In the cut

Religious meaning ... up to 90 per cent of mothers surveyed in Indonesia supported the practice of female circumcision. Photo illustration: SMH News Design

It's Indonesia's biggest secret. Most of its women have been subjected to an operation which the World Health Organisation says is unnecessary. Matthew Moore and Karuni Rompies report.

Hospitals across Indonesia are offering new parents a one-price surgical package for their just-born girls - when they pierce their ears, they'll circumcise the girls as well.

At Jakarta's Hermina Hospital the price for the two procedures is Rp95,000 (about $16); at IDI hospital in Surabaya in East Java it's only Rp15,000, while in Makassar's Khadijah Hospital in Sulawesi, hospital staff quote Rp25,000 to Rp30,000.

In some hospitals and health care centres, vaccinations are included in the package as modern medicine - attracting parents with the convenience of a one-stop shop - takes over a field long occupied by village-based healers.

While hospitals might be more hygienic, health care experts are worried by strong evidence that the move has led to more of the child's genital tissue being cut because doctors use different implements and techniques.

Village midwives and traditional healers have been circumcising girls in Indonesia for centuries, although the extent and details of the practice are only now emerging.

Two major studies were published last year, and the most comprehensive - Female Circumcision in Indonesia, by the Indonesian branch of the Population Council, an international non-government organisations - raised concerns about the move to hospitals' "medicalisation".

"Many maternity clinic midwives have begun to market female cutting (FC) as part of a birth delivery package with the service being offered to the parents right after the delivery of a baby girl," the report says.

"The danger of medicalisation of FC lies in the fact that midwives tend to use scissors instead of penknives, and thus the tools used are for real cutting of the clitoris (incision and excision) where traditional providers more often use penknives for more symbolic acts of scraping or rubbing."

While circumcision is widespread in Indonesia, it is very different to the female genital mutilation (FGC) common in parts of Africa, which often severely damages almost all genital parts.

A professor of demography at the Australian National University, Dr Terry Hull, worked on both studies and first came across female circumcision in Indonesia 30 years ago when he lived in a village outside Yogyakarta while researching infant mortality.

He learnt that symbolic circumcision involved local healers cutting a tumeric root and rubbing it on the baby's clitoris while those attending chanted and prayed. "This was very much women's business, and even if the fathers of the girls were there they would not understand what was done," he says.

In the cities, where Islamic influence was stronger, Hull found that circumcision involved drawing blood, usually by putting a pin in the clitoris.

Despite these and other related practices, Hull says that in Java at the time there was "universal denial" that circumcision of females took place. Even now, he says, there was a dearth of information because it was deemed too sensitive a topic to be discussed, or surveyed by government departments. Mothers had told him they did not know how much flesh had been removed from their babies during circumcision because they often did not look.

Dyah Agusmunwati, 36, cited "tradition, religion and health" as the reasons for circumcising her daughter soon after giving birth in a Jakarta hospital, but was vague on the details. "I don't even have any idea of which part of my daughter was cut. She was circumcised when she was a day or two days old, I guess."

To find out more about female circumcision, the USAid-funded study by the Population Council surveyed 1694 households in eight regions and found all the boys and 97.5 per cent of girls had been circumcised.

Although many questions remain unanswered, the study concluded circumcision in Indonesia at present "did not reveal any clear, immediate or long-term physical or psychological complications ... for girls or women". It listed the most common forms of circumcision as "rubbing and scraping; stretching, pricking and piercing; incision; and excision", and the cutting instruments used as "penknife; scissors; bamboo knife/razor blade and needles".

While blades of some sort have long been used, traditional practitioners used a knife only to rub or scrape in a symbolic exercise that often did not draw blood. The concern is that circumcisions in hospitals are changing that because health professionals use scissors in more than 75 per cent of cases and using scissors invariably means cutting flesh. "Where scissors were used, cutting was almost always involved including incision (22 per cent) and excision (72 per cent)," the report said.

"One midwife in Padang [West Sumatra] described how she usually cuts the clitoris, either directly or by pinching it first with tweezers, and then cutting the tip with scissors. Another said she only scratches the clitoris."

Betadine is widely used after the procedures, and infection has not emerged as a major problem.

Because of the wide variation in procedures, the report could not say how much (if any) flesh was usually removed but concluded that where tissue was excised it was generally a tiny amount.

It's not only babies who are circumcised: a third of those surveyed were circumcised between the ages five and nine, and some were even older.

SEVERAL hours out of Jakarta, in Bandung, the Assalaam Foundation has held free mass circumcisions for males and females for almost 50 years. As many as 400 people turn up.

Syarief Hamid, treasurer of the foundation, which also runs several schools, says the circumcisions were timed to honour the Prophet's birthday and were growing in popularity each year. While religion was the main reason for circumcisions, he says there are also health reasons. "I understand that a girl who is not circumcised would not have clean genitals after she urinates and sometimes that can cause cervical cancer," he says. "The religious view is, if you are not circumcised you won't have clean genitals after you urinate. If then you pray, your prayer won't be legal."

The practitioners who came from the local hospital always cut a piece off the clitoris, he says. Most of those who were circumcised were babies, but older people come, too. "Sometimes there are also women of 20 or 30. Even grandmothers aged 50 or 60 years old come." Those who had the procedure described it as "like an ant bite".

The Department of Health had come to observe, with representatives of the World Health Organisation, and had left satisfied. "What they saw here was different to what they imagined; it was different to what they saw in Africa," Syarief says. While there's a clear religious reason set out in the Koran for Muslim boys to be circumcised there's no such imperative for girls and Muslim leaders, practitioners and parents all struggle to provide clear answers on why they circumcise girls.

Religion was the reason cited by 55 per cent of mothers surveyed, although none could identify parts of the Koran or the Prophet Guidance called Hadith where circumcision of girls was stipulated. Thirty-two per cent nominated health and hygiene as the perceived benefit and 9 per cent said they did not know what benefit it would bring their daughters.

Masitoh Chusnan, from the women's wing of Muhammadiyah, one of Indonesia's two biggest Muslim organisations, says the circumcision of girls is regarded in Islam as an honourable practice. "The Hadith did not say it's obligatory, but it is recommended to have it done," she says. "There is the Prophet's words saying girls must be circumcised but you should not cut too much."

Dr Laura Guarenti, the WHO's reproductive health representative in Indonesia, said the WHO's position was of no acceptance of any genital cutting in medical institutions. Although there was not a complete picture of female circumcision in Indonesia, she was concerned about the move to hospitals.

"The danger of medication is when you have an instrument - it's easier to use scissors and it can be harmful." Guarenti, a gynaecologist with extensive experience in the practice in Africa, said circumcision was an issue that could only be addressed by Indonesian women, not by outsiders.

"People should not judge this. It should be clarified by Indonesians, not by us. I am absolutely against any female circumcision but it's the women here who have to do something. If it's just a ritual, it's not necessarily a horrible thing just because the genitals are touched."

While the report concludes there is no evidence of damage to girls who are circumcised, that it is done without the consent of the child, and without clear health benefits or religious mandate, was enough to classify it as a violation of human rights, according to the Population Council report. The practice could be seen to violate the rights of the child as stated under the Convention on the Rights of the Child, ratified by Indonesia in 1990.

Whether that's the case or not, the practice shows no signs of declining in popularity - more than 90 per cent of mothers questioned supported the practice continuing. And one in five mothers even suggested social sanctions should be imposed on girls who were uncircumcised.

This story was found at: http://www.smh.com.au/articles/2004/01/12/1073877760147.html