This article seeks to establish the connection—via shareddiscourse—between Incels and mainstream pornography. With aninterdisciplinary approach which involves a Corpus Linguisticsanalysis of Reddit forum data, research into digital behaviors, and afeminist critique, this article focuses on the commonalities betweenthe language of pornography and that of Incels. In doing so, itdemonstrates how both pornography and Incels are differentmanifestations of the same misogyny. The findings of this studyhighlight the normalization of violence against women (VAW), whichcontinues to be endemic in society, enabled and exacerbated bycontemporary technologies. We start by comparing the language used by Incels onthe news aggregator site Reddit with the language of a larger sample ofReddit threads. The linguistic analysis is carried out using a bottom-upmixed-method approach which does not impose predetermined categories ontoour data but, instead, allows themes and patterns to arise gradually fromour data (This article seeks to establish the connection—via shared discourse—betweenthose who identify as involuntary celibates online (henceforth Incels) andmainstream pornography. Using an interdisciplinary approach involvinglinguistic analysis of Reddit forum data—more precisely the r/incelsSubreddit—informed by research into digital behaviors and feminist analysis,we demonstrate how both mainstream pornography and Incels are differentmanifestations of the same deep-rooted misogyny, enabled and exacerbated bycontemporary technologies. It is not the aim of this article to establish acausal link between the watching of pornography and negative behavioralchange, nor is it our intention to cast judgments on people’s sexualpractices. We want to move beyond a simplistic pro-porn or anti-porndichotomy that discourages debate, and instead provideour data . Thus, aIncels have recently generated large amounts of interest, both inside andoutside academia  dueto cPornHub.com feature among the top 30 websites in theUnited Kingdom and is more popular than the U.K. government website  VAW, including mainstream pornography. In fact, weargue that, like offline violence, online abuse also happens on a continuum;this spectrum, however, does not simply range from unpleasant, sporadic,nonthreatening (direct or indirect) messages to frequent, highlythreatening, hateful content , p. 1469cunt, bitch, whore, slut continue to be some ofthe most commonly used forms of language abuse against women in pornographicvideos . Pornography,therefore, is both a perpetuating and innovative practice of misogyny.The link between mainstream heterosexual pornography (the most popular andwidespread type of pornography and the one that is being discussed here) and(online) VAW is not necessarily an obvious one. In fact, theconceptualization of pornography as generally and inherently misogynistic isnot without criticism . Admittecvideos , pornogrcvideos —of new treal. Yet, “fantasy expresses ideology” , an open data initiative thatprovides access to social media companies such as Twitter and Reddit. TheIncelCorpus contains 13,783,206 words and includes posts published onr/incels between June 2016 and March 2017. The RedditCorpus was collectedextracting posts and comments from Reddit using the Reddit API. Thetimeframe in this corpus varies in each Subreddit, since with the Reddit APIonly a maximum of 10 pages per Subreddit can be retrieved; therefore, timescales depend on how quickly (or slowly) users post new threads to theSubreddit. This corpus contains a collection of 688 Subreddits on disparatetopics, amounting to 89,386 posts, and ca. 55 million words.This study is based on a comparison between two datasets: a study corpus(henceforth IncelCorpus) and a reference corpus (henceforth RedditCorpus).The IncelCorpus was collected from Pushshift.io . Theanalysis was conducted using the corpus analysis tool SketchEngine(http://sketchengine.co.uk/).The RedditCorpus was used as a normative corpus  that repThe comparison between the RedditCorpus and the IncelCorpus generated a groupof keywords, that is, words that are “statistically significantly morefrequent” , p. 27 iThis research took into account the ethical implications of using onlineuser-generated content. Considering that the forum thread was no longeravailable in the public domain, accessing the forum data without attemptingto contact the community on Reddit was the most ethical course of action, asthe covert approach enabled research to be undertaken without risk or harmto the community . No persKeywords offer an indication of the main topics discussed on r/incels, comparedto Reddit in general. As shown in Stacy from the list, but presence ofChad), together with the frequent use of the pluralwomen, suggests that women tend to be discussed as ahomogeneous group, without much distinction.For reasons of space, here the focus will be mostly on the “people” and“relationship” groups. The terms in the latter group suggest a strongemphasis on both the sexual and dating sphere, while those in the formerreflect the social hierarchy of Incels, with CHAD, INCEL, but also NORMIE,that is, ordinary people who do not belong to any of the other groups.Because of their uniqueness, terms such as CHAD and INCEL would be expectedto be more salient than a generic term like WOMAN.However, WOMAN appearsmore frequently and widely than INCEL , showing that women are a focal point of discussion on r/incels.The absence of a sub-categorization of women equivalent to that of men . Due to the public, and,therefore, visible nature of the forum, these posts can also serve asa gatekeeping practice for anyone intending to challenge Incels’ideology.Many users on r/incels discuss what ale gaze onto thewomen isobese (sluthate.com).The top 20% of men get the top 80% of the women, and the bottom80% of men fight like dogs over the remaining 20% of women. Thisis why in a sexually free society, even the ugliest mostdeformed obese women can get males of averageattractivenessThere are many males that haveliterally zero options. [There is strong demand for even theugliest of women.] . While the discussion of bots isbeyond the scope of this article, it is worth considering the role ofautomatic messages triggered by specific words in reinforcing onlinemisogyny . The most commonactivities that women are presented as “not doing”  are two mental processes: LIKE and WANT(Because the majority of modern women don’t want a lovingboyfriend). These conjectures often revolve around thetype of men that women are supposedly attracted to , or around women’s sexuality,including the suggestion that women enjoy abusive relationships andaggressive sex.WOMAN co-occurs often as grammatical subject of BE, DO, and WANT. Asshown in and WANT. This meMost women don’t like it soft: they like it rough,hard, and deep). In some cases, the strong presence ofnegation, combined with the collectivization of women, signalsresistant discourse . Yet, the very need for this resistance isindicative of underlying presuppositions among Incels about women andwhat they “really” want. Furthermore, when Incels discuss what womenlike and want, they indicatethat it is specifically Westernmodern women(Western is the most common attribute of womenwant)—in other words, those they associate with feminism—whoenjoy “deviant” practices, as shown by the most frequent clusters withwomen want: women only want or womenonly truly want .Like in pornography, where the tendency is for female performers not tosay “no,” but to show pleasure when subjected to physical aggression,Incels believe that aggression and female pleasure are connected appears to be a site of constant(re)production of ways to linguistically degrade and objectify women.For example, Incels refer to women as cumdump,cumrags, or twatrags—a term that indicatesan old garment used to clean up bodily fluids following ejaculation.Another way in which Incels use sex to linguistically dehumanize womenis through verbs that are normally applied to things such as soil orroads . The verb plow here, inaddition to normally being applied to inanimate objects, also suggestsviolence . The implicationis not only that women are objects to be treated aggressively but alsothat the penis is a powerful weapon to be used against them. Thisdiscussion of women as objects used for sex or as receptacles of men’spenises and semen  recallssome of the most popular images of mainstream pornography, like, forexample, “bukkake,” in which any number of men ejaculate, often at thesame time, onto a woman’s body, face, hair, eyes, ears, or mouth, orthe “money shot” . Arguably, the very need to state theobvious, that is, that women are people, is anintertextual reference to the common presupposition among Incels thatwomen are something else . Thedehumanization of women  is part and parcel of“rape culture”  or animals, as shown by metaphors suchas culture”  and a mamen can attract women. In the Corpus ofContemporary American English—https://www.english-corpora.org/coca/—ATTRACT isnormally used in the context of entities that can bring financialadvantage , or to referto how  animals pull their  mates toward themselves, or to talk about what one isattracted to . However, Incels do not use ATTRACT todiscuss what they are attracted to, but to talk about what they canattract to themselves , in a way that resembles theliteral meaning of the verb . Incels position both themselves and women as objects,but while they are the active force in this relationship, women arethe passive element that—in spite of any potential resistance—getspulled toward Incels, as shown in this comment: You’ll find alot more on how to attract women and improve self-esteem here/r/seduction. This reinforces the impression that whatIncels are really concerned with is not women’s desires, but their ownself-esteem; for them, attracting is a utilitarian practice in whichwomen are vehicles to boost their ego.Further insight into how women are dehumanized on r/incels is provided bythe analysis of verbs that have WOMEN as grammatical object. Forinstance, ATTRACT occurs most frequently in discussions about ways inwhich inability, rather than theirunwillingness, to do so . Women are once again positioned asgatekeepers of sex and, consequently, of Incels’ happiness. Incels, incontrast, are the victims: constantly starved for sex and fightingother men to gain access to women’s bodies that are scarcely available(to Incels).This sense of entitlement to and understanding of women’s bodies asobjects (that must be obtained) also appears in the ways in whichFORCE is used. While many users do not explicitly encourage forcingwomen to have sex or be in relationships with them, the discussion ofthe obvious suggests, again, that this is indeed a possibility forIncels. In fact, not forcing women is often linked to theirforcing women” from a matter ofwomen’s rights to a matter of Incels’ rights, as articulated in thispost: Arguably the fact that I do not have the freedom toforce a woman to have sex with me is subjugation too.To address this “injustice,” Incels suggest solutions that, whileexploitative for women, they consider fair for themselves . Lack of access to women’s bodiesis perceived by Incels as a denial of a “basic right,” something thatChads can effortlessly obtain because “women always give men sex”; itis only Incels that they reject.Establishing their victimhood  is key tAs suggested by Incels have every right to hatewomen. If not a single one ever showed interest in you [. . .]it means that they dislike you and you have every right to hatepeople who dislike you. Clearly, it is their sense ofinability to control women’s freedom that leads to their hatred:I hate ugly women so fucking much. They repulse me andyet they can fuck men way out of there league while they wouldsay no to me. It is particularly feminists who areblamed. As one user put it: My inceldom stems from the factthat women have been brainwashed by society, the feminazis. [. ..] Such is the fate of any woman that isn’t subjugated and toldwhat to do.As shown in the following post, Incels’ perception of themselves asvictims, or the only group that is not having sex, springs from thisvery sense of entitlement to women’s bodies and is used to explain andlegitimize their hatred: hate and women isall. Incels seem to stress the fact that theydo not hate all women, just some of them. The womenthey hate are those who refuse to accept their world view, women whosay “no,” women who express their sexual freedom in a way that isperceived as disadvantageous for Incels but advantageous for other menand for women themselves, or in I dont hate indianwomen as a whole. Only those disrespectful stuck up bitches; Idon’t hate all women but modern Western women; I don’t hatewomen just hate feminists and sluts. Clearly, forIncels, feminism is predominantly linked to sexual freedom. For them,feminism is the reason why women are free to choose the “quantity andquality” of their sexual partners, as well as the reason why theirdesire to control women—like other men do—is constantly frustrated;therefore, Incels want a return to “traditional” values  as a way to exert the control over womenthey feel entitled to in view of women’s subordination to all men, Incels included  derogatory language than woman. In fact,based on SketchEngine Thesaurus tool, which shows terms used insimilar ways in a corpus, feminist is similar towords such as whore, bitch, cuck, slut, idiot, cunt,while woman is more similar to words likepeople, man, girl, guy, female, person. Thetype of abusive language that one may expect to find on the forum doesnot target women in general; it tends to be specifically directedtoward feminists, who receive insults for their “promiscuity.”Incels often differentiate between the women that they hate and the onesthat they do not hate. For instance, one of the most common collocatesof included . The spethem, women who sleep with several men but say“no” to Incels. It is these women who receive most online abuse abuse , arguablhumangivers  show that this category of men isoverwhelmingly sexualized and associated with sexual body parts,specifically the penis. The concordance analysis of CHAD and itscollocates cock and Thundercockshowed the traits that Incels ascribe to Chads. They are presented asstatic body parts simply waiting to have sex , and always available . Asstereotypical men, Chads are in constant need of sex and, with theirperennial sex-craving, devaluation of emotion , anti-feminine attitudes which do not stop themfrom finding  available women , dominance and aggression , Chads epitomize thearchetype of hyper-masculinity  ordescriptions of aggressive sexual practices such as anal sex . Here women are again presented asnever satisfied or hurt, and in constant need for Chad’scock .The latter example, in particular, reiterates the metaphor of women asanimals .The most frequent nouns modified by CHAD  called “roughsex gone wrong” . The dominance of Chads—embodied bytheir “success” with women—is presented as an accepted fact andinevitable reality and, as such, less enraging than women’s(“deviant”) “promiscuity.” While Incels feel they could tolerateChads’ “natural superiority” in terms of “sexual conquest,” theycannot tolerate this in women because of their “naturally inferior”status, not only to Chads  by denying Incels what they give to  alpha men . Incels seem to hate women becausethey remind them of their own “weakness” compared to other men. At thesame time, due to the acceptance of Chads’ “superiority” and awarenessof Incels’ “inferiority,” and in line with men’s general reluctance“to tell other men what they can and cannot have sexual access to” male sexuality is seen as punishing,revengeful, and violent, but also superior and, therefore, desirablefor both women and Incels , and what seems to be particularly abhorrentfor Incels is the idea of having a female sexual partner who hasalready had (numerous) sexual partners . Forexample, as shown in the following example, they use the wordcuck—a man who is “weak” and has “failed”because he has accepted to start a  relationship with a womandespite his awareness that she had sexual intercourse with a Chad—aspotentially the worst abuse for men: Anytime you start likinga female, imagine her sucking the cum out Chad’s cock. [. . .]Imagine all the Chad’s cocks that have been in her hole. [. . .]imagine having to touch all the AIDS infested Chad cum residueson her. If you’re into that shit, you are a cuck and should killyourself. Incidentally, cuck alsorefers to any man whose woman is having sex with another  male,and, as very often this alpha male is Black, the word has a clearracialized dimension too. This theme is very common in pornography,where “cuckhold porn”—which typically depicts a White man “forced” towatch his White wife have sex with a Black man—has become a popularsubgenre and has provided the “framing narrative” for groups in themanosphere to “express masculinist and racist ideologies”  andreproach of feminism for causing a loss of women’s “purity” . Incels’ aversion for women’ssexual freedom is also evidenced in their in-group slang, for example,with the word roastie, which, according to UrbanDictionary, describes sexually “promiscuous” women, in reference totheir labia resembling “roast beef” because of frequent sexualintercourse . Similarly, Chads resemble the hypersexualizedmen of mainstream pornography, particularly Black men who, accordingto mudshark . Like roastie andcuck, these specific terms suggest thestandardization of these concepts for Incels.The men that Incels perceive as being Chads and the women that have sexwith them resemble, in many ways, the men and women in pornography.For example, Incels’ linguistic abuse of women through sexualdegradation betrays hyperbolic views about their sexuality that arealso common in gonzo pornography, like the obsession with women’s“promiscuity” or the idea that women “beg for sex”  mirrors the aggressiveness ofsex in mainstream pornography, as further shown by the discoursesurrounding the verb fuck further elucidates howIncels conceptualize sex as a form of punishment for women, not simplyas imposition, but as an actual form of physical harm and degradation.This is clearly articulated in the following comments:You don’t even know how hard you could fuck her;that’s why you fuck her again and don’t stop untilshe miscarries; Thoart fuck her. I want her make uprunning down her face. Ill probably cum in her a fewtimes; I think she was into you. You should havewhipped out your dick and fucked her; You can justfuck her and degrade and mistreat her so she doesn’tget under the impression you respect her in any way;I’d definitely fuck her in the ass and then make hersuck my shit-covered dick.The discourse surrounding would, should, or coulddo, rather than what they did orare doing. In some cases, the tense isimperative (throat fuck her), suggesting a male bondcreated through encouragement and peer support for other men to beaggressive with women . Rapeapology appears on r/incels as part of a broader discussion of sex aspower, as sex is the weapon used to inflict the abuse that women both“deserve” and “enjoy.” They describe scenes of slapping, anal sex,ejaculating on women’s faces, and multiple and aggressive penetrationof different orifices, including from anus to mouth withoutwashing.These examples confirm Incels’ desire to replicate or imitate what isseen as Chads’ alpha male punitive behavior with women, as well astheir sense that Incels will never be able to do the same. Yet, likeabove, what angers Incels the most is women’s freedom and rejection ofIncels. As one user put it: nd most popular site in the United Statesand one of the most prominent results of Google searches for worddefinitions  as a weapon to inflict these andexpress their hate. On r/incels the fact that hatred is the motivationbehind the abuse is explicit. In pornography, this motive is often covertand, consequently, easier to justify. However, it sometimes filters through.For example, according to Bill Margold—porn actor and producer—“the mostviolent we can get is the cum shot in the face. Men get off behind that,because they get even with the women they can’t have” , p. xxvisexual losers. They thought collegewould present easy opportunities for sex, assume that other guys are‘getting it’, and conclude that something must be amiss withthem or the women they are trying to hook up with. They worry they arenot good-looking enough, smooth enough, or masculineenough to score, and as the porn view of the world suggests thatwomen are constantly available, these men arebewildered by rejection. They often express deep shameabout their inability to hook up, and this shame morphs into angerat their female peers who, unlike porn women, have the word‘no’ in their vocabulary” (emphasis added). Dines’s words describing thesemen worryingly echo the justification that Elliot Rodger gave for hiskilling spree and the discursive patterns found in the analysis ofr/incels.Similarly, men who watch pornography, as shown by Studying the discourse of r/incels allowed us to unveil the ideological contextthat underpins this community, to identify how assumptions that underpin“extreme” discourse are also present within the mainstream majority, and todemonstrate how these flow into each other in a mutual process of productionand reproduction of language, behaviors, and attitudes. While perhaps lesspervasive and persistent than other forms of misogyny, Incels’ sexism is oneof the faces of societal misogyny based on biological determinism and abinary gender distinction. It is rooted in the same misogyny of ordinarysexist jokes, assumptions, everyday division of labor, and mediarepresentations, including mainstream pornography and, for this reason,should not be conceptualized as exceptional or unusual. By continuing tofocus on what makes the community “extreme,” the risk is ignoring what makesit similar to the mainstream, thus contributing to the belief, often spreadby mainstream media, that misogyny is only a problem of specific individualsand their specific circumstances , 2020, rThe issue, therefore, is a broader one and a cultural one; neither Incelideology nor mainstream pornography should be problematized separately orinsulated from discussions of women’s equality, because these practices arenot detached from other forms of misogyny but are an extension of these andsymptoms of structural misogyny. Neither pornography nor Incels createdmisogyny, but misogyny underlies and correlates both practices, which,therefore, should be understood as part of a “networked misogyny”  that, seTaken separately, pornography presents itself as fiction and, therefore,harmless, but highlighting its similarities with misogynistic hate speechchallenges its legitimation. It is therefore necessary to question whetherlabels that create and reinforce this division (like “extreme” or“dangerous”) are appropriate for and can justifiably be applied to morereproached practices if they are not also ascribed to other practices that,while normalized because routine, still draw on the same ideologicalcontext. In fact, pornography, like Incels’ misogyny, can hurt individuals,“just not as individuals in a one-at-a-time sense, but as members of thegroup ‘women’” , p. 338.Whether more or less visible, the damaging effects of both pornography andIncels’ misogyny can be lasting because of the longevity and visibility thatthe internet grants violent narratives and abusive texts . Traces


In a context where snus is a legal product, its advertising is prohibited and its prevalence of use has been on the rise among adolescents and young adults, the aim of this article is to identify the extent of snus coverage in Norwegian newspapers and the themes and values communicated about snus therein from 2002 to 2011.All major Norwegian newspapers were scanned for articles with “snus” (and relevant connectors) in headings, ingresses, and/or pictures/captions as search criteria. Using the Retriever media monitoring service as a database, the search returned 943 unique articles, which were subjected to quantitative content analysis.The number of articles per year increases over the period, while their average length decreases slightly. Thematically, the greatest attention is on the extent of “snus use” (occurring in 52.7% of the articles), and then more equally divided between “tobacco policy” (24.5%), “economy/markets” (29.1%), and “health” (28.7%). A total of 48.6% of the articles are “neutral/mixed” in respect of framing, 28.1% are “negative,” and only 20.7% are “positive” in tone. Articles about tobacco policy are more often negative, while articles on economic factors are more often positive. Articles on health are usually negatively focused, or neutral/mixed.The slight predominance of negative and/or neutral/mixed articles indicates that the newspaper coverage does not glamorize the snus product. However, the sheer amount of (and growth in) articles over time, as well as positive articles available for selective exposure and perception, may nevertheless have contributed to a normalization of snus use.Little is known about media coverage of smokeless tobacco and whether editorial mass media glamorize or criticize its use. This study shows that the extent of snus coverage in Norwegian newspapers has increased over time, but also that the framing of Norwegian newspaper coverage of snus has mainly been neutral/mixed or negative toward snus and its use. There is currently considerable controversy surrounding the proposal to accept snus as a harm-reducing measure.Swedish snus is a form of smokeless tobacco legal in only a few countries, including Sweden, Norway, and the United States. Swedish snus differs from other types of snuff and chewing tobacco by following the GothiaTek standard, which means a significantly lower content of carcinogenic nitrosamines.7 Sweden went through a similar development to Norway, but there snus use among young people started rising as far back as the 1980s. In Finland, there was an increase in the period from 1981 to 2003, despite a total ban on snus sales coming into force in 1995.8 The EU banned snus in 1992, but in the UK recent initiatives have argued for a repeal of the snus ban.9 Switzerland’s ban on snus was repealed in the summer of 2019. The Norwegian experience illustrates what may happen if snus is allowed to compete with cigarettes in markets where advertising of the product is not permitted.The Norwegian (and Swedish) situation is internationally unique in that snus is not only legal, but its use has increased despite a ban on advertising in 1975  and a tobacco display ban in 2010. Simultaneously, smoking prevalence has decreased in both countries. This creates a somewhat different communicative context for tobacco harm reduction compared to most countries . The prevalence of snus use in Norway doubled from 6.1% in 2002 to 12.6% in 2012, mainly due to an increase among adolescents and young adults, before it flattened out somewhat and then increased again from 2015.10 This applies both to the governors and the governed. Stakeholders in tobacco control take to the news media to gain currency for their initiatives and objectives, and to achieve credibility and legitimacy for their proposals.12 Similarly, the snus industry may recognize the value of getting their products featured in the media, as they are at the mercy of means other than traditional advertising for creating a buzz about their products.In a context where snus is legal but product advertising is banned, general media coverage of snus becomes an important channel of information, as social definitions of the pros and cons of use, the product’s health risks, and how it should be regulated, will largely depend on mass-mediated communication.13 The agenda-setting function of the media refers to its power to decide what the public is talking about at any given time and, specifically, how it introduces tobacco issues to the public.14 Editors and journalists influence tobacco-opinion formation in society through their selection of tobacco issues15 and through the process of framing the media content on tobacco.16 The audience learns not only about a given topic, but also about the importance of the theme, based on content size, positioning, and wording. The journalistic norm is neutrality through balanced presentation, and editors often use sources with divergent views and agendas to achieve this balance.17 Different actors convey different messages, and some have a greater impact than others.18However, mass media is not just a neutral channel of information, but also a communication facility with independent powers.20 In the current media landscape, newspapers also represent an important link between the traditional, unidirectional mass media and contemporary interactive social media, as they become increasingly integrated into platforms such as Facebook and Twitter. It is therefore important to explore whether there are changes in themes, values, and actor constellations in newspaper coverage of snus over time.Although all types of media occasionally publish information useful to citizens about smokeless tobacco and its risks, the newspaper is probably the medium where snus is discussed in the most systematic and elaborate way and with broad coverage.21 Stories promoting smoking were far more common than stories concerning health hazards (71% versus 29%). We do not know if similar patterns apply to snus coverage.A study of tobacco images and texts in Norwegian magazines and newspapers found that most editors had no procedures or restrictions in respect of publishing indirect tobacco advertising or images of people smoking.23 In a study of US news coverage of smokeless tobacco in the period 2006–2010, the researchers set out to identify issues related to snuff, risk references, and perspectives/bias (“slants”) in the major national and regional newspapers and news wires.24 The study showed that the majority of stories were negative and critical towards smokeless tobacco.Internationally, several content analyses of newspaper writings on tobacco have been conducted, but only occasionally have articles about snus been studied. When snus has been a topic, it has usually been studied as part of the broader concept of “smokeless tobacco.” 26 Specifically, we will assess the magnitude of coverage and identify themes and values communicated about snus, study the diversity of messages, and identify the actors representing various topics and the factual knowledge base for the coverage. The study will provide an empirical basis for investigating the role of newspapers in glamorizing and normalizing snus use, and for assessing the extent to which messages about snus in this time period signaled positive or negative framing of health values.The aim of the present study is to describe the coverage of snus in Norwegian newspapers in a 10-year period characterized by a doubling in snus use, and changes in the demographic composition of users, most notably due to more snus use by adolescents and young adults.To explore these issues, we have conducted a descriptive content analysis of the newspapers’ overall message system, to reveal structures and changing patterns in the newspaper narratives over time.The study was based on the coverage of the snus phenomenon in Norwegian newspapers from 01 January 2002 to 31 December 2011. Since our aim was to identify the overall message system of snus that the Norwegian population had been exposed to via newspapers during this period, we strived for as complete a universe of articles as possible. The data was collected by searching the Retriever media monitoring service, which is essentially complete for all major newspapers (circulation of over 10 000 copies). The following search string was employed (in Norwegian): “snus * AND ” (SIRUS was the abbreviation for the Norwegian Institute for Alcohol and Drug Research). This search combination produced a higher number of hits than when snus was combined with each feature separately.main topic. This limitation is justified by capacity considerations in respect of coding work and by the journalistic storytelling norm of presenting the main point of a story first (the norm of “the inverted pyramid”). This may also be justified based on reception considerations. The common way to read an article is from the start (or from the “top”), and many readers read no more than the headlines and captions.27The inclusion criterion was that the word “snus,” in the relevant meaning of the word, was included in the headline or the ingress or that an image of snus appeared as an illustration. In other words, we only included articles where snus was the Based on these criteria, the search resulted in 943 unique hits in Norwegian newspapers, which included national press, regional newspapers, and local newspapers, on both paper and web platforms.28 all articles were reviewed and coded in SPSS by the second author, using article as analytical unit. All articles included were printed and archived, to ensure verifiability. To check coding for reliability, the first author conducted a reliability test of 10% of the articles (randomly drawn). Cronbach’s alpha varied between .83 and 1.00 for the variables applied in the present analysis, which must be considered satisfactory.Based on the methodological technique for quantitative content analysis,As all newspaper articles are publicly available, no ethical permissions were required.Information about extent of coverage and journalistic priorities was registered from article characteristics. In addition to newspaper name and date of article, we coded “type of article” , whether the article was “original or reproduced from news agencies/wires” and “article length” (number of words).main themes fell into four categories: “snus use” deals with issues related to use and distribution of snus in adults and youth, user rituals, and use in leisure and in school. “Tobacco policy” focuses on policy suggestions and initiatives regarding restrictions and measures to reduce snus use and make users aware of health risks and harm reduction. “Economy and market” were articles relating to market conditions, cross-border trade, sales trends, and investments. Finally, “health” concerned articles focusing on the health hazards of snus use either absolute or relative to other tobacco use, primarily smoking.To address topical issues and stakeholder interests, a set of exploratory snus variables was established, based on issues prominent in the public debate. The Framing refers to the overall key message of the article. Cases coded with “positive” frames were those that portrayed snus as pleasurable, harmless, or superior to cigarettes. Some cases also described celebrities who used snus, or included statements involving criticism of limits and restrictions on snus use or snus sales. Articles coded as “negative” were those that portrayed snus use as hazardous or unattractive. Typical examples included reports of harm to health, restrictions or prohibitions, critique of the tobacco industry, and opinions advocating increased tobacco control. Cases with a “neutral/mixed” frame included descriptive cases or news accounts, short paragraphs with no clear key message, as well as longer reports from multiple angles. Several cases included both positive and negative statements, for instance, arguments pro and contra and/or stakeholders with conflicting interests represented in the same article, which gave the overall impression of the article carrying a balanced view. Cases that could not be classified into the above categories were coded as “unclassifiable.”actor voice in each article. This refers to the sender position created in the text; it may be the interviewee or the commentator. The following twelve categories were utilized: “industry representative,” “celebrity,” “sports/athlete,” “researcher,” “politician,” “bureaucrat,” “NGO representative,” “physician,” “school pupil/student,” “teacher/headmaster,” “journalist” and “unspecified citizen.”When it came to who is represented in the articles, we identified the knowledge base  for each article. This variable was divided into three categories: “research/documentation,” meaning articles that referred to, or were based on, research reports or other documentation, “initiatives/input,” which could be, for example, politicians or interest groups, and “remarks/opinion,” i.e. letters to the editor from citizens, statements of schoolchildren and the like.29Finally, we recorded the To consider multidimensionality, all categories of the snus variables were coded as multiple choices based on a logic of “occurring/not occurring,” with the exception of the “framing” variable, where we used mutually exclusive categories to enforce identification of one overall key message.Descriptive statistics (univariate frequency tables and bivariate crosstabs) were applied. As categories are overlapping, the reported percentages do not necessarily add up to 100%. To visualize stability and change over time we included trend lines. The linear trend line is a regression line based on the least-squares method. As the data includes nearly the total universe of articles, inferential statistics, i.e. significance testing, were not applied.The analyses were performed using SPSS 25 and Excel.The number of articles about snus increased during the period 2002–2011, with the most conspicuous expansion (a doubling of articles) happening from 2002–2003 to 2004–2005 . 64.6% oThematically, the largest group of newspaper articles fell within the thematic category “snus use” , while there was a more equal split between the categories “tobacco policy” (24.5%), “economy/markets” (29.1%) and “health” (28.7%) . HoweverMost articles (48.6%) were neutral/mixed in respect of frames, and only 20.7% were positive . NeutralAlmost half of the articles carried a reference to “research/documentation” as a factual basis . This teArticles on snus use had no apparent value bias, with 47.1% of them being neutral/mixed and the rest equally split between positive (25.0%) and negative (26.9%) framing . StoriesThe most frequently occurring actor voices in the articles were researchers (30%), journalists (25%), snus industry/line of business (22%), bureaucrats (21%), school pupils (15%), citizens (14%), NGOs (14%), and politicians (11%) .The snus industry was primarily represented in stories about economy/markets and policies, politicians and bureaucrats in articles on policies, while researchers usually addressed health conditions . FurtherIn this study, we have identified the dominant messages about snus, as expressed in Norwegian newspapers’ coverage of snus-related matters over a 10-year period (2002–2011). The most common theme was “snus use,” while “tobacco policy” was the theme that increased the most in this decade. The majority of articles were neutral/mixed or negative in respect of frames, indicating relatively few unambiguously glamorous messages about snus. Furthermore, there was a tendency for a decrease in articles that were positive about snus during the study years.7 Given the advertising ban, the tobacco display ban (from 2010), the 18-year minimum age, and a consistently negative framing of snus by health authorities, the strong growth in snus use from 2002 to 2011 might partly have been fuelled by positive symbolic content in the media. As demonstrated by earlier findings, the media, in all its forms, is likely to shape individuals’ perceptions, attitudes, and behaviors towards tobacco.30 However, given the predominance of neutral/mixed or negative content found in articles, this study does not indicate any glorifying of snus by Norwegian newspapers. These results are in contrast to an earlier study, which concluded that the coverage of smoking in the Norwegian press was predominantly positive,21 but in accordance with a similar study from the United States.24In the period of study, there was a strong growth in snus use in Norway, especially among young people and among young men in particular.31 The newspapers do not convey one simple and uniform thematic vision of snus, but rather multiple, and relatively independent, views, which are quite broadly (and repeatedly) represented over time. In sum, the overall message system tends to be heterogeneous rather than homogenous.The main topics are raised in repetitive stories dispersed over time and successively supplied with small new elements in the form of research findings, market developments, product developments, user trends etc.and more unambiguously positive news media attention than applies to the other themes. While various, and sometimes conflicting, angles tend to be common in all newspaper media,16 we particularly observed this in health-related topics. For example, these two headings were found in the same newspaper from one year to the next: “Snus is good for public health” (Adresseavisen 09/01/2007) and “Snus can cause cancer” (Adresseavisen 08/09/2008). Another example: “Yes, snus is hazardous” (Aftenposten 04/12/2008), while five months later this headline appeared “Thinks that snus can save lives” (Aftenposten 04/21/2009).31 Such to-the-point wording, bold typefaces, and tabloid headlines are designed to attract readers. The same newspaper can thus communicate that snus is “good” for public health, and that snus is carcinogenic and hazardous to health. All the wordings may individually be correct, but the overall message still appears equivocal.The most interesting tension, both analytically and in terms of framing, is linked to the stories about health. These stories are polarized and largely “incoherent,” and involve both more uniformly negative We find clear associations between topics, framing, and actor voices in the stories. The patterns uncovered are relatively predictable, in that they are clearly sector-based: the snus industry is the main source represented in positive stories about “economy/markets,” politicians and NGOs in the negative articles on “tobacco policy” and researchers in the articles on “health,” irrespective of framing.Interestingly, the journalistic voice is commonly represented in the positive articles, indicating that some journalists in commentaries tend to side with those promoting snus. Elsewhere, we find that newspapers overall seem to strive for objectivity, with various viewpoints often promoted via actors presenting different messages in the same article. About half of the articles were thus deemed neutral, in the sense of balanced—although they contained both positive and negative representations. In an era where the media often are accused of bias in news reporting, it is also noteworthy that half of the articles were based on research and documentation.The analysis has shown an increase in the extent of coverage of snus in the 10-year period we are studying. Although this increase corresponds with increases in use and sales, this does not imply that the Norwegian newspapers’ writings about snus have been a direct driver of these increases. We cannot draw conclusions from our analysis about causality or directions of influence—that is, whether more newspaper coverage leads to more use, or whether more use leads to more newspaper coverage. What we have shown is a correspondence between increased use and increased news media coverage.32 As we have seen, stories about snus are characterized by various slants, often conflicting or negative. Despite these messages not always being overtly positive, such newspaper articles may nevertheless have a promotional effect, since interviewees “share” their experiences, which in turn may contribute to normalization of snus use. Through the agenda-setting attention that any coverage provides for the snus product, even “neutral/mixed” and “negative” articles may contribute to create a buzz and interest in snus. Media influence is not entirely dependent on the message carrying an unambiguously positive connotation .In this context, can news media still have contributed to a normalization of snus use? Newspapers exert considerable social power by selecting which matters are placed on the public and political agenda, which also contributes to playing various actor groups against each other.33 In normalization processes, dissemination of the phenomenon in question is thus vital. Although snus is a legal product with a long history in the Norwegian market, there are now more users of snus compared to the 1990s. The demographic characteristics of people using snus have also changed, as the proportion of young snus users increased considerably during the investigation period.7 Many of these snus users differ from smokers by holding higher social status and having more active lifestyles.26 Simultaneously, there are fewer and fewer “denormalized” smokers (see visible in society (and thereby legitimizing both the product and its use) that newspaper media may enact a “normalizing” effect.The concept of normalization refers to an action moving from being deviant, or reserved to some subcultural communities, to becoming “mainstream” and common.kers see . These d34 (One more issue that merits future research attention is the possible influence of the snus industry on newspaper coverage).The constant telling (and retelling) of increasing snus sales and use as a trend is another factor that indicates normalization and justification of snus use. The coverage of increased use may also have contributed to the perceived norms concerning snus use having changed, perhaps making snus use appear more common to more people today than in the 1990s. While we cannot conclude that newspaper coverage of snus has created a “bandwagon effect” based on our newspaper content data only, a hypothesis for future research is that the coverage may have added to a perception that more people use snus than is actually the case, which in turn may have resulted in even more new snus users.35 There is currently consensus in the scientific community that the health hazards of snus use are considerably fewer and lower than those of cigarette smoking. Influential collective actors such as the FDA36 and the American Cancer Society37 in the United States and the Royal College of Physicians4 in the United Kingdom now all embrace the idea of tobacco harm reduction. From a public health perspective, getting established smokers to switch to snus will most likely give a positive “net effect.” 38 A combination of increasing snus use with decreasing smoking is also likely to benefit public health, as illustrated by the Swedish experience.39While increasing normalization of snus is considered “epidemic” and highly problematic from a health policy point of view that emphasizes total freedom from tobacco on the precautionary principle, it is less problematic from an alternative “harm reduction” point of view.There are some limitations to this study. As concerns the database, Retriever is not an entirely complete database of all Norwegian newspapers. Some small newspapers are not included or are only included for some of the periods under study. However, there is little reason to believe that the stories we may have missed from these minor newspapers differ systematically in themes and perspectives from the data we do have. The data set we have at our disposal is almost complete for all major newspapers (circulation of over 10 000 copies).Concerning sampling, we cannot ignore that some articles, even with such an extensive search string as described in the methods section, may still not have been encompassed by our search criteria. A strength of this research design, however, is that it provides a valid representation of the composition of the message system of snus over time.The number of snus articles per year in Norwegian newspapers increases from 2002 to 2011, while their average size decreases slightly. Variants of the same themes about snus recur throughout the study period, and newspapers convey contradictory messages and values about the risks to health of snus. The slight predominance of negative and/or neutral/mixed articles indicates that the newspaper coverage does not glamorize snus. Still, it cannot be ruled out that the sheer amount of (and growth in) articles over time, as well as positive articles and angles available for selective exposure and perception, may nevertheless have contributed to normalization of snus use in Norway.https://academic.oup.com/ntr.A Contributorship Form detailing each author’s specific involvement with this content, as well as any supplementary data, are available online at ntab171_suppl_Supplementary_MaterialsClick here for additional data file.ntab171_suppl_Supplementary_Taxonomy_FormClick here for additional data file.


Misoprostol entered the global market under the name Cytotec in the mid-1980s for the treatment of gastric ulcers. Decades of research have since demonstrated the safety and effectiveness of off-label use of misoprostol as a uterotonic in pregnant women to prevent and treat post-partum hemorrhage, treat incomplete abortion, or terminate first-trimester pregnancy. Global health experts emphasize misoprostol’s potential to revolutionize access to reproductive health care in developing countries. Misoprostol does not require refrigeration, can be self-administered or with the aid of a non-physician, and is relatively inexpensive. It holds particular promise for improving reproductive health in sub-Saharan Africa, where most global maternal mortality related to post-partum hemorrhage and unsafe abortion occurs. Although misoprostol has been widely recognized as an essential obstetric medication, its application remains highly contested precisely because it disrupts medical and legal authority over pregnancy, delivery, and abortion. I draw on fieldwork in Francophone Africa to explore how global health organizations have negotiated misoprostol’s abortifacient qualities in their reproductive health work. I focus on this region not only because it has some of the world’s highest rates of maternal mortality, but also fertility, thereby situating misoprostol in a longer history of family planning programs in a region designated as a zone of overpopulation since the 1980s. Findings suggest that stakeholders adopt strategies that directly address safe abortion on the one hand, and integrate misoprostol into existing clinical protocols and pharmaceutical supply systems for legal obstetric indications on the other. Although misoprostol has generated important partnerships among regional stakeholders invested in reducing fertility and maternal mortality, the stigma of abortion stalls its integration into routine obstetric care and availability to the public. I demonstrate the promises and pitfalls of pharmaceuticalizing reproductive health: despite the availability of misoprostol in some health facilities and pharmacies, low-income and rural women continue to lack access not only to the drug, but to quality reproductive health care more generally. Misoprostol offers a particularly vivid example of how pharmaceuticals inhabit multiple “social lives” or “biographies” throughout various stages of their production, marketing, distribution, prescription, and consumption . In the Although World Health Organization (WHO) listed mifepristone and misoprostol used together as a safe form of early MA in 2005, clinical research has shown that misoprostol alone can effectively terminate first-trimester pregnancy . WHO plaIn both popular media and public health literature, misoprostol has been described as a “revolution” in reproductive health care because of its potential to reduce mortality and morbidity related to unsafe abortion and PPH in countries with restrictive abortion laws or with under-resourced health systems . MisoproMisoprostol holds particular promise for pharmaceutically revolutionizing women’s access to quality reproductive care in sub-Saharan Africa (SSA), where the burden of abortion-related mortality is the highest in the world , where Critical scholars of global health are more skeptical about the extent to which medication alone can lead to a revolution in access to health care. More specifically, they have cautioned against reducing solutions to complex public health problems like maternal mortality to “magic bullets”: cost-effective drugs or interventions that promise to save the most lives at the lowest cost, but with inadequate attention to the social and economic context in which these technologies are applied (or not) . Magic bThe desire for technological solutions and measurable results has led to what critical scholars of global health have termed the “pharmaceuticalization” of public health, a process through which medication comes to stand in for health infrastructure and human resources that constitute public health systems . For exaFraming misoprostol as a revolution in reproductive health care further belies the complex geopolitical and professional processes—a transnational “regime of values” ”—involveMisoprostol’s relatively recent “biography” as an abortifacient is connected to a longer history of (neo)colonial population governance in SSA. In this article, I explore politics and practices related to misoprostol in the Francophone region of SSA, which includes countries in West and Central Africa. I focus on this region not only because it has some of the world’s highest rates of maternal mortality, but also the highest rates of fertility and lowest rates of modern contraceptive use. Since at least the 1980s, family planning has factored prominently into structural adjustment policies designed to increase economic growth throughout the region under the guidance of the IMF and the World Bank . By the In this article, I situate misoprostol, a highly flexible reproductive health drug with multiple obstetric indications, in a fractured landscape of reproductive governance  that incBy exploring how these actors integrate misoprostol into health policy and practice, I offer insight into the benefits, challenges, and pitfalls of pharmaceuticalizing reproductive health. I argue that access to misoprostol cannot simply be boiled down to its availability in pharmacies, or its affordability on the market. The narrative of revolution, while hopeful about the drug’s potential to reduce maternal mortality, insufficiently captures the complex transnational politics that shape how and where it is available and used (or not), and by whom. Attention to global, national, and regional practices, strategies, and discourses related to misoprostol reveals how access to pharmaceuticals falls short of reproductive justice in a region significantly influenced by gendered, racialized, and classed geopolitics of reproduction.This study was accomplished through ethnographic research conducted between July and August 2019 in Dakar, Senegal. My research on misoprostol stems from a longer professional and scholarly engagement with reproductive health, and in particular PAC, in Senegal. During the mid-2000s, I worked with Management Sciences for Health  on PAC in five of USAID’s regions of intervention in Senegal. Between 2009 and 2011, I conducted research on PAC in Senegal, and since then have remained connected with colleagues in the Ministry of Health (MOH) and national and international NGOs involved in reproductive health research and programming.First, I conducted in-depth, semi-structured interviews with 17 individuals involved in reproductive health care advocacy, research, and programming in Francophone Africa. Interviews with participants in Senegal occurred in person, while others took place over Skype with participants based throughout Francophone Africa, Europe, and the US. At the time of fieldwork, research participants worked with philanthropic agencies and NGOs. While some participants had worked in the past with national MOH or as health workers in government health facilities, I did not interview current MOH officials or government health workers as part of this study. Participants represented a variety of nationalities including Senegalese, Ivorian, Burkinabé, American, British, and Dutch. Although I purposefully selected some participants due to their organizational positions, others were referred to me through snowball sampling. This personalized approach, and my previous research experience in PAC in Senegal, facilitated sensitive conversations about misoprostol and abortion. The names of individuals and organizations have been anonymized to protect confidentiality. Permission for this project was obtained from Brandeis University and the Ministère de l'Enseignement Supérieure, de la Recherche, et de l’Innovation in Senegal.Second, I conducted literature reviews on misoprostol and MA. Sources include clinical research on misoprostol’s safety and efficacy in obstetric care; technical guidelines on abortion care issued by WHO; sociological and anthropological literature on women’s and health workers’ experiences with misoprostol in SSA; and public health literature on availability and use of misoprostol in public and private health care sectors. Also included in my analysis are data from reports on MA published by international NGOs and donor agencies. Some of these reports describe the proceedings of stakeholder meetings, while others outline national and regional strategies for expanding access to MA in Francophone Africa. In light of the sensitive nature of abortion in this context, I do not reveal the identities of individuals or organizations involved in the publication of these reports, unless the report is available to the public online.Drawing on multiple sources of data, I identify various institutions, professions, industries, communities, and technologies that make up the complex and rapidly evolving “pharmaceutical regime” : p. 207 Science and technology studies and critical studies of global health offer useful theoretical tools to understand the production, marketization, distribution, prescription, and availability of pharmaceuticals across a variety of contexts. In this section, I draw on these tools to illuminate the gap between misoprostol’s promise as an obstetric pharmaceutical in transnational arenas of maternal and reproductive health policy making and the practical realities of misoprostol on the ground. Pharmaceuticals are not inherently safe or effective, but acquire meaning through the social, economic, and political dimensions of their utilization . As pharProfessional and lay debates about what makes a particular drug or technology “the right tool for the job” , and forThe “job” that pharmaceuticals are designed to accomplish, or their “biography” at a particular moment in time, may shift in response to social, professional, economic or political factors. Pharmaceutical companies have encouraged off-label prescription of drugs, despite a lack of clinical evidence, to maximize profits through expanded patient populations. Examples include drugs for sexual disorders, social anxiety, Attention Deficit Hyperactivity Disorder (ADHD), depression, and other mental illnesses . Off-labIn the global South, pharmaceuticals are “reinscribed (p. 120)” with meaning related to safety, efficacy, and patient populations not only in clinical trials, consumer markets, and health care settings , but alsMisoprostol’s potential to improve reproductive health has been framed as revolutionary precisely because beyond its capacity as an abortifacient, it is the “right tool” for multiple obstetric “jobs,” including labor induction, preventing and treating PPH, and PAC. In this sense, misoprostol is anchored in multiple “regimes of value” related to global efforts to reduce maternal mortality. Although the 1987 Safe Motherhood Initiative called on donors and governments to invest in maternal health care comprehensively as a matter of social justice , its tweAt the same time, despite its proven safety record and integration into national and global LEM, misoprostol’s capacity to terminate pregnancy continues to threaten its legitimacy as a reproductive health drug  and rendEven for a legitimate obstetric indication like PPH, misoprostol’s capacity to disrupt medical power over pregnancy, abortion, and delivery continues to generate professional debates over where it should be used, and by whom . Indeed,Some maternal health scientists and organizations have been critical of WHO’s recognition of misoprostol as an alternative medication for preventing and treating PPH in the absence of the gold standard, oxytocin. In 2011, Maternal Life International, a faith-based organization, wrote to WHO to question the evidence base for misoprostol’s inclusion on the LEM for preventing PPH, arguing that it fostered sub-standard, unregulated care outside of health facilities for poor, rural women in SSA . SimilarGiven the recent resurgence of attention to family planning as a global health matter, surprisingly little attention has been directed to misoprostol’s capacity, as an abortifacient, to achieve global targets related to fertility reduction. Compared to modern contraception, abortion plays a limited role in fertility reduction. Yet, the “contraception-abortion paradox (p. 12)” exists in many developing countries, where limited access to or inconsistent use of contraception increases the risk of unwanted pregnancy, which in turn frequently leads to abortion . There iBefore the MVA syringe became a preferred technology for PAC in the early 1990s , it was At the 1994 UN International Conference on Population and Development (ICPD), the global community rejected the target-oriented population control paradigm in favor of the concept of reproductive health, which called for comprehensive, rights-based approaches to ensuring women’s reproductive well-being. By the early 2000s, however, fertility reduction through voluntary family planning emerged yet again as a key component of global approaches to address the environmental dangers of climate change . Over thIn SSA, family planning in the form of “birth spacing” has been tightly connected to maternal health through its capacity to avert undesired or unplanned pregnancies . In 2012Feminist scholars have argued that population, development, and climate interventions like FP 2020 must be situated in a longer history of (neo)colonial strategies to control African fertility . Some coAlthough FP 2020 uses the language of reproductive rights and maternal mortality reduction to frame contraceptive use, it reanimates neo-Malthusian logics of population control that posit fertility in SSA as a threat to the economic, political, and environmental stability— “the abundant life” —of wealtThrough its multiple “lives,” misoprostol is anchored in multiple global regimes of maternal and reproductive health governance. And yet, the qualities that render it a potentially revolutionary medication for achieving maternal mortality reduction simultaneously raise the specter of unregulated abortion and increased participation of TBAs in obstetric care. As an abortifacient, misoprostol’s ties to a neo-Malthusian past and present threaten to destabilize precarious global agreements on achieving fertility reduction targets in a post-ICPD landscape. In the following sections, I explore how reproductive health advocates have negotiated these qualities in their efforts to increase the availability of misoprostol in Francophone Africa.Some study participants are explicitly engaged in advancing access to MA, and safe abortion more generally, in Francophone Africa as part of a broader maternal and reproductive health agenda. Abortion-specific meetings have been held, either as stand-alone events or tied to other global or regional maternal and reproductive health conferences starting in 2016. Some of these events have been organized and held in secrecy because of the politically sensitive nature of abortion. These meetings have been attended by representatives from national and international NGOs, research organizations, bilateral donor agencies, UN agencies, and philanthropic agencies. During these meetings (none of which I attended), safe abortion advocates have discussed trends, progress, and challenges related to MA in the areas of research, legal environment, advocacy, commodities, community engagement, funding priorities, and services. For example, during a January 2019 meeting on safe abortion, almost 40% of participants indicated that their funds were allocated to MA services, and 88% identified Francophone West Africa as a priority region . Safe abCatherine, Maxine, and Roberta, who worked for two philanthropic foundations, identified reproductive health more generally as a long-standing goal within their funding portfolios related to “population.” Although these foundations have supported safe abortion advocacy and research among national and international NGOs for several decades, they explained that the 2012 OP served as a catalyst for increased regional interest in safe abortion, with a particular focus on MA. They identified new actors, including NGOs and bilateral donor agencies, that had become involved in family planning, and eventually began to dedicate attention and resources to safe abortion. Catherine believed that despite the OP’s focus on family planning, this initiative had catalyzed a regional approach to MA that was poised to transform the landscape of abortion:There’s a lot more interest as a region, the conceptualization of the region as a space, thinking of it regionally, like these are lots of small-ish countries so when we think regionally, a lot can be done. Donors think regionally. I think it’s been great and catalytic for safe abortion work. And of course, there’s the MA revolution happening all this time and that has really changed safe abortion work globally, of course. But I think it’s right at the precipice of being extremely fundamentally shifting, especially in Francophone Africa.Maxine agreed that there had been a “general shift towards West Africa,” but did not attribute it solely to safe abortion. Instead, she located it in a broader recognition within the global reproductive health community that Francophone Africa was underserved compared to other regions in SSA. Some stakeholders have identified the region’s official language as a deterrent among Anglophone donors . Prior tStudy participants who worked with international NGOs throughout the region identified an extensive array of abortion-related research, service provision, commodity distribution, training, and professional and legal advocacy. According to Eva, these activities were less about “promoting abortion” than they were about “reducing unsafe and less safe abortions.” NGOs conducted situational analyses on reproductive health and Knowledge, Attitudes, and Practices (KAP) surveys on abortion and contraception with women and girls. Others have evaluated the availability of MA products in public and private health care facilities. In one country, health workers were trained to monitor maternal deaths, paying special attention to the contribution of unsafe abortion to maternal mortality in their facilities.In some countries, NGOs have deployed these data in advocacy regarding the harmonization of national laws with the 2003 Maputo Protocol of the African Union, which calls for safe abortion in the case of rape, incest, or when pregnancy threatens a woman’s mental or physical health . Some coEven in countries with legal indications for abortion, study participants explained that provision of and training for MA in the public sector remained limited. PAC remained an important part of their work as women often waited until after they had terminated pregnancy (often unsafely) before seeking care. Some international NGOs were directly involved in “comprehensive” abortion training—safe abortion and PAC—for public sector health workers. Others provided abortion and PAC services in their own clinics . In counWhile some study participants were directly involved in programming these events, others took more of a behind the scenes approach. For example, Eva differentiated her organization’s “advocacy work” from its “hands-on work.” She understood “hands-on work” as technical in nature: health worker training and registration of commodities. In contrast, she understood her organization’s participation in advocacy as less direct: “We aren’t necessarily the front line to the Parliament or anything like that. I know there are partners who are much more active at that level of Parliamentarians. I would say that we’re not playing that role.” Her organization “supported the movement” by participating in working groups, and providing financial support for national organizations such as the national association of women lawyers, to meet and discuss strategies for legal advocacy.While the previous section describes advocacy, programming, and services that are directly related to abortion, and at times publicly-facing, here I describe how study participants are engaged in strategies with less direct ties to safe abortion, and more oriented toward professions and institutions in private and public sectors of the health system. These strategies entailed conducting research on misoprostol’s safety and efficacy for legal obstetric indications such as PAC and PPH, registering generic brands of misoprostol with national pharmaceutical regulatory agencies, supporting misoprostol’s integration into national LEM and clinical protocols for maternal and reproductive health, and marketing misoprostol directly to health workers and health facilities. In other words, this approach aimed to increase the availability of misoprostol for legal obstetric indications in public and private sectors of the health system, with the knowledge that it would likely be used off-label for abortion.BMC Pregnancy and Childbirth published results from a multi-country  study showing that misoprostol could be used safely for PAC , MA provision in the public sector remains low . Adja, wCatherine, who worked for a philanthropic organization, described misoprostol as a “game changer” for abortion access in Francophone Africa: “Misoprostol is such a subversive and exciting thing because if we can get this stuff on shelves and get pharmacists who know how to get it out…I mean, work within the provisions…it feels like it could be big.” Catherine discussed how MA had been “revolutionary” in countries like India and in parts of Anglophone West Africa. “We’ve seen some places in Anglophone West Africa where MA has already exploded. Ghana is just off the shelves. A pretty amazing amount of product is sold.” For her, medication abortion was a “story waiting to be told” in Francophone Africa. It was just a matter of “figuring out what—following that story and pushing it where it can be pushed.”John, who worked for an international reproductive health NGO, echoed Catherine’s vision of MA when he said that revising abortion laws should no longer be the “holy grail” of abortion advocacy. Instead, getting misoprostol directly “into women’s hands” through pharmacies should be the focus. Similarly, Julia, who had worked with an international reproductive health NGO for many years, expressed that working “outside” the government health system, through private pharmacies, was the best way to reduce unsafe abortion in places with under-resourced health systems.For Jacques, who supervised the regional MA strategy for an international NGO, the privatized approach to registering and distributing misoprostol was a double-edged sword. On the one hand, getting the drug into private pharmacies ensured access to the drug for women who could reach these facilities and purchase the medication. On the other hand, procuring an abortifacient drug within the public health system remained a serious challenge. He characterized the act of registering the drug for PPH as a “big battle” because “everyone knows that it’s a product that is used to make abortions safer.” He joked that even the MOH “hid” behind obstetric indications like PPH and PAC to place misoprostol on the national LEM. For Jacques, this approach made people reluctant to order misoprostol “publicly” in government health facilities, even for legal indications. “Everyone knows that they need the product,” he said, “but no one will say, ‘listen, we need to order miso.’ Jacques described a situation in one Francophone country where a multilateral agency donated a quantity of misoprostol to the MOH, which was “only buying contraceptives.” The MOH then sent the drug to “university hospital centers,” but not secondary health facilities. In other words, in the public sector, misoprostol was not always, as Zeinab had suggested, a “product like any other,” precisely because the medication is negatively associated with clandestine abortion.Although several participants pointed to the 2012 OP as an important catalyst to the MA revolution in the region, abortion has factored into the landscape of global reproductive governance since at least the introduction of PAC across the region starting in the late 1990s. While PAC was recognized in the 1994 ICPD as a harm reduction approach to the public health problem of unsafe abortion, health workers and health authorities in countries with restrictive abortion laws have had to frame PAC, and the MVA syringe in particular, in ways that distinguish the intervention from pregnancy termination to remain in compliance with national prohibitions on abortion and the US GGR .Study participants who worked for philanthropic agencies recognized that safe abortion had long been part of the reproductive health, or more broadly, “population” portfolios of their employers. Roberta alluded to “interest” in intersections between “climate change and environmental issues” and “reproductive health access in the Northwest and along the Sahel.” Maxine described hearing from former colleagues in West Africa “about European concerns about migration and feel that this is playing into—in negative ways—the increased attention to West Africa’s population.” Within her agency, however, Maxine believed that work on environment and reproductive health had traditionally been kept “separate.” Roberta agreed, saying “I think there’s been concern about how you talk about it together and the potential negative incentives of linking them together.” She went on to describe, however, how her agency intended to “test the waters” in supporting a project that brought together reproductive health, agriculture, and conservation in an East African country.Regardless of where one draws the start line for the MA revolution in Francophone Africa, it is clear that global abortion politics significantly complicate stakeholders’ activities related to misoprostol. The GGR prevents national organizations that receive USAID funding for family planning from using money from other sources to do abortion-related work. Consequently, international NGOs and donor agencies exercise caution in distributing abortion-related work and funding to national organizations. Eva described how her NGO ensured that, in the Francophone countries where they worked, their contracted social marketing agencies did not “touch” anything related to abortion. Her NGO had to “separate out” misoprostol and combi-packs from their national partners’ portfolios.Maxine described her philanthropic agency as one that “places a lot of emphasis on funding local organizations and not international NGOs.” The GGR affected her organization “in small and large ways.” Sometimes, she had to scrap plans for collaborating with an organization when it was discovered that they’d signed the GGR. In some situations, her organization had to increase funding for grantees that refused to sign the GGR and therefore lost USAID funding. When presented with opportunities for collaborating directly with USAID, her organization had to consider whether USAID’s “bigger dollars and influence” were worth “compromising on the abortion piece.” Sometimes, they decided “to go it alone without their support.” She described the reinstatement of the GGR in 2017 as having “a chilling effect” in terms of planning meetings and conferences at higher levels related to reproductive health:I was at a meeting the other day that was three quarters contraception, one quarter abortion, and no one from AID could come to the meeting…It’s definitely a problem. There’s plenty of other examples of meetings and conferences where all the abortion talk has to be pushed to one end of the meeting so the USAID folks could leave the room before any discussion of abortion begins.The 2012 OP has simultaneously served as a catalyst to organizing regionally around safe abortion and heightened political anxieties about abortion. Two of the OP’s donors, USAID and the Gates Foundation, do not fund abortion-related work. Due to the “stigma” of abortion, according to Catherine, “the OP, which is family planning specific, has been very resistant to allowing anything related to abortion to enter the Partnership.” Discussions related to abortion have been “limited” to PAC. Even the Gates Foundation had to be reassured of the programming connections between PAC and family planning . While CMariam, who worked for an international NGO, seemed less convinced of this approach. She explained how her organization struggled to participate in OP meetings and to integrate abortion into discussions of reproductive health commodities. “We’ve never been invited to these OP meetings which only discuss contraception.” Her organization’s solution was to continue “pushing” the issue and speaking “openly” about abortion.matrons (TBAs) for PPH, they made them record the serial number and link to each patient used.” This was a way to “safeguard” an abortifacient drug that “shouldn’t be used like aspirin.” Mariam and Eva, each representing a different international NGO, described a situation in one Francophone country where, shortly after training a group of health workers to use misoprostol, the MOH released an official statement warning health workers to limit misoprostol use and prescription to legal obstetric indications. Mariam described how, in another country, health workers reported that MOH officials had removed misoprostol from their facility because of suspicions that it was being used illegally to provide abortions. “They completely stopped supplying misoprostol,” Mariam explained, “so the health workers had to hide and use their own money to buy misoprostol and sell it to women in the facilities.” She went on to describe how in such a political context, “sometimes you have the impression that you take one step, and then there’s something that pushes you back.” Eva echoed her concerns when she said “it just shows that in the region while things are advancing, there is still a lot of possibility for things to go quickly backwards.”National abortion politics further complicated the integration of misoprostol into health systems. Laila, a midwife in Senegal who had previously worked with the MOH and now worked with an international NGO, described how “when they started giving misoprostol to Other study participants suggested that Francophone Africa was a particularly difficult place to work on MA because of institutionalized abortion stigma, even in countries with legal indications for abortion. Maxine contrasted the region to Ethiopia, “where we talk much more openly, freely with the government and the Ministry about abortion services.” When I asked John what it was like to promote misoprostol in Senegal or other African countries with restrictive abortion laws, he explained that his organization takes a “step back” when it comes to abortion by focusing on the legal obstetric indications such as PPH and PAC. From a sales perspective, he said, his organization’s hands were “clean” even if others were purchasing and using the drug for abortion. Zeinab, who worked for an international NGO in Senegal, described her activities related to misoprostol as “commercialization.” She distinguished these activities from off-label utilization for abortion, which she acknowledged was happening among some health workers. Her job, was to market the drug, and to “keep a low profile” with respect to the country’s abortion debate.Despite global and national recognition of misoprostol as an essential medication for maternal and reproductive health, study participants who worked for NGOs identified significant barriers to accessing the drug in both public and private health sectors. Mariam, who worked for an NGO with activities in multiple Francophone African countries, explained: “It’s still difficult for women to get misoprostol because of legal restrictions. There are many things that still block women.” Jacques, who worked for the same NGO as Mariam, pointed out that “just because the product is in the country does not mean that it is accessible.” This observation is relevant not only for women seeking the drug in the private sector, but also health workers in government health facilities. Ayo, who worked in Côte d’Ivoire, estimated that beyond large hospitals, less than 10% of public health facilities stocked the medication. In Senegal, a survey of obstetric care conducted between 2015 and 2016 showed that only 3.4% of referral facilities carried misoprostol . Laila eOne of the main barriers to obtaining misoprostol, despite its availability in pharmacies under various brand names, was the need for a prescription for a legal obstetric indication. Even with a prescription, Jacques pointed out that women may experience difficulty procuring the amount needed to terminate pregnancy. Misoclear, for example, is sold in packets with three 200 mcg tablets. To meet the recommended dose for up to 12 weeks of gestation, a woman would have to buccally, sublingually, or vaginally take 800 mcg (four pills) every three hours until expulsion . This woAdja, who worked for an NGO in Senegal, believed that women’s access to misoprostol depended less on prescriptions for legal obstetric indications than on health workers’ willingness “to take the product and give it to women.” Women relied on health workers for misoprostol because “it’s health workers who have the power to get the product.” Jacques agreed, saying, “there are nurses and midwives who are known for providing this kind of help. Often, it’s a business. You do it off the records, and that’s that.” Laila, a midwife in Senegal, believed that misoprostol was mostly “controlled by doctors.” Mariam explained that while obtaining misoprostol directly from health workers might increase some women’s access to the drug, dependence on health workers also left women vulnerable to exploitation. Health workers may purchase a supply of misoprostol and “resell” it to women at a higher price. “This is the kind of dysfunction that comes out of all these restrictions,” she said. “They’ll buy it with their own money and then sell it clandestinely in the system.”Study participants’ perceptions of the informal routes through which women obtain misoprostol resonate with ethnographic literature on abortion practices in SSA. In countries like Burkina Faso, Kenya, and Tanzania, women obtain misoprostol from multiple sources, including friends, relatives, health workers, pharmacists, and informal pharmaceutical vendors. While some health workers administer misoprostol directly, others dispense it to women and instruct them on how to use it at home. Women may obtain misoprostol from brick and mortar pharmacies with or without a prescription. Although many women seek misoprostol from health workers in the private sector, some health workers in government facilities may provide the service themselves, or refer women to a colleague. Women obtain misoprostol not only from skilled health workers, but also TBAs and other paramedical providers .Jacques believed that compared to urban women, rural women had less access to misoprostol and relied on “street” medication . Ayo explained that for many women, street medication was much more affordable than misoprostol purchased at a pharmacy or through a health worker. “Instead of paying 5000 CFA francs for misoprostol, she can buy Chinese medicine for between 200 and 500 francs.” Both Jacques and Ayo asserted that while such purchases might be more affordable, women faced the risk of encountering inauthentic drugs or receiving inadequate information related to dosage or gestational age, all of which could lead to complications. “In all of the Francophone African countries, we have these people who make these abortifacients available,” Jacques said. “But what is the quality of that medication? What is the quality of the prescribed dosage? That’s the problem. In these circuits you can often find good miso or bad miso, or drugs that are supposed to be miso but are not.”Jacques disagreed with people who pointed to the risk of complications as a reason to restrict misoprostol because women were “not ready” for self-medicated abortion. “It’s not true,” he argued. For him, the problem was the gap between pharmaceutical distribution systems and clients:Our pharmaceutical distribution system has completely missed its target. The environment has evolved, but our pharmacies and our distribution policies have not evolved. We wait for the client to come, thinking it’s the client who has to come to us even if they are 100 or 120 km away.According to Jacques, this gap between distribution policies and clients’ needs essentially “abandoned” those populations who lived far from pharmacies to street medication.Although SSA’s maternal mortality ratio has reduced by 38% since 2000 , the phaMisoprostol’s legal obstetric indications, PAC and PPH, firmly position the medication in harm reduction approaches to maternal and reproductive health . This haIn 2017, President Trump extended the GGR to organizations that receive US funding for infectious disease . More thMisoprostol stokes enduring tensions related to professional authority over reproduction: who can use the medication, where, and for what purpose. The medication’s safety and effectiveness in preventing PPH and PAC have facilitated its integration into LEM throughout Francophone Africa. Yet, study participants pointed to gaps in health worker training and medication supplies in national health systems in countries where they worked. To a certain extent, these gaps reflect continuing debates about the role of TBAs in obstetric care . At the Starting with the 1974 Helms Amendment, and followed by the 1984 GGR, anti-abortion advocates have actively shaped the terrain of global reproductive health funding and policy . MisoproStudy participants were eager to harness commonalities across Francophone countries, such as a tightly organized pharmaceutical market and the prominence of Islam , toward And yet, some of the abortion stigma framed as exceptional to Francophone Africa appears to be relevant in other countries. Maxine described Ethiopia as a place where the MOH was “open” to engaging with abortion. Since 2005, Ethiopia has permitted abortion in cases of rape, incest, fetal malformation, or if the pregnant woman is under the age of 18. A woman’s “word” is considered sufficient to establish her age or that she experienced rape or incest . The natDespite these inconsistencies, the language of exceptionalism remains a formidable tool in constructing Francophone Africa as a place particularly in need of resources and attention related to population. Critical development scholar Betsy Hartmann argues that the current focus on reducing fertility in SSA hinges on racialized perceptions of African fertility as “distinctive and dangerous” (2014). Population interventions are predicated on the “exceptional” nature of high fertility in SSA, despite a wide variation in fertility rates throughout the continent, and the existence of similar demographic patterns in other parts of the world during historical periods characterized by high rates of poverty and inequality . The OP,FP 2020 and regional offshoots like the OP are the most recent interventions in a longer history of population interventions in SSA. For example, in 1980, Senegal was the first country in SSA to receive a structural adjustment loan from the World Bank and the IMF. Release of the third loan during the late 1980s was conditioned upon the establishment of a concrete population policy with support from USAID, Pathfinder International, and UN Population Fund (UNFPA) . More geWhile Maxine describes population and climate change as a “European concern,” population and development scholars have traced the “securitization” of climate change and population as an American concern since at least the mid to late 2000s . ScarcitAlong with magic bullet interventions that generate statistical measures of cost-effectiveness, twenty-first century global health approaches have incentivized engagement with the private sector. In Senegal, for example, international NGOs have contracted private logistics operators to supply government health facilities with contraceptives. By closely monitoring the private operators’ performance in delivering and taking inventory of contraceptives, this approach endeavors to prevent contraceptive stock-outs in the public sector . Some ofGiven the lack of evidence that neoliberal health reform in SSA has improved maternal health outcomes , it is rStudies from middle- and low-income countries show that low-income women in particular are more likely to receive inaccurate information about misoprostol or inauthentic medication . In turnempower women through granting reproductive autonomy in contexts where legal abortion is highly restricted, and benefit them by reducing the risk of obstetric complications and death (As a feminist advocate of reproductive justice, I support access to technologies like misoprostol that nd death . Attemptnd death . At the nd death . While t