Guardianship in health: discrimination against women in Egypt

In this investigation, we reveal that doctors in both governmental and private hospitals in Egypt are refusing to carry out reproductive related surgery on female patients, without written consent from their husbands or first-degree male relatives, regardless of their health condition, in violation of Egypt’s constitution and laws.

University student "Rawan" says that she has been suffering for about ten years from severe period pain. It seems that doctors told Rawan, who was diagnosed with endometrial hyperplasia [thickening of the lining of the womb], to just live with the pain. This was not because her condition was difficult to treat medically, but because “stopping chronic monthly bleeding” required the approval of her “future” husband.

“Suppose I don’t want to get married. Will I have to go on living with the pain until someone else agrees to carry out the surgery on my body?” She put this painful question, which sum up the reality for Rawan, to a doctor when he told her she needed surgery on her uterus, but that this needed the written consent of her “husband”, in accordance with the regulations and laws in force in Egyptian hospitals; otherwise the doctor would be laying himself open to trial and a prison sentence.

The 23-year-old Rawan says that, as her condition has steadily worsened, strong painkillers and other medications are no longer effective. Living in Sharqia Governorate, she has been to a number of hospitals (even private one), seeking endometrial curettage to rid her of the pain. But she was met with the same response.

The effect on Rawan’s academic future has only added to her suffering: “My whole life is at a standstill. I can’t describe how difficult things are. I was forced to walk out of exams, so in the end I only got half the grade, even though I was capable of completing the entire exam. But the severity of the pain meant I just couldn’t go on."

Rawan aims to pursue higher level studies after university, but she fears she will eventually be forced into a "sham marriage", since all her attempts to have surgery have failed. The last time she submitted a written approval from her father, but to no avail.

Even written consent from Rawan’s guardian, in this case her father, was not enough to allow surgery to end her suffering. This raises a whole question about what it really means to be a “guardian”.

The former chairman of the Investigation and Ethics Committee of the Egyptian Medical Syndicate, Dr Tarek Kamel, thinks the doctor was right to refuse to perform uterine curettage on a virgin. This is because the doctor is the one responsible for assessing the patient’s condition and deciding whether or not she needs surgery, especially since this could lead to the breaking of the hymen.

Dr Kamel explains that the doctor may decide to operate on a virgin, even if this results in the loss of her virginity, if her condition requires it. The doctor will then produce a certificate stating that the loss of virginity occurred with the approval of the guardian. However, if the condition does not require urgent surgical intervention, he cannot operate. Otherwise, he risks being legally accountable to the girl’s “future” husband for having broken the hymen without there being any “urgent” medical need.

Dr Kamel argues that for the doctor to obtain the husband’s consent before performing any surgery on a woman’s reproductive system is in line with the professional ethical regulations issued by Minister of Health under Resolution No. 238 of 2003. These regulations remain in force now and apply to all doctors working in Egypt, whether in public or private hospitals.

However some of the items in these “professional ethical regulations” and in those applied in hospitals in Egypt, conflict with the articles of the constitution and the law.

In a bid to prove that female patients face discrimination in the provision of health services in both public and private hospitals in Egypt, the reporter gave the following questionnaire to a random sample of 50 medical staff working in obstetrics and gynaecology in Egyptian hospitals:

These results show that 66 percent of those included in the questionnaire said that they would not operate on the patient if she was married and had not obtained her husband’s consent. Nor would they do so, if she was a single woman, whether an adult or a minor, without the consent of her guardian, or if she was legally incompetent without the guardian’s consent. At the same time, 70 percent of those who answered the questionnaire said they would refuse to carry out any operation on a female patient’s uterus and ovaries without the consent of her husband, or father, or guardian.

Of those surveyed, 98 percent said they would refuse to perform any gynaecological surgery that would entail possible loss of virginity without a guardian’s consent. And 86 percent said that the regulations of the hospitals where they worked made it obligatory to obtain approval from the husband, father, or a first-degree male relative, before performing surgery on the reproductive system (uterus, ovary, fallopian tube, or vagina, etc.)

Commenting on the results of this questionnaire, the former president of the Cairo Court of Appeal, Counsellor Ramadan Gamal, argued that any surgery - whether performed on men or women, and on any part of the body – required only the consent of the patient themselves, as long as they were adult, and their condition allowed it. He emphasised that it was illegal for doctors to refuse to perform surgery on a woman without her husband’s consent.

He said: “If we suppose that a woman had a tumour in the uterus that could kill her and the uterus needed to be removed along with the tumour, then consent in this case must be from the patient. If the husband refuses the operation, this cannot stop it from being carried out because saving the patient’s life is more important than the husband’s consent.”

There are a total of 1,809 hospitals in Egypt - 664 public/government hospitals and 1,145 in the private sector - according to the latest healthcare bulletin from the Central Agency for Public Mobilization and Statistics )CAPMAS) in June 2023. There are also about 115 hospitals and medical centres at public universities.

According to the Egyptian Medical Syndicate, there are 228,862 doctors registered with the syndicate and licensed to practice, excluding those who have retired, as of March 2022 - an increase of 16,027.

The number of doctors working in the public/government sector stands at approximately 93,536 - an estimated 40.8 percent of all doctors licensed to practice and under retirement age.

A joint study that came out in 2019 – involving the Supreme Council of Universities, the secretariats of university hospitals, the technical office of the Ministry of Health, and a group of experts specialising in the medical profession, and the medical labour market – found that there were about 6,749 obstetricians and gynaecologists in Egypt.

The number of general surgeons meanwhile stood at 3,034 and the number of urologists 833.

“In hospital, whether you are married or not, you have no control over this part of your body,” says “Perry”. She describes how she suffered from an ovarian cyst, which doctors refused to remove without the approval of one of her male relatives.

“Perry Ahmed”, who lives in Cairo Governorate, decided on having a surgery to end her suffering and went to Rabaa El Adaweya Medical Center, with her older sister. She says that as soon as the doctor found out she was single, he asked her for written consent from one of her first-degree relatives, after she had told him her father had died. Perry says she was over 21 at the time, but the doctor insisted on the need for consent. Perry says: “I asked my uncles to give written consent, but they refused point blank, and told me to wait until I got married.”

Despite it being a “straightforward operation,” the doctor insisted on written consent on the grounds that some emergency could occur in the uterus, ovaries, or hymen during the removal of the sebaceous cyst, which measured around six centimetres, according to Perry.

Perry took birth control pills for three years, on the recommendation of her gynaecologist aunt, who assured her that the pills would cause the cyst to shrivel up and come out with her menstrual blood. But that did not happen and in the end the cyst burst, almost causing sepsis.

The former chairman of the Investigation Committee of the Egyptian Medical Syndicate, Dr Tarek Kamel, thinks that obtaining written consent from the husband - or from the guardian if the woman is single - prior to surgery on a woman’s reproductive system is justified on the grounds that the husband will suffer harm if his wife is unable to have children after the operation – an outcome that would be counter to his wishes.

The reporter of this investigation was struck by the response of Dr Kamel, that the reason for requiring a husband’s written consent before performing any surgical operation on his wife’s reproductive system was possible harm caused to the other party, i.e. the husband.

By the same logic, the principle of avoiding “harm to the other party” should apply if the wife was the one “harmed” by a surgical operation performed on her husband.

This reporter therefore decided to conduct a second questionnaire, comprising a random sample of 30 medical staff specializing in general surgery and male conditions. We asked the following question:

You have a male patient in the operating theatre who need non-urgent surgery/medical intervention on his reproductive and urinary system (penis, testicles, prostate, etc.). In which of the following situations would you not be carrying out the treatment?

The results showed that 66.7 percent of the general surgeons and specialists in male conditions in the survey thought that a man did not need his wife’s consent before undergoing emergency surgery on the reproductive and urinary system (penis, testicles, prostate, etc.), even if this might affect his potency or fertility. And 76.7 percent of those surveyed said that internal hospital regulations did not stipulate that a wife give consent to her husband undergoing such surgery.

Dr Eslam Eid, a urologist at the Minya Nephrology and Urology University Hospital, says that the hospital requires the wife to be “informed” of any surgery on her husband that could affect his sexual potency. But it does not ask for her written consent to operate on her husband, as her approval is sufficient. But, while Dr Eid says the wife should be informed, though her consent is not a condition for surgery to be performed on her husband’s reproductive system, many other doctors deny even the need to “inform the wife.”

Commenting on the results of the survey - which showed that the principle of “the other partner’s interest” is not applied if it is the wife’s interest that could be harmed - the head of the Egyptian Union of Human Rights, Counsellor Naguib Gibrael, declared that Egypt remains “a patriarchal society with a Bedouin tribal culture that permeates to the core of the Egyptian people.” He calls on human rights associations and the National Council for Women to act to change this culture.

“This discrimination between men and women contradicts Article 53 of the constitution, which stipulates that citizens are equal before the law, and have equal rights, freedoms, and public duties, with no discrimination between them on the basis of religion, creed, gender, or origin,” says Gibrael.

Even when it comes to operations to remove tumours, the same restrictions are imposed on women, regardless of age or marital status, and despite the health risks they face if surgery is delayed.

“Loma” developed a fibroma in her uterus and when she went to the Cairo University Student Hospital, the doctors refused to operate to remove the tumour without written consent from her guardian.

“Before doing the operation, the doctors at the hospital asked me for written consent from one of my first-degree male relatives, in case there were complications or I died,” Loma says.

The hospital administration refused to let her mother give approval, and insisted on written consent from one of her first-degree male relatives – either her father, uncle, or her brother, even though Loma was over 21 at the time.

Chairman of the Health Committee of the House of Representatives and former Minister of Health Dr Ashraf Hatem says that doctors, by insisting on such consent, are just protecting themselves: “If a woman has a hysterectomy and afterwards says, ‘I didn’t know they would do that,’ the doctor will be imprisoned. The professional regulations stipulate that the patient, or whoever is responsible for them, must give informed consent. Even though the Medical Liability Law prevents the doctor from being imprisoned, he is liable to be fined up to a million pounds."

Sara Elshafei, director of the Al-Nasih project - which aims to make citizens aware of their rights to healthcare, and to help them access these services - says that there is no obvious law requiring women or girls to obtain the consent of their husbands, or guardians, before undergoing uterine surgery. It is just a practice that has become established in hospitals.

“It is the custom in Egyptian hospitals that such approval must be obtained, and, over time, this custom has become the rule in health institutions. The doctor simply abides by the system of the hospital in which he is working,” Elshafei says.

She argues that the fear doctors have for themselves is the reason these “unconstitutional” procedures exist. Because there are no laws to protect doctors, and the Medical Liability Law is currently making little progress thorough parliament, each medical facility is looking for its own system of protection.

“According to Egyptian law, a doctor working in a public hospital is a public employee performing a public service. This service is defined in accordance with the regulations governing the activity of the health facility managed by the hospital. The relationship between the doctor and the patient is therefore governed by the laws and regulations in force at the hospital,” according to The Civil Responsibility of Doctors and Surgeons, a book written by the former president of the Cairo Court of Appeal, Counsellor Ramadan Gamal Kamel.

Eman Mahmoud (not her real name), who lives in the Ain Shams area of Cairo Governorate, was diagnosed with breast cancer. When she had completed a course of hormonal therapy, she developed uterine hyperplasia. The resulting haemorrhaging required curettage treatment and a biopsy to ensure that cancer had not spread to the uterus.

“Eman’s” three sons accompanied her to Ain Shams University’s El-Demerdash Hospital, because her husband was unwilling to go with her for such procedures, from what she said. But the doctor refused to carry out the surgery without her husband coming to give his written consent.

“Iman” says: “My children got into a heated argument with the doctor, who insisted on my husband being there to give written consent. They were obliged to tell the doctor that their father was traveling abroad, after which he finally agreed to perform the surgery, once my 23-year-old had signed the consent form.”

“If I hadn’t had a man with me at the time, they wouldn’t have done the operation,” Eman adds in amazement.

According to Chairman of the House of Representatives Health Committee and former Minister of Health Dr Ashraf Hatem, in the event of a medical emergency such as a haemorrhage needing surgical intervention, the consent of the husband or guardian is not required. “Eman” says this principle was not applied in her case.

The former president of the Cairo Court of Appeal, Ramadan Gamal, maintains that any surgical intervention, either for men or women, and irrespective of the part of the body involved, requires the consent only of the patient, as long as they are adult and their condition permits surgery to go ahead. He emphasises that it is illegal for doctors to refuse to carry out surgery on a women without the consent of the husband.

The director of The Women's Center for Guidance and Legal Awareness, Reda Eldanbouki, argues that there is no such concept - either in the Personal Status Law, or the Egyptian Constitution - as “the husband’s permission being required for surgery to be carried out on his wife’s uterus or ovaries,” if such treatment is needed for medical or other reasons. The constitution says that “A woman’s body is her own property, and over which she has complete freedom, and no one can exert guardianship over it,” according to Eldanbouki.

She points out that what is happening in Egyptian hospitals is that doctors are deciding for themselves “to avoid falling foul of the law,” because they think that the husband has a right to guardianship over his wife’s body. In fact, argues Eldanbouki, the husband has no right to seek legal redress on this basis. The only person who would have such a legal right would be the guardian of a female minor who had undergone unnecessary surgery without the guardian’s consent, and if the surgery had posed a risk to the minor.

The head of the Cairo division of the Egyptian Medical Syndicate, Dr Sherine Ghaleb, says that carrying out “abortion on medical grounds” is the only case in which the husband’s prior consent must be obtained, according to Egyptian law. She points out that a wife or any woman over the age of 21, can give consent to have any other medical procedure carried out on her uterus, and that it would be illegal to demand approval of her guardian.

Regarding the possibility of holding to account hospitals that refuse to operate on women without their husbands’ consent, Dr Ghaleb says: “A woman cannot take any legal action against the hospital if her condition is not an emergency. The hospital also is not obliged to accept her for treatment, and nor can she prove it (that the hospital refused her treatment). The hospital can claim that she is just causing problems.”

Because doctors base the requirement to obtain a guardian’s written consent before they will operate on a woman’s reproductive system, on the professional ethical code issued under Resolution No. 238 of 2003 - and which remains in force - we turned for comment to the Egyptian Medical Syndicate (EMS), which is responsible for issuing the rules regulating the work of doctors.

The treasurer of the EMS, Dr Abu Bakr Al-Qadi, denied that professional regulations for doctors in Egypt discriminate between women and men. He attributed the refusal of doctors to perform reproductive surgery on female patients without the consent of their husbands or guardians to the difficult nature, the high number, and the inherent risks of such operations. He argued that the permission of the husband or guardian was integral to the principle of “informed consent,” which is one applied worldwide.

The EMS treasurer also denied that surgery on the male reproductive system had any effect on fertility, and in fact enhanced male fertility, quoting as an example surgery to treat a varicocele.

Dr Al-Qadi argued that “it’s the nature of Egyptian society that drives the doctor to protect himself from the patient’s family. If any surgery is performed on a woman’s reproductive system, it’s possible that if the doctor doesn’t first get the husband’s consent, the husband will sue the doctor. By contrast, a wife won’t sue a doctor, because she won’t have been aware her husband was having surgery on his reproductive system.”

This reporter asked obstetrician and gynaecologist Dr Ahmed Abdelsadek, who runs a medical centre in Menoufia Governorate, to respond to the cases documented in this investigation, which show that private hospitals require written consent from a woman’s guardian before performing any surgery on her uterus or ovaries – a breach of the law, which rules out discrimination on the basis of gender in the provision of health care. Dr Abdelsadek justified the refusal of private medical centres to operate on female patients without the permission of their husband or guardian on the grounds that the doctor needed to be protected, as he put it, from the patient and their family.

“The law requires me to inform the husband of any surgical procedure to be performed on his wife’s reproductive system. That’s an inherent right of the husband because such operations may affect the woman’s fertility. No surgery carried out on a man will affect his fertility, however, except for sterilisation. And no man would think of having that done. So, he does not need to get his wife’s consent,” says Dr Abdelsadek.

Dr Abdelsadek said that before any patient is admitted to his medical centre for surgery, she is given an admission ticket, which shows all the details of her case. She and her male guardian must consent, and he can then be a witness that she is aware of the medical procedure and its possible risks. This, he argues, protects the doctor and the medical centre, and also the patient from unscrupulous doctors.

But the response of the Egyptian Ministry of Health to the findings of this investigation was striking. Official ministry spokesman Dr Hossam Abdel Ghaffar said no official document or regulation had been issued by the ministry regarding these procedures. “There are no internal regulations specific to individual hospitals. All hospitals affiliated with the Egyptian Ministry of Health are subject to the rulings of the minister of health. There is no official document showing that there are any regulations prohibiting women from undergoing surgery without their husband’s consent.”

The ministry spokesman added: “All that people say about Egyptian hospitals refusing to perform operations on women without their husband’s consent, and about discrimination between women and men in healthcare provision, is just hearsay.”

Even when the official health ministry spokesman was confronted with the results of this investigation - based on two questionnaires and the testimonies of both patients and doctors, admitting that discrimination between men and women exists in the provision of health services in both public/government and private hospitals – he still categorically denied that hospitals require the consent of guardians before performing any uterine or ovarian surgery.

This investigation was completed with support from ARIJ