BOOK CHAPTER:Sexual morality and the silencing of sexual health within Indonesian infertility care

Writer              : Linda Rae Bennett

Title                 : Sexual morality and the silencing of sexual health within Indonesian infertility

                          care
Editor              : Linda Rae Bennett and Sharyn Graham Davies

Publisher         : Routledge Taylor  Francis Group

Citing

Bennett, L. R. (2015). Sexual morality and the silencing of sexual health within Indonesian infertility care. Sex and sexualities in contemporary Indonesia: Sexual politics, health, diversity and representations, 148-166.

MY SUMMARY

Having a child after a wedlock is mostly a dream for every married couple, particularly for women. Some women and spouses will seek to medical specialist in infertility clinic to achive their plan if they cannot have a child for a certain time. Unfortunately, one cause of STI’s is related to infertility like a tubal blockage rarely investigate to the spouse who have efforts to seek help in health practitioners. Some issue is  narrow morality paradigm among medical specialist issues related to sexual infidelity and proximity of one of spouse may consider not appropriate to discuss during their patient’s consultation in order to maintain the marriage bond of their patients and taboo topics. In addition, the women and spouse may feel they are low-risk of STIs and HIV due to asymptomatic diseases, hence, they might not seek any health related to their disease. The power between patient and doctor is not asymetry in Indonesia.

Some possible consideration to reduce the silence surrounding STIs in infertility clinic, first- the power of women who have good knowledge about STIs and HIV might contribute their braveness to ask the STI’s test, including HIV test for one of their efforts to have a child. Second-an open dialogue with a good partnership with patient and doctor is suggested for better treatment for infertility among spouses. Third-The healthcare also need more investment about “culturally sensitive” or “culturally appropriate” interventions in reproductive and sexual care (pp 164)

Methodology

the chapter draws upon a range of data collected between 2010 and 2012, derived from ethnographic fieldwork with 47 Indonesian women who have experienced compromised fertility and their families, as well as extensive interaction weith male dertility consultatns. My informatns are from varied stires spanning from the east of the archipelago in Lombok on to Bali, across to Yogyakarta, on to Surabaya and then finally in Jakarta. In addition to this ethnographil work, the chapter also draws upon the process and finidngs oa a survey conducted with women patients attending Indonesian fertility clinics in 2011. pp 150

IMPORTANT QUOTATION

The foundation of sexual morality in Indonesia is heterosexual marriage, which is understood as the most legitimate context for the expression of sexuality (Bennett, 2007). Following from this, the desire to create children is upheld as the most legitimate motivation for sexual relations, although sexual enjoyment within marriage is highly valued. Conversely, sex outside of heterosexual marriage is normatively labelled as deviant and immoral, with  varying degrees if immorality attached to different people and behaviours. Immoral sex encompasses premarital and extramarital sex, queer sex, prostitution and public representations of sex, which are increasingly being labelled as pornographic.  Deviant or immoral sexual behaviour is directly equated with and blamed for poor sexual health and misunderstood as the cause of STIs, including HIV. Subsequently, individuals who contract STIs are understood as, and often understand themselves as, having poor sexual morality (see chapter 5). The association between deviant sex and immorality is batant in everyday life in the ways that Indonesians speak about themselves and others. An example of this the common term for female sex workers across Indonesia-wanita tanpa susila (WTS: “woman without morals”). Pp 149

Denis Altman’s observation that the dominant tradition of monotheistic faiths have preached “abstinence outside marriage”, even allowing men varying degrees of latitude within marriage” (2010, p 195) rings true for Indonesia. Male sexuality is typicaclly constructed as naturally aggresive or hydraulic (Robinson, 2008, p 79). Subsequently, sexual promiscuity for men is often interpreted as a sign a healthy masculinity and virility, leading for few sanction for premarital  sex for young men pp 149

The legality of polygamy for Indonesian Muslim men serves as a religious justification for an inflated notion of male sexual entitlement, which often translates into a rationalisation of premarial and extramarital for men (Nurmila, 2011; Platt, 2012, see also chapter 3). Pp 149

In contrast, premarital and extramarital sex for women is always condemned, as female sexuality should ideally be constrained, passive and confined within marriage (Bennett, 2005). Autonomous female sexuality is typically viewed as dirty, threatening, sinful, and as an indication of bad or fallen woman. Recovery from public transgression of sexual morality for women is difficult. While female sex workers are typically stigmatised, their male clients are not. In general terms, women and their bodies are the key targets for public denunciations of sexual immorality in Indonesian society. Pp 149

The dymanic of moral guardianship is also a response to the moral anxieties of doctors, who may avoid speaking about deviant sex and sexual risk so as to avoid being perceived as condoning sexual immorality.  Pp 150

My exploration of field data establishes the missing links between infertility care and sexual health from multiple perspectives, incorporating those of fertility consultants, fertility partients and a team of infertility researchers. This disconnect between sexual health and fertility care I uncover throughout the chapter encompasses the silence of fertility doctors regarding untreated STIs, the absence of dicussion of sexuality and sexual function between infertile couples and their doctors and the reluctance of some doctors to conduct physical examinations of patients with suspected STIs. Pp 150

Tracking the disconnect between sexual health and infertility care

Fertility consultants and the silence surrounding STIs

The asymmetric  social hierarchy between fertility consultants and their patients-whereby the consultants occupy an extremely high social status and patients are rarely aware of their full gamut of rights- leads doctors to assume that they can and should intuit patients’ preferences rather than making the available choices explicit.  Pp 154

Dr B reveals how the intersections of conservative sexual morality and deference to class hierarchy combine with the denial of their patients’s susceptibility to STIs prevent routine screening. Dr B reveals his class bias in favour of “high-class people” who clearly need to guard their moral superiority more diligently that their imagined “low-class” counterpart, who apparently those at tisk of STIs. In this doctor’s view, wealth and education are conflacted with high class and imagined to offer some protection against STIs, when infact the doctor should be fully aware that  only consistent condom use, abstinence or fidelity (faithfulness) can protect against STI to be misintepreted as a protective factor, the prevalence of untreated STIs among the middle classes and the elite can be expected to escalate. Pp 154

Dr B is also explicit about typical doctor-patient dynamics, whereby patients tend to rel yon doctors to suggest or initiate specific diagnostic tests and treatments. He notes that in terms of patients requesting STI tests, this ‘almost never happens’. Research by Claramita et al (2013) aimed at charatirising typical doctor-patient communication in the Indonesian contet  between Indonesian doctor and their patients. This study concurs with my observations that many patients will display passive, diffident and polite behaviour during consultations, while doctors are the primary communicators, whic lead to a “paternalistic” rather than a “partnership” communication dynamic (ibid, p 16). Pp 155

Like Dr A, Dr B perceived himself as the guardian of his patients’ sexual morality-it is he who avoids the potential discomfort of suggesting a husband’s infidelity or questioning a wife’s sexual purity. Pp 155

Dr B's moral concerns also echo and reinforce the sexual double standards of Indonesian society that tolerate male sexual promiscuity, while insisting on sexual purity from unmarried women and then fidelity from married women. Pp 155

Patients' experiences of infertility care and the silence surrounding STIs

Implications of the disconnect

The provision of comprehensive medical information to patients has long been recognised as a key responsibility of healthcare providers, as a fundamental right of patients and as essential to ensuring adequate quality in healthcare. Pp 161

Provision of adequate information to patients is a prerequisite for informed consent and also improves patients' participation in decision-making and adherence to difficult treatment regimes in the context of infertility care (Schmidt et al, 2003). Pp 161

The failure to engage with sexual health also means that spouses’ rights to partner notification of STIs and BBVs are being completely ignored. Officually, Indonesian’s national HIV strategy relies on the principal of “patient referral” for partner notification of STIs, including HIV. However, it is clearly impossible for a patient to inform their sexual partners if they are unaware of the infection themselves. Clearly both the rights to sexual health and the right to reproduce are being compromised by the failure to address sexual health in this context Pp 161

The implications of these human rights deficiencies are both a symptom and reproduce gender inequalities. Higher rates of male infidelity within marriage in Indonesia mean that men are likely transfer STIs to theri whives than the reverse (Platt, 2010; Nurmila, 2011).

Conclusion: reimagining sexual moralities within reproductive healthcare

When we revisit the narratives of the womendiscussed in this chapter in this chapter, theri piroriteis are evident in Nina’s worlds: “to have a child is more important than anything else.”  Yes, there is a mismatch between doctor’s roles as moral guardians and women’s desires for optimal reproductive health and to successfully reproduce. At present, the boundaries of the moral landscape within fertility consultations typically appear to be set and maintaiend by doctors, rather than negotiated between doctors and patients. Pp 162

My data suggest that women who seek out biomedical fertility care wish to understand the possible causes of infertility, are willing to discuss and test for STIs, often have pre-existing knowledge of infidelity in their relationships and do not necessarily see themselves as immune to STIs duet o their social status. Pp 162

There is considerable divergence between women patients’ relatively open approach to sexual health and fertility doctor’s narrow policing of sexual morality within consultations. As suggested previously, doctors may well be overinterpreting the sexual  conservatism of their patients and, in doing so, they reinforce a healthcare culture characterised by narrow sexual morality that restricts patient’s access to comprehensive  care. Pp 162

The silence around STI’s and marital infidelity in fertility consultations also derives from and reinforces sexual double standards in Indonesian society that favour men’s sexual autonomy, while denying women theirs. This is a further example of how wome’s interests are compromised by privileging sexual morality and social hierarcy over health and reproduction . pp 162

A lack of awareness of the intersection between sexual and reproductive health, of which STIs and infertility are but one example, is also highly problematic because it sustain a false sense of immunity to the sexual transmission of infection in an era when the risk of transmission is rapidly escalating and awareness of that risk is critical to prevention efforts. Pp 163

I propose that the core issue inhibitting the integration of sexual health with biomedical fertility care in Indonesia is the overmoralisation of sexual health (and non-normative sexual behaviour) rather than simply the over-medicalisation of reproductive and sexual health. Pp 163

Moral othering is both a cause and consequence of the fact that many Indonesians still fail to view themselves at risk of constracting STIs, and this will not change if Indonesians who fall outside the stigmatised categories of the most at –risk groups are not encouraged to attend to their sexual health or to do test for and treat STIs.

This expressed desire for more equal dialogue between patients and doctors suggest great potential for shifting typical patterns of interaction and reorienting social herarchy within medical consultation over time. The joint process of reimahining the roles of sexual morality within healthcare willr equire considerably more human investment than typical approaches to “culturally sensitive” or “culturally appropriate” interventions in reproductive and sexual health care. Too often, such approaches are reduced to working around “cultural barriers” or respecting “cultural sensitivieties”. Pp 164

What I am suggesting is a direct and sustained engagement with how sexual morality shapes the provision of reproductive and sexual healthcare- an approach that requires a reformation from within to imagine how sexual morality and values could be reinterpreted to best serve trhe prioriteis, needs and rights of patients. Pp 164