World Journal of AIDS, 2013, 3, 298-304
Published Online December 2013 (
Open Access WJA
I Just Trust Him: The Notion of Consideration as a Barrier
to Condom Use amongst Women Who Inject
Drugs in Central Java
Antonia Morita Iswari Saktiawati1, Heather Worth2, Elan Lazuardi1, Catherine Spooner2,
Yanri Wijayanti Subronto1, Retna Siwi Padmawati1
1Centre for Tropical Medicine-Research Collaboration Unit, Faculty of Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia;
2International HIV Research Group, School of Public Health and Community Medicine, University of New South Wales, Sydney,
Received August 13th, 2013; revised September 12th, 2013; accepted September 19th, 2013
Copyright © 2013 Antonia Morita Iswari Saktiawati et al. This is an open access article distributed under the Creative Commons
Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
The HIV epidemic in Indonesia has risen sharply since 2004, from 2682 cases in 2004 to 19,973 in 2009. The main
transmission route of HIV in Indonesia is injecting drug use. There is little research on women who inject drugs in In-
donesia. In-depth interviews were carried out with 19 women who injected drugs in three small cities in central Java.
The interviews explored the living conditions of the women and the context of HIV risk. The transcripts were coded and
the data were thematically analyzed. In this paper we report on condom use with regular partners. Condom use was very
low with their regular partners, even though both they and their partners were injecting drug users. The reasons women
gave were that they trusted their partners (although they realised this trust was shaky). The women used traditional
Javanese cultural concepts of consideration to explain why they did not use condoms. This was heightened by other
cultural norms of women’s place in Javanese society. Although the women in the study were marginalized because of
their drug use, they still hold to many Indonesian cultural precepts—of consideration and care for the other above one-
self in their relationships with their regular partners which impede condom use. While notions of consideration and
harmony were used to explain non-condom use, the same notions could also be used in couple-counseling to assist.
Keywords: Central Java; Condom Use; Drug Use; Cultural Concept
1. Introduction
International research with general populations and peo-
ple who inject drugs has identified numerous barriers to
using a condom and identified that the barriers to using
condoms vary with the type of partner (regular, casual or
commercial sexual partner). In the context of regular
sexual relationships, people are less motivated to use a
condom because they perceive themselves to be at low
risk [1-3]. Among people injecting drugs who have
regular partners, consistent condom use was associated
with greater self-efficacy, and negatively associated with
regular partner’s desire for pregnancy and needle sharing.
Among those injectors with casual partners, having fewer
sex partners was associated with consistent condom use.
Positive attitudes toward condom use and partner norms
supporting condom use were predictive of consistent use
for both regular and casual partners [4]. In
the context of women who inject drugs, the barriers of
consistent condom use are trusting that their regular
partner does not have HIV because they know them [5,6],
low risk perceptions, and discomfort in discussing con-
dom use with partners [5,7], insufficient knowledge
about how to access and use condoms [5], and the belief
that condoms interfere in sexual pleasure [8].
International research with injecting drug users has
identified that, life is quite different for women relative
to men and these gendered experiences shape their HIV
risk behaviours. For example, women who inject drugs
have difficulties in negotiating condom use, particularly
when they are dependent on men for drugs. While people
who inject drugs often experience considerable social
I Just Trust Him: The Notion of Consideration as a Barrier to Condom
Use amongst Women Who Inject Drugs in Central Java 299
stigma, economic pressure, and lack of social support
[7-9], women who inject drugs, in particular, often ex-
perience feelings of powerlessness, low self-esteem, and
poor self-confidence as they are marginalized by society
and this can influence their sexual relationship with their
partners [10]. Therefore, it is important to take a gender
perspective when discussing HIV risk amongst people
who inject drugs.
Various contexts at familial level, societal level, and
sexual-partnership level will influence sexual risk be-
haviours at the individual level [11]. For women who in-
ject drugs these include less negotiation strength in terms
of condom use due to male domination of sexual roles
[10,12,13], the stigma of injection drug use from the so-
ciety which is even worse for women as they are ex-
pected to be good wives, mothers, daughters, or nurturers
of families; and also gendered discrimination [14], which
in turn, prompts their unsafe sexual practices.
While there is a significant body of international re-
search relating to condom use among people who inject
drugs, and among women who inject drugs in particular
[4,11,15-21], there is little research about women who
inject drugs in Indonesia. One reason for this lack of re-
search with women who inject drugs in Indonesia is that
only 1% - 8% of injectors in research studies are women
[22]. The HIV epidemic in Indonesia has risen sharply
since 2004, making it among “the fastest growing in
Asia” [23]. The number of reported cases of HIV in In-
donesia increased from 2682 cases in 2004 to 19,973 in
2009 [24]. The main transmission route of HIV in Indo-
nesia has been through blood when sharing injecting
equipment to use drugs. Consequently, people who inject
drugs have been a focus of concern for Indonesia’s HIV
strategy. Among those who inject drugs, sharing inject-
ing equipment is not the only risk for HIV infection. HIV
can also be transmitted via unprotected sexual contact
with an HIV-infected person, whether that person is a
regular sexual partner, a casual sexual partner, or a com-
mercial sexual partner. It is well established that condom
use can prevent HIV transmission from an infected per-
son to an uninfected person [25].
Results of biological-behavioural surveillance among
people who inject drugs in multiple sites within Indone-
sia identify that unprotected sex is prevalent, irrespective
of the type of partner [22]. Pisani [26] indicated that con-
dom use among people who inject drugs with all types of
partners in three cities of Indonesia was not consistent—
almost 90% of people injecting drugs who bought sex
from a sex worker in the last year seldom or never used a
In this paper we report on data from a qualitative study
of HIV risk among women who inject drugs in Java, In-
donesia. While the study focused primarily on injecting
behaviour [27], we also asked about condom use.
2. Method
2.1. Study Population and Sample
The study population was women who inject drugs in
three small cities in central Java: Yogyakarta, Salatiga
and Solo. In developing the research study, consultations
were conducted from August 2009 to January 2010 with
people working in non-government organisations (NG-
Os), government health services (including methadone
programs and needle and syringe programs (NSP)), com-
munity organisations, prisons and police. Consultations
identified that injecting drug use by women in the region
was a particularly hidden behaviour due to fear of police
and social stigma. We were warned that there were few
women who injected drugs in the area and that nobody
would want to talk with researchers. Consequently, it
was clear that recruitment would only be possible via
people who had pre-existing relationships with women
who inject drugs. Participants were recruited via outreach
workers working in three non-governmental organiza-
tions in two cities and the local branch of the National
AIDS Commission in one city. The research method was
chosen because the respondents were very closed and
hidden, and focus group discussions or questionnaires
would not elicit the kind of in-depth information we
Inclusion criteria for participation in the study were
being female, aged 18 years or older, injecting drug use
within the previous month, and living or staying in a
study site (Yogyakarta, Salatiga or Solo) during the data
collection period. The final study sample comprised 19
women, two from Yogyakarta, 10 from Solo, and 7 from
Salatiga. One participant withdrew from the study be-
cause in the middle of the interview, she experienced
symptoms of drug withdrawal, and refused to meet again
for interview.
The two interviewers were Indonesian women em-
ployed as social research trainees as part of an AusAID-
funded capacity building project. They were trained in
interview method by a senior social researcher from the
University of New South Wales. The study was approved
by the ethics committees of the UNSW and Universitas
Gadjah Mada.
2.2. Data Collection and Analysis
Interviews were conducted in locations that were private,
quiet, comfortable and safe. These included public places
(cafes), and private spaces (e.g. the home of an outreach
worker). Interviews were conducted in Indonesian lan-
guage. The interview lasted for 2 hours, on average. In-
terviews were conducted until there was no novel data
found (data were “saturated”). Two researchers and one
supervisor coded the data, and no software packages were
Open Access WJA
I Just Trust Him: The Notion of Consideration as a Barrier to Condom
Use amongst Women Who Inject Drugs in Central Java
used for management or analysis of the data. For each
interview, the participant was asked for written informed
consent to participate after receiving information about
the purpose of the study and permission to record the
interview. All participants were asked to provide and use
a pseudonym so that there was no risk of information
being attributed to individuals. Written notes and audio
recordings only included these identifiers. Participants
were reimbursed for expenses incurred in their participa-
tion (e.g. phone credit, travel) and for their time assisting
with recruitment and/or participating in an interview. The
interview schedule was designed to explore the lives of
the women and the context of HIV risk. The interview
investigated background (e.g. family background, initia-
tion of drug use, sexual behaviour—reasons for not using
condoms, HIV testing, stigma and discrimination). Audio
recordings were made of each interview. Qualitative data
analysis was consistent with grounded theory with the
analysis drawing meaning from the data rather than test-
ing theories. All interview data was transcribed and
translated into English. The transcripts were coded, and
coded data were copied into separate documents; one for
each topic.
3. Results and Discussion
All of the study participants had injected an impure form
of heroin called putaw or etep in the previous month.
Injection of other drugs was rare. The average age was
25, ranging from 19 to 36 years. Three-quarters of the
sample were educated up to senior high school level and
one woman had tertiary education. The women had lived
in the city of interview for an average of 16 years. Sev-
enteen women were Javanese, while the remaining two
were of mixed Indonesian ethnicity; that is, one parent
from Java and the other from elsewhere in Indonesia.
Half of the women lived in a boarding house; three did
so with their boyfriend and one with her husband. The
others lived in their parents’ home, with parents-in-law,
or with their husband in a home.
Consistent with international literature [28], the wo-
men in our study protected themselves by being reclusive
and limiting social interactions to a small group of
friends with the same activity of illegal drug injection. In
this group, the women tended to depend upon their boy-
friend or friends to obtain drugs, injecting equipment, or
During the year prior to the interviews, 15 of the 19
women had been sexually active and this was mostly in
the context of an ongoing relationship, mostly with a
man who also injected drugs. All of the 15 women had a
regular sexual partner in the past year: ten had lived with
their spouse or boyfriend, and seven had a boyfriend with
whom they did not live. Two had both over this time.
Only one woman reported that she had a casual sexual
partner in the past year, but three women reported a
commercial sexual partner in the previous year. These
three women were being “pimped” by their boyfriend to
obtain cash to buy their drugs. Only one of these women
regularly used condoms with their commercial partners.
Desi used condoms with clients because they demanded
them, “They want to keep safe… They are afraid to get a
disease, they think like that, so I prepare myself with
condoms. Note here that Desi was not asserting the need
to use condoms for her own health; rather it was because
the client clients demanded them. In fact, she did not use
condoms with her regular boyfriend, “After I inject my-
self, I get horny, I want to have sex. But I never use a
condom when I have sex with my boyfriend, while I al-
ways use condoms with other guys.
The other two women who reported commercial sex
rarely—if ever, used condoms with clients. When ques-
tioned about why she took sexual risks with clients,
Maya said, “Maybe it is because I feel like Im in a hurry
my mind says, ‘forget it’. That happens when I have
sex with the guys who pay me. Only the ones who pay me.
I dont think I am that much in need of money, right. So,
forget it”. Rosa said, “Yeah, I do have another man (a
client) I have sex with… I didnt use condoms because I
didnt want to. The problem is I also never use condoms
with my boyfriend. It just doesnt feel right, using con-
The women who were not selling sex were nonetheless
acting outside of the expectations of Javanese women in
terms of their injecting behaviour. Though they were
clearly ashamed of their injecting drug use, these women
were in a monogamous regular relationship, and they had
established a social hierarchy in which sexual “promis-
cuity” was at the bottom:
But theyre slut girls... theyre considered low class,
junkies are also considered low but theyre lower... sluts
are considered lower class because theyre easy, they
can be taken here and taken there… used here, used
there. Thats why junkies are more respectable, what I
mean is when we use drugs, we only use drugs... we dont
get that low-to let people use us . (Sulis).
The women trusted their partners. Desi said:
Its trust. I really trust my boyfriend. I strongly be-
lieve that he never has sex with another girl”.
In general worldwide, it is understandable that women
in regular relationships tend not to use condoms [29-32].
It is difficult to expect women to use a condom within
the context of a regular relationship in which it is ex-
pected that each partner is monogamous. As was the case
with sharing needles, most of the women in this study,
particularly those who lived with their partners, tended to
say it was reasonable not to use a condom because they
Open Access WJA
I Just Trust Him: The Notion of Consideration as a Barrier to Condom
Use amongst Women Who Inject Drugs in Central Java 301
trusted their partner.
However, in the situation in which other potentially
high risk behaviours are present (in this case a partner
who injects), this trust is not so certain. In actuality the
women hoped that their partners would be faithful, even
though they realised that their partner could not be
trusted [33]. Surveys of people who inject drugs in Indo-
nesia (over 90% of the samples were men) have shown
that they often have casual, multiple and/or paid sexual
partners aside from their regular partner [22].
Well I am not really sure about it, but I rarely know
that he has sex with another woman. Ive never seen or
heard before that he slept with other girls. Actually, he
always stands by me, whenever I need him; hes always
there for me. Well, we live in one boarding house [in one
room], Miss (Desi).
Similarly, Rosa initially said that she trusted her boy-
friend, but then she changed her mind and admitted to
not really trusting him because she felt that it was impos-
sible for a man to not cheat on his partner.
I But, are you also sure that he only has sex with you?
R Yeah, I am sure. But I dont know actually, whether
he has had an affair or not. Well for me, a man is a man,
its just so impossible for a man to never cheat on his
partner, right? But with him, I can only trust. I just trust
him (Rosa).
This feeling of trust seemed to be related to the small
social network that the women had, in which trust and
loyalty were essential for survival. Further, some of the
women in the study seemed to place great trust in their
partners because they did not have other people to rely
on. Requesting that partners use condoms suggested that
they did not trust their partner and they did not want to
risk the relationship by doing so. Lau et al. [7] also found
that women who inject drugs who had a male partner
who injects drugs often do not practice HIV-related pro-
tective behaviours since it could be interpreted as “not
breaching the trust”, although there was no reason to
believe that their male partner would not get infected
from other sources.
The situation of “trust” for these women is heightened
by Javanese cultural imperatives. Women in central Java
are expected to behave in a manner that is polite and
“proper” [34]. Sex is rarely discussed openly, relation-
ships are expected to be dominated by men, and pre-
marital sex is not permitted [35]. Although the women in
the study are outside Javanese mainstream culture in
many ways because of their drug use, they still hold to
many cultural precepts—of consideration and care for the
other above oneself in their relationships with their regu-
lar partners.
Javanese culture has a belief in keeping harmony—
within oneself and within the community. This can mean
sacrificing individual wants for the sake of community
harmony and above all avoiding confrontation. Through
consideration, Javanese people try to keep the environ-
ment in a “rukun” or peaceful condition [36]. The wo-
men explained that consideration came from both sides;
they considered partner’s feeling and the same went with
their partners. This consideration could be a benefit for
condom use practices since their partners would under-
stand if the women wanted to use condoms. However,
the Javanese character of pekewuh (fear of disappointing
others who are respected) and isin (a sense of “uneasi-
ness” with respect to behaviour and expression which is
counter to social values) amplifies concerns about brea-
ching traditional gender roles. Thus, in reality, it was the
women who considered their partner’s feeling more than
the men; thus safer sex did not happen.
Actually he also likes it better without condoms too...
he said that it is not good... I dont know for sure he
loves to have sex without condoms... I just give what he
wants I mean just follow his desire. I dont want to
fight over that kind of thing. (Idra).
This consideration was heightened by the central Java-
nese expectation of women pleasing men. In Javanese
traditional culture everything that was good was intended
for the father who was the “head of the family”. A wife
had a duty to serve her husband. Although these expecta-
tions have lessened in this modern era, it has influenced
the relationship between men and women in Javanese
society. In addition, this consideration is also a result of
the dependency of the women to their partners to get
drugs and needles. To be always able to get drugs and
needles, the women were willing to please their partners,
for instance not using condom if the partners did not like
that. Women did not report being pressured to not use a
condom. Rather, women talked about wanting to be con-
siderate of their partner’s feelings and, to a lesser extent,
of partners being considerate of their feelings.
With my current boyfriend, once I asked him to use a
condom, so he used a condom but he said that he felt
uncomfortable, then I said, okay, just peel it off, its
okay...” So he peeled it off. (Icha).
Since 2002 I found out my HIV status, I started using
condoms. But, he [Nan as boyfriend who is also HIV
positive] was so sick tha t time, so I did not have the heart
to push him to wear condoms all the time (Nana).
Despite the gendered nature of Javanese culture, most
of the women asserted that there was generally equality
within their relationships. For example, Indah stated that
“There are no differences between women and me; the
feeling is the same… The position is the same”.
But while few of the women mentioned the gendered
power differentials between them and their male partners,
they obviously understood that men and women experi-
Open Access WJA
I Just Trust Him: The Notion of Consideration as a Barrier to Condom
Use amongst Women Who Inject Drugs in Central Java
ence their sexual lives differently. Dwi said:
Men tend to be careless, and never think of the fu-
ture… If [a girl] is infected by HIV, what could she say?
Your life is already stagnant at this point, you never get a
man, never get a husband, and never are able to get
pregnant. Men are different; they can do anything they
want. What about girls? They still think, but men do not
think as the girls do. As long as they are happy, every-
thing is fine. Tha t is my opinion (Dwi).
Interestingly, the women did not consider that their
non-use of condoms was putting themselves at risk.
When asked about the consequences of sex without con-
doms, it was always answered in ways that imputed risk
only to men, even in the case of the three women who
were selling sex. For example, when asked about trans-
mission of the virus Rosa answered, “But as far a s I k no w,
my boyfriend never does anything bad behind my back”.
4. Conclusions
Condom use amongst women who inject drugs in Java is
shaped by the context in which the women lived, and
very little by the type of sexual partner. From the inter-
views with the women, the Javanese cultural context
evidently influenced their sexual behaviour. This context
includes gendered power relations in which women have
few negotiating rights. Javanese culture produces a gen-
erally cohesive and considerate society, but it is one in
which women tend to give more weight and considera-
tion to their male partners. Male partners were central to
these women’s lives; they had few friends outside of
their male-dominated injecting world.
Javanese women are also expected to be polite and
trust their partners, and this tends to mitigate against ne-
gotiating condom use. This trust, which is found in stud-
ies in other countries, appeared here to stem from Java-
nese cultural traditions. For the majority of the women,
trust and consideration of a partner’s wishes were fore-
most in terms of whether or not she used condoms. This
was even so for two of the three women who sold sex.
This trust puts these women at considerable risk of HIV,
not only through their injecting behaviour but also through
sexual practice. It also puts their partners at risk of
HIV—a consideration which does not seem to occur to
If consideration of the other is cultural bedrock for
Javanese women, then there may be ways where it could
be utilised for HIV prevention, by showing how condom
use is an act of consideration. Most of the women were
in a regular relationship, and couple based-interventions
could be a way forward. Couples counseling could be
effective in settings where women’s decision-making
power is limited and male involvement and support are
critical to enable behaviour to change within couples [37].
In a couple-based intervention, they could talk about how
to care for their partner by using condoms to keep them-
selves safe sexually from HIV.
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