Infertility is a major concern in Indonesia, both in terms of the number of people affected and the cultural significance of being childless. While coming from a low base, recent years have seen a rapid increase in the number of Indonesians presenting to fertility clinics. But concerns over sexual morality and social status cloud the way that doctors and patients interact, meaning the role of sexually transmissible infections (STIs) in causing infertility is rarely discussed. This has implications not only for the fertility of the affected women and men but also for broader patterns of sexual health across the country.
Recent estimates place the country’s infertility rate at 12 to 22 per cent of the reproductive-aged population. A conservative 15 per cent female infertility rate translates to about 6 million Indonesian women experiencing infertility at some point in their reproductive lives.
According to the Association for In-Vitro Fertilization (Perfitri), between 2009 and 2013, the number of infertility clinics increased from 9 to 23 and the number of in-vitro fertilisation (IVF) cycles performed jumped from 987 to 3,581.
The only data on causes of infertility in Indonesia comes from the medical records of patients who have undergone IVF. Perfitri reported that in 2012, tubal blockage was the key cause of infertility identified for 12.5 per cent of women who underwent IVF, and the most common cause of tubal blockage is untreated STIs. Tubal blockage was significantly higher than other causes of infertility, such as ovulatory dysfunction, diminished ovarian reserve or endometriosis.
Rates of STIs that directly affect infertility, particularly chlamydia and gonorrhoea, are high and increasing in Indonesia. Condom use among the general population is extremely low, as is adequate knowledge of STI and HIV transmission routes. HIV and STI testing and surveillance involves a very low proportion of the population and focuses mainly on at-risk groups such as injecting drug users, men who have sex with men and female sex workers.
STIs are deeply intertwined with dominant understandings of sexual morality in Indonesia. The foundation of sexual morality in Indonesia is heterosexual marriage. Sex outside of marriage, meanwhile, is considered deviant and immoral (as is premarital sex, queer sex, prostitution and public representations of sex). Deviant or immoral sexual behaviour is equated with and blamed for poor sexual health and often misunderstood as the cause for STIs, including HIV. Individuals with STIs are therefore considered – and consider themselves – to have poor sexual morality.
Sexual morality also intersects with class. Lower class Indonesians are often depicted as having poorer sexual morality by elites. At the same time, poorer Indonesians who engage less with global consumer culture often view middle class and elite youth as excessively sexually liberated and in moral danger because of an overexposure to Western values.
Research conducted from 2010 to 2012 with Indonesian women who had experienced infertility, as well as clinicians who treated it, found that the association between STIs and immorality had a significant impact on the quality of care these women experienced. Fertility consultants position themselves as the moral guardians of their patients – a role that involves protecting their patients from exposure to sexual immorality.
For many doctors, their responsibility to guard the moral wellbeing of patients appeared to trump their responsibility of ensuring best practice. When asked about how his practice dealt with the issue of STIs, one doctor said: “We have to be very careful… We cannot suggest to someone that they have an STI, or that they should have an STI test. If we do this, we may reveal infidelity in the marriage, which may lead to divorce. Then there will be no baby. It’s not our role to cause this kind of problem. We are here to make families, not to break them.”
Assumptions about conservative sexual morality and deference to class hierarchy were also found to affect the quality of care. Another doctor stated that it was not necessary to conduct routine screening. “Most of our patients are very educated,” he said. “They are quite wealthy. They are not the kind of person you expect to have an STI. If you suggest an STI test, it’s like you are accusing the wife of being unclean or accusing the husband of being unfaithful. This kind of accusation can be very insulting for high-class people. We have to respect their status. Of course, we will refer them for tests if they request them, but that almost never happens.”
“If you suggest an STI test, it’s like you are accusing the wife of being unclean or accusing the husband of being unfaithful”
These types of opinions were borne out in a survey of 212 women fertility patients from three clinics in three separate cities, which found that referral for STI testing was alarmingly low. Only 16 women (7.5 per cent) indicated that their doctor had recommended an STI test. Of these women, only half reported that their doctor had explained why a test was recommended.
In-depth interviews with women patients demonstrated that it was common for doctors to prescribe prophylactic antibiotics for STIs, without informing patients that STIs were being targeted. Doctors would sometimes describe the antibiotics as being prescribed for a “general infection” (infeksi umum) to avoid the moral anxieties associated with STIs.
But doctors’ concerns about entering the “morally uncomfortable” territory of discussing STIs are not paralleled by the concerns of their female patients. In the above survey and in-depth interviews, women indicated a strong interest in the relationships between sexuality, sexual health and fertility. Doctors appear to be over-interpreting the sexual conservatism of their patients, setting narrow limits on sexual dialogue, and in doing so, reinforce a healthcare culture that restricts patients’ access to comprehensive care.
The result of the silence around sexual health increases the risk of undetected infections and – consequently – irreversible fertility. Moreover, the failure to adequately address sexual health within fertility care is a violation of patients’ right to information, as well as their rights to sexual health and to reproduce.
The only published research that has looked at doctor-patient communication in Indonesia found that both doctors and patients wanted a more consultative communication dynamic, with a more equal dialogue between patients and doctors.
There is clearly room for a more open dialogue around how sexual morality shapes the provision of reproductive and sexual health care. But reform will have to come from within – and will require doctors to reinterpret ideas around sexual morality to better serve the needs and rights of patients.
This post is an edited extract of the book chapter “Sexual morality and the silencing of sexual health within Indonesian infertility care” in Linda Rae Bennett and Sharyn Graham Davies (eds), 2015, Sex and Sexualities in Contemporary Indonesia: Sexual Politics, Health, Diversity and Representations, published by Routledge. The book was winner of the 2015 Ruth Benedict Prize for Outstanding Edited Volume. It will be launched on 4 December at 3pm in the Ante Room in Union House at the University of Melbourne.