Table 2.

Indonesia – is the debate “harm-reduction vs. human rights” meaningful?

Indonesia has one of the highest burdens of FGM/C in the world, with 51% of the girls 0 to 11 years having been circumcised [25]. In Indonesia, it is widely believed that FGM/C is a necessary fulfilment of the Islamic religion [26, 27]. The fatwa, a recognised body for the preservation of Muslim culture in a secular-led government, argues in favour of FGM/C, by defining FGM/C as the removal of the membrane that covers the clitoris, through scratching without cutting or incision of the clitoris. FGM/C in Indonesia was traditionally conducted by traditional birth attendants, as well as traditional and religious practitioners. When the government rolled out a maternal health programme to reduce maternal deaths in the 1990s, it transferred duties of maternity care and delivery to midwives. Since then clinics and hospitals have increasingly offered FGM/C as part of the delivery package with midwives being the frequently cited personnel performing FGM/C [28]. The proportion of FGM/C performed by midwives and other medical professionals has sharply increased from 32 to 52% between 2003 and 2013 [25, 29]. Countrywide, two-thirds (65%) and two-fifths (40%) of the FGM/C in urban and rural areas respectively, are now being performed by midwives and other health personnel [25]. The last decade has seen the heightening of the debate on FGM/C in Indonesia leading to periods of banning and unbanning of FGM/C. Activists call for its banning while the fatwa religious fathers lobby for its continuation. In the 1990s and early 2000s the government was silent on the WHO’s global call to eliminate FGM/C [30]. In the absence of government policy and intervention, midwives responded to women’s demands for FGM/C by conducting FGM/C in health facilities to those who requested it [28]. Following the call for the respect for women and girls’ rights surrounding FGM/C, the government banned FGM/C in 2006. In response, the fatwa lobbied the government to rescind the ban arguing that FGM/C was a cultural rite of passage for all Islamic women and must be provided upon parental request on behalf of their children, but that it must be done without causing psychological or physical danger to the woman or girl. Instead of maintaining its stance on the ban, the government gave in and spelt out conditions under which FGM/C could be done. A standard operating procedure allowing only medical personnel to conduct FGM/C in a safe and hygienic manner and to children of parents who requested it was then put in place. In 2014 women’s organizations successfully contested the policy arguing that FGM/C has no medical benefits for women and girls as opposed to male circumcision. Despite the ban that prohibits FGM/C being in place, no sanctions are given for those who transgress this law. Women’s organizations recommended that the government should address the problem, including providing rehabilitation to women living with FGM/C, criminalise the practice and campaign against the practice [25]. Medicalized FGM/C is argued to be a better of the two evils (medicalized versus traditional FGM/C) in that it is done by trained and skilled health professionals in hygienic and medically controlled situations compared to the traditional birth attendants who conduct it in uncontrolled settings with severe pain and complications [26]. However, the opposite has been reported as midwives in Indonesia, were found to perform more invasive and painful forms of excision in 68–88% observed cases compared to 43–67% cases by traditional providers [29]. There is also some concern that as FGM/C has become more medicalised, more physically invasive forms of FGM/C are now more common. However, there is also some evidence that midwives who disagree with FGM/C are performing type 1 or type 4, to satisfy parents that FGM/C has taken place but at the same time minimizing the risk to girls, thus demonstrating that the human rights arguments might gain some impact on the medicalization of FGM/C in Indonesia. In a few instances midwives are said to provide “psychological FGM/C” and not real FGM/C. Hidayana et al. argue that since parents do not know how the midwives conduct FGM/C, some midwives who do not support it pretend to be doing FGM/C to fulfil the client’s request [28]. This case also demonstrates that medical professionals are impacted on by the same social norms as parents and stresses the role medical professionals play in ending FGM/C, which is further discussed in the following section.