Tri was 29 years old when she visited a private hospital in Kupang for a pap smear in 2016. Unmarried but wanting to get a check-up, she was made to sign a letter stating she was sexually active.
“I told the doctor I was not married yet but was sexually active,” Tri said. “She agreed to [perform a pap smear], but said I needed to sign a letter first. She said it was hospital policy, because my medical records stated that I wasn’t married. So to receive a procedure that’s normally given to married women, I had to sign the statement.”
There is no law against providing pap smears to unmarried women in Indonesia. Some clinics such as Prodia and PKBI will provide the service to anyone who asks, but many health facilities refuse unmarried women because they believe they are not (or should not be) sexually active.
“I felt uncomfortable,” Tri remembered. “Why did the hospital need to make a link between [not being] married and virginity? In Kupang, there are lots [of people] who are sexually active outside of marriage. What would happen if someone [did not want to say] she was sexually active but wanted to get a check-up? … And why did I have to write it down?”
The Indonesian Association of Obstetricians and Gynaecologists estimates that 33 Indonesian women die of cervical cancer every day. The World Health Organization (WHO) believes an additional 60 new cases are diagnosed daily.
In fact, cervical cancer is the leading cause of death for Indonesian women, with more than 12,000 dying from the disease annually.
Last week, 36-year-old dangdut singer Julia ‘Jupe’ Perez became part of the statistics, dying from cervical cancer after fighting the disease for three years.
Respected by many for her outspoken attitude about using her body as she wanted, and derided by many more for her unabashed attitude towards sex, Jupe was extremely popular across Indonesia.
So how can someone with Jupe’s wealth and status die of cervical cancer, a preventable disease with a 91% survival rate if caught early? The answer lies in Indonesia’s attitude towards sex.
Sexual relations are generally considered only appropriate within marriage and with the aim of producing children. This is despite the fact a sizable proportion of unmarried people are actually having sex – a study conducted by the Indonesian Child Protection Commission in 2007 found that 63% of surveyed teenagers were sexually active.
The social stigma surrounding unmarried sexual activity affects the accessibility of pap smears, with many medical professionals refusing to perform them on unmarried women. Pap smears involve taking a small sample of skin cells from the opening of the cervix, and are a quick method of determining whether a patient has cervical cancer.
Despite their effectiveness in diagnosing the disease, doctors are often reluctant to provide the service to unmarried women, often falsely assuming that ‘unmarried’ means ‘not sexually active’ – in other words, still a virgin.
While 19-year-old Nandra’s mum was getting a check-up from a skin and genital specialist in Jakarta, Nandra asked where she could get a pap smear for herself. “The doctor just dismissed it,” she said. “They told us, ‘Oh, it’s unnecessary for her to get one because she’s not married yet.’”
Unfortunately, the reality is that cervical cancer does not only affect married women. Anyone who is sexually active is at risk of contracting human papillomavirus (HPV), the primary cause of cervical cancer. HPV is easily passed between sexual partners – 80% of men and women will be infected over their lifetimes.
The tricky thing about HPV is that there are few symptoms. This is why pap smears are so important, including for unmarried women. Pap smears can pick up early cell changes caused by HPV, and these cells can be removed before becoming cancerous.
Women’s rights campaigner Mia remembers going for a pap smear in Jakarta in 2010. She was single at the time, and had decided to visit a doctor friend of hers at a women’s and children’s clinic.
“I thought that because she was my friend, I could ask her for a pap smear,” Mia explained. “But she refused because I wasn’t married. She said I didn’t need one and that pap smears were only for married women. I didn’t explain to her that I was sexually active because I wasn’t comfortable talking about that. I thought she would understand because she was my friend.”
Mia, now married, says being refused a pap smear had an enormous impact on her. “After that, I didn’t try to get a pap smear [anywhere else]. The doctor had been so judgemental and I was really traumatized … and disappointed,” she said. “I wanted to get checked up for health reasons – how could I be treated like that by a professional doctor?”
The Australian Cancer Council recommends that “any woman who has ever had sex” should have a pap smear every two years from the age of 18 to 70. This recommendation is standard across the globe.
A vaccine that dramatically reduces the chance of cervical cancer has also been developed in the past 20 years. The vaccine protects women against multiple kinds of HPV and is most effective if given before becoming sexually active. Even TV personality Deddy Corbuzier – an unlikely feminist ally if there was one – knows about and recommends the vaccine, and in 2016, the Ministry of Health began a pilot scheme in DKI Jakarta, providing the vaccine free of cost to grade five students. The program is being expanded to DIY Yogyakarta in 2017.
In a very real way, taboos and social stigmas about sex are causing the unnecessary death of Indonesian women. Perhaps Jupe’s tragic death can at the very least serve as a wake-up call to the country’s healthcare professionals to put aside their personal moral judgments and put the health and well-being of their patients above all else. With access to affordable pap smears and HPV vaccines, no more women should have to die from cervical cancer.
Prodia is offering free HPV vaccines and pap smears to BPJS Kesehatan, Askes, and KIS card holders across the country until November. Click here for more information. PKBI provides non-judgemental services, including both pap smears and HPV vaccines, throughout Indonesia, while in Jakarta, Angsamerah is a good option for non-judgemental reproductive health services.