Putting Men in the Picture: Problems of Male Reproductive Health in Southeast Asia

Southeast Asian men exhibit a series of distinct behaviours related to sexuality and reproductive health. Traditional circumcision practices, use of penis implants, the practice of 'dry' sex, and the avoidance of condom use or vasectomy are behaviours that can place men and their partners at risk of disease and dysfunctional sexual relationships. This paper examines these issues with particular attention to Indonesia. While most married men worry about their wives’ reproductive health, substantial portions practice risky behaviours extramaritally. Many maintain exploitative expectations of sexual relations, sometimes based on gender-inequitable religious teachings. Programs to promote reproductive health in Southeast Asia need to address indigenous concepts of gender and sexuality more effectively. Concepts of maleness are often defined in terms of sexual rights, sexual prowess, and sexual performance. The ideas underlying dangerous sexual behaviour are based on concepts of appropriate gender relations that must be addressed more effectively through the school and health services systems, and promoted through public education campaigns. Otherwise men will remain ‘accessories’ rather than central subjects of reproductive health programs. Introduction: Men as clients of reproductive health care programs The 1994 International Conference on Population and Development in Cairo produced a Programme of Action aimed primarily at the improvement of women’s reproductive health. This was understandable given global levels of maternal morbidity and mortality, and the fact that the dominant technologies for birth control are designed for use by women. To a large degree concerns about sexually transmitted diseases focus on the potential impact of these infections on the fecundity of women. To the extent that men are mentioned in the document it is in terms of their responsibilities to support the efforts to obtain quality reproductive health services for their spouses, and their responsibilities to avoid violent and sexually risky behaviour. Certainly the health promotion messages of ICPD can be read as injunctions equally relevant for women and men, but the tone of the document, and the scope of reproductive health issues canvassed, give little direct consideration to issues of sexuality and reproductive health from a male perspective. For this reason efforts to implement the ICPD agenda are largely also framed in terms of women’s needs and male responsibilities. While this might be fully justified in terms of the relative risks of morbidity and mortality, and the predominant weight of gender bias in terms of political power and economic empowerment, the female focus of the document does not contribute to efforts to consider appropriate constellations of services directed to alleviating men’s reproductive health problems. This paper reviews some uniquely male reproductive health issues in Southeast Asia, and speculates on the forms of service delivery systems and priorities that might be effective in addressing these concerns. Of particular interest are the various forms of ‘genital cutting’ (including religious rites of circumcision) and different types of ‘penis augmentation’ carried out across the region. While these issues are male focussed, they are by no means irrelevant to women. The traditions and innovations underlying the behaviour reflect particular constructions of gender role formation that define maleness and femaleness in the societies. The behaviours in themselves may not pose a general public health problem since they seldom produce high levels of morbidity or mortality. However, as markers of misguided or exploitative gender relations they do reveal areas of social psychology related to more important pathologies worthy of attention and public health treatment. The paper concludes that by putting men more effectively in the picture of reproductive health services, programs are likely to address issues of importance to women more effectively. Male genital cutting in Southeast Asia Around the world different cultures have developed a variety of ways of dealing with problems of penile hygiene and some relatively rare issues of malformations of the genital foreskin. In some societies great stress is placed on regular bathing and the resort to traditional medications for any problems. In others preventive measures are stressed, including the practice of circumcision to remove the foreskin before any problems of infection or phimosis can develop. Over centuries the origins of such practices may be forgotten and various religious explanations may link the behaviour to individual identity with a group, to a rite of passage to adulthood, or to an interpretation of appropriate gender relationships. Broadly speaking, across Southeast Asia and into Melanesia there are three general patterns of male genital cutting: • the dominant norm for male circumcision among Muslims as an expression of Muslim identity. • the widespread traditional practice of circumcision among peoples of the Philippines, and many groups in Eastern Indonesia and Melanesia, for a variety of spiritual, identity or hygiene reasons, and • the absence of circumcision in Vietnam, Laos, Cambodia, Thailand, Burma, many groups in Melanesia and among the Chinese diaspora. 1 Phimosis, from the Greek work ‘to muzzle’, is the constriction of the foreskin with the result that it cannot retract. This can make sex and urination painful. In non-circumcising societies (such as Japan) the condition affects less than one percent of men, and is treated by either cutting the foreskin laterally or with a full circumcision. Indonesian case study In the course of the life cycle genital cutting is usually the first serious reproductive health issue to be faced by both males and females. In Indonesia virtually all Muslim males and about a quarter to half of Christian males are expected to be circumcised. Most often male circumcision is carried out on young boys between the ages of five and eighteen, but in urban settings some neonatal procedures are performed, and among some ethnic groups of eastern Indonesia adult males undergo traditional circumcision procedures. The safety of the most common practices of male circumcision in Indonesia is uncertain. This reflects the lack of any monitoring or systematic management of infection in the circumcision of adolescent Muslims. While there is obviously great concern among both patients and practitioners for safety, the institutions providing circumcision do not reflect these concerns in the formulation of standards or supervision. Traditional practitioners (such as the famous Bong Supit in Central Java whose clients include the children of the Jakarta elite) are skilled but they are not medically trained or professionally qualified to respond to complications. Community groups often arrange for ‘mass circumcisions’ for children of poor families. The practitioners in these events tend to be medical students (anywhere from second to final year students have been found to take part), male nurses, and young general practitioners attached to local government clinics. Observation indicates that the techniques used by these different groups vary greatly, and sometimes include practices of dubious clinical value, such as the retention of parts of the prepuce at the request of parents. The retained skin is tied in a ‘bundle’ or left as a flap with a hole that can be used to occasionally attach horsehair or other stimulants prior to intercourse. While circumcisers would usually not question such requests, the motive appears to be to prepare the young boy for a more pleasurable marital sex life. Clearly such procedures would be improved through the development and application of Standard Operating Procedures among the medically trained personnel (general practitioners, male nurses and medical students) who carry out most procedures. Circumcision is not included in most Indonesian textbooks on surgery or general practice, and by and large specialists would regard the operation as too simple to be included in their practice. A detailed handbook on the procedure (Karakata and Bachsinar 1994) was compiled by a specialist urologist and is intended to be a guide for general practitioners. It describes two approaches to circumcision (dorsal slit and the guillotine or ‘classical’ cut) and recommends the use of local anaesthesia and careful suturing to prevent bleeding. It has no national standing as a statement of Standard Operating Procedure (SOP). Most practitioners we have interviewed about the procedure say that they never read about techniques prior to joining a mass circumcision event and learning by observation and assisting a male nurse. The approach of learning by doing (magang) is widespread in medical training facilities in Indonesia. In fact it is unclear which professional organization or government agency would be responsible to issue and enforce the SOP for any common form of genital cutting, since so many of the procedures are carried out by nurses, paramedics, or traditional practitioners. Such people are not associated with the major medical professional associations (Indonesian Medical Association IDI, the Obstetrics and Gynecology Association POGI, and related groups) and tend to work outside the influence of the Ministry of Health. Observation and interviews indicate that procedures are often carried out without anaesthesia due to cost considerations. Infections are said to be rare due to the prophylactic use of antibiotics, but there are no studies to indicate the 2 The term genital cutting is preferred to circumcision since it focusses on all practices involving potential bloodletting in the genital area, and is applicable to both men and women. It can encompass various operations including circumcision, subincision, female genital mutilation, scarification, and the insertion or implant of various materials. incidence of infection or the prevalence of any other serious complications. While European nations have low rates of circumcision and campaigns are being waged in the Americas, the United Kingdom and Australia to reduce the practice of routine neo-natal circumcision, religious pressures in Indonesia have promoted circumcision as a secular orthodoxy for reasons of hygiene. It may be that most procedures carried out by medical professionals are safe, but there are no studies to verify that, nor are there procedures in place to record any problems that might exist. For a significant minority of Indonesian men genital cutting takes on far more dangerous and socially problematic forms. Very dangerous procedures are used for circumcision of young (and sometimes older) men in Timor, Irian and other areas of Eastern Indonesia. During January 1997 newspapers, medical staff, and social researchers in Kupang, West Timor reported the deaths of three men who had undertaken traditional circumcision ceremonies with the encouragement of their wives or lovers. Traditional healers carried out the ceremonies in the mountains at the site of cold mountain springs. They used bamboo clamps to fix the four sides of the prepuce in turn, then slicing off the skin with a sharp razor or knife. In each case the men bled profusely despite following the healers’ instruction to sit in the cold water. They died before obtaining medical attention. Health professionals have also observed serious morbidity and mortality among prisoners who attempted to carry out circumcisions on themselves, following encouragement by their peers to ‘become men’ through cutting. Non-governmental organizations in Timor, Papua New Guinea and Vanuatu have offered the services of doctors to visit prisons monthly to carry out circumcisions on men who would otherwise be tempted to do the procedure alone or with the help of other inmates. While such medical intervention might save a few lives, it does not address the broader issues of motivation. Men in Eastern Indonesian and Melanesia need counseling and education to overcome the real hygiene issues they suffer and clarify the notions of identity that they imagine to be related to cutting. The practice of adult circumcision was recorded many centuries ago in Timor as a stage of maturation leading to the recognition of a male as a headhunting warrior (McWilliam 1994). The practices in Timor and some other Easter Indonesian islands have undergone great changes over the last century as the ceremonial foundations have been modified through the suppression of headhunting, and the promotion of some traditional activities as indicators of broader ethnic rather than narrow village group identity. There is some indication that the motivation for Timorese circumcision today is being reinterpreted as a requirement for sexual hygiene, which may explain why some women encourage their partners to be circumcised. What is strange to the foreign eye, though, are some of the other traditional practices that have been maintained in Timor. Called sifon, the practices are widespread throughout the western part of Timor island in the cultural area of the Atoin Meto (Lake 1999). A few days after circumcision, when the man has developed a scab on the wound, he must have sexual relations with a woman (not his wife) who has had a number of children. After another period of recovery he has sex again, this time with a woman who has never had a child. Each time the purpose of the activity is to break the scab and ‘cool’ the wound. The women involved in providing sexual services could be commercial sex workers, but most often in rural areas they are recruited to the practice through the attraction of participating in a traditional health service that promises both them and the men health and spiritual benefits. During the time of the circumcision and the sifon 3 Referred to as ‘women of the road’ the participants in sifon are often widows who provide sexual services for a variety of traditional rituals. In the town of Kupang at least one circumciser has set up his practice in a house close to a large established brothel, and he relies on prostitutes to service his clients. the man absents himself from his home. At the end of the process he is ritually welcomed back into his home by his wife through an exchange of betel nut. Throughout the region the methods of traditional circumcision vary. Some are less drastic than the Timorese procedures. On the island of Roti to the west of Timor young boys form circumcision groups of 6 to 8 boys and go together to traditional leaders to receive advice and guidance of this rite of passage (Fox 2000). They are given or they make a small bamboo clamp which is fixed to the prepuce to cut of the flow of blood to the superfluous skin. The clamp is released when they need to urinate, and then replaced. After a couple of weeks the prepuce has shriveled and can be cut away without any bleeding. It is important in Rotinese ritual that this be a bloodless process, but it is unknown whether the procedure poses any serious threats to the boys’ immediate or long term reproductive health. Circumcision is an ideal issue and opportunity to consider male reproductive health needs and risks in Indonesia, Malaysia and the Philippines. The fact that the vast majority of men in these countries are circumcised makes the process of widespread interest. Unlike the case of female genital cutting (see Annex 2), the procedure for the male is not usually secret, and in fact it may be the focus of social celebration. The procedures are not well monitored, nor are they subject to research into safety, but there are reasons to think that for many boys and men the procedure may carry serious consequences. Traditional and modern forms of ‘penile augmentation’ Men in some areas of Indonesia, the Philippines, Thailand and Malaysia have a long history of inserting or implanting various objects in their penises. The origin of the practices is unclear, but some writers say that they were copied from Chinese traders who visited Southeast Asia, while others argue it is an indigenous innovation related to the use of other forms of amulets and inserts for medicinal and spiritual purposes. The objects used range from the very simple (the implant of ball bearings under the skin), to the magical (the use of specially selected semiprecious stones), or the elaborate (gold bars -palang -or rings inserted through the glans). While this might seem an odd and esoteric practice that should be relegated to museums recent research is finding that the use of inserts is spreading among working class men in the Southeast Asian and Melanesian regions. Researchers should pay attention to the modern manifestations of inserts and implants because of the possibility that they will cause vaginal wounds, inflammation and infection. They can also cause permanent damage to males, particularly when the cutting involved is carried out under unhygienic conditions. For an accessible overview of some of these practices see (Hammel and Friou 1997: 184). In February 2000 we examined the records of a random sample of over 700 men undergoing preemployment checks for work in the shipping, hotel and banking industries. This was an exploratory study to determine the likelihood of obtaining information on male reproductive health issues from conventional clinic records. It was found that one percent of the applicants for shipping industry jobs were wearing some form of penis implant. Anecdotal evidence indicates that prevalence of the practice is found in clusters. Since most of these men were young and inexperienced this might be taken as a minimum prevalence among sailors. Interviews with 4 Thanks to the Klinik Baruna staff and particularly Tien Irawati and Dr. Santi Rahayu Dewi for providing access to the data, and assistance in interpreting some of the results. Data collection was carried out by Lila Amaliah, Laily Hanifah, and Maryuni.. social workers and commercial sex workers suggest that upwards of ten to twenty percent of regular clients of brothels have either penis implants or holes in the glans or skin of their penises. The holes may be normally for rings or studs, but during intercourse the ring is replaced by a piece of horsehair of the strand of a stiff-leaved plant which is tied through the hole, and clipped off to a length of three or four centimetres as a ‘tickler’. The putative reason for the practice is to ‘please the woman’, and men with inserts argue quite strongly that ‘women love it’. However in the absence of systematic interviews with the lovers of such men, the testimony of commercial sex workers may be regarded as a useful commentary on the practice. Generally the women who earn their living from sex regard the use of inserts and ticklers is both strange and discomforting. One respondent recalled how one man using horsehair had caused her to bleed, while another caused great discomfort. She laughed at the idea that the devices were to ‘please the woman’. ‘That is what they say, but actually they only want the woman to reach orgasm before they ejaculate. It is a sign of their manliness to have such control.’ Variations on a theme: Methods of penis augmentation The difficulty of determining the exact spread of various penis augmentation practices lies in the fact that they are inspired and implemented in a highly informal way. Respondents have reported that they made their own implants from plastic or from semi-precious stones. Prisoners, seafarers, male sex workers and bored teenagers have also been recorded as having experimented with different forms of inserts. It appears that groups of working class males living in isolated circumstances are quite likely to discuss and attempt these practices. Interviews in a number of Indonesian cities indicate that it is not uncommon for the men to carry out this procedure on themselves or their friends, with no reference to medical facilities. Under these conditions the healing time is prolonged to perhaps two weeks. In the Philippines a variety of clinics advertise the provision of services to insert boletas or humps. These procedures involve the use of dissolvable sutures and it is estimated that the average time for healing the wound is only four or five days. Basic inserts – ball bearings. Workers in forestry and mining industries take ball-bearings from machinery, boil them and soak them in antiseptic, and then insert them under the skin of the penis, about a centimetre back from the glans. Some informants report having used three or four ball bearings simultaneously.