to avoid the birth of a sick child, to reduce population growth etc. Overall, the abortion debate in Arab countries is based on arguments that are different from those used in North America or in many European countries. Religious jurists are concerned for the women’s life, the ensoulment of the foetus, the well-being and morality of society, the preservation of the greater good etc., rather than for the foetus’ rights, although the pro-life Christian arguments have sometimes entered into the context of Islamic juridical traditions (Hessini 2008: 24). While religious arguments are commonly used in Arab and Muslim countries to justify abortion laws and local cultural attitudes, international agencies such as the WHO, the United Nations Fund for Population and Development (UNFPA), the International Planned Parenthood Federation (IPPF) and some local NGOs promote the decriminalisation of abortion on the basis of a secular discourse based on concepts such as gender equality, health and human rights (Hessini 2008, Shapiro 2013).8

Abortion in Tunisia In 2013, the feminist NGO Association tunisienne des femmes démocrates (Tunisian Association of Democratic Women, ATFD) published the booklet Le droit à l’avortement en Tunisie –1973 à 2013 (Abortion Rights in Tunisia – 1973 to 2013), in which the authors outline the situation of abortion in the country, considering its legal, medical, social and religious aspects. Worried about the political and juridical questioning of the right to abortion and the dismantling of abortion services after the revolution of 2011, ATFD decided to take an active stance and reaffirm Tunisian women’s right to abortion

Introduction9

care. The booklet denounces the fact that ‘Since 2011, we have witnessed a radical change: at the public sector level, the omerta (law of silence) allows the state to hide the impact of financial cuts and of religious conservatives’ actions who deny women abortion care without fearing legal sanctions’ (2013: 14). Indeed, on 18 January 2013, during the debate on ‘rights and freedom’ of the constituent assembly – which was elected in October 2011 to write the new constitution – Deputy Najiba Berioul requested the criminalisation of abortion. Berioul, a member of Ennahdha, the Islamist party in power from October 2011 to February 2014, expressed the opinion of a section of the public who wished to deny women the right to abortion for non-medical reasons. In her speech, she recalled the ‘right of the foetus to be born’ and asked it to be included in the new constitution, abrogating Article 214 of the Penal Code that allows abortion. Interestingly, to justify her request, she employed an argument that comes from the North American pro-life movement, according to which the foetus is a person whose rights must be taken into consideration, and that can conflict with those of the mother. Mobilising the notion of rights does not refer to the terms of classic Islamic debates on abortion but is in some way attuned to the modern Euro-American representation of the foetus. Article 214 of the Penal Code decriminalises abortion in the section on ‘Wilful killing’, which is a derogation of the law insofar as, under certain circumstances, it permits the termination of pregnancy (i.e. the killing of a person). The derogation is inscribed in a code that was inherited from the French colonial state and that considers the foetus as a person and the abortionist as a criminal. To be legal, abortion must take place in a recognised medical facility under medical supervision until the end of the first trimester (fourteen weeks’ amenorrhoea). It can exceptionally take place after that period ‘if continuation of the pregnancy threatens the women’s physical or psychological health or if the foetus suffers from a serious illness and deformity’ (Foster 2001: 74).9 In 1965, only married women who had five living children were allowed to get an abortion with their husband’s consent; in 1973, the article was amended to allow all women, married and unmarried, with or without children, to access abortion services, including minors under the responsibility of an adult. The law was also changed thanks to the intervention of the Tunisian Women’s Union.10 Its representatives were able to persuade the parliament to change the law, showing them that, because of legal restrictions on abortion, ‘hundreds of women arrive at the hospital every

10

Abortion in Post-revolutionary Tunisia

year suffering from haemorrhage after trying to abort in i­nsanitary ­conditions’ and that 55 women committed suicide in 1972 because of ‘non legitimate pregnancy’ (Asman 2004: 85). Since 1965, abortion care has been free of charge in government facilities. Although other administrative structures pre-existed it, in 1973 a specific state agency, the Office national du planning familial et de la population (ONFPF) – later to become the Office national de la famille et de la population (ONFP)11 – was created in order to coordinate family planning policies. ONFPF had five main objectives: carry out research in the domains of demography, reproduction and health; implement state policies that ‘enhance the equilibrium of families and the health of its members’ (Gastineau and Sandron 2000: 16); provide all appropriate professionals with the means to reach the mentioned objective; offer training for healthcare professionals; and educate the population. The legalisation of abortion was part of a larger project to control the demographic trends in Tunisia. Already in 1959, shortly after independence (1956), ‘public authorities started to talk about the necessity of mastering procreation, first and above all to affirm the intention of reducing birth rates, ignorance, poverty and illness’ (Gueddana 2001: 204). Demographic policies became a priority of the independent Tunisian government. Imbued with a neoMalthusian and modernist view, the first Tunisian president, Habib Bourguiba, attributed crucial importance to containing ‘the human tide relentlessly rising at a speed largely outreaching the increase of the means of subsistence’ (Bourguiba in Gastineau and Sandron 2000: 11). Demographic policies were a main concern for postcolonial Tunisia and had already been inscribed as such in the development plans of the country since the mid-1960s, insofar as they were deemed necessary to ensure human progress (Foster 2001). The High Population Council (founded in 1974) oriented the action of ONFPF and coordinated the policies of different ministries under the supervision of the prime minister. Regional population councils were active in supervising and applying the national demographic policies designed to control reproductive practices. Abortion was an integral part of the family planning policies, and for certain categories of women, it represented ‘the only accessible and efficient method of birth control’ (Gastineau 2012: 78). Some scholars even argue that in 1974 the Tunisian authorities thought that ‘40% of the targeted reduction in the birth rate would have to come from abortion with 60% from users of contraception’ (Lapham 1977: 8).

Introduction11

Although, with a few exceptions, religious leaders cautioned the use of contraceptive methods and the promotion of family planning by the state (Brown 1981; Gueddana 2001), abortion was more controversial. It was religiously forbidden by Maliki legal tradition – the dominant legal tradition in the Maghreb – but was allowed by the more permissive Hanafi and Shafi schools, according to which the ensoulment12 of the foetus does not happen before 120 days (three months). In this domain, as in many others, Bourguiba did not abandon the Islamic reference to legitimise his reforms, emphasising on the contrary that ‘we have made an effort (ijtihad) . . . we have used the reason inspired by the very principles of Islam’ (Bourguiba in Bessis and Belhassen 1992: 128). Bourguiba insisted that Tunisian reformers had ‘found inspiration in the Shari‘a . . . and chose to open the doors of interpretation in order to rejuvenate the Islamic tradition’ (Charrad 2001: 222). The modernising rhetoric of Bourguiba notwithstanding, the religious reference maintained its legitimising function, in that it was used to justify the important social reforms promoted by the state in the first decades after independence. The same rhetoric was used to legitimise the Personal Status Code promulgated in 1956, which contributed to subvert previously existing power relations between men and women and the logics of patrilineal kinship solidarity (Charrad 2001). As already mentioned, the introduction of family planning and abortion were part of a larger plan for the reform of Tunisian society in which women in particular were to be emancipated from previously existing traditions and constraints often designated as ‘backwards’, ‘archaic’ or ‘retrograde’ (Grami 2008: 353). However, ‘the family planning program was a function of the state, which aimed at furthering state goals. It was not about individual women or their needs’ (Foster 2001: 82). Precise demographic targets (Gueddana 2001), the centralised and hierarchical structure of the family planning programme and aggressive public campaigns provoked abuses and coercive practices that caused resistance and distrust among the population. Paternalistic attitudes among medical personnel were widespread and forced contraception, and (female) sterilisation was common in the early phases of the programme, targeting, above all, uneducated, rural and poor women. Disciplining female reproductive bodies justified what some called the two-in-one package (Le droit à l’avortement en Tunisie – 1973 à 2013 2013), which meant that women were often forced to accept tubal ligation or an Intrauterine device (IUD) or implant insertion – according to their age and parity – if

12

Abortion in Post-revolutionary Tunisia

they wanted to get an abortion. Surgical ­ abortions were done under general anaesthesia, many times without the women being informed that they would undergo tubal ligation, IUD or implant insertion at the same time.13 Economic incentives for health professionals performing specific acts and for women accepting to undergo tubal ligation (Foster 2001), as well as the creation of the Bourguiba prize in 1974 for the governorates that obtained better results in reducing birth rates, significantly show the nature of the programme.14 Although they also had beneficial consequences, the Tunisian family planning policies often took the form of ‘an unjustifiable intrusion of government power into the lives of its citizenry amounting in many cases to physical violence against women’s bodies’ (Hartmann 1995: XIII). Birth control became the priority rather than women’s health and the freedom to choose how many children they wanted. As effectively summed up by Nabiha Gueddana, the main objective was the limitation of births in the 1960s, birth spacing in the 1970s, the integrated approach of mother–infant health in the 1980s, and reproductive health, which she considers to be synonymous with ‘family health’, in the 1990s15 (2001: 211). The words of one of the main actors of family planning in Tunisia – as she was president of ONFP from 1994 to 2011 – significantly identify the state’s goal as that of reducing birth rates and ensuring the health of the family. Women’s own health and individual agency were possibly a by-product of a development policy in which they were made to play the main characters. Men were late to be included, and then only marginally, in the family planning programme as secondary players. Women were and still are considered the main actors of the reproductive scene, although they are caught up in a social and cultural context where they rarely make individual decisions about procreation. Many studies published by the ONFP over the last thirty years have focussed on women’s reproductive behaviours in accordance with state reproductive policies, which have targeted them as if they were autonomous individuals making decisions independently of their family, sociocultural and economic contexts. The only systematically recognised relationship was that between the women and their children insofar as mothers were (and are) considered to be responsible for the physical and social well-being of their family. Gendered conceptions of women’s and men’s roles in society and within the family guided the conception of these studies and oriented government policies in the domain of reproduction. This is to be understood in relation to several local and transnational

Introduction13

representations that heavily affected the Tunisian family planning policies. As I will elaborate below, women were to become crucial actors in the modernising policies of the independent state, and therefore their role had to be transformed to make them allies of the elite in power. They were also easy to reach, as the family planning policies were based on the adoption of biomedical contraceptive technologies that were mostly applied to women’s bodies (IUD, pill and later injectables and implants). Women’s opinions could be influenced and their bodies manipulated in order to be at the service of the new demographic policies of the state when they consulted healthcare facilities. Because of the feminine nature of biomedical contraception, they were considered responsible for reproductive decisions. Moreover, the transnational paradigm of family planning policies considered women to be more responsible than men, as if they were endowed with specific universal, biological and moral qualities (see Chapter 2).

The Code of Personal Status and the Modernisation of Society In order to enable women to be the triggers of the modernisation of postcolonial Tunisia, a few months after independence, Bourguiba promulgated the Code of Personal Status (CPS), which modified women’s status and partially disrupted the patrilineal structure of the family.16 It provided female citizens with unprecedented rights: it abolished polygamy, repudiation, jabr (the right to compulsion) and the matrimonial guardian; instituted legal divorce; and made father and mother both responsible for a child (Ben Achour 2001; Charrad 2001). It also set the minimum age for marriage for men and women at fifteen for a woman and at eighteen for a man, which was modified in 1964 to seventeen and twenty, respectively. The principle of equality between men and women was explicitly recognised in the constitution (1959) and the labour code (1966), and measures to achieve universal schooling (1958) were taken. Moreover, the creation of the retirement fund, social security, disability pension and survivor pension in the event of a spouse’s death contributed to the ‘deregulation of the previously existing family system’ (Sandron 1998: 42). These and other reforms17 were part of a modernisation process that had the effect of improving women’s rights, promoting the nuclear family model and reinforcing matrimonial bonds (Charrad 2001). The construction of the nuclear

14

Abortion in Post-revolutionary Tunisia

family was at the heart of the efforts of the legislators, who aimed to discard the logics of the patrilineal extended family that had dominated Tunisian society until independence, so as to build a new modern unit where conjugal and parental ties were central. Tunisia was a pioneer in the transformation of ayla, a relational and wide ‘network of people who depend on each other’ (Hasso 2011: 26) to survive, into usra, ‘a nuclear family of parents and children in an architecturally bounded, private household’ (ibid.). The new unit, modelled after the European modern family, represented modernity and progress within the teleological framework that colonisers presented first and that western international agencies presented later on. The creation of the usra, considered to be the basic unit of postcolonial society, was an effect of the governmentality characteristic of the new states of the Middle East and North Africa. The new family was conceived of as an entity that the state could shape and administer in contrast with the old ayla that represented a group competing with the modern state power logics. The creation of a new social unit, the usra, was thus necessary for the construction of a modern state where old tribal and family solidarities were excluded. Indeed, ‘in liberal political theory the [nuclear] family is regarded as the natural basis for civil life’ (Ali 2002: 123), and in addition, it is an economic productive unit that should adjust to state objectives. For instance, in Tunisia, land reform was enforced to abolish tribal collective property and to make each household responsible for its own survival. Although this was not the logic that postcolonial Morocco and Algeria adopted (Charrad 2001) after independence, Tunisia represented a model for future development in several other states of the region (Ali 2002; Hasso 2011). Postcolonial state policies made the family a critical space of social and cultural change, where new values, practices and concerns could be created and transmitted to modernise Tunisian society. However, the transformation did not have to entirely subvert gender logics and power relations: the man was designated as the head of the family, and women were to give priority to family life and to their duties as mothers and wives. Although the constitution established men’s and women’s equality (1959), state institutions conveyed a very different message to families. Analysing various sources of the early 1960s, Ilhem Marzouki shows that a clear division of labour was explicitly proposed to married couples: the man’s role was that of a breadwinner, whereas the woman had to be in charge of the domestic sphere, which included completing daily chores, managing the family budget, occasionally playing the role of secretary

Introduction15

for her husband and encouraging him to pursue his career. At the same time, the woman was supposed to avoid having the couple’s life become a routine; rather, she had to make every day ‘different and unexpected’ (Marzouki 1993: 180). One of the main roles of women was the education of the children, who represented the new generation of Tunisian citizens. They had to play major roles in providing education, as the men were preoccupied with their work, with school playing only a secondary role for them. A differential education for girls and boys was recommended insofar as the former should develop ‘feminine characteristics’ and the latter should acquire a sense of responsibility and duty (ibid.: 181). Mothers were urged to conveniently prepare their daughters to become wives and mothers, which included learning how to manage the house and how to become modern women (Abu Lughod 1998). Women’s work outside of the home was represented as sometimes necessary for economic reasons but was always subordinated to domestic life, as their main roles were those of mothers and wives (ibid.: 181).

State Feminism, Grassroots Feminism and Abortion Several authors have pointed out that postcolonial Tunisia was characterised by state or institutional feminism (Ben Achour 2007; Bessis 1999; Charrad 2001; Ferchiou 1996; Marzouki 1993), a political phenomenon that has significantly determined women’s postcolonial history. As mentioned above, Bourguiba took the initiative of promulgating the CPS and reforming several social institutions, extending the rights of Tunisian women in an unprecedented way. The creation of the National Union of Tunisian Women (UNFT) in 1958 to supervise social reforms and to promote the new state policies in the domains of education, family, labour etc. was a crucial moment in the history of institutional feminism.18 The union was state sponsored and was very closely linked to Bourguiba and his entourage. Its members were subordinate to various ministries and never enjoyed autonomous political power (Marzouki 1993). The first phase of the union’s activities was dedicated to the promotion of the modern family and to the new roles of women in it, whereas in the 1970s, the union began to focus on the role of women in the public sphere – employment, education, political and economic institutions. One of the stakes was the actual enforcement of women’s rights, which were often violated in the economic, political and

16

Abortion in Post-revolutionary Tunisia

social spheres. Despite the expansion of women’s rights and the overall improvement of their life conditions (Bessis and Belhassen 1992; Omri 2009), institutional, economic and social inequalities were not eliminated (Bouraoui 2001; Marzouki 1993), and even after the revolution of 2011, women were under-represented in political and economic institutions (Mahfoudh and Mahfoudh 2014: 30). Regional disparities between the cities in coastal areas and in the interior of the country are important today, and the living standards of rural women are still very different from that of urban women: their access to education, health facilities, social services and employment is limited (Omri 2009). Social conservatism, ignorance about personal rights among illiterate or little-educated women and poverty contribute to the existence of substantial inequalities. Thus, class, geographic location and education constitute major obstacles to women’s equality, in addition to Tunisian legislation that, despite the constitutional recognition of equal rights for women and men and the official withdrawal of reservations regarding the CEDAW19 (2014), entails differential treatments in various domains, such as with inheritances, where men are attributed shares twice as large as those of women.20 Despite Bourguiba’s pioneering reforms, discrimination against women is still present in Tunisia, where women’s rights are often used as ‘political commodities to be traded and exchanged between male leaders of various political groups’ (Grami 2008: 359) rather than as principles orienting state policies. Especially after 1987 – when Zine El Abidine Ben Ali21 took power – institutional feminism nurtured an official rhetoric about state modernism versus the Islamic obscurantism coming from the East (Mashrek), used as a political instrument to ‘gain the support of still hesitant opponents particularly afraid of a hypothetical strong re-emergence of Islamism in the Tunisian political arena’ (Geisser and Gobe 2007: 373). Although the narrative of the state has long monopolised the history of Tunisian feminism, emphasising that women received their rights from above without having to fight for them,22 it must be remembered that women took part in the struggle for independence in the 1930s and 1940s (Bessis and Belhassen 1992; Grami 2008; Marzouki 1993) and that three women’s autonomous associations were founded over these years that promoted women’s education rather than emancipation because they were imbued with Islamic culture and originated in a religious environment (Marzouki 1993). It was not before the end of the 1970s that a postcolonial autonomous feminist movement emerged in the context of social and

Introduction17

economic instability, where social protest and unrest were common (Mahfoudh and Mahfoudh 2014). Their struggle was nurtured by feminist and democratic ideas because promoting women’s equality and autonomy could not be separated from the larger objective of obtaining political freedom. During the 1980s, two feminist associations were created by independent groups of women – mostly belonging to the urban intelligentsia – and both were based in Tunis: the already mentioned ATFD and the Tunisian Association for Research and Development (AFTURD) (Daniele 2014; Labidi 2007; Marzouki 1993). In the same period, other feminist groups were created within the local unions as well as the Tunisian League for Human Rights and the secular opposition parties. Overall, during the 1990s and 2000s, the autonomous feminist movement engaged in a double combat against the rising Islamist movement threatening women’s acquired rights and against monopolisation by the state of women’s issues, insofar as its policies were ambivalent. The policies formally promoted equality but did not transform social practices, and they extended women’s rights beyond what the CPS achieved in 195623 (Mahfoudh and Mahfoudh 2014). After the revolution of 2011, several new feminist associations were created, often by militants, who were members of already existing associations. Many women’s associations created after 2011 are close to the Islamist movement, although they represent a variety of positions ranging from the defence of acquired women’s rights, but within an Arab-Islamic identity, to the promotion of men and women’s complementarity24 instead of equality, as well as the refusal of women’s rights to employment and abortion.25 Other associations are not explicitly feminist insofar as they consider the issue of women’s rights and equality to be transversal to other questions, such as democracy, social justice etc. (Mahfoudh and Mahfoudh 2014). Hence, the landscape is extremely diversified and cannot be simplistically divided into two fields: Islamic feminism and secular feminism. When a female deputy of Ennahdha questioned the depenalisation of abortion in early 2013, the ATFD reacted by organising internal meetings and by publishing the booklet mentioned above on the history of abortion in Tunisia. Among the historical feminist associations, the ATFD was the only one to publicly advocate the right to abortion. The UNFPA supported them as well as other NGOs working in the domain of women’s health, such as the Tunisian

18

Abortion in Post-revolutionary Tunisia

Association of Reproductive Health (ATSR) and the Groupe Tawhida Ben Cheikh, which has been extremely active in defending abortion and contraception rights since its creation in early 2012. Selma Hajri,26 the president of this association and the physician who introduced medical abortion in Tunisia (Hajri 2004), explained during an interview with the Tunisian newspaper La Presse that, by the end of the 2000s, even before Ennahdha came to power, midwives and certain physicians began to manifest religious conservatism. This religious conservatism has affected the practices of healthcare providers . . . and after the elections of 2011, these attitudes were legitimised . . . Several ONFP clinics especially in the South: Tataouine, Gafsa, Sidi Bouzid, Siliana . . . stopped providing abortion care. Some clinics provided it again after 2013; others not yet. (Lahbib 2015)

The ATFD, Groupe Tawhida Ben Cheikh, ATSR, IPPF and UNFPA together with many anonymous healthcare providers – who daily worked on the frontline despite the unstable and sometimes hostile environments in which they had to practise – have played a major role in defending women’s right to abortion when it was openly put into question.

Conducting Ethnographic Research after the Revolution of 2011 When I arrived in Tunisia in August 2013, the constituent assembly elected in October 2011 was still working on the new constitution; the transitional government that was supposed to last only one year seemed endless (Gobe 2012), and a strong feeling of uncertainty and insecurity was common among the people I met. The strong economic crisis, the ideological divisions between Islamists and secular parties and the disappointment of a large section of the population after the end of Ben Ali’s regime were also very much present in the daily lives of Tunisian citizens. Taxi drivers, medical doctors, state officials, teachers etc. were all complaining about the situation of Tunisia, which they regarded as very negative. Narratives about the country’s previous order, security, cleanliness and well-being were common, and conspiracy theories about the revolution were widespread. Abortion was probably not the main issue for many of my interlocutors, but it was crucial for the women who wanted to terminate their pregnancies, as well as for many health professionals

Introduction19

working in ONFP clinics, government hospitals and various Tunisian NGOs and international organisations, such as the UNFPA and IPPF. My research has focussed on government facilities offering abortion and contraception care in the area of Grand Tunis (Great Tunis), which includes four governorates: Tunis, Ariana, Ben Arous and Manouba, whose population is slightly more than 2.5 million inhabitants, according to the last national census completed in 2014.27 I have carried out participant observation in three ONFP clinics offering sexual and reproductive health (SRH) services and abortion care, including the family planning unit of one of the largest maternity hospitals in Tunisia.28 I have also become an active member of two Tunisian NGOs whose activities focus on women’s health. I have collaborated with the UNFPA and ATSR on various occasions as well as with the ONFP. The ministry of health and the ONFP, respectively, gave me official authorisation to carry out research in reproductive health facilities. My collaboration with the other institutions was based on mutual agreement and common interests. Although I have completed several formal interviews with healthcare professionals, university professors and personnel of health institutions, most of my ethnographic material derives from participant observation during consultations, informal conversations with the health professionals and the women using the government facilities where I conducted my fieldwork, and participation in workshops, conferences and meetings. I also collected various written, visual and digital materials produced by local and international institutions active in the domain of SRH in Tunisia. This book focusses on the ambivalent attitudes of healthcare providers and women towards abortion and contraception during the period of August 2013 to July 2014, when Tunisia was still going through a period of political transition. The public arena was characterised by an ideological division between those willing to go back to an authentic Arab-Islamic identity that was allegedly lost or repressed after independence and those defending the modernising project that Bourguiba initiated. Although many nuances exist on both sides, this division was very much present in my interlocutors’ discourses during my stay in Tunisia and affected the attitudes and ideas of healthcare providers working in clinics providing abortion care. Because the institutional supervision of public services at that time was weak due to the uncertainty of the political situation and the presence of recently appointed officials who were loyal to Ennahdha yet lacked qualified profiles and professional experience (see also Foster 2016), health professionals enjoyed a considerable

20

Abortion in Post-revolutionary Tunisia

degree of autonomy. They were able to freely express their opinions and to act accordingly, which in some cases meant that they refused to provide abortion care to certain categories of women or to all of those seeking it. Negotiations, conflicts, even the harassment of some members of staff were not uncommon, and local arrangements were found at various moments to deal with abortion cases. These arrangements depended on the personnel’s ethical and political positions in each institution, as well as on their national and local political circumstances, as I will show in the following chapters. As for my work with NGOs, without having planned it, I started to collaborate more actively with two of them, and I took part in several workshops, organisational meetings and informal discussions that significantly helped me to enter the healthcare milieu in which I was interested. It was an unforeseen opportunity that expanded on what I had hoped to study. Becoming an active member of some NGOs allowed me to have reflexive discussions with providers about their moral and professional positions, experiences and feelings towards women’s (and men’s) sexuality, reproductive trajectories and conceptions of the family and of the ontological status of the foetus. My reflections on the discourses and practices of abortion in postrevolutionary Tunisia are framed by the larger historical, political and cultural contexts in which a specific reproductive governance (Morgan and Roberts 2012), gender regime and social practices are inscribed. The language, actions and interactions of the local actors I describe must thus be interpreted in light of this context insofar as it shapes their forms of life and grammar to use a Wittgensteinian terminology.

Structure of the Book The book is organised into four chapters that through the analysis of discourses and practices related to abortion and contraception investigate larger issues related to women’s position and status in Tunisian society in the post-revolutionary period. I question the idea that there was a substantial change in clinicians’ and women’s practices and discourses related to the body, sexuality, reproduction and gender relationships after the revolution. I intend to show that although the revolution brought about some important changes it did not radically transform local values and norms in the medical domain I studied. Among the new phenomena I observed were the

Introduction21

possibility of publicly expressing one’s opinion, the open political and social engagement of clinicians, the mobilisation of previously suppressed religious and moral registers in the clinical encounter, the health professionals’ refusal to offer abortion and contraceptive care, the decreasing number of government facilities offering abortion services, the lack of state control over medical personnel, and the conservative turn witnessed by the personnel in the government sector in charge of sexual and reproductive care. However, practitioners’ conservative attitudes and symbolic and physical violence against women using government clinics and hospitals were not new and showed that the change concerned the possibility for healthcare providers to publicly express opinions and act against the law or medical regulations rather than major transformations of social norms and values. As for the clinic users I met, when comparing their discourses and behaviours with the testimonies of women in the 1980s, collected by Lilia Labidi (1989), I found that the majority of them were less concerned by religious preoccupations and social norms about abortion and sexuality. They manifested very pragmatic attitudes and, in many cases, consciously took responsibility for their sexual and reproductive conduct. The book also explores the complex moral world of healthcare providers working in government SRH facilities, as well as that of their users, who are mainly women belonging to the poorest strata of the population. Because of the methodological choices I made, I spent more time and had more opportunities to speak with healthcare providers than with women using government clinics. Although I observed the interactions between providers and patients and had frequent conversations with women seeking contraceptive and abortion care, I did not systematically interview them. As a result, I established more intimate relationships with clinicians than with their patients, and this explains why the former are given more space than the latter. Finally, the book offers an analysis of the ‘arenas of constraint’ (Inhorn 2011: 91) that shape the asymmetric relationships between clinicians and patients, as well as their impact on the contraceptive and abortive itineraries of Tunisian women who resort to reproductive and sexual health clinics in the public sector. The first chapter examines the debates around women’s role and rights in the political arena, focussing particularly on the discussions on the right to abortion that took place in the constituent assembly in early 2013. It considers the ideological struggles between Islamist and conservative forces, on the one hand, and the more secular and

22

Abortion in Post-revolutionary Tunisia

progressive parties, on the other, that focus on the new constitution and their commitment to preserving women’s acquired rights or to introducing new principles, such as that of the complementarity between women and men – which justifies openly discriminating policies. It also examines the activities of two local NGOs that are active in the domain of SRH to show how the political and social transformations that Tunisian society experienced in the first years after the revolution have affected the discourses and practices of health professionals and activists. I describe some training seminars that these two NGOs have organised for health providers and activists so as to unpack the various local moral regimes and the role of Tunisian and international actors in shaping discourses about women’s conduct and social roles. In the second chapter, I set aside public debates and discourses that NGOs have promoted and enter into the clinics and into the hospital, where I completed participant observation and explored medical practices in the domain of SRH. I analyse the medical, social and moral norms that healthcare providers transmitted during consultations, as well as the attitudes of women using government facilities. I investigate the multiple representations of the physiology of the female body that clinicians and patients have and how they affect contraceptive practices. Each contraceptive method is perceived in various ways among professionals and patients, and their effects on women’s bodies are framed according to a particular knowledge system. I also pay attention to how power relationships between healthcare providers and patients shape their interactions. A distinction is made between the contraceptive and reproductive norms that practitioners apply to married and unmarried women, as in their eyes, they belong to two separated moral and social categories of citizens and patients. I conclude with the analysis of healthcare professionals’ representations of the sexual behaviours of unmarried women and how they affect their conduct towards this category of patients. Chapter 3 investigates the question of unwanted pregnancies and the attitudes of healthcare providers working in government facilities towards women seeking contraceptive and abortion care. It shows that most healthcare providers and clinic users have internalised the ideologies of modernisation and neoliberal rationalities, although other logics or practical impediments can prevent women from abiding by the norm of the ‘willed pregnancy’. Reproductive and sexual health clinics are considered to be places where anatomo-political work is conducted on women’s bodies and subjectivities. Biomedical, discursive and administrative devices are used to ‘order’ women’s

Introduction23

bodies and regulate their moral and social lives in an attempt to subordinate them to the state’s interests and to the patriarchal norms of society. Unplanned pregnancies are apprehended as the expression of a lack of discipline, order and responsibility of women who fail to incarnate the modern feminine subject in charge of ensuring the well-being of the family and consequently of the entire society. The treatment of pregnant unmarried women seeking abortion care in government reproductive and sexual health clinics is particularly significant in that together with sex workers they represent the most marginal figures of the locally conceived feminine identity. Youth-friendly units within sexual health clinics – which are meant for unmarried users – show the strict forms of the medical, social and moral surveillance that specific administrative practices ensure, as well as the informal behaviour of healthcare providers. Surveillance devices are often not just intended to perform pedagogic and disciplinary work but also imply various forms of symbolic violence that are examined in this chapter. Policing techniques designed to identify and control women’s sexual and reproductive behaviours are part of the machinery that the medical authorities have set up and are specifically intended to control both unmarried women and married women manifesting undisciplined conduct. Particularly in this chapter, I draw on feminist literature on family planning and the imagination of the modern subject because it has significantly questioned the medical and demographic state-based rationalities dominating the work accomplished in government SRH clinics. In Chapter 4, I describe how the biomedical visual culture has affected healthcare professionals’ as well as their patients’ representations of early pregnancy, the embryo-foetus and abortion. Ultrasound scans that have contributed to the transformation of the foetus in a patient and a new moral subject in the Global North do not seem to play an important role in shaping the perceptions of most users of government SRH clinics, whereas Tunisian healthcare providers have internalised technological images and the foetal development theories of biomedicine. As a result, various conceptions of the body and of the embryo-foetus coexist in the space of SRH clinics, generating different ontologies and moral configurations in relation to abortion. Popular representations of early pregnancy are examined in light of the local theory of the ‘sleeping child’ and the Islamic precept of ensoulment, conceived as the divine act transforming the product of conception into a person. The rest of the chapter is dedicated to the analysis of the discussions that took place during several training seminars that

24

Abortion in Post-revolutionary Tunisia

a Tunisian NGO organised among health providers (and a few employees of the administration) working in SRH facilities. These discussions addressed abortion, contraception, sexuality, sex education of young people, sexual relationships and the experiences and attitudes of healthcare providers towards SRH. These exchanges were very rich and allowed me to evaluate the complexity of the postures of health providers caught up within various moral economies, rationalities, individual trajectories and material constraints. During these training seminars, which lasted two days and brought together several providers working in various facilities offering the same services, I had access to reflections, feelings and experiences that were rarely manifested in other circumstances. It is useful to think about the complexity and contradictions in which healthcare providers were caught up in light of the state rationalities examined in the previous chapters and the medical logics that frame their daily practices in the government clinics. Government SRH facilities abide by organisational, administrative and moral logics that are largely state-determined and thus play an important role in shaping clinicians’ subjectivities. In the conclusion, I consider the contradictory and paradoxical effects brought about by the democratisation of Tunisian society in the domain of SRH and on women’s sexual and reproductive trajectories. I particularly emphasise the elements of continuity embedded in the new social practices and discourses I witnessed that, despite important changes, did not radically subvert the previous configurations of Tunisian society.

Notes   1. For more detailed discussions of abortion in the Islamic tradition see Brockopp (2003); Bowen (1997, 2002); Hessini (2007, 2008); Musallam (1983); Shapiro (2013).   2. ‘Muslims universally agree that on all levels, whether the family, the community, or religious teaching, the primary concern must be for the life of the mother, and her welfare precedes any concern for the fetus’ (Bowen 2003: 64). Today, all Islamic countries recognise this principle in the abortion legislation.   3. WHO defines abortion on request as follows: ‘this legal ground recognizes the conditions for a woman’s free choice. Most countries that allow abortion on request set limitations for this ground based on duration of pregnancy’ (WHO 2012: 103). Abortion for social and economic

Introduction25

reasons is instead ‘interpreted by reference to whether continued pregnancy would affect the actual or foreseeable circumstances of the woman, including her achievement of the highest attainable standard of health.’ Some laws specify allowable reasons, such as pregnancy outside of marriage, failed contraception or intellectual disability affecting capacity to care for a child, while others only imply them. Laws may also require distress as a result of changed circumstance; for example, the distress of caring and providing for a child additional to existing family members (ibid.: 103).   4. Unsafe abortion is defined by the World Health Organization (WHO) as a procedure for terminating an unintended pregnancy carried out either by persons lacking the necessary skills or in an environment that does not conform to minimal medical standards, or both (WHO 1993).  5. This geographic notion includes Bahrain, Iraq, Jordan, Kuwait, Lebanon, the State of Palestine, Oman, Qatar, Saudi Arabia, Syria, the United Arab Emirates, Yemen as well as Armenia, Azerbaijan, Georgia, Cyprus, Israel, and Turkey.   6. In this section I voluntarily adopt the terminology of the United Nations to designate the legal grounds for pregnancy termination.  7. On this point, see Bowen (1997: 173) and Hessini (2008: 20–22). These authors underline the European origin of abortion laws in Muslim-majority countries in Asia and Africa. For example, in colonial Tunisia abortion was forbidden and, even after independence, French doctors working in Tunisian hospitals refused to perform them (Foster 2001).  8. On the complex interaction between secular and Islamic discourses on family planning and abortion, see for example the study of Emma Varley (2012) on Pakistan.   9. The French text is the following: ‘Quiconque par aliments, breuvages, médicaments, ou par tout autre moyen aura procuré ou tenté de procurer l’avortement d’une femme enceinte ou supposée enceinte, qu’elle y ait consenti ou non, sera puni d’un emprisonnement de cinq ans et d’une amende de dix mille dinars ou de l’une de ces deux peines seulement. Sera punie d’un emprisonnement de deux ans et d’une amende de deux mille dinars ou de l’une de ces deux peines seulement, la femme qui se sera procurée l’avortement ou aura tenté de se le procurer, ou qui aura consenti à faire usage des moyens à elle indiqués ou administrés à cet effet. L’interruption artificielle de la grossesse est autorisée lorsqu’elle intervient dans les trois premiers mois dans un établissement hospitalier ou sanitaire ou dans une clinique autorisée, par un médecin exerçant légalement sa profession. Postérieurement aux trois mois, l’interruption de la grossesse peut aussi être pratiquée, lorsque la santé de la mère ou son équilibre psychique risquent d’être compromis par la continuation de la grossesse ou encore lorsque l’enfant à naître risquerait de souffrir d’une maladie ou d’une infirmité

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Abortion in Post-revolutionary Tunisia

grave. Dans ce cas elle doit intervenir dans un établissement agréé à cet effet. L’interruption visée à l’alinéa précédent doit avoir lieu sur présentation d’un rapport du médecin traitant au médecin devant effectuer ladite interruption’ (Penal Code, Art. 214). 10. Since the Tunisian Women’s Union was created as ‘a transmission belt in order to enforce the state politics of women’s emancipation’ (Marzouki 1993: 176), we can reasonably imagine that the liberalisation of abortion was a government strategy to increase the efficacy of its family planning policies as also argued by Lapham (1976). 11. On the history of family planning in Tunisia: Brown (1981), Foster (2001), Gastineau and Sandron (2000), Gastineau (2012), Sandron and Gastineau (2000), Vallin and Locoh (2001). 12. This term indicates the moment in which the soul is insufflated into the foetus. 13. See for instance Gueddana (2001: 215). 14. Precise numerical targets were established at different stages of the family planning programme. For example, in 1973 ‘The Minister of Health Mohamed Mzali launched a drive to carry out 500 female sterilization in Jendouba province [in the Northwest] within a four month period . . . Eager to please, local authorities managed to carry out 1200 sterilizations in the time period’ (Jones quoted in Foster 2001: 86). Nabiha Gueddana, a former president of ONFP, explains also that 250,000 IUDs were to be inserted by midwives between 1966 and 1971 (2001: 212). 15. On this concept and its effects on the Tunisian health programme for women in the 1980s see Foster (2001: 99ff.). 16. Tahar Haddad and his book Our Women in Shari’a and Society (1930) anticipated these reforms, although the time was not ripe for accepting his ideas when he wrote it. Regarding Tahar Haddad, see, for example, Grami (2008); Sraieb (1999). 17. For more details on the reforms that contributed to change in Tunisian society, see Charrad (2001, chapter 9). 18. Women’s organisations that existed during the colonial period were dissolved, and the UNFT was created to spread the good word of the president and of the party (Bessis and Belhassen 1992: 74). Bourguiba stated that the union was created ‘to approach ordinary women, to investigate their way of life and to commit to improving it gradually’ (quoted in Bessis and Belhassen 1992: 74). 19. ‘The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), adopted in 1979 by the UN General Assembly, is often described as an international bill of rights for women. Consisting of a preamble and 30 articles, it defines what constitutes discrimination against women and sets up an agenda for national action to end such discrimination’ (http://www.un.org/womenwatch/daw/ cedaw/, consulted on 28 October 2016).

Introduction27

20. Regarding the reform of inheritance law, in postcolonial Tunisia, see the analysis of Charrad (2001: 228–31). Regarding disparities between rural and urban women, see Omri (2009: chapters 3 and 4). Regarding other legal inequalities, see Chekir (1996) and Bouraoui (1987). 21. Ben Ali removed Bourguiba from power in 1987 and became the second president of Tunisia. He fled the country in January 2011 during the revolution. 22. As Bourguiba stated in an interview, ‘Indeed, there was no feminist movement demanding the promulgation of a Code of Personal Status or the abolition of polygamy’ (quoted in Charrad 2001: 219). All historians in Tunisia recognise the absence of a grassroots feminist movement at the time of independence. See, for example: Bessis (2004); Charrad (2001); Marzouki (1993). 23. Several changes were made in the CPS after its promulgation aimed at improving women’s rights, but women’s legal status is still not equal to men’s (Ben Achour 2007, 2016). 24. The question of complementarity during the drafting of the new constitution caused a heated political debate and several public demonstrations. The engagement of feminist associations and the civil society was critical for reinscribing the principle of men’s and women’s equality in the new constitution (Mahfoudh and Mahfoudh 2014). 25. Regarding the post-revolutionary feminist movements in Tunisia, see the special issue of Nouvelles Questions Féministes dedicated to the topic ‘Féminisme au Maghreb’ (2014); Daniele (2014); Debuysere (2016); Khalil (2014); Labidi (2014); Tchaïcha and Arfaoui (2012); Zlitni and Touati (2012). 26. Selma Hajri is also a member of the ATFD and its internal Committee for Sexual and Bodily Rights. 27. In 2014, the total population, including foreigners, residing in the country for more than six months was 10,982,754, from the website of the Institut National de la Statistique http://www.ins.tn/fr/resultats. Retrieved 28 October 2016. 28. I conducted fieldwork for nine months in the hospital, eight months in two of the ONFP clinics and two months in the third one. The different duration of participant observation in every facility is related to access authorisation.

Chapter 1

Putting Abortion into Question Debates, Actors and Stakes after the Revolution

Secularists, Islamists and the Woman Question

I

mmediately after the revolution, the issue of women’s rights and their role in local society became a major topic of debate, opposing secular political forces and the newly reconstituted Islamist party Ennahdha (Gray 2012). The definition of the national identity and women’s position in the family and society were the battlefields on which adversaries fought to impose their own political agenda. While women were at the centre of the discussions, they were not the main actors on the political scene. Despite the law of gender parity1 – promulgated before the elections of October 2011 – requiring that political parties have ‘equal gender representation’ (Khalil 2014), the women elected represented only 27 per cent of the constituent assembly. The very high number of parties that allowed the election of only one representative in each electoral district and the fact that only 7 per cent of candidates were female did not grant effective parity (Chekir 2016: 371). Women were also largely absent from the transitional commissions established before the elections of 2011 and the following provisional government. Thus, after their active participation in the revolution, very few women were involved in the post-revolutionary political institutions and decision-making processes. Instead, they became an object of discussion,2 used to redefine the identity of post-revolutionary Tunisia as had already happened in two previous transitional periods: in

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1956, when Tunisia became ­ independent from France, and in 1987, when Bourguiba was deposed by Ben Ali. In both situations, women’s rights became a crucial concern for the state and civil society.3 Indeed, the CPS was promulgated in August 1956, three years before the constitution (1959), while Ben Ali officially declared his commitment to the CPS after the Islamic Tendency Movement (MTI, later Ennahdha) had proposed to modify it because it was deemed ‘a product of the West and Westernization, imposed on the country by one person’ (Ghanmi quoted in Labidi 2007: 19). In 2011, the official position of Ennahdha was that the CPS had become part of the Tunisian heritage, although it was still possible to improve it (Gray 2012).4 Ennahdha was in power from October 2011 to January 2014 but was replaced by a government of national union in the following months until the parliamentary elections took place in October 2014. Islamist attempts to replace the principle of men’s and women’s equality with that of complementarity and to criminalise abortion did not succeed thanks to the mobilisation of feminist groups, secular parties and other components of civil society. The complementarity issue in particular gave way to several demonstrations and protests, culminating on 13 August 2012 during the commemoration of the promulgation of the CPS. After repeated discussions within the constituent assembly, articles 21 and 45 of the new constitution promulgated in 2014 reaffirmed women’s and men’s equality of rights and duties. In short, after the revolution, once again in the history of Tunisia, women were at the centre of the political and ideological debate, opposing the advocates of modernist secular discourses and those of Arab-Islamic authenticity. This opposition dates back at least to the second half of the nineteenth century, when a debate took place within the reformist movement over the role of women in society. Already in 1867, the Secretary of Bey Ahmed Kheireddine emphasised the importance of educating women in order to make them good wives and mothers and help in the regeneration of the country (Ben Youssef Zayzafoon 2005). In the late 1920s, positioning himself in the nationalist debate that developed in opposition to the French colonial presence, Bourguiba argued that Tunisian women should wear the veil because ‘veiling is a custom that has entered into our ethics centuries ago. It is now part of who we are’ (quoted in Ben Youssef Zayzafoon 2005: 101). Interestingly, while Bourguiba, despite being a secular and nationalist politician trained at the Sorbonne, defended the veil against the French, Tahar Haddad, the well-known reformist who had trained at the Zaytouna

Putting Abortion into Question31

Mosque, argued for the unveiling of women. In Our Woman (1930), he wrote that the veil is an instrument of male oppression that relegates women to the role of passive individuals under men’s tutelage (Ben Youssef Zayzafoon 2005). Although after independence Bourguiba adopted a modernist view of the state and transformed many of Haddad’s ideas into social reforms, including the unveiling of women, he never adopted a secular interpretation of social institutions. He justified all his reforms by drawing on the Islamic tradition of ijtihad, which allows for interpreting and adapting the precepts and norms of the past to the present. The conflicting positions of Bourguiba and Haddad in the early 1930s also show that the debates over modernisation and authenticity/tradition cannot be reduced to the opposition between religious conservative forces and advocates of modernity. This ambiguity is still present in post-revolutionary Tunisia, where, as already noted, secular, modernising politicians are recalcitrant to adopt reforms that guarantee full equality between men and women, often in the name of cultural authenticity, whereas religious figures are sometimes ready to justify reforms in the name of Islamic principles. Similar oppositions between conservative religious actors and modernist secular forces have characterised the history of several countries in the Middle Eastern region since the time of independence (Kandiyoti 1991). In all these contexts, one of the main objects of contention was the role of women in local society because as markers of cultural specificity they played a central role in the construction of local nationalism and anticolonial discourses. Deniz Kandiyoti underlines that ‘women were used to symbolize the progressive aspirations of a secularist elite or a hankering for cultural authenticity expressed in Islamic terms’ (ibid.: 3). In Tunisia, like in many other Arab states, the ‘woman question’ was and still is very important in the process of nation building, although the social and political arrangements reached have been different and constantly readapted to the changing contexts (Abu Lughod 1998). Women and the family occupied and still occupy a central place in the search for legitimacy of the Middle Eastern states in that they are deemed the custodians of authentic cultural values and social integrity. The case of Erdogan’s Turkey (Dayi and Karakaya 2018) and that of post-revolutionary Tunisia indicate that women’s place and role in society are still used to legitimate the ideologies and actions of present political actors and define the boundaries of modern states (Kilani 2018).

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Despite their central place in the public debate, in post-­ revolutionary Tunisia, women were largely excluded from state institutions, and their image was used by political forces to gain power and impose an ideological agenda. Compared to the previous periods in which the discussion around women’s role in society appeared, what was new in the post-revolutionary period was the public emergence of an Islamist women’s movement that had been repressed and silenced in previous decades (Gray 2012; Khalil 2014). Within the movement, there were divergent positions about the role women should play in post-revolutionary society that did not correspond to the monolithic image many secular feminists had. Moreover, in 2011, Islamist female associations’ objectives were very similar to those of secular feminists, such as the ‘common struggle against authoritarianism, preservation of the CPS, freedom in dress and religious worship, increased participation of women in political and public life’ (Khalil 2014: 198). However, the suspicious attitude of secular feminists was not unfounded, because contradictory positions emerged during the electoral campaigns of 2011: while the official programme of Ennahdha entailed references to the intangibility of the CPS, this point was not mentioned during public meetings and discourses of several of the party candidates. In addition, on 29 January 2011, women taking part in the first feminist demonstration after the end of Ben Ali’s regime were verbally and even physically attacked by individuals belonging to religious movements, asking them ‘to go back to their kitchen’ (Chekir 2016: 375). After the revolution, incidents of aggression in the streets against women who did not wear the hijab or who circulated at night multiplied, especially in poor urban areas, and several episodes were on the front page of local newspapers. In 2012, when religiously motivated individuals perpetrated violent assaults against the work of female artists, the transitional government of Ennahdha did not take any measures against them. Several artists have also been the victims of legal attacks, such as the filmmaker Nadia El Fani, who has been accused of ‘insulting the sacred, and violating moral values and religious precepts’ (Labidi 2014: 163).5 Moreover, new locally unknown Islamic precepts were circulated by some representatives of Ennahdha, such as Habib Ellouz, who in 2012 proposed introducing the practice of excision in Tunisia, defining it as ‘plastic surgery’ (Ben Dridi and Maffi 2018). Ellouz was influenced by Wajdi Ghanim, a well-known Egyptian Islamist preacher, who, after the revolution, was invited by several local associations, such as the Association for the Preservation of the Quran, to come to Tunisia. He preached in several mosques,

Putting Abortion into Question33

inviting pious citizens to excise their female children. The mobilisation of civil society – mainly lawyers and feminist and secular associations – was enough to stop the attempt to introduce female excision in Tunisia, where the practice does not exist. The episode did, however, affect the opinion of some groups of Tunisian society. A friend and colleague told me that in 2012, her cleaning woman, who at the time had two very young children, started to talk about the possibility of having her girl excised in order to make her pure and beautiful. Another colleague, who is a professor at the High School for Health Science and Techniques of Tunis, told me that several of her students were convinced that excision was a religious prescription and should be introduced in Tunisia. Instead of immediately contesting the opinion of her students, she asked them to conduct research on excision, drawing on the medical literature, because she realised that most of them did not understand what the practice entails. Eventually, a group of students presented the results of the research and expressed deep indignation and outrage over female excision, thus ending the discussion of its introduction.

The Abortion Debate Since the electoral victory of Ennahdha in October 2011, secular and leftist parties, modernist elites, feminist associations and other civil society associations such as LTDH (Ligue tunisienne des droits de l’homme, Tunisian League of Human Rights) and the women’s committee of the UGTT (Union Générale des Travaillleurs Tunisiens, General Union of Tunisian Workers) have carefully observed the drafting of the new constitution, several versions of which were discussed over the period of 2011 to 2013. Demonstrations, workshops, public statements and lobbying activities among representatives of the constituent assembly by civil society organisations strongly contributed to the defence of women’s rights. They had to oppose not only male Islamist politicians but also women’s organisations linked to Ennahdha that since 8 March 2013, on the occasion of the celebration of International Women’s Day, took large-scale action to call into question Tunisia’s international engagements in the domain of women’s rights and particularly those related to the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW) (Chekir 2016). While the final text of the constitution was welcomed by feminists with relief, some articles are ambiguous and leave the door

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Abortion in Post-revolutionary Tunisia

open to conservative interpretations that might threaten women’s rights. For instance, Article 22 states that the ‘right to life is sacred.6 It is not possible to violate it unless in extreme cases established by the law’. The article might thus threaten the right to abortion if the foetus is recognised as a human life. This possibility is very concrete if we consider that, as mentioned earlier, in January 2013, a deputy of Ennahdha tried to criminalise abortion in the name of the foetus’ right to come into the world. In 2015, in an interview, Rached Ghannouchi, the political and spiritual leader of Ennahdha, declared not without ambiguity that ‘on principle abortion should not be permitted’ because ‘it is an assault against life’. He considers that a woman can avoid getting pregnant also using contraceptive methods. However, Ghannouchi is not definitive and distinguishes between abortion after a period of 4 or 5 months – which he considers as a murder – and an abortion performed ‘before the development of the foetus’, that he regards as ‘possible’. (Ben Hamadi 2015)

Even before the attempt of Najiba Berioul to change the law and the ambiguous position expressed by Ghannouchi and other Ennahdha representatives, the conservative turn taken by many healthcare providers in the late 2000s – which I have already mentioned – pushed the ATFD to organise a workshop on the ‘Right to abortion and access to abortion services in post-revolutionary Tunisia’ on 9 November 2012 during the 4th international campaign of the Coalition for Sexual and Bodily Rights in Muslim Countries (CSBR).7 The ATFD, one of the founding members of the CSBR that includes women from Arab and Muslim countries, has been active in the domain of sexuality, bodily rights and violence against women since its creation in the early 1980s (Le droit à l’avortement en Tunisie –1973 à 2013 2013: 3). The workshop of 2012 – which was the origin of the already quoted booklet Abortion rights in Tunisia –1973 to 2013 – was conducted by three ATFD members, who are committed to the defence of women’s sexual and reproductive rights: Amel Aouij, a professor of rights at the University of Tunis al-Manar and a bioethicist;8 Selma Hajri, a physician and the president of the NGO Groupe Tawhida Ben Cheikh; and Anne-Emmanuelle Hassairi, midwife and ONFP official. Spreading Opposition to Abortion Care after the Revolution Along with ATFD, another Tunisian NGO founded shortly after the revolution (which I will call the Reproductive Health Association

Putting Abortion into Question35

[RHA]), has been particularly active in the domain of women’s health, organising training seminars, workshops and conferences for healthcare providers working in the field of SRH. Its activities have not been limited to advocacy campaigns and public demonstrations but have directly targeted those practitioners in charge of reproductive health services in the government health sector. The choice to work with medical personnel was motivated by the conservative attitudes shown by health professionals in government reproductive health clinics, emphasised by the ATFD (2013) and Selma Hajri et al. (2015). The reticence of healthcare providers concerns principally, but not exclusively, abortion care because emerging religious movements have condemned abortion, equating it with murder. A young midwife with whom I collaborated over several months in an ONFP clinic told me that she felt very badly when a taxi driver once asked her whether she worked in the ‘place where they kill the babies of unmarried women’. Indeed, she had worked for a while in the youth-friendly unit, the section of her clinic meant for unmarried citizens, and she was shocked to see ‘how many babies were killed’ (Najet, 4 April 2014). This midwife – who had become very religious shortly before the revolution9 – experienced an inner struggle until she decided that she could not offer abortion care anymore. According to the head midwife in charge of the clinic where she worked, for some months, Najet10 used to read verses of the Quran in front of her patients to persuade them not to end their pregnancy. The act of reading the Quran to convince women not to abort seems to have become common practice (at least after the revolution) because on different occasions three other midwives working in government facilities related similar episodes.11 The refusal by some health practitioners to offer abortion care was not the only manifestation of the post-revolutionary changing social environment. Women seeking abortion care were not the only victims of these new behaviours, as some abortion providers were the target of (symbolically) violent discourses and actions. Another midwife, who provided abortion and contraceptive care in a hospital in the capital, told me that she had been the object of repeated verbal attacks by other members of the personnel because of her professional activities. She received a threatening letter in which the author condemned her for committing sin (providing abortion care), arguing that if the hospital were bombed by religious extremists, it would be her fault and that she would go to hell for what she had done. She also told me that she found some graffiti on the hospital walls threatening her because she offered abortion care.

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Abortion in Post-revolutionary Tunisia

The same practitioner was also the victim of repeated verbal aggressions by a secretary at her hospital, who, after a long period of sick leave, had come back to her workplace with a face veil – which she did not wear earlier – and manifested an intolerant religious attitude (fieldnotes, September 2013). An obstetrician-gynaecologist with whom I collaborated during my research and who worked in the government hospital in a city in central Tunisia told me that after the revolution the department had stopped offering abortion care because the head physician was a supporter of Ennahdha and explicitly said he was against abortion. In the spring of 2014, an official working at the ONFP told me that she had been involved in the recruitment of the new head midwife of a clinic in a southern governorate. She was very upset because the midwife who was eventually hired had publicly declared that she was against abortion, although she was going to be in charge of the paramedical personnel of a clinic offering abortion services as there is a law granting this right to Tunisian women. These fragmentary stories12 confirm what the studies I cited previously show: a conservative turn nurtured by Islamist repertoires and interpretations contributed to important changes in the medical environment I have studied. These changes – that had already started in the mid-2000s – were triggered by the revolution of 2011, which liberated the citizens from the authoritarian power of Ben Ali’s regime, leaving the possibility for repressed forces, ideas and practices to surface and take root. The fact that after the revolution ten ONFP clinics out of twentyfour and most regional hospitals did not offer abortion care anymore, together with the few episodes I narrated and the newspaper articles I mentioned, shows that abortion stigma was on the rise in Tunisia and that both women seeking abortion and healthcare providers were the victims of religion-based moralising attitudes. Healthcare providers were also sometimes reluctant to offer some types of contraceptive methods as they equated them with early abortion. For instance, several midwives working in ONFP clinics told me that some of their colleagues did not want to insert intrauterine devices (IUDs) anymore because they regarded this technology as preventing the implantation of the conceptus into the uterus. The mounting conservative attitudes of health professionals and the lack of control by state medical institutions over public hospitals and reproductive health clinics after the revolution forced an increasing number of women to undergo complex and painful therapeutic itineraries in order to get abortions and sometimes contraceptive

Putting Abortion into Question37

care (Hajri et al. 2015). Recently, testimonies of health professionals and patients have appeared in national newspapers (Bizid 2014; Boukhayatia 2016; Kapitalis, 30 March 2013; Lac 2016; Lahbib 2015), showing that women’s troublesome therapeutic itineraries – especially when seeking abortion – are attracting the attention of the media. Another important cause of women’s tribulations is related to financial cuts and medicine provision. The Tunisian state’s financial resources were heavily affected by the world financial crisis of 2008 (Mouley 2013) and the revolution of 2011, worsening an already deteriorating situation that had been sustained by Ben Ali’s regime (Allal 2010; Cassarino 1999; Hibou 2005; Tunisia: Economic and Social Challenges beyond the Revolution 2012). In April 2014, shortly after taking his functions, then Prime Minister Mehdi Jomaa affirmed that ‘“the picture is darker than he was led to imagine”. However, things seem a lot worse amid risks of payment cessation on the part of the state’ (Business News, 2 April 2014). In September 2016, during an official visit to France, Fadhel Abdelkefi, the Tunisian minister of investment, declared that Tunisia had ‘an “abyssal” public deficit at 6,5% of the GDP and a public debt at 63% (of the GDP) that has more than doubled in the last five years’ (JeuneAfrique, 29 September 2016). Thus, when in November 2016 a midwife responsible for the family planning unit of a hospital in Tunis told me that the ONFP was running out of stock of several contraceptive methods and mifepristone (used for medical abortion), I was not astonished. Already during the spring of 2014, several ONFP clinics in Tunis – that are usually better equipped than those in the internal regions – were deprived of the paper forms for medical records during one month because the ONFP had not provided them with new material. Moreover, the economic crisis had a direct impact on reproductive health services in the public sector because, as mentioned above, most regional hospitals, which are understaffed and under constant pressure, stopped offering abortion and contraceptive care. Contrary to what some have suggested (Crétois and Attia 2018), I do not believe that there was a clear political will to neglect the domain of SRH in the last few years, because the entire public healthcare sector was going through a dramatic crisis that became a central problem a few years after I left Tunisia. Although many hospitals in the south and west of the country were severely understaffed and lacked equipment and medicines well before the revolution (Samoud 2017), the lack of life-saving medicines became a reality in all regions of the country by the end of 2017 (Attia 2018).

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If IUDs, contraceptives and abortion and emergency pills were exhausted in ONFP clinics and pharmacies, according to Mustapha Laroussi, president of the Union of Retail Pharmacists, this is only the ‘tip of the iceberg’ because ‘an array of medicines is missing already, among which life-saving medicines: antiseptics, anxiolytics, antidepressants, some immunosuppressants . . . Overall, between 60 and 100 drugs are missing’ (Attia 2018). He also underlined that, although in 2016 his union had already reported the insufficient supplies in the previous years, ‘an intermittent crisis has become permanent’ (ibid.). This situation was generated by the impossibility of the Tunisian Central Pharmacy13 paying its debts to the international pharmaceutical companies that provided drugs to the country. For many months, the Central Pharmacy did not receive the monthly contributions that the Caisse nationale d’assurance maladie (The National Health Insurance) and the public hospitals were expected to pay. The devaluation of the Tunisian dinar and suspicions of corruption among the officers of the Central Pharmacy were also evoked to explain the tragic situation of the latter. Therefore, although it is true that the crisis of the ONFP had already started a few years before the revolution and that SRH had stopped being considered a national priority because the demographic preoccupations were not present anymore, faced with the dire conditions of the public health system, it seems difficult to interpret the lack of contraceptive and abortion methods as deliberate negligence.

The Values Clarification Training Seminar Confronted with this complex situation, the RHA has tried to intervene on the ground, as mentioned in the previous paragraph, organising several activities including a training seminar for healthcare providers, health workers (educateurs) and receptionists in ONFP and primary health clinics14 and Ministry of Health hospitals. This training seminar was organised regularly for a few years in different areas of Tunisia in order to reach the reproductive health professionals working in the various governorates. During my stay in Tunisia, I was able to attend five seminars and even became one of the trainers in the last two. Indeed, I was asked by the RHA president whether I was willing to take an active part in the training seminar because I had already attended three of them (one of

Putting Abortion into Question39

which was to train other trainers rather than to perform the normal activities with health professionals), and I accepted. My participation in the five training seminars was extremely enriching because I learned a lot from the discussions I had with the participants and had the opportunity to meet people working in different facilities and regions.15 The training seminars lasted a day and half and usually included ten to fifteen people from among the public and three to five ­trainers. The official aims of the RHA in offering this seminar were clearly expressed in the introductory pages of the booklet for trainers: This manual is our first action to reach more equality between men and women in terms of reproductive health . . . to defend women’s reproductive rights, although the battle will not be easy. One of the main factors we want to tackle is the negative perception that healthcare providers have of reproductive health, emphasising the importance of their work to save women’s lives and reminding them of their professional obligations as health professionals and of the fact that their personal opinions should not violate women’s rights. (RHA 2013: 3)

The training seminar aimed particularly to ‘improve the knowledge and commitment of reproductive health professionals and contribute to eliminating the barriers hindering the access to abortion and contraceptive care as well as facilitate the access to these services for young people’ (ibid.: 6).16 The handbook is an adaptation of several other publications by three US-based NGOs (IPAS, CFC and NAF)17 that are active in the field of sexual and reproductive rights in the United States and around the rest of the globe. At the beginning of the seminar, the trainers made several presentations that tackled different topics: statistics and legislations regarding abortion worldwide, global maternal mortality related to banning abortion; sexual and reproductive rights and the international treaties protecting them; abortion in Arab countries and in Tunisia; and abortion and Islamic teaching. They also explained that the training seminar sought ‘to examine the fundamental values of each participant and reflect on them in order to understand what is important and meaningful’ (from one of the slides used in the presentation). While the trainers insisted that they do not want to change the participants’ ideas and values, they nevertheless conveyed a clear message: women have the right to make their own choices and health professionals working in reproductive health clinics and hospitals must respect their patients’

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rights to self-determination. The logical solution if they do not agree to offer abortion care is to work in another type of facility, as reproductive health clinics are meant to offer all sexual and reproductive services – or at least refer women to other abortion providers. However, testimonies of healthcare professionals and patients indicated that in many facilities women were turned away without being directed to other providers (Hajri et al. 2015; Maffi 2016). It is interesting to note that these practitioners’ behaviours were not officially declared and classified under what is called ‘conscientious objection’ in many countries. The president of the RHA told me that they had trouble translating this expression in the Values Clarification handbook, since, according to her, it does not exist in Arabic (or at least is not used). The expressions proposed by the Tunisian translators, rafad al-damir or ta’nib aldamir (RHA booklet: 22), were not really understood by the health professionals participating in the training seminar and hence did not create a debate. However, in all seminars I attended, one of the trainers introduced this concept to affirm that health professionals should respect the International Federation of Obstetricians and Gynaecologists (FIGO) Resolution on Conscientious Objection (2006), which states that they have to: 1. Provide public notice of professional services that they decline to undertake on grounds of conscience; 2. Refer patients who request such services or for whose cares such services are medical options for other practitioners who do not object to the provision of such services; 3. Provide timely care to their patients when referral to other practitioners is not possible and delay would jeopardize patients’ health and well-being; and 4. In emergency situations, provide care, regardless of practitioners’ personal objections.18 The minor relevance of this concept during my fieldwork was probably derived from its absence in the local medical culture, where reproductive policies decided by the regime could not be questioned by practitioners if they wanted to retain their job and their social and economic status (Hibou 2006). The lack of democracy affected all spheres of life, including medical practice – especially in the domain of reproductive health – which, as already noted, was crucial in the socio-economic modernisation process promoted by the postcolonial state. Finally, it is also to be noted that, in Tunisia, ‘providers are

Putting Abortion into Question41

not officially able to object to providing abortion services, given the lack of a legal medical conscience clause’ (Raifman et al. 2018: 48). The political victory of Ennahdha, the wide circulation of conservative ideas about women’s role in society, the legitimation of previously banned or publicly condemned religious practices and values and the opening up of new spaces of expression all contributed to eliciting new attitudes among healthcare providers and created unprecedented situations. While their expression was new, conservative attitudes were nonetheless already present; in her Çabra Hachma: Sexualité et tradition (1989), Lilia Labidi describes the discourses of health professionals working in family planning clinics in the early 1980s as well as those of women she interviewed. According to Labidi, unmarried women seeking abortion were treated as ‘abnormal’, ‘asocial’ and ‘marginal’ persons as well as bad citizens (1989: 102). Many providers introduced a ‘non institutional’ interview – since the law does not require it – with these women ‘based on the midwife’s moral understanding of sexuality and dominant ideology’ (ibid.: 103). Labidi cites the shocking sentence of a physician who had to provide abortion care for a pregnant unmarried girl who was still a virgin:19 ‘I will take her virginity with my scissors to give her a lesson . . .’ (ibid.: 102). Despite the birth control policies of the time, health professionals transformed some medical acts into ‘dramatic events’ (ibid.: 102) so that women would avoid the abortion experience in the future. Unmarried women seeking abortion were (and are) particularly disturbing patients, since they ‘subvert the group’s order according to which sexuality is possible only within marriage’ (ibid.: 103).20 Labidi interviewed many women who had abortions and were imbued with a negative moral and religious view of this act. In the early 1980s, they often described abortion ‘as a crime, an infanticide – or as a fruit extracted before the term, an uprooted plant, in short, a sin’ (ibid.: 392). Thus, while it is true that after the revolution of 2011 many women had troublesome abortion itineraries, the attitudes publicly manifested by healthcare providers existed well before the recent emergence of Islamic moral repertoires. While in the previous decades the moral condemnation of unmarried women’s sexuality did not bring about the refusal of abortion care, it nevertheless elicited health professionals’ symbolic and physical violence against female patients. Moreover, the attitudes towards unmarried women in the 1980s were but an expression of a much older maledominated medical and social culture characterised by ‘contempt and distrust of women’ (Labidi 1989: 406).

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In light of these considerations, it is easier to understand the emphasis trainers put on the presentation about Islam, the law and abortion during the Values Clarification training seminar. They insisted on the complexity of the Islamic texts regulating abortion, emphasising the divergent positions of the four major legal schools in Sunni Islam and the necessity to take into consideration the circumstances in which an abortion is performed. They also cited the phases of foetal development – described in the previous chapter – stressing that ensoulment does not happen at conception but after a period of time that can vary according to the interpretations. Islamic ethics’ general principles were mentioned, such as that of the ‘lesser evil’ according to which between two prohibited acts, it is necessary to follow the rule of ahamm wa al-muhimm (the more important and the important). This means that, when one makes a choice, the less important has to be sacrificed to the more important. The trainers also insisted on the Quranic verse stating that ‘no mother should be harmed through her child’ (Surah 2: 233) (from a slide of the presentation). Without going into more detail, the trainers argued that religion cannot be glossed over, despite the existence of a state law granting women the right to abortion. As evoked above, Islam has become an idiom used in medical settings to justify behaviours and discourses contrary to women’s rights, state law and clinics’ regulations. The participants were often divided into two groups, one willing to completely separate religion from medical practice and the other regarding it as impossible when the life of a (future) human being, the foetus, is at stake. The Tunisian law and women’s rights were evoked by some participants, especially medical doctors. Halima, the president of the RHA, explained every time that, after the revolution, the ideological and political climate had changed and that reproductive health practices have become controversial. In a training seminar meant for future trainers, she said that ‘it is not possible anymore to impose on health professionals to do certain acts and that they have rather to be convinced’ (fieldnotes, 8 January 2014). She argued that ‘women’s sexual and reproductive rights and autonomy are not perceived as legitimate arguments, and one should rather stress that SRH services are important for the preservation of women’s health and to limit the social costs of illegal practices such as clandestine abortion’ (fieldnotes, 8 January 2014). Halima also suggested to health professionals that the ‘embryo’ shall be conceived of and presented to their patients and colleagues as the ‘project of a baby rather than already a baby, an unfinished being’ (fieldnotes, 9 January 2014). She thus adopted a view that

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conflates the Islamic-based theories considering ensoulment as happening one or more months after conception with what Luc Boltanski calls the ‘parental project’ (2004: 135). According to the French sociologist, the ‘authentic foetus’ is the one that is desired and planned within a specific relationship between parents who engage in a long-term arrangement (ibid.: 173). All other embryos are ‘tumoral’, and thus ‘instead of being attracted by the future like the authentic foetus’, which is already conceived of as ‘child’ (ibid.: 174), are pushed back to the condition of non-existence. However, Halima did not make a clear distinction between a planned and unplanned foetus, which in the French medical context have two different terms, emphasising their differential ontological and moral nature: ‘baby’ if the pregnancy is inscribed in a parental project, and ‘embryo’ if it is not (ibid.: 178).21 She merges the two notions in order to underline that abortion cannot be compared to the killing of a child because the latter has to be thought of as an incomplete entity that can potentially become a human being. Despite Halima’s affirmation, in all training seminars I attended several participants were firmly convinced that as soon as women learn they are pregnant they feel as though they are mothers. The idea of a parental project deserves further consideration, as it is a crucial concept in the ideological background of international family planning. On the one hand, it assumes that women (and men) choose, plan and decide whether they want to procreate, an idea that is very much related to a definition of the subject promoted by a liberal model of thought in which the individual’s acts are rational, conscious and the result of choice and self-discipline (Ruhl 2002). Originally, the model of this subject was a middleclass, educated, white individual living in an industrialised democratic society. The medicalisation of contraception and the ethics of reproductive responsibility (Bajos and Ferrand 2006) that have emerged in the second half of the twentieth century triggered by the convergent efforts of different forces, such as the population policy establishment, the feminist movements and the US- and Europeanbased pharmaceutical industry (Petchesky and Judd 1998) have also played an important role in shaping the new self-disciplined reproductive subject. Family planning policies in many previously colonised countries funded and enforced by international and EuroAmerican donors have brought about new concepts and practices related to the notion of the liberal subject mentioned above (Ali 2002). Therefore, when designing early pregnancy as the project of a child, the RHA president communicated a message in a language

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corresponding to an international paradigm about the subject, women and the family within which parents ‘are self-conscious engineers who artfully construct the optimal conditions for their children to flourish’ (Ruhl 2002: 656). However, the idea of early pregnancy as a project is contradictory in the case of women seeking abortion because the concept presupposes the intention of procreation, and in most cases these women did not intend to procreate. In Tunisia, as I will illustrate in the next chapters, women who seek abortion did not use contraception correctly, were breastfeeding and thought this would protect them from getting pregnant, were afraid of using biomedical family planning methods, ignored when conception can occur, thought that superficial penetration would not get them pregnant, etc. Words Matter While the notion of early pregnancy as a project did not sound familiar to many participants in the training seminars I attended, more than once a discussion took place on how to speak about abortion with patients. During consultations, many practitioners and some patients used the term (t)unahhi el-saghir (eliminate the little one) or (t)unahhi el-bébé (in French, baby) instead of the standard Arabic term ijhadh, which is almost never employed. Trainers insisted that words are not neutral and that in the case of abortion, practitioners should never use expressions such as ‘Have you come to kill your baby?’ (tuqtul saghirik) or ‘You are a killer’ (anti mujrima) because they are a form of violence. They argued that these kinds of statements were not uncommon in government SRH facilities and that providers should change their discourse. They insisted on the necessity of avoiding these expressions and replacing the terms ‘baby’ or ‘little one’ with the word hbela (pregnancy),22 which, according to Boltanski, is a euphemism employed to deny the existence of the embryo and ‘pull it back to the nowhere from where it just came out’ (2004: 174). Trainers asked health practitioners to speak about ‘ending the pregnancy’ rather than ‘making the baby come out’ or ‘killing the baby’ and thus accusing women of being a ‘murderer’ or a ‘sinner’. They insisted that an embryo/foetus does not receive the ruh (human soul) before 120 days and therefore is not a human being in the first trimester.23 While many healthcare providers I met seemed to use the terms bébé, saghir, hbela, without consciously reflecting on the ontologies they imply, more than once I have attended consultations where the midwife or the doctor intentionally employed the term ‘baby’

Putting Abortion into Question45

to discourage the patient from getting an abortion for reasons I will explore in Chapters 3 and 4. This is a case of ‘ontological manipulation’ (Boltanski 2004: 171), which is often consciously attempted by healthcare providers who oppose abortion or oppose it in the case of a specific woman. Another issue partly related to semantics concerned the arguments providers should employ to legitimise abortion in front of opponents. One of the discussions elicited by the Values Clarification seminar offered health practitioners the ‘good reasons’ they might evoke to justify abortion care. The suggested arguments drew on medical, social, psychological and, in a limited way, legal registers. Although trainers presented information based on international conventions, the legal argument was perceived as weak because they thought that the ‘religious backlash’ of Tunisian society that took place especially after the revolution made citizens not ready to accept it. Therefore, evoking women’s rights to control their bodies, including their sexual and reproductive health, was often counterproductive, as this was considered as coming from the West and not aligned with local Arab-Islamic values and identity. Another possibility was to remind people that local ulamas (religious scholars) had agreed that ensoulment does not occur until 120 days after conception and therefore the law allows abortion until the end of the first trimester. If some women believe that it happens after forty days, they should be offered abortion care before this period has elapsed. Trainers insisted on the health argument because they believed that women’s health cannot be related to cultural or religious discourse. The high rate of women’s mortality related to unsafe and illegal abortions around the world was presented as important because it shows that women will still try to end pregnancies when there are no medical services available, even if it means risking their life. Trainers stated that abortion will not disappear if it is illegal, but it will cause the death or impairment of many women. Some providers confirmed that the health argument had been easily accepted by Tunisian imams when the issue of domestic violence was raised in the late 2000s, and they were asked to collaborate with the government in an attempt to reduce it. The social argument was related especially to the destiny of ‘unwanted children’. Participants at the seminar were aware that the majority of children born from unmarried women are abandoned and often become unhappy and deviant individuals. They also mentioned that very few families adopt abandoned children, and abandonment causes acute suffering in mothers who do not

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have the means to keep their children. As said by a midwife, these children will swell the ranks of marginalised citizens. ‘Unwanted’ children born from married couples can also have a hard life, as they may live in a family where they are ignored. During the seminar, one trainer told the story of a woman with whom she had followed up as an example of the force of social and psychological arguments. The woman, a health provider, got pregnant early after marriage. For different reasons and despite her desire to wait before having a child, she had to keep the pregnancy and gave birth to a girl. The relationship between the mother and the daughter was difficult from the start, and, at the time of the seminar, the girl had severe behavioural disorders and was following psychiatric therapy. She was obese, and the doctor in charge suggested that if she ate so much it was because she was trying ‘to fill the affective void’ (fieldnotes, 21 June 2018). Doubts and Moral Dilemmas in the Clinical Encounter During the second part of the training seminar, several activities were organised that, despite their ludic nature, elicited serious discussions about professional and personal experiences of abortion, sexuality and contraception. These were role play situations, quizzes or even physical activities such as moving into different corners of the room according to one’s opinion on an SRH topic. One of the participants had to play the role of the patient and another that of a health provider and simulate different situations: one in which the practitioner wants to help the woman to get an abortion, and another where she/he opposes it and tries to discourage her, etc. Each participant had to improvise her/his role drawing on her/his professional experience, knowledge and values. While the situation generally elicited comic behaviours because the role players tended to exaggerate the characters they had to play, it allowed them to think about the possible positionality of the actors in a setting that was relatively neutral. A central aspect tackled during these activities was indeed the relationship between abortion providers and patients. In Tunisia, as no social or psychological interview is required – but for unmarried patients – and there is no waiting period before undergoing an abortion, at least theoretically, midwives and doctors sometimes feel uncomfortable if they have to immediately implement the woman’s decision to terminate the pregnancy. Their discomfort is even stronger when the patients themselves hesitate because there is no institutional space in which to discuss their decision. If it is true that the majority of women I

Putting Abortion into Question47

have met seemed very convinced of their decision when they came to the clinic, a few were not, sometimes because they were forced by their husband to terminate the pregnancy or they were caught up in difficult social or economic situations. I will shortly describe a situation in which I was involved to illustrate the embarrassment and distress that health providers can face in certain cases: A 25-year-old woman who already had a child was ten weeks’ pregnant when she came to the clinic where I met her. Her husband opposed her decision to keep the pregnancy because he thought they could not afford to have another child due to their precarious economic situation. Even if husbands or partners are not usually allowed to take part in the consultations, in this case the midwife asked him to enter the room to discuss the situation together with his wife. Her objective was to play the role of mediator between the spouses and help them to make a consensual decision. She began by telling the husband that only the woman can decide whether or not to keep the pregnancy, that it is her right. However, she argued that they are a family and they should share responsibilities and therefore she should listen to her husband when she makes a decision that will affect them all. She also said that the fact that he had come with her to the clinic and was ready to discuss the topic in front of the midwife meant that he was a responsible husband and father. During the midwife’s discourse, the young woman began to cry, while the man kept looking at the floor, visibly tense and troubled. After giving them some time to exchange some words, the midwife suggested that they ‘wait twenty-four hours to consider the pros and cons of the situation, focusing on material as well as psychological aspects’ (fieldnotes, 10 March 2014). Before the end of the consultation, she also encouraged the man to accept his wife’s decision, stating that it is easier to take care of a second child because parents have gained experience with the first one and know how to do things. She added: ‘when your new baby is born, the eldest child will have stopped wearing diapers and you will need to buy them only for the youngest’ (fieldnotes, 10 March 2014). In this case, the health provider adopted a benevolent attitude in trying to help the woman make her decision and even involving her husband. If in some way this is a story with a happy ending, in that the woman met an understanding midwife, not all practitioners have the time, sensibility and will to help hesitant women. Many of them are caught up in the daily routine of having to provide care to a high number of patients in a setting characterised by limited resources. Patients and healthcare providers are also separated by an

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educational and social distance that makes communication difficult, as I will explain in the following chapters. As for husbands or partners, they are rarely present in SRH government facilities because these spaces are mostly feminine: the staff are almost exclusively female, and men very rarely seek care as patients. According to the discourses of the women I met, when they decide to get contraception or abortion care, they inform their husband although they do not legally need their consent. Even if this is positive in that women can make reproductive decisions against their husband’s will and without informing him, there are situations when it could be helpful to discuss a specific issue as a couple. Overall, as the law does not require interviews with abortionseeking women, an empty space is left to healthcare providers that can be kept as such or filled in with information that sometimes does not give the woman the possibility of making a serene and autonomous decision. Reading verses of the Quran to persuade women not to terminate their pregnancy, making moralising and stigmatising discourses and showing them the image of the embryo on the screen during an ultrasound are also possible ways to fill the unregulated space left by the law. The situation generated by Tunisian law is the opposite of what existed in France over several decades, where a state device aimed at controlling women was set up when abortion was decriminalised (Veil Law, 1975). Until 2001, abortion-seeking women had to go through two medical consultations and one psycho-social consultation if they wanted to terminate a pregnancy.24 Dominique Memmi’s work has shown that women had to produce ‘a biographic narrative measured against the legitimate narrative expected by experts’,25 revealing the state’s determination to control women’s reproductive behaviour through words (2001: 79). If the ‘governmentality through words’ (gouvernement par la parole, Memmi 2003) does not officially exist in Tunisia, it was nonetheless applied by many practitioners I met in an unregulated fashion according to their moral, religious and social convictions, as I have noted above (for more details, see Chapter 3). To return to the discussions that took place during the Values Clarification seminar, the absence of an institutionalised space in which abortion could be discussed was identified by many health providers I met as problematic because, for them, abortion is a medical act with complex and contradictory implications. The training seminars organised by the RHA offered them an entirely new

Putting Abortion into Question49

democratic space where they could discuss with each other their professional principles, personal experiences and values (for more details see Chapter 4). The opening of these spaces can be seen as a direct consequence of the revolution of 2011, which made the expression of one’s own opinion and the choice of one’s own behaviour possible for health practitioners offering SRH services. Although the process of democratisation I witnessed clearly had a positive aspect, it also had negative consequences for many unprivileged women. Most practitioners in one of the training seminars I attended were firmly convinced that ‘women don’t think enough before getting an abortion’, ‘they don’t think about the future, they are concerned only by the present’ and ‘they regard abortion as a contraceptive method’ (fieldnotes, 4 April 2014). These opinions were shared by many providers I met in the ONFP clinics where I carried out participant observation; they even said that the introduction of pharmacological abortion had contributed to making it a banal act that women choose without thinking of its moral consequences. Many were convinced that since the introduction of medical abortion there were more women choosing to terminate the pregnancy as it has become easier and does not imply a surgical intervention, as in the case of contraception, which requires daily discipline and has several side effects. They did not seem aware of the fact that the number of abortions in the public sector has been more or less stable since the introduction of medical abortion in the country (Avortement médicamenteux 2016: 4) and that the majority of abortions take place in the private sector where they are performed with the surgical method (Ben Hamida 2011). Only a minority of the providers I met in the training seminars said that they try to listen to the women’s reasons and help them to reflect autonomously on their decision, perhaps suggesting to their patients that they take a few days to think about it. The practitioners who expressed these opinions worked in government facilities located in urban and peri-urban areas, where they deal with women who belong to the poorest strata of the population with mostly basic or no formal education. These women often do not work or work in the informal sector, and their life is characterised by structural violence, as economic, social and gender discriminations are inscribed in their ordinary experience. Understanding their reproductive strategies can be difficult for health providers, who are better educated, often enjoy a superior socio-economic status26 and belong to a different social milieu. However, in another seminar,

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an experienced midwife said that ‘unmarried young women suffer more than married women when they get an abortion: they are often alone; they feel guilty and different from their friends and acquaintances’ (fieldnotes, 20 June 2014). All participants in the seminar agreed that unmarried women should always get an abortion because it is their right and it ‘preserves their future life’ (fieldnotes, 20 June 2014). To counterbalance the opinions of those health providers who considered women irresponsible, Halima offered a broader image of women seeking abortion by drawing on international studies, arguing that: 90 per cent of women don’t take easily the decision to terminate a pregnancy. They have thought about it; they are afraid to go to the clinic and to experience the medical act of abortion. 80 per cent of them hesitate, feel guilty, consider that they are doing something wrong. Health providers should help them to do what they feel is right for them and not just say to women: do whatever you want! (Fieldnotes, 4 April 2014)

I will revisit several other discussions that took place during the training seminars in Chapter 4, but here, I want to emphasise that one of the unforeseen results they produced – which I was able to observe over several months – was to create personal relationships among physicians, midwives and health workers of various clinics and regions. This allowed them to learn more about the situations in other clinics and hospitals – including the attitudes of providers, supply-related challenges, women’s behaviours and stories, etc. – and it created links among participants that at least some of them used to overcome obstacles related to their professional activities and to help their patients to obtain the care they needed. For example, the head midwife who works in the family planning unit of the hospital where I completed my fieldwork often dealt with women who were supposed to go to ONFP clinics in the area of Grand Tunis. She called her colleagues from the clinics to investigate why or whether women were being turned away, or they called her to see if she could take care of certain women with serious health problems, social troubles or psychological distress. The seminars thus contributed to creating or reinforcing a network that was beneficial for many women and that helped practitioners to identify engaged colleagues who were willing to collaborate to make the system work despite the difficult conditions of the postrevolutionary period.

Putting Abortion into Question51

ATSR Training Seminar on SRH and Rights Another NGO that is active in the domain of SRH is the Association Tunisienne pour la Santé Reproductive, or ATSR (Tunisian Association for Reproductive Health), which was founded in 1968 and which the IPPF27 sponsors. The activities of this association, which has local representatives in all governorates, are conducted by volunteers, mostly women, and include SRH services, education and information. Five of the six ATSR-run clinics are located in southern and western areas, where state services are weaker and where the population’s health needs are not being sufficiently met (Tataouine, Medenine, Sidi Bouzid, Kasserine, Beja). ATSR collaborates with the ONFP, IPPF and UNFPA and other actors of civil society in organising workshops, trainings, advocacy campaigns, etc. It particularly addresses young people’s needs related to sexual and reproductive education, as well as access to SRH services, and it participates in the IPPF international campaign aimed at the recognition and application of sexual and reproductive rights, especially those of youth and adolescents, in all countries (IPPF 2014). In November 2013, I was kindly invited to take part in a four-day training seminar that the ATSR organised in collaboration with the IPPF on ‘Comprehensive Sex Education’ (al-tathqif al-jinsi al-shamil) based on the IPPF’s publication It’s All One Curriculum (2011).28 The trainers included an Egyptian physician and two Moroccan experts, all members of the IPPF Arab Word Regional Office (AWRO). The audience featured ATSR members from all Tunisian governorates: there were nineteen women – because the few men who had planned to come were eventually unable to do so – and among them, eight were midwives volunteering in ATSR clinics, whereas the other participants had different backgrounds but had completed at least secondary education. Most participants were in their twenties and had come to the training seminar to become trainers so that they could ‘educate and inform’ the populations in their areas about SRH and rights. The choice to invite to the seminar the younger members of the ATSR local bureaus was meant to facilitate communication between the former and the group that the seminar was indirectly targeting: young people. The training seminar was organised around the IPPF’s curriculum: SRH, gender, sexuality, interpersonal relationships, human and RS rights, the body and reproduction, sexually transmitted infections

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(STIs), HIV, contraception and abortion, and advocacy. Some topics were treated using a strictly medical idiom (anatomy of male and female body, sexual pleasure, sexual disorders, contraception, abortion, conception, pregnancy, etc.); others involved a human rightsbased discourse aimed at introducing notions of the subject and her/ his rights based on a Western neoliberal model of the individual presented as universal. As Ali noted about the discourse on contraception that NGOs in Egypt have promoted, the ‘liberatory’ aspect of notions such as rights and choice ‘forecloses discussion of any other viewpoint or practice . . . and leaves no space to manoeuvre except within a tightly constricted arena’ (2002: 54). The adoption of the ‘dialect of rights’ (Abu Lughod 2009: 84) implies adhesion to a Western liberal feminist paradigm that has been appropriated and often emptied of its original meanings by international agencies that represent ‘transnational and supranational governance structures and discourses dominated by the interests of powerful states and groups but ostensibly focused on the “well-being” of the people in the world’ (Hasso 2009: 70). Reading the IPPF booklet Sexual and Reproductive Health and Rights – A Crucial Agenda for the Post-2015 Framework (2014), which constitutes the background of the training seminar in which I participated, the neo-Malthusianism view that the IPPF has promoted is clear. The demographic and economic assumptions behind the arguments used to justify the promotion of RS rights are related to supranational economic interests that can genealogically be traced back to the population policy establishment that (still) supports the initiatives aimed at enforcing the principles and moralities implicit in the notions of SRH and rights.29 As the booklet’s authors synthesised: ‘Population size, density and growth rates have a major impact on production, consumption, employment, income distribution, poverty, social protections and pensions, as well as environmental degradation. SRH services must therefore be an integral part of short- and long-term government planning processes’ (IPPF 2014: 10). To introduce these concepts in societies of the Global South, international agencies promote new reproductive and sexual behaviours that imply new forms of subjectivity, as well as relationships among the state, citizens and with morality. As Heather Paxson elegantly summed up: This subjectivity employs rational calculation in maximizing personal interest and is purportedly open equally to women and men, that is, gender neutral. Viewed from the perspective of the IPPF, this subjectivity transcends local cultural idiosyncrasies; it is a unifying

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‘philosophy of life’, politically charged with seeing personal freedom flourish in the face of patriarchal domesticity, nationalistic population agendas, and other traditionally based regimes of reproductive control. (Emphasis in the original, 2002: 312)

Because SRH and rights are related to new selves and to a new ethics of responsibility, they are supposed to also change local gender regimes, transform family relationships and promote the democratisation of societies. The principles underpinning SRH are deemed ‘above cultural values’ so that ‘if a particular culture has a practice that contravenes a human right, the cultural value should be changed’ (PAHO/WHO 2000 quoted in Giami 2002: 19). The extensive discussions about gender (al-naw al-ijtima‘i), equality (musawa), human and sexual and reproductive rights (huquq insaniyya wa jinsiyya wa injabiyya), gender-based violence, love, intimacy and sexual satisfaction that took place during the seminar revealed the aim of ATSR and IPPF of conveying to participants a new philosophy of life with the goal of creating ‘new selves’ (Ali 2002). Although many topics of the IPPF manual were tackled according to the IPPF official publication meant for any country worldwide, a special session was added to the basic curriculum because Tunisia is a Muslim country. This session was called ‘Sexual Culture and Family Planning’. AWRO experts conceived of ‘the Islamic view’, which provides ATSR members with religious sources they can use to justify their teaching about five topics: ‘sexual desire’, ‘sexual pleasure’, ‘sexual intercourse’, ‘female circumcision’ and ‘family planning’. The choice of these topics is significant because it allows one to understand what aspects of the international definition of SRH and rights can possibly be (and are) contested if formulated in terms of human rights or in the psychological and medical register, at least in the eyes of IPPF designers. The existence of reproductive and sexual rights for both men and women must thus be legitimated by mentioning verses of the Quran and several relevant hadiths. For example, regarding female circumcision (khitan al-inath), the ATSR presentation argues that in the Quran there is no mention of this practice and, according to Islamic specialists, the hadiths that mention it are not reliable. The text emphasises the un-Islamic nature of female circumcision, affirming that because experts have proved that it causes physical and psychological damage, the practice goes against several Quranic verses and hadiths that recommend not causing injury, damage or loss. Trainers were thus trying to apply – at least to a certain extent – what Carla Obermeyer

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Makhlouf suggested more than twenty years ago when she wrote: ‘Only when we comprehend local notions of rights can we begin the two-way process of translation and develop culturally relevant definitions and policies’ (1995: 380). However, I suspect that ATSR and RHA trainers were more familiar with the international dialect of rights than with the local language of rights based on religion or social norms entrenched in Tunisian history and society. Moreover, the religious and social registers that have gained legitimacy since the mid-2000s must not be viewed as authentic local traditions dating back to time immemorial but rather as changing ‘discursive traditions’ (Asad 1986) and practices based on the country’s historical transformations. As I mentioned earlier in this chapter, the religious conservatism that emerged during the 2000s and especially after the revolution is a contemporary phenomenon that produces new definitions of the relationships between Islam and the state, the Arab-Islamic identity and women’s rights. The session of the ATSR training seminar dedicated to the Islamic view of sexuality and family planning was meant to provide Tunisian future educators with a list of arguments supported by religious texts, allowing them to defend or justify their teachings about the abovementioned topics. According to trainers, the adoption of the religious language allows ATSR members to plead for sexual and reproductive rights to possibly persuade colleagues and patients to adhere to new practices in accordance with their convictions. This was particularly important in the first years after the revolution, when the religious conservative ideology that Ennahdha promoted became politically and morally legitimate, affecting the discourses and practices of many healthcare providers and women attending SRH clinics. As already mentioned above, the RHA was also using the same strategic rhetoric because its members believed that the religious discourse was more acceptable to the local population. The Hidden Gender Regime Although one of the main goals of the training seminar was to deconstruct social stereotypes about men and women; promote gender equality; fight against all forms of violence against women and sexual minorities; eliminate social and sexual discriminations; provide information about STIs, HIV, contraception and abortion; and convey a liberal view of the individual as a subject entitled to make autonomous choices to realise a satisfactory life, the definition of the latter was clearly inscribed in a specific gender regime. This is due to the trainers’ cultural backgrounds and to the pedagogic

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material used during the seminar, especially the short videos and documentary films, some of which dated back to the 1980s. One of the short videos shown to the participants narrated the story of a young girl who does not want to assume her feminine identity and who does not behave as socially expected because she sees that her male cousin enjoys privileges to which she is not entitled. Eventually, the paternal uncle helps her to overcome her difficulties and to fully accept her role as a dutiful daughter, diligent pupil and, later in life, as a respectable wife, mother and citizen. The message that the short film conveys is not that discriminatory behaviours against girls and boys and differential education should be changed but rather that correct communication about social and sexual roles should take place within the family to allow every individual to grow up according to socially legitimate roles. A differential gender normativity was present in a short cartoon illustrating the importance of communication between mothers and adolescent daughters about the menstrual cycle. Mothers should speak with their daughters before menarche to explain the physical, psychological and social aspects of the menses, and they should do it according to scientifically correct representations that specialists have suggested – medical doctors or psychologists – to fight against social prejudice and to ensure the young woman’s harmonic personal development. Whereas menstruation and female puberty are represented as women’s topics that mothers and daughters should discuss among themselves, fathers should discuss sexuality with their sons as illustrated by another video in which a boy and a girl end up discussing sexual matters with the wrong persons, acquiring false and harmful knowledge from their friends and acquaintances, who do not possess the right information. The video’s message is that the father should offer sex education to his son and the mother to her daughter, thus allowing them to exert their authority and control over their teenage children. The content of the education in the videos for girls and boys is not the same: whereas boys learn about sexual intercourse and look for pornography, girls learn about menstrual periods and first love romances. In this video, as in several others used during the seminar, the main characters are modern middle-class urban families with only two children, usually a boy and a girl. They transmit a bourgeois model of the nuclear family in which the woman is in charge of the domestic sphere and the man has a job and is responsible for the maintenance of the family. The quite outdated visual material – mostly Egyptian short films and videos – used in the training seminar revealed the culturally

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determined normative division of sexual roles of a specific time and social group, with the trainers unintentionally nurturing some of the gender stereotypes they were supposed to deconstruct according to the It’s All One Curriculum. In the section of the training dedicated to the notion of gender, the trainer tried to deconstruct gender categories by first asking people, in groups, to list the characteristics of men and women to compare them. Unsurprisingly, all groups attributed similar ­stereotypical features to men and women. Women were described as loyal, in charge of the house and the children, patient, weak, sensitive, irrational, attractive, curious, jealous and affectionate, whereas men were described as responsible, strong, courageous, powerful, authoritarian, free, selfish, rational, determined and occupying the space outside of the house. The trainer emphasised that these traits (safhat ijtima‘iyya) are not universal but can vary in time and space, and men and women can share them. He stressed that these traits have to be separated from the ‘natural sex’, which can be masculine or feminine (jins dhikri aw unthi). The trainer also insisted that there are no female and male jobs; rather, both women and men can do them, and ‘the more a society evolves the more the differences between women and men tend to disappear’ (fieldnotes, 16 November 2013). He also argued that the differences between men and women that we believe to be natural are created by differentiated educational practices that mould the ideas and behaviours of children and adolescents. This module of the seminar notwithstanding, two factors often drove the trainers’ discourse: a patriarchal locally based sociocultural view of men’s and women’s roles, and the international ‘medical and hygienic language of sexuality’ that is also morally and culturally oriented (Pigg and Adams 2006: 21). For instance, when he presented the changes that girls and boys experience during puberty, one of the trainers argued that girls are ‘ashamed’ by their bodily changes, whereas boys are ‘surprised’ by them, as if these were universal feelings emerging from a ‘natural’ process. His message was that, everywhere, a boy becoming a man is a positive experience, whereas a girl becoming a woman is a painful and negative experience. He did not mention the specific cultural and social configurations that determine these feelings and the meticulous pedagogical work done on the subject (Bourdieu 1998, Young 2005). In the trainer’s discourse, culture, gender and social rules were replaced with a naturalising and essentialising medical discourse that contrasted with other sessions of the seminar dedicated to the deconstruction of gender

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categories, during which participants were invited to critically reflect on male and female social roles as well as personal characteristics in their own societies. This discourse reflects what Pigg and Adams call ‘covert and political ethnocentrisms’ entailed in ‘unexamined definitions of health and sexuality’ (2006: 20), where social representations of trainers and participants intertwine with those that the IPPF’s publications convey. Hence, the content of the training was an ‘assemblage’ (Ong and Collier 2008) of various local, regional and transnational meanings, values and ideas regarding sexuality, gender, health, rights, science and modernity. Another episode that revealed the culture of the trainers was one in which sexual pleasure was described as being determined by gender. According to their description, men have more sexual desire than women do because they have higher rates of testosterone, and they experience orgasm as a consequence of a mechanic and uniform process; women have lower sexual desire and different types of orgasms that last longer. The representation conveyed is that the differences between men and women are rooted in the ‘opposition between the biological and irrepressible nature of male sexuality and the “needs” related to its “drive” and the psychological and controllable nature of female sexuality mostly associated with romance and love feelings’ (Giami 2007: 135). Trainers also conveyed a normative message entailing ‘assumptions and value judgments’ (Pigg and Adams 2006) when they explained that ‘sexual relationships must be affective rather than just mechanical and physical relationships’ (fieldnotes, 18 November 2013). Marriage is the framework within which ‘the relationship between a man and a woman must be affective, characterised by mutual respect, and go beyond the mechanical and physical aspect’ (fieldnotes, 18 November 2013). Representations of the difference between male and female sexualities – inspired by the North American sexology of the 1950s and 1960s – are thus conflated with a psychologically and morally founded representation of the legitimate heterosexual relationship, conceived of as normal and based on affective bonds. Abortion Concerning abortion, the IPPF supports the access of all categories of women to it because it regards abortion as an SR right and as a means to avoid maternal mortality and morbidity (IPPF 2014: 28). Because abortion is legal and – at least officially – available for free in government clinics to all women in Tunisia, the presentation used in the seminar does not address the specific situation

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in the country but rather provides an overview of the abortion issue, tackling various aspects of it.30 After defining, according to the World Health Organization’s definitions, safe and unsafe abortion, the medical techniques used to terminate pregnancy and the illegal means to do it, the IPPF tackles the reasons why women usually terminate pregnancy. The examples listed are as follows: They cannot afford or manage to rear a child (whether a first child or another child). They don’t want to become a parent at the time of the pregnancy. They want to finish their education. Their relationship with their partner is becoming difficult, or they are not in a stable relationship and do not want to rear a child alone. The pregnancy threatens their physical or mental health. They became pregnant as a result of sex that was forced or otherwise coerced. (IPPF 2014: 214)

Other (valid) reasons for abortion are listed in seminar slides related to the relationships between contraception and unintended pregnancy (haml ghayr marhub fihi) and also to health risks for the mother or the foetus. More generally, the importance of abortion for reducing maternal mortality is emphasised, transforming it into a health rather than a moral or rights issue. This reflects the general trend in the international discourse about SRH and rights, where the ‘rationality of health’ is being transformed into the ultimate moral value that orients the philosophy of ‘responsible sexual behaviour’ (Giami 2002: 20). The presentation offers a normative message about ‘normal’ sexual behaviours and communicates the idea that there are ‘good’ or ‘valid’ reasons inducing women to terminate pregnancies. Most of these reasons originate from exterior factors rather than from the woman’s own desire, such as health disorders, social pressure, poverty, violence, etc. The idea that a woman should have a child within a stable and serene relationship is also presented, communicating a Western model of the parental bond that, as already mentioned, can be defined as a ‘parental project’. This point does not easily fit within the many countries in the Arab world, including Tunisia, where procreation is the couple’s choice only in a limited fashion, as family pressure and social norms are imposed on married people to have children (Maffi 2012). A long section of the presentation about abortion focuses on the consequences of unsafe abortion (ijhadh ghayr al-aman) for women’s health, the family and society. It first explains the (safe) medical techniques of abortion and then describes the unsafe means used to provoke abortion and their side effects. It also explores the position

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of the ICPD in Cairo (1994) for whom women in countries where abortion is legal should be offered safe and easily accessible abortion services, and it illustrates the international policies related to the fifth Millennium Development Goal regarding lowering maternal mortality by 75 per cent in the period from 1990 to 2015. A special section is dedicated to the Arab world, providing information about the number of illegal abortions in the Arab region (al-watan al‘arabi) between 1995 and 2000, the number of women who died following illegal abortions, and the legal dispositions about abortion in the various Arab countries. Lastly, the presentation emphasises that illegal abortions are regularly practised in the countries where it is forbidden and that this increases maternal mortality, therefore women should have the right to receive safe medical information, to freely use contraception, and to have access to medical facilities. Linking abortion with (more neutral) biomedical techniques, maternal mortality and the right to receive appropriate health information and services has two effects: it obliterates the (often unacceptable) international feminist rhetoric affirming that women have the right to control their own bodies and to make autonomous choices, and at the same time, it promotes a non-gendered discourse about health that can more easily be accepted in non-Western contexts.

Notes   1. See Chekir (2016) for more details.   2. This is not new, as noted by Deniz Kandiyoti, who writes that women’s rights are ‘part of an ideological terrain where broader notions of cultural authenticity and integrity are debated and where women’s appropriate place and conduct may be made to serve as boundary markers’ (Kandiyoti 1991 quoted in Abu Lughod 1998: 3). On the recurrent nature of this exclusion, Lamia Ben Youssef Zayzafoon writes, ‘The history of Tunisian nationalism shows not only the deployment of the “Muslim woman” in the nationalist effort to resist the French politics of assimilation but also her exclusion from the debate over women’s role in the anticolonial struggle’ (2005: 127).   3. See also Charrad (2008).   4. Bouraoui (1997) and Geisser and Hamrouni (2004) analyse the evolution of the Islamist discourse on the CPS. Chekir (2016) shows the double talk of Ennahdha on the issue of the CPS in the post-revolutionary years.   5. For more details on this and other cases, see Labidi (2014). Further­ more, in the post-revolutionary period, several journalists, bloggers,

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i­ ntellectuals and artists of both sexes have been under trial, imprisoned or had to flee the country.   6. In the French text: ‘Le droit à la vie est sacré. Il ne peut y être porté atteinte, sauf dans des cas extrêmes fixés par la loi’.  7. http://www.csbronline.org.   8. She is also the founder of the Tunisian Association for the Right to Health (Association Tunisienne de Droit de la Santé) and a member of the Tunisian National Ethics Committee.   9. As noted by Kerrou (2010) and Najar (2012), Islamism gained visibility in Tunisia during the 2000s. 10. All names are pseudonyms. 11. I will provide more details on the negotiations that occurred within ­government facilities during my stay in Tunisia in the next chapters. 12. I will describe in more detail the situations I encountered in the SRH clinics in the following chapters. 13. All medicines used and sold in Tunisia are purchased and distributed by the Central Pharmacy. 14. Primary health clinics provide several RH services such as contraception and prenatal and post-partum care. 15. Because at the beginning of the seminar each participant had to introduce herself/himself, I was always able to explain who I was and what I was doing. My presence apparently did not bother the Tunisian health professionals who were present, and I even became friends with some of them. The languages used during the training seminars were French and Tunisian Arabic. 16. These are my translations. The handbook includes a French and an Arabic version to make it accessible to all categories of providers. Midwives and physicians usually master French, but health workers and receptionists can be less fluent in this language. 17. For more information about IPAS (International Pregnancy Advisory Service), CFC (Catholics for Choice) and NAF, see their websites: https://www.ipas.org, http://www.catholicsforchoice.org, https://pro choice.org. 18. http://www.figo.org/sites/default/files/uploads/OurWork/2006%​20​ Reso​lution%​20on%​20Conscientious%​20Objection.pdf. Retrieved 21 November 2016. 19. This is quite common in Tunisia, as many women believe that they cannot get pregnant when they avoid penetration (having only superficial penetration). 20. I will discuss this aspect in Chapters 2 and 3. 21. However, French doctors also use the term ‘project’ when they refer to early pregnancy in a situation where the woman wants to get an abortion (Boltanski 2004: 177). I will further develop this distinction in the Tunisian context in Chapter 3.

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22. Many women even avoid the term pregnancy and replace it with the French ‘retard’ (delay). When they explain the reason of their visit to abortion providers, they say ‘indi retard’ (my period is late). 23. Mateo Dieste quotes Al-Suyuti’s Al-Tibb al-Nabbi, in which a paragraph dedicated to ‘Embryology and Anatomy’ affirms that ‘the person is completed in the fourth month: “We breathed a soul into it. All wise men agreed that no soul is breathed in until after the fourth month”’ (Mateo Dieste 2013: 295). 24. According to the law, the psycho-social consultation had to take place one week after the first medical consultation to give the woman time to think about her decision to terminate the pregnancy. 25. Until 2014 when the law was changed and her ‘will not to continue the pregnancy’ (Marguet 2014: 29) was deemed a sufficient reason, a woman seeking an abortion had to demonstrate her état de détresse (psychological distress) to obtain it. 26. Although the socio-economic differences depend on the provider and the patient, most women with a good enough income choose the private sector, where they can easily and rapidly get the services they seek. Differences also exist among health providers: physicians, midwives, nurses and health workers do not belong to the same social milieus. Doctors usually have a better socio-economic background than the other categories of professionals. 27. ‘L’Association Tunisienne de la Santé de la Reproduction (ATSR) créée au mois d’avril 1968, est une Association de volontaires à but non lucratif œuvrant dans le domaine de la Santé Sexuelle et de la Reproduction et contribue à répondre aux besoins non satisfaits des femmes, des hommes, des jeunes et des groupes défavorisés, en particulier, dans les zones d’ombre, par une action d’éducation et d’information et de prestations des services de qualité, et ce, dans un cadre d’un partenariat multisectoriel. L’Association est représentée par ses comités régionaux dans tous les 23 gouvernorats de la république’ (http://atsrtn.org. Retrieved 15 December 2016). 28. The manual is available online: https://www.ippfwhr.org/en/publica tions/its-all-one-curriculum. Several international agencies, such as the Population Council, United Nations Educational, Scientific and Cultural Organization and UNFPA promote the programme. 29. This is clear when we consider that It’s All One Curriculum and other similar publications can be downloaded from the websites of the Population Council, IPPF and UNFPA. 30. Abortion was to be treated during the third day of the seminar, but because all participants, including myself, were victims of food poisoning, almost nobody was able to attend the sessions on that day. I do not know if the few persons who were able to attend actually discussed abortion. I base this discussion on the written and digital material distributed to the participants.

Chapter 2

Female Bodies, Contraception and Reproductive Norms

O

n a cold and humid January morning, while I was attending daily consultations in the family planning unit of Hospital T, a woman in her late thirties came into the room and asked a midwife to remove a hormonal implant (gheraset, or ‘urf) that she had being wearing for nine months because ‘it was bothering her’ (yataqallaqni), (fieldnotes, 7 January 2014). When the midwife asked her to explain in more detail how the implant had affected her health, the woman complained about ‘pain in her arm, her hip and even in her scalp’.1 She also added that she had ‘frequent spotting and therefore was seldom “clean”’ (nadhifa). The midwife asked the woman if she had taken the vitamins that had been prescribed for her and explained that at least six months must pass before ‘the body acquires a regular rhythm’. The midwife also added that the implant modifies hormonal production so that the woman would not have her monthly period. She stressed that this does not mean that the woman is pregnant. To clarify the effects of the implant’s hormones, the midwife showed the woman two colour images from a booklet on her desk. These images are meant to help patients understand the biomedical model of the body; they show a stylised female body in which the brain, ovaries and uterus are the only visible parts, as well as graphics that indicate the hormone levels related to the three mentioned organs. These illustrations are designed to show the effects that hormonal contraceptive methods have on the physiology of the brain, ovaries and endometrium. The midwife

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Figure 2.1  Image from a booklet used to explain the effects of hormonal contraception. Drawing by Marina Centonze, labelled by the author.

had good intentions, but I found that, in most situations, her patients did not understand these images, in large part because the majority of them had little education; some were even illiterate. My impression was that, for many women, looking at these drawings was like reading text in an unknown language. Based on the patients’ reactions, most women (including contraception users) did not understand what the midwife was saying – despite her well-meaning efforts. After listening to the midwife, the woman insisted on having her implant removed because she also felt pain in her heart. The

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midwife argued that the implant has no effects whatsoever on the heart and asked the woman to describe the quality and quantity of her periodic bleeding. At this point, the woman removed her trousers and underwear and showed the midwife a small piece of cloth with traces of blood. Instead of recognising the patient’s complaints and accepting her request, the midwife argued that the problem was not with the implant but with the woman’s endometrium. The midwife went on to say that she wanted to have a clear idea of the frequency and quantity of bleeding before continuing; she then handed the woman a menstrual calendar to complete during the following months. Because the midwife did not seem convinced of the necessity of removing the implant, the woman added that her husband ‘was very unhappy’ and was afraid of having sexual intercourse while she was bleeding because of the religious prohibition on sex during the menstrual period. The midwife replied humorously, saying that the woman should tell her husband that, if he does not want to make love, she would say bislema (goodbye); the provider also suggested that the woman and her husband should make love with only a veilleuse (night light) so that he cannot see the traces of blood. Anyway, the midwife decided to prescribe the patient a month-long treatment of Microval2 (a progestin-only pill) to ‘see what would happen’. At the end of the consultation, the practitioner also suggested that the woman have a third child (as she was already in her late thirties), but the patient vigorously rejected that idea, claiming that her personal situation did not allow her to have another child.

Conceptions of the Body This ethnographic fragment concerns several considerations about contraceptive practices in Tunisia. One aspect is related to the model of female physiology that many Tunisian women I met – ­especially those who were poor and or had little education – shared. After a few months of research, I noticed that many of the public clinic users were suspicious of biomedical contraceptive methods and complained about recurrent symptoms while using them. An experienced midwife patiently explained to me that many Tunisian women conceive of the body in a way that differs from the biomedical model. She said that women consider menstrual blood to be a dirty fluid (wasakh) that the body has to regularly get rid of because retaining it can supposedly cause cancer or infectious disease (Maffi

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and Affes 2017). Many of these women had a somatic condition that had caused interruptions in their menstrual cycles, and they described this condition in terms of filth from menstrual blood accumulating in their bodies, leading to swelling and a build-up of toxic substances. They also described sensations of exhaustion and suffocation. These women justified their requests to end their contraception (e.g. have their implants removed, stop taking pills or end the administration of injectable medications) by saying that they needed ‘to breathe’ or ‘to rest’. In Tunisia, most of the women and healthcare providers whom I met in public clinics emphasised the hygienic aspect rather than the ritual and legal nature of menstrual blood. Although the ritual aspect is not absent (as shown in the consultation described above), the usual language for speaking about blood coming out of a woman’s uterus is permeated with images of uncleanliness, accumulation and poisonous substances, as compared to the cleanliness and discharge of a healthy and uncontaminated body. In Tunisia, menstruation (dawra) is also called ghassala, a word that derives from the Arabic root gh-s-l (to wash, to clean), which is also the root of the term ghusl (the major ritual ablution); this term clearly alludes to the cathartic nature of menstrual blood. The suffocation metaphors that women commonly used are extremely interesting in that they are reminiscent of a pathological condition from ancient Greek medicine called ‘suffocation of the matrix’, which refers to the retention of menstrual blood within the uterus; this concept remained current in European medicine until modern times (Van de Walle and Renne 2001). A midwife also told me that many of her patients view their uterus as a bag that retains whatever enters into it and thus needs to be regularly cleaned and emptied.3 Many women’s representation of female physiology is related to old Arab-Islamic medical theories, which, in turn, are based on ancient Greek medicine. Ibn Sina and Ibn Rushd creatively incorporated the Hippocratic and Galenic traditions together with Aristotle’s theories about human conception (Inhorn 1994); in addition, Al-Suyyuti, the author of The Medicine of the Prophet, placed those theories at the origin of prophetic medicine (Del Vecchio Good 1980). In particular, ‘the idea of menstruation as cleansing’ that ‘dominates the Hippocratic tradition’ (Van de Walle and Renne 2001: xix) was very much alive in the representations and bodily experiences of many of the clinic users I observed. In pre-modern and modern Europe and in the Arab region, amenorrhea without pregnancy was deemed to be caused by an excess of blood in the

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body; this pathological state was called plethora in Latin. In fact, for many centuries, two interpretations, based on humoral medicine, coexisted: the first sees excess blood in a woman’s body as pathological (the plethoric model), and the second considers such accumulated blood to contain toxic substances that cause female disorders (the cathartic model; Stolberg 2005). Van de Walle and Renne stress the longstanding influence of these conceptions in the Western medical tradition, noting that ‘any book on official or home medicine for treating women’s diseases written in Europe between the fifth century B.C. and the beginning of the twentieth century discusses the retention of menses as a pathology’ (2001: xxi). Researchers have proven the diffusion and persistence of this model of female physiology in the Arab-Islamic world via ethnographic works conducted in Iran (Del Vecchio Good 1980), Turkey (Delaney 1991), Egypt (Abu Lughod 1989; Ali 2002; Inhorn 1994, 1996) and Morocco (Mateo Dieste 2013). In these countries, menstrual blood is described as a ritual and physical pollutant; a danger for plants, animals and (especially) men; a contaminant; and a source of shame (Delaney 1991; Dwyer 1978; Saadawi 1980). In the Turkish village where Delaney (1991) conducted her research, menstruation was considered an illness and as a reminder of a woman’s physical imperfection; it was commonly designated with a term that means soiled, blemished or canonically unclean. Among the Awlad Ali (Abu Lughod 1989), menstruation contributed to a culture in which women were seen as lacking self-control and independence4 (two of the most cherished values in that society). Both the Turkish peasants depicted by Delaney and the Awlad Ali Bedouins studied by Abu Lughod considered menstruation to constitute a punishment that was inflicted on Eve (and thus all women) after she disobeyed one of God’s orders. Among the Awlad Ali, menstruation was deemed to make women permanently less pure and less pious than men, even before menarche and after menopause. In contemporary Morocco, menstruation generates very negative feelings and representations among both women and men; according to Mateo Dieste (2013: 144), it can even engender fear and horror and cause women to be seen as contaminated. In rural areas of Morocco, mothers present the menstrual cycle to their daughters as a curse and describe menstrual blood as dangerous. This interpretation is extreme, as it characterises a woman as religiously impure (just like other fluids and excreta of the human body). Surah 2:222 of the Quran explicitly prohibits

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sexual ­ intercourse during menstruation: ‘The question thee (O Muhammad) concerning menstruation. Say: It is an illness, so let women alone at such times and go not unto them till they are cleansed’ (quoted in Delaney 1991: 94). According to the legal Islamic tradition, menstrual blood is a major impurity (janaba) in a category with lochia and sperm, but the other bodily products are only minor impurities (h’adath) (Bouhdiba 1986: 61).5 Bouhdiba (1986) examines in detail the hygienic and ritually defined practices that Muslims have to follow if they want to be religiously pure. All excreta – semen, milk, post-partum discharges, urine, faecal matter, blood, pus and so on – create a state of defilement that has to be overcome via specific rituals in order to reestablish religious or legal purity. Because menstruation, lochia and the products of sexual intercourse (sperm and the female humours) are major impurities, Muslims must practise ghusl (major purification) to eliminate them. Ghusl consists of washing the whole body (including the hair) to remove the state of ritual impurity. Menstruation in Popular Culture and in Sunni Islam Bouhdiba stresses that, although menstruation is considered particularly repellent in popular culture (1986: 68), the Sunni Islamic legal tradition does not confer on women a permanent status of impurity. During the menstrual period, women have to avoid praying, touching the Quran or other sacred texts, and entering mosques or saints’ tombs; they also cannot fast during Ramadhan and cannot go to Mecca for pilgrimage during this time.6 As mentioned above, women and men both must abstain from sexual intercourse during the menstrual period and during the first forty days of the legally defined post-partum period (couches légales) (Bouhdiba 1986: 69). These restrictions are removed once women recover their legal and ritual purity.7 It is important to distinguish between the popular conception of menstruation – which emphasises menstrual blood’s filth and ostensibly dangerous qualities (Abu Lughod 1989; Delaney 1991; Dwyer 1978; Inhorn 1994) related to hygiene (nadhafa) – from the legal and religious definition of menstrual blood as a major impurity (janaba) (Mateo Dieste 2013). The view of menstrual blood8 as shameful, filthy and defiling (thus making the female body impure) still permeates the mind set of Tunisian teenagers, as the sociologists Dorra Mahfoudh Draoui and Imed Melliti documented (2006: 116–20). This research forms a striking continuity with the past, as Lilia Labidi 9 showed in a study on women’s sexuality during the 1980s:

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Men’s disgust about women’s blood and every smell that their body emanates induce female subjects to experience their own body according to the male view, which means that it is apprehended as flawed, “stinking”, a harmful malediction, an object of defilement and subordination, hardly mastered by women in the critical moments of their existence: defloration and childbirth . . . (1989: 199).

It is no coincidence that many women I met in ONFP clinics defined themselves as sick (maridha) when they were menstruating. Local culture defines menstruation as a sickness, and these women have been told from a young age that because their menstrual blood is impure and dirty it must be hidden from other people. They experience their bodies through categories dominated by men’s perceptions and concerns that nonetheless define collective and individual affective states, symbols, spaces and behaviours related to menstruation or other female bodily functions. Thus, the Tunisian women I met manifested ‘somatic modes of attention’ that are ‘culturally elaborated ways of attending to and with one’s body’ rather than ‘biologically determined’ perceptions (Csordas 1993: 140).10 The perception of menstrual blood as dirty and shameful produces specific modes of attention in Tunisian women, thus eliciting culturally specific perceptions and experiences. Moreover, these modes of attention related to menstruation (or lack thereof) are also class-related, as Delanoë et al. (2012) demonstrate in a study on menopause among Tunisian and French women. Ambivalence in the semantics of menstruation – which is also present in other contexts, including in Brazil (Sanabria 2016), the United States (Martin 1987) and France (Delanoë 2007) – exists in Tunisia. There, despite its negative associations, menstrual blood is also a symbol of fertility. Having a menstrual cycle is associated with procreation, sexual desirability, youth, beauty and social value, as the feminine identity is strongly connected with maternity and fertility (Delanoë et al. 2012). This side of the semantic networks related to menstruation is illustrated by a short story that a doctor at an ONFP clinic once told me. A relative of hers had undergone a hysterectomy and had decided to hide it from her husband out of fear that he would neglect her and look for another woman, even though they already had children.11 She told her husband that the operation she underwent was meant to remove a uterine fibroid; every month, she simulated the menstrual cycle by buying and throwing away pads as if she had used them (fieldnotes, 24 January 2014). The woman performed this mimicry to keep her feminine identity in the eyes of her husband, as fertility is central to that identity.

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Popular and Biomedical Semantic Networks The metaphors described above are related to the popular Tunisian model of physiology and are present in the language of not just patients but also health providers, who refer to these images to help patients understand concepts. Although biomedical literature has been translated into Arabic and although technical expressions exist to describe every condition, anatomical part and physiological process, the latter are seldom used in favour of more popular and understandable terms. There is thus disparity between healthcare providers’ biomedical representations of the female body and the language that they use with less educated patients (which is based on a different physiology). This difference is reinforced by the providers’ use of French terms to define medical conditions, diagnoses and therapies (personnel are trained in French). An example can help clarify the coexistence of these two systems, a coexistence that is present in other contexts of the Middle East as the works of Mary-Jo Del Vecchio Good (1980) in Iran and Marcia Inhorn (1994, 1996) in Egypt reveal. Women who undergo medical abortions sometimes do not expel all the material within the uterus; in French, this condition is known as rétention partielle (partial retention)12 and corresponds to the biomedical model of it. If there is partial retention, then the midwife or doctor usually informs the woman that the abortion was incomplete and that she will require further treatment. If a patient is not well educated, the provider does not use the word ‘retention’ and instead says that ‘there is still filth’ (famma wasakh). It is clear that the French biomedical term is conceptually and symbolically very distant from the Arabic expression. The two terms are part of different semantic networks (Good 1977) in that they not only refer to different medical models but also belong to different ‘domains of meaning associated with core symbols and symptoms . . ., domains which reflect and provokes forms of experience and social relations . . .’ (Good 1994: 54). The coexistence of the biomedical and popular semantic networks allows for a better understanding of why patients often misunderstand (or are uninterested in understanding) health providers’ attempts to explain the effects of hormonal contraception. The articulation of these two models generally follows educational, linguistic and socio-economic lines; those who belong to the middle or upper class and who have secondary or university education generally use the biomedical discourse, but poor and undereducated people generally adhere to the popular physiology of the female body. Despite their

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use of the biomedical model, upper-class women can also be hostile to (or at least suspicious of) hormonal contraceptives; several times I heard educated women, including doctors, say that they favoured ‘natural methods’ (such as periodical abstinence or retreat) over biomedical contraceptives. Their reasons included the belief that hormonal contraception interferes with ordinary physiology and that it can have harmful effects.13 However, those same healthcare providers, including those who work in ONFP clinics, considered natural or traditional methods to be unreliable. They often scolded patients who used such methods and urged them to adopt more reliable methods. These providers believed that, as most of their patients are poor and have primary or no education, both the difficulties of ordinary life and their specific understanding of female physiology can be obstacles to the correct use of biomedical contraception.

Contraceptive and Reproductive Norms Women’s and providers’ attitudes towards contraception constitute the second aspect of this investigation, as introduced in the ethnographic fragment at the beginning of this chapter. Firstly, it is necessary to describe the contraceptive methods that are freely available to women via local dispensaries, regional hospitals and ONFP clinics. In these three types of facilities, women can (at least theoretically) access the various biomedical contraceptive methods that the Tunisian government makes available for free: condoms, oral contraceptives (Microval and Microgynon), copper intrauterine devices (IUDs), injectable contraceptives (Depo-Provera), implants (Implanon) and (more recently) female condoms14 and emergency contraceptive pills (NorLevo; Manuel de références en Santé Sexuelle et Reproductive 2013). As in other national contexts, women are officially free to choose whichever contraceptive method they prefer, but this is often not the case in practice; their marital status, education, social class, economic situation and parity also contribute to which method they choose or are allowed to adopt (see, for example, Ventola 2016). Firstly, their choices15 are limited by the available methods and the possibility of purchasing them: poor women usually adopt one of the contraceptive technologies offered in government clinics because other methods can be obtained only through the private sector. For example, due to cost concerns, a poor woman cannot use a hormonal IUD (Mirena)16 or any of the contraceptive pills other than the two types offered in ONFP clinics. Though many users of public

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SRH clinics did not seem aware that in the private sector there are contraceptive methods with fewer side effects than those provided in government facilities, I often heard women ask the provider whether they could get an IUD made of silver or gold instead of the ordinary IUD made of copper. I think that the popular belief in the existence of medical devices made of more precious metals – which are not offered to government clinic users – reveals unprivileged women’s consciousness about the possibility of ­receiving better care. Secondly, practitioners tended to impose upon women the method they considered suitable for them. Each health provider had a medically based preference for specific methods, but all practitioners also had shared unwritten social and moral norms that they attached to certain types of contraceptive as well as the patient’s socio-economic situation, age and marital status. Medical considerations are thus only one aspect that practitioners evaluate when they prescribe specific contraceptive methods, as I illustrate below. Following Nathalie Bajos and Michèle Ferrand’s terminology, these unwritten norms can be called ‘contraceptive and reproductive norms’ (2006). They are related to social habits, moral representations, state policies and medical logics. Although in the discourses and practices of healthcare providers these norms are conflated, they refer to two different orders of meaning. The reproductive norm refers to the desirable and socially legitimate conditions in which a child should come into the world; this includes the age of procreation for the mother and father, the family size, the relationship between the parents, their professions, the family’s educational and economic situation, the family’s housing and so on. The contraceptive norm, on the other hand, refers to: ‘the duty to use contraception if one does not want to have a child (dissociating sexuality and reproduction) and the necessity to adapt one’s contraception to the phase of the life cycle . . .’ (Bajos and Ferrand 2006: 91). These two norms are not only related to each other but also strongly associated with the biomedical model because that model defines contracepted parental bodies as good and has a monopoly on contraceptive technologies. The superposition of these three orders of meaning – health providers’ personal preferences, contraceptive and reproductive norms – is patent in the discourses of most of the healthcare providers I have met who did not limit themselves to contraceptive counselling and clinical acts and who thus transmitted many other messages. Their tasks included teaching poor and ­undereducated women about ‘bodily regimes’ (Ong 1995: 1250) with the aim of transforming them into modern and disciplined

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citizens who will take care of themselves and their families in appropriate ways. The Reproductive Norm To unpack these norms, I now describe each configuration of meaning, beginning with an examination of Tunisian reproductive norms as I have understood them from the consultations I attended in SRH facilities and the conversations with women and healthcare providers. Contemporary reproductive norms include families having no more than three children – a standard that emerged more than thirty years ago. Since the 1980s, the Tunisian government has promoted small families17 with the aim of reaching a replacement level at which the national population is stable and stops significantly increasing or decreasing. The family planning programme that the independent Tunisian government has promoted is but one element of the dramatic demographic decrease that the country has witnessed since the last decades of the twentieth century; important social and economic transformations have also played a determinant role (Vallin and Locoh 2001). Hence, within the past few decades, the total fertility rate (TFR) has dramatically decreased, reaching 2.4 in 1997 and remaining more or less stable since.18 The basic unit of the reproductive norm is the married couple: children are socially legitimate and welcome only within marriage. Despite this, Tunisian law – an exception within the Arab-Islamic countries – allows for the name of the mother’s descent group to be given to a child born outside of wedlock, thus granting that child legitimate social status (Le Bris 2009).19 However, unmarried mothers very often abandon their children, either because having a child compromises their possibility of marrying in the future or Table 2.1  Evolution of the total fertility rate in Tunisia. Year

Total fertility rate

1966 1975 1984 1994 1997 2000 2008 2016

7.2 5.8 4.7 2.9 2.4 2.0 2.0 2.3

Source: Evolution of the total fertility rate in Tunisia (Sandron et Gastineau (2000); Gastineau (2012); Institut National de la Statistique (2016)).

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because they are unable to take care of children without their family’s help. The ideal age at which to have a child is usually determined by both local nuptial practices and the medical model of the reproductive female body. For Tunisia in the mid-2000s, the average age of marriage was 32.9 for men and 29.2 for women (Ben Brahim 2006: 302); many women began their reproductive careers in their late twenties or early thirties. Biomedical discourses, for their part, consider that the best age for a woman to have children is between twenty-five and thirty-five years. During my fieldwork, I never heard health practitioners discuss the minimum age for which it is acceptable to have a child, but I heard innumerable people speak about the desire to ‘complete the family’ before the age of forty (for women). A few ethnographic snippets illustrate the kind of arguments that both the personnel of family planning clinics and patients use to justify their attitudes. A 30-year-old woman came to the ONFP clinic where I was doing participant observation and stated that she would like to start using the IUD. The midwife took a look at the patient’s medical file and realised that ‘she only had one child’ and therefore tried to convince her to have another one because ‘she is already thirty’ (fieldnotes, 27 March 2014). For a few minutes, the woman stubbornly requested the IUD, justifying her choice with the same vague argument that many patients use when looking for an abortion: dhuruf (which literally means ‘circumstances’). This word can hint at wildly varying situations, and women usually do not go into detail unless their providers manifest a personal concern for their case. Another woman in her early thirties came to the family planning unit of Hospital T because she wanted to get an abortion. She was not veiled, seemed to be well educated (as she spoke French with the midwife), and looked very calm. She explained that after many years of trying to conceive a baby with her husband she had gotten pregnant but now did not want to keep the baby because she was seeking a divorce. The midwife insisted that the woman wait before making such an important decision because this might be her only chance to have a child, but the woman was adamant and apparently very serene about her choice. She wanted to sever all ties to her husband, and a child would constitute a bond between them that would disrupt her attempt at complete separation. The woman eventually got the abortion that she desired. I conversed with another woman in her early thirties in the waiting room of Hospital T; she told me that she was officially

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engaged and that she already knew her stepfamily well. She had engaged in a regular sexual relationship with her future husband and had unintentionally become pregnant. Although she was educated and economically independent, she did not want to keep the child because she was afraid of what her partner’s family would say about a hastily planned wedding party that would be necessary to keep up appearances. She had not told her future husband that she was pregnant and intended to get an abortion because he would have opted to organise a quick wedding instead. She also wanted to be sure that if, in the future, something went wrong between them nobody would be able to reproach her for having married too hurriedly because of the pregnancy. She was also afraid of losing her job at the call centre where she had been working for five months, as a pregnancy would have jeopardised a regular work contract. In ONFP clinics, women’s and couples’ economic and educational situations were rarely discussed because many patients belonged to the lower social classes, had only primary education or were illiterate, and were unemployed or had irregular jobs.20 In the eyes of healthcare providers, the most desirable condition for the birth of a child was to be married and not have a large family (one with more than three children). As I discuss below, the patients’ marital status and hence the legitimacy of their sexual behaviours played a crucial role in shaping the discourses and implicit norms that health practitioners applied. However, the patients’ economic situations as well as their relationships with their partners and family members were very important; women tried to adapt their reproductive trajectories according to those factors. Some women needed to work – especially if their husbands were unemployed or had an irregular income; others had a desire to complete their education. Having to take care of a sick or disabled relative was also a good reason to postpone children for a few years or indefinitely. The emphasis on women’s employment and education varies from one social milieu to another, and in Tunisia, most women continue to play the traditional role of mothers, wives and caregivers (Mahfoudh Draoui 2007); the maternal identity continues to be central in the definition of their social status and role.21 Childless women are therefore stigmatised or considered to be failures, although a higher socioeconomic position can reduce social blame, especially if they have built a socially recognised professional career. During my time at the ONFP clinics, I happened to attend a few consultations in which recently married women in their late thirties had come to seek hormonal treatments to enhance their

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chances of getting pregnant. Interestingly, in some cases, these women did not think to involve their husbands in the medical consultations, despite the fact that part of the purpose was to verify whether the husbands were infertile. This attitude is understandable in light of the common and gendered representation according to which women hold the responsibility for procreation, including its failure (Inhorn 1994; Jansen 2000). More generally, as mentioned above, few men attend ONFP clinics,22 and they are typically absent when their wives or partners consult providers on whether to adopt or change contraceptive methods (see also Chapters 1, 3 and 4 on the exclusion of men from SRH clinics). The contraceptive responsibility lies entirely with women, and healthcare providers do not mention men except in very specific cases such as when a woman has an infection that requires both her and her partner to undergo medical treatment or to adopt condoms as an additional contraceptive method. Even when men do accompany their wives or partners to the clinics, providers often see them as intruders and try to keep them away. This happens for several reasons. Firstly, reproduction has traditionally been seen as a woman’s domain that is best managed by female family members and female healers (Foster 2001; Gherissi 1992). Secondly, biomedical contraceptive technologies have strongly reinforced the feminisation of reproductive responsibility insofar as ‘women are perceived and perceive themselves as the “guardians of the temple of sexual and reproductive health”’ (Beltzer and Bajos 2008: 442). Contraceptive technologies have thus far applied almost exclusively to female bodies (Oudshoorn 1994, 2003), and modern states have promoted frequent and regular access to gynaecological care for women across their life spans (Ruault 2015). These are all crucial components of the different roles that men and women play in reproduction. The large majority of Tunisian women resort to hormonal and mechanical contraceptives during their lives, and sterilisation has never been practised on men because it threatens their masculinity, which is defined by intact sexual and reproductive strength (see, for example, Inhorn 1996, 2012). Women, Men and the Reproductive Responsibility The feminisation of reproductive and sexual responsibility brought about by biomedical contraception was confirmed in a recent study of unmarried young men and women in Tunisia; the results show that only a small fraction of men think that they should

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take ­responsibility for the consequences of their sexual relationships (Gherissi and Tinsa 2017). This confirms what I observed during my own research: the recurrent critical remarks of health providers to women who did not use contraception or who used it in what the providers saw as the wrong way are significant. I witnessed several midwives rebuke women coming to the SRH clinics for repeated abortions; they told the women that they had to use contraception (tasbir) and take responsibility for their careless behaviour by becoming more disciplined. However, I never heard a health practitioner mention a husband’s or partner’s responsibility for a woman’s unwanted pregnancy. In these discourses, the husbands and partners were either absent or considered unwelcome parts of the women’s decisions about contraception. One of the midwives whom I worked with had an explicit discussion with a patient who had refused to use an implant because her husband was hostile to the idea. The woman stated that a doctor with whom her husband was acquainted had told him that the gheraset (implant) makes women nervous and causes other side effects. The midwife was irritated and treated the intrusion of the woman’s husband as illegitimate and undesirable because ‘the choice of contraception should be only hers’ (see also Chapter 4). She continued, saying that many doctors are ignorant about contraception and that she ‘hated men meddling in their wives’ affairs’ for the sake of ‘controlling and dominating every aspect of their lives’ (fieldnotes, 7 April 2014). I also witnessed health providers reprimand women for refusing to use a biomedical contraceptive method instead of periodical abstinence (calendrier; literally, ‘calendar method’) or coitus interruptus, or for seeking to change their contraceptive method after only a few months of use. Although, especially in the first case, the male partner was clearly involved in the contraceptive practice, the midwives and doctors never mentioned them. Whether modern contraceptive technologies are empowering or (on the contrary) oppressive devices for women cannot be determined without considering the local context and the specific situations in which they are prescribed. Each category of actor can use technologies in ways that were originally unforeseen. Indeed, users of a technical object play a crucial role in its definition and diffusion: they define the object’s quality in relation to their environment, develop a practical knowledge of it that allows for its use to be made routine, and create a network to further circulate it (Akrich 2006). There is thus a ‘reciprocal adjustment between the technical object

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and its environment’ (Akrich 1992: 207). In the case of biomedical contraception, healthcare providers and patients can be considered two categories of users;they both use contraceptive methods but in different ways: providers apply them on women’s bodies, women apply them to their own bodies. Health practitioners possess technical and scientific knowledge that patients lack but are committed to ‘achieving high continuation rates’ (Hardon 1992: 762); therefore, they downplay the side effects of contraceptive technologies as not important, whereas women are often more concerned about avoiding those effects as they can interfere with their ordinary lives. The primary intention of a technical object cannot entirely determine its social use, as can be illustrated using the example of the contraceptive pill. Originally conceived of as ‘foolproof birth control that would help stem population growth in underdeveloped parts of the world’ (Tone 1997: 378), both doctors and population experts ended up considering it as a technology that ‘only middle-class women, presumed to be white, educated, and responsible, could be “trusted” to swallow’ every day for twenty-one days per month (ibid.: 380). On the contrary, the IUD was conceived as a technology under the exclusive control of healthcare providers; it was (and still is, in countries within the Global South) promoted for use among women who are deemed unwilling or unable to control their fertility (Dugdale 2000) as well as among marginalised and poor groups in the Global North (Corea 1977, Hartmann 1995, Takeshita 2010). However, in the Global North, the IUD is today used by middle-class women (Takeshita 2010) and is even recommended for young nulliparous women who do not want to take hormonal contraceptives (Lohr, Lyus and Praeger 2017). Although they disagree,23 several European and North American feminist scholars have criticised the effects that the introduction of biomedical contraception has had on women’s lives, in that they reinforce women’s social and moral responsibility in the domain of sexuality and reproduction (Bajos and Ferrand 2004; Giami and Spencer 2004; Krasnow 2007; Oudshoorn 2007 quoted in Ventola 2014). These methods can also cause somatic troubles, psychic constraints and social abuse (Hardon 1992, 1997; Hartmann 1995). Despite the ‘biotechnological inequality’ of modern contraception (Fennell 2011: 515), some Tunisian activists have argued that, in North African societies, biomedical contraception offers women control of their own bodies independently of their partners, thus granting women the possibility to make reproductive decisions without male interference (Maffi, Delanoë and Hajri 2017). This

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position can be interpreted in light of studies whose results indicate that responsibility for contraceptive decision making is so firmly masculinized in many developing countries that the theme of “covert contraceptive use” has emerged among researchers to refer to the frequent phenomenon of women in these societies using contraceptive methods deliberately without telling their partners. (Fennell 2011: 498)

I do not share the assumption made by the researchers in these studies – according to which, women in developing countries are oppressed but those in developed countries are not. However, I do believe that states’ coercive family planning policies – as well as institutional practices, legal and social inequalities, patriarchal norms, insufficient medical facilities and economic vulnerability – place a greater burden on women living in the Global South (Dudgeon and Inhorn 2004) than on those in the Global North. If men play a very important (and often ignored role) in women’s reproductive decisions, other family members, and specifically mothers-in-law, are also crucial actors in women’s ability to exercise their agency, as shown, for example, in Marcia Inhorn’s works on infertility in Egypt (1994, 1996), Emma Varley’s research on Islamic family planning in Pakistan (2012) and my own study on childbirth practices in Jordan (Maffi 2012). Hence, the forms of agency that biomedical reproductive technologies can generate need to be examined within specific political, social, cultural and economic arrangements that determine the ways in which actors use them. An ethnographic fragment helps to illustrate this complexity. A woman in her early thirties and a mother of one came to Hospital T to get an abortion. During the medical interview with a midwife, she started crying and said that she would like to keep the pregnancy but that her husband did not want to have another child at that time. The woman had tried to persuade him to keep the child, but he was adamant. She was afraid that, if she did not end the pregnancy, it would affect her marriage or even induce her husband to leave her. The midwife asked whether he would be willing to come to the hospital to discuss it, but she said that he was unwavering. Eventually, the midwife advised the woman to accept her husband’s decision but to change her discourse in order to make the abortion appear to be her own decision. She suggested that the woman tell her husband that she had realised that she did

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not want to have another child and that the abortion was her decision. Although forced to accept her husband’s will, the woman thus resorted to a trick to reaffirm her autonomy, at least in front of him. In this case, abortion technologies – which are liberating for women who do not want to have (more) children – have become an instrument of oppression. The ambivalence of abortion and contraceptive technologies is clear in certain cases; as already noted, in Tunisia, these methods were introduced to limit population growth rather than to empower women, and health practitioners have often used them coercively. Forms of coercion that contradict the rhetoric of sexual and reproductive rights are still present in the country,24 as I observed in ordinary interactions between health practitioners and women at the clinics. However, this coercion was probably less violent than it was in earlier periods and was reserved mainly for poor and undereducated women who cannot access the private sector. Ridha Gataa, an official and previous president of ONFP, noted that staff youth-friendly clinics continue to deal with young women according to traditional views of sexual conduct; as a consequence, patients at ONFP clinics are confronted with ‘a lot of external control and a lack of freedom’ (Gataa 2008 quoted in Hassairi 2009: 19; see also Ksontini 2017). Getting an abortion in the private sector is very easy for women who can afford it; moreover, users of private-sector clinics are not subject to moralising and stigmatising discourses. This category of women also has a wider choice of contraceptive methods, including options that are available only in pharmacies or from private gynaecologists. The Contraceptive Norm I now turn to the contraceptive norm that emerged during the consultations in ONFP clinics. A clear distinction is to be made between the contraceptive norm that is applied to married and unmarried women. Although this distinction can also be observed in countries such as France and the United States (Bajos and Ferrand 2004; Takeshita 2010; Thomé 2016), the logics behind it are different because, in Tunisia, they include a strong moral and religious stigmatisation of unmarried women that is absent (or less present) in the other mentioned countries. I begin with the investigation of the contraceptive norm for married women whose sexuality in particular is socially, legally25 and religiously legitimate. After marriage, couples do not generally adopt a contraceptive method because they are expected to procreate as soon as possible to prove that they are fertile.26 Social and family pressure to quickly procreate is still

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very strong, although today a minority of young married couples, especially of the middle and upper class, wait some months or a few years before procreating. However, unless they have infertility problems, most women I met in ONFP clinics had their first child within one year after marrying, as I could easily verify in their medical records. Once they have their first child women are usually offered the pill, the IUD or, more rarely, the implant or injectable. A considerable number of midwives discouraged women from using the IUD before the birth of their second child, perpetuating the idea – that was internationally consolidated in the 1980s – that this method can cause sterility. The origin of this idea is probably related to the tragic affair of the Dalkon Shield, which occurred in the United States in the 1970s and 1980s and caused the almost complete withdrawal of the IUD as a contraceptive method (Hartmann 1995, Takeshita 2010).27 Although not all practitioners shared the idea that the IUD should not be used before the birth of the second child, it was regularly communicated to patients by several health providers. On the contrary, after two or more children have been born, the contraceptive norm that most midwives seemed to recommend is the IUD because artificial hormones were often considered to have harmful side effects. Only a few midwives I met encouraged the use of hormonal contraceptives, especially the implant, because it is effective for three years and releases hormones daily and in small doses, contrary to the injectable, which has to be renewed every three months and contains a high dose of hormones administered in one shot. Health providers often considered the implant and IUD to be more reliable, especially if their patients were impoverished and not well educated, because their use is not dependent on the latter’s will. Most women I met in ONFP clinics or at Hospital T either agreed with the providers’ choice of contraceptive or had a very difficult time negotiating their preferred means or a change of contraception. For example, once a woman had adopted a type of contraceptive that was suggested and controlled by the health practitioner, it was extremely difficult to convince him/her to remove it. The various side effects of each contraceptive method were the main reasons women gave when they asked to change it. Despite women’s complaints, the personnel often downplayed their discourses by arguing that women were imagining and exaggerating side effects or were unwilling to accept the small drawbacks that came with contraception as illustrated at the beginning of this chapter.28 The incompatibility of the popular physiological model described above and the biomedical paradigm shared by health practitioners played a

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major role in the miscommunication between them and clinic users. For example, I once heard a midwife scold a woman because she was complaining about the side effects of the implant and wanted it to be removed. The woman said that her legs and hands were swollen, that she had gained weight and had stopped menstruating. The health provider said, using an emphatic tone, ‘you want everything: to avoid pregnancy and the side effects of contraception!’ (fieldnotes, 14 April 2014). The woman insisted that her blood was suffocating her body as it could not be replenished each month and that she needed to rest (tartahu) because ‘the implant (gheraset) made her tired’. The midwife emphasised that her ovaries and uterus ‘rest’ when she is under the effects of the implant rather than when she does not use contraception. The woman did not accept this explanation, but her implant was not removed; instead, she was prescribed a pill to take for the next three months in order to provoke an artificial menstrual cycle (withdrawal bleeding). Other women wanted the IUD removed because of backache, long and heavy menstrual periods or because their husband was bothered by the rope during sexual intercourse.29 These arguments were usually rejected by the ONFP clinics’ staff members and considered as pretexts. Their resistance to abide by the women’s desire to have the IUD removed and adopt another means, usually the pill, was even stronger when the woman had already had one or more abortions. The personnel believed that some women were unable to correctly use the pill and thus exerted pressure on them to use a technology that they did not directly control. Despite the contraceptive norm that health providers in the public sector promoted for married women, recent ONFP statistics (Annual Report 2016) indicate that the pill is the most used biomedical method of contraception, followed by condoms and the IUD; implants and injectable medications are far less frequently chosen (Institut National de la Statistique 2016).30 Until the 1990s, the IUD was the most used biomedical contraceptive method, followed by tubal ligation, which was largely employed from the mid-1970s through the mid-1990s.31 An important change took place in contraceptive practices among married women during the 2000s.32 The IUD – which was still the most-used method in 2006 – was abandoned by almost half of its users (from 46% to 25.3%), whereas the pill was used by 19 per cent of married women (MICS 2013). Tubal ligation is no longer available in ONFP clinics: in 2006, almost 10 per cent of women were still using it, but in 2012 that number had dropped to only 3 per cent (ibid.).

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Figure 2.2  Evolution of contraceptive use by type. Scan of a figure from the book Population et Développement en Tunisie: La métamorphose, edited by J. Vallin and T. Locoh (Cérès Editions, 2001), published with permission. Translation: Pilule: Pill; Stérilet: IUD; Ligature: Tubal ligation; Autres: Others.

I believe that the recent and rapid evolution of contraceptive practices must be seen in relation to the already mentioned ­laissez-faire attitude of the Tunisian state, which, in the late 1990s, strongly reduced its commitment to population policies after the demographic transition took place in the country. By the end of the 1990s, the reproductive behaviours of Tunisian citizens significantly corresponded to what the independent state had planned and struggled to attain since the mid-1960s. As unanimously affirmed by the Tunisian health providers with whom I spoke, over the last fifteen years family planning policies have ceased to be a national priority. At the same time, international and foreign aid agencies such as the WHO, the World Bank and USAID, which have played a major role in the past, have stopped funding local programmes in the domain of reproductive health (Paulet and Gachem 2001).33 The necessity of controlling the natality rate had pushed the Tunisian state to adopt contraceptive practices that aimed less to allow its citizens to freely plan the size of their family than to authoritatively limit it in order to trigger the socio-economic development of the country (see Introduction). Therefore, these factors lost their importance; more freedom was left to Tunisian citizens to take autonomous reproductive decisions that were, however, determined by a family model and

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lifestyle that had significantly changed. Thus, it became less important to impose contraceptive methods that only health ­providers could control (such as the IUD) or that were definitive (such as tubal ligation) for women. Tubal ligation has become impossible to obtain because the operation is a burden for the impoverished and under pressure public health system. Many times I attended consultations in which women asked to have a tubal ligation because they could not tolerate the side effects of regular contraception but were denied it. Premarital Sexuality To understand the contraceptive norm for unmarried women, it is necessary to describe the local moral and social rules that apply to premarital sex. First of all, it has to be said that sexual relationships outside of wedlock are socially and religiously condemned. However, it is not punished by law if the individuals concerned have reached the age of consent34 and it does not happen in public places (Hrairi 2017; Voorhoeve 2017). Stigmatisation and moral condemnation was palpable in the attitudes, gaze, voice and words of many health professionals working in ONFP clinics, including the personnel in charge of the youth-friendly clinics (fadha sadiq li-al-shebab), who are officially trained to offer services to unmarried individuals ‘without judgment and lessons of morality, despite their age and even if they are very young’ (Manuel de référence en santé sexuelle et reproductive 2013: 18).35 It must also be stressed that the moral condemnation of unmarried individuals visiting the family-planning clinic was particularly strong because they are mostly women. Indeed, if Islamic moral precepts condemn both men and women who have sexual relationships outside of marriage (Bouhdiba 1986), the patriarchal moral regime (Morgan and Roberts 2012) dominating Tunisian society only stigmatises women’s sexuality (Ben Dridi and Maffi 2018; Labidi 1989; Mahfoudh and Melliti 2006). Dominant social codes prescribe that a woman be a virgin and inexperienced and a man be sexually active and mature when the time of marriage comes. In this field, social norms do not seem to have significantly changed since the promulgation of the CPS, as emphasised in several socio-anthropological studies.36 Nedra Ben Smaïl, a Tunisian psychoanalyst who has investigated the contemporary sexual life of Tunisian women, argues that ‘the norm of virginity perpetuates itself despite the social transformation of Tunisian society’ (2012: 35)37 because, even if virginity is not

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regulated by the state, according to the law several types of sexual relationships such as those that involve concubinage and adultery are crimes.38 Thus, young unmarried women who have a sexual life before marriage are not considered in the same way as men: lack of sexual experience, ignorance and innocence are appreciated in unmarried women, and as a midwife in her late fifties declared during a conference I attended on sexuality,39 when she married, she did not know anything about sexuality and was afraid of it. She argued that she had learned all about sexuality from her husband, whom she considered her teacher (fieldnotes, 30 May 2014). This asymmetric position in sexual matters has thus been internalised by several women I met, at least among the older generations. Today, sexual relationships are much more common among young unmarried people, not only because the age of marriage has risen but also because sexual habits have changed. In the early 2000s, Foster remarked that there was a ‘consensus among health service providers that the average age of women’s first sexual experience is decreasing and that the percentage of girls engaging in premarital intercourse is increasing’ (2002: 99). Although not much is known about the sexual practices of young people in Tunisia, as very few studies have been conducted on this subject 40 due to social and religious taboos that have led institutions and researchers to see it as ‘a forbidden and unspeakable domain’ (Hamza and Chaabouni 2006: 409), the ONFP conducted research on family health in the mid-2000s (PAPFAM). This included a chapter on the sexual health of unmarried individuals (15 to 29 years old). The results of this research indicate that unmarried people primarily have occasional sexual relationships with different partners and only rarely use contraceptive methods to avoid conception and sexually transmitted infections. According to the ONFP survey, 50 to 60 per cent of men and 12 to 18 per cent of women have sexual relationships before marriage – although it is very probable that the percentage of women is underestimated. First sexual relationships, in 2002, were found to happen at either sixteen or seventeen years for both men and women (ONFP 2002: 216). If sexual relationships have become ordinary, moral norms have not changed at the same pace and virginity continues to be a necessary physical, if not moral, condition for most women to get married (see Foster 2002; Hassairi 2009; Hrairi 2017). The flourishing surgical industry in Tunisia that pertains to hymen reconstruction and the preoccupation with it as expressed by many young women

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I met in ONFP clinics is but one consequence of the social norm of female virginity. Ben Dridi argues that hymen reconstruction has become so common in Tunisia that some people say that ‘it has become part of the bride’s trousseau’ (2017a: 155). Meryem Sellami’s research on Tunisian teenagers belonging to different social classes shows that differential and unequal norms regulate men’s and women’s sexuality despite the state’s efforts to achieve modernisation. Thus, ‘the boys interviewed claim their “legitimate virile desire” and the possibility of expressing it through sexual acts (errajel rajel; literally, ‘the man is a man’), while girls consider their sexuality as a dangerous practice for their body, their reputation and their “purity”’ (Sellami 2017: 103). Sameh Hrairi (2017) confirmed this in a survey of 735 high school students in various regions of Tunisia. The results of Hrairi’s work show that the large majority of the young generation place immense value on female virginity. However, most of them revealed that they had already had a boyfriend or girlfriend, and all the young people who were interviewed seemed to talk much more easily about sexuality, expressing curiosity and asking questions, than their biology professors, 95 of whom were also interviewed. Being in charge of teaching human anatomy and physiology, including of the sexual organs, Hrairi examined how they interpreted and performed their role as educators in the sexuality domain. Most Tunisian professors were embarrassed and declared their discomfort when they had to listen to their students and answer their questions on the topic of sexuality (Hrairi 2017: 411). As I detail in Chapter 3, healthcare providers in ONFP clinics were accustomed to asking unmarried women seeking abortion care if they were sbiyya (a virgin), a question that initially puzzled me. Talking to healthcare providers, I realised that many unmarried women have superficial sexual relationships (without penetration) in order to keep their hymen intact.41 Indeed, according to Radhouan Fakhfakh (2010: 63), two thirds of young Tunisians (12 to 24 year olds) do not know that superficial sex can cause a pregnancy – a fact also confirmed in other socio-anthropological studies (Ben Dridi 2010; Hrairi 2017). Moreover, the persistence of a specific ritual called tasfih·,42 which is designed to preserve a girl’s virginity until her wedding day, was documented by Ben Dridi (2004) in south Tunisia in the early 2000s; she showed that several young women thought that they could not lose their hymen and become pregnant if they were under the effect of tasfih·, despite the fact that they had sexual intercourse.

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The Imposed Contraceptive Norm To return to the contraceptive norm in Tunisia, the ONFP clinics where I conducted fieldwork included a separate youth-friendly clinic, although one of them was only partially accessible because the clinic had been devastated during the revolution. These clinics play a paradoxical role because, on the one hand, they reinforce the idea that unmarried women – who also include divorced women or widows, who are not necessarily very young – are a separate category of citizens that requires specific treatment and classification; on the other hand, they offer a setting that can be experienced as protecting the users from the not always benevolent gaze of married women. This is especially important for young women, who usually want to conceal their sexual life from family members, acquaintances, neighbours or colleagues. While, as I show below, the youth-friendly clinics do not protect their users from the gaze and discourses of healthcare providers and the control of the state, they generally do allow them to get the service they have come for without making it known in their circle. This is at least the case for unmarried women who live in large cities, where anonymity is easier to keep, but women who live in smaller cities will often travel to clinics in larger cities in order to avoid being recognised (Ben Dridi 2017b; Gherissi and Tinsa 2017). The contraceptive norm that ONFP personnel communicated to unmarried women, especially if they were young, varied according to their education and sexual practices. Generally, the pill, injectable and implant were considered the best methods as they are reversible and can be used for short periods of time without compromising the woman’s fertility. The preference for the methods controlled by health professionals was clear in cases in which the woman had little education and/or was suspected of having many partners or engaging in prostitution, whereas the pill was more readily proposed to women with secondary or higher education and those with only one partner. If women sought an abortion more than once or twice, they were suspected of engaging in prostitution or at least of being irresponsible. Thus, health practitioners tried to impose methods that patients were unable to directly control, such as Depo-Provera or the implant. They sometimes required it as a condition of having an abortion; however, women could refuse to come back to the clinic after the medical abortion was over, which obviously made it much more difficult for the medical personnel to force them

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to accept contraception. Until the end of the 1990s, doctors were allowed, during surgical abortion, to insert an IUD or an implant or to perform a tubal ligation while a patient was under general anaesthesia; however, the medical abortion procedure has changed the terms of the negotiation between healthcare providers and women. It is possible to say that, if they can get an abortion, women have more power to autonomously decide whether they want to go back to adopt a contraceptive method. Although medical abortion can open up new spaces for negotiations about contraception, the asymmetric relationships between health practitioners and women has not been subverted as clinic users can be denied an abortion altogether. This primarily happened with women coming for repeated abortions, who were usually designated as ‘recidivists’ – a label that has very negative connotations, as it alludes to individuals who continue to repeat crimes after punishment (see Chapter 3). Whereas many health providers did not seem to understand why young unmarried women fail to use contraception and treated them as irresponsible and immature, the latter had their own logic, which revealed a contraceptive norm that differs from the one the state and SRH institutions promote. Firstly, as mentioned above, they often avoided vaginal penetration and thus thought that they could not get pregnant. The pregnancy could come as a surprise that is discovered quite late; inexperienced women thought that conception was impossible if the hymen is intact (Ben Dridi 2004). They attributed the absence of menstruation and other possible symptoms of pregnancy to stress, fatigue or already existing troubles with the menstrual cycle. Another reason why unmarried women did not continuously use a contraceptive method lies in the fact that many of them affirmed they had irregular sexual intercourse (see also ONFP 2006). Hence, they did not wish to regularly take the pill or use other methods that interfere with their ordinary life, either because of their side effects or because they involve constraints, such as going to the clinic or remembering to take a tablet every day. Secondly, they thought that hormonal contraceptives could compromise their fertility and preferred to get an abortion rather than use medical technologies that can be harmful. As already stated when describing married women’s attitudes, mistrust of hormonal methods is widespread in the Tunisian population and unmarried women are not an exception to it. Even some health practitioners share this opinion, as I realised while talking to midwives, nurses and doctors in family planning clinics and at Hospital T. Thirdly,

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young women who would like to use contraception were afraid of its side effects, even when they did not think that hormones could compromise their fertility. They believed, for example, that they could gain weight or become nervous. They were also afraid that their mother or sisters might discover that they use contraception. Several young women I interviewed expressed fear that, because their mothers regularly inspected their rooms and bags in an attempt to control them, their mothers or other family members would find their pills or see their implants under their skin. These anxieties are meaningful in that they reveal the existence of strong social control over unmarried women’s behaviours; control that can take different forms. Labidi (1989) illustrated the way in which this control was exerted from an early age upon the women she interviewed in the 1980s. She explains that education for girls and boys was already clearly differentiated by the time they reached the age of six or seven: their rights, duties, responsibilities and tasks were defined as belonging to two different symbolic and material domains (Labidi 1989: 55). The completion of domestic chores and providing care was reserved for girls, whose movements in the public space were limited from infancy and strictly controlled by their mothers and female relatives. A main part of girls’ education focused on the inculcation of bodily habits that were intimately related to female virtues: ‘restraint in desires and passions, continence, resignation, detachment, discretion and finally patience and the acceptation of good and evil’ (ibid.: 67). Girls’ and women’s gestures, bodily posture and voice had to translate these virtues into visible traits. Girls had to learn to move slowly, speak in a low voice, avoid looking into men’s eyes and cover their body to avoid shameful behaviour. More recently, researchers have indicated that girls’ sex education continues to be a maternal responsibility. It is still oriented toward the suppression of female sexual desire, ignorance of one’s own body, preservation of virginity and mistrust of men (Ben Smaïl 2012; Mahfoudh Draoui and Melliti 2006; Sellami 2014, 2017; see also Chapter 4).43 Anne-Emmanuelle Hassairi (2009), who carried out a study on attitudes toward sexuality of a group of women from various generations active within the ATFD and thus claiming a feminist stance, shows that even the most progressive actors are caught up in a conservative ideology when it comes to sexuality. Several of her interlocutors affirmed, for example, that sex is a natural need for men but a pleasure for women. However, others have argued that it is both a need and a pleasure for men and women (Hassairi 2009: 45). They also agreed that boys are educated

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to take the sexual initiative and learn about sexuality from infancy, whereas women are ‘educated to sexual frustration and have to repress their sexual desires until marriage’ (ibid.: 39). The case of Salwa, an unmarried woman in her late twenties with a university education and a good job, illustrates some effects of this education on female sexuality and the culpability feelings it can generate when it comes to sexual penetration. Although Salwa has had several partners and a few stable relationships, she was still a virgin when I met her. She told me that, although she ‘had done everything’ (alluding to various non-penetrative sexual practices), she could not perform vaginal intercourse and did not even want to engage in that act (Tunis, 11 March 2014). Her mother, like the majority of Tunisian women, taught Salwa that she has to preserve her virginity for her future husband. Her maternal aunt once taught her a Tunisian adage reminding women that, before marriage, they can do whatever they want except ‘that’ (meaning vaginal intercourse). The hymen is a sacred membrane that must be preserved as a precious gift or a good to be offered to the future husband: it entails the honour of the girl and her family and is also a kind of public and familial good (Sellami 2017; Zemmour 2002). Although this kind of education is pervasive, even among the middle and upper classes, as explained by the psychanalyst Nedra Ben Smaïl (2012), many young women are able to step back and have a fulfilling sexual life before marriage (Ben Dridi 2017a). Such was the case of Hanan, an unmarried and well-educated woman in her late twenties, who told me that she had avoided vaginal penetration until the day she realised that society had imposed the norm of virginity upon her. She did not recognise the value of this norm and felt that it exists to preserve men’s power over women. Hanan synthesised her idea about the unjust and gendered nature of the norm of virginity, stating that ‘Tunisian men like to plant a flag on the body of their wife’ (fieldnotes, 25 March 2014), as if the female body was a territory for the male partner to conquer (on this, see Young 2005: 80). The Practised Contraceptive Norm To return to unmarried women’s sexual practices, the contraceptive norm followed by those I met in ONFP clinics and at Hospital T differs from the one promoted by healthcare providers, although both are affected by the moral and social condemnation of female premarital sexuality. The norm that unmarried women followed

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entails either no contraception at all before marriage or a limited use of contraception because of the anxieties surrounding the effects of hormonal biomedical technologies, the desire to avoid effects on their somatic or psychic well-being or the fear of being discovered. The dissonance between the puritanical education (Boufraioua 2017: 12) that most Tunisian women receive and their sexual practices is also translated into the refusal to use contraceptives, as if not using them would indicate that they do not breach the rules. Interestingly, young women who practise premarital sex often feel themselves to be in a liminal state, which can provoke a severe existential crisis. They experience their body as a territory that can be contaminated, soiled and made impure by sexual contact with men through sex outside of the legitimate framework of marriage, thus causing feelings of culpability that can bring women to engage in self-mutilation practices or to resort to various purification rituals (Ben Dridi 2017b; Sellami 2017). The defilement is to be removed from the body but also from the moral person, as the contamination coming from illegitimate sexual acts affects the spiritual aspect of the woman. Purification rituals, as well as surgical repairs of the hymen, can produce moral reform for a woman, who, for example, will begin to wear the headscarf to signify her interior transformation (Ben Dridi 2017b; Ben Dridi and Maffi 2018).

Notes   1. The implant is usually inserted under the skin in the upper inner part of a woman’s arm.   2. Microval and Microgynon (a combined pill containing oestrogen and progestogen) are the only two pills that Tunisian family planning clinics, dispensaries and hospitals provide for free. Other types of pills are available from pharmacies for those who can afford to pay for them.   3. This is one potential reason why women who are not virgins can be designated as rotten (Sellami 2014); in this view, a man’s sperm remains in the uterus and deteriorates.   4. Héritier (2002) and Mateo Dieste (2013) also mention that women’s subordination originates from a lack of control over ‘blood spilling’.   5. Classical Islamic texts distinguished between menstrual blood that flows every month (damm al-hayd), blood outside the regular cycle, and blood that flows after childbirth (damm al-nifas; Mateo Dieste 2013: 76).   6. The same is true for men ‘who do not practice the ghusl after ejaculation’ (Dwyer 1978: 169).

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  7. For a comparison between the conception and treatment of menstruation in these three religions, see Jodelet (2007).   8. On the conception of blood in the Arab tradition, Edouard Compte remarks that blood (damm) is an ambivalent substance because it has a feminine origin and ‘appears either as the substance nurturing the fœtus or as a defilement (hayd). Spilled blood is also ambivalent because it is sometimes the medium of sacrifice, sometimes a stain on the collective honour of its (male) guardians. Blood that runs through the veins is for its part considered as the seat of individuality, soul and humour’ (2001: 67).   9. A similar attitude is still present in Euro-American societies, as Martin (1987), Lee and Sasser-Cohen (1998), Young (2005) and many others have shown. 10. For a brilliant example of how women’s perceptions of their bodily functions are culturally constructed, see Lock’s (1993) study on the conceptualisation, treatment and perception of menopause in the North America and Japan. 11. A sterile wife is considered a valid justification for a man to divorce and remarry. 12. I use the French term because the Tunisian providers always use French when they speak about medical conditions. 13. Scholars have recently shown that a significant number of women with tertiary education prefer the ‘traditional methods’. According to Jalila Attafi (2015), 19%​of women with university education (as compared to 6%​of women with primary education) use non-biomedical contraception. 14. During my fieldwork, I never met a woman who used this method or a provider who suggested it. I only discovered that it was available in SRH government clinics by reading the ONFP’s (2013) Manuel de référence en santé sexuelle et reproductive. 15. On the notion of choice, see Chapter 3. 16. In 2013/2014, Mirena cost 250 Tunisian Dinars (85 euros), which is a very high sum compared to local salaries. 17. The ideal family size according to the Tunisian government has decreased over time, as demonstrated in the evolution of the country’s labour, fiscal and family laws. In the 1980s, tax relief was passed for families with two or three children; in this law, ‘child allowances were limited to the first three children while over the 1960s and 1970s, legislation, discourses and the mass media were allowed to inscribe in “the unconscious of Tunisian families” four children as the ideal number’ (Gastineau and Sandron 2000: 21). In addition, the number of months of paid maternity leave per woman has been reduced to three from four. 18. According to the latest national census from 2014, the average size of a Tunisian family is 4.05, down from 5.15 in 1994.

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19. For Morocco, see Bargach (2002) and Capelli (2016); for Algeria, see Rahou (2006); for the Maghreb region, see Barraud (2011). 20. The World Bank (2015) indicated that, in Tunisia, 72%​of the female population is literate. Retrieved 14 August 2017 from https://donnees. banquemondiale.org/indicator/SE.ADT.LITR.FE.ZS?view=chart. 21. This is not specific to Tunisia; in contemporary France, the female identity is still defined by maternity (Bajos and Ferrand 2004). 22. According to ONFP statistics, fewer men than women have visited its clinics; the number of male visitors has also decreased significantly since the revolution. In 2010, 341,617 males attended but only 56,774 in 2013 and 64,446 in 2014. By contrast, 977,406 females attended clinics in 2010 and 872,128 in 2014 (Institut National de la Statistique 2016). 23. For the various positions that feminists from the Global North and South hold on this issue, see Rozario (1999). 24. On the coexistence of logics based on neo-Malthusianism and reproductive rights in contemporary societies, see De Zordo (2012). 25. As I explain below, Tunisian law does not directly sanction premarital sex and restricts it in various ways. Nédra Ben Smaïl (2012) cites the case of a 2004 state-promoted campaign during which ‘more than seven hundred young women and men were arrested for “offending public decency”’ (ibid.: 35) because they had, for instance, held hands while walking in the streets. Another law forbids hoteliers from hosting unmarried Tunisian couples (Ben Smaïl 2012). 26. In Tunisia, the henna ceremony is still widely practised at marriage; in this ritual, parts of the bride’s body are coloured with henna; the intent is for her to get pregnant or even give birth to a child before it fades away. 27. The Dalkon Shield was a ‘particularly poorly designed’ IUD that caused ‘sterilizing injuries to numerous women and killed several users who suffered overwhelming infections’ (Takeshita 2010: 43). 28. Other researchers have shown that health professionals tend to dismiss women’s complaints about the side effects of biomedical contraception (see, for example, De Zordo 2012; Hardon 1992, 1997; Van Kammen and Oudshoorn 2002; Watkins 2010). This attitude seems to be intimately related to the logic of medical knowledge, as well as to the neoMalthusian policies of population control that institutions and states have implemented based on concerns related to efficacy rather than acceptability. 29. Interestingly, in the ONFP’s (2013) Manuel de référence en santé sexuelle et reproductive, the husband’s discomfort because of the rope is mentioned as a legitimate complaint that can justify the insertion of a new IUD (p. 100). 30. However, according to Dimassi et al. (2017), the IUD is still the mostused biomedical contraceptive method in Tunisia. 31. Interestingly, the women I met at the ONFP clinics or at Hospital T who wanted to undergo tubal ligation were denied that procedure

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for ­various reasons. One was that, today, there are reliable long-term methods that allow for control of one’s fertility without resorting to surgical intervention; another was that health providers have other priorities and no longer perform tubal ligations unless doing so is strictly necessary for health reasons. The ONFP (2013), in its Manuel de référence en santé sexuelle et reproductive, no longer includes tubal ligation on the list of available contraceptive methods. 32. With few exceptions, the research on Tunisian women’s reproductive and family health has only considered married women because implicit moral rules have affected local research (see also Dimassi et al. 2017). When I asked some ONFP researchers about the absence of studies on unmarried women (and men), they told me that the various ministries involved in the organisation of such surveys would not accept unmarried people’s inclusion in research plans. This attitude is not unique to Tunisia; for instance, sexuality – and especially extramarital sex – was taboo until the 1970s in Euro-American anthropology on the Middle East, as Nikki Keddie (1979) emphasised. 33. At the turn of the century, Paulet and Gachem wrote, ‘Having reached a relatively high level of development, cooperation agencies no longer consider Tunisia as a country in need of important support’ (2001: 564). 34. The age of consent in Tunisia was 18 for men and 20 for women until the promulgation of a new comprehensive law on violence against women (July 2017), which stipulates 18 for both men and women. 35. In 2000, the ONFP introduced specific training modules for personnel who worked in youth-friendly clinics to help them deal with unmarried patients in the best way. In a 2010 booklet, the Directorate of School Medicine, the ONFP, the Ministry of Health and UNFPA discuss the main aspects of this training. 36. See Ben Dridi (2010, 2017b), Hrairi (2017), Mahfoudh Draoui and Melliti (2006), Sellami (2014) and Voorhoeve (2017). 37. Several legal dispositions limit and criminalise sexual relationships outside of wedlock: Article 236 of the Penal Code punishes adultery; Article 226 of the same code punishes those who ‘infringe public morality through words and gestures’; Article 18 of the CPS punishes all forms of union that differ from the state-recognised monogamous marriage – including not just polygamous marriage but also cohabitation. Article 226 of the Penal Code potentially allows punishment for premarital relationships, although there is no specific article regulating this matter. On this topic, see Voorhoeve (2014, 2017). 38. See Ben Smaïl (2012: 35), Article 236 of the Penal Code and Article 18 of the CPS. 39. The one-day conference was hosted by the Union des sages-femmes de Tunisie du Nord on 30 March 2014. The speakers included a few well-known Tunisian sexologists.

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40. On this topic, see Capelli (2017) and Tremanye (2004). 41. On this topic, see Ben Dridi (2010, 2017a, 2017b). 42. Literally, the term tasfih indicates the actions of armouring, sealing and shoeing a horse (Ben Dridi 2004: 16). ‘This protection is the subject of a first ritual phase, which takes place before the puberty of young girls (between 6 and 10 years old) and is based on two precautions affecting both women and men: under its action, the girl becomes impenetrable and any man approaching her loses his sexual power. Pre-marital sexual intercourse, voluntary or forced, is therefore no longer theoretically possible. On the eve of the wedding, a second ritual phase allows everyone to regain their sexual abilities. Thus the ritual succeeds one another with a time of “closure” and a time of “opening” of sexuality’ (Ben Dridi 2010: 100). 43. For similar considerations regarding sex education in Morocco see, for example, Dialmy (1985) and Guessous Naamane (1988).

Chapter 3

Reproductive Governance, Moral Regimes and Unwanted Pregnancies

Wanted Children and Reproductive Governance

O

n 28 September 2013, the Tunisian NGO Groupe Tawhida Ben Cheikh organised a flash mob in the central Avenue Bourguiba in Tunis to defend women’s right to abortion1 with the slogan: ‘It is my right to get an abortion. My grandmother and my mother could have access to it and I cannot anymore! We are wanted children; we would like to have wanted children’. The flash mob was organised on International Safe Abortion Day a few months after the attempt of Najiba Berioul, deputy of Ennahdha, to change the article of the Penal Code allowing Tunisian women to end a pregnancy within the first trimester (see Introduction). The concept of ‘wanted children’ has belonged to the birth control ideology since its very beginning, as it was conceived and promoted by Margaret Sanger in the United States in the early twentieth century. According to Sanger, women could be free only by being able to determine the number of children they want and the moment most appropriate to have them (Ruhl 2002). Despite the promotion of birth control a hundred years ago by Margaret Sanger and other women’s health activists as a means to emancipate women and promote a new conception of sex ‘not merely as a biological necessity for the perpetuation of the race, but as psychic and spiritual avenue of expression’ (Sanger quoted in Ruhl 2002: 654), population control logic was dominant in the decades ­following

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the Second World War. This logic, inspired by neo-Malthusian ­principles, prioritised the control of population growth – seen as a phenomenon threatening the economic and social order of the modern world – rather than the rights of individuals to decide independently from the state whether and when to have children (Krause and De Zordo 2012). It was only in the 1990s that emphasis on individual choice and women’s rights to autonomous decisions in reproductive and sexual matters was internationally acknowledged and encouraged. The reproductive health paradigm2 in which women have the right to choose if, when and how to have children emerged within the Euro-American feminist movements of the 1960s and 1970s (Lottes 2000). Enshrined as a woman’s right by the International Conference of Population and Development in Cairo (1994) and the Fourth World Conference on Women in Beijing (1995) (Petchesky 2003), female agency in sexual and reproductive behaviours had already been recognised by the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW)3 and the World Health Organization through its definition of sexual and reproductive health. The WHO’s definition states that ‘Sexual and reproductive health is a state of complete physical, mental and social well-being in all matters relating to the reproductive system. It implies that people are able to have a satisfying and safe sex life, the capability to reproduce, and the freedom to decide if, when, and how often to do so’ (quoted in Lottes 2000: 9). Though a shift from family planning discourse to rhetoric on reproductive and sexual health and rights took place in the 1990s (Lane 1994), policies and practices on the ground reveal that in many countries, ‘the old neo-Malthusian rationales are still alive and well’ (Krause and De Zordo 2012: 144). This is also the case of Tunisia, where, as illustrated in previous chapters, reproductive and contraceptive norms, forms of coercion and moral judgments oriented by demographic rationalities are still present. Norms about the necessity to regulate one’s own sexuality, reproductive behaviours and conducting a well-ordered life are modelled according to at least four different orders: the political, the economic, the biomedical and the moral. In this chapter, I will investigate how these four orders frame the logic of healthcare providers and the clinical encounters between them and the women seeking contraceptive and abortion care. I will explore the ways in which the medical and administrative apparatus shapes the trajectories and subjectivities of women who seek contraception and abortion care, analysing how they are defined, clas-

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sified and treated. How are women who frequently ask to change contraceptive method or become unintentionally pregnant considered and treated? What role do state institutions play in the definition of these women? What work do healthcare providers do on women’s subjectivities and reproductive trajectories? Are married and unmarried women treated differently? Are men considered at all when treating contraceptive and reproductive failures? What are the effects of the technical and administrative procedures women have to go through in SRH clinics on their therapeutic itinerary and personal experience? What forms of power do healthcare providers exercise on clinic users? What agency do women who use government SRH clinics have?

Orderly Bodies, Responsible Citizens A woman has come to the family planning unit of Hospital T where I am doing participant observation to get an abortion. She has been transferred to the hospital by the staff of an ONFP clinic because they estimate that her pregnancy is too advanced to be terminated using a medical abortion. The woman, thirty-eight years old, comes from a poor area of Tunis, does not have remunerated work and is unmarried. Although she initially denies it, she had a previous abortion less than a year earlier and is now pregnant again. Interrogated by the midwife, she says that she does not use contraception but would like to use the pill. The midwife tells her that she needs to use a method continuously to avoid another pregnancy, even if she has only occasional sexual relationships. She also tells her that she has to take the responsibility for her choices, implying that the two unwanted pregnancies she has experienced are synonymous with her failure to be responsible. Moreover, the midwife sees in the woman’s medical record that, after the previous abortion (a medical abortion), she did not come back to the clinic as required to verify whether the expulsion of the uterine content took place. She scolds her and affirms that she will not include her in the clinical trial she is conducting on a new self-administered urinary test to assess whether a woman who has had a medical abortion is still pregnant or not.4 The inclusion in the study would have allowed the woman to get a combination of mifepristone misoprostol treatment, considered more effective than the misoprostol alone for medical abortion.5 Finally, the midwife threatens the patient, stating that, if she comes back to get another abortion without adopting an (effective) contraceptive method, she

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will not accept her.6 She ­suggests the woman use the implant, which lasts for three years and, once inserted, does not require any action by the user (fieldnotes, 4 February 2014). In this and many other situations, I heard healthcare providers rebuke women, inviting them to take responsibility and use contraceptive methods to avoid unintended pregnancies. As already mentioned in the previous chapter, it was a theme of many consultations, in that women had to accept being treated as undisciplined and irresponsible individuals who were unable to regulate their behaviour and foresee the consequences of their actions. This discourse is located at the crossroad of the four orders I mentioned above – the political, the economic, the medical and the moral – and shaped by the ‘modern liberal governance’ that considers the subject as a rational and self-regulating individual evolving in an abstract context (Ruhl 2002: 645). This model, which excludes placing individuals in a specific social and political context and is gender-blind (Paxson 2002), shapes demographic and biomedical discourses (Bier 2010). However, from the 1960s, after the introduction of biomedical contraceptive technologies, the female liberal subject was placed as a rational and self-regulating individual within demographic and medical discourses and deemed responsible for reproduction and sexual behaviours – ‘a paradigm of responsibility that assumes forethought and planning in reproductive matters’ (Ruhl 2002: 645). The ‘willed pregnancy’ is a requirement and an expression of the modern female subject that the liberal governmentality presupposes. Reproductive and sexual behaviour is a ‘natural’ domain that has to be regulated and controlled by modern, self-reliant, responsible citizens who have internalised the norms of society and respect the interests of the state (Ali 2002). It is a woman’s individual and collective duty and right to control her sexual behaviour and plan parenthood. The paradoxical notion of freedom as control is captured by the family planning ideology, which considers individual ‘choice’ as ‘what happens when a plan is properly conceived and efficiently executed’ (Klawitter quoted in Granzow 2007: 48). Those individuals who fail to submit (to a contraceptive model/plan) are morally deviant, bad citizens and non-compliant patients, as they are failing to exert the required self-control. They are also described as irrational insofar as rationality7 is identified with self-control and planning, and as abiding by ‘traditional’ norms rather than modern ideas (Paxson 2002). Being modern implies being educated and able to make rational and autonomous choices, with ‘tradition’ or ‘culture’ conceived of as imposing upon individuals’ collective and unconscious logic (ibid.).

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Family planning clinics are important institutions where the modernisation and disciplining of women as patients and citizens takes place: ‘biomedicine goes beyond providing healthcare to shaping, in both intended and unintended ways, the cultural citizenship of different categories of patients’ (Ong 1995: 1254). The Anatomo-political Work on Women’s Bodies The use of contraceptive methods and the social, moral and somatic injunctions women are subject to in SRH clinics are highly political because they contribute to moulding their bodily perceptions, emotions and personal and social existence in order to ‘normalise’ them (ibid.: 1246). Anatomo-political work is accomplished by healthcare providers in ONFP clinics, where women’s bodies and selves are subject to regulation and socialised in the ‘regimes of anticipation’ (Adams, Murphy and Clarke 2009). Regimes of anticipation play a crucial role in many domains of contemporary societies, including population control – that is, ‘managing reproduction now to “avert” future births and bring about modelled futures of increased GDP and modernity’ (Murphy quoted in Adams, Murphy and Clarke 2009: 253). If we look, for instance, at the ONFP report Impact of the Family Planning Programme on Social Sectors (Impact du programme national de planning familial sur les secteurs sociaux 2003), we find the concept of ‘avoided births’,8 which contains the idea of a possible (negative) future that family planning policies have been able to (positively) transform. The reproductive rationalities behind state policies in the field of contraception and abortion have thus colonised the future through actions in the present. These actions have drawn on ‘simulations or probabilistic anticipations of the future’ (Adams, Murphy and Clarke 2009: 255). Past, present and future are strictly related in anticipatory regimes and are often made measurable through numbers. Numbers, statistics and Gaussian bell curves produce sociological concepts (Hacking 1991) that contribute to the shaping of state rationalities and policies. They also have emotional dimensions in that they produce ‘affective economies of fear, hope, salvation and precariousness oriented temporally towards futures already made “real” in the present’ (Adams, Murphy and Clarke2009: 260). That reproductive rationalities and anticipatory regimes promoted by state institutions have been internalised by a large section of the population was evident in the many situations I witnessed where women came to the clinic to get an abortion for primarily economic and social reasons. Among the main reasons women used

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to justify their desire for interrupting the pregnancy were economic hardship, having already completed the family (usually two or three children), already having a very young child, their husband’s refusal to have another child, the necessity of completing their education, a precarious work situation, being unmarried or divorced or a widow, etc. I remember dialogue between a young woman who had recently married and the doctor of an ONFP clinic in which reproductive rationalities and anticipatory regimes were clearly present. The woman had come to get an abortion and in doing so was going against the norm, which prescribes that young couples immediately procreate after marriage, because she wanted to do an internship and pass the final exams in the following months. The woman was apparently not using a contraceptive method and expressed the desire to adopt the IUD. The doctor said that she could not use the IUD and advised her to use the pill, as she had recently married and did not need to hide it. She also added that she did not understand why the woman had married before finishing her training and that she should have waited. The health practitioner concluded by saying that for her it was unclear why the woman did not want to use the pill despite it being the most appropriate method in her situation, considering she wanted to postpone having a child in the immediate future. The doctor’s negative judgement and injunctions notwithstanding, she and her patient did not disagree in an essential way because they followed the same neoliberal rationality that subjects should organise the present according to a planned future. The woman got married for reasons that were not discussed in the clinical encounter and wanted to avoid getting pregnant before finishing her studies, but she nevertheless did not adopt a contraceptive method – possibly because she did not think she could get pregnant, or because she wanted to prove her fertility.9 In the immediate future, she wanted to complete her professional training rather than become a mother. Even if the doctor’s rationality was not contradictory to that of her patient, as she agreed that the latter had to complete her training before having a child, she did not approve of her actions: she had married too early and had not adopted a contraceptive method. The doctor scolded the woman for not acting in the appropriate way in the present, rather than because she disapproved of her plans for the future (fieldnotes, 21 May 2014). This is only one episode of a long series I attended where discourses of patients or health providers hinted at the notion of a reproductive plan.

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Women as Planners Overall, according to my ethnographic experience, Tunisian women were pushed to internalise the institutionally promoted notion of planning their sexual and reproductive behaviour, while men were largely excluded from this (at least in medical institutions). It was very common during consultations in ONFP clinics and in Hospital T to hear the midwife or doctor ask a woman in her fertile age what her (not her and her husband’s) plans were for the future. If a woman was shortly to be married, the health practitioner advised her to use the pill or condoms, as most women try to get pregnant immediately after marriage, as mentioned above. If the woman was not considering marriage, she was usually advised to use a long-term method such as the implant or injectables rather than the pill, which was deemed less reliable because of its dependence on its user’s discipline. If patients were married, health providers asked women about their plans for the future of the family: they insisted on the age at which they should have children (before forty) or recommended those who had one or two children to have three. A fragment of a clinical encounter is meaningful here, as it entails a typical conversation I heard many times. A woman in her midthirties comes to the clinic to seek abortion care. She is married, has two children – 10 and 5 years old – and works as a beautician. She was using the pill but had forgotten to take it one day and was now pregnant. It is not the first time she has experienced an ‘unwanted pregnancy’: she already had two abortions, one in the private sector and one in an ONFP clinic. The practitioner scolds her and suggests she should adopt the implant as a contraceptive method because of her very long menstrual cycles and because the IUD might cause her anaemia. She also asks what her ‘reproductive plans’ (barnamaj) are. Although the woman replies that she does not want to have any more children, the provider tells her that the ideal number is three. When the woman repeats with an assertive tone that she does not want any more children, the midwife argues that she will ‘repent and regret it’. The woman is indifferent to the provider’s argument and goes on asking questions about the abortion procedure and future contraception (fieldnotes, 27 January 2014). The ideology of family planning was also present in the discussions that took place during training seminars for health providers in the RHA, the association I presented in Chapter 1. In one session, the discourse of one of the trainers I heard was paradigmatic. She insisted on the fact that ‘as women have jobs, take care of the

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family and are subject to more constraints than their spouses, they should have access to reliable contraceptive means so that they can plan their reproductive future and flourish in life’ (fieldnotes, 10 January 2014). In Tunisia, the healthcare providers I met considered women who have too many children, seek too many abortions, change their contraceptive method too often, do not use biomedical contraception or have had several sexual partners as irrational, undisciplined, irresponsible, uncontrolled and even immoral. The personnel of SRH clinics work to ‘order’ women’s bodies through the contraceptive technologies and the biomedical, political, social and moral injunctions that they transmit during consultations. Their task is not only to provide them with reproductive care but also to turn them into reliable patients, respectful citizens, dedicated mothers, loyal wives and morally good subjects. Contraceptive practices and discourses thus reveal the reproductive biopolitics of the state that targets bodies, particularly female bodies of individuals belonging to underprivileged groups (Hartmann 1995; Petchesky 2003). The history of the demographic policies of independent Tunisia that I have traced in the previous chapters is significant because it shows how reproductive governance has been systematically applied since the mid-1960s, affecting reproductive behaviours and shaping a specific rationality as well as a moral and political regime. As already discussed, the family and women within it were attributed a central role in the state’s programme to modernise Tunisian society: the family was conceived of as a ‘factory to manufacture modern citizens’ (Bier 2010: 412) and women as the managers in charge of it. The focus on the family ‘as fundamental instrument’ in the government of the population (Foucault in Burcher, Gordon and Miller 1991: 99) is a characteristic of modern governmentality. The large body of demographic reports and statistical studies on fertility and contraceptive practices of different categories of citizens regularly published by the ONFP (often in collaboration with UNICEF, UNFPA or other international agencies) during the second half of the twentieth century demonstrate the state’s will to precisely count the population and document in detail its reproductive and sexual behaviours.10 The majority of these documents are based on statistical data collected through local or national surveys and the analysis of individual medical records that are carefully stored in ONFP facilities and public hospitals. Over the last few decades, this mass of data has allowed the construction of what Foucault defines as an ‘apparatus of writing’ in the domain of a medically

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conceived of and managed reproduction and sexuality. Thus, the medicalisation of reproduction and sexuality has allowed Tunisian public health authorities to create a new individual ‘as a describable, analysable object . . ., in order to maintain him in his individual features, in his particular evolution, in his own aptitudes and abilities, under the gaze of a permanent corpus of knowledge’ (Foucault in Rabinow 1984: 202). The apparatus of writing has also produced a ‘comparative system that made possible the measurement of overall phenomena, the description of groups, the characterization of collective facts, the calculation of the gaps between individuals, their distribution in a given population’ (ibid.: 202). Thanks to the ONFP’s bureaucratic apparatus and that of other related institutions, the modern Tunisian state can count and classify its citizens based on their sexual and reproductive behaviour, health, age, sex, marital status and so on to create specific disciplinary instruments to regulate its citizens’ lives according to its biopolitical aims. This apparatus has another characteristic: it is modelled by gender logics that produce more capillary forms of classification of surveillance and control over women, while men fall only indirectly under the state’s gaze, as I will illustrate below. The concern for improving the socio-economic situation of the population manifested by the Tunisian independent elite is typical of modern governmentality, of which biopolitics is an essential part. Modern governmentality motivates the production of numbers on the population in order to regulate it. As emphasised by Talal Asad, ‘the practice of assembling and classifying figures periodically’ is not ‘merely a mode of understanding and representing populations but an instrument for regulating and transforming them’ (1994: 76). The anatomo-political work accomplished on women’s bodies, such as in SRH facilities, and the ‘regulatory controls’ or biopolitics that frame the legal, social, political and economic domains are the two faces of governmentality within which ‘the managing of population not only concerns the collective mass of phenomena, the level of its aggregate effects, it also implies the management of population in its depth and details’ (Foucault in Burcher, Gordon and Miller 1991: 102). Resistance to Bio-contraceptives’ Normalisation In SRH clinics, women are subject to medical and administrative procedures that, as already shown, involve the creation of disciplined bodies. Female bodies have to become reproductive or nonreproductive or sexually active or inactive, according to specific

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norms already analysed in Chapter 2. The contraceptive practices encouraged in ONFP clinics are based on statistical knowledge of the population’s reproductive behaviours and oriented by quantified demographic trends. Biomedical contraceptive technologies play a fundamental role in this anatomo-political and biopolitical work in different ways. First, they act on the female body, modifying its metabolism, capacities, and sensations and producing an artificial hormonal cycle that aims to standardise its functions. The assumption is that bio-contraception produces universal effects as it acts on ‘standardised bodies’ (Lock and Nguyen 2010: 43); that is, bodies have the same biological constitution and thus should react in the same ways. Despite the standardising script of biomedical contraceptive devices, somatic resistances are very common and manifest themselves in the form of side effects. For example, while the pill’s script is to prevent ovulation and induce a withdrawal bleed during the seven pill-free days (to mimic the physiological menstrual cycle), many women suffer from various side effects that interfere with this normalised model. Many Tunisian women I met complained about headaches, nervousness, dizziness, weight gain or irregularities in the bleeding rhythm. Resistance to biomedical contraception is not only rooted in women’s ‘situated bodies’ and ‘local biologies’ (ibid.: 108) but can also originate in the deliberate choice of individuals to adopt less invasive and less providerdependent methods, such as withdrawal and periodical abstinence (calendrier or hisab in the Tunisian dialect). Most health providers I met consider the so-called ‘traditional methods’ unreliable and the women who do not adopt ‘modern methods’ as irresponsible and ‘unruly’ (indisciplinées). These women are seen as unable to stand the side effects of biomedical contraception – which providers tend to underestimate – despite its efficacy and beneficial influence on their life. Health practitioners are aware that several biomedical contraceptive technologies require disciplined users to willingly exert regular control over their sexual behaviour – that is, take the pill every day (at the same time), go to the clinic to receive an injection every three months, regularly verify the position of the IUD or have a blood test, etc. Besides the side effects of biomedical contraception and the clinical follow-up required, women must adopt forms of voluntary asceticism in the name of aesthetic or health reasons. For example, one of the most common side effects of the implant is an increased appetite, and many women complained that they had gained weight after they started to use it. More than once I heard the health provider answer women who

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complained about their enlarged body that they just had to control their appetite, eat less and better and walk or exercise. These habits, which correspond to a bourgeois model of the Global North, can be very difficult to adopt: most women are poor and do not have the possibility to practise sports or even regularly walk because they work, take care of the family and the house or live in an area where it is not possible to do it or they are unable to incorporate it in their ordinary habits. They also cannot afford to change their diet following the suggestion of health providers because it would be too expensive to regularly buy fish, meat and fruits and vegetables. Indeed, for patients who were overweight, midwives and doctors recommended they eat less sweets, sugar and cereal-based products and have a more varied and rich diet. In each ONFP clinic I attended, there was also a nutritionist to help women adapt their diet to their health status, the contraceptive method they use, and their age. I believe thus that in the anatomo-political work done by providers in SRH clinics women are encouraged to take care of themselves for health reasons that go beyond reproduction and that concern their general health and fitness. Although it was not among her routine tasks, one of the midwives with whom I worked regularly made comments about the physical appearance of her patients and scolded them when she thought they were overweight. She always made her comments in front of several other patients but without visibly upsetting the targeted woman. Although I have no doubt that this midwife’s purpose was to help women improve their health condition, the very direct way she spoke to them and the fact that she did it in public was disturbing. It was even more difficult for me to accept that the women who were asked to change their diet, eat less and practise physical activity because they were ‘too fat’ were poor, not well educated and, in short, occupied a lower social position than the midwife, who belonged to the middle class. For women who were using the IUD and complained about backaches or longer menstrual cycles, providers often answered that the IUD cannot affect the back and that they would do well to tolerate longer bleeding periods in the name of effective and reliable contraception.11 Thus, biomedical contraception is meant to not only produce a somatic order in female bodies in accordance with local political and moral regimes but also make disciplined selves. Good female citizens do not have too many children, do not waste contraceptive technologies by asking to change the method they are using if it is not necessary, keep strict control on their body, judiciously

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comply with medical indications and adopt moral behaviours by avoiding sexual intemperance and unhealthy practices. The opinion of a doctor of an ONFP clinic about medical abortion significantly synthesised this point: ‘All these medical abortions constitute an economic waste for the nation, unnecessarily increase the workload of health practitioners and are a threat to women’s health’ (fieldnotes, 6 February 2014).

When a Pregnancy Is Not Planned In light of the above considerations, it is clear that in Tunisia, like in many other countries, a pregnancy is expected to be planned – that is only after carefully considering one’s personal, social and economic situation. The norm of the willed pregnancy coincides with the ‘planned child’, which makes deviations from the norm unacceptable (Régnier-Loilier and Solaz 2010). I will now consider how unplanned pregnancies are defined and treated in SRH clinics and in Hospital T, and what kind of behaviours and affects they elicit in healthcare providers and patients. An important preliminary distinction has to be made between the procedures married and unmarried women have to go through. I have already mentioned the fact that unmarried women have access to a youth-friendly facility while married women attend the ordinary SRH clinic. While the two institutions are usually located in the same building and constitute two services of the same regional ONFP clinic, they are usually staffed by different individuals – although some circulation between the two is possible – and they are supposed to adapt clinical procedures to the specific social profiles of their users. The youthfriendly facility is intended to receive unmarried individuals, men and women, between the age of 15 and 29 (ONFP 2010). Following the recommendation of the ICPD in Cairo (1994) and in accordance with the Tunisian Code for the Protection of Children, these spaces offer ‘reproductive health services for young and adolescent people, including counselling, basic services and, if necessary, transfer to more specialized facilities’ (ONFP 2010: 3). Youth-friendly spaces are supposed to include a recreational space, a polyvalent room where young volunteers offer information and counselling, an advice unit managed by a ‘trained and available specialist’ and a medical service offering ‘confidentiality’ and ‘quality of care’ (ibid.: 4). According to ONFP internal rules, the personnel of youth-friendly facilities have to receive specific training to enable them to interact with patients

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who do not have the same characteristics and needs of married individuals (ONFP 2013: 134). A paragraph of the Manuel de référence en santé sexuelle et reproductive (2013) specifies the principles orienting the ‘counselling’ for ‘young, unmarried, sexually active individuals’: Young, sexually active individuals are entitled to receive services offered without moral judgment, their very young age notwithstanding. Services for young people shall include meetings where counselling and information on sexuality are offered using simple words and avoiding incomprehensible medical terminology. Sexually active young individuals are concerned by the use of contraceptive methods: SRH facilities for young people should provide them with condoms and emergency pills. Healthcare providers in charge of young women seeking abortion care should provide it without stigmatising and discriminating against them, ensuring their privacy and the respect of their intimacy. (2013: 18)

If these are the recommendations of the ONFP officers in charge of training the personnel, the interactions I have witnessed, in some cases, are close to what is described in the above excerpt. Although I have never had the opportunity to attend a collective session of information and counselling for young people, I have attended several hundred consultations between health practitioners and unmarried women. I will base my analysis on the exchanges between patients and health practitioners during the consultations and the conversations among the personnel, as well as those I had with the clinicians and patients I met.

Women and Men in Youth-Friendly Clinics When they came to the clinic, the women were first interviewed by a health worker, then interviewed and examined by a midwife or a nurse and then, according to the reason for their visit, they were interviewed by a doctor, though not always; they also had the option to see the psychologist and/or the nutritionist if needed. Despite men not being welcome in youth-friendly clinics, these spaces were designed to be gender neutral. For example, when a young woman arrived for an abortion, her partner, if she had one, was usually not allowed to enter the clinic.12 I personally never saw young unmarried men come into the clinics where I ­participated

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in observation, even when accompanying their girlfriends.13 Those who came with their partners usually waited outside the clinic. The only young male I met was a ‘peer educator’, trained in reproductive and sexual health matters, who provided information sessions mostly in public high schools in the Great Tunis region. In an ONFP clinic, I even witnessed a dispute between a midwife and another member of the personnel over the presence of a senior male employee, who was in charge of managing medical records. His task was to carry patients’ medical records, which were all in paper form, to and from the clinic’s archive. The female personnel contended that his presence made the clinic’s users feel uncomfortable, while the midwife argued that the patients did not care at all and that he was a respectful and discrete person. I can cite another significant episode to confirm the marked feminisation of the youth-friendly spaces, the official intention of the ONFP notwithstanding. I was present at an ONFP clinic when a young woman who had just taken misoprostol, used to induce abortion, was severely reprimanded by the staff for not waiting in a room with other patients. She had left the clinic but was stopped by a member of staff and told to return to the waiting room with her boyfriend. Another young woman in the room subsequently complained to the personnel, saying that the couple were being inappropriate. The accused patient, an attractive and confident young woman, argued that ‘it was the other woman who was strange’ and that she and her partner had done nothing but sit close to each other. She was not afraid and defended herself in front of the health practitioner, who insisted on rebuking her, emphasising the fact that she had given her the misoprostol on Saturday morning – although doing so is usually not allowed – because she was still a virgin (sbiyya) and they did not want to let her wait any longer.14 Excluding men from the ONFP clinics when they accompany their partners reinforces the social fiction shared by most providers I met that women are the only responsible subjects when it comes to sexuality and unwanted pregnancies. In the eyes of providers, women are the only reliable interlocutors because men are uncontrollable, violent, subject to their sexual needs and do not care about the consequences of their behaviours;15 at the same time however, women are also ‘guilty’ when they have sexual relationships and do not take the necessary measures to prevent negative events, such as having an unplanned pregnancy, losing her virginity or obtaining a sexually transmitted infection. The feminisation of sexual and reproductive responsibility is not only a result of the

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available biomedical contraceptive technologies but foremost of the social division of labour in which women are seen as the main party responsible for the couple and the family. Whereas this corresponds to the stereotypical roles that family planning discourses attribute to women, this contradicts the subordinate position women have in the family and in society, where they are discriminated against legally, economically and politically. The exclusion of men from SRH clinics is not exceptional and corresponds to what Brenda Spencer (1999) describes when analysing the hidden assumptions behind the international family planning and AIDS prevention policies of the 1980s and 1990s. International health programmes conveyed the old stereotype according to which men are irresponsible and dominated by their sexual drives, whereas women are responsible for family health and protection, and their sexual desire is rarely mentioned (ibid.). These assumptions explain why men are absent or marginalised in most international family planning programmes and reproductive health policies, despite numerous studies showing their crucial role in determining women’s sexual and reproductive trajectories at both the macro and micro levels (Dudgeon and Inhorn 2004). This has also been the case in Tunisia, where, despite several attempts to involve men in reproductive decisions (Foster 2001, Gueddana 2001), family planning policies have mainly targeted women. Clinical Encounters in Youth-Friendly Clinics In regards to the routines of the youth-friendly unit, when a woman came to the clinic, she was received by an animatrice (female health worker or facilitator), whose task is to listen to the woman’s request and fill in the social section of her record. During this preliminary stage, women could be subject to a moralising or threatening discourse by health workers, especially if they were at the clinic for an abortion. The personnel often depicted (medical) abortions as dangerous, arguing that they can cause sterility or even cancer and insisted that not using contraception is irresponsible.16 In one of the three ONFP clinics where I did fieldwork, the staff members’ unfriendly tones of voice, disagreeable attitudes and cold gazes contributed to a hostile environment for the young women who came to the clinic for an abortion. Here, the arrangement was that of a trial in a courtroom: while two and sometimes even three animatrices were sitting at their desk, the patient was often left standing in front of them. They questioned her one after the other, and in supporting each other’s arguments expressed moral

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judgments and scolded the woman as if she were a naughty child. The description of one of these encounters – where I involuntarily became one of the accomplices due to the mere fact that I was in the room – offers an idea of the staff members’ attitudes. Lina, a health worker, calls one of the young women by her first name. The young woman is sitting in the waiting room and comes to the room in which clinic users are received for the first interview. I sat in front of Lina and Rim, the other health worker in charge of filling in the first part of the medical record. There was no chair for the patient, who stayed standing in front of us. Lina asked in an unfriendly and bureaucratic tone why the woman had come to the clinic and, without looking at her, continued to stare at the papers scattered on her desk. The woman spoke in a voice that was barely audible, saying that she had come to the clinic because of retard (she was late, which means she had missed her menstrual period). She did not say that she wanted to get an abortion, although this was the reason for her visit. Sometimes the young women who came to the clinic would declare that they ‘had a stomach ache’ or ‘were late’ without explicitly saying that they wanted to get an abortion; while others explicitly confirmed this, asking for curetage (curettage or D and C) or to take the harabish (the pills). I will examine such phrasing below. One of the health workers in the room asked if the woman had had any sexual relationships and when she first experienced sexual intercourse. The woman – who was 25 years old – was confused and answered that she did not remember but confirmed that she was not a virgin. Lina treated the woman as though she was not asking for a service to which she is entitled but a favour that the health providers can decide to graciously provide17 (fieldnotes, 15 May 2014). During the interview, the woman was asked if this was the first time she had sought an abortion, and she confirmed it was. This is a very sensitive question that was routinely asked, even if the woman had come to the clinic for the first time, in which case she might have had abortions in another ONFP clinic or in the private sector and may not declare them.18 Healthcare providers often threatened to refuse women’s requests for abortion care if they did not agree to use biomedical contraception, and they sometimes wrote this information down on their medical record.19 The staff of all of the clinics I attended always insisted on the gravity of not adopting a reliable contraceptive device, but many women preferred not to use contraception because they could not easily take responsibility for their premarital sexuality in a society that heavily stigmatises it, as noted

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in the previous chapter (see also Ksontini 2017). Most women I saw silently accepted enduring humiliating and stigmatising discourses in exchange for abortion care and were ready to beg the providers; they even cried in front of them to increase the staff members’ compassion and empathy. Anxiety, fear and sometimes even despair were common in the words and facial expressions of young women seeking abortion care. Although health professionals often thought that patients lied20 about the number of sexual partners they had had, the date of their last menstrual period21 and the fact that they smoke or drink alcohol, they took young women’s attitudes very seriously when they were pregnant and manifested great distress. On at least three occasions, in different clinics, health practitioners reacted compassionately when unmarried women cried, shouted or even threatened to kill themselves. On one of these occasions, an unmarried woman in her early twenties with an early secondtrimester pregnancy was very distressed because legally she had lost the ability to get an abortion. Alarmed by her moral distress, the midwife in charge of abortion care called a medical doctor to ask for help. The doctor called a friend, who was a psychiatrist in a government hospital, asking him to take in the young woman and write a medical certificate indicating that the continuation of the pregnancy could compromise the patient’s mental health. Despite being fifteen weeks’ pregnant, the young woman rapidly got an abortion thanks to the intervention of several healthcare providers because Tunisian law allows second-trimester abortions if the mother’s physical or mental health is endangered. On another occasion, I was present during the following scene: a doctor received a 22-year-old woman who was greatly distressed because she had had a medical abortion two weeks before but her uterus had not expelled its contents. She cried desperately, terrified, and said she wanted to leave the clinic and seek help elsewhere. The doctor was concerned and told me that she was afraid that the woman would try to commit suicide. She prescribed her two more tablets of misoprostol and tried to comfort and reassure the woman, stating that the abortion would take place soon. The woman did not listen to her and seemed out of control. After a few hours, the clinician asked the young woman to come back to her room so she could perform an ultrasound to see if the abortion was progressing to reassure the patient and to improve her mental status. When the doctor showed her that the expulsion was taking place, the young woman hugged and kissed the provider and the health worker present in the room. Joy and relief were depicted on her face (fieldnotes, 15 May 2014).

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As Ksontini (2017) also stresses that it is very rare that unmarried women are turned away without receiving abortion care because their whole life is at stake; the personnel, although acting as moral entrepreneurs (Ben Dridi and Maffi 2018) and ‘orthopedists of individuality’ (Foucault in Rabinow 1984: 235), rarely refused to rescue unmarried patients. Virgin unmarried patients were even more rapidly taken care of than those who were no longer virgins. Health providers payed specific attention to the virginity of unmarried women because, as already emphasised, it is an important social value that should be preserved by any means. Thus, young women who, in the eyes of some healthcare providers, had failed to show rational and moral behaviour were usually helped so as to preserve their virginity because its loss would compromise their future. This is also the reason that doctors and midwives always asked unmarried women if they were virgins before performing a pelvic examination because they would adapt their clinical procedures in accordance, such as by not inserting a speculum into the woman’s vagina. The staff’s behaviour was different when it came to married women, who, at the time I conducted fieldwork, were turned away more frequently than unmarried women; this was because their pregnancies were deemed less socially and personally disruptive, which I will explore in the next section.

The Health Record for Youth and Adolescent Individuals In the youth-friendly clinics, interactions with women are framed by the content of the Dossier santé Jeune/Ado (medical record for youth and adolescents), which is specifically designed for unmarried patients; a different record is used for married women. The existence of two types of medical records and two units within an ONFP clinic allows practitioners to precisely count the number of unmarried and married SRH clinic users. Data are produced and collected in each clinic and centralised by the ONFP central bureau of statistics. The health record for young people contains three different parts: the first aims at gathering social information about the patient, the second at collecting the patient’s medical story and the third at documenting the patient’s psychological profile (if necessary). In the division of labour within the clinic, health workers are usually in charge of the social section, doctors or midwives/

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Figure 3.1  First page of the Dossier santé Jeune/Ado. Scanned by the author.

nurses are in charge of the second and psychologists22 are in charge of the third. Because the interview with patients is conducted following the Dossier santé Jeune/Ado,23 it is important to analyse the kind of information it aims to collect and the performative effects it produces when used. Two different aspects that emerge when we compare the records for unmarried and married individuals must be emphasised: the medical gaze aims at penetrating the intimate life of young or adolescent patients much more deeply than the private space of married women (and men), which is precisely because married

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women seem to be of less concern for the state. In the very first lines of the record for married women, patients are required to indicate their husband’s name and the date of marriage, as if doing so would delimitate a space where the state cannot intrude. This is consistent with other aspects of Tunisian governmentality, according to which the state does not interfere with the sexual life of its married citizens. In regards to this point, citing a recent work by the Tunisian feminist legal scholar Sana Ben Achour is of interest, as she describes the role of a man and a woman within marriage according to the Tunisian law and jurisprudence (2016: 36–39). She argues that the main functions of the ‘payment of the bridewealth’ (mahr), of ‘the customary marital duty’ and of ‘the consummation of marriage’ are the ‘reification of the bride, her reduction to a sexual object, and as a consequence to her subjugation’ (ibid.: 36). This is also the reason that, in her opinion, the CPS ‘is hermetically sealed in the face of the idea of marital rape’ (ibid.) because once the man has paid the bridewealth, he can compel his wife into the consummation of marriage.24 According to Ben Achour, in Tunisia, the duty of cohabitation, the marital duty, the marital home and the husband’s status as head of the family all contribute to perpetuating institutionalised forms of violence against women. Additionally, state institutions consider married citizens to have a regular, orderly and disciplined intimate sex life, in which the state intervenes only to regulate the number of children and possibly the rhythm of their birth. For example, unlike the medical record for unmarried women, the one for married women does not contain boxes where the health provider should indicate when the patient had her first sexual relationship, if she has many partners, if she uses condoms on all or some occasions, if she has already used emergency contraception and so on. Even if married women (and men) can have multiple partners, irregularly use contraception and resort to emergency contraception institutionally, they are not subject to the same questions and the same forms of control as unmarried women. It should be noted that although the Dossier Jeune/Ado is officially designed for male and female individuals, young men very rarely consult state clinics for sexual and reproductive health concerns, and therefore unmarried women’s sexual behaviour implies a specific apparatus of surveillance that has no equivalent among other categories of citizens. This can be explained by the fact that women’s bodies – and particularly those of unmarried women – continue to be ‘the citadel of the patriarchal moral order and of the family honour’ (Ben Achour 2016: 62).

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The Social Interview The first part of the medical record for young/adolescent patients is meant to acquire information about their socio-economic situation: it contains questions about their education or occupation, family configuration and ‘life habits’. This last category includes questions about whether they smoke and, if so, how many cigarettes; if they drink alcohol and how often; and if they use drugs and what type. This part of the questionnaire, which is theoretically meant to allow health providers to form a general idea about the patient’s social profile and her sanitary conduct, is often used to form moral judgement about her and possibly about her family. It is also the moment where health practitioners can rebuke the patient and try to moralise to make her conscious of her bad and irresponsible behaviour. The unintended effect of these medically motivated questions is to remind health practitioners and patients of the moral, social and political world in which they are caught up. This world is very different from the apparently universal and neutral medical frame underpinning the questions contained in the record. It is one in which unmarried individuals should not have sexual relationships, women should be virgins when they marry, men’s sexual experience and strength are appreciated, parents and male and/or elderly family members should control the sexual conducts of their daughters and female relatives, women and men do not enjoy the same legal rights, social class and level of education determine differential access to medical facilities, the state applies different disciplinary forms of control on women and men and married and unmarried individuals. An ethnographic fragment can allow the reader an insight into how these records produce effects that are well beyond the official medical intention lying behind them. At the end of the morning, after she had finished examining her patients, a doctor working in an ONFP clinic within the youth-friendly clinic meets with me for a discussion. She tells me that she believes that at least two of the patients she examined that day exchange sexual services for money. Her opinion is largely based on the information contained in the women’s records and on the fact that they have a genital tract infection. The doctor says, ‘They do it for money, they have slacked off (se sont laissées aller), it is debauchery (c’est la débauche). I am sure they have several partners. One of them already had five abortions and she also smokes!’ While she does not say anything to the women, she can hardly look the patients in the eye and speaks with a soft

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and monotonous voice, as if she is trying to create as much distance between herself and the women as possible. Later, this practitioner tells me that she is against abortion and that she explicitly says the same thing to her patients because they often ignore that it is haram (religiously proscribed). She confirms that she says it without insisting that they change their mind and without turning them away, although she knows that another member of the staff does so. In the last part of our conversation, she narrates a few dramatic stories of young female victims who suffered sexual violence at the hands of one of their family members, whom she examined in the previous months. In her daily work, she sees a lot of women experiencing sexual, physical, social and economic violence and aches for them. Talking about ordinary violence, she laments the fact that many husbands do not want their wives to use an IUD (which she ­considers to be a good contraceptive method): ‘They are bothered by the device and egoistically impose on women not to use it.’ She notes that women should freely choose their contraceptive method and that husbands are not entitled to interfere. In this doctor’s discourse, like in that of many other healthcare providers, medical considerations intertwine with moral and social arguments, showing that the medical record for young adults and adolescents elicits attitudes, behaviours and discourses that transcend the clinical domain (fieldnotes, 2 February 2014). The Medical and Psychological Interview The questionnaire intended to determine the social profile of the patient is followed by the medical section of the record, which is similar to the record for married women, although more detailed. Here, the health practitioner should indicate the reason for the consultation, the patient’s obstetric and gynaecological history and her personal and family medical history. A specific section on sexual and reproductive health, which I mentioned above, follows in which the patient must provide detailed information about her age at first sexual intercourse, number of partners, use of contraception, number of abortions, etc. The following pages contain boxes to be filled in with medical details of the patient following a clinical exam. In the required information, the medical personnel should also indicate the patient’s emotional status, which can be documented in more detail in the last section. This section is dedicated to the ‘psychological consultation’, which is not compulsory but seems to be considered a normal part of the follow up for unmarried individuals. It is not a coinci-

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dence that the specific attention paid to the patient’s psychological life is absent in the record for married women. The hidden assumption is that if unmarried individuals consult a SRH clinic, they must have psychological problems, either because they breach social and moral norms related to sexuality and are subject to guilt or because they face the reprobation and violence of family members and acquaintances. While this is unfortunately the case for some young unmarried women, it is not limited to them, as married women are also subject to different forms of physical, psychological and sexual violence. This is not only documented by the Enquête nationale sur la violence à l’égard des femmes en Tunisie (National Survey on Violence Against Women in Tunisia) (2011), but over my own research I attended several situations in which married women sought a midwife’s or doctor’s help because they were subject to violence at the hands of their husbands or family members. Particularly in the family planning unit of Hospital T, I regularly met women who experienced dramatic forms of structural violence: young women incarcerated (sometimes under the age of eighteen) for prostitution or theft, girls under the protection of the institution in charge of child victims of violence because they have been abused by one or more men, unwed mothers in very precarious socio-economic situations, homeless women and mothers and women with mental disorders. For example, in Hospital T, I once attended the consultation of an incarcerated 16-year-old girl, who came to seek abortion care accompanied by two female guards from the detention centre. During the exchange with the midwife, the girl never said a word and persistently stared at the ground. She was ten weeks pregnant and was to be admitted to the hospital a few days later to undergo a medical abortion ‘to expel the baby’, as the midwife told her. Another time, I met an incarcerated girl of the same age, who had had been pressured by an older friend to become a sex worker. She belonged to a disadvantaged family but was a student in a high school and had stopped attending classes to engage in sex work. She had been raped by two men and was almost three months pregnant the first time I met her (fieldnotes, 4 March 2014). During the consultation, the midwife spoke to her gently, encouraging her to go back to school and leave the ‘wrong path’ she had taken. Listening to the midwife, the girl, visibly affected, began to cry but did not say anything. Encounters with socio-economically disadvantaged women victims of structural violence were also common in ONFP clinics. I

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will describe another situation I witnessed as it captures the profile of a large number of patients who attend government SRH facilities. In a youth-friendly clinic, a 30-year-old woman was discussing contraception with the doctor who had examined her. She had had no menstrual cycle but was not pregnant; she had adopted the injectable contraceptive method one year earlier but had stopped using it. She explained that she had undergone a throat ­operation – she probably had her thyroid removed – and needed to take medication. However, she had no money and could not afford to buy them in the pharmacy. Apparently, she had not received the special ticket allowing very indigent persons to get free medical services and medication. She lived alone and explained that she worked as a cleaning lady in several houses. The doctor asked many questions in an attempt to learn more about her situation, and the woman began crying softly: she was an unwed mother but could not afford to keep her 12-year-old son with her. The father of the child married another woman and did not care for his son. Her parents were dead, and her brothers did not want to help her and rejected her son because he was illegitimate. The doctor sent her to a hospital where she could get the medication she needed, prescribed her medication that induces menstruation and suggested she return for contraception after resuming her cycle. Once the woman left the room, the clinician looked at me and said: ‘When I began to work in this clinic, stories such as this generated a lot of suffering in me’ (fieldnotes, 3 April 2014). However, violence against women also occurs in more affluent families. One morning, I attended a conversation between two staff members at a youth-friendly space. One told the other that in the waiting room was a young woman she knew, the daughter of a high-ranked state official, who was raped by her cousin after she refused his proposal to become engaged. She had not told anybody what had happened because she was afraid it would affect her father’s and family’s reputation. The health worker was saying, ‘She cannot tell her parents because they cannot understand and forgive her’ (fieldnotes, 3 April 2014). The young woman had probably come to the clinic because she was pregnant and wanted an abortion. As she had no personal money and did not dare to ask a family member for help, she had to resort to a public SRH clinic instead of getting abortion care in the private sector, as most affluent women do. While many poor women are caught up in structural violence, which impacts their health and moral well-being, violent behaviour

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on the part of their husbands and relatives can make their lives even harder. As I said, I did participant observation in public SRH clinics mostly attended by the poorer strata of the population. Many women did not have shoes, only slippers or plastic sandals. They wore cheap sweat suits under their jellabiya and often did not have the money to buy menstrual pads. A large number of them were overweight because their diet was very poor in fruits, vegetables, fish and meat, as they could not afford to buy them. Many suffered from various disorders – diabetes, high pressure, obesity, or other disorders – unrelated to reproductive health and were not well cared for by the healthcare institutions.

Symbolic Violence in Reproductive and Sexual Health Clinics The treatment unmarried women receive in some SRH clinics is a form of symbolic violence modelled by the medical record, which elicits and legitimates stigmatising and moralising behaviours among some health providers. An unmarried woman seeking repeated abortions or consultations for repeated genital infections is often accused of being a prostitute, lying about her sexual conduct, hiding illicit relationships, or being irresponsible towards herself and her partners. A recent ethnographic study carried out by Ksontini (2017) on the attitudes of personnel towards unmarried women at a youthfriendly clinic in a coastal city in Tunisia offers significant elements of comparison with my own observations in the Greater Tunis area. Ksontini defines the youth-friendly clinic as ‘social purgatory’; a place where young women seeking abortion care must go through a moral and social process of punishment, expiation and reparation, although at the end they can usually be rescued.25 She describes their experiences in the clinic as going well beyond a medical procedure despite the absence of coercion and control through words of the sort French women had to go through in France until the early 2000s (Memmi 2003a) and even later (Mathieu and Ruault 2014). Examining the forms of biopower enacted in France in the 1980s and 1990s to administer life and death, Memmi considers the procedures a woman had to go through if she wanted to get an abortion. She shows that, after the decriminalisation of abortion in 1975 until 2001, when the law was changed,26 French women had to undergo three compulsory interviews, two medical and one psychosocial,

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and wait one week before getting abortion care so that they would have time to reflect before making the decision to terminate the pregnancy. The psychosocial interview was ‘clearly meant as a dissuasive interview’ (2003b: 35) aimed at ‘persuading women not to abort’ and ‘fighting in any case against the recidivism’ (ibid.). In France, the model behind the abortion procedure presupposes a patient able to exert self-control and reflexivity to duly motivate her decision and master her bodily drives, transforming them into words. Even though the compulsory psychosocial interview was suppressed by the law reform of 2001, Mathieu and Ruault show that the ‘policing of speech’ has not disappeared but is today included in the medical consultation. Thus, the legal amendment has brought about the ‘extension of the domains of action of the doctors that includes the responsibility for the psychological and moral aspects’ of abortion (2014: 42). Moreover, Memmi compares the clinical encounter, including the collection of information about the patient’s private life, with religious confession, showing the similarities between the two situations. Among the common elements, she identifies the centrality of spoken words and their power of salvation, the asymmetric relationships between patient and expert, the forced and institutionalised nature of the confession and the nature of the professionals’ activity, which consists of manipulating ‘the views of the world directly affecting the private life, manipulating the speech’ (2003b: 73). The clinical encounter is also the moment during which many health professionals try to arouse the affect of a patient to correspond to the representation of abortion as a ‘difficult or even traumatic event for the bodies and the minds’ (Mathieu and Ruault 2014: 52). As previously described, in Tunisia, as in France, women have to express their distress, sorrow and psychological troubles when going through the abortion procedure because for most healthcare providers it is not a normal part of reproductive and sexual health but an exceptional and controversial one (Ksontini 2017, Raifman et al. 2018, see also Chapter 4). The social control exerted on women who seek abortion care is present even in very progressive Scandinavian countries, as shown by Mette Lokeland, who writes that in Norway women are expected to express normative feelings when they seek abortion care (2004). A woman has to say that she is sorry and express doubt about her ‘decision to have an abortion in order to be regarded as a moral person’ (ibid.: 172). Lokeland also notes that the narrative of the guilt, sorrow and even trauma women experience when they get an abortion is used both by pro-choice and

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anti-choice movements, as if these are the only legitimate emotions when deciding to terminate a pregnancy. This narrative forecloses other possible ways of framing abortion, such as the expression of a woman’s agency, and supports the idea that abortion is exceptional, morally despicable, a transgression of ordinary feminine identity. Women who abort are thus turned into pathological subjects, as they infringe their essential (natural) disposition: the desire to become mothers (Kumar, Hessini and Mitchell 2009). Governing through Words As in ONFP clinics, interviews in French institutions are central to the disciplinary work accomplished by the personnel to redress deviant patients’ behaviours and transmit and reinforce the normative model of self-control, prevention and orderly moral and sexual conduct. Memmi considers the work accomplished by the medical and paramedical personnel during interviews as a fine and complex form of pedagogy: pedagogy of the gaze, of the speech and of the subject, in that the way of looking at and speaking of the pregnancy/ egg/embryo/baby and of abortion determines how an individual experiences or should experience it. Medical and psychological interviews can be used to shape, control and train the subjectivity of women seeking abortion care (2001). I will come back to these various forms of pedagogy in the next chapter, showing how they are performed in the Tunisian clinics where I conducted participant observation. Because the distinction between bodily and moral work cannot easily be traced, especially in the domain of sexual and reproductive behaviours, it is legitimate to speak of punishment, expiation and reparation, as Ksontini does, when describing the process that unwed women – but also married women – have to go through when they seek abortion care. Although Tunisian law does not imply a discourse such as the one that existed in France, and although unmarried women who seek abortion care do not have to go through compulsory interviews with psychologists in order to produce a specific type of narrative, a ‘conform biography’ in order to receive abortion care (Memmi 2000: 6), they are nonetheless subject to informal processes of moral blame and reprimand that are part of the local pedagogy of the subject. These processes are aimed at obtaining the expiation, repentance and redress of immoral female individuals and/or irresponsible citizens, whose role and identity are powerfully rooted in Tunisian society. At the same time, and despite the negative aspects described above, these facilities offer women the

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possibility of finding a solution and avoiding a worse scenario, as in the case of women victims of sexual violence or pregnant unmarried women, who risk compromising their future if they have a child. The degree of moralisation women are subject to and the type of pedagogy applied varies according to the ‘rigorism’ of the healthcare provider, who can make the clinical encounter more or less psychologically and materially comfortable for the patient. Although the discursive rhetoric might have changed after the revolution, this is not new. In the 1980s, Labidi described the encounter between a woman seeking abortion care and the midwife as a ‘non-instituted’ or ‘unregulated’ interview shaped by the provider’s relationship with sexuality and the dominant ideology (1989: 103). In Tunisia, as in France, the health practitioner can refuse to provide the service the patient requires or ‘deliver it reluctantly letting her pay another price’ (Memmi 2003b: 65). While some providers, as shown above, try to make women reflect on their faults and set them back on the right path, others adopt a pragmatic attitude, avoiding moral judgments. Several practitioners I collaborated with had this attitude and were convinced that women should not be judged but helped when they come to the clinic to seek abortion care. These practitioners generally did not rebuke their patients, did not try to humiliate them and did not treat them as undisciplined children but, on the contrary, were willing to facilitate and expedite the procedure. They were also morally supportive when women were distressed or experiencing hardship, as in the case I mentioned above of the 16-year-old girl who left school to practice sex work. In another more complex case, the support of the health practitioner was expressed in a way that did not necessarily correspond to the wishes of the woman in front of her. A 25-year-old woman who was twelve weeks’ pregnant came to Hospital T with a referral letter from an ONFP clinic because her pregnancy was too advanced to receive abortion care there. Although the woman had signed a marriage contract four months earlier, she had not yet officially celebrated the wedding, and the social service department treated her as an unmarried woman. Her husband’s name was probably not yet indicated on the woman’s identity card. The midwife in charge of abortion care was going to take a two-week holiday, and there was nobody to replace her and ensure a follow up with the woman (fieldnotes, 10 December 2013). She first thought to organise her hospital admission a week later in agreement with one of the resident physicians, but then she remembered that, as the head of the department was absent and another doctor who is against abortion

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would replace him, the woman would probably not be able to get abortion care. Therefore, the midwife modified her discourse, saying that the pregnancy was too advanced and that ‘the baby is already so big’ – showing with her hands the dimension of the foetus’s body – in order to dissuade the woman from terminating the pregnancy (fieldnotes, 10 December 2013). On another occasion, the same midwife, usually very supportive of women’s decisions when they wanted to terminate a pregnancy, tried to discourage a couple from getting abortion by resorting to an ultrasound scan. The woman had come together with her husband. They were poorly clothed and, although they were in their early forties, seemed much older. The couple were from a rural area and had eight children already. The woman did not have a job, and the man was a day labourer. The woman was fourteen weeks’ pregnant, and the midwife doubted that the head of the department would authorise abortion. She showed the couple the little black and white image of the conceptus and drew the contour of the foetus’ body with a pen so that they could see a human form (see also Chapter 4). The woman and the man looked at the picture for a few seconds but seemed completely indifferent. They repeated that they did not want to have another child and insisted on an abortion. When she was in the department head’s office, the midwife presented the couple’s case, but he rejected their request. However, the midwife decided to introduce him to the couple, who were waiting outside her room. When he saw them, he changed his mind and agreed that the woman should receive abortion care. I believe that this happened because he realised that they lived in very difficult conditions based on their very modest clothes, their sloppy physical appearance and the very bad condition of their teeth (fieldnotes, 31 March 2014).

The Abortion Procedure in Hospital T Since the early 2000s, unmarried and married women officially access different sections of the regional ONFP clinics to protect their privacy and provide them with adapted services. In Hospital T, the family planning unit where I did participant observation did not have different sections or specialised personnel. However, thanks to the initiative of the previous head of the hospital department in which this family planning unit was located, consultation for contraception and abortion were separated from the outpatient clinic receiving women for other reasons, such as prenatal care or

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g­ ynaecological disorders. According to the midwife in charge of the family planning unit since its creation in 2006, before its separation from the other departments, the hospital staff used to discriminate against and mistreat women seeking abortion care by making them wait until they had finished seeing all other patients. After the creation of the family planning unit, women seeking abortion and contraception could wait in a different room and avoid staff members’ discriminatory attitudes. As in ONFP clinics, unmarried women seeking abortion care had to go through an administrative procedure that allows medical authorities to track their number and impose a specific form of surveillance on them. When women arrived to the hospital, they first had to register and explain the reason for the visit at the reception desk, where the triage of patients takes place. They had to show their identity cards, where their marital status is indicated. If they were unmarried and were seeking abortion care, they had to go first to the bureau of the Service social (social service department), located within the hospital, where social workers enquire about the circumstances of the pregnancy and write the women’s names in a specific register. The department also offers psychological support to women victims of violence, especially those under the age of twenty. In 2013–2014, both rape and nonviolent sexual relationships with girls under the age of twenty were criminal acts according to the Tunisian Penal Code,27 so all pregnant unmarried women under this age had to pass an interview with the personnel of the hospital’s social service department before gaining access to the family planning unit. During my research, there was an ongoing conflict between these personnel and the head of the social service department for two main reasons: the first concerned the ambiguity surrounding the age at which women are considered adults, and the second concerned the decision to register unmarried pregnant women with pregnancies of more than three months at the family planning unit instead of the obstetric unit. As for the age of consent, a law in 2010 promulgated eighteen, replacing the previous age of twenty-one. This reform also concerned the legal status of women and modified the articles of the CPS. Thus, all unmarried women aged eighteen or above should be able to get abortion care without their legal representative’s consent (Méziou 2011). Despite this amendment to the law and the personnel of the family planning defending the right of these women to get abortion care without the intervention of a legal guardian in Hospital T, all unmarried women between the ages of eighteen and twenty28 were

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systematically sent to the social service department by the reception desk, whose personnel continued to apply the old law. Asked to take a position on the matter, the head of the department refused to intervene to avoid a possible conflict. His attitude did not help to solve the situation, and each woman between eighteen and twenty seeking abortion care was caught up in harsh discussions between the personnel of the family planning unit and of the social service department. This made their therapeutic itineraries more complicated and conflict-ridden than those of other women, as they had to go back and forth between the two. The case of a 19-year-old girl who came to Hospital T seeking abortion care provides a meaningful illustration of this trajectory. The young woman, who came from a rural area, was afraid that her family would discover her pregnancy and had come to Tunis to seek abortion care. Nobody at home knew she was pregnant, and she explicitly told the midwife that her family members would kill her if they learnt about her condition. Eventually, the midwife helped her to get an abortion, opposing the decision of the head of the social service department, who had requested the consent of the girl’s parents. A serious dispute followed this case, during which each party tried to impose its point of view. Although the family planning unit and the social service department tried to persuade the head of the department to make a stand, he refused to do so for various reasons not directly related to the dispute. The conflict lasted for several weeks, until the head of the social service department eventually reconsidered her position. The second reason for the conflict between the family planning unit and the social service department was related to the treatment of (especially unmarried) women who were more than three months pregnant, as the law states that abortion for social reasons can be performed only until the end of the third month. As already mentioned, Tunisian women desperately try to avoid giving birth to a child outside of wedlock because it compromises their future life, causing them – and possibly their children – great social and personal suffering. It was not rare for unmarried women with pregnancies of sixteen or even seventeen weeks to come to Hospital T to seek abortion care, ready to do all that was possible to get rid of their ‘belly’ (qirsh). While ONFP does not provide abortion services after the first trimester, Hospital T can provide it in case of severe malformations or genetic disorders of the foetus and when the physical and mental health of the mother is endangered. Many of the women who sought abortion care in the second trimester lived in precarious socio-economic situations, were poorly educated, were sometimes

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homeless, had psychological troubles or were victims of violence. For the staff of Hospital T’s family planning unit, it was necessary to help them and also avoid bringing into the world ‘a child who would be abandoned and possibly become a criminal’. A midwife told me that it was difficult for her to help these women to get an abortion because, for her, they were already carrying a baby (bébé). Nonetheless, each time providers hesitated to help a woman seeking abortion care, they thought about the miserable destiny anticipated for the baby to overcome their feelings of guilt. The usual way of allowing these women to get abortion care, despite the expiration of the legal term, was to ask them to bring a certificate from a psychiatrist stating that the mental health of the woman would be compromised by the continuation of the pregnancy. To get this certificate, the staff used to let women write down the address of one or two private psychiatrists – whose cards were kept in a drawer – who they knew were ready to help them. Interestingly, there was no formal agreement between the staff and these doctors, as they had never met or been in contact. Illiterate women in very precarious situations were sent to some local NGOs that are active in the domain of women’s rights and who offered them material, psychological and legal help in getting the certificate. The same midwife who felt guilty about aiding the abortion of what she considered an advanced pregnancy (hbela kabira) – an older patient and not a victim of sexual violence, although very poor – had a very different attitude towards an adolescent victim of rape who had to wait until the second trimester before getting an abortion – usually up to fourteen or fifteen weeks – because for legal reasons an amniocentesis should be performed in order to identify the biological genitor.29 In this case, the midwife was more worried about the girl, who had to experience a late medical abortion, than the foetus. Generally, when she was not at ease with the decision of a patient, this midwife used to say to women that their situation was complicated or even against the law and that she could not ignore the rules, or even that what they were carrying was a baby (saghir) and abortion could not take place so easily. In these cases, her strategy was to tell women with advanced pregnancies that she had to talk to the head of the department to get his advice. While this was true for all cases (because as a midwife she was not entitled to authorise abortions), she used this argument when she did not agree or only partially agree with the opportunity to terminate the pregnancy. In that way, she did not have to negotiate with the patient and could discuss each case with the head of the

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department. For him, the family planning unit was not a priority and medical abortions were not at all interesting. Therefore, he used to delegate the responsibility to the midwife and for the most part rarely interfered in her decisions, as far as I could see during their conversations. Contrary to the hospital staff, the women seeking abortion care in the second trimester, who, as I said, often experienced difficult socio-economic situations, did not seem hesitant about terminating a pregnancy and were only worried about the possibility of not being able to do so. A few of them who were young and unmarried were very distressed, and they cried and shouted during the consultations, overtly expressing suicidal thoughts. Others, often married, insisted that they could not keep the pregnancy and that their husbands would drive them out of the house. They stated their husbands were violent and beat them and their children or that their economic situation made it impossible to keep a child without compromising the life of the whole family. Other women who had mental health problems or were homeless did not even need to explain why they wanted an abortion, why they did not come earlier, why they did not use contraception – the usual questions clinic users had to answer – as the health providers assumed they were not in a position to take responsibility for their actions. Because of their stressful and sensitive situation, I did not ask these women questions and only observed the exchanges between them and the health providers. I did discuss some cases with the practitioners when the women were not present, especially if I had not attended the previous encounters between the patient and the provider and did not fully grasp the situation. Tribulations in Abortion Itineraries I also met many women who had tried to get abortion care in at least two or three different government facilities in Great Tunis before ending up in Hospital T: some of them had spent several weeks trying to find a clinic where abortion was offered and had arrived at Hospital T at the beginning of the second trimester after the legal term for abortion had passed; others were still on time to get an abortion in the hospital but not in ONFP clinics and had expressed anger, fear and anxiety and were extremely distressed when I met them at the family planning unit of Hospital T. For some of these women, the reasons why their abortion itineraries were long and complicated were very banal but had completely changed their experience of it or even made it impossible. For example, a

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mother of two who had come to an ONFP clinic quite early after a missed period to get abortion care was turned away by the personnel at the reception desk without being asked anything further, such as possible date of conception. The staff told the woman to come back after ten days because it was too early to get abortion care. She had gone to another ONFP clinic where the doctor had told her that she was already eight weeks pregnant, and therefore it was too late to get a medical abortion in her facility and she could not offer her surgical abortion. When she arrived at Hospital T, she was already at the end of the first trimester and the midwife who examined her was not sure whether the head of the department would accept her request to terminate the pregnancy. The woman, who was very distressed at the time I met her, was denied abortion care and had gone through a very difficult time largely because of the superficial attitude of the personnel at a reception desk of a clinic. It is possible that the staff member at the reception desk was not even trying to dissuade her from getting an abortion, as some practitioners do by postponing access to medical care, but was just overwhelmed by work. In other cases, the staff of ONFP clinics used medical reasons to turn away women (e.g. arguing that they had a health condition that made medical abortion dangerous or impossible). In Hospital T, I met many of them who came with a letter containing a diagnosis that was not a contraindication for pharmacological abortion such as asthma or a previous C-section. As already mentioned, the denial of women’s right to abortion was sometimes explicitly justified by staff members, who in front of the women defined it as a crime, an act forbidden by religion and morally reprehensible, but often such denial was the result of negligence, superficiality or overloaded facilities.30

‘Recidivists’, ‘Unmarried Mothers’ and ‘Social Outcasts’ or the Bad Figures of Maternity So far I have described the official administrative and medical procedures women who seek abortion care have to go through in the government SRH facilities I studied. Before concluding this chapter, I intend to examine the terms health professionals use in order to designate the categories of women considered as morally corrupted. These terms define the moral nature of women’s sexual and reproductive behaviours and have nothing to do with medical or administrative categories that, at least theoretically, should orient

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the interactions between practitioners and patients. In fact, these informal categories are more or less explicitly present in many health providers’ discourses and contribute to moulding their attitudes and behaviours, revealing complex moral regimes in which diverse ideologies and rationalities intertwine. They also constitute impersonal and standardised ideal-types to which the complexity and specificity of each individual’s trajectory is reduced, allowing health professionals to create and/or reinforce a moral and social distance from women who fall into these categories. They frame ‘women who abort’ (Kumar, Hessini and Mitchell 2009: 629) as deviant in that they infringe stereotypical moral, social and even medical norms defining the feminine subject. These categories contribute to building the abortion stigma to which women and healthcare providers are subjected in Tunisia and elsewhere and that is inscribed in a multilayered configuration that includes discourses, structural and organisational elements, community norms and individual representations (Kumar Hessini and Mitchell 2009: 630). What are these terms? What are the profiles of the women so labelled? Abortion care providers use the terms ‘recidivists’, ‘unmarried mothers’ (ummahat a’zibat) and ‘social outcasts’ (cas sociaux) to designate, respectively, women who repeatedly seek abortion care, women who become pregnant out of wedlock, and sex workers (cas sociaux is also used for the latter two groups). As I previously mentioned, ‘recidivist’ entered the discourse of healthcare providers in the mid-2000s, when religious conservatism was on the rise, and is used for married and unmarried women perceived as unable to exert self-restraint and responsible reproductive behaviour. The condemnation this term implies seems to be confirmed by a similar use in Morocco, where it is employed to designate women who have more than one child outside of wedlock (Capelli 2017). The term ‘recidivist’ comes from juridical language and indicates ‘a convicted criminal who reoffends, especially repeatedly’.31 Hence, the idea behind categorising women as recidivist is that abortion is an infraction rather than a right – as sanctioned by Tunisian law – and that women who repeatedly seek abortion care are offenders persisting in a deviant behaviour. A recidivist woman is perceived as a subject infringing moral and social laws. But what social law? Is it the law that prohibits killing a human being? Or is it the law that prohibits women exerting control over their bodies and reproductive capacities? Or is it the law imposing men’s control over women’s sexuality? In all cases, health practitioners’ discourses and acts are often

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meant to remind women of the social rules and to punish or steer deviant women back on the right track. Although ‘recidivist’ is a term of reference rather than of address, in that health professionals employ it to talk among themselves about a woman rather than to address her directly, it orients their behaviours affecting their ordinary ethics (Das 2012). This concept allows ‘thinking of the ethical as a dimension of everyday life in which we are not aspiring to escape the ordinary but rather to descend into it as a way of becoming moral subjects’ (ibid.: 134). Ordinary ethics displace our attention from universal abstract principles towards everyday gestures, tones of voice, linguistic expressions and bodily attitudes, perceived as the expression of the moral engagement of individuals. It also allows consideration of the unpredictability of the subjects’ actions because they have different moral sensibilities, social commitments and forms of consciousness that change and adapt to the flux of ordinary life. However, when health professionals employ the label ‘recidivist’ to designate a patient, they automatically adopt a specific stance that pushes them to deny or threaten to deny a woman abortion care and to talk to her in a moralising, infantilising or even humiliating way if she does not adopt a reliable contraceptive method, which usually means a method she cannot control (i.e. implant or IUD). A hierarchy exists between married and unmarried recidivist women in that becoming pregnant outside of wedlock means that one practices illicit sex while within marriage sexuality is normal and only the lack of control over reproduction is sanctioned. Unmarried women who have sought several abortions are thus more strongly condemned than married women who have done the same. To define unmarried women who seek abortion care (not necessarily repeatedly), healthcare providers also use the term ‘social outcast’ (cas social). This term is not only used in informal conversations but also in referral letters written by health professionals to their colleagues and in the documents of the police sent to health practitioners presenting the case of an incarcerated and/ or raped woman younger than eighteen, as I personally observed when reading the medical records of unmarried patients in Hospital T. ‘Social outcast’ is employed to designate unmarried pregnant women who are ‘cas’ (cases; i.e. exceptions or abnormal individ­ uals), who constitute a social problem and have to be taken care of by specialised state institutions. The term ‘outcast’ is polysemic: on the one hand, it labels women who get pregnant outside of wedlock, which is an illegitimate framework for procreation; on the

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other, it defines them as having experienced difficult trajectories and specifically in need of institutional attention. As noted above, state institutions have created administrative procedures to count, define and sometimes ‘protect’ these women, but they simultaneously place women in a special and discriminatory category. Youthfriendly clinics, the socio-medical records for unmarried patients, the training in sexual and reproductive health for ‘young people’, and the official register of unwed mothers constitute an apparatus of knowledge, technology and place that produce subjects and subjectivities located outside of the norm. In the domain of SRH, ‘young people’ are perceived as extraordinary medical subjects who must be treated differently from married citizens. Finally, I would like to emphasise that in Tunisian public health institutions, the term ‘cas social’ is also commonly used to designate sex workers, those exercising the profession under state surveillance and those who do it illegally (Msakni 2017), be they pregnant and married or not. The fact that the term ‘outcast’ can be used to designate unwed pregnant women and sex workers is not a coincidence and seems to confirm that healthcare providers situate both groups in the same moral, social and political space. The last category I would like to examine is that of ‘unwed mothers’ (ummahat a’zibat). Although in Tunisia this label can be used to designate women who decide to keep their pregnancies and raise their children outside of wedlock, in the SRH clinics where I did participant observation, it is employed almost exclusively to indicate unmarried girls who seek abortion care. Beginning in the first weeks of pregnancy, healthcare institutions and staff consider them ‘mothers’, whereas they do not see themselves as such as far as I could observe. It is to be noticed that the men who had sexual intercourse with the women seeking abortion care are completely absent from the discourses of practitioners, and there is no register of ‘unwed fathers’ as there is one for unwed mothers. ‘Fathers’ are not taken into consideration by institutional practices in that compulsory research of the ‘father’ takes place only if a woman was raped or is younger than eighteen. In these cases, they are apprehended as criminals rather than ‘unwed fathers’. The mere somatic inscription of pregnancy in women’s bodies turns women into mothers (and not into female genitors), making the physical materialisation a social fact. This explains why, according to several midwives I met, ‘a woman feels she is a mother as soon as she learns she is pregnant’. However, this opinion does not seem to take into account the discourses and experiences of women coming to the

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clinics for abortion care, which I will examine in the next chapter. As mentioned earlier, unwed women who came to the clinics often said they wanted to get rid of their belly (qirsh) or that they had a retard (their period is late) or that they had ‘stomach ache’. The expression ‘stomach ache’ is particularly interesting to examine. It is at the same time a euphemism, a metonymy and a displacement of meaning. It is a euphemism because it does not indicate the pregnancy or a disorder in the menstrual cycle as the reason for the consultation; a metonymy because it replaces the effect with the cause; and a displacement of meaning because it shifts the moral consciousness of one’s condition to abdominal pain. Other unwed women ask for a curetage (D and C) or more explicitly say they ‘want to drop the pregnancy’ (unahhi el-hbela) or ‘make the baby come down’ (unahhi el-saghir). The last two phrases are especially employed by married women, as if they were more legitimate in expressing their requests than unwed users of SRH clinics insofar as the latter are socially and morally condemned for their sexual conduct. To sum up, the expressions ‘unwed mother’, ‘outcast’ and ‘recidivist’ produce negative categories of female subjects, incarnating the possible deviations from the dominant social model of femininity. SRH professionals working in public facilities often become guardians of public morality, agents of the state in charge of imposing the correct (normal) sanitary and social conduct on female citizens, and ‘orthopedists of individuality’, inculcating women who do not abide by the rules inscribed in the various moral economies present in Tunisian society (e.g. patriarchal, religious, biomedical and civic). The three characterisations of the unwed mother, the outcast and the recidivist represent the woman who is undisciplined, immoral, irrational and lacking self-reliance. The unregulated sexuality of these figures denotes their deviant nature escaping from the four main forms of authority: state, religion, family, patriarchy. They are the counter-models of the ideal female figure who respects morality, religiousness and family norms while being a modern political subject and compliant biomedical patient.

Policing Female Users of SRH Clinics Education and transmission of reproductive, moral and civic norms is not the only function healthcare providers fulfil in SRH clinics. They are also in charge of policing (female) citizens in that they carefully have to verify and register the identities of SRH services

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users. Every time a woman comes to an ONFP clinic or hospital T, she has to show her identity card at the entrance so that her personal data can be registered on her medical record. Women who cannot show their identity cards are excluded from medical services. Several examples can illustrate the attitudes of healthcare providers and women confronted by the state imposition of registering and precisely counting citizens using its SRH facilities. On a sunny and warm day in early June, I attended a consultation with a young midwife who had only recently began to work for ONFP. That particular month, she was responsible for abortion care two days a week and she had to see both married and unmarried women. Fifteen married women had come to receive abortion care and were sitting together in a large room waiting to be administered mifepristone and receive information about the procedure of medical abortion and contraception. Unmarried women are received separately and individually in another room where they can enjoy a higher degree of privacy. Once the consultation with the married women had concluded, the provider went to the room where she received the unmarried patients who had come for abortion care. A woman in her early twenties entered. When the midwife asked for her identity card, she says she did not bring it with her. The midwife asks a more experienced colleague whether she can accept a patient without her identity card; she cannot ‘otherwise women could come many times, always with different identities’ (fieldnotes, 6 June 2014). The midwife goes back to the room where the young woman is sitting and tells her to come back the day after with at least a photocopy if not her original identity card. The woman insists that she does not have it, but the midwife is adamant: she will not get abortion care without showing her identity card. When the woman exits, the midwife tells me that she thinks the mother of the young woman has her identity card and that the latter is afraid of asking her for it. A few months earlier, in a youth-friendly ONFP clinic, I had attended a similar situation where the legal and administrative surveillance that providers had to exercise was more important than their task of offering medical services. A woman entered a room where two members of the staff filled in the socio-medical records of each patient. When asked, she pretended it was the first time she had come, but one of the practitioners was convinced that she was already a patient of the clinic and asked the member of the staff in charge of the archive to search for her medical record. The woman’s record was found, and she was forced to admit that she lied. The

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woman was probably afraid that the staff would realise that she had already had an abortion in the same facility and therefore would refuse her request for another one (fieldnotes, 5 February 2014). In another ONFP clinic, the provider in charge of filling in the records of the women seeking abortion care told me that he had recently had to deal with a woman trying to deceive him. A married woman in her mid-thirties and a mother of two who had come to the clinic for abortion care had shown him the identity card of her sister-in-law, but she already had a record in the archive. When he found the record corresponding to the identity card that the woman had given him, it turned out that it was not hers but that of her sister-in-law. The provider realized it because the patient described in the record had successfully completed an abortion only three weeks earlier and could not be a few weeks pregnant again within so a short time (fieldnotes, 22 January 2014). Another episode reveals the tactics adopted by Tunisian women to avoid or reduce the state control over their intimate lives. I was sitting in the room of an ONFP clinic with a doctor and patient when one of the secretaries entered and explained that she had found two medical records that had the same identity card number but apparently concerned two different women. The names of the women were the same, but the names of the husbands were different. When she was asked to explain the situation, the woman obstinately denied that she had given false information. The providers dealing with the patient’s case suspected that the woman was not married but had lied to avoid the stigma of being unwed. Commenting on the double record, a member of the staff even said, ‘I have worked here since 1986 and I still learn new things!’ (fieldnotes, 26 March 2018). Patients’ tricks to avoid these forms of administrative surveillance can be interpreted as a tactical move employed to obtain the health services they need. A tactic, to quote Michel De Certeau (1984), ‘lacking its own place, lacking a view of the whole, limited by the blindness (which may lead to perspicacity) resulting from combat at close quarters, limited by the possibilities of the moment . . . is determined by the absence of power . . .’ (ibid.: 38). Tunisian women seeking abortion care in public facilities mobilise different types of resources to reach their objective and overcome the asymmetrical power relationships in which they are caught up. Be they tactics or forms of low intensity ordinary resistance (Scott 1976), the discourses and practices of many women I met aim at finding a way through the constraints imposed on them by institutional

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policies, dominant moral regimes and health providers’ convictions and behaviours. A different administrative procedure is adopted in Hospital T, showing the variability of the forms of surveillance the state exercises through its institutional medical apparatus. As described above, in Hospital T, unmarried women have to undergo an interview with the staff of the social service department and obtain their authorisation before getting abortion care, even when legally they are adults. It was mid-December and the practitioner in charge of the family planning unit was having a lively exchange with a young woman who had come to get an abortion. She was almost three months pregnant and had signed a marriage contract four months earlier although she had not celebrated the wedding. The department of social affairs had registered her as an unmarried patient because she had not yet changed her identity card. The midwife was trying to convince her to keep the child because in the state’s view she is officially married, but the woman did not agree because she very much dislikes her husband’s family and for this reason was about to divorce him. The midwife was also worried that the doctor who will be replacing the head of the department – who will be absent for a short period – will refuse to offer this woman abortion care because the pregnancy is advanced, she is married and therefore she can keep the baby without major social consequences. These fragments are just a few episodes of the ordinary practices I observed in government facilities and they deserve some remarks. First, they show that the right to SRH services is granted only to individuals whose social and medical trajectory can be clearly monitored by state authorities. Users of ONFP clinics and government hospitals must be identified and correspond to the required criteria to access SRH services. Second, they show that women’s access to abortion is de facto strictly related to their marital status because medical and administrative personnel base their decisions on that. As a doctor in an ONFP clinic told me, the priority are ‘pregnant virgins’, while married women (especially with only a few children) should keep their pregnancy (fieldnotes, 15 May 2014). Third, they show that users of SRH public services are not passive but adopt different means and tactics to overcome the forms of surveillance and discrimination to which they are subjected. Finally, they reveal the power that healthcare providers have over the users of government facilities. Clinic and hospital personnel possess the authority to control patients’ identities and to determine which patients should have contraception and abortion care; they can decide almost

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i­ndependently whether to allow access to SRH services to a given patient. Although, overall, healthcare providers have experienced increased freedom since the revolution because of a lack of supervision from the ONFP and the Ministry of Health, the level of freedom depends on the micro-level power dynamics within each clinic or hospital. Each facility that I observed acted as a micro-arena, with various configurations of values and norms that sometimes clashed. The degree to which a facility’s specific configuration shaped its medical practices was determined by the power relations between the local staff members and the actors who served as moral entrepreneurs. In the facilities where the doctor and the midwife in charge supported abortion services, the professionals who opposed these services were usually forced (one way or another) to treat women who sought abortion care; however, several forms of resistance were still present. In my observations, conflicts, negotiations and discussions were frequent – as the case of Hospital T illustrates – but a compromise was often reached. In one of the ONFP clinics that I attended, the head midwife reminded her colleagues of their professional duties and established that each provider had to take turns being in charge of abortion services. At another clinic, after all of her colleagues refused to participate, a midwife agreed to be in charge of all the abortion care and to exclusively treat the women who sought it. At some other clinics –especially those where the heads of personnel did not intervene – abortions were not offered at all (see Chapter 1). Hence, although providers’ agency increased after the revolution (in some cases at the expense of patients), some forms of local control still limited the possibility of acting against Tunisian law and the rules that govern medical institutions.

Notes   1. The video of the flash mob is available at https://www.youtube.com/ watch?v=1DtHHwg7xTc. Retrieved 7 November 2017.   2. ‘Women promoted the use of the term “reproductive health” in order to emphasize an approach to family planning that included considerations of women’s needs and views, in contrast to the previous approach, which focused primarily on population control’ (Lottes 2000: 7).   3. Article 16 of the CEDAW states that men and women ‘have the same right to decide freely and responsibly on the number and spacing of their children and to have access to the information, education and means to enable them to exercise these rights’. Retrieved 8 October

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2018 from http://www.un.org/womenwatch/daw/cedaw/text/econ vention.htm#article16.   4. In early 2014, in various clinics of Tunis, a new urine test measuring hormonal levels was administered to women having medical abortions in the framework of an international clinical trial. The test was designed to allow women to use it at home without health providers’ intervention to verify that they were no longer pregnant. See also Chapter 4.   5. In 2013–2014, only ONFP clinics applied the protocol of medical abortion, which includes the administration of a dose of 200mg of mifepristone the first day and a dose of 400mg of misoprostol the second day. In the hospitals, only misoprostol was available, which is considered less effective than the combination of mifepristone and misoprostol (Hajri 2004).   6. Interestingly, very similar logics were described by Rivkin-Fish (2005) in the context of post-soviet Russia.   7. ‘Rational citizens are defined as those that embody and reproduce state-supported priorities in their values, conduct, and comportment’ (Morgan and Roberts 2012: 244). The existence of multiple reproductive rationalities is often not recognised by family planning literature and state demographic policies, which strictly define what they consider ‘rational’ (Krause and De Zordo 2012; Marchesi 2012).   8. The following excerpt from the above-quoted report perfectly illustrates the point I want to make: ‘At the level of the demographic structures, avoided births are more relevant; they have to be inscribed in the population pyramid, reducing members of the young generations so that the increasing enlargement of its sides and top will after several years significantly modify the distribution. The numerical decrease of the new generations in twenty years will inevitably affect marriage rates and hence the formation of households, and finally the number of mothers and births . . .’ (Impact du Programme National de Planning Familial sur les Secteurs Sociaux 2003: 37).   9. As emphasised by several midwives I worked with, some unmarried women feel reassured when they get pregnant, even if they decide to terminate the pregnancy, because it proves that they are fertile. 10. For an exhaustive analysis of these documents, see Vallin and Locoh (2001); Sandron and Gastineau (2000). 11. For more information on this attitude in other sociocultural contexts, see: De Zordo (2012); Hardon (1997); Van Kammen and Oudshoorn (2002). 12. The exclusion of men from abortion procedures is also documented by Mathieu and Ruault in French medical facilities (2014). 13. The de facto feminisation of the youth-friendly clinics is confirmed by the studies by Soraya Ksontini (2017) and Atf Gherissi and Francine Tinsa (2017).

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14. Regarding women who are pregnant and still virgins, see the previous chapter. 15. Very negative discourses about men were common among female health providers, who depicted men as being despotic and violent and expecting obedience from wives who had to do all of the domestic chores. 16. The continuity of these discourses is attested by Labidi, who writes that ‘The dissuasive argument employed by the health staff emphasizes the behaviour of the morally good woman and stresses the complications that can take place after an abortion. This dissuasive ethics is based on two arguments: to make young women feel guilty and frighten them’ (1989: 103). 17. In Hospital T, the midwife in charge of the family planning unit insisted several times that the women who begged to get abortion care and who even tried to kiss her hands had the right to an abortion and therefore did not have to behave in such a way. 18. If a patient has no medical record in an ONFP clinic, she might have had abortions in another ONFP clinic or in the private sector and may not declare them. If she has already had an abortion in the clinic, it is registered in her record. From what I observed, patients often declared if they had previous abortions and where they had them. 19. This practice is also documented in contemporary France (Mathieu and Ruault 2014). 20. I attended several discussions among health professionals and social workers where the honesty of a patient was questioned. 21. Some women lie about the date of their last menstrual cycle because they want to get rid of the pregnancy as soon as possible, as in ONFP clinics. If their pregnancy is at the very beginning, the personnel make them wait a week or more before an abortion (see Chapter 4). 22. There is a psychologist in every ONFP clinic. 23. All medical records are in French and should be filled out in the same language. In the public sector, this can increase the gap between patients and healthcare providers, as the former usually have a low level of education and cannot speak French, while the latter receive their professional training in this language. 24. Regarding this, see Voorhoeve, who, by drawing on her ethnographic research on the application of law in regards to sexual behaviours, argued that in Tunisia, ‘for the judges, local customs and habits prescribe sexual relationships within marriage’ and ‘do not forbid the use of force’ to make a woman respect her marital duties (2017: 349). 25. The previous ethnographic works of Lilia Labidi (1989) and Ibtissem Ben Dridi (2004) show that health providers played the role of guardians of public morality and social order long before the revolution of 2011. 26. The law has been amended two times in the last two decades: in 2001, the obligation of the psychosocial interview for adult women (above

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eighteen years) was cancelled, and in 2014 the part of the law women had to invoke as a valid reason to receive abortion care, ‘that her state places her in a situation of distress’, was replaced by the woman’s desire to not pursue the pregnancy (Marguet 2014: 29). 27. A new ‘comprehensive law on violence against women’ was promulgated in the summer of 2017 and changed several previous laws, although it has not eliminated all forms of legal discrimination between men and women (Ben Achour 2016; Chennaoui 2016). 28. According to CPS, married women are considered adults if they are at least seventeen. The ordinary legal age for marriage is eighteen for women and men, but women can marry at seventeen with the permission of their legal guardian. 29. At the time I did fieldwork, the chorionic villus sampling technique that can be performed before the end of the first trimester was not available in Hospital T, and thus women had to wait until an amniocentesis could be performed in order to collect the genetic material enabling identification of the perpetrator of a sexual crime. The vacuum aspiration technique, which would also allow doctors to perform abortions in early pregnancy and collect the material for the genetic exam, was not used because surgical theatres were not available and doctors were not interested in practising this technique. 30. A recent study has examined the high economic, social and moral suffering of women seeking abortion care who were turned away by local health providers (Hajri et al. 2015). 31. https://en.oxforddictionaries.com/definition/recidivist. Retrieved 23 April 2018.

Chapter 4

Imagining Early Pregnancy Ontologies of the Foetus and the Moral Perception of Abortion

Conceiving Early Pregnancy in Light of Technological and Administrative Procedures

T

his chapter will focus on clinic users and healthcare providers’ representations, discourses and emotions related to early pregnancy and abortion. In particular, it will show that healthcare providers have different and sometimes conflicting values and convictions, that their stances are not static, and also that they evolve in relation to personal and professional experiences as well as broader political and religious transformations of society. To understand the apparent indifference of most women who seek abortion care and the often hostile or controversial attitudes of the medical and paramedical personnel towards abortion, exploring how early pregnancy is apprehended and how clinical and administrative procedures and technologies frame it is important. In ONFP clinics, after filling in the medical record and before getting abortion care, all women undergo a sonogram to date the pregnancy. Although it is not recommended in the ONFP’s Manuel de référence (2013), the ultrasound allows the practitioners to avoid the clinical exam to date the pregnancy. Even if, officially, ONFP clinics should provide abortion care to all women until the end of the first trimester, in 2013–2014, the staff used to transfer women between nine and ten weeks’ pregnant to the hospital, affirming that the pregnancy was too advanced to terminate with pharmacological abor-

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tion; many clinics did not offer surgical abortion anymore or only did so in a few cases (Hajri et al. 2015). I could not explain this practice until I met a doctor who worked with ONFP for several years; this doctor told me that in the late 1990s, Nabiha Gueddana – who was president of ONFP from 1994 to 2011 – issued an internal circular according to which abortions from eleven to fourteen weeks were not to be performed in ONFP clinics. According to this physician, the reason behind Gueddana’s decision was to lower the number of interventions in ONFP clinics and push regional hospitals to take on their responsibilities, since abortion care was to be provided by all public hospitals (fieldnotes, 26 March 2014). It is, however, worth noting that during the same period, Tunisian authorities did not consider family planning policies to be a priority anymore, as the demographic transition had already taken place (see Introduction). During my fieldwork in ONFP clinics and in the family planning unit of Hospital T, women were never allowed to choose whether they preferred to get a surgical or medical abortion, as the latter was the default method. Most women preferred getting a medical abortion, but some explicitly asked to get a surgical abortion because it was easier to plan and the procedure was shorter. For example, I met two students who had to prepare for their exams and asked to get a surgical abortion so as to spend only one day in the clinic so they could go back to their ordinary lives. The same logic was behind the request of women who had a job and were not able to take leave for long. Other women I met insisted on having a surgical abortion because of a previous negative experience with getting a medical abortion. In the clinics where I attended consultations, this type of request was usually not accepted, because the operation theatre did not work or worked only one or two days a week for women in very specific cases.1.Therefore, the women I met were not given the choice between a pharmacological and a surgical abortion, as is recommended in the ONFP’s Manuel de référence (2013). Similarly, they could not choose between different contraceptive methods because often only one type was available in a specific clinic (or overall in the public sector) or because the practitioners did not allow it, even in the case of a woman experiencing side effects, as mentioned. The Ultrasound Returning to the medical routines that women had to go through before getting an abortion, dating the pregnancy was crucial because the result determined whether patients could have an abortion, the type of procedure they could get and the setting in which it

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Figure 4.1  Sonographic image used in ONFP clinics. Photograph scanned by the author.

was to take place. My impression was that most Tunisian women attending government clinics were unable to understand what the sonographic image contains. Carried out using older machines, their low quality and small format (6cm x 8cm) contributed to making them insignificant in women’s eyes. As mentioned above, many government clinic users have little education and are not socialised in a technologically visual culture, including sophisticated ultrasound images (Morgan and Michaels 1999). The presence of old technological infrastructures and their limited use in public facilities combined with the scarce diffusion of foetal images in the media, have certainly contributed to minimising the ‘imaging of the baby’ (Rapp 2000: 119) and to the lack of interest in ultrasound images on the part of the Tunisian women I met. My experience in Tunisia confirms that, as already demonstrated by many authors (e.g. Boltanski 2004; Duden 1993; Fellous 2001; Luker 1985; Morgan and Michaels 1999; Petchesky 1987), biomedical visual technologies have radically transformed the scientific and popular perceptions of the embryo, contributing to its singularisation (Morgan 2009; Rapp 2000; Théry 2006) and socialisation (Boltanski 2004), understood as the process taking place when ‘a being enters social life and speaks, or somebody speaks on its behalf, and a discussion, a debate or possibly a dispute about it begins . . .’ (ibid.: 205).

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The lack of a public visual culture of the embryo has contributed to entertaining the ensoulment theory adopted by the Tunisian state, according to which a foetus does not become a human being before the end of the first trimester. As already discussed, when the law decriminalising abortion was promulgated (1973), a group of religious leaders justified it by referring to the Islamic schools that consider the embryo to be a human being only 120 days after conception. Although theories locating ensoulment after forty days from conception circulated in 2013–2014 (and even earlier), most women did not allude to the possible killing of a human being – a baby – when I observed them in ONFP clinics. Only some were in a hurry to receive abortion care and insistently requested to interrupt the pregnancy before forty days after conception because, they argued, ‘after this period, it becomes a baby’ (fieldnotes, 12 December 2013). A woman said to the provider asking her to come one or two weeks later that she did not want to wait too long ‘for her conscience’ (damir). This shows that various versions about the moment of ensoulment circulate in Tunisia and that not all women share the same conceptions. According to the interpretation of ensoulment they adhere to, abortion becomes a more or less serious sin or morally reprehensible act related to the period in which it takes place. Overall, as far as I could observe, visual considerations were absent from the discourses of the women I met. Another element caught the attention of a few ONFP clinic users: the noise of the embryos’ heartbeats. I heard two women with secondary education – who already had children – say that during an ultrasound performed in a gynaecologist-obstetrician’s private office2 they heard ‘the heart of the baby’, and that caused them pain. Although they did not change their mind and decided to terminate the pregnancy anyway, they said that they had the impression of ‘killing a baby’. Although these situations can take place in private offices where doctors have more modern machines, in the ONFP clinics and government hospital where I carried out participant observation, practitioners never let women hear the sound of the embryo’s heartbeat, nor did they shift the ultrasound scan’s screen towards the woman to let her see the moving image during the exam. That many Tunisian women I met were unable to interpret the sonographic images as the picture of a baby was confirmed by an experienced midwife with whom I discussed the perception her patients have of the ultrasound performed before abortion. She told me that in a large hospital where she had worked

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for many years before the revolution, her colleagues tried to ­persuade women coming to get abortion care to keep the pregnancy by showing them the sonographic image and indicating what they described as the head, arms and legs of the baby.3 According to this midwife, patients were generally not interested in or moved by the view of the imagined baby and did not change their mind. I rarely witnessed attempts by clinicians to apply a ‘pedagogy of the gaze’ to persuade patients to follow their advice (but see Chapter 3), as Memmi observed in the French hospitals where she carried out her research in the early 2000s (2001, 2003a, 2003b) on the criteria used by clinicians to evaluate the opportunity to keep or end a pregnancy in cases of foetal malformation or genetic disorders. The French sociologist describes how health practitioners employ a specific discursive rhetoric coupled with the sonographic images to convince their patients to get an abortion or not to get one based on their ideas regarding the foetus’s condition and its possible future life. Although the pedagogic effort aimed at making women imagine an embryo that is a few weeks old as a baby was generally absent among doctors performing the ultrasound in the ONFP clinics and in the family planning unit of Hospital T, it was present among the paramedical staff, who resorted to the religious register (reading the Quran in front of the patients, for example) or to a biologically based discourse (evoking the fact that the foetus is already a baby with arms, legs and a head). Interestingly, women coming to SRH clinics for abortion care only a few days or one week after a missed period were usually asked to wait at least one or two weeks to see if the pregnancy was successful (nejiha) before starting the pharmacological abortion. A few practitioners were used to telling them that they had to see the heart (qalb) before giving them the pills (harabish) to stop the pregnancy. Even if their discourse often did not intend to hint at a specific representation of the conceptus, it entailed an anthropomorphic view, suggesting that it is already a human being with a beating heart. The recurrent insistence of health practitioners that, before starting the abortion procedure, a woman should wait to ascertain whether the pregnancy is successful puzzled me, as, in my view, this went against the woman’s intention to terminate it. Why should a woman care to know whether the pregnancy is successful and whether the embryo’s heart beats when she wants to get rid of it? I assimilated it to the ‘tentative pregnancy’ (Katz Rothman 1986) or the period when women of the Global North often wait before openly declar-

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ing that they are pregnant, which corresponds to a liminal phase where things can still go awry. When I asked some providers about this practice – which is not mentioned in the ONFP protocol of medical abortion – they told me that if the pregnancy is not successful, they will not administer the mifepristone (the first pill used in medical abortion), only the misoprostol. This allows them to preserve the stocks of mifepristone in a situation in which supplies are not guaranteed. Some providers also thought that the procedure would be more successful when the pregnancy is well-established, or as one midwife told me, ‘it is useless to give the mifepristone to a woman with a non-viable pregnancy. Therefore, it is better to wait and see if it is viable’. The providers’ rationality nonetheless contradicts the convictions and feelings of the many women who, either for religious and moral reasons or for personal anxieties and fears, want to terminate their pregnancy as soon as possible. Although the logics of both categories of actors are legitimate, they are incompatible and generate moral and social suffering in women, who have to wait until the provider decides that the time has come to offer abortion care. In other cases, women were asked to wait to dissuade them from terminating the pregnancy or made to wait too long to be able to get abortion care according to the law (Hajri et al. 2015; Raifman et al. 2018). The widespread practice of asking women to wait one week or more is the reason they went from one clinic to another to get abortion care as soon as possible. I could verify this occurrence because I met the same women in the various clinics where I conducted my research within the same week. These women were usually not satisfied with the ordinary argument used by providers that theirs was a very early pregnancy (hbela saghira). Distress and anxiety were particularly difficult to manage for unmarried women, whose lives could be completely ruined by the continuation of the pregnancy. Pre-abortion Discussions In ONFP clinics and in the family planning unit of Hospital T, after undergoing the ultrasound, women returned to see the midwife or nurse4 in charge of filling in their medical record and handed the image to her so that she could add it to their documentation. Later, women had to give their informed consent before the pharmacological abortion procedure,5 which they never read. However, before they swallowed the first pill (mifepristone or RU 486), they had to hear the practitioner’s explanations about how medical abortion works. In the clinics for married women, these explanations

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were given collectively to all patients who had come on the same day to begin the procedure. I have seen groups of three or four women, and even groups of nineteen or twenty women, gathered in one room, listening to the abortion provider’s explanation. Once, in one of the ONFP clinics, there were also two small children in the room with the women. Their mothers had to bring them along because there was nobody at home to take care of them.6 The words the abortion provider employed to describe the pharmacological abortion procedure, especially its effects on a woman’s body, are very significant insofar as they revealed the foetus’s ontology and the moral economy that she/he adheres to. In the facilities where I did participant observation, the descriptions of pharmacological abortion were similar and included the explanation of how each type of pill works (mifepristone and misoprostol), the temporality of the procedure, the possible side effects of the medicaments, the signs that should make the patient seek consultation, where to go in case of haemorrhaging, how to recognise if the procedure has failed and what to do. The words the SRH clinics’ staff used to designate the pills’ effects are particularly significant, as they carry powerful moral meanings.7 In one of the ONFP clinics I regularly attended, Alia, the midwife in charge of abortion care, used to tell women that the first pill (mifepristone) ‘stops the growth (al-numu’) of the pregnancy’ and that the second one (misoprostol) ‘causes heavy menstruations (dawra) or the expulsion of the pregnancy’ (tarmi el-hbela). Alia was in her late fifties, did not wear a headscarf and was the only member of this SRH clinic’s staff who offered abortion care, while the two other midwives were hostile towards it for religious reasons because they considered abortion to be killing a child, thus adhering to the orthodox Malekite school, according to which the conceptus is already a human being.8 One of the midwives working in this clinic and opposing abortion was even reprimanded by the head midwife because, after the revolution, she began to read verses of the Quran in front of the patients coming in for abortion care to convince them to keep the pregnancy. Despite her apparent morally and religiously neutral attitude, Alia never missed the opportunity to rebuke women who were seeking abortion care for not using contraception. Before or after explaining how pharmacological abortion works, she asked women why they had not used contraception and what method they wanted to adopt after the abortion. She publicly asked every woman to explain why she had become pregnant, as she considered them to be responsible

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for the abortion or even ‘guilty’ for it, as they should have used contraception. In the midwife’s unspoken opinion, married women should know how babies are conceived and use the contraceptive methods that are available and free in all government dispensaries and ONFP clinics. The refrain she used to repeat every time to women was ‘sabbiri!’9 (use contraception!) or ‘alesh ma tusabbiri?’ (why don’t you use contraception?). In Tunisia today, as in France or in other countries, despite being legal and a woman’s right, abortion is not an ordinary act that women can repeat as frequently as they wish, unlike having an IUD inserted or receiving an injectable. In the eyes of the large majority of practitioners I met, abortions are problematic and need to be justified by women and should only be used as a last resort (see also Raifman et al. 2018). Rim, a counsellor in an ONFP clinic, stated something significant in front of a group of women waiting to receive abortion care: ‘I hope this will be the first and the last time you resort to abortion; you have to adopt a contraceptive method that is free and available in our clinic’ (fieldnotes, 11 June 2014). Wisam, a midwife working in another ONFP clinic where I regularly attended consultations, used slightly different words from Alia when describing medical abortion effects; her words hinted to another ontological status of early pregnancy. In her forties, Wisam was not veiled, and her discourses did not aim to moralise or punish women seeking an abortion. However, when she described the pharmacological abortion procedure, she used to say that the first pill stops the ‘growth of the baby’ (saghir), rather than the pregnancy, and the second makes the baby go down (iahbit). She also explained that after the second pill, her patients will have heavy bleeding and might see a ‘little piece of white skin’, which she designated ‘the baby’ (al-saghir). Another midwife in another clinic indicated the possibility of noticing a white piece of skin (jilda) or a little bag (shkara) in the middle of the blood during the pregnancy’s expulsion but rarely said it was the baby. Each time I was present during Wisam’s collective explanations, the group of women discussed personal matters amongst themselves without showing particular concern for the midwife’s words. Like in other clinics, a public discussion about why every woman got unintentionally pregnant and the method of contraception they were going to adopt after the abortion followed. Wisam, like Alia, scolded several women for their negligence and explained how to use the contraceptive methods available at the clinic. I wish to emphasise that public discussions were only for married women,

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while unmarried patients were generally given individual explanations and scolded privately (see Chapter 2). Overall, the pre-abortion discussions meant that women could be (re-)educated as medical subjects, citizens and spouses/mothers to reinforce their sense of responsibility, their rationality and their self-control. For Wisam and Alia, abortion, especially if repeated, was reprehensible. However, the arguments they used with their patients were based on typical modern values, such as discipline, responsibility and self-control rather than on Islamic or moral precepts. Alia affirmed that some women prefer abortion because it is ‘harmless and does not cause bodily disorders like contraception’ (fieldnotes, 22 May 2014).10 Another midwife argued that several of her patients preferred to get an abortion if they unintentionally got pregnant rather than regularly use a contraceptive method because the latter caused them long-term side effects whereas medical abortion is not invasive and bodily inconveniences last only a few days. She was convinced, like several other providers I talked to, that ‘women are not too much troubled by abortion, even those who wear the hijab or the niqab’ (fieldnotes, 27 November 2013). On two occasions, a doctor at one ONFP clinic inserted an implant into an unmarried woman who had had repeated abortions as a condition to perform a new abortion because she did not believe the woman would come back to the clinic to adopt a contraceptive method.11 She felt it necessary to protect these patients from other abortions and therefore that her ethically and medically problematic behaviour was justified. She also told me that she felt guilty for giving abortion pills to patients and considered it unjust that so many women get abortions when many others struggle to conceive (fieldnotes, 21 May 2018). A midwife told her patient in a consultation I attended that it was difficult for her to be in charge of abortions and that during some periods of her life she had frequent nightmares because of the abortions she had to offer every day (fieldnotes, 5 December 2013). The doctor and midwife had both resorted to reproductive medical technologies to get pregnant, having suffered with infertility for several years, and had eventually succeeded in having children. In their case, it was not religion and moral concerns but personal infertility stories that affected their professional practice.12 The widespread dislike of abortions notwithstanding, specific situations made even the most conservative and religious practitioners overcome it. In my experience, this was always the case when they had to deal with young girls who were victims of rape or incest, or

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married women who were victims of violence at the hands of their husband. I will give two examples. I attended several consultations in Hospital T between the midwife in charge of abortion care and a 16-year-old girl, who was twentytwo weeks pregnant when she came to seek abortion care for the first time. She first had to undergo an amniocentesis to analyse the genetic material of the foetus and to identify the genitor;13 later, she underwent an abortion. This girl was convinced by an older friend to work at an illegal brothel with her.14 She had been discovered and, at the time I met her, was living in a government institution for adolescents who are removed from their families and put under state protection. She ignored everything about contraception, sexuality and pregnancy, as we realised when the midwife asked her very basic questions about these subjects. Administrative slowness made this girl come to the hospital several times before she could undergo the amniocentesis. Her pregnancy was thus well into the second trimester when she eventually had an abortion. The midwife never said anything that would hurt the girl or let her think that she was going to ‘kill her baby’. The provider nonetheless – probably to help the girl understand her explanations – said that she had to undergo an exam to identify the ‘father’ (bou), implicitly suggesting that she was carrying a human being (fieldnotes, 17 March 2014). The other example was relayed to me by a nurse working in a youth-friendly unit. She was very touched by the story of a 17-yearold disabled girl who sought abortion care after she had been raped by her maternal uncle in retaliation for a conflict between him and the girl’s father.15 This clinic’s staff members were usually very critical of women seeking abortion care, but were all on her side and were sincerely moved by the events that had befallen her. The girl could not walk and was in a wheelchair, making the uncle’s act even more despicable in their eyes. Moral and religious concerns were thus invoked in what they saw as more ordinary situations but could be suspended when the circumstances of a pregnancy were considered to be violent and independent from the woman’s will. Moreover, as noted long ago by Kristin Luker when describing the attitudes towards abortion in the United States during the 1960s, some providers’ hostility towards abortion often seemed ‘connected with sexuality’ rather than with ‘the taking of human life’ (1985: 107), especially in the cases of unmarried women who had had repeated abortions. For example, Khawla, an educator in one ONFP clinic, told a young woman coming in for abortion care for the third time within a year ‘haram alayk’ (shame on you), and then

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she threatened her, saying, ‘it will cause you cancer of the uterus’ (fieldnotes, 18 March 2014).

Two Ways of Imagining Early Pregnancy Health professionals have a view of early pregnancy that is often not the same as the one that the women I met in the clinics shared. Whereas the popular representation of early pregnancy seems closer to the classic Islamic view, which sees the conceptus first as semen, blood clot, lump of flesh and eventually as human being, the biomedical concept of the foetus is much more precise as it ‘relies on a theoretical work – potential patterns created from an amalgamation of individuals and mathematical patterns of morphogenesis’ (DiCaglio 2017: 12). In the contemporary biomedical model, the embryo is conceived of as something that will become a human being and thus will lose its present state in the name of its ‘predestined future point’ (ibid.: 19). The embryonic model of foetal development according to the classic Islamic texts and contemporary biomedical theories are therefore very distant and do not entail the same temporal conception: the former – at least in some of its interpretations – allows for the establishment of a frontier between the pre-human and the human stage of the embryo, and the latter tends to conflate all stages in a unique process in which it is difficult to identify the clear beginning of human life. For many providers I talked to, sonographic images of the baby and the sound of the foetal heart were a sign of life (Duden 1993), although professionals did not see the embryo in the same way. In one of the clinics where I carried out participant observation, a member of staff showed me an embryo of eight or nine weeks floating in a small jar. She told me that she had put it there after a woman had expelled it at the clinic. She looked at it with curiosity rather than with disgust, but despite my questions, I was unable to learn why she had kept it and whether she showed it to the women coming to seek abortion care. For the many providers who considered the embryo/foetus already a baby, they struggled with this conception when offering abortion care, even when they were secular and believed in women’s right to control their bodies. For example, the head of a public hospital’s department of obstetrics and gynaecology, whom I met several times, was opposed to abortion. Despite being emancipated and having had a brilliant professional career, she had decided that her

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department would not offer abortion care. Hers was not an official act of conscientious objection, as there is no law regulating this (see Chapter 1). Rather, it was an informal decision that reflected the practices of most public hospitals, where (for various reasons) abortion services were not provided in the years 2013 and 2014 (Maffi 2017b).16 Another female obstetrician-gynaecologist, working in a large teaching hospital and specialising in sonographic images, was also totally opposed to abortion and did not miss any opportunity to show it. Both physicians were against abortion not for religious reasons but because they thought women must be responsible for their sexuality and accept the pregnancy if it happened. With regards to patients’ views, as mentioned, women in their early pregnancies seeking abortion care sometimes described the content of their womb as a baby (saghir) but very often designated it as pregnancy (hbela) or as having a belly (qirsh) or used metaphors or metonymies that do not involve anthropomorphic images but allude to their bodily functions and disorders in which the embryo/ foetus is absent (see Chapter 3). Because I did not interview the women about their ideas of the foetus/embryo, I can only infer their conceptions from their attitudes during the abortion procedure, the exchanges they had with providers during the consultations, the discourses I heard in the clinics’ waiting rooms and the informal conversations I had with a few of them. First, the feelings of guilt and the fear of God’s punishment that were said to be widely present among the Lebanese women Zeina Fathallah interviewed (2011) were generally absent in the situations I observed. The prevailing feelings of the women I met were anxiety, fear and distress before abortion and relief afterwards, with only a small minority of women expressing sadness and fear of God’s punishment.17 I was sometimes struck by the physical changes I observed in many women: their faces were often contracted and pale before abortion but relaxed and luminous when I saw them post-abortion, so sometimes I barely recognised them. The attitudes towards early pregnancy of most women I met in the ONFP clinics and Hospital T were also different from those reported by Lilia Labidi in her study in the early 1980s among Tunisian women (1989). Many of Labidi’s interlocutors considered abortion to be the murder of a baby and a sin (see Chapter 1). A conversation I had with a mother of one in her late twenties who had come to an ONFP clinic for abortion care is interesting, as it shows that some women desire to end their pregnancies to preserve their lifestyles and realise their aspirations rather than for material and social reasons. She told me that she had

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a university education and wanted to have a professional career and not stay at home for two more years. She had to stay in bed during her first pregnancy, and the baby did not sleep for the first year. She had gained weight and stopped all physical activity. She did not want to have another baby now. She went back to work, resumed playing sports and was losing weight; she was going ‘back to her previous life’. While talking, she showed me her abdomen, which was still too swollen for her from the previous pregnancy, and said, ‘it is still as if I had a baby in it’ (fieldnotes, 13 March 2014). She was clearly alluding to the previous pregnancy and did not think she had (another) baby in her abdomen although she was pregnant again. The young woman was quite joyful and calm, and she chatted with me without showing any embarrassment. When she swallowed the tablet of mifepristone, she laughed because she had a hard time doing so. Amused, she explained me that since she was a child, she had had difficulty swallowing pills and used to cut them into small pieces. Her attitude seems to confirm the opinion of some providers I met, who claimed that for certain women swallowing the pills is perceived as a preventive treatment rather than the termination of a pregnancy. These providers were convinced that the technology of medical abortion allows women to deny that this act is the destruction of what they see as an embryo-foetus. Although it was easier to spend time talking with married women – as they were not so preoccupied by the possibility of people knowing that they were in the SRH clinic for abortion care – my attempts to spend time with unmarried women in ONFP clinics did not succeed. I realised that it was extremely embarrassing for them to share the room with me, and when I tried to talk to them, they were very reticent. For ethical reasons, I therefore decided not to stay in the same room during the few hours they had to spend in the clinic after swallowing the first abortion pill. Young unmarried women were very distressed, often subjected to moralising discourses and aggressive tones by providers, and I did not want to increase their discomfort. The fact that they were mostly in their early twenties and that I was already in my early forties was also an important factor to consider in understanding why they did not feel at ease speaking to me. I was still able to occasionally talk to older unmarried women who were more confident and felt less embarrassed in front of a foreign woman and researcher. My access to unmarried women was mainly made possible by the fact that I attended the individual consultations preceding abortion care or when I was sitting in the waiting room.

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Women’s Doubts and Fears The women I met generally did not hesitate to swallow the abortion pills and were mostly preoccupied by the medication’s side effects on their body, such as pain, blood loss, milk corruption – if they were nursing a baby – rather than concerned with the fate of the conceptus. I once attended the discussion between a health provider and a young married mother of two, who regretted trying to end her pregnancy. Her torment stemmed from a failed abortion she had attempted following pharmacological treatment prescribed by a private obstetrician-gynaecologist.18 A few weeks had passed since she had started the procedure and she was still pregnant. Although she was in the first trimester, the woman had started to think that the conceptus was becoming a baby and hence regretted having tried to terminate the pregnancy. However, she decided anyway to begin a new abortion procedure at the ONFP clinic as she was convinced that the hormones she was administered had probably caused abnormalities in the foetus.19 Several times I heard women who already had children say they knew abortion was a sin (haram) but they could not keep the baby because their circumstances were very difficult. For example, a woman in her late thirties living in a very poor area of the capital said that she had a disabled child and was not able to take care of another baby. When she swallowed the abortion pill in front of the midwife, this woman said ‘Bismillah’ (in God’s name)20 as if she knew God would understand and forgive her. Similarly, another woman who had a girl who was one and half years old told me that she was sad and did not want to terminate the pregnancy but her husband did not want to immediately have another child. She added that her child was often sick and that she and her husband were very tired and, as they both had a job, could not take care of another child. She hoped that God would forgive her.

Women’s Descriptions of the Products of Conception A midwife in charge of the family planning unit at Hospital T used to ask every woman who went through the pharmacological abortion procedure to describe the products of expulsion to ensure that they had successfully completed it. She did it systematically over several months also because she was taking part in an international trial aimed at experimenting with a new urinary test women could use at

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home to determine whether they were still pregnant without coming back for a medical exam two weeks after the abortion. As they took the misoprostol (second pill of the pharmacological abortion) at home,21 the hospital personnel did not attend the expulsion, unlike what happened in several French hospitals where Luc Boltanski conducted his research (2004). Here, the nurses attending abortions had to observe the product of the expulsion in a sink to immediately verify the procedure’s success (ibid.: 201). The French women Boltanski interviewed were shocked by this and commented on what they saw by saying such things as ‘It is super, super appalling’, ‘It is horrible to do something like that to somebody [the foetus]’, or ‘It was really hard because I have seen it. I have felt it coming out’ (ibid.: 202–3). The perception these women had of the product of a few weeks’ pregnancy is related to the biomedical visual culture and the specific conception of a foetus I mentioned above. They saw in what came out from their womb a human being or a baby, which, although not easily recognisable, provoked a strong negative reaction and even physical disgust.22 The descriptions of the product of conception and the emotional states of the Tunisian women I met were very different. They usually maintained an indifferent or neutral attitude and gave a precise description of what they had seen, sometimes even adopting a humorous tone. For example, during a consultation I attended in December 2013, a woman in her thirties – who seemed to have at least a secondary education from her style of dress and way of speaking – described that she saw blood and a ‘long and hard thing’ in it. She washed it in the water to observe it more in detail. The midwife told her that she believed it was not the embryo but the trophoblast. The patient went on telling the midwife that it was very different from what her sister had observed when she got an abortion. Feeling strong pain, she expelled into the toilet a small body that had tiny hands and legs (fieldnotes, 13 December 2013). While describing this scene, the woman laughed as if she was saying something funny. Other women with primary education or who were illiterate were less able to give precise descriptions of the product of conception and generally spoke of ‘blood’ or ‘blood clots’. Some said they saw a ‘thing’ (haja) or a little white bag23 (shahma) together with blood.

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The ‘Sleeping Child’ and the Biomedical Conception of Abortion During a Values Clarification seminar that took place in early January 2014 (see Chapter 1) in a hospital in the capital, a midwife who had worked for twenty years in a rural area of northern Tunisia and an obstetrician-gynaecologist who had served in different areas of the country told the other participants that on two occasions they had been confronted with a case of the sleeping child. The midwife explained that she had met a childless widow who was pregnant but whose husband had died three years earlier. Her relatives and her husband’s family were convinced that the deceased was the father of the child, a child who had slept for several years in her uterus and recently woken to come to life. The physician said that a few years earlier, while he was giving a sex education course at a student residence, he had explained that the sleeping child does not exist and is only a popular belief. Immediately, a female student took the floor and vehemently argued that the sleeping child was not a belief or a legend but a fact. She declared that she had herself been a sleeping child (fieldnotes, 10 January 2014). In 2016, I gave a course on medical anthropology at a Tunisian University, and during a break between classes, a female student in her early twenties came to talk to me. She asked me whether I thought that the ‘sleeping child’ could exist. She was convinced that it was possible despite the absence of biomedical explanations. Another student joined our conversation and expressed the same conviction. I was very surprised because I thought that this belief had disappeared or existed only among certain categories of the population in rural areas, where formal education is weak. However, the concept of the sleeping child seemed alive and well in the culture of these two university students coming from the area of the Sahel (a coastal area of Eastern Tunisia), where the population is usually considered progressive and educated. In her PhD thesis based on an ethnographic study conducted in the late 1990s, Angel Foster (2001) describes the existence of this belief in many areas of western and southern Tunisia, a belief that Marie-Louise Dubouloz-Laffin had described in her book Le BouMergoud: Folklore Tunisien, published in 1946. Although I never heard visitors to ONFP clinics speak about the sleeping child, Foster’s work, the testimonies of the two healthcare providers mentioned above and the occasional conversations I had

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with the two students I mentioned convinced me of the importance of exploring the impact of the concept of the sleeping child on the representation of early pregnancy and abortion. Because many women I met in ONFP clinics and in Hospital T shared a conception of the female body that was different from that of biomedicine, as mentioned in Chapter 2, it is worth exploring what were/are the local representations of the foetus related to the sleeping child. The concept of the sleeping child (bou margoum, sghir yurqud or raquid) that was described by European scholars in Morocco, Tunisia and Algeria24 had a symbolic, social, legal and ethnomedical nature. The concept, which has been documented since the late nineteenth century by studies on the Maghreb, entails the idea that ‘a child can “fall asleep” in its mother’s womb’ (Jansen 2000: 218). The belief in the sleeping child dates back to the first centuries of Islam and was discussed by the main Islamic law schools, who argued that the maximum duration of pregnancy could vary from nine months to several years. The Malikite school, which was dominant in the Maghreb, believed a pregnancy could last seven years (ibid.). The concept of the sleeping child was used to protect a woman who had repeated abortions, spontaneous or voluntarily induced; to justify the secret use of contraception; and explain the absence of the menstrual period or early menopause (Foster 2001, Jansen 2000). The sleeping child offered infertile women who would otherwise be stigmatised and ostracised ‘a solution to the social insecurity and loss of social status’ (Jansen 2000: 226). A theory circulating in contemporary Morocco affirms that ‘traditional midwives’ and religious men can intervene to wake the child and allow the woman to give birth to it, or that the sleeping child might be woken by the introduction of sperm into a woman’s uterus without resorting to therapeutic remedies (Mateo Dieste 2013). Moreover, a belief in the sleeping child allowed a man or his family to claim the paternity of the child of a divorced woman or widow even years after separation or the husband’s death (Colin 2003). It was thus a means to save the woman’s and her family’s honour and to maintain the legitimacy of a child born outside of wedlock. In her study on Algerian and Moroccan women’s narratives about the sleeping child, Jansen emphasises that raquid is often a euphemism for abortion and birth control. The sleeping child is a ‘frozen’ foetus whose fate is suspended and ambiguous. In Morocco, the herbal remedies used to ‘make the period return’ were the same as those used to ‘wake up the child’ (Jansen 2000: 228). These

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r­ emedies could clarify a woman’s reproductive condition by bringing her out of the ‘liminal state of abortion’ (ibid.). The Tunisian women interviewed by Foster in the late 1990s believed that pregnancy could last between one and nine years and that early pregnancy – between three and six months old – was not seen as implying the existence of a full-fledged human being. It is significant that foetuses less than three months old were not considered sleeping children but something that could be miscarried. It is unclear whether three months (120 days) as the minimum age for a sleeping child is a recent evolution that developed in relation with the temporal limits established by the Tunisian law of abortion or if it existed before the law. In any case, it is possible to say that in the popular representations and in the official legal discourse, as early as the late 1960s, early pregnancy was already not seen as implying the existence of a fully-fledged human being.

Controversies in the Values Clarification Training Seminars Until now, I have described the representations of early pregnancy and the embryo-foetus of clinic users as well as the words and behaviours of healthcare providers I observed during the consultations with patients seeking contraception or abortion care. I will now move to the discussions about abortion and only marginally contraception that took place during the Values Clarification training seminars I participated in. As I stressed in a previous chapter, these seminars constitute an innovative space where for the first time healthcare providers had the opportunity to publicly discuss their ideas, experiences and emotions about abortion and contraception as well as their patients’ sexual and reproductive behaviours. Although these discussions were probably not new as they could take place among individuals in private conversations, the post-revolutionary period in which I conducted my research has created new semi-institutional spaces where practitioners previously working under the authoritarian regime of Ben Ali could not publicly express their views and act accordingly. They indeed had to obey and apply the family planning policies decided and imposed from above, their moral convictions notwithstanding (see Introduction). In the training seminars I attended in 2013–2014, I took part in explicit exchanges revealing the participants’ moral and social

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attitudes about abortion and contraception and was able to talk about the daily professional practices of different providers that I had witnessed during my participant observation. These protected spaces where providers could quite freely express their opinions were extremely valuable as they allowed them to share among themselves their experiences with abortion, contraception and sexuality that they had had in the workplace or within their families or friendship group; as I will describe below, some providers did not hesitate to tell personal stories of abortion or express their opposition to abortion. Others shied away from expressing personal stories but were nevertheless able to share their feelings, revealing their moral stances. Abortion Stories The Values Clarification seminars were structured to encourage participants to speak about their personal and professional trajectories as well as tell stories that had changed their perceptions of abortion, contraception, sexuality and reproduction. Not only participants but also trainers were ready to share their personal stories, which were sometimes very intimate, including a story told by one of the trainers at the beginning of the seminar about the tragic death of a woman who lost her life because she could not get a safe abortion. 25 In a seminar I attended, several participants narrated similar experiences. A young female doctor said she had been affected when, as a student, she had had to perform an autopsy on a girl who had died because of a lethal haemorrhage caused by a clandestine abortion. A midwife said that at the beginning of her career she also saw a woman who had had a clandestine abortion and who was referred to the hospital having spent a whole night bleeding in the room of a private clinic. In a case where another young woman had died, what painfully struck the midwife was that the woman’s mother seemed more worried about what she would tell her husband than about the death of her child. A less tragic story was of a pregnant girl who had asked her mother to help her secretly get an abortion in a private clinic without revealing the event to her father. In the midwife’s eyes, this episode showed that Tunisian society is changing and that women can find support within their own families. In another seminar meant to train the trainers, where participants knew each other quite well and shared a common stance on abortion, several providers narrated their personal experiences of ­abortion.

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Amel, a midwife in her fifties with three children, said that with great surprise she discovered that she was pregnant when moving into a new apartment. She was very uncertain about whether she should keep the pregnancy as it was unplanned. She hesitated until she was nine weeks’ pregnant. First, she consulted her doctor and a midwife colleague, who both encouraged her to get an abortion. As she was still not convinced, she phoned another midwife and friend, who told her, ‘Do not let others tell you that you have to abort’ (fieldnotes, 16 April 2014). Despite some minor health problems, she decided to keep the baby, and she did not regret her decision. It is worth noting that Amel is religious and wears the hijab but supports women’s right to abortion not only in her discourse but also in her practice, which I observed when I conducted participant observations in the SRH clinic where she works. Although not a feminist, she was an advocate for women’s reproductive and sexual rights and was involved in several NGOs active in this field. In another seminar, Amel narrated how she had changed her mind about abortion, which she had previously opposed although had to offer it under Ben Ali’s rule. She explained that several years earlier, she had known two ‘brilliant students’, who were both in high school and had been together for several years. The young man wanted to marry the girl, but her father did not agree because they were very young and he wanted his daughter to complete her studies before forming a family. After three years, the young man decided to leave her, and he then began dating his ex-fiancée’s best friend. However, he did not stop seeing his previous girlfriend and had sexual relationships with both women. They got pregnant at the same time and by chance met at the clinic to which they had gone to seek abortion care and where Amel worked. The abandoned fiancée decided to keep the pregnancy out of spite and gave birth to her baby three days before her baccalaureate examinations. However, the baby was not her ex-fiancé’s son but of one of her clients; while still dating her ex-fiancé, she had got involved in sex work to pay for baccalaureate examinations, which she had not passed the first time, at a private school. Rim, another experienced midwife who worked in a government hospital, related the circumstances in which she had an abortion. It happened two months after her son’s premature birth, after which he had to spend several weeks in the neonatology department. She inadvertently got pregnant and immediately decided to have an abortion as she could not imagine having another child when her first son was still in the hospital and in need of special care. She

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never regretted her decision and was happy that she could easily access abortion care. Dounia, a medical doctor and an activist for women’s rights, was seventeen when she discovered she was pregnant. Afraid of the consequences of her condition, she went to a hospital wearing a very large coat and asked to see the head of the obstetrics and gynaecology department and got an abortion. She stressed several times that she was ‘ready to do anything in order to get rid of the pregnancy’, which she said would have ruined her life (fieldnotes, 10 January 2014). Other participants who had not personally experienced an abortion told stories about close relatives or friends. For example, Dorra, a midwife, said that when she was in high school one of her classmates got pregnant. She did not want to tell her parents but as a minor needed their authorisation to get an abortion in the public sector. Dorra and some classmates raised enough money26 to allow their friend to go to a private clinic, where she was able to get an abortion without informing her parents.27 Najet, another midwife, explained that although she believed that abortion is a woman’s right, when her sister-in-law contacted her because she wanted to get an abortion, she did not feel like helping her. Najet’s relative already had two girls but wanted to have a boy. When she got pregnant and discovered that they were twins, she was frightened because she was not ready to have two more children. Therefore, she decided to terminate the pregnancy but had to wait till the end of Ramadhan.28 According to Najet, when her sister-in-law went back to the doctor for the abortion, she learned that the twins were boys and changed her mind. The twins were born a few months before the Values Clarification Seminar, and Najet’s sister-in-law was reported to be ‘the happiest mother in the world’ (fieldnotes, 26 March 2014). Sharing testimonies about abortion with family members is quite difficult and therefore uncommon in Tunisia. Some participants explained that if they did share their abortion experiences, it was usually with a female friend or colleague. Ignorance about Abortion Procedures In one of the discussions elicited by the seminar, participants were asked to discuss how they had learnt about abortion and if, when they were young, it was possible to discuss contraception and abortion in their family. Only a small minority said that it was a subject discussed within the family and, if it was, abortion was usually

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depicted as a sin or a morally tainted act to be kept secret. A young midwife said that, until her training, she thought abortion was the killing of a baby because in her family it was depicted this way. A midwife working in a rural area of north-western Tunisia said that one of her close relatives told her several times that her salary was religiously illicit (flusstik haram). Some said that they were afraid to talk with their relatives about their activities in the clinic or hospital, whereas others said that they tried to talk freely about abortion and contraception with their teenage children to make them aware of these subjects. Almost all of the midwives – who were the majority of the participants in all seminars I attended – had learned about abortion during their professional practice and not during their training. For example, Dorra, who worked for many years in the delivery room of two government hospitals, had learned about abortion only when she was transferred to the family planning unit. The absence of abortion from the training of midwives is significant because it shows that even though they are the main providers of medical abortion care in the public sector they are not prepared for it. The absence of abortion from health providers’ curricula and training contribute to its marginalisation and devaluation within their professions and may explain why only a very limited number of practitioners are willing to perform it. In several cases during the Values Clarification seminars, midwives and doctors asked to know more about the technical and medical procedures used for abortion as well as the legal conditions in which it can be performed. A medical doctor explained that in the private sector, where mifepristone is generally not available, the minority of doctors who do use the pharmacological method for abortion do not know the official protocols used in ONFP clinics, which are based on WHO protocols, and tend to use a bricolage of methods, which is not always effective. He explained that he used two vaginal and two oral tablets of misoprostol at the same time to induce abortion. However, as already mentioned, most abortions in the private sector are surgical procedures performed under general anaesthesia (D and C29 or aspirations). Another doctor who was the head of a large government maternity ward in the capital said that, in her department, nobody was trained to offer abortion care and women could not get it. She admitted that she did not know the official protocols30 and discussed for several minutes with one of the trainers about the legal definition of the end of the first trimester of pregnancy. The ambiguity lies in the fact that the law does not define the number of weeks of pregnancy but mentions the first

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three months as the limit to obtain abortion care. According to the interpretation of the text of the law, one might understand it as fourteen weeks of amenorrhoea or twelve weeks of pregnancy. One of the trainers at the Values Clarification seminar, a medical doctor, said that although in the early 2000s government authorities had organised several training sessions for all categories of health providers to inform them about the official protocols for medical abortion, later on the training stopped. According to her, local authorities ceased paying attention to reproductive and sexual health in the public sector from at least 2008. Moreover, she argued that the decline of the political, economic and social commitments of medical authorities to this domain has been evident since the late 1990s. An experienced midwife working in the public health sector added that she had heard that between 2008 and 2009 ‘there had been a decision to stop or at least reduce abortions performed at government facilities because birth rates were very low’ (fieldnotes, 4 April 2014). The same midwife also said that in 2008 and 2009 she took part in several workshops organised by government institutions about problems related to the ageing population. One of the trainers at the Values Clarification seminar vigorously replied that ‘it was not possible to take a political decision about the reproductive and sexual rights of women’. Being against Abortion During the Values Clarification seminars, few providers expressed clearly that they were against abortion. It was clear that even for providers supporting women’s right to abortion it was a ‘highly emotional’ subject, to use the words of one of the trainers (fieldnotes, 1 February 2014). A religious provider compared the contradictory feelings she experiences offering abortion care to those she had when she took part in a dinner with some relatives where all other participants drank alcohol. Another very religious midwife said that, although she knew that sometimes abortion can save the life of a woman or help her to improve her situation when she is subject to physical and symbolic violence at home, she was morally conflicted about offering abortion care because she could not avoid thinking of ‘all the murdered children’ (fieldnotes, 16 April 2014). I worked with this midwife for many months, and although she was very committed to her work and sincerely interested in her patients’ well-being, after the revolution she began to refuse abortion care and even tried to convince women not to abort. At the time I met her, the head midwife at her clinic had arranged things so that she

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did not have to offer abortion care anymore. Nevertheless, during the seminar she declared that when her colleague in charge of abortion care was absent, she sometimes replaced her. A hospital midwife who took part in one of the seminars was explicitly against abortion, which she called ‘an aggression to the woman’s body’ (fieldnotes, 1 February 2014). Another midwife with thirty years of professional experience said that she opposed abortion in the second trimester because she had had a traumatic experience when she worked in a private clinic at the beginning of her professional career. There she had attended appalling situations in which foetuses of six months were left dying on a table after birth, sometimes they were even left outside the window in cold weather. For her, these were intolerable acts that had scarred her for the rest of her life, even if the abortions were meant to rescue the life of a young, unmarried girl. Another very experienced midwife serving in an ONFP clinic in north-western Tunisia who had worked in the private sector for several decades told similar stories and manifested the same feelings of moral revolt and personal sorrow describing medical practices that were possibly from the 1980s. She, like the other midwife, expressed her opposition to second trimester abortions. Interestingly, many providers I met linked moral character and acceptability of abortion to the physical aspects and dimensions of the conceptus. Having ‘a human shape’ with ‘arms and legs’, ‘having a brain’ and ‘being big’ were indicated as features that made the embryo/foetus a person, whereas the lack of a recognisable bodily form and a tiny physical mass were synonymous with the absence of humanity. To illustrate the resistance of many professionals towards second trimester abortions, a midwife working in a government hospital in the capital related that, a month earlier, a doctor in the ultrasound department had refused to perform a scan on an unmarried girl who was seventeen weeks’ pregnant and wanted an abortion (fieldnotes, 8 January 2014). Overall, personal and professional experiences with abortion and visual representation of the foetus seemed crucial in determining the way most providers who took part in the Values Clarification seminars framed and comprehended this act. Earlier in this chapter, I mentioned that even the most progressive providers perceived abortion as a medical act not like others and always, though to varying degrees, as kha’ib (ugly) or mush behi (not good) and not morally neutral (fieldnotes, 20 June 2014). It is important to mention what providers said not only during ­consultations but also during the Values Clarification seminars, as

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providers could better express their doubts, emotions and moral dilemmas in the latter context – i.e. outside of their ordinary work environments. In one discussion about how providers feel about offering abortion care, several participants said that their feelings of guilt were not related to religion but rather to their personal ethics. They emphasised that their feelings towards abortion were not always the same but were related to the circumstances of each woman’s situation. If a woman had ‘good reasons’ to get an abortion, they could more easily offer it and feel less guilty, whereas when they thought that a woman had made the decision carelessly, they felt a moral repulsion for the act. Some providers stated that offering abortion when ‘there is no reason’ is difficult. And even when there were ‘good reasons’ to offer abortion, such as in the case of unmarried young women, especially if the pregnancy was already advanced it caused ‘internal conflicts and suffering’ in health providers (fieldnotes, 20 June 2014). To understand the criteria that informed the moral judgments of the providers I met, it is useful to analyse the replies they gave during an exercise at the Values Clarification seminar, in which they were asked to describe the situation in which a woman usually wants an abortion. Replies varied from one group to the other, but common answers were that a woman generally wants an abortion when her life or health is at risk, she lives in a difficult economic situation, she goes through a conjugal crisis or is divorcing, she is ‘old’ (over forty), the foetus suffers from genetic disorders or severe malformations, she is not married, she was raped or was a victim of violence within the family, her husband or relatives forced her to terminate the pregnancy, she has enough children, wants to complete her studies, or has professional ambitions.31 Only rarely did seminar participants suggested that abortion can be a woman’s choice not motivated by external circumstances. Men’s Role in Abortion Significantly, during an exchange between one of the trainers and a midwife, a discussion developed about who within a couple can choose to end the pregnancy. Representing the opinion of many providers I met during fieldwork, a midwife argued that ‘family is sacred’ and a woman has to respect the decision of her husband if he does not want to have children anymore and not force him to have a larger family. Another provider said that the decision to have a child should always be made together as a couple. Conversely, one of the trainers strongly affirmed that to have a child or not is an

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individual right of women (fieldnotes, 3 April 2014). Further, this trainer, a well-known feminist, defended an individualistic conception of women’s right to control their bodies, which contrasted with the first midwife’s view of a collective decision in which women are members of a family whose interests come first. Although men (or better, husbands) were often represented as trying to illegitimately interfere in women’s decisions about their sexual and reproductive lives, such as during discussions about contraceptive methods and domestic violence, in the case of abortion, several female providers had a different outlook. They could not imagine women making decisions about a future child without involving their husbands, whose opinions, they argued, matter. During one of the seminars, a young midwife shared that she had decided to get an abortion without telling her husband. As a mother of two, she did not wish to have more children, so after she got pregnant, she told her husband that she had had a miscarriage and needed to go through an abortion procedure to expel the conceptus (fieldnotes, 3 April 2014). Although most providers wanted husbands to be involved in the decision to end a pregnancy, they did not, however, want them to decide independently of their wife’s will. Therefore, when a woman came to the clinic manifesting sorrow and sometimes crying because she did not want to end her pregnancy but her husband was forcing her to, these health providers asked her to come back with her husband to discuss the issue together (see Chapter 1; Maffi and Affes 2017). The implication of men in abortion decisions was evoked by participants at the seminar only if the woman was married. Partners of unmarried women were never mentioned, as if in lacking the marital status they were automatically excluded from participating in the pregnancy decision. I have already noted that men were largely excluded from SRH clinics even when they wished to accompany their wife or partner and that their presence was felt by some providers and clinic users to be disturbing and illegitimate. Although there was a consensus about the importance of helping unmarried women abort to preserve their future lives, some providers encouraged those who decided or were forced to keep the pregnancy not to abandon their child after birth without including the partner in the discourse. Minors, Sexuality and Ignorance The Values Clarification seminar elicited specific discussions about unmarried girls and their possibility of choosing whether to abort or keep the child. A large number of providers considered

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that minors should not get an abortion without their parents’ consent insofar as being informed will allow them to supervise their daughters. As a midwife summarised: ‘Parents should better control their daughters so that they do not come for repeated abortions’ (fieldnotes, 20 June 2014). Many providers I met shared the conviction that young women are not responsible and require parental supervision. Never were young men the object of ­ providers’ discussions about control over sexual behaviours, as if not having to directly deal with the consequences of an unintended pregnancy excluded them from consideration. These attitudes could at least partially be related to the already analysed patriarchal model according to which men’s sexual needs and desires enjoy more legitimacy than those of women and that their sexual conduct is thus more acceptable than that of women (see Chapter 2). However, I believe that they also derive from a very pragmatic observation: providers know that it is easier to control women’s sexual behaviours, as they come to SRH clinics for contraception and abortion, than men’s conduct, in that they rarely resort to government health services. The same midwife also insisted that it is a heavy responsibility for health providers to offer abortion care in these situations insofar as the girls might have sterility problems in the future or the pregnancy may be the result of rape or incest, which requires a compulsory police investigation.32 Once a discussion took place about the possibility of unmarried minors keeping their pregnancy despite their parents’ opposition, which brought to light that practices differ across institutions and that not all of them understand the law. Some providers said that girls between sixteen and eighteen could freely make a decision about whether to keep the pregnancy, whereas others said they could not make the decision if they were under eighteen. As recalled by one trainer, the international conventions that Tunisia has signed allow a 14-year-old girl to keep her pregnancy if she wishes, but this is not applied as it is in contradiction with the CPS. Whereas this discussion did not focus on a usual situation – because unmarried girls would normally do anything to get an abortion – exchanges were made on very ordinary problems adolescents and young women encounter in relation to the topic of unintended pregnancy. The most debated topic during the seminars I attended was how a lack of sex education determines adolescent behaviours – as it results in ignorance of anatomy and physiology, including the mechanisms of conception (on this see also: Foster 2002, Ben Dridi 2010).

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Many of the episodes regarding knowledge of sexuality among young people narrated by the health providers who participated in the Values Clarification seminars align with the perceptions of many providers I have met as a whole. A midwife working for ONFP, who like many of her colleagues regularly gave courses about contraception, STIs and HIV transmission at high schools, universities and even factories, said that a few years earlier in a high school class she asked the students to draw anatomical pictures of the genitals of the opposite sex. Only a small minority was able to correctly draw them. Although in the ninth grade the natural sciences teachers should introduce the human body and dedicate several hours to sex organs and reproduction, many will only go over it quickly or skip it entirely (see Chapter 2). According to the already mentioned study of Hrairi (2017) in fourteen high schools in Tunisia, 27 per cent of the girls and 38 per cent of the boys involved did not understand how a woman loses her virginity and whether it can be recovered. Of the 735 students, 54 per cent did not know whether a woman is still a virgin after a sexual relationship, and 63 per cent wondered if it is possible to know whether a future spouse had already had sexual relationships (ibid.: 409). Another midwife who took part in one of the seminars said that while she was giving a sex education class in a student residence, she explained the dynamic of sexual intercourse and the way conception happens. She saw ‘all female students present in the room become pale and manifest a sudden anxiety’ when she explained that a woman could get pregnant even if she has sexual intercourse without penetration. According to another midwife, ‘Young women ignore everything about their anatomy and physiology and even how to wash their intimate parts correctly’ (fieldnotes, 5 April 2014). Another provider stressed that young women’s ignorance derives from lack of education and female sexual repression within the family, where they do not talk about their sex organs or their breasts and are discouraged from exploring and touching them. She described how difficult it was to convince other providers to take part in a campaign aimed at promoting self-palpation techniques for the detection of breast cancer. For many of her colleagues, it was scandalous to teach adolescent girls these techniques because it meant a discovery of their body and physical pleasure. The same midwife explained that because of miseducation, Tunisian girls do not keep an upright position when walking because they try to hide their breasts, which are perceived as provocative and disturbing. She also said that ‘if they wear elegant clothes and proudly show

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their breasts, people will tell them that they have to be ashamed, thus frustrating their positive perception of their body’ (fieldnotes, 4 April 2014). Several providers lamented the fact that after the revolution it had become difficult to talk about STIs and HIV/AIDS transmission during classes either because they had been threatened or they were afraid of being attacked by ‘les barbus’ (men with beards, i.e. religious extremists), as a provider humorously said, or because some members of the staff were opposed to it. A midwife working in a very disadvantaged area of the capital stated that one of her colleagues told her that she could speak about STIs and HIV/AIDS and distribute condoms to young people only ‘over her dead body’ (fieldnotes, 5 April 2014). Moreover, several providers complained about the violent attitudes of some of their colleagues after the revolution; they preached abstinence instead of contraception and accused those promoting sex education of ‘encouraging’ morally unacceptable sexual conducts among unmarried people. Violence, the Law and Religion A provider who took part in several Values Clarification seminars more than once told other participants about the various forms of violence she had faced after the revolution because she was in charge of abortion care in her facility. She related, for example, that one morning a member of staff suddenly entered the room while she was receiving a patient and violently threw an envelope on her desk, shouting, ‘Read! What you do is forbidden!’ She informed the head of the facility about the event and also had a heated exchange with the colleague who had given her the letter. This midwife explained to her colleague that clinics and hospitals are not religious places but medical and scientific institutions where religious opinions are not legitimate. The midwife further shared that since the revolution she had regularly been the object of critique and verbal attack by the personnel – especially those working in administration – and that she was reluctant to answer using the religious register like them. Although this midwife offered sexual and reproductive healthcare at her facility, she was identified as the one who performs abortions because she was the only one willing to do it. Her professional identity was thus exclusively related to abortion care even though this did not correspond to her actual professional practices. The issue of religion came up regularly in the seminars and especially during the presentation ‘Islam and abortion’, as mentioned in Chapter 1. The objective was to show that the Quran says nothing

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about abortion and that in the history of Islam there are several interpretations of foetal development theory and dissimilar positions about the permissibility of abortion according to juridical tradition (see Introduction). The central thesis was that if Islamic schools have no unitary view of abortion, it is because the textual tradition contains a multiplicity of positions that are inconsistent and allow different interpretations. It is thus necessary to draw on the general principles of Islamic ethics to build arguments justifying abortion. One of the last slides of this presentation summed up the view of trainers: Islam does not give any clear indication about the issue of abortion. Islam, as a religion of a pristine nature, is never opposed to what is good for human beings. It has always supported efforts to do right insofar as it is not in contradiction with divine law. Islamic law is directed towards avoiding evil and promoting the best for the humanity, and this principle comes from the prophetic verse ‘No evil, no harm in Islam’. (My translation)

As noted in Chapter 1, trainers stressed that Islamic ethics promote the well-being of individuals, and that the principle of the lesser evil should be evoked to justify the necessity to end a pregnancy to preserve the physical or mental health of the mother. The example they used to illustrate how this principle can be applied to abortion is that of a raped woman who has to choose between ending the pregnancy and having a child conceived from violence. After this presentation, there was discussion among participants who did not agree with Islamic interpretations of foetal development, the number of days before ensoulment or the existence of an authoritative text about ensoulment, etc. These debates showed the variety of opinions among clinicians and the fact that there was no unique and clear interpretation of religious tradition among Tunisian health practitioners. In addition to the trainers’ presentation, health providers spontaneously tackled the relationship between abortion and Islam when they discussed the violence they had faced from other members of personnel or their relatives and acquaintances because they offered this service; the refusal of their colleagues to offer it; or patients asking whether it was haram or halal (religiously licit) to end the pregnancy. Many providers said that they refused to tackle the topic of religion in their professional practice because they were there only to apply the law, which grants women access to abortion care under precise social and medical circumstances. Some insisted that

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it was necessary to evoke only the legal and medical aspects in front of patients and colleagues, while others argued that religion could not be rejected as something out of place because it was important for their patients. For these providers, evoking religion was not employed to oppose women’s decisions – like in the case of those clinicians who were reluctant to offer abortion care – but to help them make their decisions in a more serene way by affirming, for example, that Islam does not oppose abortion before 120 days after conception. However, especially for providers confronted with symbolic violence by their colleagues, venturing into religious territory was perceived as dangerous and often useless because they did not hold authority in this field and their interlocutors were often aggressive and not open to discussion. The legal and professional duties of SRH personnel were considered crucial by many participants in the seminars, who insisted that those practitioners who do not wish to offer abortion care should work in other facilities where they do not have to practise activities that do not conform to their moral and religious values. One of the advocates of legal discourse, for example, argued that it was absurd to accept sentences such as ‘tubal ligation is haram and abortion is halal’, as she had heard in her hospital. These are medical acts regulated by law and clinical protocols, and the hospital is not the place where religious judgment should be expressed (fieldwork, 5 April 2014). Some p ­ roviders also underscored that patients rather than providers carry the moral responsibility for their acts and therefore the latter should not feel guilty when they offer abortion care. For many of the participants in the seminars, the issue of responsibility was important because it contributed to their definition of subjectivity. As noted by Tine Gammeltoft, describing the complex world of the Vietnamese parents who had to choose whether to keep a foetus with serious disabilities or terminate the pregnancy, ‘ethically demanding ­decisions . . . are arenas for the making of subjects’ (2014: 19). For the large majority of the health providers I met, offering abortion care was a morally, socially and even politically relevant action that shaped their morality and their social and professional identity. All of these discussions show that providers’ attitudes and professional choices are complex and that they are entangled in multiple networks of moral regimes, which are dynamic and sometimes in conflict. Some providers who were against abortion but had to offer it during Ben Ali’s regime had stopped performing it after 2011 or, on the contrary, had changed their mind once they were free to decide. Others who had always offered abortion care without

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­ eveloping a deep moral stance embraced a conservative religious d view after the revolution and ceased to offer abortion care. Each provider defined her or his moral stance and discourse in relation to the legal, medical, moral and religious context, with the balance being determined by one’s professional experience. Whereas a certain fluidity and uncertainty seemed dominant in the discussions generated at the seminars, in day-to-day practice, professionals appeared less ready to negotiate their attitudes, although, as noted, they were able to modulate their decisions according to the situation of the woman in front of them. Only a fragment of the discussions that took place during the Values Clarification seminars I attended allowed glimpses of the moral dilemmas of healthcare providers offering reproductive and sexual care. Although it has not radically changed the opinions of the providers I met, the revolution of 2011 has legitimised the circulation of different moral registers and discourses, which has oriented their attitudes in new ways. The freedom to refuse abortion or contraceptive care is new, and providers working in government health facilities who exercised this were the object of heated debates among participants, perhaps for the first time in the history of Tunisia.

Notes   1. During my fieldwork in the ONFP clinics and in Hospital T, I did not meet a woman who was to undergo a surgical abortion, but several had previously had surgical abortions in the private sector.   2. In ONFP clinics, I never saw a physician making the sound of an embryo’s heartbeat audible to women undergoing a sonogram.   3. On the relevance of the human form for the clinicians sharing the biomedical visual culture in Mediterranean countries, see De Zordo (2015).   4. In some of the clinics, this task was accomplished by an anaesthetist because the operating theatre was not functioning, and they had no other options.   5. The staff in charge of abortion care had to do considerable bureaucratic work around each abortion procedure: aside from filling in the medical or socio-medical fact sheet, they had to prepare a rose card containing the date of the appointment for the post-abortion control and information about the hospital that the woman could go to in case of severe haemorrhage during the procedure. They had to check that the informed consent was signed and that the woman’s blood test (with

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her blood group) and her sonogram were in the record. Finally, they had to fill in the clinic’s monthly register with the patient’s name, the date and the type of procedure. All providers had to fulfil this task for all types of procedures, not just for abortions. As mentioned in a previous chapter, the bureaucratic inscription of all medical acts allows a detailed surveillance of women’s sexual and reproductive behaviours – at least of those who use government facilities.   6. Children were sometimes present during ordinary gynaecological exams.   7. The sensitive nature of these words explains why they were very often discussed during the Values Clarification seminars for healthcare professionals that I described in Chapter 1.   8. It could also be that they were influenced by the neo-conservative Islamic trends that have been circulating in the country since the mid2000s.   9. Interestingly, in Tunisian Arabic, sabbara (the act of using a contraceptive method) is from the root s-b-r, which means patience: to be patient. Therefore, using contraception literally means being patient. The noun tasbir, derived from the same verb, means contraceptive method in Tunisian Arabic. Interestingly, the morally good woman was locally defined as sabra wa hashma (patient and modest) (Labidi 1989). 10. Johanna Mishtal, who has extensively studied abortion practices in Poland, states that: ‘In Catholicism, abortion is seen as a one-time sin and you can repent properly, whereas wearing an IUD or taking the pill is seen as much worse because you are sinning every day and have no intention of stopping so you can’t repent’ (personal communication). For more details see Mishtal (2015). 11. This practice reminds me of the two-for-one package I mentioned in Chapter 1, which consisted of inserting, without consent, an IUD for women getting a surgical abortion. 12. I once heard an exchange in which a woman already in her late fifties told a much younger woman who had come to get abortion care that she should not terminate the pregnancy and that she was going to regret it. The older woman declared that she had had fertility disorders and had gone through a troublesome reproductive trajectory and could not understand women seeking abortion. 13. Sexual intercourse between adult men and adolescent girls is punishable by law; the younger the minor the more severe the punishment. DNA identification is compulsory for all cases in which a minor becomes pregnant to identify the perpetrator. 14. In Tunisia, sex work can only be practised under specific conditions. Sex work that is not officially recognised is illegal and punishable by law. On this topic, see Msakni (2017). 15. A very similar story is also reported by Zeina Fathallah in her thesis on abortion in Lebanon (2011). She emphases the fact that raping a virgin

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woman is a stain on the reputation of her whole family, including its male members. 16. Despite the differences between the two contexts, in Tunisia like in Poland, the refusal of medical doctors who hold a position of authority in public hospitals to offer abortion care has caused ‘the shift from individual objection to systemic restrictions’ (Mishtal 2009: 168). 17. The attitudes towards early pregnancy of most women I met in the ONFP clinics and Hospital T were different from those reported by Lilia Labidi in her study realised in the early 1980s among Tunisian women (1989). Many of Labidi’s interlocutors considered abortion to be the murder of a baby and a sin (see Chapter 1). 18. I collected several stories of women who had tried pharmacological abortion in the private sector, following procedures that are not in accordance with international standards, and were unsuccessful. The lack of training of obstetrician-gynaecologists and the fact that mifepristone is not available in private clinics unless it is officially requested from the Central Pharmacy are two main problems. However, as already noted, the large majority of abortions in the private sector are surgical because they are more lucrative. 19. Healthcare providers think that abortion pills can cause foetal abnormalities and usually suggest that patients who experience a failed abortion retry the procedure and terminate the pregnancy to avoid giving birth to an impaired child. Those who are unaware of a failed abortion and come back to the clinic with second-trimester pregnancies are always sent to the hospital to undergo specific exams to ascertain the foetus’s health. 20. Mateo Dieste notes that in Morocco the expression ‘bismillah’ ‘conveys protecting intention or seeks to propitiate good, and it is used before undertaking all sorts of actions . . .’ (2013: 62). 21. Only women with pregnancies of more than ten weeks were hospitalised for the pharmacological abortion procedure. A specific protocol was used for late first trimester pregnancy based on the administration of 400mcg of Misoprostol every 3 hours (Avortement médicamenteux: 15 ans d’innovations au service de la femme en Tunisie 2016: 18). 22. On the cultural construction of disgust, see Memmi, Raveneau and Taïeb (2011). 23. It is the term used by professional when they speak to their patients to designate the gestational sac. 24. On the topic of the sleeping child, see Colin (2003); Foster (2001); Jansen (2000). 25. Often the story told at the beginning of a seminar was a narrative of a true event; other times it was made up according to a plausible locally based plot. 26. A Tunisian friend told me that when she was a student, she and her girlfriends created a common fund to be used in case one of them got

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pregnant and needed an abortion. Abortion prices can vary according to the client’s marital status and age as well as the stage of pregnancy 27. In the private sector, identity cards are usually not requested. 28. In Najet’s narrative, it was unclear whether her sister-in-law could not access abortion care or did not want it during Ramadhan. 29. The expression ‘D and C’ means dilation and curettage. 30. As mentioned several times by a doctor active in the defence of abortion rights, ONFP only offered training for medical abortion in the late 1990s and early 2000s, when the method was introduced in the country. Doctors and midwives who began to work in government and private facilities after that period did not receive any training. Moreover, in the private sector most providers offer only surgical abortion under general anaesthesia and do not have easily access to mifepristone. 31. If women do not feel like having a baby even if they do not face material constraints this is not considered a valid reason for abortion by providers. 32. As already mentioned, according to the Penal Code, having sexual intercourse with a minor is a crime.

Conclusion

A

t the end of January 2018, I returned to Tunis and met Dounia, one of the healthcare providers with whom I had collaborated during my research in 2013–2014. She had retired but was still a very active member of several NGOs, for which she organised seminars, workshops and training in the field of women’s rights and sexual and reproductive health. The topics we discussed included the evolution of the attitudes of the personnel working in the sexual and reproductive health sector since 2014. A feminist and leftist, Dounia was not very optimistic about the situation, but she was working hard to modify and improve it. To illustrate the rise of religious and conservative ideologies among the personnel working in the government clinics, she recalled the trajectory of Asma, a midwife I had worked with for many months. Dounia knew her very well; in the 1980s and 1990s, they had worked together in an ONFP clinic located in a city in North Tunisia. About Asma, she said: ‘she was a fantastic midwife and I liked her very much’ (fieldnotes, 25 January 2018). Dounia remembered that, despite the social and political climate triggering hostility to religious symbols, Asma used to wear the hijab, which was almost forbidden in the public sector. Dounia, as she held a position of responsibility, had defended Asma and another midwife working in her clinic from the interference of the local governor, who wanted to sanction the providers for wearing the hijab. She said that, even if they were religious, Asma and her colleague had never refused to offer abortion care and were very respectful of their patients’ decisions. However, Dounia

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recognised that ‘after the revolution, Asma had radically changed’. She had become very conservative and, although still working in an ONFP clinic, had begun to refuse to offer abortion care. In her opinion, Asma seemed to have lost the enthusiasm for her work and manifested less respect and concern for her patients. This fragment of conversation allows me to show the paradoxical effects that the democratisation of Tunisian society has brought about in the domain of sexual and reproductive health. As I have shown through the chapters of this book, new discourses and practices have appeared that have created ruptures, yet there has also been a strong continuity with the past. Islamic discourses and practices, often related to transnational, very conservative interpretations of the Sunni tradition, have gained public legitimacy, thus affecting political, social and even medical institutions. At the same time, feminist and secular NGOs have started to actively work for women’s rights in the domain of sexual and reproductive health and make the authorities aware of the failures in the healthcare system. A new law was approved in 2017 against all forms of violence, including the rights of women in the public and domestic spheres. At the time of writing, the Tunisian government was working on a law to establish equality in the right to inherit between men and women, which shows that progressive forces are as present as conservative and religious ones. Hence, if Ben Ali’s rule – so often regretted by my interlocutors in 2013–2014 – in some respects allowed women to obtain sexual and reproductive services they had difficulty receiving after the revolution, it was also the consequence of the acquired freedom of expression and action. Before the revolution, healthcare providers had to adhere to the rules; in consequence, there was no space for ethical dilemmas, discussions and dissension. Especially in the 1970s and 1980s, ordinary women (and men) were forced to accept the state’s demographic policies aimed at reducing the natality rate and symbolic and physical violence towards women was not uncommon. In Tunisia, contraception was introduced not as a result of women’s struggles to control their sexual and reproductive life but as a state instrument to control their fertility and reproductive decisions. In the aftermath of the revolution, new spaces have emerged that allow for unprecedented individual freedom and moral negotiations but also conflicts and new forms of symbolic violence. Healthcare providers are free to support women’s reproductive decisions but also refuse services – that is, turn away women seeking abortion care and attack colleagues who have different opinions. Their behaviour

Conclusion177

has made apparent the presence of diverging rationalities and dissimilar moral economies, gender regimes and forms of knowledge about the body. It has also allowed for the open recognition that reproductive and sexual healthcare is not a mere political, medical and technical fact but an arena of contention where different moral subjectivities take shape and meet or clash. The shaping of subjectivities can be understood as an active and passive process at the same time. If state institutions perform anatomo-political work on women’s bodies and subjectivities through the actions of healthcare providers, they also shape the administrative, technical and medical categories and practices in which professionals’ subjectivities are inscribed. However, the medical encounter is not only a setting where institutions fashion practitioners’ and patients’ identities but also a space where the agency of individuals can unfold and their subjectivities form and evolve. Finally, this book has also shown how, besides all of these aspects, material constraints, the dramatic economic crisis Tunisia has experienced since the revolution, severe understaffing in many government facilities and the absence of medical services in rural regions must also be taken into consideration if one wants to understand the current situation of public sexual and reproductive health facilities and how they shape women’s existence. The revolution of 2011 has revealed and exacerbated political, economic, social, religious and moral dimensions that were already present in the country and that the question of women’s sexual and reproductive governance has brought to the forefront.

Glossary

blood-like clot why don’t you use a contraceptive method? Al-naw al-ijtima‘i gender Al-numu’ the growth (of the embryo) Al-tathqif al-jinsi al-shamil comprehensive sex education Al-watan al-‘arabi Arab region Anti mujrima you are a killer ‘Ayla extended family Barnamaj plan (reproductive plan) Bébé baby Bou father Bou margoum, sghir yurqud sleeping child  or raquid Calendrier or Hisab calendar method Cas social social outcast Curetage D and C (dilation and curettage) Damir conscience Dawra or Ghassala menstruation Dhuruf circumstances, hardship Dossier santé Jeune/Ado health record for youth and adolescents Educateurs health workers Ela IUD Fadha sadiq li-al-shebab youth-friendly clinics Fluss money Gheraset or ‘Urf hormonal implant Ghusl major purification H’adath minor impurities Haja thing Halal religiously licit or permitted ‘Alaqa ‘Alesh ma tusabbiri?

Glossary179

Haml ghayr marhub fihi unintended pregnancy Harabish (sing. harbusha) pills (used for medical abortion) Haram religiously prohibited Haram ‘alayk shame on you Hayd defilement Hbela pregnancy Hbela kabira advanced pregnancy Hbela nejiha successful pregnancy Hbela saghira early pregnancy Huquq insaniyya wa jinsiyya human and sexual and reproductive   wa injabiyya rights Ijhadh abortion Ijhadh ghayr al-aman unsafe abortion ‘Indi retard my period is late Insan human being Janaba major impurities Jabr right to compulsion Jilda piece of skin Khitan al-inath female circumcision Mahr bridewealth Maridha sick (woman during the menstrual period) Mudgha lump of flesh Musawa equality Mush behi not good Nadhafa hygiene Nadhifa clean Nutfa semen Qalb heart Qirsh belly Qyas analogical reasoning Rafad al-damir or Ta’nib conscientious objection  al–damir Ruh human soul Sabbiri! use contraception! Safhat ijtima‘iyya social traits Saghir baby, foetus Sbiyya virgin Shahma bag Shkara bag Tarmi el-hbela to expulse the pregnancy Tasbir contraception

180

Glossary

(T)Unahhi al-bébé or al-saghir to eliminate the little one (or baby) Tuqtul saghirik to kill your baby Ulamas religious scholars Ummahat a‘zibat unmarried mothers Usra nuclear family Wa‘d infanticide Wasakh dirt

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Index

abortion abortive itineraries, 21 Arab countries, 3, 4, 5, 6, 8, 39, 59 debate, 8 dhuruf, 73 good reasons, 45, 164 ijhadh, 1, 44, 58 illegal, 5, 6, 45, 59 itineraries, 41, 127 law, 3, 4, 5, 7, 8, 25 legal term, 126, 127 medical, ix, 18, 37, 49, 86, 87, 97, 106, 111, 117, 126, 127, 128, 133, 141, 145, 147, 152, 161, 162, 174, 179 mifepristone, 37, 97, 133, 137, 145, 146, 152, 161, 174 misoprostol, 97, 108, 111, 137, 145, 146, 154, 161 partial retention, 69 pharmacological, 49, 128, 146, 147, 153, 154, 173 product of the expulsion, 154 recidivist, 87, 129, 130, 132, 139 repeated, 76, 87, 119, 148, 149, 156, 166 second trimester, 125, 126, 127, 149, 163 surgical, 87, 128, 141, 171, 172, 174 technologies, 79 tribulations, 37 unsafe, 5, 6, 58, 179

uterine content, 97 valid reasons, 2 adolescents, 51, 56, 112, 116, 149, 166, 178 aesthetic, 104 agency, 10, 12, 78, 96, 97, 121, 136, 177 AIDS, 109, 168 alcohol, 111, 115, 162 Algeria, 4, 5, 6, 7, 14, 92, 156, 185 Al-Suyuti, 61 amniocentesis, 126, 139, 149 animatrice, 109 anthropomorphic images, 151 anticipation, 99, 100 barnamaj, 101 planned future, 100 regimes of, 99 reproductive plans, 101 anxiety, 88, 90, 127, 145, 151, 167 Arab-Islamic countries birth control policies, 3, 72 Arab-Islamic identity, 17, 19, 54 Arab-Islamic medical theories, 65 Association Tunisienne pour la Santé Reproductive (ATSR), 17, 18, 19, 51, 53, 54, 61 Ben Ali, x, xi, 16, 18, 27, 30, 32, 36, 37, 157, 159, 170, 176 biomedical visual culture, 23, 154, 171

198

biomedicine, 23, 99, 156 biomedical discourses, 98 biomedical paradigm, 80 biomedical representations, 69 biomedical term, 69 biopolitics, 103, 104 biopolitical work, 104 birth control policies, 4, 41 blood, 1, 2, 64, 65, 66, 67, 68, 81, 90, 91, 104, 147, 150, 153, 154, 171, 172, 178 blood clots, 154 blood test, 104, 171 body bodily functions, 68, 91, 151 bodily habits, 88 bodily products, 67 bodily regimes, 71 excreta, 66, 67 images, 23, 62, 63, 65, 69, 142 model of the body, 62 organs, 62, 85 popular physiological model, 80 sex organs, 167 breastfeeding, 44 bridewealth, 114, 179 childbirth, 68, 78, 90 choice, 6, 24, 35, 42, 43, 49, 51, 52, 53, 58, 60, 73, 76, 79, 80, 91, 96, 98, 104, 120, 121, 141, 164 clinical trial, 97, 137 Coalition for Sexual and Bodily Rights in Muslim Countries (CSBR), 34 Code of Personal Status (CPS), 13, 15, 17, 27, 30, 32, 59, 83, 93, 114, 124, 166 complementarity between men and women, 17, 22, 27, 30 conceptus, 36, 123, 144, 146, 150, 153, 163, 165 Conference of Population and Development in Cairo(ICPD), 6, 59, 96, 106, 195 confidentiality, 106

Index

conscientious objection, 40, 151, 179 rafad al-damir, 40 conservative actors, 21, 31, 35, 36, 41, 88 conservative turn, 21, 34, 36 constituent assembly, 9, 18, 21, 29 constitution, 9, 13, 14, 18, 21, 27, 30, 33, 104 contraception calendrier, 76, 104 condoms, 70, 75, 81, 101, 107, 114, 168 contraceptive technologies, 13, 70, 71, 75, 76, 77, 98, 104, 109 Depo-Provera, 70, 86 female condom, 70 gheraset, 62, 76 harabish, 110, 144 hisab, 104 hormonal contraceptives, 70, 77, 80, 87 Implanon, 70 implant, 11, 12, 62, 63, 64, 76, 80, 81, 86, 87, 90, 98, 101, 104, 130, 148, 178 injectable, 65, 70, 80, 81, 86, 118, 147 IUD, 11, 12, 13, 26, 36, 38, 70, 71, 73, 77, 80, 81, 82, 83, 87, 92, 100, 101, 104, 105, 116, 130, 147, 172, 178, 195 mechanical contraceptive methods, 75 Microgynon, 70, 90 Microval, 64, 70, 90 Mirena, 70, 91 modern method, 104 natural method, 70 periodical abstinence, 70, 76, 104 pill, 13, 64, 77, 80, 81, 86, 87, 90, 97, 100, 101, 104, 145, 146, 147, 152, 153, 154, 172 side effects, 49, 58, 71, 76, 77, 80, 81, 83, 87, 88, 92, 104, 141, 146, 148, 153 tasbir, 76, 172

Index199

traditional method, 70, 91, 104 tubal ligation, 11, 12, 81, 83, 87, 92, 93, 170 withdrawal, 16, 80, 81, 104 contraceptive norm, 71, 79, 80, 81, 83, 86, 87, 89, 96 Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), 26, 33, 96 counselling, 6, 71, 106, 107 culpability, 89, 90 cultural authenticity, 31 Dalkon Shield, 80, 92 Damascus Conference on Unsafe Abortion and Sexual Health in the Arab World, 5 damir, 40, 143, 179 demographic transition, 82, 141 dialect of rights, 52, 54 diet, 105, 119 disabilities, 170 distress, 25, 47, 50, 61, 111, 120, 139, 151 divorce, 13, 73, 86, 91, 100, 135, 156 DNA, 172 drugs, 38, 115 economic crisis crisis, 18, 37, 38, 90, 164, 177, 193 financial resources, 37 insufficient supplies of medicines, 38 Egypt, 4, 5, 6, 7, 52, 66, 69, 78, 181, 183, 185, 189 embryo, 2, 23, 42, 43, 44, 48, 121, 142, 143, 144, 150, 151, 152, 154, 157, 163, 171, 178 emergency pill, 38, 107 NorLevo, 70 emotions, 121, 140, 157, 164 Ennahdha, xi, 9, 17, 18, 19, 29, 30, 32, 33, 34, 36, 41, 54, 59, 95 Islamic Tendency Movement, 30

equality between men and women, 8, 13, 14, 16, 17, 27, 30, 31, 39, 54, 176, 179 excision, 32, 33 expiation, 119, 121 family, xii, 1, 4, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 19, 20, 23, 24, 25, 26, 29, 31, 37, 41, 43, 44, 45, 46, 47, 50, 53, 54, 55, 58, 62, 71, 72, 73, 74, 75, 78, 79, 82, 83, 84, 86, 87, 88, 89, 90, 91, 93, 96, 97, 98, 99, 100, 101, 102, 105, 109, 114, 115, 116, 117, 118, 123, 124, 125, 126, 127, 132, 135, 136, 137, 138, 141, 144, 145, 149, 153, 155, 156, 157, 158, 159, 160, 161, 164, 165, 167, 173, 178, 180 family planning avoided births, 99, 137 demographic rationalities, 96 policies, 10, 12, 13, 26, 78, 82, 99, 109, 141, 157 population control, 92, 95, 99, 136 project of a baby, 42 services, 5, 6 father, 13, 47, 55, 71, 118, 131, 149, 155, 158, 159, 178 feelings, xii, 20, 24, 56, 57, 66, 89, 90, 120, 126, 145, 151, 158, 162, 163, 164 feminine identity, 23, 55, 68, 121 feminism, 15, 16, 17, 27, 33 Association tunisienne des femmes démocrates (ATFD), 8, 17, 18, 27, 34, 35, 88, 181 National Union of Tunisian Women, 15 secular, 17, 32 Tunisian Association for Research and Development (AFTURD), 17 feminist movements, 16, 17, 27, 43, 96

200

fertility, 186 fertile, 79, 101, 137 fœtus baby, 42, 43, 44, 47, 73, 117, 121, 123, 126, 132, 135, 142, 143, 144, 147, 149, 150, 151, 152, 153, 154, 159, 161, 173, 174, 178, 179, 180 bébé, 44, 126, 180 heartbeat, 143, 171 human shape, 163 little one, 44, 180 qalb, 144 saghir, 44, 126, 132, 147, 151, 180 France, 30, 37, 48, 68, 79, 92, 119, 120, 121, 122, 138, 147, 182, 183, 186, 196 gender, 8, 14, 20, 29, 49, 51, 52, 53, 54, 55, 56, 57, 98, 103, 107, 177, 178 normativity, 55 regimes, 53, 177 genetic disorders, 125, 144, 164 genitor, 126, 131, 149 governmentality through words, 48 Greek medicine, 65 Groupe Tawhida Ben Cheikh, xii, 17, 18, 34, 95, 182 guilt, 117, 120, 126, 151, 164 Habib Bourguiba, 10, 11, 12, 13, 15, 16, 19, 26, 27, 30, 31, 95, 183, 184, 187 Habib Ellouz, 32 halal, 169, 170 haram, 116, 149, 153, 161, 169, 170 health disorders, 58 heart, 13, 63, 64, 143, 144, 150, 179 herbal remedies, 156 high school, 85, 108, 117, 159, 160, 167 honour, 8, 89, 91, 114, 156

Index

hormones, 62, 63, 69, 70, 74, 75, 77, 80, 87, 88, 90, 137, 153, 178 artificial hormonal cycle, 104 artificial hormones, 80 human conception, 65 human soul, 44, 179 ruh, 44 humanity, 163 husband, xiii, 4, 9, 14, 47, 48, 64, 68, 73, 74, 75, 76, 78, 79, 81, 84, 89, 92, 100, 101, 114, 116, 117, 119, 122, 123, 127, 134, 135, 149, 153, 155, 156, 158, 164, 165 hygiene, 67, 179 Ibn Rushd, 65 Ibn Sina, 65 identity card, 122, 124, 133, 134, 135, 174 ignorance, 10, 16, 84, 88, 166, 167 imams, 45 impurity, 67 janaba, 67 major impurities, 67, 179 minor impurities, 67, 178 religiously impure, 66 infertility, 78, 80, 148 infertile, 75, 156 informed consent, 145, 171 injection, 104 International Federation of Obstetricians and Gynaecologists (FIGO), 40, 189 International Planned Parenthood Federation (IPPF), xii, 8, 18, 51, 52, 53, 57, 58, 61, 189 interview medical, 78 psychological, 46, 121 intimacy, xii, 107 Iran, 3, 4, 5, 66, 69, 185, 188, 192, 196 Islamic ethics, 42, 169

Index201

Islamic juridical traditions, 2, 7, 8 Islamic legal traditions, 67 Maliki legal tradition, 11, 156 Islamic moral repertoires, 41 Islamic schools, 143, 169 Islamic theory of fœtal development alaqa, 2 insan, 2 mudgha, 2 nutfa, 2 Islamism, 16, 60 Jordan, 4, 5, 6, 7, 25, 78, 191 Lebanon, 3, 5, 25, 172 legal guardian, 124, 139 malformations, 164 Margaret Sanger, 95 maridha, 68 marriage, 13, 25, 41, 46, 72, 73, 78, 79, 83, 84, 89, 90, 92, 93, 100, 101, 114, 122, 130, 135, 137, 138, 139 marriage contract, 122, 135 married couples, 14, 46, 80 wedding, 74, 85, 94, 122, 135 maternal deaths, 6 maternal mortality, 5, 39, 57, 58, 59 medical file, 73 medical record, 37, 80, 97, 102, 108, 110, 112, 114, 115, 116, 119, 130, 131, 133, 134, 138, 140, 145 dossier santé Jeune-Ado, 112, 113, 114, 178 health record, 112, 178 medical technologies, 87, 148 men, 11, 12, 13, 14, 15, 16, 17, 20, 22, 27, 30, 31, 39, 43, 48, 51, 52, 53, 54, 56, 57, 61, 66, 67, 68, 73, 75, 76, 78, 83, 84, 85, 88, 89, 90, 92, 93, 94, 97, 101, 103, 106, 107, 108, 109, 113, 114, 115, 117, 129, 131, 136,

137, 138, 139, 156, 165, 166, 168, 172, 176 unmarried men, 107 menarche, 55, 66 menopause, 66, 68, 91, 156 menstruation, 55, 65, 66, 67, 68, 87, 118, 178 bleeding, 6, 64, 104, 105, 147, 158 cathartic model, 66 clean, 62, 65, 179 dawra, 65, 146 dirt, 180 dirty fluid, 64 ghassala, 65 illness, 9, 10, 66, 67 menstrual calendar, 64 menstrual cycle, 55, 65, 66, 68, 81, 87, 101, 104, 105, 118, 132, 138 menstrual period, 55, 64, 67, 81, 110, 111, 156, 179 missed period, 128, 144 monthly period, 62 nadhifa, 62 plethora, 66 plethoric model, 66 punishment, 66, 87, 93, 119, 121, 151 retention of menses, 66 semantics of menstruation, 68 spotting, 62 wasakh, 64, 69 mental health, 4, 6, 7, 58, 111, 125, 126, 127, 169 miscarriage, 165 modernisation, 13, 22, 31, 40, 85 modernity, 31, 57, 99 moral dilemmas, 164, 171 moral economy, 132, 146, 177 moral judgments, 96, 122, 164 moralisation, 36, 48, 79, 109, 119, 122, 130 Morocco, 3, 4, 5, 6, 7, 14, 66, 92, 94, 129, 156, 173, 182, 185, 186, 192

202

mothers marital status, 70, 71, 74, 103, 124, 135, 165, 174 maternal identity, 74 unmarried, 72, 117, 131, 180 nadhafa, 67 Najiba Berioul, 9, 34, 95 natality, 82 neoliberal model, 52 neoliberal rationalities, 22 neo-Malthusianism, 52, 92, 96 Norway, xiii, 120 Office national de la famille et de la population, 10, 12, 18, 19, 26, 27, 34, 35, 36, 37, 38, 49, 50, 51, 68, 70, 73, 74, 75, 79, 80, 81, 83, 84, 85, 86, 87, 89, 91, 92, 93, 97, 99, 100, 101, 102, 103, 104, 105, 106, 107, 108, 109, 110, 112, 115, 117, 121, 122, 123, 124, 125, 127, 128, 133, 134, 135, 136, 137, 138, 140, 141, 142, 143, 144, 145, 146, 147, 148, 149, 151, 152, 153, 155, 156, 161, 163, 167, 171, 173, 174, 175, 176 ontology, 146 ontological, 20, 43, 45, 147 ontological status, 20, 147 ordinary resistence, 134 ovaries, 62, 81 parental project, 43, 58 partner, 47, 48, 58, 74, 75, 76, 77, 78, 84, 86, 89, 102, 107, 108, 111, 114, 115, 116, 119, 165 patriarchy, 132 patriarchal, 22, 53, 56, 78, 83, 114, 132, 166 patriarchal moral regime, 83 pedagogy, 121, 122, 144 of the gaze, 121, 144 peer educator, 108 Penal Code, 6, 9, 26, 93, 95, 124, 174

Index

population management of, 103 pregnancy advanced, 126, 179 belly, 125, 132, 151, 179 early, 23, 43, 44, 60, 139, 140, 145, 147, 150, 151, 156, 157, 173, 179 expulsion of, 146 hbela, 44, 126, 132, 145, 146, 151, 179 hbela kabira, 126 hbela saghira, 145 retard, 61, 110, 132, 179 stomach ache, 110, 132 unintended, 25, 58, 166, 179 viable, 145 willed, 22, 98, 106 pre-human, 150 privacy, 107, 123, 133 professional identity, 168, 170 prophetic medicine, 65 prostitution, 86, 117 prostitute, 119 sex work, 23, 117, 122, 129, 131, 159, 172 sex workers, 23, 129, 131 psychiatrist, 126 purity, 67, 85 legal purity, 67 purification rituals, 90 Quran, 1, 32, 35, 48, 53, 66, 67, 144, 146, 168 surah, 1, 2, 42, 66 Rached Ghannouchi, 34, 183 Ramadhan, ix, 67, 160, 174 rape, 6, 7, 8, 114, 124, 126, 148, 166, 195 raped, 7, 117, 118, 130, 131, 149, 164, 169 reforms, 11, 13, 14, 15, 16, 26, 30, 31, 90, 120, 124 religious conservatism, 54, 129 reparation, 119, 121

Index203

Repoductive Health Association, 35, 38, 39, 40, 42, 43, 48, 54, 101 reproduction reproductive behaviours, 12, 23, 82, 104, 128, 157, 172 reproductive decisions, 13, 48, 78, 109, 176 reproductive rationalities, 99, 100 reproductive governance, 20, 102, 177 reproductive norm, 22, 71, 72 reproductive responsibility, 43, 108 irresponsible, 50, 87, 98, 102, 104, 109, 115, 119, 121 paradigm of responsibility, 98 RHA Values Clarification seminar, 42, 45, 48, 155, 158, 161, 162, 163, 164, 167, 168, 171, 172 right to abortion, 6, 8, 9, 17, 18, 21, 34, 42, 95, 128, 159, 162 ritual ablution, 65 ghusl, 65, 67, 90 Safe Abortion Day, 95 Sana Ben Achour, xii, 114 self-mutilation practices, 90 Selma Hajri, xii, 18, 27, 34, 35 semantic networks, 68, 69 sexual and reproductive rights, 34, 39, 42, 51, 53, 54, 79 sexual intercourse, 53, 55, 67, 81, 85, 87, 94, 110, 116, 131, 167, 174 sexual relationships, 24, 57, 76, 83, 84, 85, 93, 97, 110, 115, 138, 159, 167 sexual repression, 167 sexual role, 55, 56 sexuality extramarital sex, 93 female sexuality, 57, 89 first sexual relationship, 114 pleasure, 52, 53, 57, 88, 167

premarital, 83, 89, 90, 92, 110 premarital intercourse, 84 sexual behaviour, 22, 52, 58, 74, 98, 102, 104, 114, 138, 166 sexual conducts, 115, 168 sexual desire, 53, 57, 88, 89, 109 sexual penetration, 89 sexual practices, 84, 86, 89 sexual relationships outside of wedlock, 83, 93 Sexually Transmitted Infections, 52, 54, 167, 168 sin, 35, 41, 143, 151, 153, 161, 172, 173 sleeping child, 23, 155, 156, 157, 173, 178 bou margoum, 156 raquid, 156, 178 sghir yurqud, 156, 178 smell, 68 social outcasts, 129 social service department, 122, 124, 125, 135 somatic resistance, 104 sonogram, 140, 171, 172 sonographic image, 142, 143, 144, 150, 151 sperm, 67, 90, 156 statistics, 39, 81, 92, 99, 112 statistical studies, 102 stigmatisation, 36, 129, 134 students, 33, 85, 141, 155, 156, 159, 167 subject moral, 23, 130, 177 pathological, 121 reproductive, 43 self-control, 66, 98, 120, 121, 148 surveillance, 23, 103, 114, 131, 134, 135, 172 tactic, 134, 135 Tahar Haddad, 26, 30, 31, 188 technical object, 76, 77

204

teenagers, 67, 85 therapeutic itineraries, 36, 37, 97, 125 Turkey, 4, 5, 7, 25, 31, 66, 185 ulamas, 45 ultrasound, 48, 111, 123, 140, 142, 143, 144, 145, 163 United Nations Children’s Fund (UNICEF), 102 United Nations Fund for the Population (UNFPA), 8, 17, 18, 19, 51, 61, 93, 102, 193 United States International Agency for International Development (USAID), 82 unwanted children, 45 urinary test, 97, 153 uterus, 36, 62, 65, 69, 81, 90, 111, 150, 155, 156 endometrium, 62, 64 violence domestic, 45, 165 sexual, 116, 117, 122, 126

Index

structural, 49, 117, 118 symbolic, 23, 119, 162, 176 virginity, 7, 41, 83, 84, 85, 88, 89, 108, 112, 167 hymen, 7, 84, 85, 87, 89 hymen reconstruction, 84, 85 sbiyya, 85, 108 surgical repairs of the hymen, 90 tasfih, 85, 94 virgin, 41, 83, 85, 89, 108, 110, 167, 172, 179 visual technologies, 142 Wajdi Ghanim, 32 weight, 81, 88, 104, 152 overweight, 105, 119 withdrawal bleeding, 81 World Bank, 82, 92, 196 World Health Organisation (WHO), 6, 8, 24, 25, 53, 82, 96, 161, 196 youth-friendly clinics, 79, 83, 86, 93, 107, 108, 112, 118, 137, 178