“RISKY” BUSINESS: CULTURAL CONCEPTIONS OF HIV/AIDS IN INDONESIA by Piper Lauren Crisovan BA, University of Toledo, 1996 Submitted to the Graduate Faculty of the Department of Anthropology, School of Arts and Sciences in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Pittsburgh 2006 UNIVERSITY OF PITTSBURGH GRADUATE SCHOOL OF ARTS AND SCIENCES This dissertation was presented by Piper L. Crisovan It was defended on March 31, 2006 and approved by Dr. Joseph Alter, Professor, Department of Anthropology, School of Arts and Sciences, University of Pittsburgh Dr. L. Keith Brown, Professor Emeritus, Department of Anthropology, School of Arts and Sciences, University of Pittsburgh Dr. Carol McAllister, Associate Professor, Dept. of Behavioral and Community Health Sciences, Graduate School of Public Health, University of Pittsburgh Dissertation Advisor: Dr. Richard Scaglion, Professor and Chair, Department of Anthropology, School of Arts and Sciences, University of Pittsburgh ii Copyright © by Piper L. Crisovan 2006 iii RISKY BUSINESS: CULTURAL CONCEPTIONS OF HIV/AIDS IN INDONESIA Piper L. Crisovan, PhD University of Pittsburgh, 2006 This research examines Indonesian cultural conceptions of HIV/AIDS, including perceptions of “risk.” Two years of fieldwork allowed for an in-depth assessment of three diverse and important populations in Jogjakarta, Indonesia: (1) female sex workers, (2) waria, Indonesia’s third-gender, and (3) university students. Surveys (N=413) and interviews (N=60) were partnered with anthropological participant observation to form a more holistic understanding of the impact and efficacy of available HIV/AIDS education programs. Results suggest that Western notions of “risk” are utilized to define, construct, and fund HIV/AIDS education programs throughout the archipelago. These constructions often fail to adequately consider Indonesian cultural conceptions relating to HIV/AIDS. This dissertation problematizes notions of “high-risk” groups, as well as “high-risk” behaviors. An anthropological understanding of the nuances of local cultural perceptions around HIV and “risk” helps to illustrate how Western notions of “risk” are incompatible with local Indonesian realities. For instance, fieldwork with Indonesian sex workers illuminates the importance of understanding identity as it applies to perceived “risk.” Islamic ideas of polygyny often create an acceptable “non-risky” identity for sex workers as lesser wives. Information collected from and about Indonesia’s third gender illustrates how cultural categories within the parameters of religious ideologies allows a niche market in which sex with a waria, not being between a man and a woman, is not considered “sex” nor “high-risk.” Interviews with Indonesian university students exemplify how local realities and definitions iv of “high-risk” sex and “low-risk” monogamy often differ greatly from the definitions assumed by HIV/AIDS prevention and education programs. HIV/AIDS programs based on Western biomedical and cultural models can create pockets of misinformation and confusion when they fail to fully incorporate critical Indonesian cultural categories, identities, and definitions. Results of this study suggest that more effective HIV/AIDS educational programs in Indonesia would result from recognizing: (a) the multifaceted identities of the people for whom programs are provided; (b) the importance of cultural categories and how they operate within complex state and religious ideologies; and (c) that cultural and programmatic definitions of “risk” are often inconsistent. Understanding Indonesian cultural conceptions allows for a deeper understanding of effective ways to implement culturally sensitive and appropriate HIV/AIDS programs and policies throughout the archipelago. v TABLE OF CONTENTS TABLE OF CONTENTS ...........................................................................................................VI LIST OF TABLES ....................................................................................................................... X LIST OF FIGURES .................................................................................................................. XII PREFACE...................................................................................................................................XV CHAPTER 1. INTRODUCTION: “RISK” AND DENIAL .................................................. 1 1.1. THE CASE OF INDONESIA............................................................................. 4 1.2. RESEARCH DESCRIPTION ............................................................................ 9 1.3. “RISK” AND BLAME ...................................................................................... 13 1.4. CHAPTER DESCRIPTIONS........................................................................... 14 CHAPTER 2. MEDICAL ANTHROPOLOGY, PUBLIC HEALTH, AND HIV/AIDS IN INDONESIA........................................................................................................ 18 2.1. INTERNATIONAL HEALTH AID AND HIV/AIDS.................................... 18 2.2. INTERNATIONAL AID GONE WRONG..................................................... 20 2.3. BLAME AND PUBLIC HEALTH................................................................... 22 2.4. APPLIED MEDICAL ANTHROPLOGY AND HIV/AIDS.......................... 27 2.5. CRITICAL MEDICAL ANTHROPOLOGY (CMA).................................... 29 2.6. WESTERN “RISK” IN INDONESIA ............................................................. 32 2.7. RESEARCH DESCRIPTION .......................................................................... 34 vi 2.8. FIELD SITE DESCRIPTION AND METHODOLOGY .............................. 36 2.9. SIGNIFICANCE................................................................................................ 47 CHAPTER 3. WARIA: A POPULATION PARADOXICALLY POSITIONED.............. 49 3.1. WARIA IN CONTEMPORARY INDONESIA............................................... 49 3.2. SOCIALIZATION OF WARIA........................................................................ 54 3.3. BEHAVIORS THAT INCREASE THE LIKELIHOOD OF CONTRACTING HIV........................................................................................ 62 3.4. HIV/AIDS KNOWLEDGE AND USAGE OF THAT KNOWLEDGE........ 73 CHAPTER 4. SEX WORKERS AS WOMEN, WIVES AND MOTHERS....................... 91 4.1. SEX WORKERS AS WOMEN ........................................................................ 92 4.2. SEX WORKERS AS MOTHERS .................................................................... 97 4.3. SEX WORK IN SOSROWIJIAN..................................................................... 99 4.4. PRELIMINARY RESEARCH, BREAKING DOWN ASSUMPTIONS, AND GAINING ENTRÉE ......................................................................................... 107 4.5. “GUESTS” OF SEX WORKERS .................................................................. 113 4.6. SEX WORKERS AS “WIVES” ..................................................................... 117 4.7. GUESTS AS “HUSBANDS” AND “BOYFRIENDS”.................................. 125 4.8. PERCEPTIONS ABOUT CONDOMS.......................................................... 129 4.9. SEX WORKERS’ HIV/AIDS KNOWLEDGE LEVELS ............................ 141 CHAPTER 5. UNIVERSITY STUDENTS: SIMULTANEOUSLY EXALTED AND IGNORED ......................................................................................................... 145 5.1. PRELIMINARY INVESTIGATIONS AND REASONS FOR CHOOSING UNIVERSITY STUDENTS ............................................................................. 145 vii 5.2. WHAT IS SEX? ............................................................................................... 147 5.3. “FREE SEX” VS. MONOGAMY .................................................................. 151 5.4. IF ONLY “FREE SEX” EQUALS AIDS, THEN SHOOTING UP IS OKAY! ........................................................................................................................... 160 5.5. SEXUAL EDUCATION.................................................................................. 164 5.6. MYTHS ABOUT HIV..................................................................................... 170 5.7. PRIMA’S STORY ........................................................................................... 174 5.8. CONCLUSION ................................................................................................ 176 CHAPTER 6. CONCLUSION: LESSONS FROM INDONESIA .................................... 178 6.1. A NEW CULTURAL FRAMEWORK.......................................................... 186 6.2. FUTURE SUGGESTIONS: “ACTION-RESEARCH” ............................... 189 APPENDIX A............................................................................................................................ 195 THE SURVEY INSTRUMENT IN ENGLISH ............................................................. 195 APPENDIX B ............................................................................................................................ 205 THE SURVEY INSTRUMENT IN INDONESIAN ...................................................... 205 APPENDIX C............................................................................................................................ 217 SURVEY QUESTIONS FROM IDRAYANTI 1997..................................................... 217 APPENDIX D...........................................................................................................................