Intersections: Infertility, womanhood and motherhood in contemporary Indonesia: Understanding gender discrimination in the realm of biomedical fertility care

Intersections: Gender and Sexuality in Asia and the Pacific
Issue 28, March 2012

Infertility, Womanhood and Motherhood in Contemporary Indonesia:
Understanding Gender Discrimination in the Realm of Biomedical Fertility Care

Linda Rae Bennett

Womens' reproductive success determines their social status, the roles they play in a given society, and indirectly, the control they can exercise over their own lives and those of their children, and their continued wellbeing. Women's status... affects their access to property and resources, but also their access to health care, their access to information that influences treatment seeking behaviour in the event of illness,...and their ability to control their own bodies.[1]

Introduction

The principle goal of this article is to explore how narrow gender ideals of Indonesian women and their reproductive capacity underpin a culture of gender discrimination that disadvantages Indonesian women in the realm of biomedical fertility treatment. I achieve this by identifying precisely how sexist gender stereotypes apparent in society more generally manifest in the realm of fertility treatment. Specifically, I explore fertility doctors' attitudes towards infertile women, highlight the gender inequality in clinic practices and treatment guidelines, and critique the power asymmetry in doctor-patient interactions. This critique is integral to a broader study of Compromised Fertility in Indonesia, which constitutes the first comprehensive social research into infertility among Indonesians.[2]
While this paper concentrates on interactions, attitudes and practices that occur in the biomedical realm, it is important to note the preference for medical pluralism in Indonesian societies, including spiritual, traditional and popular healing practices.[3] My research into fertility treatment thus far has confirmed that the biomedical realm is not the dominant location where Indonesian women seek solutions to infertility. Hence, this article presents a partial picture, examining closely one sphere in which Indonesian women negotiate their fertility concerns, and how gender dynamics are central to their experiences in this sphere. Despite this focus on one piece of a significantly larger puzzle, I believe this part of the jigsaw is highly pertinent to developing a deeper understanding of the varied ways in which gender discrimination operates within the realm of biomedical fertility treatment, and of exactly how infertile women are disadvantaged by such discrimination. This article highlights the necessity of challenging sexist beliefs about women, their roles, bodies and worth in society, both within and beyond the medical profession in order to achieve any systemic shift in the current culture of gender discrimination in the context of fertility care.
The article begins by providing some background information on infertility and biomedical fertility treatment in Indonesia. It then proceeds to discuss the methodology of the project. The next section explores dominant constructions of motherhood, womanhood and infertility prevalent in Indonesian societies to provide a foundation for understanding how popular notions of gender and sexuality underpin gender discrimination in the realm of fertility treatment. The core section of the article is concerned with explicitly identifying how gender discrimination operates in the context of biomedical fertility care. This involves examining doctors' attitudes, women's experiences, clinic practices and medical guidelines. I conclude the article with a discussion of the consequences of gender discrimination and suggest what is required for change.

Background to the research and methodology
Infertility among Indonesian couples is estimated to be at least 12 percent, according to the Indonesian Association of Obstetricians and Gynecologists (POGI).[4] From an analysis of the 2002 Indonesian Demographic Health Survey data the World Health Organisation (WHO) recently concluded that 22 percent of married female respondents reported infertility.[5] These estimates are comparatively high when compared to those reported in better resourced nations. Lower levels of development are thought to be associated with higher levels of non-genetic and preventable causes of infertility such as poor nutrition, untreated sexually transmitted infections (STIs), unsafe abortion, exposure to smoking and exposure to leaded petrol and other environmental pollutants.[6] Amidst overall high incidences of infertility in Indonesia, rates of female and male infertility are thought to be equivalent.[7] Despite parallel infertility rates between the sexes, men seek treatment (both biomedical and alternative) at a significantly lower rate than women. Consequently, women form the focus of this study as they are most visibly seeking fertility treatment and thus are the easiest to access as research participants. Women are also overwhelmingly perceived as being the party responsible for a couple's infertility, and subsequently the social suffering associated with infertility tends to be greater for them than their husbands.[8]
The majority of Indonesian women who experience fertility problems do not access specialist biomedical care due to a range of barriers that are yet to be fully understood.[9] In a recent discussion regarding access to treatment, a POGI spokesperson estimated that approximately 3.9 million Indonesian couples will be experiencing fertility difficulties during their reproductive careers, and yet less than 5 percent of those couples will ever seek specialised medical treatment—including assisted reproductive technologies (ART).[10] A key barrier to accessing biomedical fertility care is undoubtedly poverty. Lack of financial resources deters women from even contemplating biomedical fertility treatment due to fears about the prohibitive costs involved. Therefore, the women whose experiences are depicted here belong to a minority who can afford to access biomedical fertility care. Indonesian women who do present to reproductive specialists are typically well educated and affluent. However, as this paper reveals their high levels of education and relative affluence does not appear to undercut their subordinate positioning in doctor/patient relationships.
This article stems from my interaction with two groups of key informants. The first are Indonesian women who have experienced compromised fertility and have sought out biomedical fertility treatment. The second are Indonesian obstetricians and gynaecologists (known colloquially as OBSGIN in Indonesia) who treat infertility. The article draws upon life histories with twenty married women of varied ethnicity, the majority of whom (n=18) are Muslim. Of these twenty women, five have been successful in having biological children, four have adopted children, and eleven remain childless. In-depth interviews, informal group discussions, and observations of industry training workshops and seminars have been used to collect the perspectives of OBSGIN. It is important to note that none of my women informants have disclosed the names of their treating doctors. Thus, women's descriptions of their interactions with specific doctors cannot be linked with any of the doctors who have also acted as key informants.
In-depth interviews with eleven OBSGIN, all of whom have been male, have been conducted thus far. This reflects the gender imbalance in biomedical fertility consultants in Indonesia, whereby males currently outnumber women at around five to one. To date, I am able to comment only on patterns of 'female patient' and 'male doctor' gender dynamics as I am yet to include women fertility doctors as informants. While gender relations are undoubtedly important in understanding patterns of doctor-patient interaction, marked differences in social status between patients and doctors that are compounded by the enormous esteem with which doctors (particularly specialists) are held in Indonesian society, also underpin the power dynamics between male and female patients and their doctors. The doctors whose views are included in this article are all registered fertility consultants, who are specifically qualified to practice fertility medicine. Yet, it is common in Indonesia for OBSGIN who lack specialised training and certification in fertility medicine, to offer fertility treatment to patients. While high tech treatments such as ART can only be offered at accredited clinics, diagnosis and low tech treatments for infertility can legally be provided in any registered OBSGIN practice. Consequently, women often consult OBSGIN who may not have the particular skills or full knowledge required to offer the best diagnosis or treatment available.
Ethnographic fieldwork with women fertility patients and OBSGIN was conducted over six months in 2009 and 2010, and will be followed by further fieldwork over the next three years. Interviews were conducted with informants residing in Denpasar, Jakarta, Mataram, Surabaya and Yogjakarta. Names of fertility clinics and identifying characteristics of doctors and patients have been excluded from this article to ensure their anonymity, and pseudonyms have been used when quoting informants. A final note on methodology concerns my relationships with the Indonesian fertility doctors who are involved in ongoing ways with this research. I would describe these relationships as being characterised by mutual respect and a shared concern for improving the quality of fertility care in Indonesia. Nonetheless, this article involves a pointed critique of doctors' attitudes and practices, which I believe is necessary in order to begin to address our shared goal of promoting the best quality of fertility care possible.

Motherhood, womanhood and infertility in contemporary Indonesia
At the heart of Indonesian women's fear of not becoming mothers is the fear of never having a child to love, to raise, or to call one's own. As one infertile woman explained, it is the fear of always having an 'empty heart' (hati kosong). This core emotional response is compounded by a myriad of negative social meanings and consequences that are attached to childless women in Indonesian society. The dominant construction of idealised womanhood in Indonesia depicts childless women as inadequate, and unsuccessful for failing to achieve their socially designated roles as mothers.[11] The popular notion that women who fail to become mothers are essentially incomplete or lacking is succinctly encapsulated by the words of a young Indonesian woman from Lombok, who described her desire to become a mother despite still being in her teens, in the following way; 'perempuan tidak lengkap tanpa anak' (a woman is incomplete without a child). Individuals or couples without children are also typically understood to be highly vulnerable in their old age, as care for the elderly is still a social responsibility that is primarily met from within the family and most often by one's children in Indonesia.[12]
Parenthood for both men and women is typically highly desirable and an indicator of adulthood throughout Indonesia. Yet it is only motherhood that has been actively promoted by the state as integral to women being successful members of Indonesian society (and not fatherhood for men).[13] The state's positioning of motherhood as central to women's identities can be detrimental to those women who cannot or may choose not to become mothers. State gender ideology during the New Order period (1965 –1998), which Julia Suryakusuma labelled 'State Ibuism' (ibu literally means mother) perpetuated a narrow ideal of acceptable motherhood. State Ibuism promoted the systematic domestification of women, officially positioning them as appendages to their husbands, and valuing women solely on their ability to reproduce, raise children and nurture the 'modern' Indonesian nuclear family.[14] An effect of this ideology has been the privileging of the role of 'housewife'. Freedom from having to be involved in generating household income is now widely considered a privilege for women and is strongly associated with middle class and elite status.[15] In contrast, women who work outside the home are thought to be less able to care properly for their children, and are often criticised for neglecting their 'natural' role as mothers.[16] Despite the reality that the majority of married Indonesian women need to generate some household income to meet their families' needs, and the fact that Indonesian women have historically been very active economic agents, the ideal of the domesticated mother/housewife has been relentlessly promoted in national development ideology.
The assumptions that motherhood is women's primary role in society, and that women are essentially responsible for reproduction, have had significant implications for both fertility treatment and family planning in Indonesia. The National Family Planning Program has had an overwhelming emphasis on female methods, and yet has not included infertility treatment for women within its essential services. While the Indonesian Family Planning Program has been hugely successful in its goal of reducing the national total fertility rate (TFR) (the TFR fell 50%, from 6.0 in 1970 to 2.59 in 2000), women's reproductive rights were a marginal consideration up until the Reformation Era (post 1998).[17] During the New Order regime, state policy treated women's health as synonymous with maternal health, and maternal health was conflated with the use of modern contraception.[18] Indonesian women have been expected not only to become mothers, but to control their maternal desires by limiting their family size to two children for the good of the nation. These assumptions are strongly reflected in the attitudes of the fertility doctors discussed below.
Beyond motherhood, idealised womanhood in Indonesia is constituted by a range of socially sanctioned 'feminine' characteristics. Although feminine ideals vary for women of different age, ethnic and class groups, a number of normative notions of femininity prevail across Indonesia. Ideally, an Indonesian woman is not just a mother, but is required to practise maternal self-sacrifice for the welfare of her family.[19] Personal interest and initiative are seen as an anathema to the 'good Indonesian woman'. Public expressions of autonomous female desire are shunned; threatening to the status quo and associated with 'deviant' out of control women. The model Indonesian woman is also a person who exercises restraint; she is polite, mild mannered and never loses control.[20] She is expected to defer to male authority in public decision making, which has serious implications for women's positioning as fertility patients.
The essentialism of Indonesian motherhood has also been perpetuated within conservative Islamic discourses by emphasising the 'duty' of Muslims to marry and reproduce.[21] However, in the Reformation Era, the opening up of political and religious debate has seen gender politics become fertile ground for significant power struggles in Indonesian society. As Kathryn Robinson has documented, recent history has involved ongoing attempts to establish alternatives to the dominant stereotype of the good Indonesian woman.[22] Indonesian women strategically appropriated 'motherhood' as a respected identity to gain political ground when protesting against the economic and political crises at the end of the New Order.[23] Yet, despite the ongoing contestation of the meanings of motherhood and womanhood in contemporary Indonesia, childless women continue to be pitied, pathologised and excluded from full membership of society. More inclusive and realistic ideals of womanhood that are not predicated on essentialised notions of motherhood have remained marginal.

Discriminatory attitudes embedded in doctors' views of women
Gender discrimination in the realm of biomedical fertility care is evident in the sexism embedded in fertility doctors' attitudes towards their women patients. A key theme in interviews with fertility doctors was the progression and uptake of fertility treatment in Indonesia over the past decade. The quote below highlights the prevalent attitude among fertility doctors that women are essentially to blame for infertility.
This interview excerpt powerfully illustrates popular sexist stereotypes about what it means to be a successful woman in Indonesian society. It is clear from this doctor that women are thought to have, or amount to, nothing if they are not mothers. Evidently, in this doctor's view for a woman to be well educated and to have a career is meaningless if motherhood is not achieved. Reading further into this quote we can infer that women themselves are responsible for infertility, they become 'the problem' when they transgress gender norms and put what are perceived as male pursuits such as higher education and a career before the female imperative of reproduction. The doctor's assertion that his patients are 'marrying too late' is countered by national demographic data on the singulate mean age at marriage. The most recent data available suggests that while urban and more highly educated women do tend to marry a few years later than their poorer rural counterparts, Indonesian women are still overwhelmingly married by the age of twenty-five.[24]
Due to the high value placed on children and their centrality to the notion of family, Indonesian women typically attempt to conceive as soon as they are married, even if this means a temporary interruption to higher studies for more privileged women.[25] Despite unsuccessful attempts at unassisted conception, women often delay seeking biomedical treatment for years. There are a variety of reasons for these delays.[26] Many also see multiple doctors before they find one who they feel can help them. Typically, women with fertility concerns do not believe that late marriage is the cause of their fertility problems. In many cases women who present to doctors in their thirties have been married and attempting to have children for five or more years. They may also have attempted a range of alternative therapies before trying their luck in the biomedical realm. In such cases, it is clearly not women's age of marriage that reduces their likelihood of conception, but rather delays in their presentation to biomedical services, that could be perceived as compromising their chances of success due to more advanced age.
Doctors also commonly view women as responsible for the failure of their fertility treatment. According to the doctor quoted below, treatment failure can be blamed on the undisciplined bodies and emotions of his female patients.
From this doctor's perspective, infertile women are understood as undisciplined, out of control, and desperate—in short hysterical. According to this doctor this hysteria is innate to women and needs to be controlled in order for women to be redeemed through successful fertility treatment. However, despite seeing women as biologically and emotionally culpable for their infertility, doctors are not typically openly hostile towards infertile women. Rather, doctors generally express considerable sympathy and paternalism towards their women patients. Fertility doctors, often acknowledge that women suffer greatly as a result of infertility, and they are genuinely committed to assisting such women to conceive. From the doctors' perspective, they do their best to help, instructing these 'desperate' women to control themselves and providing the medical technologies required to discipline women's bodies. Women fertility patients are understood as both the cause of infertility and the cause of treatment failure, the onus lies with them, yet the formal authority in patient/doctor interactions lies with doctors (who are usually men).

Discriminatory clinic practices and medical guidelines
An inordinate focus on women's role within reproduction and subsequently their failure to conceive is not just apparent in doctors' attitudes. While most clinics articulate an official policy of treating 'the couple' for infertility, this policy appears to be undermined by the persistent attitudes that reproduction is essentially a woman's duty and that men are subsequently absolved of responsibility for participating in fertility treatment.
In this doctor's approach, women are clearly not treated as autonomous decision makers. While husbands are assumed to be autonomous actors—'who cannot be forced'—there is no such assumption for women. It is entirely reasonable to expect any couple to confer on their treatment options and make a decision based on their mutual goals. However, the fact that only men are accorded the status of autonomous decision makers is highly discriminatory. In the scenario described above, a woman's consent to treatment is simply presumed by her presence at the consultation, whereas a man's explicit consent for testing and treatment is thought to be necessary. It is accepted that a woman will follow the doctor's recommendations and her husband's wishes. She will be compliant with what men direct her to do. This perception of women patients as passive and docile has also been noted elsewhere in Indonesia. In the field of medicalised birth for Balinese women, Lyn Parker has identified the negation of women patients' dignity and their treatment as 'docile bodies'.[27] Wider critiques of the power relations inherent in modern reproductive medicine have also revealed how women from varied cultural backgrounds have come to be positioned as passive objects of medical intervention.[28] Such positioning negates women's ability to negotiate health care, to negotiate informed consent and ultimately to refuse poor quality treatment.
In the approach above, a man's pride over his virility is privileged over best medical practice, and the fear of emasculating a husband prevails over the medical imperative of accurately establishing the cause/s of the couple's infertility. Conversely, it is assumed that a woman's pride or self esteem, can and will be compromised, in order to protect that of her husband. Again the sexist assumption that infertility is a women's problem and that it is a women's duty to solve the problem is prominent in fertility doctors' attitudes, and in this case directly influences actual clinical practice despite the rhetoric of treating 'the couple'.
The consequences of failing to implement the policy of treating couples are illuminated by the experiences of Mala, quoted below. From the age of twenty-six, Mala underwent six years of biomedical fertility investigations and three unsuccessful cycles of in vitro fertilization (IVF), without her husband's sperm being assessed. After the failure of the third IVF cycle, Mala herself requested that her husband have his sperm checked, which led to the confirmation that he was the infertile party in the marriage.
Mala's words attest to the reality that women are neither ignorant nor necessarily accepting of the gender discrimination they experience in fertility care. In this instance, Mala felt the injustice of her experiences so keenly that she and her husband opted to adopt a child, and postpone their efforts to have a biological child indefinitely.

As Terri Kapsalis asserts, teaching medical practice involves the process of constructing medical realities.[29] It is through the demonstration of medical protocols that doctors learn how to position themselves in relation to their patients.[30] Medical education also plays a critical role in determining how patients are viewed and positioned within medical interactions. The guidelines below (also referred to as the 'protocol') were presented at a training workshop for Indonesian OBSGIN wishing to specialise in the area of fertility treatment. The guidelines were for 'an initial fertility assessment of the couple'. They were presented in English and the content of the original slides has not been altered.

Women / wives	Men / husbands
First take relevant history: Age Menstrual history Marital history Obstetric history - if secondary infertility History of surgery Family history of infertility Then do: General examination Local (vaginal) examination Lab tests - routine and endocrinal	First take relevant history: Age & occupation Smoker Addictions Sexual history and STIs History of surgery Family history of infertility Then do: General examination

Figure 1: Guidelines for an initial fertility assessment of the couple

These guidelines view age as an important indicator of fertility for both women and men. Occupation however, is apparently not relevant to women's health or fertility. Indonesian fertility specialists encountered throughout this study have expressed concern regarding the impact of environmental (lead poisoning) and workplace factors (industrial pollution) on men's fertility. However similar discussions regarding how environmental and occupational factors may impact on women's fertility have been notably absent. The ideological domestification of Indonesian women also extends to the focus on their bodies as primarily reproductive bodies, rather than as productive bodies that also occupy the public realm. This oversight stems from the privileging of motherhood as the central (and essential) component of successful Indonesian womanhood. The failure to include women's occupation in the guidelines reinforces the dominant stereotype of the good Indonesian woman as a 'mother and home maker', and devalues the enormous contributions women make to household incomes and society more broadly.
The protocol above concentrates exclusively on women's reproductive capacity, and ignores their sexual health. Investigations for STIs are not recommended for women and their sexual history is also left unaddressed. Apparently, the only sexual history relevant to an Indonesian woman is that of her husband. Within these guidelines the only opportunity to establish whether women may have had more than one sexual partner is implicitly, through asking about women's marital history. However, by focusing on their marital history rather than their sexual history, the domestification of women's sexual desire remains unchallenged. Moreover, as the training facilitator suggested, the question of marital history can be posed in a manner that suggests its purpose is to assess whether fertility difficulties have been apparent in past marriages. In doing so the investigation is safely focused on female reproductive capacity thus avoiding the need to acknowledge female sexuality.[31]
In sharp contrast to women, men are explicitly acknowledged within the protocol as sexual beings whose sexual history is deemed relevant to their reproductive health. This reflects the normative expectation that Indonesian men will typically have more than one sexual partner in their lifetimes—a social expectation that is not extended to Indonesian women who wish to conform to dominant notions of the good woman.[32] By extension, the acknowledgment that men may have more than one sexual partner, both before and while married, also points to the associated risk of men contracting STIs. Ironically, the two STIs associated with the greatest reductions in fertility worldwide, which are chlamydia and gonorrhea, are either asymptomatic for women (chlamydia) or often have very mild or nonspecific symptoms that are easily mistaken for other types of infections among women (gonorrhea), and yet women are not routinely screened for STIs. Moreover, the permanent damage caused to women's reproductive potential, due to blocked fallopian tubes as a consequence of these infections, makes the health burden that women endure as a result of such diseases significantly greater than for men. In this instance, the sexual double standards embedded in the dominant moral code of Indonesian society function in the medical realm to put women at greater risk of having untreated STIs and associated infertility. I posit that the critical links between sexual health and infertility for Indonesian women are not being adequately addressed in treatment protocols precisely because of the reluctance of Indonesian society, within which fertility specialists are firmly embedded, to affirm women's sexual autonomy.
Men's sexual potency and the possibility of men contracting STIs are acknowledged in the treatment protocol, yet the notion that men may be equally, or solely, responsible for a couple's fertility difficulties is ignored. According to this model, it is women's reproductive organs and hormonal makeup that are the default focus of initial infertility investigations. The dual messages in this model are clear: reproduction is women's business (and responsibility); and sexuality is men's business and privilege. The reluctance to invade the privacy of men's bodies, through performing routine genital examinations or testing sperm, also contrasts starkly with the assumption that women's bodies will automatically become the objects of medical investigation in the quest to determine the causes of infertility. Precisely because the woman is assumed to be the infertile party in a marriage, local (genital) investigations and lab tests are recommended.
These divergent notions of gender and gendered bodies are also salient in the construction of the male body as open to intoxication and addiction. Good women in Indonesian society are simply not expected to smoke, drink alcohol or have substance addictions and if they do, they are expected to conceal the evidence.[33] Indonesian masculinity however, is positively associated with smoking, and men who do not smoke are rare.[34] The notion of masculine playfulness and being 'a rogue' is often also used to explain men's use of alcohol and other drugs in a manner that does not reflect negatively on their status.[35] For women, this is not the case, and public disclosure of alcohol and drug use typically damages the reputations of women. The failure to investigate the significance of smoking and drug use on women's reproductive health within these guidelines again reflects dominant gender ideals. It assumes that female fertility patients will all live up to the iconic ideal of the good woman and therefore will not encounter the same health risks as their spouses.
This gendered critique of a standard treatment protocol used to educate Indonesian doctors demonstrates exactly how gender discrimination becomes routine and institutionalised, from the initial fertility assessment. It follows that when the protocol for fertility assessments incorporates the assumption that women are the cause of infertility, that women will also be disproportionately targeted for treatment and will experience further discriminatory attitudes throughout their treatment. This discriminatory pattern is not only problematic because of its gender bias, but it also promotes medical ineptitude, as it overlooks the possibility that fertility may be due to either male factors or a combination of male and female factors. When men are not incorporated fully into fertility assessments and treatment, the potential success of the fertility treatment is jeopardised from the outset.

Women's rights and doctor/patient interactions
This section of the article shifts into the realm of the fertility consultation to examine the dynamics of one woman's experiences of treatment. The excerpt below is from the life history of a woman who has endured a prolonged and unsuccessful search for a correct biomedical diagnosis and appropriate treatment for secondary infertility. At the time we met, Ninuk was forty-three years old, with one healthy teenage son. She had suffered from secondary infertility for sixteen years, during which she had four miscarriages and one stillborn child. Below Ninuk describes just one of the many encounters she has had with OBSGIN in her quest for answers to her fertility problems.
Nunik's experiences powerfully illustrate the gender asymmetry present in doctor/pateint interactions. She is explicit in describing the dehumanisation she felt during her physical examination, likening her treatment to that of a 'cow' and 'not like a person'. Ninuk also asserted her distress at the doctor not asking permission to examine her, or even speaking to her in an appropriate manner. It is sometimes assumed that in lesser developed nations, where patient advocacy and consumer groups are not well formed, that people will be less aware of their rights to informed consent. However, Ninuk's response to her encounter with this doctor demonstrates a keen awareness of her right to human dignity and to determination over her own body in the context of reproductive care. Regardless of whether her concerns were expressed using formalised terminology such as 'informed consent', Ninuk clearly felt her right to indicate agreement to a physical examination was not respected. Moreover, Ninuk's desire and right for information about her body, was disregarded on multiple occasions by numerous OBSGIN. While Ninuk clearly wanted a diagnosis, she eventually abandoned her efforts to understand her fertility problems without receiving results to her tests or gaining a plausible explanation for the cause of her infertility.
Similar experiences to Ninuk's were not uncommon among the group of twenty women who reflected on their interactions with doctors. The failure to provide women with adequate information and counselling appears to be widespread. In many cases women's desire for information on the causes and treatment of their infertility is made explicit, but is ignored or inadequately addressed by doctors. While women are caught in prolonged cycles of inadequate diagnosis and ineffective treatment, the likelihood of conceiving decreases as they age. Because age is a greater factor for women than for men, in determining the likelihood of both assisted and unassisted conception, women are disproportionately disadvantaged by poor quality fertility care. Women's narratives also indicate that negative experiences with fertility doctors are a barrier to them accessing follow up care and act as a prime motivator for women to switch between doctors. Sadly, the trauma associated with unpleasant fertility consultations (such as Ninuk's) goes unregistered and unaddressed, as there are no formal complaint mechanisms in place. Thus, the impetus to ensure quality of care in the fertility field remains low. Women who experience inadequate fertility investigations typically perceive them as a waste of their time and money, and are often relieved when they reach the point when they decide they will no longer seek assistance from biomedical specialists (as was the case for both Mala and Ninuk).

Conclusion
The foregoing discussion has demonstrated how fertility doctors tend to hold women responsible for infertility both biologically (due to their failed bodies) and socially (due to the pursuit of education or careers). Doctors also tend to blame their women patients for unsuccessful fertility treatment due to their innate faults as women (e.g. due to their hysteria). As a result women are treated within the realm of biomedical fertility care as docile bodies that need to be disciplined in order to make them succeed by fulfilling the ideal of motherhood. Women's subordinate position within fertility treatment is further reinforced by guidelines that incorporate sexist assumptions that all women are primed for motherhood, that their alternative roles and identities are irrelevant, and that they have no sexual history (other than that with their husband). In contrast, men are understood to have a relevant sexual history but, unlike women, are not considered to be docile bodies. Men's right to active consent to examination, testing and treatment is acknowledged. The example of doctor/patient interaction examined above highlights how doctors' attitudes towards women, as well as clinic practices and treatment guidelines, can coalesce to result in poor quality fertility care. This low quality of care, which is predicated on discriminatory attitudes, undermines women's faith in fertility doctors and often compromises the success of their treatment due to reluctance to attend follow up care or to persist with treatment.
The consequences of gender discrimination in the realm of biomedical fertility care are manifold. The gender imbalance in fertility care, whereby women are disproportionately targeted for fertility investigations and treatment means that women shoulder more than their share of responsibility for a couples' compromised fertility. In many cases this is despite the reality that female factors are not the cause or sole cause of the couples' problems. Men's relative absence from biomedical fertility care also discriminates against them, because they are not receiving adequate reproductive care themselves. Ultimately, the failure to adhere to best practice guidelines and treat couples for infertility, disadvantages both women and men because fertility treatment is most successful, most efficient and most cost effective when men are fully included in the process.
There is currently a culture of gender discrimination within the realm of biomedical fertility care, which leads to recurrent cycles of disadvantage for women with compromised fertility. The sexist attitudes underpinning discrimination against women stem from dominant beliefs about womanhood in wider Indonesian society, and their re-articulation in the medical arena compounds the social suffering associated with infertility for women. Many women have described how their suffering has escalated following unsuccessful fertility treatment (Mala's experiences are a case in point), as they feel they have done everything in their power to find a solution to infertility and yet are still perceived as having failed. The links between gender discrimination and poor quality of fertility care ensure the perpetuation of this cycle of disadvantage for women. When women receive poor quality care they are less likely to have successful outcomes, and because women are held responsible for infertility this results in further discrimination against them. Breaches in patient rights reported by women, such as the failure to provide adequate information and counselling, or to respect women's right to informed consent, are supported by sexist notions of women as passive acceptors of medical intervention, and the assumption that women will necessarily comply with their husband's and doctors' wishes. Women's experiences of poor quality care also impact upon their health seeking choices. Some are reluctant to continue treatments that they feel ill-informed about. Others fail to attend follow up appointments after feeling disrespected or traumatised in prior consultations. Due to negative experiences, other women adopt a pattern of switching between multiple doctors—which is costly and frustrating for them—and some simply drop out of their quest for biomedical solutions to infertility.
A mix of factors is likely to be responsible for the failure to ensure an adequate quality of fertility care in different situations and these include skills deficits, time pressure, and the belief among some doctors that the provision of information and counselling are not essential. However, based on my observations of the ways in which male doctors discuss their female fertility patients, I propose that the institutionalised asymmetry in doctor/patient relations, whereby doctors are considered the experts on women's bodies and women are considered to be passive recipients of doctors' knowledge and instructions, underpins doctors' lack of attention to women's rights as patients. Improving the quality of fertility care will require the widespread promotion of client-oriented and rights-based approaches, in which gender stereotypes and sexist beliefs about women and their reproductive roles are openly challenged. It also necessitates the revision of teaching materials to correct gender bias, and universal adherence to models of best practice designed to promote gender equality and the best medical outcomes. This article has shown that fertility doctors are not immune to the gender bias within their profession or in wider Indonesian society. However, through a systematic exposure of the disadvantages for their patients that stem from such gender bias, it is possible to see exactly how and where the foundations of gender discrimination can be challenged. Precisely because of the high esteem in which fertility doctors are held in Indonesian society, and because of the genuine compassion many doctors feel for their fertility patients, I believe there is enormous potential for Indonesian fertility doctors to play a leading role in shifting the culture of gender discrimination in the field of fertility medicine.

Acknowledgements

I wish to thank: all the women and their families who have shared their stories; the fertility doctors who have opened up their practices and answered my questions frankly; Eni for her transcribing; my fellow panelists at the Women in Asia Conference 2010 where this paper was first presented; Mia Urbano for her constructive feedback; and the Australian Research Council for funding the project.

Endnotes

[1] Pranee Liamputtong Rice and Lenore Manderson, 'Introduction in Maternity and Reproductive Health in Asian Societies, eds Pranee Liamputtong Rice and Lenore Manderson, Amsterdam: Harwood Academic Publishers, 2006, pp. 1–20, p. 3.

[2] To provide the necessary context for understanding Indonesian women's experiences of infertility, the Compromised Fertility project examines a number of interrelated topics, including: the history and contemporary use of biomedical fertility treatment in Indonesia; the regulatory framework of fertility treatment; social suffering related to infertility; and infertility and ethno-gynaecology in various Indonesian communities. The project is funded by the Australian Research Council, and is a Discovery Project awarded under the Future Fellowships scheme.

[3] For instance see Linda Connor's introductory essay on the pluralism of healing in Asian societies, Linda Connor, 'Healing powers in Contemporary Asia,' in Healing Powers and Modernity: Traditional Medicine, Shamanism, and Science in Asian Societies, ed. Linda Connor and Geoffrey Samuel, Westport: Bergin and Garvey, 2001, pp. 3–25. For an extensive discussion of the history and functions of medical pluralism in Indonesia see Steve Ferzacca, 'Governing bodies in New Order Indonesia in New Horizons in Medical Anthropology, ed. Charles Lesley, London: Routledge, 2002, pp. 35–57.

[4] Budi Wiweko, 'Industry profile paper,' presented at the Annual Meeting of the Indonesian Association for In Vitro Fertilization (PERFITRI), Jakarta, 6 July 2009, pp 1–16.

[5] For a detailed discussion of the variation in infertility rates in developing countries see the World Health Organization (WHO), 'Infecundity, infertility, and childlessness in developing Countries DHS Comparative Reports no. 9. Geneva: WHO, 2004, pp 1–56.

[6] For an overview of environmental causes of male infertility see Stewart Irvine, 'Epidemiology and aetiology of male infertility,' in Human Reproduction, vol. 13, no. 1 (1998): 33–44.

[7] Budi Wiweko, 'Industry profile paper,' p 4.

[8] Linda Rae Bennett, 'Social suffering and infertility in Indonesia,' paper presented at the 18th Annual Conference of the Indonesian Association for Obstetrics and Gynecology, Jakarta, 6–10 July 2010.

[9] Linda Rae Bennett, 'Barriers to accessing infertility care in Indonesia,' invited paper at the 18th Annual Conference of the Indonesian Association of Obstetrics and Gynaecology, Jakarta, 7–9 July 2010.

[10] ART were established in Indonesia in the late 1980s and there are now sixteenregistered clinics nationally. While limited in number and concentrated in central Indonesia (mostly in Java) Indonesian ART clinics have state-of-the-art technology and the cost of treatment is parallel to the cost in Australia. Success rates for in vitro fertilization (IVF) in different Indonesian clinics fall in a similar range to those reported internationally, that is between 15% and 45%. POGI estimates that less than 30% of the current capacity of Indonesian ART services is being utilised. Budi Wiweko, '23 years of IVF in Indonesia: Practice and data collection,' paper presented at the 5th Annual Conference of the Indonesian Association for Fertility and Endocrinology, Denpasar, 22–26 January 2011.

[11] Marcia Inhorn has documented how infertile women in Egypt also experience a similar sense of lack as a result of their experiences of 'missing motherhood.' She has also commented extensively on the ways in which Middle Eastern patriarchal institutions, particularly the Egyptian family, have perpetuated narrow conceptions of womanhood in Egypt that require women to become mothers in order to achieve successful membership of their society. See Marcia Inhorn, Infertility and Patriarchy: The Cultural Politics of Gender and Family Life in Egypt, Philadelphia: University of Pensylvania Press, 1996.

[12] Raden Koentjaraningrat, Javanese Culture, Singapore: Oxford University Press, 1985.

[13] Susan Blackburn, Women and the State in Modern Indonesia, Cambridge: Cambridge University Press, 2004, pp. 139–40.

[14] Julia Suryakusuma, 'The state and sexuality in New Order Indonesia,' in Fantasizing the Feminine in Indonesia, ed. Laurie Sears, Durham: Duke University Press, 1996, pp. 92–119; Julia Suryakusuma, State Ibuism: The Social Construction of Womanhood in the Indonesian New Order, Masters Thesis, The Hague: Institute of Social Studies, 1987.

[15] Valerie Hull, 'Women in Java's rural middle class: progress or regress?' in Women of Southeast Asia, ed. Penny Van Esterik, Illinois: Northern Illinois University, 1982, pp. 26–39.

[16] Siti Ruhaini Dzuhayatin, 'Role expectation and the aspirations of Indonesian Women in socio-political and religious contexts,' in Women in Indonesian Society: Access, Empowerment and Opportunity, ed. M. Atho Mudzhar, Yogyakarta: Sunan Kalijaga Press, 2002, pp. 154–94, p. 173.

[17] Blackburn, Women and the State in Modern Indonesia.

[18] Linda Rae Bennett, Women, Islam and Modernity: Single Women, Sexuality and Reproductive Health in Contemporary Indonesia, London: Routledge, 2005.

[19] Madelon Djajadiningrat-Nieuwenhuis, 'Ibuism and priyayization: path to power?' in Indonesian Women in Focus, ed. Elsbeth Locher-Scholten and Anke Niehof, 1987, pp. 42–51.

[20] Sylvia Tiwon provides a detailed discussion of the historical and contemporary importance of self-control to Indonesian notions of ideal womanhood in 'Models and maniacs: articulating the female in Indonesia,' in Fantasizing the Feminine in Indonesia, ed. Laurie Sears, Durham: Duke University Press, 1996, pp 47–70.

[21] Dzuhayatin, 'Role expectation and the aspirations of Indonesian women in socio-political and religious contexts,' p. 175.

[22] Kathryn Robinson, Gender, Islam and Democracy in Indonesia, London: Routledge, 2009.

[23] See Robinson on the 'politics of milk' for further discussion of women's political power as mothers, Gender, Islam and Democracy in Indonesia, 2009, pp.151–53.

[24] According to Gavin Jones, the singulate mean age of marriage for Indonesian women recorded in the 2006 National Census was 23.5 years. See Gavin Jones, 'Changing marriage patterns in Asia,' in Asia Research Institute Working Paper Series, no. 131, 2010, pp. 1–23.

[25] See Linda Rae Bennett's discussion of the strong impetus not to delay childbirth after marriage for Indonesian women in 'Young Sasak mothers—"tidak manja lagi": transitioning from single daughter to young married mother in Lombok, Eastern Indonesia,' in Growing up in Indonesia: Experience and Diversity in Youth Transitions, ed. Kathyrn Robinson, Amsterdam: KLTIV Press (manuscript submitted).

[26] Popular reasons for delaying or avoiding biomedical infertility treatment include: strong religious faith, fear of being diagnosed as sterile, fear of invasive treatments, previous negative experiences in the biomedical realm, fear of being unable to pay for treatment, lack of knowledge about where to access treatment and reluctance to travel far distances for treatment. Bennett, 'Barriers to accessing infertility care in Indonesia.'

[27] Lyn Parker, 'Resisting resistance and finding agency: women and medicalized birth in Bali,' in The Agency of Women in Asia, ed. Lyn Parker, London: Marshall Cavendish, 2005, pp. 62–97.

[28] Terry Kapsalis, Public Privates: From Both Ends of the Spectrum, Durham: Duke University Press, 1997, p. 63.

[29] Kapsalis, Public Privates, pp. 63–69.

[30] Kapsalis, Public Privates, p. 63.

[31] The failure to acknowledge women's sexual autonomy is not just problematic in terms of women's rights, but also has grave consequences in terms of preventative approaches to health care. It is now widely acknowledged that premarital sex does occur for Indonesian women and that the morbidity stemming from untreated STIs and unsafe abortion among single women is significant. Thus, the denial of female sexuality outside of marriage also amounts to the denial of adequate reproductive and sexual health care for a growing number of women who negotiate their sexuality outside of marriage. Bennett, Women, Islam and Modernity.

[32] Bennett, Women, Islam and Modernity.

[33] Harriot Beazley, '"I love dugem": young women's participation in the Indonesian dance party scene,' in Body, Sexuality and Gender among Contemporary Indonesian Youth, Special Edition of Intersections: Gender and Sexuality in Asia and the Pacific, ed. Lyn Parker and Linda Bennett, issue 18, October 2008, online: http://intersections.anu.edu.au/issue18/beazley.htm, accessed 21 March 2011.

[34] Lee Nawi and Lauren Weinehall, '"If I don't smoke, I'm not a real man"—Indonesian teenage boys' views about smoking,' in Health Education Research, vol. 22, no. 6 (2007): 794–804.

[35] Maria Platt, Patriarchal Institutions and Women's Agency in Indonesian Marriages: Sasak Women Navigating Dynamic Marital Continuums, PhD Thesis, Melbourne: La Trobe University, 2010.

Published with the support of Gender and Cultural Studies, School of Culture, History and Language, College of Asia and the Pacific, The Australian National University.
URL: http://intersections.anu.edu.au/issue28/bennett.htm
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