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Story Publication logo February 12, 2014

Southeast Asia: 'A Certain Medical Procedure'

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In Indonesia and the Philippines, explosive growth and rapid modernization test religious belief and...

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Jean Ariola (left), who lives in Tondo, a poor district of Manila, has three children. Like many women in the Philippines, she says she cannot afford contraceptives. Image by Tom Hundley. Philippines, 2013.

We hadn't planned on going undercover, but clearly we looked the part. Me — the 60-year-old expat gone soft around the edges; she — the pretty, 20-something local girlfriend.

When we asked the rickshaw driver to take us to Jakarta's Raden Saleh Street, his head swiveled and he gave me a knowing wink. Raden Saleh is where girls in trouble go.

A slightly seedy strip of down-market hotels and a jumble of small shops did not suggest anything out of the ordinary about this street. I was not even aware that we had reached our destination until the driver slowed to a crawl and young men began crowding around, thrusting their faces inside our little three-wheeled vehicle.

"You need help, miss?"

"You need clinic?"

My "girlfriend," Ulma Haryanto, is actually a 28-year-old journalist who was working with me as an interpreter and fixer. She is happily married to a financial consultant and they are the proud parents of a 7-month-old son.

To the most persistent of the touts, Ulma indicated that, yes, we were looking for a clinic.

He hopped on his motorbike and beckoned our driver to follow. "We'll let this play out," I whispered to Ulma.

A right turn, a left turn, down a few blocks and we were there, in front of a walled residential compound in a leafy neighborhood. The neatly-painted shingle indicated that we had arrived at the office of a fully-licensed OB-GYN specialist, not the back-alley shack I was half expecting. A vaguely menacing young man stood guard at the entrance. He gave me the same knowing nod the driver had, and unbolted the front gate. We crossed a small, shaded courtyard and went into the reception room. It was sparse but clean.

A very pleasant young woman behind the reception desk wearing a hijab invited us to take a seat. There was another couple sitting in the corner, waiting their turn. From their age and appearance, Ulma judged them to be college students, well-off. The young man seemed to be trying to lighten the mood; she looked stricken. When a nurse summoned them into the examination room, the receptionist turned her attention to Ulma — routine questions about health and medical history, but each time warmly addressing Ulma as "dear."

Ulma had questions of her own:

Would the doctor himself be performing the procedure? Yes.

Would there be an anesthetic? Yes.

How long would the procedure take? Varies, but probably no longer than 30 minutes.

How much will it cost? Varies, but probably around $400 — not an insignificant sum in a country with an annual per-capita GDP of $2, 500. Meanwhile, I made a mental note of the medical diplomas on the wall.

When the receptionist told Ulma that the doctor was ready to see her for the initial consultation and ultrasound, Ulma finally confessed that it wasn't she who was pregnant, but that she had come on behalf of a "friend" to make sure that this clinic was clean and safe.

The receptionist did not seem surprised or in any way put out by our minor deception. She told us that, of course, we would have to bring our friend to the office. She gave us the doctor's card and told us to call for an appointment.

Outside the compound, our driver was waiting. He told me that he's made the trip to Raden Salah Street many times. "At least one every day," he said.

Turning to Ulma, he tried to be reassuring: "Don't be afraid, miss. They just suck it out of you and it's done."

Welcome to Indonesia's abortion underground.

Our brief encounter revealed that despite being highly restricted and mostly illegal, it was fairly easy for an Indonesian woman of middle- or upper-class means to obtain what would probably be a safe abortion from a competent medical professional.

Despite this generally benign experience in Indonesia and an equally improbable one in the Philippines — more on that later — most of the abortions in these two countries are considered unsafe. The World Health Organization estimates 14 to 16 percent of the maternal deaths in both countries are the result of botched abortions; in addition, tens of thousands of women are hospitalized annually for complications related to unsafe abortions.

Indonesia, with an estimated 2 million abortions a year — about 37 for every 1,000 women of child-bearing age — is second only to Vietnam in the percentage of pregnancies that end in abortion. Among Muslim nations — and Indonesia is the world's most populous Muslim nation — it appears to have the highest rate of abortion. The Philippines also has an alarmingly high abortion rate — about 600,000 a year, or 27 per every 1,000 women of child-bearing age — but one that is in line with other Catholic countries in the developing world, according to research from the Guttmacher Institute and local NGOs.

In a region that already suffers from some of the highest abortion rates in the world, predominantly Muslim Indonesia and its neighbor, the profoundly Catholic Philippines, offer a set of instructive case studies on the failure of public policy dictated by religious teachings to dent the abortion rate or provide a viable alternative. In the Philippines, lawmakers have passed legislation that would make modern contraceptives available to millions of poor women across the archipelago nation, an initiative that would almost certainly result in a dramatic decrease in the number of abortions. But the Catholic Church, which battled the law for 14 years, continues to block its implementation because of its opposition to birth control. Meanwhile, in Indonesia, where 86 percent of the population identifies as Muslim, religious authorities have signaled their measured acceptance of abortion, but politicians uncomfortable with the social taboos surrounding abortion have been unwilling to fix the country's punitive but unenforced anti-abortion laws.


Islam — or at least Islamic jurisprudence — takes a relatively pragmatic approach to abortion. Arab and Indian traders introduced Islam to the Indonesian archipelago in the 13th century. The new faith gradually supplanted Buddhism and Hinduism, while at the same time incorporating many of the archipelago's traditional cultural practices. When the Dutch colonizers came in the early 17th century, they made little effort to convert the native population — historically a lost cause in Muslim lands — though they did impose a legal code, mainly to assure that trade benefits continued to flow in Holland's direction.

Back then, abortion was hardly the hot-button issue that it would later become. In non-urban agrarian societies, women married at a young age and large families were considered both a blessing and an economic necessity. But in the early 20th century, as much of the world began to move into crowded urban spaces and economies based on wage-earners made large families impractical, the colonial overlords of what was then known as the Dutch East Indies introduced a new law that criminalized abortion in all circumstances — a standard that conformed with European thinking at the time. Although Indonesia gained its independence in 1949, the 1918 Dutch anti-abortion law has remained in effect. (The Dutch themselves have moved on, adopting some of the most liberal abortion laws — and recording one the lowest abortion rates — in the world).

In the years after independence, high birthrates were encouraged as a matter of national prestige, but things in Indonesia changed the 1960s, with the arrival of modern contraceptives and the authoritarian Suharto regime which recognized the need to curb population growth. Back then, U.S. aid programs supported both family planning and safe abortions. And while Indonesia's restrictions on abortion remained on the books, doctors routinely ignored them with little fear of repercussions. Things changed again in the 1980s when the Reagan administration sharply curtailed support for family planning programs and fundamentalist Islamic groups seized on the general aversion to abortion as a means to rally opposition to the Suharto regime.

The Shafi'i school of jurisprudence, predominant in Indonesia and much of Southeast Asia, allows abortion within 40 days of conception — the time at which most Muslim scholars believe Allah instills the fetus with a soul. Followers of the Hanafi school, which also carries some weight in Indonesia, believe a pregnancy can be terminated within 120 days of conception. Opinion varies widely among Islamic scholars — the ulema — on permissible grounds for abortion. Almost all agree that abortion is acceptable when a woman's life is in danger; a smaller percentage accept abortion in the case of contraceptive failure or when an unwanted pregnancy would impose severe economic hardship.

This kind of thinking on the part of religious authorities — along with a concurrent push by increasingly vocal Islamic women's groups (and Suharto's forced resignation in 1987) — led to a 2005 fatwa that could be described as Indonesia's Roe v. Wade moment. The fatwa, issued by the Ulema Council of Indonesia, the country's highest Islamic authority, declared abortion permissible within 40 days of conception if the mother's life was in danger or in cases where the fetus was "genetically disadvantaged." It also permitted abortion in cases of rape and incest, but only after the victim's family consulted with a medical doctor and an ulema. The fatwa did not allow a pregnancy to be terminated in cases of adultery or "fornication."

While not exactly a ruling that would thrill the hearts of Western feminists, it did seem to be an opening for at least a discussion on the topic in Indonesia. But the only change brought about by the fatwa was a modest adjustment to the existing health law passed by Indonesia's parliament in 2009 that tolerates what it delicately refers to as "a certain medical procedure" when a woman's life was in danger — but only if her husband consents and religious authorities are duly consulted.

Ruth Benedict, the eminent anthropologist who studied under Franz Boas and mentored Margaret Mead, coined the terms "shame culture" and "guilt culture" to explain certain differences between Asian societies and the West. According to Benedict, Asian societies tend to rely on the threat of public shame as the primary mechanism for maintaining social order and good behavior; in the West, social order is maintained by the notion of "sin" and by constantly reinforcing a sense of individual guilt for transgressions. In Indonesia, shame culture most strongly manifests itself in avoidance or denial of taboo subjects. Indonesians — women and men — seemed to become physically uncomfortable when I brought up the subject of abortion. They avoided eye contact. They changed the subject. Women who have had "a certain medical procedure" rarely admit it — not so much because it is illegal and subject to criminal sanctions, explains demographer Terence Hull, but because of the shame factor.

"In studies in the 1980s, I was impressed by the large numbers of women who were quite committed to terminate their pregnancies and felt no guilt or concern about the consequences, but who went to great lengths to ensure that their activities were not revealed to family members or the public," said Hull, a professor at the Australian National University who has done extensive research in Indonesia.

"You find that people avoid talking about it, or they talk about it in a very disengaged way," he told me. "The culture simply does not want to discuss these moral issues."

No surprise then that official abortion figures collected by government health authorities in Indonesia are preposterously low. Few people outside the fairly limited circles of public health professionals and abortion rights activists are aware of the magnitude of the problem in Indonesia. And the country's political leaders seem relieved to keep it that way.

Abortion is not a hot-button issue political here as it is in the Philippines. "It's just not part of our politics," said Irwan Hidayana, who heads the Center for Gender and Sexuality Studies at the University of Indonesia. "Most people believe that abortion is something shameful, and you will not find too many politicians willing to challenge the public morality on this," he told me. "Any politician who promoted sex education and safe abortions — he would be a loser for sure."

In almost every conversation about abortion and maternal health that I had in Indonesia, the phrase "free sex" seemed to pop up. To Indonesians, the words encapsulated everything negative they had gleaned from TV or films about the presumed licentiousness of the West, especially the United States. Even women who agreed that abortion restrictions should be eased told me that they believed sex education was tantamount to teaching children how to have free sex, and that providing access to contraceptives and safe abortions would merely grease the slippery descent to promiscuity for these young people. The conventional wisdom here holds that promiscuous young women are the ones having all the abortions.

Actual studies tell a different story: Most of the women who have abortions in Indonesia — about two-thirds — are married and nearly half already have had at least two children. Their pregnancies are unintended and are generally blamed on an unmet need for modern contraceptives. The studies also show that very few of those seeking abortions are under age 20.

But actual studies are no match for the powerful shaming mechanisms deeply embedded in this society. Schoolgirls who become pregnant are promptly expelled in what seems to be a universal and mostly unquestioned practice (there are rarely consequences for the boy involved). In the national press, sensationalized "scandal" stories about raids on abortion clinics are far more common than serious reporting on a major public health crisis. And for any woman who has had an abortion — should her secret ever become known — she would likely be labelled "promiscuous," even "murderous." If she is single, her chances of marriage will be greatly diminished. Even more, she will be stigmatized for bringing shame to her family. This is because it will be assumed that she has gone against the will of her father or husband, thereby dishonoring them.

A lot of this can be explained by the deeply embedded attitudes one would expect to find in any patriarchal and paternalistic society. It's not all about religion or about shame culture. Still, it sounded strange to hear young, educated and thoroughly cosmopolitan women say that they do not believe their bodies "belong" solely to them. But here was Diana Pakasi, a researcher in the University of Indonesia's gender studies program, pointedly explaining how various local NGOs, supported by some of the most prominent women's advocacy organizations in the world, often made the mistake of trying to impose "Western values" without fully considering the power of deeply held Indonesian values, a mistake that led to bruised feelings and ineffective reproductive health programs.

"In our culture, you have to consider what your father says, what your husband and your extended family say. You have to consider what your religion says," Pakasi told me. "In all aspects of your life — how you dress, your marriage, your relation to your husband — always you have to listen to what the family says."

Or Tunggal Pawestri, one of the leading feminist voices in Indonesia, put it: "Even within women's groups, you find that [support for abortion rights] is not really solid. There are so many who think, 'My body is not my own. It belongs to my father, my husband, my family.'"


A woman in Manila faced with an unwanted pregnancy might start looking for help in the plaza in front of Quiapo Church, a centuries-old gathering place that encapsulates the deeply spiritual but highly eclectic Catholicism of the Philippines. Near the entrance to the much-rebuilt church, past the confessionals, stands a line of sweet, smiling old ladies who, in exchange for a small donation, will relieve penitents of the burden of actually saying their prayers of penance — not exactly a Vatican-certified practice, but one that local church authorities have grown to accommodate. Quiapo is also home to the Black Nazarene, a life-size statue of Jesus that is said to possess miraculous capabilities. Only a replica is on display most days, but the faithful still line up to touch it, or to rub handkerchiefs on it, hoping that some of the miraculous powers will rub off.

Outside the church there is another statue quite unlike the first — this one is a giant, faux marble hand of Jesus cradling a fetus in its palm; other cherub-like fetuses circle the hand like planets around the sun. As art, this fails miserably; as political theater, it is just plain creepy. While displays like this are common throughout the Philippines, you would never see anything like it in Indonesia, where taboo subjects are avoided, and certainly not displayed in public squares.

The hands-of-Jesus statue presides over a sprawling outdoor market that fans out from the church. Vendors sell live chickens, knock-off designer clothing, articles of religious devotion or the latest bootlegged DVDs. Fortune tellers offer palm readings; table-tops are clustered with an assortment of amulets for sale — there's one for fertility, another for success in business, another for bringing back straying husbands.

Other vendors sell abortifacients, either the home-made herbal variety, or one of the common pharmaceuticals such as misoprostol, a product sold under the trade name Cytotec and used to treat ulcers but also effective for inducing abortions.

I was curious about the herbal potions, so on a weekday morning last spring I enlisted the help of Sol Vanzi, a veteran Filipina journalist. Sol, who is in her 60s, had been on this same shopping mission about a year earlier with another American journalist. On that occasion, her cover story for the woman selling the potions was that the journalist was her "foreign husband," and they had come to her stall because their granddaughter was in trouble. Sol spotted the vendor from her previous visit, and we made our way over to the stall where the woman was offering a variety of traditional medicines. My presence was clearly causing some consternation, but Sol reassured her:

"You remember my foreign husband. We were here about a year ago."

"Ah, yes," the women said, not entirely convinced.

"Now it's our other granddaughter who is in trouble," Sol explained.

This seemed to click with the woman, whose look of wariness gave way to a knowing smile. "That's what happens when you marry a foreigner," she clucked. "Your granddaughter of mixed blood is probably very pretty."

She reached into a basket hidden beneath her table and withdrew an unlabeled pint whiskey bottle filled with a thick brown liquid. Then, on a scrap of paper, she wrote out the instructions. Take 1/3 of a cup, three times a day before meals, she told us, adding that it was very important to pray before swallowing the stuff or else it would be ineffective.

She charged us 120 pesos, about three dollars, and gave us her phone number in case of problems.

One notable exception to Professor Benedict's shame culture/guilt culture construct is the Philippines, at least as far as the abortion debate is concerned. In general, Filipinos do not like to cause a fuss or risk any sort of public embarrassment; this is reflected in the importance attached to the notion of hiya, which refers to both shame and having a proper sense of one's place. But the abortion debate in the Philippines is both public and extremely noisy. And no conversation about abortion takes place here without some mention of "sin." This, of course, is a reflection of the power and depth of its Roman Catholic heritage.

An island nation like Indonesia, the Philippines became a Spanish colony in 16th century, named in honor of the reigning monarch, Philip II. The real power, however, was not the Spanish crown, but the Catholic Church, especially its religious orders — Franciscans, Dominicans and others — that took charge not only of the spiritual lives of the natives, but also their land, their economy, even their sexual mores.

The church and its minions enjoyed an increasingly exalted status in the Philippines for three centuries until the 1898 Spanish-American War, when the United States took over. The influence of the church declined somewhat under American rule, continuing to wane after independence in 1946, but it came roaring back when church leaders — most notably Cardinal Jaime Sin, the archbishop of Manila — played a decisive role in rallying "People Power" against the dictatorial rule of Ferdinand Marcos. When the church hierarchy helped draft a new constitution in 1987, it recognized a separation between church and state but protected "the life of the unborn from conception."

Today, nearly three decades later, little has changed. Abortion remains strictly forbidden, no matter what the circumstances. Even though an estimated 600,000 are performed each year, and the number seems to be rising (the church disputes that increased growth rate), it seems likely that abortion will remain illegal for the foreseeable future.

And most Filipinos would be happy to keep it that way. "Pollsters don't even ask the question," said Junice Melgar, a physician and one of the country's leading activists for reproductive rights. "Most people in the Philippines agree that [abortion] is immoral. Ninety percent accept the church's teachings; only about 50 percent say they would accept abortion in cases of rape or incest."

It's a religious and political reality that keeps even the most ardent of abortion rights supporters from pushing too hard on the issue, preferring to keep their ammunition dry for the more immediate fight against the church's attempts to outlaw contraceptives. Even so, the Catholic Church's teaching on abortion is a topic on everyone's lips. Almost every politician in the country has staked out a position, and the overheated rhetoric associated with the debate very much echoes the culture wars being fought in places like Texas, Virginia and North Dakota.

I arrived in Manila last May in the midst of a particularly nasty election season in which the most contentious issue was a new Reproductive Health Bill that President Benigno Aquino III had signed into law a few months earlier, despite threats from Catholic bishops to excommunicate him. The law, which the church had successfully blocked for 14 years, makes no mention of abortion, but would make subsidized contraceptives available to poor women. Polls indicate that 70 percent of the population supports the law. In March, a few days before the law was to go into effect, the Philippine Supreme Court issued a stay while it considered the constitutional implications of contraception. Meanwhile, the powerful Catholic Bishops Conference of the Philippines was in the midst of a full-throttle campaign to peel back the law and punish legislators who had voted for it. The church put forward its own list of candidates, blessed them as "Team Life," and labeled their opponents "Team Death." It was an unprecedented intrusion of the church into the country's electoral politics — and one with a considerable risk of backlash.

A few days after the vote I spoke with Lito Atienza, the gregarious former mayor of Manila and a Team Life candidate who had just been elected to a seat in the Philippine congress. Back when he was mayor (1998-2007), Atienza achieved a measure of celebrity by declaring Manila a "pro-life city" and trying to impose a city-wide ban on contraceptives. He succeeded in preventing public hospitals and clinics from distributing contraceptives, but came up short on a total ban.

"I'm a Catholic, so I thought I should behave like one," he explained. "The other side accused me of doing things because I am a Catholic. No — I do these things because that's the constitution, and right now our constitution is a Catholic constitution."

Atienza, who remains very popular in Manila, won his seat handily, but the overall election results were inconclusive. Team Life and Team Death pretty much fought to a draw — a disappointment for the church which was hoping for a crushing victory. According to Catholic conservatives like Atienza, the abortion fight is one the church simply cannot afford to lose. Even in a limited "guilt culture," the church has to be the final arbiter of public morality. If the church loses control over this, the Philippines become, in the succinct characterization of one Filipino priest, "Europe" — where both church attendance and the church's moral authority are in sharp decline. (And so, it should be noted, is the number of abortions.) "We see what has happened in Europe. This is what the Vatican calls extreme secularism — the domination of science and technology over everything else; people who think, I don't need God, who think morality is all relative," said Father Francis Lucas, a radio broadcaster with a huge audience across the Philippines. Father Lucas is widely regarded as the voice of the bishops' conference.

"Europe," he told me disapprovingly "is on its knees."

To avoid the fate of Europe and to maintain their power and prestige within Philippine society, the bishops' conference is pulling out all stops in its attempt to kill the Reproductive Health law. Part of this is simply reflexive — to demonstrate fealty to the Vatican. According to Mary Racelis, a sociologist who has written extensively on the subject, the church here believes itself to be "special" in the eyes of the Vatican. It sees itself as a bastion of Catholicism in Asia, a reliable fortress of conservative faith that clings to the old ways in a rapidly changing world. The Philippines now has the distinction of being the only nation in the world where divorce is still illegal. Strict adherence to church teachings, zero tolerance for dissent — this was the tone set during the long reign of Pope John Paul II and his successor, Benedict XVI. Bishops here are only too happy to go along, understanding that the best way to advance a career is to toe the company line.

But a quiet debate has been stirring within the church. It began in the sociology and theology departments of the Ateneo de Manila, a Jesuit university with close links to President Aquino and his four immediate predecessors. A 2012 letter signed by 192 of the university's professors urging passage of the Reproductive Health bill stunned the church hierarchy and brought dissent within the church's ranks into the open for the first time.

To avoid an awkward situation, no Jesuits on the Ateneo faculty were asked to sign the letter, but several of them have played critical roles in shaping the arguments that there is a place for dissent in the modern church and that church's social justice mission is at least as important as rigid enforcement of its teaching on contraception.

"I believe a Catholic politician could vote for it [the Reproductive Health bill] in good conscience. In a pluralistic society, we must act for the common good," said Father John Carroll, an American Jesuit and sociologist with long experience in the Philippines.

Father Carroll, who lives in a small, book-lined room in the Ateneo's Jesuit infirmary, told me he was disturbed by the "tremendous damage" the church's strident lobbying against the Reproductive Health law was causing to its image. He spoke of how Catholics in the Philippines have been "turned off by incessant sermons and prayers against it," giving rise to a new anti-clericalism and further erosion of the church's moral authority.

Father Carroll and a few other Jesuits at the Ateneo are regarded as outliers by the church hierarchy in the Philippines. But some months after our conversation, another Jesuit, Pope Francis, voiced the same concerns, warning in a much-quoted interview that the church's moral authority could "fall like a house of cards" if its obsession with "small-minded rules" about abortion, gays and contraception overshadowed the greater need to make Catholicism a merciful place for all.

A few days after the pope's interview was published, I emailed Father Carroll, asking if he thought this might shake up the debate in the Philippines.

He wrote back: "Unfortunately, the official word of the [bishops' conference] so far is 'Nothing has changed.' We go on with our fight."


Last year, the Philippines surpassed China, becoming the fastest growing economy in the region. Indonesia is not far behind. Explosive economic growth, rapid urbanization and the need for smaller families will continue to put pressure on couples in both countries to have fewer children. In the short term, this may increase the number of abortions, but over the longer term, the inevitable access to modern contraceptives is likely to lower the number.

We have a good idea how this scenario plays out in guilt cultures. In the Catholic countries of Europe and among Catholics in America, couples simply walk away from the church, or those who still identify as Catholics say they don't accept the church's teaching on contraception. In either case, the church loses.

The process can be trickier in an Islamic culture where avoidance of public shame takes precedence over individual guilt. It would be wrong to suggest that Islam itself embraces a shame-based theology. It does not. It has, however, flourished in the shame-based societies of Asia and the Middle East and it is a much more encompassing faith than Christianity in the sense that its teachings govern almost all aspects of social relations. Muslims do not walk away from their faith lightly. The traditional punishment for apostasy is death. Not that anyone in Indonesia today would expect to be executed for this sin, but it remains a measure of how Muslims view their faith.

As one reproductive rights activist in Jakarta told me, "For an Indonesian woman, resigning from Islam is not an option, so we will have to try to find our rights through religion." But, before that can happen, the conversation will have to come into the light. Sometime in March — perhaps sooner — the 15 justices of the Philippine Supreme Court are expected to hand down their ruling on the controversial Reproductive Health law. Former Manila mayor Atienza says there is no way the court will uphold the law. Junice Melgar and Mary Racelis admit they are worried. Court watchers tell me there a six votes in favor of the law, five against and four swing votes.

If the court rules in favor of the church, will the bishops continue to press their advantage? If the ruling goes against them, will they prolong the struggle? Either way, the stakes are enormous. The outcome will determine the ability of poor women in the Philippines — which is to say most women in the Philippines — to have access to modern contraceptives and plan the size of their families.

When I returned to my hotel room after the visit to the market near the Quiapo Church, I contemplated the bottle of brown goo that I had purchased. A medical doctor in Manila told me there was no evidence the concoction could cause an abortion in and of itself, but that drinking it in sufficient quantities could make a woman ill enough to miscarry. I dabbed a bit of the liquid on my finger and put it to my tongue. It had the flavor and texture of cough syrup, cut with dirt and rotten eggs. The sulfurous taste lingered. I can only imagine what it must be like for a woman who felt she had no choice but to down the whole bottle.


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