At the third meeting in the Islam, Gender, and Reproductive Health series, which is sponsored by The Middle East Program and Environmental Change and Security Project and supported by USAID's Office of Population and Reproductive Health and the Interagency Gender Working Group, Ellen Gruenbaum of California State University, Fresno, and Marcia C. Inhorn of the University of Michigan offered in-depth looks at the intersection of reproductive health and gender issues in the Islamic world. Dr. Gruenbaum discussed community-based efforts to change attitudes toward female genital cutting in Sudan, and Dr. Inhorn focused on the impact of Islamic teachings on the spread of infertility technologies in the Middle East.
Why Study In Vitro Fertilization (IVF)?
According to Dr. Inhorn, the 1994 United Nations International Conference on Population and Development in Cairo first put infertility, as a reproductive health problem, on the global agenda. At any one time, approximately 80 million couples suffer from infertility, averaging around 10 percent. In addition, researchers have found an "infertility belt" in sub-Saharan Africa, where average infertility reaches about 30 percent, primarily due to trace infections in the reproductive system.
Though women are usually blamed for infertility, male factor infertility accounts for more than 50 percent of all cases worldwide. Despite the general unwillingness to address male factor infertility in some regions, researchers have found evidence that male factor infertility may be increasing.
In the developing world, many couples face secondary infertility, which is caused by sexually transmitted infections (like gonorrhea), birth injuries, inadequate post-abortion care, and unsafe medical practices.
IVF in the Middle East
Due to enormous demand, Middle Eastern countries—particularly Lebanon and Israel—have the highest number of IVF clinics per capita. For example, Lebanon has approximately 15 IVF centers and Israel has approximately 24. Egypt, another popular IVF center in the Middle East, has around 50 IVF clinics.
IVF and Sunni Teachings
Since the first successful IVF procedure in 1978, the Islamic religious community has extensively discussed IVF. Egypt issued the first Sunni fatwa regarding IVF in 1980.
The tenets of this fatwa, which holds today, influence IVF practice in both the Sunni and Shi'a Muslim world:
- IVF with the husband's sperm is allowed, and the offspring is the couple's legal child;
- Artificial insemination is allowed as long as the husband's sperm is used;
- Third-party donation (male or female) is not allowed, as this would be considered a form of adultery;
- You can not adopt a child produced by third-party donation, as the child belongs to the mother;
- Posthumous or post-divorce IVF is not allowed;
- Cryo-preservation is allowed, but couples must use the frozen embryos during the marriage;
- Selective reduction is allowed if the mother's health and life are in jeopardy;
- All forms of surrogacy are not allowed; and
- Sperm banks are not allowed.
In the Muslim Middle East, only physicians are allowed to perform IVF treatments and procedures. They can be jailed for conducting illegal practices, but Inhorn did not know of any instances.
A 1997 survey found that Sunni Muslims did not use third-party donation. In Lebanon, couples listed their concerns regarding third-party donation, including the possibility of unintentional incest; confusion of bloodlines and lines of descent; and the possibility of adultery by introducing a third party to the marriage.
IVF and Shi'a Muslim Teachings
Though the 1980 Sunni fatwa has generally held sway in the Shi'a world, a 1999 fatwa issued by Iran's Ayatollah Ali Hussein Khamanei allowed third-party donation, although the children thus produced are considered "adopted." This fatwa opened discussion among Shi'a religious leaders of third-party donation, including such questions as which name does the child take; and is anonymous donation allowed? In addition, the unique Shi'a practice of "muta marriage"—a temporary form of marriage—has allowed men to avoid adultery by marrying the third-party donor, if their first wife gives permission.
Harmful Traditional Practices and Islam in Sudan
Dr. Gruenbaum, who has studied the practice of female genital cutting (FGC) in Sudan since the 1970s, said that people living in Sudan's northern and central provinces are primarily influenced by Sunni Muslim teachings while they belong to Sufi tariqahs. Many people still practice pre-Islamic religious rites, such as river rituals, spirit possessions, and visiting the tombs of saints. In recent years, a stronger conservative Muslim influence has engendered a reexamination of "authentic" Islam, throwing discourse on reproductive health issues and traditional practices like FGC into flux.
Reproductive Health and Health Indicators
Reproductive health indicators in Sudan are among the worst in the world. The infant mortality rate is about 71 per 1000 births, the total fertility rate is around 5.6 births per woman, and child survival rates suffer due to poor nutrition, lack of access to latrines, and lack of access to clean water. The practice of FGC contributes significantly to a high maternal mortality rate. Surveys have found that about 80 percent of girls in north and central Sudan are circumcised.
FGC in Sudan
Sudanese custom favors an extremely invasive form of FGC called pharaonic circumcision. After undergoing FGC, girls and women experience lifelong reproductive health problems as a consequence of the procedure. These long-term consequences include cysts and abscesses, keloid scarring, damage to the urethra resulting in urinary incontinence, painful sexual intercourse, sexual dysfunction, and difficulties with childbirth. Practitioners believe circumcision ensures propriety, virginity, and honor by reducing sexual urges in unmarried women, thus preventing pre-marital sex and maintaining the family honor. Even though the ritual originated in pre-Islamic times, many mistakenly believe the Koran stipulates this practice.
FGC Prevention Campaigns
Dr. Gruenbaum found that some Sudanese communities are trying to combat FGC using different models, such as the Tosten model, which focuses on women's empowerment; training midwives to view FGC as a harmful practice; and encouraging religious and community leaders to advocate against FGC.
Of these three models, Gruenbaum has found that educating religious leaders to be advocates and improving midwifery training have been the most effective ways to educate people about the consequences of pharaonic circumcision. Regional leaders bring together local religious leaders and community elders to discuss FGC's harmful consequences, and reinforce these ideas by using scripture from the Koran to demonstrate that FGC is neither required, nor condoned, by Islam.
Other Reproductive Health Practices
In addition to anti-FGC campaigns, family planning has been a major focus of efforts to improve reproductive health in Sudan. In general, these campaigns have only been successful in promoting birth spacing, not reduced family size. The Sudanese continue to value large families, despite some findings that the desired family size is decreasing in urban areas. A major initiative to increase access to girls' education is a large part of efforts to encourage smaller family size in Sudan.
Drafted by Jennifer Kaczor.